The Weird Link Between E-Cigarettes and Mental Health Disorders

Dan Kedmey, TIME

A new study finds elevated rates of depression, anxiety and other mental disorders among users of e-cigarettes

A new study has found that people suffering from depression, anxiety and other mental disorders are more than twice as likely to spark up an e-cigarette and three times as likely to “vape” regularly than those without a history of mental issues.

Researchers at the University of California, San Diego drew their findings from an extensive survey of American smoking habits. Among 10,041 respondents, 14.8% of individuals suffering from mental health disorders said they had tried an e-cigarette, compared with 6.6% of individuals who had no self-reported history of mental disorders.

The e-smokers’ elevated rates of mental disorders reflected the elevated rates of mental illness among smokers in general. The authors note that by some estimates, people suffering from mental disorders buy upwards of 50 percent of cigarettes sold in the U.S. annually.

Many respondents said they switched to e-cigarettes as a gateway to quitting. The FDA has not yet approved e-cigarettes as a quitting aide.

“People with mental health conditions have largely been forgotten in the war on smoking,” study author Sharon Cummins said in a university press release. “But because they are high consumers of cigarettes, they have the most to gain or lose from the e-cigarette phenomenon.”

The study will run in the May 13 issue of Tobacco Control.

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.

Letter: NDQuits wins a commendation

By: Jessie Azure, West Fargo, INFORUM
I would like to commend those with NDQuits on finding a creative way to reach a “tobacco at risk community!”
Clearly, representatives from the North Dakota Policy Council need to sit down and read the 2007 Best Practices manual issued by the CDC on Tobacco Prevention and Control Policy before commenting. Maybe then they’d understand the importance of reaching target populations with education and support.
Their comments make me ask a far more important question: What if the parade had been for an organization raising awareness for mental health (as this is another community with a high rate of tobacco use)? Would Zach Tiggelaar still be compelled to question such actions? I bet he’d agree that we shouldn’t dismiss one community over another; rather, look to find ways to reach all of our citizens, just as the folks at NDQuits did. After all, as Rep. Josh Boschee, D-Fargo, reminds us, the cost of tobacco is far more staggering to treat than prevent.

Mental illness, tobacco turn out to be deadly combo

By: John Lundy, Duluth News Tribune
It’s hard to quit smoking.
For individuals struggling with a mental illness, it’s even harder.
“They have higher levels of biological or physical addiction to nicotine, in many cases,” said Dr. Jill Williams, an addiction psychiatrist. “In illnesses like depression, studies show that they’re more addicted than other smokers.”
Yet mental health treatment is lagging when it comes to tobacco addiction, said Williams, who specializes in mental health and tobacco at the Robert Wood Johnson Medical School in New Jersey.
Her effort to correct brings Williams to Duluth today. At the behest of the American Lung Association in Minnesota, Williams is conducting a daylong conference for mental health professionals at the University of Minnesota Duluth.
About 75 people were signed up for the event, said Pat McKone of the lung association. Earlier this week, Williams led a similar conference in Moorhead, Minn., with 100 in attendance.
The Minnesota group brought Williams to the state because of the toll smoking takes on people with mental illness, an American Lung Association news release said. It cites studies from several states showing that people with severe mental illness die, on average, 25 years earlier than the general public. Their No. 1 cause of death? Heart disease related to tobacco use, the studies show.
Moreover, the percentage of people with mental illness who smoke is much higher than that of the general population, the Centers for Disease Control and Prevention reported earlier this year. From 2009-11, 36 percent of adults with mental illness smoked, compared with 21 percent of the rest of the population, the CDC said.
The numbers in Wisconsin are similar, but the discrepancy in Minnesota is even greater: Just over 40 percent of Minnesota adults with mental illnesses smoke, compared to just under 20 percent of the rest of the population.
Part of the problem, Williams said in a telephone interview, is the lack of treatment.
“If you get your care from the behavioral health system, it’s just unlikely that you’ll be able to get treatment for your tobacco addiction in those settings,” she said. “Traditionally, that’s not been offered there.”
People with mental illness respond to medication and counseling to treat tobacco addiction, Williams said, although it may need to be more intense. And the mental health treatment centers and residences already have the counselors trained in addiction treatment, she said. They just need the specific training for tobacco.
“That’s why these trainings are so important,” Williams said. “When we do the training, it’s not unusual that people say this is the first time they ever had training on tobacco addiction in their professional career.”
Another issue, Williams said, is addressing public policy so that people who provide tobacco treatment are reimbursed as well as people who treat other forms of addiction.
“If we paid people better to do tobacco treatment, I think a lot more of it would be available,” she said.