A Hidden Epidemic

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A Hidden Epidemic

By Steven A. Schroeder
Sunday, November 18, 2007; B07

Virtually everyone knows about the connection between smoking and health. Smoking causes 440,000 deaths a year in the United States (50,000 of which are from exposure to secondhand smoke) and 5 million worldwide. It shortens smokers' lives by 10 to 15 years, and those last few years can be a miserable combination of severe breathlessness and pain.

But few are aware that smoking is concentrated among people with mental illness, often compounded by substance-abuse disorders such as alcoholism. Go to most Alcoholics Anonymous meetings, and the room will be so full of smoke that you can cut it with a knife. Ask the members, and they will tell you that it was much easier to stop drinking than to stop smoking. Indeed, nicotine, the addictive component of tobacco smoke, is as habituating as cocaine or heroin, and it has a similar effect on chemical receptors in the brain.

The facts about smoking and mental illness are stark. Almost half of all cigarettes sold in the United States (44 percent) are consumed by people with mental illness. This is because so many people who have mental illnesses smoke (50 to 80 percent, compared with less than 20 percent of the general population) and because they smoke so many cigarettes a day -- often three packs. Furthermore, smokers with mental illness are much more likely to smoke their cigarettes right down to the filters.

Yet for years, mental health professionals ignored smoking. Why did patients, their families and clinicians do nothing to help smokers quit?

One reason is well-intended but uninformed compassion. The reasoning goes something like: "Poor Joe is suffering so much from his illness and gets such pleasure from his cigarettes that I don't want to take them away from him." Another reason lies in the extent to which smoking is integrated into mental health treatment. In psychiatric hospitals the denial of the opportunity to take a smoke break is used as a disciplinary tool, and cigarettes have become part of the culture -- often being traded for goods or sexual favors as a form of currency. Another factor is that many clinicians who work with people with mental illness have themselves recovered from psychiatric conditions, including substance abuse, but have not been able to stop smoking. They feel hypocritical about trying to help patients quit when they are unable to do so themselves.

After years of tolerating, and even encouraging, smoking among people with mental illness, mental health professionals are beginning to recognize the hazards of smoking. Two things have been especially powerful: the spread of facts about the dangers of secondhand smoke and a recent analysis showing that people with chronic mental illness die 25 years earlier than the rest of the population, with many of those lost years attributable to smoking.

Earlier this year a landmark meeting in Virginia brought together representatives of mental health clinicians and advocates for mentally ill people; the goal was to see whether a consensus existed about the need to help people stop smoking. To the surprise of many, that consensus was achieved, and a National Mental Health Partnership for Wellness and Smoking Cessation was founded. It consists of 28 organizations and is growing. Many who participated in the summit confessed to feeling guilty about having abetted smoking habits among this population. Indeed, stories emerged about nonsmoking patients who became smokers during psychiatric hospitalizations.

So, what can be done to help people with mental illness stop smoking? Despite strong addictions or concerns about patients' quality of life, this isn't a futile effort. Like the general population, most smokers with mental health conditions would like to quit. Although their odds of actually quitting are not as high -- about half that of smokers who don't have mental health conditions -- there are many success stories. Opportunities exist in both hospital and community settings. There is a growing trend to make mental health hospitals smoke-free, both indoors and on their campuses. For the first time ever, more than half of these institutions in the United States are now smoke-free, and those numbers are increasing. Predicted complications of increased violence and the need for disciplinary actions in the wake of going smoke-free have proved false. In fact, removing smoking as a cause of staff-patient friction has meant fewer violent incidents and more opportunity for staff to interact therapeutically with clients. Tools to help smokers quit -- including counseling and drugs such as nicotine replacement, buproprion and varenicline -- are available but are still greatly underused.

It will not be easy to reverse the long alliance of smoking and mental illness. But the fact that mental health clinicians and patient and family advocacy groups have recognized the problem and are willing to address it is an essential first step toward wellness.

Steven A. Schroeder is a professor at the University of California at San Francisco, where he directs the Smoking Cessation Leadership Center. He is the former president and chief executive of the Robert Wood Johnson Foundation.