Smoking and mental illness--breaking the link.

“M doctor told me I’m too stressed out to quit smoking,” remarked a woman hospitalized with severe depression. “Well, 43 years later, I’m still stressed and I’m still smoking.” This woman’s dilemma is all too familiar to health care providers and patients seeking the ideal time to treat tobacco dependence in the face of chronic mental illness. Since smoking and mental illness commonly occur together, many clinicians see them as inextricably linked and believe that smoking in the mentally ill is therefore particularly challenging to treat. Little examined are the systemic and treatment factors that have contributed to disparities in tobacco use and tobaccorelated morbidity and mortality among people with mental illness. Twenty years ago, the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO, now the Joint Commission) proposed a national ban on tobacco use in hospitals, noting the contradiction between hospitals’ health care mission and their exposing of patients, staff members, and visitors to the harms of secondhand smoke. Patient-advocacy groups for the mentally ill strongly opposed the ban, arguing that tobacco’s therapeutic, calming effect was valuable and warning that psychiatric patients who were denied their cigarettes would revolt. JCAHO conceded and exempted psychiatric and drugtreatment units from the smoking ban. Psychiatric hospitals that voluntarily adopted such bans, however, have documented both little-to-no disturbance in patients’ behavior and time savings for staff members. Yet even in smoke-free psychiatric settings, treatment of tobacco use remains relatively rare. In my group’s recent studies, among 337 smokers recruited from inpatient psychiatry units, 82% reported having attempted to quit, and 42% reported having done so within the previous year; only 4% reported receiving assistance with quitting smoking from a mental health care or general health care provider. Moreover, there are still outpatient mental health programs that provide cigarettes as an incentive for patients to comply with treatment. The devastating consequences of tobacco use among smokers with mental illness are evident. Smokers with serious mental illness are at increased risk for cancer, lung disease, and cardiovascular disease, and they die 25 years sooner, on average, than Americans overall. Tobacco use also complicates psychiatric treatment. Components in tobacco smoke accelerate the metabolism of some antidepressant and antipsychotic medications, resulting in lowered blood levels and probably reduced therapeutic benefit. Studies have revealed higher hospitalization rates, higher medication doses, and more severe psychiatric symptoms among patients with schizophrenia who smoke than among those who do not. Though the mechanism is unclear, tobacco use also is one of the strongest predictors of future suicidal behavior.1 Smoking results in substantial social and financial costs to patients, their families, and society. As greater restrictions on exposure to secondhand smoke are implemented in many public areas, tobacco use is further isolating an already-marginalized group. Five prevailing myths have contributed to continuing tobacco use among people with mental illness. The first is that tobacco is necessary self-medication for the mentally ill. The tobacco industry has fostered this belief by funding research and presentations on the self-medication hypothesis, supporting opposition to the JCAHO smoking ban, publishing articles in the lay press, and marketing cigarettes to people with mental illness.2 Nicotine is a powerful reinforcing drug that transiently enhances concentration and attention, regardless of the smoker’s mental health status. But it has proved ineffective as an adjunctive treatment for mental disorders (e.g., depression, schizophrenia, and attention-deficit disorder), possibly because of the rapid decrease in drug response with repeated exposure. The reality is that tobacco is another problem, not a solution. Myth number two is that people with mental illness are not interested in quitting smoking. Research argues otherwise: studies involving patients recruited from outpatient and inpatient psychiatric settings suggest that they are about as likely as the general population to want to quit smoking.1 In the United States, 20 to 25% of smokers report that they