Anyone who works with the mentally ill knows that they smoke more than other people. In fact, people with mental illness (hereafter, MI, not to be confused with myocardial infarction) are about twice as likely to smoke as people without mental illness, with smoking rates of 60-90%. One of my favorite stats is that “44% of the cigarettes smoked in the United States are by individuals with a psychiatric or substance-abuse disorder.” People with MI are also heavier smokers, and may even be better at extracting nicotine from the cigs that they smoke.
Studies have shown that people with MI can in fact quit, but from a front line perspective, this is really, really tough. In fact, quit rates aren’t all that great for people without the added burden of mental illness, so any barriers to quitting are formidable ones.
The reasons for high smoking rates in schizophrenics and others with serious mental illness are both socio-psychological and physiologic, with nicotine acting on CNS nicotine receptors and dopamine pathways. Smoking is sometimes viewed as a form of “self-medication”, but it can be difficult to differentiate the symptoms of nicotine withdrawal from symptoms attributable to the pre-existing mental illness.
As an internist, I take a very aggressive approach with my patients to help them quit smoking. Tobacco abuse kills a large number of my patients, and studies have borne out that people with MI suffer tobacco-related disease and death at a much higher rate than people without MI.
But in patients with co-morbid MI, the challenge of quitting smoking is often poorly met. Since data show that it is possible for the mentally ill to quit smoking, how should we approach this problem?
The answers aren’t clear. When someone is in crisis, we tend to put off taking care of all but the most immediately life-threatening issues. Since depression has a high fatality rate, when someone comes to me acutely depressed, this has to be dealt with and other health concerns are often pushed aside, with the thought that if the patient survives the crisis, we can move on to other things. I’m not sure if this is the best approach. For example, many psychiatric units have no provision for smoking, which probably scares away a number of patients. And why shouldn’t a person’s psychiatric and physical health be treated equally?
Why can’t we have a more comprehensive approach to treating mental illness, recognizing that tobacco abuse is an important co-morbidity? Before we get to this step, we need an intact national mental health care system, something that seems a long way off.
Karen Lasser, MD; J. Wesley Boyd, MD, PhD; Steffie Woolhandler, MD, MPH; David U. Himmelstein, MD; Danny McCormick, MD, MPH; David H. Bor, MD (2000). Smoking and Mental Illness: A Population-Based Prevalence Study The Journal of the American Medical Association, 284 (20), 2606-2610
Nady el-Guebaly, M.D., Janice Cathcart, B.S.N., M.Ed., Shawn Currie, Ph.D., Diane Brown, R.N. and Susan Gloster, R.N., B.N. (2002). Smoking Cessation Approaches for Persons With Mental Illness or Addictive Disorders Psychiatric Services, 53 (9), 1166-1170 DOI: 12221317
J WILLIAMS (2004). Addressing tobacco among individuals with a mental illness or an addiction Addictive Behaviors, 29 (6), 1067-1083 DOI: 10.1016/j.addbeh.2004.03.009