Is smoking cessation beneficial for people with mental illness, and can they quit?
Key message: Quitting smoking improves mental health conditions. People with mental illness are as motivated and able to quit as those without. To improve the physical and mental health of patients, encouraging and supporting smoking cessation should be a priority in the mental health treatment setting.
What is the issue?
There have been claims over the years that people with mental illness benefit from smoking, do not want to or cannot quit, and that this is not a priority area for action.
What is the evidence for concern?
- Smoking rates are high among people with mental health disorders, especially the most severe cases [1], and people with schizophrenia or Post-Traumatic Stress Disorder (PTSD). A review of studies on smoking and schizophrenia in 20 countries, including 12 countries in the European Region, estimated a smoking prevalence of 62% among people with schizophrenia [2]. Another review estimated smoking rates among people with clinical PTSD at 40-86% [3].
- Smoking rates are also high among those with depression, bipolar disorder, anxiety disorders, stress [4], ADHD [5][6], and Alzheimer's Disease [7].
- Smoking is often not seen as a high priority by those working in the mental health setting. This is largely due to popular misconceptions about smoking and mental illness [8], including that:
- Many clinicians and others see smoking and mental illness as being inextricably linked, and difficult if not impossible to treat;
- Some people believe that smoking is beneficial or a necessary self-medication for those with mental illness;
- Some believe that people with mental illness are not interested in quitting, not able to quit, or that quitting will interfere with their recovery from mental illness; and
- Some people believe that implementing smoke-free mental health facilities is difficult and will create further problems.
What is the reality?
- Smoking is the single largest contributor to the 10-15 year reduced life expectancy in people with conditions such as depression, bipolar disorder, schizophrenia and other serious mental health disorders [9][10][11].
- Smoking has a negative impact on mental health. Levels of stress, irritability, and depressed mood are often higher in smokers than in non-smokers [12], and smoking has a negative impact on conditions such as anxiety and depression [13][14][15]. Smoking is also associated with more severe symptoms and suicidal ideation or attempts in bipolar disorder [16][17].
- Smoking may be a causal factor in mental illnesses such as major depression [18] and Alzheimer's Disease [7].
- While mental health professionals are ideally positioned to address smoking among their patients, many are reluctant to actively do so, in terms of both treatment and public health advocacy [19][20].
- The tobacco industry is an important reason why there are still misconceptions about smoking and mental health. Tobacco companies have funded research to support the self-medication hypothesis [8], and the idea that smoking relieves stress [21] or symptoms of Alzheimer's Disease [22]. Many such studies were poorly designed; later, more robust studies not funded by tobacco companies show otherwise [7].
- Tobacco companies have also targeted people with mental health disorders in their marketing [8], given donations and free cigarettes to mental health facilities [23], and opposed smoking bans in psychiatric hospitals, arguing that these were "inhumane" [24].
- Quitting smoking has a positive impact on mental health. It is associated with reduced levels of depression, anxiety and stress, improved mood, and better quality of life compared with continuing to smoke [25], and can improve the symptoms of disorders such as Attention Deficit Hyperactivity Disorder (ADHD) [26].
- Smoking cessation also allows patients on certain medications to reduce their dosage. For some antipsychotic medications, dosage can be reduced up to 25% which reduces the side effects and long-term risks associated with taking these medications [27].
- There is also good evidence that quitting smoking among people with mental illness does not lead to further mental health concerns [25].
- Although some smokers with mental health disorders tend to experience nicotine withdrawal symptoms more than other smokers [28], these can be easily addressed with nicotine replacement therapy (NRT), varenicline, bupropion, cessation counselling and other evidence-based interventions [29][30].
- Smokers with mental health disorders are frequently motivated to quit [31][32], and capable of doing so with appropriate encouragement and support [33].
- When restrictions and bans on smoking in mental health facilities are carefully implemented, with appropriate supports, the negative outcomes predicted do not occur, and overall experiences for patients are very positive [1][34][35]. Facilities in the UK, for example, saw better sleeping patterns among patients, reduced risk of self-harm with cigarette lighters, and the conversion of smoking rooms into new recreational spaces [36].
Key messages
- Action to reduce smoking among people with mental illness should be a very high priority, whether through health systems or by clinicians. There is nothing that would do more to reduce the life expectancy gap.
- High rates of smoking among people with mental illness bring devastating consequences to their mental and physical wellbeing, and are the largest single contributor to the massive life expectancy gap for this already disadvantaged group.
- People with mental illness want to quit as much as other smokers and can do so with appropriate help and support.
- When properly planned and implemented, bans on smoking in mental health facilities work well and do not result in the negative consequences that some predict.
- Action to reduce smoking in people with mental illness should be a very high priority, consistent with the WHO Framework Convention on Tobacco Control and human rights treaties including the Convention on the Rights of Persons with Disabilities [37] and the Universal Declaration on Human Rights [38], which state that everyone has a right to health without discrimination.
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