Cited by 519Smoking Behavior and CessationSubstance Abuse Treatment and OutcomesMental Health Treatment and Access

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Trends in Smoking Among Adults With Mental Illness and Association Between Mental Health Treatment and Smoking Cessation

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Cook, Benjamin Lê, Wayne, Geoff Ferris, Kafali, E. Nilay, Liu, Zimin, Shu, Chang, Flores, Michael·2014·JAMA

DOI 10.1001/jama.2013.284985PMC PMC5555156

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Abstract

IMPORTANCE: Significant progress has been made in reducing the prevalence of tobacco use in the United States. However, tobacco cessation efforts have focused on the general population rather than individuals with mental illness, who demonstrate greater rates of tobacco use and nicotine dependence. OBJECTIVES: To assess whether declines in tobacco use have been realized among individuals with mental illness and examine the association between mental health treatment and smoking cessation. DESIGN, SETTING, AND PARTICIPANTS: Use of nationally representative surveys of noninstitutionalized US residents to compare trends in smoking rates between adults with and without mental illness and across multiple disorders (2004-2011 Medical Expenditure Panel Survey [MEPS]) and to compare rates of smoking cessation among adults with mental illness who did and did not receive mental health treatment (2009-2011 National Survey of Drug Use and Health [NSDUH]).The MEPS sample included 32,156 respondents with mental illness (operationalized as reporting severe psychological distress, probable depression, or receiving treatment for mental illness) and 133,113 without mental illness. The NSDUH sample included 14,057 lifetime smokers with mental illness. MAIN OUTCOMES AND MEASURES: Current smoking status (primary analysis; MEPS sample) and smoking cessation, operationalized as a lifetime smoker who did not smoke in the last 30 days (secondary analysis; NSDUH sample). RESULTS: Adjusted smoking rates declined significantly among individuals without mental illness (19.2% [95% CI, 18.7-19.7%] to 16.5% [95% CI, 16.0%-17.0%]; P < .001) but changed only slightly among those with mental illness (25.3% [95% CI, 24.2%-26.3%] to 24.9% [95% CI, 23.8%- 26.0%]; P = .50), a significant difference in difference of 2.3% (95% CI, 0.7%-3.9%) (P = .005). Individuals with mental illness who received mental health treatment within the previous year were more likely to have quit smoking (37.2% [95% CI, 35.1%-39.4%]) than those not receiving treatment (33.1% [95% CI, 31.5%-34.7%]) (P = .005). CONCLUSIONS AND RELEVANCE: Between 2004 and 2011, the decline in smoking among individuals with mental illness was significantly less than among those without mental illness, although quit rates were greater among those receiving mental health treatment. This suggests that tobacco control policies and cessation interventions targeting the general population have not worked as effectively for persons with mental illness.

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“Introduction Declines in smoking rates over the past few decades have been much lower among individuals with psychiatric disorders than those without (Cook et al., 2014).”
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Background
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Background
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Background
Time trends in access to smoking cessation support for people with depression or severe mental illness: a cohort study in English primary care
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“8 16 17 Furthermore, the gap in CVD-related mortality for those with mental illness has also been rising over time, 4 increasing the need to better understand primary care management of smoking cessation in people with SMI and to inform strategies to promote smoking cessation in people with poor…”
Equitable implementation of lung cancer screening: avoiding its potential to mirror existing inequities among people who use tobacco
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Anxiety and Depressed Mood Decline Following Smoking Abstinence in Adult Smokers with Attention Deficit Hyperactivity Disorder
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Changes in Voluntary Admission and Restraint use after a Comprehensive Tobacco-Free Policy in Inpatient Psychiatric Health Facilities
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“The American Psychiatric Association recommends provision of NRT during hospitalization of smokers with mental illness to manage their nicotine withdrawal symptoms without interfering with their clinical management and pharmacological treatment,(12) and studies suggest that tobacco cessation enhances addiction treatme…”
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Characteristics of participants utilising a telephone-based coaching service for chronic disease health risk behaviours: A retrospective examination comparing those with and without a mental health condition
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Does nicotine exposure during adolescence modify the course of schizophrenia-like symptoms? Behavioral analysis in a phencyclidine-induced mice model
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Clustering of chronic disease risks among people accessing community mental health services
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The Short-Term and Long-Term Associations Between Receiving Tobacco Discounts or Coupons and Smoking Cessation Among U.S. Adult Cigarette Smokers With Intention to Quit
Wang, Y., Duan, Z., Weaver, S. R., Self‐Brown, S., Ashley, D. L., Emery, S., & Huang, J. (2022) · Nicotine & Tobacco Research · doi:10.1093/ntr/ntac216 · Cited by 9
Temporal trends in cardiovascular disease risk factor profiles in a population-based schizophrenia sample: a repeat cross-sectional study
Chiu, M., Rahman, F., Vigod, S. N., Wilton, A. S., & Kurdyak, P. A. (2017) · Journal of Epidemiology & Community Health · doi:10.1136/jech-2017-209565 · Cited by 9
The need to incorporate smoking cessation into behavioral health treatment
Compton, W. M. (2017) · American Journal on Addictions · doi:10.1111/ajad.12670 · Cited by 9
Depression and smoking characteristics among HIV-positive smokers in Russia: A cross-sectional study
Lasser, K. E., Lunze, K., Cheng, D. M., Blokhina, E. A., Walley, A. Y., Tindle, H. A., Quinn, E. K., Gnatienko, N., Krupitsky, E. M., & Samet, J. H. (2018) · PLoS ONE · doi:10.1371/journal.pone.0189207 · Cited by 9
Association of Marijuana, Mental Health, and Tobacco in Colorado
Stewart, S. B., Bhatia, D., Burns, E. K., Sakai, J. T., Martín, L., Levinson, A. H., Vaughn, A. M., Li, Y., & James, K. A. (2019) · Journal of Addiction Medicine · doi:10.1097/adm.0000000000000533 · Cited by 9
Tobacco Screening and Treatment of Patients With a Psychiatric Diagnosis, 2012–2015
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Support and attitudes of Qatar mental health professionals to a proposed mental health inpatient smoking ban: Results of a cross‐sectional survey
Badanapurkar, A., Nelson, D., Varghese, S., Singh, R., & Haddad, P. M. (2021) · Journal of Psychiatric and Mental Health Nursing · doi:10.1111/jpm.12777 · Cited by 8
‘Clients are the problem owners’: a qualitative study into professionals’ and clients’ perceptions of smoking cessation care for smokers with mental illness
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“…to three times more likely to smoke (Asharani et al., 2020; Lawrence et al., 2009; Smith et al., 2014) and often less successful at smoking cessation (Cook et al., 2014; Fagerström & Aubin, 2009), which contributes to lower quality of life and life expectancy within this group (Krebs et al., 2018).”
Examining the effects of illicit drug use on tobacco cessation outcomes in the Helping HAND 2 randomized controlled trial
Streck, J. M., Regan, S., Chang, Y., Kelley, J. H. K., Singer, D. E., & Rigotti, N. A. (2017) · Drug and Alcohol Dependence · doi:10.1016/j.drugalcdep.2017.06.005 · Cited by 8
“Our findings cannot be generalized to these populations who smoke at higher rates and have more difficulty quitting (Cook et al., 2014; Jackson et al., 2015; Richter et al., 2001).”
Background
Effects of primary care clinician beliefs and perceived organizational facilitators on the delivery of preventive care to individuals with mental illnesses
Yarborough, B. J. H., Stumbo, S. P., Perrin, N., Hanson, G. C., Muench, J., & Green, C. A. (2018) · BMC Family Practice · doi:10.1186/s12875-017-0693-2 · Cited by 8
Treatment engagement mediates the links between symptoms of anxiety, depression, and alcohol use disorder with abstinence among smokers registered on an Internet cessation program
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Examining the Relationship Between PTSD Symptomatology and Cigarette Smoking Among Ohio Army National Guard Soldiers
Bergman, H. E., Chan, P. K., Cooper, A. A., Shirley, E. R., Goto, T., Fine, T. H., Cohen, G. H., Sampson, L., Ganocy, S. J., Tamburrino, M., et al. (2019) · Military Behavioral Health · doi:10.1080/21635781.2018.1556139 · Cited by 8
“%) compared to individuals who did not receive mental health treatment (33.1%; Lê Cook et al., 2014).”
BackgroundInfluential
Prevalence and determinants of tobacco use amongst South African adults with mental illness in the Eastern Cape
Tindimwebwa, L. K., Ajayi, A. I., & Adeniyi, O. V. (2021) · South African Journal of Psychiatry · doi:10.4102/sajpsychiatry.v27i0.1637 · Cited by 8
Examining pathways between family or peer factors and smoking cessation in a nationally representative US sample of adults with mental health conditions who smoke: a structural equation analysis
Nagawa, C. S., Wang, B., Davis, M., Pbert, L. A., Cutrona, S. L., Lemon, S. C., & Sadasivam, R. S. (2022) · BMC Public Health · doi:10.1186/s12889-022-13979-z · Cited by 8
“We did not account for other factors that may impact cessation outcomes in this population, such as access to mental health services [45].”
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Providing Tobacco Treatment in a Community Mental Health Setting
Okoli, C. T. C., Mason, D. A., Brumley-Shelton, A., & Robertson, H. E. (2017) · Journal of Addictions Nursing · doi:10.1097/jan.0000000000000157 · Cited by 8
“0% in 2012), smoking among persons with mental illnesses (MIs) has only slightly decreased and is two to three times the national prevalence (Centers for Disease Control and Prevention, 2009, 2013; Cook et al., 2014).”
BackgroundInfluential
Characteristics and clinical treatment of tobacco smokers enrolled in a VA substance use disorders clinic
Gass, J. C., Morris, D. H., Winters, J. J., VanderVeen, J. W., & Chermack, S. T. (2017) · Journal of Substance Abuse Treatment · doi:10.1016/j.jsat.2017.10.006 · Cited by 9
Rate of Tobacco Smoking Among Psychiatric Outpatients Attending a Tertiary Care Hospital in Oman: A Cross-sectional Study
Alrisi, K. A., Al-Maqbali, M., Asiri, W. A., & Sinawi, H. A. (2018) · Oman Medical Journal · doi:10.5001/omj.2018.41 · Cited by 8
Tobacco Screening and Counseling in the U.S.: Smokers With Mental Health and Substance Use Problems
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Ten-year experience of smoking cessation in a single center in Japan
Tomioka, H., Wada, T., Yamazoe, M., Yoshizumi, Y., Nishio, C., & Ishimoto, G. (2019) · Respiratory Investigation · doi:10.1016/j.resinv.2019.01.007 · Cited by 8
Effects of State-Level Tobacco Environment on Cigarette Smoking are Stronger Among Those With Individual-Level Risk Factors
Shmulewitz, D., Stohl, M., Keyes, K. M., Brown, Q. L., Saha, T. D., & Hasin, D. S. (2016) · Nicotine & Tobacco Research · doi:10.1093/ntr/ntw114 · Cited by 8
Characteristics of and Reasons for Electronic Cigarette Use among Adult Smokers with Schizophrenia/Schizoaffective Disorder
Wong, J. A., Pratt, S. I., Ferron, J. C., Gowarty, M., & Brunette, M. F. (2022) · Annals of Clinical Psychiatry · doi:10.12788/acp.0050 · Cited by 7
“7,8 The 2018 Review by the National Academies of Sciences, Engineering, and Medicine 9 suggested that e-cigarettes are less harmful than combustible cigarette products, and recent studies of smokers with SMI have advocated for the use of e-cigarettes as a possible smoking cessation tool.”
Through the Lens of Psychiatrists: Understanding Smoking Cessation Behaviour Among People with Serious Mental Illness
Parul, P., Joseph, B., Datta, S., Desousa, A., & Rahman, M. A. (2025) · Community Mental Health Journal · doi:10.1007/s10597-025-01460-1 · Cited by 7
“However, people with mental health issues have been more likely to smoke compared to the general population (Lê Cook et al., 2014).”
Smoking in Substance Use Disorder Patients: Prevalence, Comorbidities, Impulsivity, and Patterns of Readiness to Change
Syan, S. K., Belisario, K. L., Rahman, L., Levitt, E. E., McCarron, C. E., Radman, H., Amlung, M. T., Praecht, A., George, T. P., & MacKillop, J. M. (2025) · Nicotine & Tobacco Research · doi:10.1093/ntr/ntaf089 · Cited by 9
“8 Although estimates suggest that 55% of individuals try to quit smoking annually, 9 less than 25% of individuals who receive smoking cessation treatment will achieve successful abstinence at 12 months.”
Increasing prevalence of mental disorders in smokers seeking treatment of tobacco dependence: a retrospective observational study
Zvolská, K., Tichopád, A., Štěpánková, L., Pánková, A., Adamcekova, Z., Donin, G., Ráfl, J., & Králíková, E. (2023) · BMC Psychiatry · doi:10.1186/s12888-023-05115-x · Cited by 7
“It is therefore important that effective smoking cessation strategies are used to help people with severe mental disorders to stop smoking [1].”
Background
The Effect of Tobacco Control Mass Media Campaigns on Smoking-Related Behavior Among People With Mental Illness: A Systematic Literature Review
Perman‐Howe, P. R., McNeill, A. D., Brose, L. S., Tildy, B. E., Langley, T. E., & Robson, D. (2022) · Nicotine & Tobacco Research · doi:10.1093/ntr/ntac079 · Cited by 8
Adapting Peer Researcher Facilitated Strategies to Recruit People Receiving Mental Health Services to a Tobacco Treatment Trial
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“Smoking rates are much higher among people who experience severe mental illness (SMI) compared to the general population (1).”
Background
Task and barrier self-efficacy among treatment-seeking smokers with current, past or no psychiatric diagnosis
Clyde, M. J., Tulloch, H. E., Reid, R. D., Els, C., & Pipe, A. (2015) · Addictive Behaviors · doi:10.1016/j.addbeh.2015.03.002 · Cited by 7
“…50% of all cigarettes purchased each year are consumedby this population (Lasser et al., 2000); this suggests that current interventions are not as effective within this at-risk population (Cook et al., 2014), and a better understanding of modifiable factors related to smoking cessation is needed.”
Background
Evaluation of Community-Based Cessation Programs: How Do Smokers with Behavioral Health Conditions Fare?
Meernik, C., McCullough, A., Ranney, L. M., Walsh, B., & Goldstein, A. O. (2017) · Community Mental Health Journal · doi:10.1007/s10597-017-0155-2 · Cited by 7
“The smoking rate for persons without behavioral health conditions has significantly decreased over the past decade, but smoking among persons with behavioral health conditions has declined at a much slower rate (Cook et al. 2014).”
Background
Multi-method assessment of distress tolerance and smoking-related factors among adult daily smokers.
Mathew, A. R., Heckman, B. W., Froeliger, B., Saladin, M. E., Brown, R. A., Hitsman, B. L., & Carpenter, M. J. (2018) · Experimental and Clinical Psychopharmacology · doi:10.1037/pha0000238 · Cited by 8
“…& Leventhal, 2016; Leyro et al., 2010; Vujanovic, Rathnayaka, Amador, & Schmitz, 2016) which are increasingly overrepresented among smokers (Cook et al., 2014), examination of how DT impacts smoking outcomes within these psychiatric populations is another important direction for future…”
Multimethod Formative Research to Improve the Training and Delivery of Tobacco-cessation Interventions in Behavioral Health Settings
Allen, A. M., Muramoto, M. L., Campbell, J., Connolly, T. E., McGuffin, B. A., & Bernstein, A. D. (2019) · Journal of Addiction Medicine · doi:10.1097/adm.0000000000000522 · Cited by 7
Is there a place for cutting‐down‐to‐stop in smoking cessation support?
Lindson, N., Klemperer, E. M., & Aveyard, P. N. (2019) · Addiction · doi:10.1111/add.14928 · Cited by 7
“People who chose CDTS may have been more addicted, less motivated to quit or those who had struggled to quit previously; for example, those with mental health problems.(9) This is supported by an analysis from RRT, which found that participants who favoured CDTS at baseline were significantly less likely to be abstine…”
Dying to Quit: Understanding the Burden of Tobacco in Psychiatric Patients—A Clinical Review
Sprenger, S., & ANDERSON, J. S. (2024) · Journal of Psychiatric Practice · doi:10.1097/pra.0000000000000764 · Cited by 6
“11 However, the ef ﬁ cacy of smoking cessation for people with mental illness can be evaluated without evoking comparisons to dissimilar groups.”
BackgroundInfluential
Investigation of Smoking Cessation Status and Its Influencing Factors in Patients with Chronic Obstructive Pulmonary Disease
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Therapeutic Potential of Glucagon-Like Peptide-1 Receptor Agonists for Smoking Cessation
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Cigarette Smoking and Depression Among U.S. Veterans: Longitudinal Associations With Posttraumatic Stress Disorder
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Authors: Cook, B. L., Wayne, G. F., Kafali, E. N., Liu, Z., Shu, C., & Flores, M.
Affiliations: Cambridge Health Alliance (US)
Harvard Medical School/Cambridge Health Alliance, Department of Psychiatry, Cambridge, Massachusetts
Southwest University (CN)
Harvard University (US)
Brown University (US)
ORCID: Cook, Benjamin Lê
Kafali, E. Nilay
Liu, Zimin
Shu, Chang
Flores, Michael
Venue: JAMA
Publisher: American Medical Association (AMA)
Published: 2014-01-08
Volume: 311
Issue: 2
Pages: 172
ISSN: 0002-9955 (ISSN-L)
0098-7484
DOI: 10.1001/jama.2013.284985
PMC: PMC5555156
OpenAlex: W2028087632
Cited by: 519
References: 46
Citations by year: 2026: 17 · 2025: 32 · 2024: 21 · 2023: 38 · 2022: 59 · 2021: 46 · 2020: 54 · 2019: 59 · 2018: 47 · 2017: 46 · 2016: 44 · 2015: 35 · 2014: 18
FWCI: 31.69
Type: journal article
Language: en
Open access: green
www.ncbi.nlm.nih.gov
Locations: JAMA (publishedVersion)
PubMed (publishedVersion)
PubMed Central (acceptedVersion)
Funders: National Institutes of Health (5r01mh091042-02)
National Institute on Aging (T32AG023482)
National Institute of Mental Health (R01-MH091042)
Topics: Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Smoking Behavior and Cessation
Health Sciences › Medicine › Epidemiology › Substance Abuse Treatment and Outcomes
Health Sciences › Medicine › Psychiatry and Mental health › Mental Health Treatment and Access
Keywords: smoking, tobacco use, mental illness, smoking cessation, psychotherapy, nicotine dependence, tobacco use trends, depression, psychological distress, tobacco cessation interventions, tobacco control, adults with mental illness, tobacco harm reduction
MeSH terms: Adolescent, Adult, Aged, Mental Disorders, Female, Health Surveys, Humans, Male, Mental Health, Middle Aged, Smoking, Social Control, Formal, Tobacco Use Disorder, United States, Prevalence, Smoking Cessation, Young Adult

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Trends in Smoking Among Adults With Mental Illness and Association Between Mental Health Treatment and Smoking Cessation

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