By Jim Gogek

Outdated views on smoking among the mentally ill and addicted need to be changed.

The new frontier in the war against tobacco is special populations, particularly people with mental disorders, including addiction. Unfortunately, an uninformed, paternalistic public view prevails about smokers with schizophrenia or alcoholism, and it goes like this: “Oh, those poor people. Why don’t you just leave them alone and let them smoke? God knows they’ve got enough problems.”

That presumes, at best, that people with behavioral conditions don’t want to quit smoking or, at worst, that their lives aren’t worth saving. Fortunately, this blindness to the problem of smoking among people with mental illnesses is beginning to clear as reality dawns:

Smoking rate in the general US population is about 20%, although it’s as low as 12% in California

• People with psychiatric diagnoses have much higher rates of smoking and smoke more cigarettes than the general populations. In the United States, 44% of cigarettes are consumed by people with mental illnesses, including substance use disorders. People with serious mental illnesses die on average 25 years earlier than the general population, usually from tobacco-related disorders such as heart and lung disease.

• Alcoholics are three times more likely to smoke than the general population.  Alcoholics are more likely to die from tobacco than from alcohol.

In the past, psychiatrists, drug treatment counselors and other clinicians believed that patient smoking wasn’t their problem. Many still believe that. But a growing number are changing their minds. Drug counselors – many of whom are themselves recovering addicts who smoke – are facing up to the findings that quitting smoking during treatment doesn’t harm recovery and, in fact, may help it. A belief-change is growing among psychiatrists and other clinicians in behavioral health that confronting smoking among patients is part of their job. An editorial in the September 2011 edition of the American Journal of Psychiatry concluded that when a psychiatrist is faced with a patient who smokes, “doing nothing is now unacceptable.”

The editorial categorically rejects those unthinking assumptions that have cost the lives of countless people with mental illnesses:

• “These patients do not want to quit.” In fact, they do, and at rates (70%–80%) comparable to those in the general population.

• “They are not able to quit.” But many do, and with only slightly less success than the general population.

• “If they quit, their mental health or substance abuse conditions will worsen.” Mental health conditions can be stable or even improve, alcoholics who stop smoking are more likely to stay sober, and hospital wards that go smoke-free have fewer aggressive incidents and more staff time freed up for therapeutic encounters.

Excellent support exists for clinicians who want to help patients quit smoking: http://smokingcessationleadership.ucsf.edu/BehavioralHealth.htm

The Smoking Cessation Leadership Center at University of California San Francisco launched a comprehensive effort to train and support behavioral health clinicians in how to help patients quit smoking, including through a good series of newsletters that anybody can subscribe to. Clinicians who are tired of watching their behavioral health patients kill themselves with cigarettes should check it out.