Smoking Among Adults With Mental Illness

Janice has suffered from mental illness for most of her life. She had depressive disorders starting in adolescence, and was admitted to a mental health facility for a time when her symptoms became severe. While there, she began smoking because many other patients were doing it, and she wanted to fit in. She noticed that the staff didn’t seem to mind patients smoking, and sometimes even used cigarettes to reward good behavior. By taking medication for depression and carefully following her treatment plan, Janice has been able to live a more productive life. She graduated from college and now is able to maintain a job. But she hasn’t been able to give up smoking, despite repeated attempts.
Photo: Woman looking depressed

The character Janice is not drawn from any one person, but is a blend of the experiences of many smokers with mental illness. Despite overall declines in cigarette smoking in the United States, more people with mental illness smoke than people without mental illness. And just like many others who smoke, many people with mental illness will get sick, become disabled, or die early from smoking-related diseases.
The latest Vital Signs from CDC notes that many adults with mental illness who smoke want to quit, can quit, and will benefit from proven stop-smoking treatments. It’s true that some people with mental illness face issues that can make it more challenging to quit, such as low income, stressful living conditions, and lack of access to health insurance and health care. All of these factors make it more challenging to quit. But that doesn’t mean that smokers with mental illness can’t benefit from the same proven treatments as anyone else. Read the full MMWR Vital Signs issue to find out more.

Smoking Prevalence is Much Higher Among People with a Mental Illness

Nationally, nearly 1 in 5 adults (or 45.7 million adults) have some form of mental illness, and 36% of these people smoke cigarettes. In comparison, 21% of adults without mental illness smoke cigarettes. (Mental illness is defined here as diagnosable mental, behavioral, or emotional conditions and does not include developmental and substance use disorders.)
There are other troubling statistics from the report:

31% of all cigarettes are smoked by adults with mental illness.
40% of men and 34% of women with mental illness smoke.
48% of people with mental illness who live below the poverty level smoke, compared with 33% of those with mental illness who live above the poverty level.

You can read more about smoking prevalence among people with mental illness in the Vital Signs Report.

What Contributes to Higher Smoking Prevalence in this Population?

While many mental health providers and facilities have made progress in reducing smoking in their facilities and among their patients, others are just now beginning to address tobacco use. Because they are more focused on treating the mental illness of their patients, some providers and facilities may not consider smoking to be a problem, or ignore it.
Smoking can cause unique issues for people with mental illness. Nicotine has mood-altering effects that put people with mental illness at higher risk for cigarette use and nicotine addiction.
However, recent research has shown that adult smokers with mental illness—like other smokers—want to quit, can quit, and benefit from proven stop-smoking treatments. These treatments need to be made available to people with mental illness and tailored as needed to address the unique issues this population faces.

What Can Be Done to Reduce Smoking Among People with Mental Illness?

Mental Health Professionals:

Find out if patients smoke. Sometimes patients aren’t asked whether they smoke when beginning mental health treatment.
If they do smoke, offer to help patients quit by providing proven quitting treatments, including referring them to the toll-free 1-800-QUIT-NOW quitline, the Web site www.smokefree.gov , or other resources.
Make quitting tobacco part of an approach to mental health treatment and overall wellness. Mental health professionals should be especially aware of the behavior changes that may occur when withdrawing from nicotine, and should make sure that their patients are aware of them. Medicines used to treat mental illness may need to be monitored and adjusted for people with mental illness who are trying to quit tobacco use.

Mental Health Facilities:

Include tobacco cessation treatments as part of an overall mental health treatment strategy.
Make mental health facilities and campuses completely tobacco-free (no use of any tobacco product by anyone anywhere inside or outside at any time).
Call attention to and stop practices that encourage tobacco use (e.g., providing cigarettes to patients, allowing smoking as a reward, selling tobacco products on site, and allowing staff to smoke with patients).

Success Stories: Rochester, New York and Austin, Texas

Daryl Sharp, Associate Dean for Faculty Development and Diversity in the School of Nursing at the University of Rochester, developed a nurse-managed program

in Rochester, New York, that provided intensive tobacco dependence interventions for clients through a university-based mental health outpatient facility. The program, which ran from 2006 to 2009, included a variety of interventions, and program nurses worked with the treatment staff to support the integration of tobacco dependence treatment into clients’ recovery plans.
The program doubled the proportion of people who were tobacco-free for at least 7 days, from 8.1% to 16.5% at 1 year, and reduced the average number of cigarettes smoked by participants from 21.6 to 13.5 per day. The program was even more successful among those who were moderately to highly nicotine dependent. Clients, clinic staff, and administrators all reported very positive impressions of the program, including an increased likelihood that when there was an intensive intervention readily available on site, that treatment staff would talk with their clients about stopping smoking.
The Smoking Cessation Leadership Center Web site

—associated with the University of California, San Francisco—has additional information, including resources focusing on tobacco dependence treatment for people with mental illnesses and substance use disorders.
In another success story, officials with the Austin-Travis County (TX) Integral Care (ATCIC) program sought to change the culture by implementing a Tobacco Cessation Initiative (TCI), making all of the agency’s mental health facilities tobacco-free. They also treated patients and staff who were addicted to nicotine, and implemented nicotine prevention measures. The Tobacco Free Workplace policy implemented in February 2011 prohibited consumption of all tobacco products on ATCIC property and resulted in a significant drop in smoking rates among staff and patients. According to Dale Mantey, Tobacco Cessation Coordinator for ATCIC, TCI's curriculum has been widely replicated statewide and has contributed significantly to Texas’s progress toward achieving its goal of making all state mental health facilities tobacco free.

Support to Quit

For free quit support, call 1-800-QUIT-NOW (1-800-784-8669). This number routes callers to their state quit lines, which provide free support and advice from experienced counselors, a personalized quit plan, self-help materials, the latest information about quitting medications, and more. Specific services vary from state to state. Quitting services and resources are also available online in English

, and in Spanish

. These Web sites provide free, evidence-based information and professional assistance to help support the immediate and long-term needs of people trying to quit tobacco use.

More Information

For more information on the health consequences of tobacco use and exposure to secondhand smoke, as well as resources on how to quit, consult the following: