Tobacco Control Playbook

Is smoking cessation beneficial for people with mental illness, and can they quit?

June 8th, 2017

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.
Show References
  1. Smoking and Mental Health. 2013; Royal College of Physicians and Royal College of Psychiatrists ( ↩︎ ↩︎

  2. de Leon J, Diaz FJ. A meta-analysis of worldwide studies demonstrates an association between schizophrenia and tobacco smoking behaviors. Schizophr Res 2005;76:135-157. ↩︎

  3. Fu SS, McFall M, Saxon AJ, et al. Post traumatic stress disorder and smoking: a systematic review. Nicotine Tob Res 2007;9:1071-1084. ↩︎

  4. McClave AK, McKnight-Eily LR, Davis SP, Dube SR. Smoking characteristics of adults with selected lifetime mental illnesses: results from the 2007 National Health Interview Survey. Am J Pub Health 2010;100:2464-2472. ↩︎

  5. Wilens TE, Vitulano M, Upadhyaya H, et al. Cigarette smoking associated with attention deficit hyperactivity disorder. J Pediatr 2008;153:414-419. ↩︎

  6. Matthies S, Holzner S, Feige B, et al. ADHD as a serious risk factor for early smoking and nicotine dependence in adulthood. J Attention Dis 2013;17:176-186. ↩︎

  7. Cataldo JK, Prochaska J, Glantz S. Cigarette smoking is a risk factor for Alzheimer's disease: an analysis controlling for tobacco industry affiliation. J Alzheimers Dis 2010;19:465-480. ↩︎ ↩︎ ↩︎

  8. Prochaska JJ. Smoking and mental illness: breaking the link. N Engl J Med 2011;365:196-198. ↩︎ ↩︎ ↩︎

  9. Callaghan RC, Veldhuizen S, Jeysingh T, et al. Patterns of tobacco-related mortality among individuals diagnosed with schizophrenia, bipolar disorder, or depression. J Psych Res 2014;48:102- ↩︎

  10. Tam J, Warner KE, Meza R. Smoking and the reduced life expectancy of individuals with serious mental illness. Am J Prev Med 2016;51:958-966. ↩︎

  11. Lawrence D, Hancock KJ, Kisely S. The gap in life expectancy from preventable physical illness in psychiatric patients in Western Australia: retrospective analysis of population based registers. Brit Med J 2013;346:f2539. ↩︎

  12. Parrott AC, Murphy RS. Explaining the stress-inducing effects of nicotine to cigarette smokers. Hum Psychopharmacol Clin Exp 2012;27:150-155. ↩︎

  13. Williams JM, Ziedonis D. Addressing tobacco among individuals with a mental illness or an addiction. Addict Behav 2004;29:1067-1083. ↩︎

  14. Picciotto MR, Brunzell DH, Caldarone BJ. Effect of nicotine and nicotinic receptors on anxiety and depression. Neuroreport 2002;13:1097-1106. ↩︎

  15. Mendelsohn C. Smoking and depression: a review. Austr Family Phys 2012;41:304-307. ↩︎

  16. Ostacher MJ, Nierenberg AA, Perlis RH, et al. The relationship between smoking and suicidal behaviour, comormidity, and course of illness in bipolar disorder. J Clin Psychiatr 2006;67:1907-1911. ↩︎

  17. Ostacher M, LeBeau RT, Perlis RH, et al. Cigarette smoking is associated with suicidality in bipolar disorder. Bipolar Dis 2009;11:766-771. ↩︎

  18. Boden JM, Fergusson DM, Horwood LJ. Cigarette smoking and depression: tests of causal linkages using a longitudinal birth cohort. Brit J Psych 2010;196:440-446. ↩︎

  19. Williams JM, Stroup TS, Brunette MF, Raney LE. Tobacco use and mental illness: a wake-up call for psychiatrists. Psych Serv 2014;65:1406-1408. ↩︎

  20. Lawn S, Condon J. Psychiatric nurses' ethical stance on cigarette smoking by patients: determinants and dilemmas in their role in supporting cessation. Int J Mental Health 2006;15:111-118. ↩︎

  21. Petticrew MP, Lee K. The "father of stress" meets "big tobacco": Hans Selye and the tobacco industry. Am J Pub Health 2011;101:411-417. ↩︎

  22. Cataldo JK, Glantz SA. Smoking cessation and Alzheimer's disease: facts, fallacies and promise. Expert Rev Neurother 2010;10:629-631. ↩︎

  23. Apollonio DE, Malone RE. Marketing to the marginalised: tobacco industry targeting of the homeless and mentally ill. Tob Control 2005;14:409-415. ↩︎

  24. Prochaska JJ, Hall SM, Bero LA. Tobacco use among individuals with schizophrenia: what role has the tobacco industry played? Schizophr Bull 2008;34:555-567. ↩︎

  25. Taylor G, McNeill A, Girling A, et al. Change in mental health after smoking cessation: systematic review and meta-analysis. Brit Med J 2014;348:g1151. ↩︎ ↩︎

  26. Pagano ME, Delos-Reyes CM, Wasilow S, Svala KM, Kurtz SP. Smoking cessation and adolescent treatment response with comorbid ADHD. J Subst Abuse Treatment 2016;70:21-27. ↩︎

  27. Desai HD, Seabolt J, Jann MW. Smoking in patients receiving psychotropic medications. CNS Drugs 2001;15:469-494. ↩︎

  28. Weinberger AH, Desai RA, McKee SA. Nicotine withdrawal in US smokers with current mood, anxiety, alcohol use, and substance use disorders. Drug Alcohol Depend 2010;108:7- ↩︎

  29. Evins A, Cather C. Effective Cessation Strategies for Smokers with Schizophrenia. Int Rev Neurobiol 2015;124:133-147. ↩︎

  30. Ziedonis D, Das S, Tonelli M. Smoking and mental illness: strategies to increase screening, assessment, and treatment. Focus J Lifelong Learning Psych 2015;13:290-306. ↩︎

  31. Caosella AM, Ossip-Klein DJ, Owens CA. Smoking attitudes, beliefs, and readiness to change among acute and long term care inpatients with psychiatric diagnoses. Addict Behav 1999;24:331-344. ↩︎

  32. Siru R, Hulse GK, Tait RJ. Assessing motivation to quit smoking in people with mental illness: a review. Addiction 2009;104:719-733. ↩︎

  33. Hitsman B, Borrelli B, McChargue DE, Spring B, Niaura R. History of depression and smoking cessation outcome: a meta-analysis. J Consul Clin Psych 2003;71:657-663. ↩︎

  34. Cormac I, Creasey S, McNeill A, Ferriter M, Huckstep B, D'Silva K. Impact of a total smoking ban in a high secure hospital. Brit J Psych Bull 2010;34:413-417. ↩︎

  35. Lawn S, Pols R. Smoking bans in psychiatric inpatient settings? A review of the research. Austr NZ J Psych 2005;39:866-885. ↩︎

  36. Fact sheet: Smoking and Mental Health. 2016; ASH UK ( ↩︎

  37. Convention on the Rights of Persons with Disabilities. 2006; Paris: United Nations ( ↩︎

  38. Universal Declaration of Human Rights. 1948; Paris: United Nations ( ↩︎


References accessed on May 29th, 2017.

Modified on June 7th, 2017. See History and Revisions