Reviewing the Evidence
Reprinted from the "Tobacco" issue of Visions Journal, 2007, 3 (4), pp. 6-7
Tobacco use is prevalent among people with mental illness or addictions, and the effects of tobacco use are more widespread in this population than in the general population. Because of this high tobacco use rate, thousands of smokers with mental illness or addictions die each year due to smoking. They experience greater physical health consequences and deaths related to tobacco compared with the general population.
Additional costs of tobacco addiction include the financial burden associated with buying tobacco products. Because of their strong tobacco addiction, people with mental illness and other addictions sometimes choose to buy tobacco products instead of buying food and taking care of their other basic needs. In addition, smoking can affect a person’s ability to secure housing and employment.
There is conflicting information about the benefits and limitations of encouraging people with addictions and mental illness to stop smoking. This conflict creates a barrier to moving forward with tobacco reduction programs and strategies for these populations. This past year, under the direction of Dr. John Millar and Lydia Drasic, the Centre for Addictions Research of BC conducted a review of the evidence related to tobacco reduction in the context of mental illness and addictions.
In this review, we considered the complex reasons why people with mental illness and addictions continue to smoke. We explored the evidence related to whether nicotine has a therapeutic benefit for people with mental illness and addictions, and we examined the approaches that could be used to address the harmful effects of their tobacco smoking.
Statements made in this article are based on our findings, which are presented in the 2006 report, Tobacco in the Context of Mental Illness and Addictions.
Biological and social reasons reinforcing use
Our review revealed that there are many factors contributing to the high rates of tobacco use among those with mental illness or addictions. Nicotine is known to trigger several biochemical events, including enhanced release of neurotransmitters such as dopamine, norepinephrine and serotonin. These neurotransmitters are implicated in many psychiatric disorders and are involved in the reward systems associated with other addictive substances. Not surprisingly, people with mental illness have used tobacco to cope with the effects of their illness. Those with addictions have used nicotine as a replacement when withdrawing from other drugs.
Self-medication is only part of the issue. While biological factors are powerful, social factors continue to reinforce tobacco use among people with mental illness or addictions. Tobacco use has traditionally been part of the culture of mental health and addictions services. Cigarettes have been used to reinforce behaviour, and tobacco use has been seen as an acceptable substitute for other substance use.
Impacts of stopping
We considered the benefits and harms associated with smoking cessation for people with addictions and mental illness. The positive health benefits of smoking cessation are well known. Smoking cessation dramatically reduces the risk of heart disease and cancer and prevents continued impairment of lung function in those with chronic obstructive pulmonary disease.
There are a number of potential negative consequences that must be balanced with these outcomes. Nicotine withdrawal can include symptoms of depressed mood, insomnia, irritability, frustration or anger, anxiety, difficulty concentrating, restlessness, and increased appetite or weight gain. Some of these symptoms might become particularly aggravated among people with mental illness or addictions. For example, nicotine withdrawal may aggravate some psychiatric disorders, mimic or worsen medication side-effects, and, for some people taking medications for psychiatric symptoms, blood levels of these medications may rise. This can happen because the tar in cigarettes affects the way the liver metabolizes certain medications.
On the up side, the evidence suggests that, in general, smoking cessation among those with a history of other substance use problems does not increase the risk of addiction relapse.
Evidence suggests that those with mental illness or addictions have many of the same barriers for smoking cessation as other smokers—addiction and fear of withdrawal, weight gain and failure.
Evidence also suggests that people with mental illness and addiction face additional challenges. They tend to have more extensive histories with cigarettes. They have more severe tobacco dependence, because their smoking has been positively reinforced. They express attitudes reflecting less readiness to quit—in part, because they’ve not been encouraged to quit. They can also experience a worsening of their psychiatric symptoms during their smoking cessation attempts and may lack the focus and motivation to be successful with cessation.
Because of these challenges, those with mental illness and addictions represent a subset of smokers for whom specialized smoking treatments are needed.
Based on the evidence we reviewed, the following approaches to tobacco control were recommended:
Tobacco treatment for people with mental illness or addictions should be integrated into existing mental health and addictions services
Service providers need support and training to incorporate brief tobacco-related interventions into their practices
Nicotine replacement therapy should be provided to all individuals with mental illness or addictions who want to quit or reduce their smoking
Individuals who are taking antipsychotic medications and quit smoking should have their medication dosages monitored in the first months following cessation
Smoke-free spaces support and encourage individuals with mental illness and addictions to remain smoke-free
About the author
Joy is the UBC Site Director for the Centre for Addictions Research of BC. She is also Professor and Associate Director of Graduate Programs and Research at the University of British Columbia School of Nursing