Doug Tipperman, Tobacco Policy Liaison, Office of Policy, Planning, and Innovation, Substance Abuse and Mental Health Services Administration (SAMHSA)
Cigarette smoking remains the single largest preventable cause of death and disease in the United States, responsible for over 480,000 deaths a year. Even though smoking has been decreasing overall, the smoking rate for persons with behavioral health conditions (mental and/or substance use disorders) is about twice that of the rest of the population. The rate is even higher for persons with serious mental illness or who have been in substance use disorder treatment in the past year.
Persons with behavioral health conditions make up about 25 percent of the U.S. population; however, they account for 40 percent of all cigarettes smoked in the U.S. This disproportionate use results in devastating health consequences. But despite the heavy disease and mortality burden, smoking cessation interventions are not routinely offered within behavioral healthcare settings. In these settings, it has often been believed that quitting smoking could jeopardize treatment efforts. To the contrary, research is showing that quitting smoking may improve mental health and addiction recovery outcomes; and continued smoking is associated with poor outcomes.
Research showing these poor outcomes has found that cigarette smoking is associated with increased risk for major depression and higher risk of suicidality. In addition, smoking can complicate mental health treatment by accelerating the metabolism of certain psychiatric medications, resulting in the need for higher doses to achieve a therapeutic benefit. In regard to addictions, a seminal study conducted in 1996 found that smoking tobacco causes more deaths among people who had been in alcohol and other drug abuse treatment than alcohol-related causes.
Quitting smoking, on the other hand, has many physical and behavioral health benefits. A meta-analysis published in 2004 found that smoking cessation interventions provided during addiction treatment have been associated with a 25 percent increased likelihood of long-term abstinence from alcohol and illicit drugs. Research continues to support this finding including a recent nationally representative, prospective longitudinal study, which found that smoking was associated with greater odds of substance use disorder relapse. Concerning mental health, a 2014 review and meta-analysis found that “smoking cessation is associated with reduced depression, anxiety, and stress and improved positive mood and quality of life compared with continuing to smoke. The effect size seems as large for those with psychiatric disorders as those without. The effect sizes are equal to or larger than those of antidepressant treatment for mood and anxiety disorders” (see video interview with the researchers).
Research has consistently found that smokers with behavioral health conditions—like other smokers—want to quit, can quit, and benefit from evidence-based smoking cessation treatments. They may face unique challenges in quitting and benefit from tailored and more intensive counseling and/or longer use or a combination of cessation medications.
To reduce the disparate use of tobacco by people with behavioral health conditions and reap the benefits of quitting, the Substance Abuse and Mental Health Services Administration as well as other national behavioral health organizations recommend the adoption of tobacco-free facility/grounds policies and the integration of tobacco treatment into behavioral healthcare.