Historically, there’s been a connection between cigarettes and psychiatric illness. According to the National Alliance on Mental Illness, people with psychiatric disorders consume almost half of the cigarettes smoked in the United States. Those who live with mental illness and/or substance abuse disorders are about twice as likely to smoke as others.
Some have theorized that smoking is an attempt to self-medicate. And traditionally, many of the health professionals who treat psychiatric patients have assumed it’s best to treat other problems first and to work with their patients on smoking cessation once they have addressed issues such as depression or anxiety.
But a series of studies from researchers at Washington University School of Medicine is challenging the traditional idea that smoking, as unhealthy as it may be, can be tolerated in psychiatric patients.
Smoking and suicide
In one study, a team led by psychiatric epidemiologist Richard Grucza, PhD, reported that cigarette smokers are more likely to commit suicide than people who don’t smoke. In the past, that statistic has been attributed to the fact that numerous people with psychiatric disorders, who have higher suicide rates, also tend to smoke. But Grucza’s study found that smoking itself may increase suicide risk in the United States and that policies to limit smoking reduce suicide rates.
Grucza and his colleagues found suicide rates declined in states that implemented higher taxes on cigarettes and stricter policies to limit smoking in public places. And that’s true for all smokers, not just for psychiatric patients who smoke cigarettes.
“Our analysis showed that each dollar increase in cigarette taxes was associated with a 10 percent decrease in suicide risk,” said Grucza. “Indoor smoking bans also were associated with risk reductions.”
Smoking, drinking and drug use
A second study found that rates of smoking, drinking and drug use are significantly higher among those who have severe psychiatric illness such as schizophrenia and bipolar disorder as compared to people without psychiatric illness. Within the psychiatric illness group, for example, more than 75 percent were regular smokers.
That finding is of particular concern because individuals with severe mental illness are more likely to die at younger ages than people who don’t have those psychiatric disorders.
“These patients tend to pass away much younger, with estimates ranging from 12 to 25 years earlier than individuals in the general population,” said psychiatrist Sarah M. Hartz, MD. “But many don’t die from drug overdoses or suicide — the kinds of things you might suspect in severe psychiatric illness. They die from heart disease and cancer, problems that are linked to chronic alcohol and tobacco use.”
Hartz cares for a large number of patients with severe mental illness, many of whom are sick enough that they are on disability.
“And it’s always surprising when I encounter a patient who doesn’t smoke,” she says. “With public health efforts, we’ve effectively cut smoking rates in half in healthy people, but in the severely mentally ill, we haven’t made much of a dent.”
Quitting to improve mental health
Meanwhile, a third recently published Washington University study led by Patricia Cavazos-Rehg, PhD, shows that people who struggle with mood problems or addiction can safely quit smoking and that kicking the habit or cutting back significantly is associated with lower risks for mood disorders like depression.
In that study, Cavazos-Rehg and colleagues looked at data from surveys of smokers taken three years apart. At the time of the first interview, about 40 percent of daily smokers suffered mood or anxiety disorders or had a history of these problems. In the second survey three years later, 42 percent of those who had continued smoking suffered mood disorders, compared with 29 percent of those who quit smoking.
“We don’t know if their mental health improves first, and then they are more motivated to quit smoking, or if quitting smoking leads to an improvement in mental health,” Cavazos-Rehg said. “But either way, our findings show a strong link between quitting and a better psychiatric outlook.”
In addition, she believes the serious health risks associated with smoking make it important for doctors to work with their patients to quit, regardless of whether they have other psychiatric problems.
And Hartz said health professionals who treat the mentally ill need to do a better job of trying to get them to stop smoking, drinking and using drugs.
“Some studies have shown that although we psychiatrists know that smoking, drinking and substance use are major problems among the mentally ill, we often don’t even ask our patients about those things,” she said. “We can do better.”