Co-occurring Mental Illness

Providing tobacco use prevention and cessation treatment to clients coping with co-occurring disorders can be challenging; however, a foundation of research about how to meet the special needs of this population is being established.

Tobacco Use and Mental Illness

      Over the last 50 years, recent data has shown a steady yet significant decrease in the smoking rates of adults in the U.S. population. As of 2006, the CDC estimated the smoking rate in the United States to be at a modern-low of 22.5% for the general population¹. This is a promising statistic, if it were not a misrepresentation of the population. The mentally ill minority do not resemble the general population in their smoking patterns.  For instance, they:

• Smoke 44% of the cigarettes sold in the United States even though they only encompass 22% of the entire population.^2,3
• Tend to smoke more cigarettes per day.⁴
• Tend to smoke the cigarettes down to the butt.⁴

What do these statistics mean for this population? 

• On average, individuals with chronic mental illnesses die 25 years earlier than individuals in the general population.⁵
• The top three causes of death in this population were cardiovascular disease, lung disease, and diabetes mellitus; which have all been known to be caused by, exacerbated by, or at least linked to smoking tobacco.⁶

      As the devastating consequences of tobacco use among smokers with mental illness are evident, there is a critical need to engage health care providers, policymakers, and mental health advocates in the effort to increase access to evidence-based tobacco treatment.

Provider’s Room to Improve

      Considering the severity of the problem, what can be done to help? Currently, there is a considerable research dedicated to alleviating this problem among those diagnosed with a mental illness. Recent research has shown that there is a significant interest to quit smoking in this population.

• Roughly 77-79% of individuals with mental illnesses intend to quit smoking in the next month.⁷

      The difficulty, however, is that few of them are provided with the assistance that would be necessary to quit. The bulk of the responsibility falls on the doctors and other health care providers of this population as many individuals diagnosed with a mental illness rely on them to help maintain their mental and physical health. Unfortunately, many healthcare professionals simply fail to ask their patients about their smoking habits.

• Behavioral health specialists rarely asses for smoking status.⁸
• Physicians give cessation counseling to psychiatric patients in only 38% of visits.⁹
• Psychiatrists give cessation counseling to psychiatric patients in only 12% of visits.⁹
• In inpatient settings only 1% of patients were assessed for smoking status and none were assessed for nicotine dependency.¹⁰
• Smoking status was not included in treatment plans in inpatient settings.¹⁰

      Imagine how many more individuals would have more successful quit attempts if those numbers were any higher. Only 4-7% of unaided quit attempts are successful, but there are treatments that significantly enhance those odds¹¹. However, these treatments are futile if providers don’t expose their patients to these treatment plans.

Treatment for this Population

Nicotine dependency often requires multiple attempts before individuals are able to quit for good.  In general, combining counseling and nicotine replacement therapy (NRT) or other FDA approved smoking cessation medications is the most effective treatment option for this population.¹¹  For more detailed information about NRT, please click here. 

• Counseling for this population has been shown to be efficacious in various forms including motivational interviewing, cognitive behavioral therapy, and in individual or group formats.^11,12
• Peer based programs have also been helpful in working with this population to help increase smoking cessation. 

Health care professionals see thousands of patients diagnosed with mental illnesses every year and are understandably pressed for time.  Regardless, they only need a few minutes to assess and identify a smoking problem.  The 5 A’s serves as a basic platform for all tobacco cessation services because it allows the provider to work through assessment of use all the way through referring to treatment if necessary.  The techniques that can be employed for all health professionals are the 5 A's and the 2 A's and R models.

• Full “5 A’s” model:
  • Ask if the patient is using tobacco.
  • Advise the patient to refrain from tobacco use.
  • Assess patient’s willingness to quit or past tobacco use.
  • Assist patient with answers to their questions or with referral to treatment programs.
  • Arrange follow-up meeting to check in on progress of patient.
• Abbreviated “2 A’s and R” model:
  • Ask if the patient is using tobacco.
  • Advise the patient to refrain from tobacco use.
  • Refer patient to assistance programs or quit lines.

      For clinics that lack an onsite cessation service, the “2 A’s and R” model works best as clinicians are encouraged to invest only a few minutes per patient to get an approximation of what type of assistance, if any, would be ideal for that specific patient. For more on the 5 A’s, please click here.

It is important to remember that because this population demonstrates a higher dependence on nicotine, they may require more intensive interventions.¹³  As Schroeder and Morris pointed out in their review of tobacco cessation for persons with a mental illness:¹⁴

• Pharmacotherapy and counseling strategies need to be individualized to the patient’s current mental health and substance abuse status, quit history, and level of dependency. 
• Generally, they should be supported if they are interested in quitting unless there are ongoing medication changes or worsening symptoms.

      As stated above, tobacco use is a considerable health risk to the population suffering from mental illnesses.  Research has repeatedly indicated that their increased tobacco use in comparison to the general population likely contributes to their increased mortality rates and decline in mental and physical health.  While there are barriers to increasing treatment and reducing use among this population, there has been recent research and clinical application of treatment models that have shown promise in helping this population make successful quit attempts.

¹ Ziedonis DM, Guydish J,Williams J, Steinberg M, Foulds J. 2006. Barriers and solutions to addressing tobacco dependence in addiction treatment programs. Alcohol Res. Health 29(3):228–35

² Kandel DB, Huang FY, Davies M. 2001. Comorbidity between patterns of substance use dependence and psychiatric syndromes. Drug Alcohol Depend. 64:233–41

³ Lasser K, Boyd JW, Woolhandler S, Himmelstein DU, McCormick D, Bor DH. 2000. Smoking and mental illness: a population-based prevalence study. JAMA 284:2606–10

⁴ D’Mello DA, Bandlamudi GR, Colenda CC. 2001. Nicotine replacement methods on a psychiatric unit. Am. J. Drug Alcohol Abuse 27:525–29

5 Colton CW,Manderscheid RW. 2006. Congruencies in increased mortality rates, years of potential life lost, and causes of death among public mental health clients in eight states. Prev. Chronic Dis. 3(2):A42

⁶ Mauer B. 2006. Morbidity and mortality in people with serious mental illnesses. In Technical Report 13, ed. J Parks, D Svendsen, P Singer,ME Foti. Alexandria, VA: Nat. Assoc. State Mental Health Prog. Dir. Coun. 87 pp.

⁷ Prochaska JJ, Rossi JS, Redding CA, Rosen AB, Tsoh JY, et al. 2007. Depressed smokers and stage of change: implications for treatment interventions. Drug Alcohol Depend. 76(2):143–51

⁸ Zvolensky MJ, Baker K, Yartz AR, Gregor K, Leen-Feldner E, Feldner MT. 2005. Mental health professionals with a specialty in anxiety disorders: knowledge, training, and perceived competence in smoking cessation practices. Cogn. Behav. Pract. 12:312–18

⁹ Thorndike AN, Stafford RS, Rigotti NA. 2001. US physicians’ treatment of smoking in outpatients with psychiatric diagnoses. Nicotine Tob. Res. 3(1):85–91

¹⁰ Prochaska JJ, Gill P, Hall SM. 2004. Impact of nicotine withdrawal on an adult inpatient psychiatry unit. Presented at Annu. 10th Meet. Soc. Res. Nicotine Tob., Scottsdale, AZ

¹¹ Fiore MC, Jaen CR, Baker TB, Bailey WC, Benowitz N, et al. 2008. Treating Tobacco Use and Dependency: 2008 Update Practice Guideline. Rockville, MD: US Dep. Health Hum. Serv. Public Health Serv. 179 pp.

¹² Deci, E.L., & Ryan, R.M. (1985). Intrinsic motivation and self determination in human behavior. New York: Plenum.

¹³ Ziedonis, D., Hitsman, B., Beckham, J.C., et al. (2008). Tobacco use and cessation in psychiatric disorders: National institute of mental health report. Nicotine and Tobacco Research, 10(12), 1691-1715.

¹⁴ Schroeder, S.A., & Morris, C.D. (2010).  Confronting a neglected epidemic: Tobacco cessation for persons with mental illnesses and substance abuse problems. Annual Review of Public Health, 31, 297-314.