Psychiatric Disorders and Cigarette Use

Although the number of people who smoke cigarettes has dropped significantly since the mid-1960s, about 16% of the U.S. adult population still smoke. A much greater percentage of those with certain psychiatric disorders smoke cigarettes. A viewpoint recently published in JAMA Psychiatry by Robert Kleinman and Brian Barnett reviews important information about cigarette use by patients with psychiatric disorders and concludes that psychiatrists should prioritize smoking cessation with their patients. We would go further and extend that advice to all mental health professionals.

Data from the 2019 U.S. National Survey on Drug Use and Health indicate that 24% of individuals who had an episode of major depressive disorder in the previous year smoke. According to a study published in 2018, about 62% of those with schizophrenia and 37% of those with bipolar disorder smoke. Similarly, two to three times as many individuals with alcohol use disorder or other drug use disorders smoke cigarettes compared to the general adult population.

Why is this important? According to the “Tobacco, Nicotine, and E-Cigarettes Research Report” published in 2020 by the National Institute on Drug Abuse (NIDA), “smoking is the leading preventable cause of premature death in the United States,” killing about 480,000 persons a year. Cigarette use is a major reason for shortened life span in those with psychiatric disorders.

Data on the deleterious effects of smoking on physical health have motivated many to stop smoking. Individuals with psychiatric disorders are no different, and many indicate they would like to quit smoking. However, smoking cessation often is not addressed by their health care team, including mental health providers. Visits with primary care providers are often brief, but mental health professionals typically spend more time with patients and may interact with them on a more routine basis than primary care teams. Thus, they are in a key position to help this group of patients.

Pharmacological and psychological approaches can be successful in helping people quit smoking, including those with psychiatric disorders. One approach for evaluating and helping patients stop smoking is known as the 5As: ask about smoking, advise about the benefits of quitting, assess motivation, assist in quitting, and arrange follow-up. Such an approach can be implemented by all mental health professionals. Non-physician clinicians can provide psychologic care and coordinate with a psychiatrist or primary care doctor in providing pharmacologic treatments such as varenicline or bupropion. Psychiatrists and primary care teams can provide both pharmacologic and psychologic care.

Although many of these concepts are analogous to those mental health professionals use to treat patients with psychiatric disorders, Kleinman and Barnett point out that many psychiatrists don’t have extensive experience providing smoking cessation treatment. The authors suggest that clinicians avail themselves of continuing medical education programs on tobacco cessation offered by the American Psychiatric Association. They also encourage residency programs to ensure that trainees gain experience in using smoking cessation strategies with their patients.

Mental health professionals try to help patients decrease symptoms and improve everyday functioning and quality of life. Some clinicians may not consider addressing their patients’ addiction to cigarettes to be part of their charge. However, by addressing smoking cessation, mental health professionals can help substantially decrease long-term morbidity and mortality associated with psychiatric disorders. Shouldn’t this be part of their job in providing comprehensive care?

This post was written by Eugene Rubin MD, PhD and Charles Zorumski MD