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​​​​​​Mental Health and/or Other Addiction(s)   Background


People ​with mental illness are two to four times more likely to smoke, are heavier smokers, smoke more numbers of cigarettes per day, and have lower quit rates compared to smokers from the general population1,2.
Prevalence of smoking among those diagnosed with mental disorders has been well documented. Smoking rates, differing by diagnoses, vary between 40 to 90%, compared to 17% in the general Canadian population3. Studies have shown smoking rates amongst people suffering from the following disorders: bipolar disorder 51 to 70%; major depressive disorder 40 to 60%; anxiety disorders 8 to 66%4. Smoking prevalence for persons with schizophrenia has been found to be considerably high, ranging from 45 to 88%5. The burden in morbidity and mortality due to high smoking rates among the mentally ill and addicted clients is alarming; this population suffers disproportionately from smoking related disabilities and this causes great financial burden to the heath care system. It appears that the mentally ill and addicted population are more likely to suffer from various physical problems such as cardiovascular, lung diseases, and diabetes6, and tend to die much earlier than the general population7.
Similarly, smoking prevalence within substance abuse/addicted populations is also high ; people reporting substance abuse problems have higher smoking prevalence than the general population, with nearly 50%  having nicotine dependence8. Rates ranging from 11 to 48% have been found for those who abuse alcohol, cannabis, cocaine, amphetamines and opioids9.
There are various factors contributing to higher smoking rates among people with mental illness and/or addictions including social, environmental and biological factors. Self-medication theory, shared genetic vulnerability and pathophysiological mechanisms may provide some explanations for high rates of comorbidity. Nicotine triggers release of various neurotransmitters involved in some psychiatric disorders and are associated with the reinforcement effects of some addictive substances10. Consequently, people with mental illness may smoke for various reasons including to self medicate the effects of their illness11.
The high smoking rates among those with mental illness and/or other addictions translates into more widespread health consequences and deaths due to smoking among this group12. People with mental health and addictive disorders who smoke also face enormous economic and social challenges. Studies have also shown that up to 27% of their disability income budge may be spent on tobacco products13.
Need for Effective and Specialized Treatment
Smokers experience negative nicotine withdrawal symptoms when they stop smoking. These withdrawal symptoms are more pronounced in smokers who suffer from mental illness or have other addictions when they stop smoking. Some studies, for example, have found that nicotine withdrawal can mimic or worsen psychiatric disorders, although other studies have not confirmed this14. Smoking cessation may also aggravate medication side-effects15. This means that clients on some psychotropic medications must be reviewed by health care professionals when quitting smoking, as they may need adjustment in their medication dosages in order to avoid drug toxicities due to increased drug levels in the blood16. Thus close monitoring of the amount smoked, cessation treatment, medication side effects and psychiatric symptoms becomes important when addressing tobacco dependence treatment in populations with psychiatric disorders.
Historically, the culture of tobacco use has been ingrained in the mental health and addictions fields with cigarettes having been used as reinforcement for compliant behaviour and enhancing social activity among individuals with mental illness17. This common practice in most mental health institutions and residential programs poses great challenges in addressing tobacco use problems in such settings. However, studies have shown that mentally ill clients are interested in quitting smoking18, and are able to quit with successful rates19. This means that tobacco use interventions should be an integral part of the comprehensive mental health care delivery system.

1 Ziedonis D, Hitsman B, Beckham JC, et al. Tobacco use and cessation in psychiatric disorders: National Institute of Mental Health report. Nicotine Tob Res. 2008:10(12); 1691 – 1715.
2 Lasser K, Boyd JW, Woolhandler S, et al. Smoking and mental illness: a population-based prevalence study. JAMA. 2000:284(20); 2606 – 2610.
3 Canadian Tobacco Use Monitoring Survey (CTUMS). 2010. Annual Results. Accessed November 21, 2011
4 Kalman D, Morissette SB, George TP. Co-morbidity of smoking in patients with psychiatric and substance use disorders. Am J Addict. 2005 Mar-Apr;14(2):106-23.
5 Ibid
6 Action on Smoking and Health (2001). Mental health patients are victims of tobacco. Accessed 25 Aug 2011.
7 Colton CW & Manderscheid RW. Congruencies in increased mortality rates, years of potential life lost, and causes of death among public mental health clients in eight states. Prev Chronic Dis. 2006:3(2); A42.
8 Le Strat Y, Ramoz N, Gorwood P. In alcohol-dependent drinkers, what does the presence of nicotine dependence tell us about psychiatric and addictive disorders comorbidity? Alcohol Alcohol. 2010 Mar-Apr;45(2):167-72.
9 Ibid.
10 Farnam CR. Zyban: a new aid to smoking cessation treatment – will it work for psychiatric patients? Journal of Psychosocial Nursing & Mental Health Service. 1999:37(2); 36 – 42.
11 Ibid.
12 Johnson JL, et al. Tobacco Reduction in the Context of Mental Illness and Addictions: A Review of the Evidence. Prepared for Dr. J. Millar and L. Drasic of the Provincial Health Services Authority by the Centre for Addiction Research of British Columbia. May 1, 2006. Accessed Nov. 19, 2010:
13 Steinberg ML, Williams JM, & Ziedonis DM. Financial implications of cigarette smoking among individuals with schizophrenia. Tob Control. 2004:13; 206.
14 Baker A, Richmond R, Haile M, Lewin TJ, Carr VJ, Taylor RL, et al. A randomized trial of a smoking cessation intervention among people with a psychotic disorder. Am J Psychiatry. 2006:163(11); 1934 – 1942.
15 Lopes FL, Nascimento I, Zin WA, Valenca AM, Mezzasalma MA, Figueira I, et al. Smoking and psychiatric disorders: a comorbidity survey. Brazilian Journal of Medical and Biological Research. 2002:35; 961 – 967.
16 Farnam CR. Zyban: a new aid to smoking cessation treatment – will it work for psychiatric patients? Journal of Psychosocial Nursing & Mental Health Service. 1999:37(2); 36 – 42.
17 Williams JM & Ziedonis D. Addressing tobacco among individuals with a mental illness or an addiction. Addictive Behaviors. 2004:29; 1067 – 1083.
18 Prochaska JJ, Rossi JS, Redding CA, Rosen AB, Tsoh JY, Humfleet GL, et al. Depressed smokers and stage of change: implications for treatment interventions. Drug Alcohol Depend. 2004:76(2); 143 – 151.
19 George TP, Vessicchio JC, Sacco KA, Weinberger AH, Dudas MM, Allen TM, et al. A placebo-controlled trial of bupropion combined with nicotine patch for smoking cessation in schizophrenia. Biol Psychiatry. 2008:63(11); 1092 – 1096.

  Mental Health and/or Other Addiction(s)