Tobacco Cessation For People With Mental Health Problems

Tobacco smoking is the leading cause of preventable death in the United States. But the fact is that people with mental health problems are among those with the highest smoking prevalence. According to the most recent estimates, 75 percent of people with mental health problems or addictions smoke cigarettes, compared to 23 percent of the general population.

Americans with mental health problems represent an estimated 44.3 percent of the U.S. tobacco market. And half of all deaths from smoking occur among patients with mental illnesses or substance use disorders.

Clearly, smoking cessation programs could benefit people with mental health problems. In fact, these individuals express a desire to quit smoking just as much as smokers in the general population. Let’s look a bit closer into this area.

Alarming Statistics

Consider the following statistics, which should be alarming to anyone:

• At least 1 in 5 people has a diagnosable behavioral health disorder during the course of any given year
• Individuals with behavioral health disorders die up to 25 years earlier than those in the general population
• People with mental health problems and addictions are nicotine-dependent at a rate 2 to 3 times higher than the general population, represent over 44 percent of the U.S. tobacco market, and consume over 34 percent of all cigarettes smoked in the U. S.

Tobacco Use by Diagnosis

Researchers have determined the following tobacco use by diagnosis:

• Schizophrenia – 62 to 90 percent
• Bipolar Disorder – 51 to 70 percent
• Major Depression – 36 to 80 percent
• Anxiety Disorders – 32 to 60 percent
• Post-Traumatic Stress Disorder (PTSD) – 45 to 60 percent
• Attention Deficit Hyperactivity Disorder (ADHD) – 38 to 42 percent
• Alcohol Abuse – 34 to 80 percent
• Other Addictions – 49 to 98 percent

Barriers to Smoking Cessation

Significant barriers to smoking cessation exist among people with mental health problems, just as they exist for smokers in the general population. While the barriers may be the same, for persons with mental health problems, some of these barriers are particularly vexing. Included are:

• Nicotine addiction
• Socially-reinforced habits
• Expectation of failure
• Lack of motivation
• Lack of adequate support to quit
• Lack of hope that quitting will be successful
• Fear of gaining weight
• Fear of the side effects of withdrawal
• Difficulty in coping with anticipated increase in anxiety and tension
• Loss of pleasure
• Loss of the social reinforcements for smoking

Suspected Targeting by Tobacco Industry Revealed

A 2007 study by Prochaska, Hall, and Bero analyzed previously secret documents from the tobacco industry. They found that the tobacco industry monitored or directly funded research supporting the idea that people with schizophrenia were less susceptible to the harmful effects of tobacco or needed tobacco as a means of self-medication.

The study further found that the tobacco industry promoted smoking in psychiatric settings by providing cigarettes to patients and by supporting efforts to block hospital smoking bans.

Smoking Cessation Concurrent with Mental Health or Addiction Treatment

Results of several studies from 2005 to 2008 show that smoking cessation has no negative impact on psychiatric symptoms. Rather, quitting smoking may lead to better mental health and overall functioning.

Numerous studies (from 1993 through 2004) show that participation in smoking cessation efforts while engaged in other substance abuse treatment has been associated with a 25 percent greater likelihood of long-term abstinence from alcohol and other drugs. In other words, treating the primary addiction concurrent with tobacco addiction, patients actually may do better.
Responding to the clinical needs of patients requires programs that hit both the physical and the behavioral side of interventions. On the physical side, addictions and biology mean treatment that involves medications and medical procedures, monitoring, follow-up. The behavioral side involves a person’s habits and environment and treatment that include a program to change behavior.

Smoking Cessation Programs Work

The facts are indisputable. Some 70 percent of smokers say that they want to quit, while about 40 percent attempt to quit. But it’s not a simple matter to just say you want to quit or attempt to quit. Quitting smoking is a difficult process, but it is feasible – if the individual has help to quit.

Consider these statistics:

• Willpower alone accounts for quit rates of about 4 percent
• Nicotine replacement therapy (NRT) alone accounts for quit rates of 22 percent
• Quit line counseling in conjunction with NRT accounts for quit rates of 36 percent
• Medication (Varenicline) accounts for quit rates of 44 percent

Interestingly, smokers who have insurance coverage are more than twice as likely to quit.

Results of smoking cessation programs among people with mental health problems show that most combine medications and psychoeducation and/or cognitive behavioral therapy (CBT). Eight studies of patients with schizophrenia who were smokers attempting to quit showed quit rates of 35 to 56 percent post-treatment, and 12 percent at 6 months. Another eight studies of patients with depression who smoked and tried to quit showed quit rates of 31 to 72 percent post-treatment, and 12 to 46 percent at 12 months.

Advice Helps Reinforce Quitting

People with mental health problems who want to quit smoking have a better chance of successfully doing so if they receive advice as part of their smoking cessation program. Compared to people who smoke who do not get help from a clinician, those who do receive help are 1.7 to 2.2 times as likely to successfully quit smoking for 5 months or more.

Wellness Resources and Tools

There are a number of wellness resources and tools available to help people with mental health problems in their quest to quit smoking. These include:

• Medications and medical interventions
• Cognitive behavioral therapy (CBT)
• Motivational enhancement therapy (MET)
• Individual counseling
• Group meetings
• Individualized treatments based on diagnoses
• Family-based strategies
• Peer-to-peer support
• Referrals – such as a quitline

FDA-Approved Smoking Cessation Products

With smoking so prevalent in the U.S., it’s not at all unusual to see the progression of medications and products approved by the Food and Drug Administration (FDA) over the years. The first tobacco cessation product approved by the FDA was prescription nicotine gum in 1984. A prescription transdermal nicotine patch got the go-ahead in 1991. In 1996, a trio of products was approved: an over-the-counter (OTC) nicotine gum and patch, and a prescription nicotine nasal spray.

In 1997, a prescription nicotine inhaler was approved, along with the prescription medication, bupropion SR. A nicotine lozenge reached the marketplace in 2002 and in 2006, the prescription drug, varenicline. Drugs currently in development include rimonabant and a nicotine vaccine known as NicVAX (currently in a second FDA Phase III clinical study).

Smoking Cessation Program – NYC

The New York City Department of Health and Mental Hygiene instituted a campaign for mental health providers to assist their patients to stop smoking. The program began in 2003 and was modeled after the pharmaceutical sales approach. This approach sells the benefits of good health and promotes public health interventions. It consists of brief, one-on-one interactions with health care providers and staff.

The goals of the detailing program are to promote preventive health interventions to mental health providers in the primary care practice setting, to promote use of clinical systems so that opportunities for care are not overlooked, and to develop relationships and serve as a resource to the staff of the mental health practice.

After visits to 400 mental health sites in January and February 2009 and follow-up visits in July and August 2009, the following key recommendations were made for mental health providers:

• Assess smoking status and readiness to quit at intake and at least every 3 months thereafter
• Provide smoking cessation medications and treatments to assist people in becoming free of tobacco
• Provide education and raise awareness about how to become and remain tobacco-free

Smoking Cessation Action Kits were provided to mental health providers which included clinical tools, provider resources, patient education, medications, health bulletins, and incentives (such as post-it pads and pens). Provider resources included peer-reviewed articles and clinical guidelines on evidence-based care, vital statistics, and information on smoking interventions.
Materials available to patients through the NYC smoking cessation program include Still Smoking. The brochure, targeted to all literacy levels and available in multiple languages, provides key patient messages and prompts discussion with a health care provider.

Sites involved in the initial and follow-up visits received copies of “Smoke Alarm: the truth about smoking and mental illness,” for consumer use in waiting rooms.

What were the lessons learned? By every measure, the campaign proved to be a success. Programs assessing smoking status at every treatment review increased from 21.2 percent to 58 percent. Programs providing smoking cessation education, medication, and counseling, increased from 34.9 percent to 49.5 percent. Willingness to use clinical tools and/or adopt key recommendations increased from 5 to 52 percent. Sites are also requesting additional support and assistance from the NYC
Department of Health and Mental Hygiene.

Successful Strategies

Among other lessons learned are those involving successful strategies. These include:

• Holding regular group sessions
• Addressing smoking at intake and regular reassessments
• Including smoking cessation in treatment planning
• Educating and counseling clients on health benefits and the expense of smoking
• Providing medication
• Providing one-on-one counseling
• Shifting the focus from quitting to reducing amount smoked
• Educating the staff
• Providing a smoke-free facility

Peer-to-Peer Support for Smoking Cessation

One organization has had considerable success in peer-to-peer support for smoking cessation. This group is CHOICES, or Consumers Helping Others Improve their Condition by Ending Smoking. CHOICES employs mental health peer educators and consumer tobacco cessation advocates to deliver two messages to smokers with mental illnesses:

• Addressing tobacco use is important and can improve their quality of life in numerous ways
• Seeking tobacco treatment will increase their chances of successfully quitting

In essence, what CHOICES personnel do is to provide information and support and motivate individuals who smoke to seek treatment. They do not attempt to “force” the individual to quit, nor is this a formal stop-smoking treatment. Each CHOICES member receives 30 hours of tobacco education prior to going out into the field to work with smokers. They also are involved with advocacy, organizing events with agencies, and have ongoing supervision.

This approach, peer-to-peer support, has several advantages. First, it involves shared experiences. Second, there’s increased trust. Third, the interaction is relaxed and non-structured. Fourth, there is no element of judgment. Fifth, consumers find such peer-to-peer support empowering. And, finally, consumers rate the approach as highly satisfactory.

Why do mental health consumers say they want to quit? The answers may or may not be surprising, dovetailing quite a bit with answers from the general population. These consumers want to quit smoking for reasons of health, cost, smell, children, and relationship to other addictive behavior.

The barriers these consumers list to their ability to stop smoking also mirror that of consumers in the general population. The barriers include:

• Stress
• Weight gain
• What else is there?
• What if everyone around me smokes?
• What if I don’t have the willpower?
• Where can I get free treatment?

What Else Is Required to Stop Smoking?

Smoking cessation, in order to be effective, also requires accurate information, support, self-discipline, motivation, and a determination to live a healthier lifestyle. Whether a person has a mental health illness and/or substance abuse, the desire to quit smoking is similar to that voiced by smokers in the general population. The barriers to quitting are similar, and the tools and resources available are also similar in nature.

The fact that there are smoking cessation programs that are tailored to individuals with mental health problems is encouraging. The fact that mental health providers are getting on board is even more encouraging.

Resources

The following resources may prove helpful in understanding smoking cessation programs for people with mental health problems.

• CHOICES, available at http://www.njchoices.org
• Bringing Everyone Along, available at http://www.tcln.org/bea/
• Rx for Change: Clinician-assisted Tobacco Cessation, available at http://rxforchange.ucsf.edu/curricula/
• Smoking Cessation for Persons with Mental Health Illnesses: A Toolkit for Mental Health Providers, available at http://smokingcessationleadership.ucsf.edu/Downloads/MH/Toolkit/Quit_MHToolkit.pdf
• Tobacco-Free Living in Psychiatric Settings, available at http://www.nasmhpd.org/general_files/publications/NASMHPD.toolkitfinalupdated90707.pdf

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