Ending the Tobacco Problem - Resources for Local Action
Institute of Medicine

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Cessation Programs for Various Groups of Smokers

Smoking rates have always differed among groups in the population. Epidemiological studies indicate that men smoke more than women, white people smoke more than Hispanic, African American, and Asian adults but less than American Indians and Alaskan Natives. People in lower socioeconomic status (SES) groups smoke more than those in high SES groups. Other groups unrelated to age, gender, or ethnicity— inmates in prisons or jails, homeless people, mentally ill adults, gamblers, disabled people, those in the military, and the LGBT (lesbian, gay, bisexual or transgender) community—also tend to have higher smoking rates. While these groups need to be studied further, efforts should continue to create effective and specialized programs to help them quit. 

One Example: Combating Smoking in People with Mental Illness

In the United States, Americans who have mental illnesses use tobacco products at higher rates than the general population. In fact, individuals with mental illnesses comprise almost half—44 percent—of the tobacco market [1]. While only seven percent of Americans have been diagnosed with a psychiatric-related illness, more than 34 percent of these individuals consume cigarettes each year. Furthermore, this population experiences nicotine dependency at rates two-to-three times higher than the general public, and smokers with mental illness experience higher rates of morbidity and mortality than their nonsmoking peers due to tobacco use [2]. Most smokers with mental disorders will die of tobacco-related diseases rather than related to the psychological disorder they have. Patients with psychiatric disorders should be a priority for community tobacco control programs [3]. The American Psychiatric Association guideline recommended in 1996 that patients with mental illnesses should also be treated for tobacco use, but little has been done due to lack of resources [4]. 

Over the past decade, there have been concerns that health care providers may not be discouraging their patients with mental illness from smoking for two reasons: first, because cigarette smoking is believed to be an effective method of self-medication for individuals with mental illness who may benefit from the calming effects of cigarette smoking; and second, because health providers believe that getting the mental health problem under control should be the patient’s main focus and that smoking cessation can come later [5]. Health care providers should keep in mind that while smoking may offer temporary beneficial effects, there are better coping strategies to assist people with mental illnesses.

Health care providers treating patients with mental illness need to be educated about additional side effects experienced by individuals with mental illness who attempt to quit smoking. For example, cigarette smoking has been known to alter medication levels of certain antipsychotic drugs. When individuals taking these medications quit smoking, they experience a dramatic rise in blood plasma levels of certain medications and may experience side effects such as depression; agitation, especially among patients with schizophrenia; and/or mania, particularly in individuals with bipolar disorder. In addition, smokers with mental illnesses experience higher levels of nicotine dependence, putting them at greater risk for developing health problems related to tobacco use. Therefore, physicians must use different cognitive-behavioral strategies to help patients with mental illness quit smoking.

A Case Study in Colorado

In Colorado, approximately eight percent of the adult population has been diagnosed with a major psychiatric illness [6]. In 2001, Colorado’s State Tobacco Education & Prevention Partnership (STEPP) began providing funds to the Department of Psychiatry at the University of Colorado Denver and the UC Denver Health Sciences Center to research ways to eliminate tobacco-related health disparities among smokers with mental illness. Under the guidance of Dr. Chad Morris, a professor in the Department of Psychiatry at the University of Colorado Denver, several needs assessments were completed, and strategic planning for research and interventions began.

In 2001, Morris began incorporating a cessation program for individuals with mental illness into the Behavioral Health and Wellness Program at UC Denver, which already has interventions for a variety of other health issues such as alcohol and substance abuse and obesity. The primary goal of Morris’ program is to eliminate tobacco-related health disparities experienced by smokers with mental illnesses. Compared to smokers in the general population, individuals with mental illness are just as likely to express an interest in smoking cessation; however, fewer smokers with mental illnesses are likely to receive the help they need from health care providers.

Morris and his colleagues are encouraging psychiatric facilities to establish smoke-free campuses and training psychiatric providers, peers, and patients using a toolkit they created in 2006 for mental health providers. A culmination of their research, this toolkit consists of facts about the effects of smoking among people with mental illnesses, a Colorado quit line referral form, a survey for health care providers to use in order to screen for tobacco use, key research findings, information about best practices for intensive cessation interventions as well as behavioral interventions for smoking cessation, an overview of cessation medications, counseling advice, cultural competency considerations, relapse prevention tips, a thorough literature review, and local and national tobacco cessation resources. Between 2005 and 2006, the team began international research on smoking cessation for individuals with mental illness. In January 2009, they updated the toolkit based on new data.

In addition, Morris and his colleagues have undertaken a number of training opportunities. They offer training to healthcare providers and mental health facilities in 20 states and several foreign countries. These training sessions use a peer-to-peer model and involve health care providers and clients while integrating evidence-based research. Morris’ team is also completing an effectiveness study on community-based advocacy for smoke-free campuses at mental health facilities in Colorado.

[1]http://www.cohealthproviders.com/ or www.tcln.org/bea/docs/Quit_MHToolkit.pdf.
[3] Grant BF, Hasin DS, Chou SP, Stinson FS & Dawson DA  (2004)  Nicotine dependence and psychiatric disorders in the United States:  results from the national epidemiologic survey on alcohol and related conditions.  Archives of General Psychiatry 61(11): 1107-1115
[4] APA (American Psychiatric Association)  (1996)  American Psychiatric Association Practice Guidelines  Washington DC: APA
[5] Personal Communication with Chad Morris, PhD, on May 21, 2009.