Recognition of a disconnect between what patients with serious mental illness want and what health providers think they want appears to be a crucial step in reducing smoking rates among such patients.
Those who have serious mental illness have significantly higher smoking rates than the general population. But researchers at Washington University School of Medicine in St. Louis have found they can help such patients kick the habit using low-burden, common-sense strategies that begin with simply recognizing that many such patients want to quit smoking.
The study is published June 1 in the American Psychiatric Association’s journal Psychiatric Services.
Using questionnaires to survey patients and their doctors, nurses and caseworkers, the researchers discovered a disconnect between what patients want and what their health providers think they want.
“We’ve found that 80 percent of patients who smoke and have a serious mental illness want to quit smoking and that 60 percent made an attempt to quit in the last year,” said Li-Shiun Chen, MD, the study’s first author and an associate professor of psychiatry. “Yet 85 percent of the health-care providers surveyed report that the main reason they don’t offer medication or smoking-cessation counseling to their patients is because patients don’t want it.”
The current smoking rate in the United States is 15 percent, and in Missouri, about 23 percent. But among those with serious mental illness, the rate of smoking is 57 percent. Chen’s team found that many of these patients want to quit but don’t get treatment.
After surveys of patients made it clear that they had interest in stopping smoking, and health-care providers in four St. Louis-area community mental health centers were trained about medications and other options to help patients quit, previous assumptions were turned upside down.
During a two-year period from 2014 to 2016 in which the researchers surveyed patients at the community mental health centers, they found that prescriptions for smoking-cessation medications quadrupled, from 4.6 percent to 18 percent of patients. Meanwhile, smoking rates among patients treated for schizophrenia, post-traumatic stress disorder, bipolar disorder and clinical depression declined about 3 percent, from 57 percent to 54 percent. Additionally, many more patients reported decreasing the number of cigarettes they smoked on a typical day.
“The eventual decline in the rate of smoking was rather modest, falling from 57 percent to 54 percent, but this system of clinics treats 4,000 patients, meaning that about 120 people actually quit smoking, and more reduced the number of cigarettes they smoked,” Chen said.
Mental health providers traditionally have focused primarily on patients’ psychiatric problems and have not been as concerned with smoking. Yet even when psychiatrically stable, such patients die an average of 12 years earlier if they smoke, Chen said.
“If we don’t address lifestyle factors such as smoking, we can manage a patient’s psychiatric health but not have much of an impact on the length of a patient’s life, due to smoking,” she said.
Chen’s primary goal has been to address barriers to smoking-cessation treatment, such as a lack of time and training on the part of providers, as well as the assumption that patients are not interested in quitting. The effort has involved supporting patients’ decisions to quit smoking and determining if doctors recommend smoking cessation to improve health, as opposed to simply asking whether a patient is interested in quitting.
“We’re starting to think about smoking more like a chronic illness,” said senior author Laura Jean Bierut, MD, the Alumni Endowed Professor of Psychiatry. “We wouldn’t ask for a patient’s permission to treat high blood pressure or diabetes; we would prescribe medications and recommend lifestyle changes. We think smoking should be treated the same way in patients with serious mental illness.”
Chen and Bierut plan to increase the number of clinics where they employ this approach to learn whether their strategies of support and enhanced communication between patients and providers can help others with mental illness kick the habit.
“If we were to continue to achieve a 3 percent reduction every two years, it would take some time, but eventually smoking rates would get significantly lower,” Chen said.