Smoking, Mental Illness, and Public Health

“Clinical practice guidelines recommend combining medications with counseling to optimize quit rates (42), and evidence from network meta-analyses support the efficacy of combining short- and long-acting forms of NRT (25).”

“Research is greatly needed to determine effective intervention strategies to reduce smoking and its burden for this disadvantaged group (62).”

“While there is a growing appreciation and prioritization among tobacco researchers of the high smoking prevalence among those with mental illness (28, 34, 62), the lack of decline in use over time, despite population trends (29, 62, 134, 145), suggests that efforts at the general population level are not effectively a…”

“The self-medication hypothesis posits that individuals with mental illness smoke to lessen their symptoms (11).”

“In terms of exposure risks, analysis of 12 first-generation (cigarette-like) products of ENDS found varying levels of toxic and carcinogenic compounds in the aerosols, about 9–450 times lower than cigarette smoke, and toxicants in some brands, on some measures, were comparable with those in the nicotine replacement th…”

“Reported in the United States, the United Kingdom, and Australia, smoking is two to three times more prevalent among people with mental illness, when compared with the general population (38, 75, 78).”

“A recent meta-analysis of 38 studies with 16,369 mental health professionals concluded that 42% [95% CI (36, 49)] perceived barriers to smoking cessation intervention, 41% [95% CI (30, 51)] had negative attitudes toward smoking cessation, and 45% [95% CI (32, 58)] had permissive attitudes toward smoking (113).”

“In the emergency room setting, treating nicotine withdrawal with NRT (versus placebo) among smokers with schizophrenia increased cooperation and decreased agitation acutely (5).”

“Published in 2016, the EAGLES (Evaluating Adverse Events in a Global Smoking Cessation Study) trial was a postauthorization safety study that was developed with the FDA, conducted in 16 countries, and designed to evaluate the neuropsychiatric safety of varenicline and bupropion versus placebo and nicotine patch in pat…”

“A meta-analysis of 26 tobacco intervention studies found that smoking cessation was significantly associated with decreased anxiety, depression, and stress and improvements in overall mood and quality of life (125).”

“Comparable estimates in years of life lost have been reported in Australia, New Zealand, and Canada (74).”

“Cigarette smoking induces the metabolism of some psychiatric medications leading to lower therapeutic blood levels and the need for higher doses (146).”

“, e-cigarettes, e-hookahs, vape pens) is growing in the United States and internationally (3, 10, 39, 49, 65).”

“prior suicidal acts, and other substance use (21, 85, 87).”

“Another meta-analysis, focused on smokers in treatment for substance use disorders, found that tobacco-cessation interventions were associated with a 25% increased likelihood of sobriety from alcohol and drugs relative to usual care (90).”

“While there is a growing appreciation and prioritization among tobacco researchers of the high smoking prevalence among those with mental illness (28, 34, 62), the lack of decline in use over time, despite population trends (29, 62, 134, 145), suggests that efforts at the general population level are not effectively a…”

“Reported in the United States, the United Kingdom, and Australia, smoking is two to three times more prevalent among people with mental illness, when compared with the general population (38, 75, 78).”

“Bupropion, a blocker of dopamine and, to a lesser extent, norepinephrine reuptake, also has some nicotine receptor–blocking activity (115).”

“On a social level, smokers experience discrimination and stigma (22, 111, 123), contributing to increased alienation and poorer mental health.”

“In contrast, numerous studies indicate that smoking may cause depression, anxiety disorders, and schizophrenia and is a gateway to problematic substance use (20, 50, 64, 121, 138).”

“, e-cigarettes, e-hookahs, vape pens) is growing in the United States and internationally (3, 10, 39, 49, 65).”

“On a social level, smokers experience discrimination and stigma (22, 111, 123), contributing to increased alienation and poorer mental health.”

“Mental illness is associated with heavier smoking, greater nicotine dependence, greater withdrawal symptoms when quitting, and lower quit rates (19, 45, 70, 78, 90, 124).”

“Research has now clearly demonstrated that people with mental illness carry a disproportionate share of medical burden from tobacco use (35, 60, 76, 108, 117).”

“, e-cigarettes, e-hookahs, vape pens) is growing in the United States and internationally (3, 10, 39, 49, 65).”

“Menthol cigarettes have been aggressively marketed as healthier and safer alternatives to regular cigarettes to groups at high risk for smoking, including African Americans, Native Hawaiians, adolescents, and low-income communities (44, 47, 104, 141).”

“Heavier smokers have increased positive symptoms (hallucinations, delusions) and reduced negative symptoms (anhedonia, alogia, flat affect) compared with nonsmokers and nondaily or light smokers (148).”

“Among smokers hospitalized with mental illness, 65% were interested in quitting (114).”

“Research has now clearly demonstrated that people with mental illness carry a disproportionate share of medical burden from tobacco use (35, 60, 76, 108, 117).”

“, e-cigarettes, e-hookahs, vape pens) is growing in the United States and internationally (3, 10, 39, 49, 65).”

“Depression is twice as common in smokers than nonsmokers, and four times as common in heavy smokers (66).”

“Notably, the association is stronger with PTSD diagnosis than with trauma exposure alone (43).”

“Our perspective here is public health oriented, so we refer those seeking a more clinical focus to prior reviews (54, 89).”

“A recent epidemiologic study in California found that approximately half of the deaths in those who had been hospitalized for schizophrenia, bipolar disorder, or major depressive disorder were due to diseases identified as causally linked to tobacco use (26).”

“Among studies in the general population, the different forms of NRT have comparable efficacy (53).”

“Our perspective here is public health oriented, so we refer those seeking a more clinical focus to prior reviews (54, 89).”

“Bidirectional models maintain that smoking and psychiatric symptoms influence each other (139).”

“When assessed by psychiatric diagnoses, smoking prevalence is particularly high (almost fivefold greater) among those with schizophrenia, bipolar disorder, post-traumatic stress disorder (PTSD), and alcohol/illicit drug use disorders.”

“A recent meta-analysis of 38 studies with 16,369 mental health professionals concluded that 42% [95% CI (36, 49)] perceived barriers to smoking cessation intervention, 41% [95% CI (30, 51)] had negative attitudes toward smoking cessation, and 45% [95% CI (32, 58)] had permissive attitudes toward smoking (113).”

“Menthol cigarettes have been aggressively marketed as healthier and safer alternatives to regular cigarettes to groups at high risk for smoking, including African Americans, Native Hawaiians, adolescents, and low-income communities (44, 47, 104, 141).”

“In contrast, numerous studies indicate that smoking may cause depression, anxiety disorders, and schizophrenia and is a gateway to problematic substance use (20, 50, 64, 121, 138).”

“Newer research, however, indicates that quitting smoking is associated with improvements in mental health, including reductions in depression, anxiety, and PTSD symptoms (63, 80, 88).”

“In contrast, numerous studies indicate that smoking may cause depression, anxiety disorders, and schizophrenia and is a gateway to problematic substance use (20, 50, 64, 121, 138).”

“Home smoking bans reduce harmful secondhand smoke exposure, increase quit attempts and abstinence, and decrease cigarette consumption in adult smokers (82).”

“Evidence also shows that secondhand smoke exposure is related to the development of depression, generalized anxiety disorders, attention-deficit/hyperactivity disorder, and conduct disorder (13, 15).”

“prior suicidal acts, and other substance use (21, 85, 87).”

“In contrast, numerous studies indicate that smoking may cause depression, anxiety disorders, and schizophrenia and is a gateway to problematic substance use (20, 50, 64, 121, 138).”

“A 2015 meta-analysis of 39 randomized placebo-controlled trials of varenicline in the general population (n = 10,761) found no evidence of an increased risk of suicide or attempted suicide, suicidal ideation, depression, or death (126).”

“With a similar intervention approach tested in inpatient psychiatry (95), the mean cost of smoking cessation services was $189 in the treatment group and $37 in the usual care condition.”

“For those with substance use disorders, a recent meta-analysis found that nicotine patches improved continuous abstinence at 6 months, and nicotine gum improved continuous abstinence at 12 months (127).”

“Research has now clearly demonstrated that people with mental illness carry a disproportionate share of medical burden from tobacco use (35, 60, 76, 108, 117).”

“Tobacco companies funded research in support of this hypothesis (96).”

“Despite their high levels of tobacco use and the potential challenges of living with mental illness, this population’s motivation to quit smoking is high and comparable with estimates of intention to quit smoking in the general population (2, 83, 91, 98).”

“Research has now clearly demonstrated that people with mental illness carry a disproportionate share of medical burden from tobacco use (35, 60, 76, 108, 117).”

“Studies have long established that smoking cessation services are costeffective (136).”

“Mental illness is associated with heavier smoking, greater nicotine dependence, greater withdrawal symptoms when quitting, and lower quit rates (19, 45, 70, 78, 90, 124).”

“NRT has been available since 1984, yet a recent meta-analysis failed to identify a single randomized trial reporting six-month or greater abstinence outcomes of NRT monotherapy in the serious mentally ill versus placebo or other monotherapies (105); this is a major gap in the literature.”

“Despite their high levels of tobacco use and the potential challenges of living with mental illness, this population’s motivation to quit smoking is high and comparable with estimates of intention to quit smoking in the general population (2, 83, 91, 98).”

“Evidence also shows that secondhand smoke exposure is related to the development of depression, generalized anxiety disorders, attention-deficit/hyperactivity disorder, and conduct disorder (13, 15).”

“prior suicidal acts, and other substance use (21, 85, 87).”

“These beliefs combined with perceptions that tobacco use is a chronic, rather than acute, concern have been significant barriers to treating tobacco use in mental health settings (79).”

“Despite their high levels of tobacco use and the potential challenges of living with mental illness, this population’s motivation to quit smoking is high and comparable with estimates of intention to quit smoking in the general population (2, 83, 91, 98).”

“Until recently, clinicians in psychiatric treatment centers would smoke with patients, provide cigarettes as incentives, or give cigarettes in response to agitation (73, 140).”

“For example, Massachusetts saved more than $3 for every $1 spent on cessation services for state Medicaid program beneficiaries (103).”

“Psychiatric hospitals are increasingly adopting smoking bans, although they are still not nationally mandated (71).”

“Mental illness is associated with heavier smoking, greater nicotine dependence, greater withdrawal symptoms when quitting, and lower quit rates (19, 45, 70, 78, 90, 124).”

“In the emergency room setting, treating nicotine withdrawal with NRT (versus placebo) among smokers with schizophrenia increased cooperation and decreased agitation acutely (5).”

“Vigorous debate in the public sphere and scientific literature concerns the potential for ENDS as a safer alternative to tobacco cigarettes for smokers unable or unwilling to quit or for use as a cessation aid (31, 41).”

“In a survey study conducted in the United Kingdom in 2003 with inpatient psychiatry nursing staff, 53% believed clinicians smoking with patients was therapeutic, and 22% believed that cigarettes should be handed out to patients as part of therapy (122).”

“Among smokers with mental illness, research shows a similar rise over time in ENDS ever use (94).”

“Despite their high levels of tobacco use and the potential challenges of living with mental illness, this population’s motivation to quit smoking is high and comparable with estimates of intention to quit smoking in the general population (2, 83, 91, 98).”

“On a social level, smokers experience discrimination and stigma (22, 111, 123), contributing to increased alienation and poorer mental health.”

“Vigorous debate in the public sphere and scientific literature concerns the potential for ENDS as a safer alternative to tobacco cigarettes for smokers unable or unwilling to quit or for use as a cessation aid (31, 41).”

“In an online patient survey of 519 smokers with bipolar disorder, few reported that a psychiatrist (27%), therapist (18%), or case manager (6%) had ever advised them to quit smoking, and several reported discouragement to quit from mental health providers (97).”

“A recent meta-analysis of 38 studies with 16,369 mental health professionals concluded that 42% [95% CI (36, 49)] perceived barriers to smoking cessation intervention, 41% [95% CI (30, 51)] had negative attitudes toward smoking cessation, and 45% [95% CI (32, 58)] had permissive attitudes toward smoking (113).”

“In a survey of US psychiatry residency training programs, for example, only about half of training directors reported having a tobacco-cessation curriculum, and the time devoted to this topic was minimal (median = 1 h) (93).”

“Newer research, however, indicates that quitting smoking is associated with improvements in mental health, including reductions in depression, anxiety, and PTSD symptoms (63, 80, 88).”

“While there is a growing appreciation and prioritization among tobacco researchers of the high smoking prevalence among those with mental illness (28, 34, 62), the lack of decline in use over time, despite population trends (29, 62, 134, 145), suggests that efforts at the general population level are not effectively a…”

“(46), the HAVE model, as a public health framework, considers the diversity of influences on the prevention and control of tobacco use: The four broad domains are as follows:”

“The program has been associated with improvements in psychiatry residents’ knowledge, attitudes, confidence, and counseling behaviors for treating tobacco use among their patients; initial changes from pre- to post-training were sustained at three-month follow-up (92).”

“The low intensity and high accessibility of the treatment approach make it an important option for clinician referral, and supportive adjuncts may improve rates further (56).”

“A 2016 randomized trial with 577 mental health patients in the Veterans Health Administration found that a specialized quitline for smokers with mental health concerns outperformed standard state quitlines, with significantly greater 30-day abstinence at 6 months (26% versus 18%) and greater patient satisfaction (106).”

“Contrary to earlier beliefs that persons with mental illness and their relatives may harbor protection from tobacco’s harms (55, 102), researchers now recognize that those with mental illness are disproportionately affected by smoking-related morbidity and mortality.”

“If smoking cessation yields an additional 6 months of life (conservative estimate for smokers in general, not for those with mental illness), the cost would be $5,170 per life-year, which is costeffective (17).”

“Among 188 veterans who were current smokers of tobacco cigarettes and who were seeking mental health and/or substance use services, 31% reported current e-cigarette use (57).”

“Even when acute psychiatric settings ban smoking, the hospital stays are typically short (one week on average), and many patients are discharged to residential treatment settings where smoking is widely permitted or they return home to neighborhoods with a high density of tobacco retailers (142).”

“101 additional QALYs, resulting in an incremental cost-effectiveness ratio of $428 per QALY, which was deemed highly cost-effective (18).”

“A recent meta-analysis of 38 studies with 16,369 mental health professionals concluded that 42% [95% CI (36, 49)] perceived barriers to smoking cessation intervention, 41% [95% CI (30, 51)] had negative attitudes toward smoking cessation, and 45% [95% CI (32, 58)] had permissive attitudes toward smoking (113).”

“A second study in a public psychiatric hospital with an ethnically diverse and low-income sample showed a similar pattern of effects (59).”

“with a significantly reduced risk of developing major depression (14).”

“Menthol cigarettes have been aggressively marketed as healthier and safer alternatives to regular cigarettes to groups at high risk for smoking, including African Americans, Native Hawaiians, adolescents, and low-income communities (44, 47, 104, 141).”

“A similar analysis with a focus on deaths among those hospitalized for opioid-related conditions concluded that the major causes of death were related to tobacco and alcohol, not to opioids (135).”

“A recent bibliometric analysis of the literature on tobacco and mental illness documented a steady increase in research outputs from the two-year periods of 1993–1995 (n = 65) to 2003–2005 (n = 153) to 2013–2015 (n = 329) (81).”

“Furthermore, in a sample of 1,042 adult smokers hospitalized in the San Francisco Bay Area with serious mental illness, menthol use was twofold greater (57%) relative to the general population of smokers in California (24%) (143).”

“In a study of veterans quitting smoking, tobacco abstinence at follow-up was associated with mental health functional improvement, including depression, psychotic symptoms, and emotional lability (69).”

“In the United States, a 2013 front-page article in the New York Times on smoking bans in psychiatric hospitals generated online public commentary revealing stigma and devaluation of life for persons with serious mental illness (23).”

“Analysis of Florida state data indicated that smokers with poorer mental health were more likely to smoke menthol than nonmenthol cigarettes (137), and in a national sample, menthol use was more likely among smokers with severe psychological distress than among smokers with none or mild distress (58).”

“With the burst of available cessation programs online and via mobile applications, there is a need for greater evaluation, including among specialized groups (37).”

“Analysis of data from the 2000–2001 Healthcare for Communities Survey demonstrated sensitivity to cigarette prices among individuals with alcohol, drug, or mental disorders: A 10% increase in cigarette prices was associated with 18% less smoking participation (84).”

“Menthol cigarettes have been aggressively marketed as healthier and safer alternatives to regular cigarettes to groups at high risk for smoking, including African Americans, Native Hawaiians, adolescents, and low-income communities (44, 47, 104, 141).”

“A national US study found that statewide smoking bans in restaurants and bars were associated with reduced smoking among those with select psychiatric conditions (116).”

“0259 quality-adjusted life years (QALYs), producing an incremental cost-effectiveness ratio of $32,257 per QALY, concluded to be 86% cost-effective (16).”

“In 2013, more than 3 million smokers used the NCI websites, making the collection the most accessed smoking cessation website in the world (24).”

“In Europe, complete smoking bans in inpatient psychiatry are still debated; patients are often permitted to smoke outside (9).”

“In contrast, alcohol is not permitted on addiction treatment and mental health campuses in recognition of the need for a culture of recovery protected from obvious relapse triggers (147).”

“While there is a growing appreciation and prioritization among tobacco researchers of the high smoking prevalence among those with mental illness (28, 34, 62), the lack of decline in use over time, despite population trends (29, 62, 134, 145), suggests that efforts at the general population level are not effectively a…”

“321,322 Therefore, reducing smoking rates is a priority.”

“Although 19.8% of US adults are currently smokers, the lowest rate ever recorded, cigarette smoking is disproportionately common among individuals with low socioeconomic status, low educational levels, and psychiatric comorbidities, including those with another substance use disorder (SUD) [1, 2].”