Tobacco use remains the leading cause of preventable disease and death in the United States, accounting for approximately one in five deaths. An estimated 11.5% of U.S. adults are current cigarette smokers. That translates to 28.3 million adults in our country who are currently smoking. More than 16 million Americans are living with smoking-related disease.1 Interestingly, the rates of cigarette smoking have actually declined significantly over the past 40 years, except among those with mental health or substance use disorders.2
It likely comes as no surprise to those who work with individuals experiencing mental health and substance use disorders that smoking rates among this population are high. The nicotine dependency rate for individuals with behavioral health disorders is two to three times higher than the general population.3 And smoking rates are particularly high among people with serious mental illness. People with a mental health disorder who smoke are also likely to smoke more than those in the general population, putting them at an even greater risk.4 While estimates differ, as many as 70-85% of people with schizophrenia and as many as 50-70% of people with bipolar disorder smoke.5 6 Individuals with alcohol use disorders smoke at rates between 34 and 80%. And people with other substance use disorders smoke at rates between 49 and 98%.7
Rates of smoking among those experiencing inequities in multiple areas of their lives are higher, with the highest smoking rates of those with mental illness noted in young adults who have low levels of educational attainment and those living in poverty.8
It has historically been understood that smoking is more prevalent among people with depression and schizophrenia because nicotine, as a stimulant, may temporarily reduce symptoms of these illnesses. In particular, nicotine can improve low mood and difficulty concentrating. 9 10 11 Yet, it’s been proven that smoking cessation correlates with an improvement in mental health, including a decrease in depression, anxiety, and stress, and overall improvement in mood and quality of life.12 Furthermore, research has illustrated that smoking is actually associated with worse behavioral and physical health outcomes in people with mental illness, and that quitting smoking has clear benefits, including improving mental health.13
Most people who smoke want to stop and those with mental health and/or substance use disorders are just as ready to quit as the general population.14 15 16 Smokers with mental illness and/or substance use disorders want to quit for many of the same reasons cited by others. However, they may be more vulnerable to relapse related to stress and other challenges. Smokers with mental health and/or substance use disorders report increased and more intense symptoms of nicotine withdrawal.17 18 19 20
Comprehensive tobacco control programs and enhanced efforts to prevent and treat nicotine addiction among those with mental illness and substance use disorders reduces morbidity and mortality.21 And despite the common myth that those in treatment for mental health and/or substance use disorders cannot address nicotine dependence at the same time or risk relapse by doing so, research shows that integrated treatment, with concurrent therapy for mental illness and nicotine addiction, proves to have the best outcomes.22 23 24 25 26 27
Systemic, evidence-based screening and treatment of tobacco dependence is integral to improving patient health outcomes. These standards are in alignment with the US Public Health Service’s Clinical Practice Guideline – Treating Tobacco Use and Dependence: 2008 update, which includes best practice systems strategies for organizations to use with their clientele. Systems Strategy One ensures that a tobacco-user identification system is present in every clinic. That system should include the evidence-based tobacco dependence treatment prompts of the 5A’s: Ask, Advise, Assess, Assist and Arrange. Systems Strategy Two ensures that education, resources, and feedback are present to promote provider intervention. The final Systems Strategy is to identify dedicated staff at a given provider location to dispense tobacco dependence treatment and assess the delivery of this treatment with other staff members in the office.
For more information on how to best address tobacco use, visit the Center for Disease Control website to identify your state’s tobacco control program contacts.
Kristen Richardson, RN, CTTS, is Director and Danielle O’Brien, CTTS, is Program Coordinator of the Central New York Regional Center for Tobacco Health Systems at St. Joseph’s Health in Syracuse, NY. The program is funded through a grant from the New York State Department of Health Tobacco Control Program. More information can be found at www.nyhealthsystems.org. Kristen Richardson or Danielle O’Brien can be reached directly at Kristen.Richardson@sjhsyr.org and Danielle.L.Obrien@sjhsyr.org.
- U.S. Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014.
- Cornelius ME, Loretan CG, Jamal A, et al. Tobacco Product Use Among Adults — United States, 2021. MMWR Morb Mortal Wkly Rep 2023;72:475–483.
- Schroeder SA, & Morris CD. Confronting a neglected epidemic: Tobacco cessation for persons with mental illnesses and substance abuse problems. Annu Rev Public Health. 2010; 31: 297-314.
- Agrawal A, Verweij KJH, Gillespie NA, et al. The genetics of addiction-a translational perspective. Transl Psychiatry. 2012;2:e140.
- Goniewicz ML, Delijewski M. Nicotine vaccines to treat tobacco dependence. Hum Vaccines Immunother. 2013;9(1):13-25. doi:10.4161/hv.22060.
- Bellamoli E, Manganotti P, Schwartz RP, Rimondo C, Gomma M, Serpelloni G. rTMS in the treatment of drug addiction: an update about human studies. Behav Neurol. 2014;2014:815215. doi:10.1155/2014/815215.
- University of California San Francisco Smoking Cessation Leadership Center. Behavioral Health. https://smokingcessationleadership.ucsf.edu/behavioral-health.
- Sousa AD. Repetitive Transcranial Magnetic Stimulation (rTMS) in the Management of Alcohol Dependence and other Substance Abuse Disorders – Emerging Data and Clinical Relevance. Basic Clin Neurosci. 2013;4(3):271-275.
- Dinur-Klein L, Dannon P, Hadar A, et al. Smoking cessation induced by deep repetitive transcranial magnetic stimulation of the prefrontal and insular cortices: a prospective, randomized controlled trial. Biol Psychiatry. 2014;76(9):742-749.
- Chaloupka FJ, Yurekli A, Fong GT. Tobacco taxes as a tobacco control strategy. Tob Control. 2012;21(2):172-180.
- Warner KE. Tobacco control policies and their impacts. Past, present, and future. Ann Am Thorac Soc. 2014;11(2):227-230.
- Adachi-Mejia AM, Carlos HA, Berke EM, Tanski SE, Sargent JD. A comparison of individual versus community influences on youth smoking behaviours: a cross-sectional observational study. BMJ Open. 2012;2(5).
- Taylor, Gemma, et al. “Change in mental health after smoking cessation: systematic review and meta-analysis.” Bmj 348 (2014).
- Prochaska, Judith J., et al. “Depressed smokers and stage of change: implications for treatment interventions.” Drug and alcohol dependence 76.2 (2004): 143-151.
- Prochaska, Judith J., et al. “Return to smoking following a smoke-free psychiatric hospitalization.” American Journal on Addictions 15.1 (2006): 15-22.
- Nahvi, Shadi, et al. “Cigarette smoking and interest in quitting methadone maintenance patients.” Addictive behaviors 31.11 (2006): 2127-2134.
- Weinberger, Andrea H., et al. “Cigarette use is increasing among people with illicit substance use disorders in the United States, 2002–14: emerging disparities in vulnerable populations.” Addiction 113.4 (2018): 719-728.
- Zvolensky, Michael J., Norman B. Schmidt, and Beth T. McCreary. “The impact of smoking on panic disorder: An initial investigation of a pathoplastic relationship.” Journal of anxiety disorders 17.4 (2003): 447-460.
- Grant, Bridget F., et al. “Nicotine dependence and psychiatric disorders in the United States: Results from the national epidemiologic survey on alcohol and related conditions.” Archives of general psychiatry 61.11 (2004): 1107-1115.
- Waxmonsky, Jeanette A., et al. “Prevalence and correlates of tobacco use in bipolar disorder: data from the first 2000 participants in the Systematic Treatment Enhancement Program.” General hospital psychiatry 27.5 (2005): 321-328.
- Hurt, Richard D., Taylor J. Hays, and Ivana T. Croghan. “The Mayo Clinic Nicotine Dependence Center.” Casopis Lekaru Ceskych 156.1 (2017): 17-18.
- Hall SM, Prochaska JJ. Treatment of smokers with co-occurring disorders: emphasis on integration in mental health and addiction treatment settings. Annu Rev Clin Psychol. 2009; 5:409-31.
- Prochaska JJ, Delucchi K, Hall SM. A meta-analysis of smoking cessation interventions with individuals in substance abuse treatment or recovery. J Consult Clin Psychol. 2004 Dec;72(6):1144-56.
- Stuyt, EB. Recovery Rates After Treatment for Alcohol/Drug Dependence. American Journal on Addictions. 1997; Vol 6; 2: (159-167).
- Substance Abuse and Mental Health Services Administration. Implementing Tobacco Cessation Programs in Substance Use Disorder Treatment Settings: A Quick Guide for Program Directors and Clinicians. HHS Publication No. SMA18-5069QG. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2018.
- Weinberger, A. H., Platt, J., Esan, H., Galea, S., Erlich, D., & Goodwin, R. D. (2017). Cigarette Smoking Is Associated with Increased Risk of Substance Use Disorder Relapse: A Nationally Representative, Prospective Longitudinal Investigation. The Journal of clinical psychiatry, 78(2), e152–e160.
- Prochaska, Judith J. “Failure to treat tobacco use in mental health and addiction treatment settings: a form of harm reduction?” Drug and alcohol dependence 110.3 (2010): 177-182.