News Release

Adults with mental illness have lower rate of decline in smoking

Peer-Reviewed Publication

JAMA Network

In recent years, the decline in smoking among individuals with mental illness was significantly less than among those without mental illness, although the rates of quitting smoking were greater among those receiving mental health treatment, according to a study in the January 8 issue of JAMA.

"Despite significant progress made in reducing tobacco use within the general population, individuals with mental illness smoke at rates approximately twice that of adults without mental disorders and comprise more than half of nicotine-dependent smokers," according to background information in the article. Mental illness is associated with higher levels of nicotine dependence, intensity of smoking, and smoking severity (i.e., number of cigarettes/week). Tobacco cessation efforts have focused on the general population rather than individuals with mental illness.

Benjamin Lê Cook, Ph.D., M.P.H., of the Harvard Medical School/Cambridge Health Alliance, Cambridge, Mass., and colleagues used nationally representative surveys of U.S. residents to compare trends in smoking rates between adults with and without mental illness and across multiple disorders (2004-2011 Medical Expenditure Panel Survey [MEPS]) and compared rates of smoking cessation among adults with mental illness who did and did not receive mental health treatment (2009-2011 National Survey of Drug Use and Health [NSDUH]).The MEPS sample included 32,156 respondents with mental illness (reporting severe psychological distress, probable depression, or receiving treatment for mental illness) and 133,113 without mental illness. The NSDUH sample included 14,057 lifetime smokers with mental illness.

The researchers found that adjusted smoking rates declined significantly from 2004 to 2011 among individuals without mental illness, decreasing from 19.2 percent to 16.5 percent, but did not change significantly among those with mental illness, decreasing only from 25.3 percent to 24.9 percent. "… the fact that smoking rates for individuals receiving mental health care have not experienced the same rates of decline as the general population suggests limited adoption of integrated treatments and ongoing barriers to cessation treatment in mental health care settings."

The rate of quitting smoking among individuals who received mental health treatment was 37.2 percent, significantly higher than the 33.1 percent quit rate among those who did not receive mental health treatment. Receiving any mental health treatment significantly increased the probability of having quit.

"These results suggest that smokers can quit and remain abstinent from cigarettes during mental health treatment and that this is a promising setting to promote smoking cessation. It also indicates the importance of assisting smokers with mental illness in overcoming barriers to accessing mental health care (e.g., insuring the uninsured, increasing the supply of mental health care professionals, improving linkages between primary care and mental health care) as a means to address smoking-related harm," the authors write.

"The mechanisms that support persistently higher rates of smoking among individuals with mental illness are complex and remain understudied. Patients with mental illness may attribute greater benefits and reward value to smoking compared with patients without psychiatric disorders or may experience more difficult life circumstances, higher negative affect, or a relative lack of alternative rewards. Identifying new interventions to address mechanisms specific to this population should be a priority for tobacco control policy."


(doi:10.1001/jama.2013.284985; Available pre-embargo to the media at

Editor's Note: This study was supported by a National Institute of Mental Health grant (Dr. Cook, principal investigator) and the William F. Milton Fund. All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

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