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

There is significant comorbidity between tobacco use and mental disorders. People with mental illness smoke at two to four times the rate of the general population. Among people with a mental illness, 36.1 percent smoked from 2009 to 2011, compared with 21.4 percent among adults with no mental illness.140 Smoking rates are particularly high among patients with serious mental illness (i.e., those who demonstrate greater functional impairment). While estimates vary, as many as 70-85 percent of people with schizophrenia and as many as 50-70 percent of people with bipolar disorder smoke.141,142

Rates of smoking among people with mental illness were highest for those younger than 45, those with low levels of education, and those living below the poverty level.143 Longitudinal data from NSDUH (2005–2013) indicate that smoking among adults without chronic conditions has declined significantly, but remains particularly high among those reporting anxiety, depression, and substance use disorders.3 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

Analyses of longitudinal NSDUH data also found a higher prevalence of smokeless tobacco use among individuals with mental health and substance use disorders.3 Other research drawing on data from the National Epidemiologic Survey on Alcohol and Related Conditions 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 percent among patients in addiction treatment.149

Additionally, smokers 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 serious mental illness comprised only 6.9 percent of past-month smokers, they consumed 8.7 percent of all cigarettes sold, according to data from the 2008–2012 NSDUH.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 mental and substance use disorders 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 percent of lifetime smokers without mental illness smoked during the past month, compared with 66 percent of those with mental illness.150 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 negative feelings.154

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