Between 50% and 80% of people with mental disorders smoke cigarettes. Are the tobacco companies targeting this population, and are mental health care facilities promoting the use of tobacco? What are psychiatrists' responsibilities in the overall health of their patient?
Those who suffer from mental illness smoke cigarettes at astoundingly high rates compared to those without some form of mental illness. We have published data showing that between 50% and 80% of those suffering from a major mental illness (such as major depression, bipolar disorder, generalized anxiety disorder and schizophrenia, among others) smoke, whereas less than 40% of those who have never had mental illness smoke (Lasser et al., 2000). In all, people with mental illness consume 44% of all cigarettes in the United States, an exceedingly high figure that might surprise even the most sanguine mental health care professional.
This statistic bears within it numerous individual stories of pain and suffering. Consider the case of one of our patients, whose woeful story no doubt mirrors that of many others we treat who suffer with chronic mental illness:
"Mario" started hearing voices over a decade ago after experimenting with LSD, developing a prolonged psychosis that required several extended stays in psychiatric hospitals with a diagnosis of chronic paranoid schizophrenia. At 35 years old, Mario is perpetually disheveled, with a starry look in his eyes. Mario receives $650 per month from Social Security for disability and, except for his occasional brief forays into the working world (which usually end when voices tell him to quit or when he decides that his bosses are conspiring against him), has no other income. He spends $350 on rent for a subsidized apartment in western Massachusetts and about $50 per month on food beyond what his food stamps will pay.
Like so many others with chronic mental illness, at two packs per day and about $4 per pack, the rest of Mario's money -- roughly $240 per month, nearly 37% of his total monthly income -- goes to cigarettes. Since virtually all of Mario's income comes from the government, in a more cynical moment we might think that he is little more than a bagman whose job is to deliver government money to Big Tobacco.
What will become of Mario in 30 years, almost $100,000 in cigarettes later? Perhaps, like one 65-year-old patient with schizophrenia we met, as a result of smoking-related damage to his respiratory tract, Mario will become an "aspiration risk," unable to prevent food from passing down his trachea into his lungs. And maybe, like this patient, Mario will develop repeated pneumonias, will require frequent ventilation support in the intensive care unit and eventually will need a feeding tube placed directly into his stomach to prevent further pneumonias, costing our health care system thousands of dollars.
Or, perhaps like another 65-year-old patient with schizophrenia we have encountered, Mario will develop a massive lung cancer that, because of his psychosis, he will refuse to have treated.
Tobacco hits the mentally ill especially hard. Roughly one-third of all smokers will die early because of their habit (American Lung Association, 2001). Living with lung cancer or emphysema is hard enough, but imagine trying to make decisions about treatment options or end-of-life issues in the midst of a dark depression or active psychosis. Those with mental illness are often the least capable of coping with the devastating medical illnesses caused by smoking.
Various groups use the association between mental illness and smoking to their advantage. Psychiatric units that allow smoking are generally much more popular among patients than smoke-free units and thus generate more revenue. Many of these psychiatric units further use smoking to their advantage by offering cigarette privileges as rewards for good behavior. At one local unit, patients who break minor rules (such as yelling or refusing to participate in groups) are not allowed to go on the next scheduled smoke break. (At that unit, there were six such breaks throughout the day.) Those patients who are assaultive or require restraints are not allowed to smoke for 24 hours.
The tobacco industry also uses the association between mental illness and cigarette smoking to its advantage. R.J. Reynolds Tobacco Co. noted the perception among smokers that tobacco "helps perk you up" and "helps you think out problems," as well as providing "anxiety relief," and helping people "gain self-control," "calm down" and "cope with stress" (Nordine, 1981, as cited in Lasser et al., 2000). (Recent studies have shown that the opposite is true and that smoking often precedes the onset of mental illness.)
Could the tobacco industry be unaware that advertising that highlights the youthful, healthy effects of smoking might be particularly appealing to those with mental illness? After all, the Marlboro Man is the epitome of calm self-assuredness. He does not appear to be anxious, depressed or hallucinating -- though we might wonder if he gets a bit sad riding all alone. Have all of his cowboy buddies passed on to the great prairie in the sky because of their tobacco habits?
Unfortunately, tobacco does not deliver any mental health benefit. In fact, it directly contributes to depression and anxiety. In addition, its physical effects -- emphysema, cancer and heart disease -- can certainly make a person feel blue. If the tobacco companies have not hesitated to peddle their goods to children and the Third World, why should we presume they do not also target those with mental illness -- the group that comprises 44% of their market?
What should we do with this information? First, we need to pressure tobacco companies not to mislead their customers by falsely promoting their products as avatars of health. Those with mental illness probably have a more difficult time than most sorting out the specious claims and implications of tobacco advertising. Second, physicians need to target their patients with mental illness for smoking-cessation efforts. People with mental illness are able to quit smoking, despite some attitudes to the contrary. Third, parents should be alert to the smoking habits of their children -- a child who begins smoking may be at increased risk for mental health problems (including substance abuse) and warrants close observation. Fourth, we need to advocate raising taxes on tobacco. Studies have shown that increased cigarette taxes cut cigarette consumption by teenagers. Perhaps the same would be true for the chronically mentally ill, many of whom, like Mario, have very limited incomes. Fifth, we should pressure our legislators to expand Medicaid coverage (which is the only insurance many with mental illness have) to include smoking-cessation counseling and medications. Finally, we ought to work to ensure that all of the money that states receive in settlements from Big Tobacco be earmarked for tobacco control. Some of this money should be devoted specifically to smoking-cessation and tobacco education efforts aimed at the mentally ill.
We must do all we can to protect everyone, especially our patients who are among our society's most vulnerable, from the devastating effects of tobacco.
American Lung Association (2001), Quitting smoking: Why should cigarette smokers think about quitting? Available at: www.lungusa.org/tobacco/quitting_smoke.html. Accessed Aug. 30.
Lasser K, Boyd JW, Woolhandler S et al. (2000), Smoking and mental illness. A population-based prevalence study. JAMA 284(20):2606-2610.