Everyone knows that tobacco use is a major cause of illness and death—from heart disease, lung cancer, head and neck cancer, colorectal cancer, etcetera, etcetera. The good news is that, in the USA, the prevalence among adults of currently smoking cigarettes has come down in the last several decades to the current prevalence of about 14% (Cornelius et al., 2020; Creamer et al., 2019).
But, the bad news is that even today, about 1 in 5 adults in the United States still uses a tobacco or nicotine product (Cornelius et al., 2020). in case you are wondering, the breakup is as follows: cigarettes 14%, e-cigarettes 5%, cigars 4%, smokeless tobacco 2.5%, pipes 1% (Cornelius et al., 2020).
Persons with mental disorders are at MUCH higher risk
Mental health clinicians should be the ones who are most concerned about patients smoking cigarettes or using another tobacco or nicotine product.
Persons with mental disorders are MUCH more likely than others to be current smokers. Over one-third of persons with a mental disorder and over two-thirds of persons with a substance use disorder are current smokers (Kathuria et al., 2018). The rates are highest among those with schizophrenia. In one study, 62% of individuals with schizophrenia, 37% with bipolar disorder, and 17% of those without a mental disorder were current smokers (Dickerson et al., 2018).
And, when comparing those with mental disorders to others, the disparity has only been increasing over the years.
And, this is not a minor issue. Persons with mental disorders are more likely to die from smoking-related illnesses. It has been estimated that for persons with “serious psychological distress”, used in large national surveys to indicate mental illness (Tam et al., 2016):
– One-third of their deaths could be attributed to smoking
– They die earlier and two-thirds of the difference in life expectancy compared to those without serious psychological distress could be attributed to smoking.
Sadly, our patients are less likely to quit tobacco use (Zeng et al., 2020). But, what I think is unacceptable is that persons with mental disorders are much less likely to even be offered or given tobacco cessation treatment.
What can we do?
As part of the routine evaluation of patients, I think that ALL clinicians, including mental health clinicians, should ask ALL patients about whether they smoke cigarettes or use any other tobacco/ nicotine products.
And, if tobacco/ nicotine use is present, ask at least a few high yield questions to evaluate its seriousness, just like we do for alcohol or other substance use. For our tips on how to do this quickly, given the time crunch, please see the following article on this website:
By “flag it”, I mean that we should add the problem to the diagnoses for that patient, for example, “Tobacco Use Disorder (F17.2)“. In my opinion, explicitly noting the problem as a diagnosis can help to some extent to remind everyone that this is a problem that we are taking seriously and intend to treat, either now or in the near future.
Start the process of offering tobacco cessation treatment
We should not make the mistake of thinking that there is not much we can do if the person is not motivated to stop using tobacco. ALL persons with tobacco use disorder—regardless of their “readiness to quit”—should be offered treatment (Choi et al., 2021). For our tips on how to do this, please see the following article on this website:
Are varenicline (Chantix) and bupropion safe for smoking cessation in persons with mental disorders?
Choi HK, Ataucuri-Vargas J, Lin C, Singrey A. The current state of tobacco cessation treatment. Cleve Clin J Med. 2021 Jul 1;88(7):393-404. doi: 10.3949/ccjm.88a.20099. PMID: 34210714.
Cornelius ME, Wang TW, Jamal A, Loretan CG, Neff LJ. Tobacco Product Use Among Adults – United States, 2019. MMWR Morb Mortal Wkly Rep. 2020 Nov 20;69(46):1736-1742. doi: 10.15585/mmwr.mm6946a4. PMID: 33211681; PMCID: PMC7676638.
Creamer MR, Wang TW, Babb S, Cullen KA, Day H, Willis G, Jamal A, Neff L. Tobacco Product Use and Cessation Indicators Among Adults – United States, 2018. MMWR Morb Mortal Wkly Rep. 2019 Nov 15;68(45):1013-1019. doi: 10.15585/mmwr.mm6845a2. PMID: 31725711; PMCID: PMC6855510.
Dickerson F, Schroeder J, Katsafanas E, Khushalani S, Origoni AE, Savage C, Schweinfurth L, Stallings CR, Sweeney K, Yolken RH. Cigarette Smoking by Patients With Serious Mental Illness, 1999-2016: An Increasing Disparity. Psychiatr Serv. 2018 Feb 1;69(2):147-153. doi: 10.1176/appi.ps.201700118. Epub 2017 Sep 15. PMID: 28945183.
Kathuria H, Leone FT, Neptune ER. Treatment of tobacco dependence: current state of the art. Curr Opin Pulm Med. 2018 Jul;24(4):327-334. doi: 10.1097/MCP.0000000000000491. PMID: 29677028.
Tam J, Warner KE, Meza R. Smoking and the Reduced Life Expectancy of Individuals With Serious Mental Illness. Am J Prev Med. 2016 Dec;51(6):958-966. doi: 10.1016/j.amepre.2016.06.007. Epub 2016 Aug 10. PMID: 27522471.
Zeng LN, Zong QQ, Zhang L, Feng Y, Ng CH, Ungvari GS, Chen LG, Xiang YT. Worldwide prevalence of smoking cessation in schizophrenia patients: A meta-analysis of comparative and observational studies. Asian J Psychiatr. 2020 Dec;54:102190. doi: 10.1016/j.ajp.2020.102190. Epub 2020 Jun 6. PMID: 32622029.
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