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A reminder that this article from our magazine Visions was published more than 1 year ago. It is here for reference only. Some information in it may no longer be current. It also represents the point of the view of the author only. See the author box at the bottom of the article for more about the contributor.

The CACTUS Project

Cultivating the Awareness of the Context of Tobacco Use

Syd Malchy, BA, MSc and Joy L. Johnson, PhD, RN

Reprinted from the "Tobacco" issue of Visions Journal, 2007, 3 (4), p. 9

“I wish something could be done. All my problems in life are related to smoking.”
—CACTUS participant

These are the powerful words of a person living with a mental illness and tobacco addiction. Tobacco addiction affects from 50% to 90% of people living with a mental illness.1 It has been estimated that more tobacco is consumed by people living with a mental illness than any other population in the Western world.2 The severity of this addiction is extreme, and the lives of mentally ill smokers are often consumed by procuring and maintaining their tobacco supply as well as spending much of their time smoking cigarettes.

Nicotine addiction, cigarette reduction and tobacco cessation are all concepts that deserve attention within the mental health and addictions arena. For the past year, the CACTUS Project (Cultivating Awareness of the Context of Tobacco Use) has been examining the role that tobacco plays in the lives of people living with mental illness, in the context of their communities.

Who we talked to

We surveyed mental health consumers about their tobacco use, and, in addition to developing a statistical profile of tobacco use patterns, we uncovered compelling accounts about the impact of tobacco use.3

We surveyed 781 outpatient clients of the Vancouver community mental health teams and learned that almost half of these clients are current smokers. This is almost three times the current rate of smoking in BC overall. The clients also tended to be heavy smokers, smoking on average 20 cigarettes every day, and they considered themselves to be extremely addicted to cigarettes—62% described themselves as “chain smokers.”

What they told us about tobacco’s impacts

The implications of such a severe addiction include a long list of adverse health consequences. Many of the smokers we surveyed, most in their late forties, were already experiencing serious health repercussions of their cigarette habit. Over half revealed they had experienced symptoms of a disease or illness that was caused or worsened by their smoking (e.g., lung infections, emphysema).

A more hidden cost of tobacco use is the extreme economic hardship these individuals endure as a result of their tobacco consumption. Many indicated that they spend most of their disposable income on cigarettes, having no money left at the end of the month and giving up necessities like food and toilet paper so they will have money for cigarettes. ‘Bumming’ cigarettes, picking up butts from the street and buying smuggled tobacco are just some of the ways in which these individuals maintain their pack-a-day habit.

In our study, 69% of the smokers reported that they smoke to cope with the symptoms of their psychiatric illness. There is scientific evidence to suggest that nicotine affects people living with mental illness in a different and possibly more profound way, making quitting smoking particularly difficult. Nicotine affects receptors (brain chemicals) on the same pathways implicated in mental illness.

The social implications of smoking were exposed by clients’ reports of shame and guilt about their tobacco use. Most clients who smoked reported that they received looks of hostility and messages of reproach about their tobacco use. Almost three-quarters of the smokers indicated that they felt people—family, friends and the general public—were judging them because of their smoking habit.

Social isolation can be an important aspect of tobacco addiction. The majority of smokers indicated that they avoid settings where they cannot smoke, and over a third found it difficult not to smoke in hose places. Often, clients use cigarettes as a substitute for these missing social interactions.

But it is more complex: tobacco use can enable both isolation and socialization, depending on the person. Within the context of the mental health care system, smokers’ tobacco use is often validated by health care providers and other peers with serious mental illness. This normalizes tobacco use for clients who smoke. It also may alienate clients who do not smoke and may magnify the difficulty for those who wish to reduce or quit smoking, or who have already quit smoking.

The good news

While the study results may seem dismal, there is encouraging news as well. Contrary to widely held beliefs that people with mental illnesses are not interested in reducing their tobacco use, 86% of clients indicated that they do want to quit smoking. The majority indicated that they had made several attempts to quit. Even more promising is that these clients described times when they successfully stopped smoking, sometimes for as long as one to five years before returning to cigarettes. Over half of the smokers were considering making a serious attempt to cut down on cigarettes or to quit entirely.

This new information implies a conversation is needed between those struggling with tobacco addiction and those struggling to help support them. The CACTUS Project will be hosting a forum in the spring of 2007 to promote awareness and encourage dialogue about these issues. Anyone concerned is invited to attend. For more details, please check our website at Both the client and provider survey results are also available on this website.

About the authors

Syd is Project Director of the CACTUS Project, a project of the Nursing and Health Behaviour Research Unit in the School of Nursing at the University of British Columbia.

Joy is the UBC Site Director of the Centre for Addictions Research of BC. She is also Professor and Associate Director of Graduate Programs and Research in the School of Nursing at the University of British Columbia.

  1. The evidence regarding the exact rate of tobacco use among people with mental illness is not entirely clear. There is some suggestion in the literature that tobacco use varies by diagnosis, with the higher rates for those individuals with schizophrenia. The 50% to 90% figure is from Johnson, J.L., MacDonald, S., Reist, D. et al. (2006). Tobacco reduction in the context of mental illness and addictions: A review of the evidence. Vancouver: Provincial Health Services Authority.

  2. McNeill, A. (2001). Smoking and mental health – A review of the literature. London, UK: SmokeFree London Programme, National Health Service London Region.

  3. The findings reported here are part of a larger study that also included a survey of mental health professionals. For the first of a four-part series on the study, see Johnson, J. & Malchy, S. (2007, January). The CACTUS PROJECT: The prickly subject of smoking and mental health. Newsletter, 1: 1-4.


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