A pilot program in New York City is challenging a long-held belief about cigarette smoking—that people with mental-health problems aren't interested in quitting.
The results so far are promising. Therapists say they are surprised that some patients with mental illness have been eager to join the anti-smoking program. And for some patients, giving up smoking has helped them feel more confident about other parts of their lives. The results also hold potential for helping hard-core smokers in the general population stop smoking.
Nearly half of all the cigarettes sold in the U.S. are smoked by people with a serious mental illness, according to a study in the Journal of the American Medical Association in 2000. People with schizophrenia, bipolar disorder and other mental illnesses are twice as likely to smoke as the general population, and they tend to smoke about 50% more cigarettes per day.
New York City's anti-smoking campaigns have pulled few punches.
Heaviest Smokers
People with significant mental illness smoke at much higher rates than the general population, but their addiction has long been a low priority among doctors.
- 44% of cigarettes in the U.S. are smoked by people with a serious mental illness.
- 75% of smokers have a past or current problem with mental illness or addiction.
- 25 years—People with serious mental illness die that much sooner, on average, than the general population, mainly due to smoking-related illnesses.
- 27%—The percentage of an average monthly budget spent on cigarettes by people on public assistance.
- 1.5%—The proportion of patients seeing an outpatient psychiatrist who receive treatment for tobacco addiction.
Sources: JAMA; National Comorbidity Study; National Association of State Mental Health Program Directors; Tobacco Control; American Journal of Addiction
The pilot program began in January at the International Center for the Disabled (ICD), an outpatient psychiatric clinic. It uses nicotine-replacement therapy and one-on-one counseling with therapists trained to keep patients motivated and work through problems that arise.
Convincing mentally ill patients to quit has been a low priority in mental-health care in the past. "There was a belief that it was too much of a problem and it would cause too much pain for our patients to stop smoking," says Greg Miller, medical director of the division of adult services at the New York State Office of Mental Health. Smoking also was seen as a way to keep patients calm and entertained, and was used as a reward for good behavior in psychiatric hospitals.
"I was already so stressed out, I just figured, 'What else can go wrong?' So I made my mind up to quit," says Michael King, 46, an ICD patient who stopped smoking in March as part of an effort to turn his life around after a long history of mental, legal, family and substance-abuse problems.
"Michael was in crisis at the time. Smoking was one of his ways of coping, and I was concerned that quitting was going to make it worse," says his therapist, Andy Petronio. "But I was completely wrong. Quitting gave him his confidence back. It actually made him a lot stronger."
Smoking can take a heavy toll on patients already struggling with mental-health issues. People receiving Social Security disability spend one-quarter to one-third of their income on cigarettes each month. And people with serious mental illnesses die, on average, 25 years earlier than the rest of the population, largely due to high rates of smoking-related illnesses like cancer, heart disease and stroke.
Concern over the physical health of such patients—and high medical costs—has prompted some states to begin addressing the issue. About 60% of state mental hospitals now prohibit smoking. But only one-third of them offer treatment to help patients quit. And few people living on their own with mental-health problems have access to smoking-cessation programs.
"It's amazing that there hasn't been a national call to make this a big agenda item," says Jill Williams, director of addiction psychiatry at the Robert Wood Johnson Medical School in New Brunswick, N.J. "This is not a small problem. It's half the population of smokers."
The ICD program is funded by a grant from SAMHSA, the Substance Abuse and Mental Health Services Administration, to test model programs integrating medical and mental-health care. Of ICD's 500 patients, many of whom are homeless, jobless and struggling with legal and family problems as well as their psychoses, 35 are now working to quit smoking or have stopped.
Like hard-core smokers in the general population, many with severe mental illnesses think they need to smoke to cope with the stresses in their lives. Therapists are trained to gently challenge those beliefs with questions like, "Why do you think that?... Have you ever tried to quit to see what happens?"
"A lot of times, smoking doesn't really help with stress—people just think it does," says psychologist Daniel F. Seidman, director of Smoking Cessation Services at Columbia University Medical Center who designed the program for ICD.
Another key component is what Dr. Seidman calls "smoking by the clock." Patients smoke their typical number of cigarettes but at predetermined times, so they learn they can exert some control over their habit. Therapists also work with patients to set a firm quit date.
Nicotine patches, gum, lozenges and inhalers help patients avoid an abrupt withdrawal when they quit smoking; Medicaid typically pays for two 12-week trials per year.
Some studies suggest that people with mental illnesses may have stronger dependence on nicotine than other smokers, although the science isn't yet clear. It's also possible that some symptoms of mental illness may be heightened by nicotine withdrawal.
A study in the American Journal of Psychiatry this month of 40 smokers with schizophrenia treated in emergency departments found that nicotine replacement significantly lowered their agitation compared to medication alone.
Mr. King, the ICD patient, says he struggled for years with significant mental-health issues and substance abuse. "After 20 years of living in shelters, psych wards, institutions, I couldn't plan my day without having a pack of cigarettes with me."
Mr. King set his quit date as March 21, his father's birthday. He tried to outsmart the "smoking by the clock" part of the program by waking up at 4 a.m. to smoke, before his official schedule began. But armed with a 21-milligram nicotine patch, he stopped smoking on March 21 and hasn't lit up since
Mr. King is putting his life together in other ways too. He has lost 25 pounds, moved to a new apartment and can walk up the five flights of stairs without stopping. "My daughters are proud of me. I'm starting to feel better about myself," he says. "I see some sunshine down the road for me."
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