Integrated Care: Tobacco Use and Mental Illness: A Wake-Up Call for Psychiatrists

Smoking often leads to early death and disability among people with mental illnesses and substance use disorders. A recent large epidemiological study found that smoking accounted for half the deaths among persons with schizophrenia, bipolar disorder, or depression (1). Fortunately, quitting tobacco use improves life expectancy; quitting has a greater impact on cardiovascular risk than do changes in blood pressure, weight, physical activity, or lipids (4). Despite the powerful benefits of quitting, integrated efforts to address cardiovascular risk factors among people with serious mental illnesses have only cursorily included tobacco cessation efforts.

As smoking becomes less common in the community, smokers experience greater barriers to community integration and will increasingly struggle to secure jobs and housing. Employers prefer to hire nonsmokers because of higher productivity and lower insurance costs. Landlords also prefer nonsmokers. A national movement is promoting smoke-free public housing that prohibits smoking even in one’s own apartment because of the toxic effects of secondhand smoke (5). Individuals with behavioral health conditions, like others with low incomes, suffer a high economic burden from tobacco use, spending about a third of their monthly disability income to purchase tobacco products (6).

Nicotine dependence (now tobacco use disorder) has been included in the DSM since 1980, yet it may be the only substance use disorder that is not routinely diagnosed and treated in mental health settings. Similar to other drugs of abuse, nicotine activates the brain reward pathways, causes release of dopamine in the nucleus accumbens, and fulfills criteria as a behavioral syndrome associated with distress or disability. Tobacco use disorder thus warrants formal diagnosis and treatment.

The once popular notion that smoking stabilizes psychiatric illness is not supported by evidence. Rather, smokers go through cycles of uncomfortable withdrawal that are relieved by smoking, which may be misinterpreted as reduction of symptoms of mental illness. Nicotine withdrawal results in agitation, anxiety, restlessness, and impaired concentration that emerge hours after last tobacco use and are temporarily improved by smoking, giving the tobacco user with mental illness the false sense that smoking is calming and improves concentration. A study of smokers with schizophrenia in a psychiatric emergency department showed a significant reduction in agitation from the use of a nicotine patch (7). The reduction in agitation with nicotine replacement was similar to that seen with an antipsychotic medication. There is evidence that patients with mental illness experience more nicotine withdrawal symptoms than other smokers (8), underscoring the strong need for medication treatment both for cessation attempts and for periods of temporary abstinence.

Multiple studies show that smokers with mental illness who receive treatment for quitting remain psychiatrically stable. A recent meta-analysis showed that for smokers with and without psychiatric disorders, smoking cessation was associated with reduced depression, anxiety, and stress and improved mood and quality of life. The effect sizes of symptom improvement associated with quitting smoking were equal to or larger than those seen with antidepressant treatment for mood and anxiety disorders (9). Stopping smoking also does not have a negative impact on treatment for other addictions and may increase long-term abstinence (10). Studies have also found that smoking is an independent risk factor for suicidal thoughts, attempts, and completions (11).

Cigarette smoking is a potent P450 CYP1A2 enzyme inducer and reduces drug levels of many antipsychotics and antidepressants, including clozapine, olanzapine, and fluvoxamine. Smoking results in the need for higher medication doses, which may pose a risk of medication toxicity during a quit attempt.

Clinical practice guidelines recommend interventions for all tobacco users, not just those expressing a desire to quit. For tobacco users not motivated to quit, motivational interventions should be provided. It is now time for full implementation of long-existing American Psychiatric Association guidelines recommending that psychiatrists treat tobacco use disorder among all their patients. Referrals to telephone quitline services may be appropriate for some.

All smokers should routinely have access to nicotine replacement therapy in treatment settings where acute abstinence occurs (such as emergency departments). These settings provide an opportunity to teach tobacco users about nicotine withdrawal and to motivate them to try or continue cessation treatments.

Tobacco training programs that are tailored to behavioral health settings are still rare. Extensive research in the past decade has led to advances in evidence-based practices for treating tobacco use. Psychiatry residency leaders can create standards for training to ensure that future generations continue this essential work.

Now is the time to incorporate tobacco use treatment into behavioral health systems, as leaders and policy makers become more concerned about health disparities among people with mental illnesses. Policies should address both restricting tobacco in the environment and promoting assessment and treatment at all levels of care. Tobacco use treatment should be incorporated into substance use disorder policies.

Smokers with mental illnesses or substance use disorders deserve to be listed as a disparity group or priority population by national public health or tobacco control groups. Designation as a disparity group is needed to enhance funding and resources for tobacco use treatment. Because population approaches for reducing tobacco use may be less effective for these groups, a tailored, disparity-driven approach may be warranted. Psychiatrists must speak up within advocacy and professional organizations to focus on the need for tobacco control resources for this population.