Smoking Rates Still High Among the Mentally Ill

By John Gever, Deputy Managing Editor, MedPage Today
Reviewed by Zalman S. Agus, MD; Emeritus Professor, Perelman School of Medicine at the University of Pennsylvania and Dorothy Caputo, MA, BSN, RN, Nurse Planner
Smoking rates among Americans with mental illnesses didn’t budge from 2004 to 2011, a period during which rates in the rest of the population fell 14%, researchers said.
Data from the federal Medical Expenditure Panel Survey (MEPS) found that, among respondents with mental illnesses, 25.3% reported current smoking in 2004-2005 (95% CI 24.2%-26.3%), versus 24.9% in 2010-2011 (95% CI 23.8%-26.0%, P=0.50) after adjustments for other predictors of smoking such as income and education, according to Benjamin Le Cook, PhD, MPH, of Harvard Medical School in Cambridge, Mass., and colleagues.
Over the same interval, adjusted smoking rates in other MEPS respondents declined from 19.2% (95% CI 18.7%-19.7%) to 16.5% (95% CI 16.0%-17.0%, P<0.001), the researchers reported in the Jan. 8 issue of the Journal of the American Medical Association.
On the other hand, individuals with mental illnesses who were undergoing treatment showed somewhat greater quit rates than those who were untreated (37.2% versus 33.1%, P=0.005), Cook and colleagues found from a different data set, the 2009-2011 National Survey of Drug Use and Health (NSDUH).
“The mechanisms that support persistently higher rates of smoking among individuals with mental illness are complex and remain understudied,” they wrote. “Patients with mental illness may attribute greater benefits and reward value to smoking compared with patients without psychiatric disorders or may experience more difficult life circumstances, higher negative affect, or a relative lack of alternative rewards.”
Other experts contacted by MedPage Today offered differing views on the high smoking rates among the mentally ill.
John Spangler, MD, MPH, of Wake Forest Baptist Medical Center in Winston-Salem, N.C., said in an email that the nicotine in cigarettes “is very effective at relieving stress and improving mood. You can ask any smoker about that. It also can increase concentration in those with ADHD, and it improves memory as well.”
But Joseph McClernon, PhD, of Duke University, told MedPage Today that smoking as self-medication is not very effective. “Among dependent smokers, much of the relief or improvement in cognitive performance they experience from smoking likely has as much to do with reversing the effects of withdrawal,” he said in an email, which appears to be more severe in patients with some mental illnesses.
A similar viewpoint was expressed by Glen Getz, PhD, of Allegheny Health Network in Pittsburgh. The positive subjective effect of smoking “is only briefly effective and ultimately has counterproductive effects on mood, anxiety, and other emotional problems,” he said.
There was general agreement, however, that it may be more difficult for the mentally ill to quit smoking.
Among the factors cited by Cook and colleagues is a “smoking culture” that has long pervaded the mental health community, including clinicians as well as patients.
They noted that psychiatric inpatients historically were allowed and even encouraged to smoke “to decrease agitation and encourage patient adherence.” Even today, they suggested, many mental health professionals shy away from encouraging their patients to quit smoking for a variety of reasons, ranging from concern that it may distract from other therapeutic efforts to “lack of confidence” that patients can succeed in quitting.
But although such a culture did exist in the past, that’s changing, Douglas Ziedonis, MD, MPH, of the University of Massachusetts Medical School in Worcester, told MedPage Today.
“Nowadays we’re much more focused on wellness in recovery and also looking at the physical health of individuals who have mental illnesses,” he said in an email. “Mental health treatment providers are now realizing that they need to better address tobacco and wellness issues in mental health treatment.”
Said Martin Mahoney, MD, of Roswell Park Cancer Institute in Buffalo, N.Y., and director of New York state’s smoking quitline, “I don’t think there’s anything more important than helping a patients who is addicted to nicotine to get off of that addiction.”
For the current study, Cook and colleagues analyzed data on more than 32,000 MEPS respondents with mental illnesses and some 133,000 without. Participants were considered to have mental illness if they met any of several criteria: having a healthcare visit linked to a psychiatric ICD-9 code, receiving psychotherapy or mental health counseling, filling a prescription for a behavioral health disorder, or having scores on neuropsychiatric tests indicating severe psychological distress or at least moderate depression.
The data on quit rates associated with mental health treatments covered some 14,000 participants in the NSDUH from 2009 to 2011 whose responses indicated at least mild mental illness according to criteria established by the Substance Use and Mental Health Administration.
Differences in smoking prevalence in the MEPS data between those with and without mental illnesses were most pronounced among respondents with apparent depression or distress, for whom the gap was consistently around 15 percentage points through the 8-year study period.
Cook and colleagues acknowledged that the ascertainment of mental illness in both surveys could be faulty because they didn’t use structured diagnostic interviews. Also, as in most federal surveys, persons in institutional settings (including psychiatric inpatients) were excluded.
Another limitation was that the NSDUH did not include data on the timing of smoking cessation versus provision of mental health treatment, leaving open the possibility that some respondents may have quit smoking before receiving treatment. The researchers cautioned that “reverse causality” could therefore have occurred: patients may be more likely to seek mental health treatment after they quit smoking.
Primary source: Journal of the American Medical Association
Source reference: Cook B, et al “Trends in smoking among adults with mental illness and association between mental health treatment and smoking cessation” JAMA 2014; 311: 172-182.
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