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Behavioral Health Care Providers

1. Cigarette smoking is more common among adults with behavioral health conditions than in the general population. Smoking rates in people with serious mental illness (SMI) are disproportionately high compared with the general population and cessation rates are low in this group, even though many people with SMI are motivated to quit.1 In 2016, 32% of U.S. adults with any mental illness reported current use of tobacco compared with 23.3% of adults with no mental illness.2 Smoking rates among people with SMI are even higher.3

New York State collects surveillance data on the link between “frequent mental distress” and cigarette smoking, which likely includes less severely impaired individuals than those with SMI. In NYS, the smoking rate among adults with frequent mental distress is 85% higher than the general adult smoking rate (26% compared with of 14.2%).4 eople with frequent mental distress may smoke more heavily and frequently compared with those without frequent mental distress. While the disproportionately high rate of smoking in this subpopulation is likely due to a combination of factors, one thing is clear—tobacco use among people with behavioral health conditions can be prevented, and you can help those who smoke quit.5

2. People with behavioral health conditions who smoke get sick, become disabled, and die early from smoking-related diseases. Estimates of the mortality gap between people with mental illness or substance use disorders and people without these disorders varies widely but is minimally about five years and may be as high as ten years or more, and cigarette smoking causes many of these deaths.6,7,8 Adults who use drugs and smoke cigarettes are four times more likely to die prematurely than those who do not smoke.9 Because of the heavy disease burden, smoking cessation interventions should be routinely offered within behavioral health care settings. Integrating evidence-based tobacco use disorder treatment into the behavioral health care you provide is an important part of your patients’ behavioral health recovery and overall wellness.

3. Many people with behavioral health conditions who smoke want to and can quit smoking. A common misconception is that people with behavioral health conditions who smoke either cannot or will not quit smoking.10 However, research shows that adults with behavioral health conditions who smoke—like other people who smoke—want to quit, can quit, and benefit from proven smoking cessation treatment.11 NYS Medicaid covers the evidence-based smoking cessation treatments of counseling and all seven FDA-approved cessation medications; however, in 2017, less than half of NYS Medicaid enrollees who smoke or were recent quitters were aware of the benefit.12 You can help by asking patients about their tobacco use, providing support and education, including information about the Medicaid smoking cessation benefit, and providing treatment to those who are ready to quit.

4. Quitting smoking does not interfere with behavioral health recovery and may have mental health benefits. It’s a myth that smoking has mental health benefits and helps patients cope with their psychiatric symptoms.10 Smoking is associated with poor clinical outcomes, including greater depressive symptoms, greater likelihood of psychiatric hospitalization, and increased suicidal behavior.13,14 Smoking can complicate treatment by accelerating the metabolism of certain psychiatric medications, resulting in the need for higher doses to achieve the same therapeutic benefit.10 When you provide proven cessation treatment, people can quit without worsening their psychiatric symptoms.15,16 Quitting smoking is associated with significant reductions in depression and anxiety, improved cognitive functioning, lower rates of re-hospitalization, lower rates of suicide, and is associated with marked improvements in mental health over time, whereas continued smoking is associated with little change over the same period.13,14,17,18,19,20,21

5. Providing smoking cessation assistance is an important part of behavioral health treatment. Providing treatment for tobacco use disorder is an important part of behavioral health treatment. Evidence-based tobacco use disorder treatment follows the same principles as integrated treatment for co-occurring mental health disorder and other addictions. You already have skills to help people with behavioral health conditions successfully quit tobacco use and enjoy the mental, emotional, and physical benefits of a tobacco-free life. Go to the Helpful Links tab to learn more about how to make tobacco cessation part of your behavioral health treatment and wellness approach.

Adapted from the Centers for Disease Control and Prevention – Smoking and Mental Health: Five Things Every Health Care Provider Should Know

Behavioral Health Care Providers

Providers play a key role in treating tobacco use disorder as part of their therapeutic work with people who smoke or use other tobacco products. Five things to know before your next clinical encounter:

References:

  1. Annamalai, A., Singh, N., & O'Malley, S. S. (2015). Smoking Use and Cessation Among People with Serious Mental Illness. The Yale journal of biology and medicine, 88(3), 271-7.
  2. Substance Abuse and Mental Health Services Administration. (2017). Results from the 2016 National Survey on Drug Use and Health: Detailed Tables. Rockville, MD: Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality.
  3. Dickerson F., Schroeder J., Katsafanas E., Khushalani S., Origoni A. E., Savage C., Schweinfurth L., Stallings C. R., Sweeney K., & Yolken R. H. (2018). Cigarette Smoking by Patients With Serious Mental Illness, 1999-2016: An Increasing Disparity. Psychiatr Serv., 69(2):147-153. doi: 10.1176/appi.ps.201700118
  4. New York State Department of Health. (2018). Cigarette Smoking – New York State Adults, 2016. BRFSS Brief, Number 1802.
  5. Ziedonis, D., Hitsman, B., Beckham, J. C., Zvolensky, M., Adler, L. E., Audrain-McGovern, J., Breslau, N., et al. (2008). Tobacco use and cessation in psychiatric disorders: National Institute of Mental Health report. Nicotine & Tobacco Research, 10(12), 1-25.
  6. Druss BG, et al. (2011). Understanding Excess Mortality in Persons With Mental Illness: 17-Year Follow Up of a Nationally Representative US Survey. Medical Care 2011; 49(6), 599–604.
  7. Centers for Disease Control and Prevention. (2013). Vital Signs: Current Cigarette Smoking Among Adults Aged ≥18 Years With Mental Illness—United States, 2009–2011. Morbidity and Mortality Weekly Report; 62(05):81-7.
  8. Centers for Disease Control and Prevention. (2013). Vital Signs Fact Sheet: Adult Smoking Focusing on People With Mental Illness, February 2013. National Center for Chronic Disease and Health Promotion, Office on Smoking and Health.
  9. Smoking Cessation Leadership Center. (2015). Fact Sheet: The Tobacco Epidemic Among People With Behavioral Health Disorders. San Francisco: Smoking Cessation Leadership Center, University of California.
  10. Prochaska, J. J. (2011). Smoking and mental illness — Breaking the link. New England Journal of Medicine, 365(3), 196-198.
  11. Siru, R., Hulse, G. K., & Tait, R. J. (2009). Assessing motivation to quit smoking in people with mental illness: a review. Addiction, 104(5), 719-733.
  12. New York State Department of Health. (2018). Independent Evaluation of the Tobacco Control Program, Special Study of Medicaid Enrollees, 2017. Unpublished data.
  13. Khaled, S. M., Bulloch, A. G., Williams, J. V., Hill, J. C., Lavorato, D. H., & Patten, S. B. (2012). Persistent heavy smoking as risk factor for Major Depression (MD) incidence: Evidence from a longitudinal Canadian cohort of the National Population Health Survey. Journal of Psychiatric Research 46(4), 436-443.
  14. Berlin, I., Hakes, J. K., Hu, M. C., & Covey, LS (2015). Tobacco use and suicide attempt: Longitudinal analysis with retrospective reports. PLoS ONE, 10(4): e0122607.
  15. Tidey, J. W. & Miller, M. E. (2015). Smoking cessation and reduction in people with chronic mental illness. British Medical Journal, 351: h4065.
  16. Evins, A. E., Cather, C., & Laffer, A. (2015). Treatment of tobacco use disorders in smokers with serious mental illness: Toward clinical best practices. Harvard Review of Psychiatry, 23(2), 90-8.
  17. Cavazos-Rehg, P. A., Breslau, N., Hatsukami, D., Krauss, M. J., Spitznagel, E. L., Grucza, R. A., Salyer, P., et al. (2014). Smoking cessation is associated with lower rates of mood/anxiety and alcohol use disorders. Psychological Medicine, 44(12), 2523-2535.
  18. Kahler, C. W., Spillane, N. S., Busch, A. M., & Leventhal, A. M. (2011). Time-varying smoking abstinence predicts lower depressive symptoms following smoking cessation treatment. Nicotine & Tobacco Research, 13(2), 146–150.
  19. Prochaska, J. J., Hall, S. E., Delucchi, K., & Hall, S. (2014). Efficacy of initiating tobacco dependence treatment in inpatient psychiatry: A randomized controlled trial. American Journal of Public Health 104(8), 1557-1565.
  20. Vermeulen, J. M., Schirmbeck, F., Blankers, M., van Tricht, M., Bruggeman, R.,  van den Brink, W., de Haan, L. (2018). Association Between Smoking Behavior and Cognitive Functioning in Patients With Psychosis, Siblings, and Healthy Control Subjects: Results From a Prospective 6-Year Follow-Up Study. American Journal of Psychiatry, 175(11), 1121-1128.
  21. Taylor, G., McNeil, A., Girling, A., Farley, A., Lindson-Hawley, N., & Aveyard, P. (2014). Change in mental health after smoking cessation: systematic review and meta-analysis. British Medical Journal, 348: g1151.