By Jill Williams, M.D., and Marie Verna
In February, the Centers for Disease Control and Prevention (CDC), in collaboration with the Substance Abuse and Mental Health Services Administration (SAMHSA), issued a report about the rates of smoking among adults with some form of mental illness, Vital Signs: Current Cigarette Smoking Among Adults Aged ≥18 Years with Mental Illness — United States, 2009–2011. The report finds that 36 percent of adults with a mental illness are cigarette smokers, compared with only 21 percent of adults who do not have a mental illness. This translates to about 16 million smokers with mental illness in the United States today.
This report is historic for many reasons, but the most important is that it clearly reveals the lack of attention given to the needs of people managing mental illness by our health system. Now that we mental health advocates—both individuals with mental illness and those without—see these stark numbers, our response must be strong, focused and forceful.
Although the CDC routinely publishes reports on smoking rates among the general population, this analysis is the first to also include smoking rates among individuals with mental illness. For the last 50 years, an area of public health termed “Tobacco Control” has been effectively reducing smoking rates in the U.S. through policy, public education and regulation. Smokers with mental illness, however, have benefitted very little from these efforts and, even today, have very few opportunities to access services that could help them quit.
Based on the trends in the CDC report, smokers with mental illness could easily represent the majority of U.S. smokers in the near future. This has many serious implications for individuals with mental illness.
As smoking becomes less common, it will no longer be considered the community norm. We know that smokers often experience discrimination in housing, but for people with mental illness, who are already struggling to find jobs and housing, the challenge will be even greater. Not only do employers prefer to hire non-smokers, landlords prefer to rent to non-smokers due to lower damage and insurance costs. Programs that provide multi-unit, publicly funded housing, are already forming policies that prohibit smoking (not even in one’s own apartment) because second-hand smoke circulates through a building’s airways and poses a risk to all residents. Increasingly, landlords are discriminating against smokers for the simple reason that being a cigarette smoker has become a marker for individuals who have a mental illness or other substance use disorder, adding to the stigma of having a mental illness.
The financial implications are great as studies confirm that people in low-income brackets spend up to one-third of their monthly income on cigarettes. But the most important reason to think about addressing tobacco is that consumers who smoke have a 50 percent chance of dying from a tobacco-caused illness. This is at least 25 years before the average age of death among those who do not smoke. People who struggle to overcome the symptoms of a mental illness don’t deserve to die from tobacco use.
As advocates, we have many ways to address this problem, just as public health advocates had when they brought about change in the general population. But we’ll need to start by acknowledging that within the existing mental health system, unique barriers exist, and we’ll have to start by cleaning up our own house.
Professionals in the treatment community have been slow to change. Most behavioral health treatment programs (including both mental health and addictions) still do not offer routine access to tobacco treatment in their range of services. Many professionals are not up-to-date on advances that have been made in tobacco treatment, therefore, offer old fashioned, ineffective approaches.
State programs that offer free or low-cost treatments still target middle class community smokers who are able to quit with brief interventions. But smokers who have a mental illness often smoke more cigarettes per day and are more addicted than other community smokers, warranting a more intensive treatment approach. This means that, although most states invest significant dollars into tobacco control programs, they never see a return on that investment because they’re targeting the wrong people. The bottom line is that these programs in fact, may not benefit the smokers who need help the most.
Perhaps one of the biggest barriers is that smoking remains part of the culture in most mental health and residential facilities. In partial hospital programs, daily schedules take into account the needs of smokers. In inpatient programs, consumers are allowed outside only during smoke breaks. In housing programs, we expect people who want to quit to live side-by-side with people who smoke, a pack of cigarettes a day. In case management programs, we consider it our jobs to drive people to stores to buy cigarettes.
At the same time, mental health professional and family advocacy organizations have hesitated to demand tobacco treatments. Indeed, some have continued to lobby for exemptions to smoke-free air provisions for hospitals and other mental health treatment facilities.
Collectively, we, as advocates, have failed to raise this issue onto the national agenda. When we buy cigarettes for others, or remain silent because of our own ambivalence, we allow another generation of our loved ones to be lost to this deadly addiction. The same rules and standards we apply to other addictions should be applied to tobacco use whether in the hospital, the clinic or the home. We should feel the same outrage about the lack of services for smoking cessation as we feel about the lack of crisis, housing or employment services.
Community-based initiatives for addressing tobacco are a foundation of current CDC best practices and are critical in transforming the social norms around the way tobacco is promoted and used. Community tobacco coalitions help to build demand for services, strengthen advocacy, move treatment efforts forward and enhance the importance of the issue among administrators and key decision makers.
Creating strong coalitions by partnering with individuals and community agencies will facilitate more rapid systems change by making tobacco use in mental health systems less desirable, less acceptable and less accessible. The same strategies that have been effective in targeting tobacco in our communities need to be applied to our mental health system.
People living with mental illness, organizations advocating for those individuals, families, provider agencies federal, state and local government allies are all essential. Through an organized advocacy effort we can begin to undo the legacy of smoking and mental illness. This will require that we work together to disseminate education, develop local policy, garner resources and, most importantly, ensure that every smoker who has a mental illness can access evidence-based treatment to try to quit.
The CDC/SAMHSA report, while the first of its kind, cannot be the last word from us. As people who care deeply about the wellbeing of those among us who manage serious, life-changing mental illnesses, we must use the hard facts it reveals to fight the hard battle we face in changing our public health system and ourselves.
Jill Williams is a Professor of Psychiatry and Director of the Division of Addiction Psychiatry at UMDNJ-Robert Wood Johnson Medical School. Marie Verna is a Program Support Coordinator at UMDNJ-University Behavioral Health Care and MPAP Candidate at Rutgers University Bloustein School of Planning and Public Policy.