The overall rate of cigarette smoking among adults has been falling steadily since the 1960s, but people with mental illnesses have been left behind.
About 20 percent of American adults have a mental illness, but they smoke more than 30 percent of the cigarettes smoked by adults in the United States, according to the Centers for Disease Control and Prevention (CDC).
Smoking rates are also higher among people with mental illness — 36 percent — compared to about 21 percent in the general population.
This doesn’t include people who only have a substance abuse or developmental disorder, so the rates could be higher.
Smoking rates are also higher for certain mental illnesses. Some studies have found that more than 80 percent of people with schizophrenia smoke cigarettes while only 34 percent of those with phobias or fears do.
While some factors may make it harder for people with mental illness to quit smoking, a big part is getting them the treatment they need.
“There are barriers for people with mental illness to access smoking cessation treatments, so I think we really have failed smokers with psychiatric disorders,” Jennifer Tidey, PhD, a professor of psychiatry and human behavior and of behavioral and social sciences at Brown University, told Healthline.
A long history
In popular culture, smoking and mental illness have long been intertwined, especially in movies and books depicting psychiatric hospitals.
There is some truth to this.
Sigmund Freud, the “father of psychoanalysis,” was a heavy smoker, averaging 20 cigars a day. He smoked up until his death, even after 33 operations for cancer of the mouth and jaw.
Some studies have also found that smoking rates among practicing and training psychiatrists are higher than for other medical specialties. Psychiatrists are also less likely to help patients quit smoking.
Historically, the culture of mental health facilities has even supported smoking by patients.
“If you look back 20 years in the United States, cigarettes were handed out in inpatient units and sometimes given as rewards,” Joelle Ferron, PhD, an assistant professor of psychiatry at the Dartmouth Psychiatric Research Center, told Healthline.
Some psychiatric hospitals requested free cigarettes from tobacco companies to hand out to long-term psychiatric patients.
The tobacco industry also reinforced the mistaken belief that people with mental illness can use tobacco to self-medicate their symptoms.
Research, though, shows that the opposite is true — giving up tobacco can reduce depression, anxiety and stress, as well as improve mood and quality of life.
There are signs that the culture at mental health facilities is changing, but it still has a long way to go.
About 90 percent of general hospitals have now gone smoke-free, but only 49 percent of mental health facilities have done so, according to a 2016 survey by the Substance Abuse and Mental Health Services Administration.
Can people with mental illness quit smoking?
The cultural link between smoking and mental illness is so strong that many clinicians once thought that people with mental illness didn’t want to quit smoking or couldn’t quit.
This is not true.
“People with mental illness are able to quit smoking,” said Ferron. “They just need a little more help sometimes.”
Research shows that people with mental illness are just as interested in giving up smoking as the general population.
They are also able to quit successfully, although they may need longer and more intense treatments.
“There are studies showing that when people with psychiatric disorders try to quit, they make quit attempts but relapse very quickly,” said Tidey. “And they have a harder time successfully quitting.”
This can be more difficult because people with mental illness are particularly vulnerable.
Many have fewer financial resources, more unstable living conditions and lack health insurance.
Even “quit lines” — one of the most common tools for stopping smoking — may not work as well for people with mental illness.
“Unless we can modify the quit lines, they’re not as effective for people with mental illness,” said Ferron. “That’s the same for most of the treatments. They need to be modified to be effective.”
She said that smoking cessation programs need to be tailored to a person’s mental illness.
For example, people with schizophrenia may have trouble learning. This can make it difficult for them to read written materials that are part of a smoking cessation program.
Ferron said that using more multimedia tools, including text-to-speech, can help people focus more on the content, not the reading.
“It’s another layer to decode what something says and then comprehend it,” said Ferron. “Text-to-speech takes away the decoding, so all they have to do is focus on comprehension.”
There are many myths surrounding mental illness and smoking. These can be dispelled by educating patients, doctors and the general public.
But a big part of helping people with mental illness quit smoking is to make them believe that they can.
“When so many people have told you during your whole life that you can’t do so many different things, it’s really hard to believe that you can do something so hard,” said Ferron.