The recent nationwide decline in the rate of cigarette smoking in the general population of adults did not extend to those with mental illness, according to a report published online Jan. 7 in JAMA.
In a study of serial, nationally representative samples of noninstitutionalized American adults, the smoking rate significantly declined from 19.2% in 2004 to 16.5% in 2011 among adults without mental illness. But it declined only negligibly during that period among those with mental illness, from 25.3% to 24.9%, said Benjamin Lê Cook, Ph.D., of the department of psychiatry, Cambridge (Mass.) Health Alliance, and his associates.
Dr. Benjamin Le Cook
"This suggests that tobacco control policies and cessation interventions targeting the general population have not worked as effectively for those with mental illness," they said.
Noting that until now "there have been no studies that examine smoking trends among persons with mental illness," Dr. Cookand his colleagues examined smoking rates over time using data from the Medical Expenditure Panel Survey. This survey assesses health care use in about 15,000 U.S. households each year, and it includes such data as smoking status and medical treatment.
For their study, Dr. Cook and his associates tracked smoking rates among 165,269 participants from 2004 through 2011. The overall smoking rate was higher among adults with mental illness (28.2%) than among those without mental illness (17.5%), which was expected, because many previous studies have noted an approximately twofold higher rate of smoking among people with mental illness.
In an initial, unadjusted analysis of the data, the smoking rate dropped from 19.5% to 15.6% in adults without mental illness, compared with a much smaller decline from 28.8% to 27.0% in those with mental illness. After the data were adjusted to account for numerous potentially confounding factors such as age, sex, race/ethnicity, marital status, income, and urban versus other areas of residence, those rates changed slightly, but the pattern persisted: Smoking rates were consistently higher and showed only a nominal decline among people with mental illness.
These findings remained robust in further analyses that varied the definition of mental illness to include milder neurotic, anxiety, and mood disorders, the researchers said (JAMA 2014 [doi:10.1001/jama.2013.284985]).
The investigators also performed a separate analysis of data regarding 14,057 adult smokers with mental illness who participated in the National Survey on Drug Use and Health in 2009-2011. They found that the rate of quitting smoking was significantly higher (37.2%) in those who received mental health treatment during that interval than among those who did not (33.1%).
In addition, receiving any mental health treatment significantly raised the likelihood of quitting smoking, even after the data were adjusted to account for substance use therapy, the severity of the mental illness, and other factors likely to affect smoking status.
"For many individuals receiving mental health treatment, interactions with mental health professionals are their only access to preventive health counseling," added Dr. Cook and his associates. "Effective tobacco treatments, interventions that integrate mental health and substance abuse treatment, and nicotine replacement therapies are now readily available and can dovetail easily with psychosocial treatments and prescription of psychotropic medications."
One barrier to these approaches is that some professionals in both primary care and behavioral health "continue to believe that smoking cessation can adversely affect psychiatric treatment." Even if they don’t believe that, smoking culture is normalized in many psychiatric treatment settings.
Some health professionals also consider individuals with mental illness to lack the willingness or ability to quit smoking, or think these individuals do not appreciate its adverse health effects. "Few mental health care professionals assess clients’ tobacco use, advise and assist them in quitting, or arrange follow-up, and most individuals with mental illness are not afforded the same cessation opportunities as the general population," Dr. Cook and his associates said.
Dr. Cook and his colleagues cited several limitations of the study. Among them is that the prevalence of smoking within the U.S. population might have been underestimated, because the survey excluded people with mental illness who were institutionalized.
Still, these results suggest that "smokers can quit and remain abstinent from cigarettes during mental health treatment and that this is a promising setting to promote smoking cessation," they wrote.
This work was supported by the National Institute of Mental Health and the William F. Milton Fund. No financial conflicts of interest were reported.