Tobacco, Nicotine, and E-Cigarettes Research Report
Do people with mental illness and substance use disorders use tobacco more often?

A larger proportion of people diagnosed with mental disorders report cigarette smoking compared with people without mental disorders. Among US adults in 2019, the percentage who reported past-month cigarette smoking was 1.8 times higher for those with any past-year mental illness than those without (28.2% vs. 15.8%).140 Smoking rates are particularly high among people with serious mental illness (those who demonstrate greater functional impairment). While estimates vary, as many as 70-85% of people with schizophrenia and as many as 50-70% of people with bipolar disorder smoke.141,142

Rates of smoking among people with mental illness were highest for young adults less than age 45, those with low levels of education, and those living below the poverty level.143 The 2005-2013 National Survey on Drug Use and Health (NSDUH) data indicated that smoking among adults without chronic conditions has declined significantly, but remains  higher among those reporting anxiety, depression, and substance use disorders.3 Similarly, a recent study based on the 2006-2019 NSDUH data showed higher smoking rates in adults with psychiatric disorders than in those without; however, most importantly, smoking rates among adults with major depression and/or substance use disorder declined significantly during 2006-2019 in every examined age, sex, and racial and ethnic subgroup, except for non-Hispanic American Indian or Alaska Native adults. These results suggest that tobacco cessation is achievable among adults with psychiatric disorders and tobacco use.238

Smoking is believed to be more prevalent among people with depression and schizophrenia because nicotine may temporarily lessen the symptoms of these illnesses, such as poor concentration, low mood, and stress.144–146 But it is important to note that smoking cessation has been linked with improved mental health—including reduced depression, anxiety, and stress, and enhanced mood and quality of life.147

In addition to smoking, there is also a higher prevalence of smokeless tobacco use among individuals with anxiety or substance use disorders.3 Other research drawing on data from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) found that all types of substance dependence were associated with dependence on nicotine.148 Smoking is also highly prevalent among people in treatment for substance use disorders,149 with most studies finding rates between 65-85% among people in addiction treatment.149

Additionally, people who smoke with a mental health disorder tend to smoke more cigarettes than those in the general population. The average number of cigarettes smoked during the past month was higher among those with a mental illness compared with those without one—331 versus 310 cigarettes.150 High cigarette consumption is a particular problem for people with serious mental illness. Although adults with both tobacco addiction and co-occurring mental disorders apart from substance use disorders comprised only 7.1% of the total U.S. population, they consumed 34.2% of all cigarettes smoked in the U.S., according to data from the 2001–2002 NESARC.151

High Prevalence of Smoking Among People with Schizophrenia

Researchers are working to identify the brain circuits that contribute to the high prevalence of smoking among people with schizophrenia. Schizophrenia is associated with widespread reductions in functional connectivity between the dorsal anterior cingulate cortex and diverse parts of the limbic system. One report identified 15 circuits for which the reduction of functional connectivity correlated with severity of nicotine addiction.152

People with substance use disorders and other mental illnesses, do not quit smoking at the same rate as those in the general population.4 Survey responses from people who have smoked at some point during their lives indicated that fewer smokers with mental illness had quit compared to those without psychiatric disorders: 47.4% of lifetime smokers without mental illness smoked during the past month, compared with 66% of those with mental illness.150 A recent study  found that among U.S. adults in 2019, the percentage who reported past-month cigarette smoking was higher among those with past-year major depressive episodes than those without (24.2% vs. 17.6%) and among those with past-year substance (alcohol or drug) use disorders than those without (35.8% vs. 16.8%).238

Having a mental disorder at the time of cessation is a risk factor for relapse to smoking, even for those who have sustained abstinence for more than a year.153 Many smokers with mental illness want to quit for the same reasons cited by others (such as health and family), but they may be more vulnerable to relapse related to stress and other negative feelings.154

The disparity in smoking prevalence is costing lives. A recent study found that tobacco-related diseases accounted for approximately 53% of deaths among people with schizophrenia, 48% among those with bipolar disorder, and 50% among those with depression.155

Since the 1980s, many providers have believed that people with schizophrenia smoke to obtain relief from symptoms like poor concentration, low mood, and stress.147 But research is now showing that smoking is associated with worse behavioral and physical health outcomes in people with mental illness, and quitting smoking is showing clear benefits for this population.147,156 Comprehensive tobacco control programs and enhanced efforts to prevent and treat nicotine addiction among those with mental illness would reduce illness and deaths. Integrated treatment—concurrent therapy for mental illness and nicotine addiction—will likely have the best outcomes.157

Smokers who receive mental health treatment have higher quit rates than those who do not.6 Moreover, evidence-based treatments that work in the general population are also effective for people with mental illness. For example, people with schizophrenia showed better quit rates with the medication bupropion, compared with placebo, and showed no worsening of psychiatric symptoms.158,159 A combination of the medication varenicline and behavioral support has shown promise for helping people with bipolar and major depressive disorders quit, with no worsening of psychiatric symptoms.160 A clinical trial found that a combination of varenicline and cognitive behavioral therapy (CBT) was more effective than CBT alone for helping people with serious mental illness stop smoking for a prolonged period—after 1 year of treatment and at 6 months after treatment ended.161