Individuals with a psychiatric or substance abuse disorder smoke 44 percent of the cigarettes smoked in the United States.1 This major segment of the smoking population has received little attention. Individuals with mental health or addiction problems are about two to three times more likely to be nicotine dependent than the general population,2 and they experience medical morbidity and mortality at a similarly increased rate. For example, one research study found that chronic schizophrenic consumers smoke at a rate that approaches 90 percent,3 rates of smoking are estimated to range from 50-60 percent in patients with a clinical diagnosis of depression,4 and about 80 percent of alcohol/drug abusers who are in treatment are smokers.5,6 Although the deaths of many individuals with a history of mental illness or addiction can be linked to tobacco-caused illnesses, the prevailing culture in most mental health or addictions settings has historically accepted and normalized tobacco use and dependence.1,7
In addition to increased medical co-morbidity, smokers with addiction and/or mental illness have other concerns. Smokers with mental illness can experience increased psychiatric symptoms, more hospitalizations, and a need for higher medication doses. The metabolism of tobacco can dramatically effect psychiatric medication dosing requirements and blood levels by inducing the P450 liver cytochrome (CYP1A2) enzymes. Often smoking requires a doubling of medication dosage. Tobacco use can also trigger cravings for other substances and therefore worsen the long-term outcome recovery rates for individuals with other substance use disorders.8,9
Recently there has been successful development and implementation of smoking cessation treatment specific to this population. Psychosocial treatments have been adapted and developed for co-occurring mental illness or addiction--particularly for depressed smokers, schizophrenic smokers, alcoholic smokers and drug-addicted smokers. Recent research has found that these treatments have been effective in helping smokers in this population abstain from tobacco.10-13 For example, nortriptyline has been demonstrated to be effective in helping relieve depression and reduce tobacco usage in several studies.14,15 The patch has been found to be effective in smokers with a mild, current (within the last year) or past alcohol problem, and long-term tobacco abstinence in these groups was similar to controls without an alcohol history,10 and bupropion has been helpful in contributing to reduced smoking in schizophrenics, as measured by reduced expired carbon monoxide (CO) in more than one trial.11-13
Treatment facilities had begun to address smoking when the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) mandated that health care facilities transition to smoke-free environments in 1992. Many psychiatric and substance abuse treatment facilities had to transition to smoke-free environments. Researchers have just begun to examine this transition. Inpatient studies of units transitioning to tobacco-free environments have documented the lack of any increase in disruptive behaviors, "against medical advice" discharges, additional seclusion and restraints, or use of PRN medications when tobacco use was prohibited.17,18
Even though the evidence points to addressing smoking cessation in these settings, resistance remains. One main obstacle to achieving an encouraging and nurturing environment for cessation is the treatment setting staff’s attitudes towards smoking and cessation. Staff might actually hinder the smoking cessation efforts of patients. Due to their own elevated rates of smoking, the likelihood of counseling or even recommending cessation are significantly lower. This is a particularly salient issue in AOD treatment where a large number of staff, including counselors, smoke. A study examining staff attitudes found that only 35 percent of staff thought recovering alcoholics who smoked should be encouraged to quit early in their sobriety.19 This has also been an issue in mental health, where in the past 50 years tobacco use has even been encouraged in mental health settings through the use of cigarettes as a behavioral reinforcer for appropriate behavior on inpatient units and as part of a patient reward system.
Another barrier to smoking cessation in these settings is cost. As stated before smoking for recovering substance abusers is correlated with relapse, and for mental health patients smoking is correlated with higher medication dosage and hospitalization. Both these outcomes lead to higher societal costs, e.g., Medicaid costs related to care of individuals with tobacco-related diseases, costs for repeated treatments, additional medication, etc. One can conclude reductions in smoking within this population could also be cost beneficial. Evidence supports the benefits of addressing smoking in substance abuse and mental health treatment facilities. There is a great need for an organized effort to address tobacco among this segment of smokers.
Therefore, APHA urges mental health and substance abuse treatment professionals and facilities to adopt and implement integrated smoking cessation plans for their patients and for these substance abuse and mental health treatment facilities to become smoke-free. APHA also urges the Substance Abuse and Mental Health Services Administration to disseminate and promote this policy in the treatment centers it funds or supervises.
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