InForum: Mentally ill more likely to smoke, die from tobacco-related illness

The mentally ill and those battling substance abuse are much more likely than others to smoke, and suffer higher illness and death rates as a result.
The American Lung Association in North Dakota is launching an effort to target smoking cessation programs at those who are mentally ill or dealing with addictions.
Tobacco control advocates also are working with mental health professionals to take a more aggressive approach to help those with behavioral health problems quit smoking.
“We have seen a decline in all populations except those with mental illness or substance abuse,” said Reba Mathern-Jacobson, director of tobacco control for the American Lung Association in North Dakota, referring to the drop in smoking among most groups.
As a result, those with mental illnesses and addictions can die decades earlier than the general population, and smoking is a major contributor to sickness and early death, according to statistics cited by the federal Substance Abuse and Mental Health Services Administration:
• About half of people with behavioral health disorders smoke, compared to 23 percent of the general population.
• People with mental illnesses and addictions smoke half of all cigarettes made, and are only half as likely as other smokers to quit.
• Smoking-related illnesses cause half of all deaths among people with behavioral health disorders.
“Folks are dying a lot sooner than they need to,” said Carlotta McCleary, executive director of Mental Health America in North Dakota, an advocacy group. The issue is starting to draw more attention, she said, and collaborations are forming to address the problem.
“People who are alcoholic die from tobacco-related diseases more than they do from alcohol-related diseases,” Mathern-Jacobson said.
Those with mental illness or substance abuse problems find it more difficult to quit smoking for a variety of reasons.
Nicotine’s mood-altering effects put people with mental illness at greater risk for cigarette use and nicotine addiction. Also, people with mental illness are more likely to face stressful lives, have lower incomes and lack access to health care, making quitting more difficult.
“People might be self-medicating, that kind of thing,” by using nicotine, McCleary said.
Another problem is what tobacco control advocates view as a lackadaisical attitude among some mental health professionals.
“It’s been seen as a lesser of evils,” Mathern-Jacobson said. “Now that population is bearing the brunt of it.”
Mental health professionals are significantly more likely to smoke than other health professionals, surveys show, which might suggest a culture that is more tolerant of tobacco, she said.
It’s worth noting that nicotine dependence is listed as a behavioral disorder in the diagnostic manual used by mental health clinicians, Mathern-Jacobson said. “Nicotine is a drug, let’s treat it like one.”
Melissa Markegard, a tobacco control coordinator with Fargo Cass Public Health, said she believes mental health clinicians are increasingly more likely to take nicotine addiction seriously.
“A lot of times, smoking is a trigger for other substances, especially alcohol,” she said. “It’s kind of like you can’t do one without the other.”
More integration of behavioral health and general health care would help to combat smoking among the mentally ill and those battling addictions, McCleary said.
“It’s not just OK to focus on behavioral health alone,” or on physical health in isolation, she said. There is a growing movement in health care to do more to combine the two, McCleary added, but said much more integration is needed.
The American Lung Association in North Dakota is bringing in an expert to help train behavioral health professionals including psychiatrists, counselors, nurses, social workers and other treatment providers who serve people with mental illness or substance abuse disorders.
The training sessions will be June 21-22 in Fargo and will feature Dr. Jill Williams, an addiction psychiatrist from Rutgers Robert Wood Johnson Medical School. Details still are pending. Anyone interested can contact Mathern-Jacobson or by calling 701-354-9719.

Duluth News Tribune: Training targets high tobacco use among addicts, mentally ill

By John Lundy

If someone is dealing with other addictions or mental health issues, it’s not the time to ask them to stop smoking.


Wrong, says an addictions psychiatrist from New Jersey who’s in Duluth to help lead a two-day training seminar on helping individuals with special challenges overcome tobacco use.

“The newer research suggests that when people address their smoking they actually have better long-term outcomes,” said Jill Williams, who specializes at Rutgers University’s Robert Wood Johnson Medical School in treatment of tobacco and other addictions in mentally ill populations. “When you cue the brain with nicotine, it’s really not different than other drugs.”

Williams is making her third visit to Duluth at the behest of the American Lung Association in Minnesota. After conducting a one-day session in the Twin Cities, she came to the Public Safety Building in Duluth on Thursday to work with about 60 behavioral health professionals from throughout Northeastern Minnesota; the training continues today.

The target is a topic that has “been shuffled to the side,” in the words of Pat McKone, regional senior director for the American Lung Association.

Even as tobacco use overall in the United States continues to decline to unprecedented lows, use by vulnerable groups such as addicts and the mentally ill remains stubbornly high, McKone and Williams said.

For instance, according to Williams:

  • Although the rate of smoking in Minnesota is down to 14 percent, the rate for Minnesotans with addictions or mental illness is between 40 and 60 percent.
  • The No. 1 cause of death in alcoholics is health problems related to tobacco use.
  • Fifty percent of people with mental illness die of tobacco-related causes.

“We always remark to the audience: Imagine if 50 percent of our patients died of suicide, how that would be front page news,” Williams said. “Fifty percent die from tobacco and we don’t do anything about it.”

People with serious mental illnesses die, on average, 25 years earlier than the rest of the population, McKone said. “And it’s not from suicide; it’s not from drug overdose. It’s from heart disease, COPD and cancer.”

Over a couple of years, Williams has offered the training to about a thousand specialists in Minnesota, she said. But they still represent a minority.

“What we hear them say … is that they’re the lone voice at their agency and everyone else is sort of opposed or still believes the myths or the idea that we should let people smoke and not pay attention to it,” Williams said. “So we still have a lot more people to get to.”

One sign of that is that only one in four mental health treatment centers has a smoking-cessation program, she said.

Families of individuals being treated for addiction or mental illness should advocate for treating their loved one’s tobacco addiction along with the other problems, McKone said. She called the reduced life expectancy for people with addictions and mental illness a social injustice.

Williams added: “Everyone has someone in their family with mental illness or addiction, and we can’t just look the other way.”

Patient-centered care helps patients overcome mental illness and tobacco use

People diagnosed with chronic mental illness will die an average of 10 years earlier than those without mental illness.
A number of social and biological factors contribute to early mortality, but 40 percent of people with a mental health condition also practice one of the most preventable health risk behaviors — smoking.
A study from the National Institutes of Mental Health found that people with a mental illness smoke nearly half of all cigarettes in America. The Journal of the American Medical Association provided evidence that people with severe mental illness are at a higher risk of cardiovascular death. Depression is three times higher in smokers than in non-smokers, and an estimated 70 to 85 percent of people with schizophrenia are tobacco users.
Evidence supports a bi-directional relationship between tobacco use and depression. For some patients, smoking can alleviate pre-existing symptoms of depression and anxiety by releasing dopamine, a source of pleasure, in the brain. But evidence also suggests that smoking causes depression and other forms of psychosis, and some people with decreased dopamine levels are genetically predisposed to tobacco use and dependence.
Health care providers must address the patient’s tobacco use, a chronic addictive condition, in conjunction with the mental illness to preserve health. To accomplish this, we must:
Treat both conditions at once
Some evidence-based pharmacological methods are dually effective in treating tobacco use and mental illness. For one, bupropion hydrochloride has proven successful in reducing depression and serving as a smoking cessation aid.
Acknowledge the mental health effects of quitting
The decision to quit smoking benefits the patient in the long term, but nicotine withdrawal might exacerbate or lead to depressive symptoms. Patients must communicate with a health care provider about any side effects associated with quitting, such as depression. Patients can also participate in group therapies or meet with a counselor to mitigate the negative effects of quitting smoking.
Ensure that intervention is patient-centered
When patients give up smoking, they’re letting go of a coping mechanism or a companion. The patient should remain the central focus in any intervention, and providers should act with empathy and understanding, because quitting is a process requiring perseverance. A patient-centered plan should incorporate aids to quit smoking as well as mental health support and accessible resources.

Dr. Chizimuzo Okoli is an assistant professor in the UK College of Nursing.

Smoking not 'lesser evil' in mental health treatment settings

By: Maiken Scott, Newsworks
Picture an AA meeting, and a gigantic coffee urn and a cloud of smoke come to mind.
In fact, the two men who started AA, Dr. Bob and Bill W. both died from tobacco-related illnesses.
Public health experts say smoking is still pervasive among people living with addiction and mental illness, and it’s often not seen as a priority in treatment settings.
For example, smoking rates in Philadelphia have dropped significantly over 10 years, but haven’t budged among people with mental illnesses and substance-abuse issues.
Smoking is often seen as a “lesser evil” in mental health and addiction treatment settings, explained Ryan Coffman, tobacco policy manager for Philadelphia’s Department of Public Health. It’s not a priority, and some providers assume it helps their clients cope.
Research shows the opposite to be true, says Coffman. “Individuals living with mental illness and substance-abuse disorders who smoke have more severe symptoms, poorer well-being and functioning, they have more hospitalizations, and are at a greater risk for suicide,” he said.
Research also shows that people who quit smoking along with quitting other drugs have better recovery outcomes.
Philadelphia is increasing efforts to train mental health providers on tobacco-cessation programs, and to provide them with the most up-to-date resources available to their clients, Coffman said.
But for these efforts to really take root, a major cultural shift will have to occur, said University of Pennsylvania psychiatrist Robert Schnoll, who studies tobacco cessation.
“Research indicates that upwards of 25 percent of mental health care facilities still permit smoking on the grounds and on the premises,” he explained. “There’s pervasive use of cigarettes, or cigarette breaks, as a reward for pro-social behavior, so that’s certainly one of the issues we need to address going forward.”
Some providers think their clients don’t care about tobacco cessation, he said, or don’t understand the benefits. Some also simply don’t see it as their responsibility.
Research also indicates that smoking rates are high among people who work in mental health treatment settings, Schnoll said.

Report: Smoking bans, cigarette taxes linked to lower suicide rates

SALT LAKE CITY — Utah mental health and public health officials say a new report that links stronger anti-smoking initiatives to lower suicide rates suggests an added benefit of states’ prevention and cessation efforts.

The report, published in the journal Nicotine & Tobacco Research, found that public health interventions, such as raising cigarette taxes and imposing indoor smoking bans, could reduce risk of suicide by as much as 15 percent.

Janae Duncan, coordinator of the Utah Health Department’s Tobacco Prevention and Control Program, said Utah’s Indoor Clean Air Act “is really strong.”

While the state’s rate of adult smoking of 10.6 percent is the lowest in the nation, Utah’s tobacco taxes are relatively low at $1.70 per pack of cigarettes, Duncan said. Utah’s rate is higher than the national average but well below the rates of some East Coast states such as New York, which imposes a tax of $4.35 per pack.

“The study said each dollar increase in cigarette taxes was associated with a 10 percent decrease in (the relative risk of) suicide,” she said. “Even though we have a low tobacco use rate, it may be a good reason to look at raising our excise tax for tobacco.”

Other Utah officials say the report lends credence to mental health and substance abuse treatment practices that encourage wellness across the spectrum.

The state’s 2013 Recovery Plus initiative, for instance, required all publicly funded substance abuse and mental health treatment facilities to be tobacco free by March 2013.

“When we first started talking about doing this, there was a lot of talk such as, ‘You can’t expect someone with substance abuse or mental illness to also give that up. It’s too much on a person.’ They found that’s not the case. It actually helps with their recovery,” said Teresa Brechlin, coordinator in the Utah Department of Health’sViolence and Injury Prevention Program.

Kim Myers, suicide prevention coordinator with the Utah Division of Substance Abuse and Mental Health, said Utah officials have long observed that clients in publicly funded substance abuse and mental health facilities smoke at substantially higher rates than the general population.

The authors of the report noted that clinical and general studies have likewise documented elevated rates of smoking among people with anxiety disorders, alcohol and drug dependence, and schizophrenia, among other diagnoses.

“However, it is also possible that smoking is not merely a marker for psychiatric disorders, but rather directly increases the risk for such disorders, which in turn increases the risk for suicide,” the study’s authors wrote.

Myers said the study raises the question whether nicotine itself raises suicide risk.

“How do we use that information on a population level, but also on an individual level, to reduce someone’s risk, especially when it comes to people who have some of those other risks such as serious mental illness or substance use disorders?” she asked.

The study also determined that smokers’ risk for suicide is two to four times greater than nonsmokers.

Duncan said more research is needed to understand how the link applies to Utah. Utah’s suicide rate has been consistently higher than the national rate for the past decade, according to state health department statistics, while smoking rates are very low.

“The study doesn’t give those clear answers. I think what it does do, it helps us see we should be looking at whole health, and it’s important to look at it across the board, not just issue by issue, but how all these things are tying together,” Duncan said.

Smoking may increase suicide risk, study says

MONTE MORIN, Los Angeles Times

It’s well known that cigarettes are bad for your health, but does smoking make you more likely to kill yourself too?

In a paper published Wednesday in the journal Nicotine & Tobacco Research, authors argued that smoking and suicide may be more closely related than previously thought.

The researchers analyzed suicide rates in states that aggressively implemented anti-smoking policies from 1990 to 2004 and compared them to suicide rates in states that had more relaxed policies.

Those states that imposed cigarette excise taxes and smoke-free air regulations had lower adjusted suicide rates than did states with fewer anti-smoking initiatives, authors wrote.
“There does seem to be a substantial reduction in the risk for suicide after these policies are implemented,” said lead study author Richard Grucza, a psychiatric epidemiologist at Washington University School of Medicine in St. Louis.

“For every dollar in excise taxes there was actually a 10% decrease in the relative risk for suicide,” Grucza told Washington University BioMed Radio. “The smoke-free air policies were also very strongly associated with reduced suicide risk.”

Study authors said that states with lower taxes on cigarettes and more lax policies on public smoking had suicide rates that were up to 6% greater than the national average.

This is not the first study to document a correlation between cigarette smoking and suicide, but it is among the first to suggest smoking and nicotine may be specific factors.

Up until now, researchers believed smoking coincided with suicide because people with psychiatric problems or substance abuse problems were more likely to smoke as well as to commit suicide.
“Markedly elevated rates of smoking are found among people with anxiety disorders, alcohol and drug dependence, schizophrenia and other diagnoses, in both clinical and general studies,” authors wrote. “However, it is also possible that smoking is not merely a marker for psychiatric disorders, but rather directly increases the risk for such disorders, which in turn increases the risk for suicide.”

Grucza said that the imposition of anti-smoking rules presented the researchers with a naturally occurring experiment. However, the authors did note that there were limitations on their research.

In particular, they said that since they considered state-imposed anti-smoking efforts only, their research would not account for local-level policies aimed at smoking behavior.

“While further studies may be required to establish a compelling weight of evidence, this study provides strong epidemiological support in its favor of the proposition that smoking is a casual risk factor for suicide,” authors wrote.