Maryland's Tobacco Resource Center - Linking Professionals to Best Practices

Mental Illness

Providing tobacco use prevention and cessation treatment to clients coping with mental health issues 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. The CDC estimated the smoking rate in the United States to be at a modern-day low of 18.1% for the general population in 20121. However, people living with mental illness are more likely to smoke than the general population. People living with mental illness:

·        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

·        Have a much higher smoking rate (41%) than the general population3.

What are the consequences of these higher smoking rates? 

·        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 are cardiovascular disease, lung disease, and diabetes mellitus; all of these are linked to smoking.6

The table below compared current and lifetime smoking rates among individuals diagnosed mental illness compared to those with no such lifetime diagnosis. It shows how smoking rates tend to be elevated among individuals with either a current or lifetime mental disorder diagnosis.

Mental Disorder Diagnosis

Lifetime Diagnosis in U.S. Population (%)

Current Smoking Rates


Lifetime Smoking Rates (%)

No diagnosis




Anxiety disorders




     Social Anxiety Disorder




     Post-Traumatic Stress Disorder








     Generalized Anxiety Disorder




     Panic Disorder




Mood Disorders




     Major Depressive Disorder




     Bipolar Disorder




Psychotic Disorders




     Schizophrenia and other psychotic disorders




Source: 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 Health31, 97-314.


Providers’ Room to Improve

Considering the severity of the problem, what can be done to help? Currently, there is 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 do not 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 often 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.

Treatment for this Population

Nicotine dependence often requires multiple attempts before individuals are able to quit for good.  Combining counseling and nicotine replacement therapy or other Food and Drug Administration approved smoking cessation medications is typically the most effective treatment option for this population.11

·        Counseling for this population has been shown to be effective 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. 

A critical step is assessing use and connecting individuals who want to quit with services.  This only takes a few minutes with the 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 patients who want to quit with referral to treatment programs. Motivate and encourage quitting for those who are not ready to quit yet.

·        Arrange follow-up meeting to check in on progress and to prevent relapse.


It is important to remember that because this population demonstrates a higher dependence on nicotine, they may require more intensive interventions.13

·        Pharmacotherapy and counseling strategies need to be individualized to the patient’s current mental health and substance abuse status, quit history, and level of dependence14

·        Providers should become more knowledgeable and promote smoking cessation in people living with mental illness14.

Tobacco use is a considerable health risk to people living with mental illness.  Research has 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.  Recent research and clinical application of treatment models have shown promise in helping this population make successful quit attempts.


1 Centers for Disease Control and Prevention. Current Cigarette Smoking Among Adults—United States, 2005–2012.. Morbidity and Mortality Weekly Report 2014;63(02):29–34 [accessed 2014 June 28].

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.