• Behavioral Health and Tobacco Cessation

    Executive Summary

    Individuals with a mental health disorder smoke at higher rates than the general population. Due to their underlying mental health disorder, they may have a more difficult time quitting smoking and are more likely to relapse. There are options for treating this population to quit smoking, including counseling, behavioral therapy, and medications. As a family physician, you can provide tools to promote long-term cessation of smoking. Several links to resources are provided in this document.


    Each year, more people in the United States die from smoking-related causes than from AIDS, alcohol, cocaine, heroin, homicide, suicide, motor vehicle crashes, and fires combined.1 Tobacco use is the leading preventable cause of disease, disability, and death in the U.S.2 Tobacco dependence is a chronic condition characterized by remission and relapse, and family physicians should approach treatment with this in mind.3

    Adults who have a behavioral health disorder (i.e., a mental health disorder and/or a substance use disorder) are disproportionately affected by tobacco use. These individuals have higher rates of smoking, find it harder to quit smoking, and face disparities in treatment.4

    Confidence may be an issue for patients who have a behavioral health disorder. They may require more motivation and encouragement to try to quit smoking than other patients. Considering they have other conditions and disorders being treated, it may take these patients longer to quit smoking. Any reduction in tobacco use should be recognized as progress. Careful follow up is also important. Tobacco cessation goals for these patients should be re-evaluated on a regular basis and adjusted as necessary.

    Smoking Prevalence

    The past month smoking rate of people in the U.S. who have a mental health disorder (33.3%) is higher than the rate of adults with no mental health disorder (20.7%),5 with those adults with a behavioral health disorder smoking 40% of all cigarettes smoked by adults.5 Lifetime smoking rates are even higher in patients who are diagnosed with major depression disorder (59%), bipolar disorder (82.5%), or schizophrenia and other psychotic disorders (90%) compared to individuals with no current or lifetime mental health disorder.6 Studies have linked some mental health disorders with biological tendencies to use nicotine and difficulty quitting.7

    People who have substance use disorders tend to be highly dependent on nicotine.8 Individuals who use cocaine (80%) and opioids (>80%) have high rates of comorbid cigarette smoking.9 An estimated 200,000 adults who have a mental health disorder and comorbid substance use disorder die from tobacco-related diseases each year.4 This is higher than the general population estimate due to higher smoking prevalence among individuals who have a behavioral health disorder, as well as disparities in access to prevention and treatment. Substance use and concurrent tobacco use is similar among youth, as more than 80% of youth who have a substance use disorder currently use tobacco, the majority smoke daily, and many will be become high dependent and use tobacco long term.8


    Individuals who have a mental health disorder are more likely to have stressful living conditions, have a low income, and lack health insurance and access to health care, making it more of a challenging to quit.10 National data indicate that the quit ratio (i.e., the proportion of people who have ever smoked and then quit) is 34.7% among adults who have a mental health disorder, compared with a 53% quit ratio among those who do not.11 Research indicates that 68% of people who currently smoke among the general population would like to quit smoking, and 55.4% try to quit smoking at some point in the course of a year, regardless of any other diagnoses, including mental health disorders.3

    People who have a mental health disorder and/or substance use disorder want to quit smoking and want information on cessation services and resources. According to one study, people addicted to cocaine (52%), people who have alcoholism (50%), and people addicted to heroin (42%) were interested in quitting smoking at the time they started treatment for other addictions.12 One survey queried a sample of smokers in treatment for depression about their cessation goals. The results indicated that 33% wanted to quit smoking forever, 47% named some form of reduced smoking as a goal, and only 20% said quitting was not a current goal.8 Similar assumptions of people who have a substance abuse disorder have been made that they do not want to quit smoking. These have also not been supported by research results. 

    Challenges of Quitting

    The reinforcing, mood-altering effects of nicotine,13 genetic factors,14 and reduced coping for cessation15 have been identified as contributing factors to elevated rates of cigarette smoking in people who have co-occurring mental health disorders and/or substance use disorders.

    Cigarette smoking appears to be an attempt to self-medicate or cope with symptoms of depression, anxiety, boredom, loneliness, and other feelings common in people who have a mental health disorder.16 Smokers often report that cigarettes improve their mood, anxiety, and concentration.16 However, research studies of cognitive functioning show that non-smokers outperform smokers in nearly all tasks, and the benefits of smoking seems to be restricted to modest increases in attention during simple, repetitive tasks.17-20

    Individuals with mental health disorders who smoke may fail to recognize that they may be using tobacco to simply prevent or treat the unpleasant symptoms of withdrawal that the tobacco dependence has created. Withdrawal symptoms include increased anxiety, sadness, agitation, and worsening concentration. These are temporarily alleviated by smoking, but reinforce the cycle of repeated use and are best addressed through pharmacological treatments for tobacco dependence.16

    For individuals who have a mental health disorder, smoking cigarettes can reduce the therapeutic blood levels of a number of psychiatric medications, thereby decreasing their effectiveness.21,22 Decreased effectiveness of medications can be due to nicotine and/or tobacco smoke itself. Nicotine can counter the pharmacologic actions of certain drugs since it activates the sympathetic nervous system.22,23 The effect on medications needs to be considered when patients quit tobacco use. See the AAFP Drug Interaction with Tobacco Smoke Guide (https://www.aafp.org/dam/AAFP/documents/patient_care/tobacco/drug-interactions.pdf) for more information.

    Lastly, a challenge exists in the treatment settings and clinical culture in which people who have mental health disorders are treated. Psychiatric settings have a long history of providing cigarettes to patients as a reward for other treatment compliance.8,24,25 In fact, as recently as the 1990s, the tobacco industry and some mental health patient advocacy groups fought efforts by hospitals, states, and the Joint Commission on Accreditation of Healthcare Organizations to ban cigarette smoking in inpatient psychiatric facilities.25 Prioritization of mental health treatment,26 lack of an appreciation of the negative health effects of cigarette smoking,8,25,27 and beliefs among clinicians that people who have mental health disorders are not able or willing to quit8,24,25 have contributed to a culture in mental health treatment settings that accept and normalize cigarette smoking.

    Recommended Interventions

    The U.S. Public Health Service (USPHS) clinical practice guideline, Treating Tobacco Use and Dependence: 2008 Update, calls on physicians “to change the clinical culture and practice patterns to ensure that every patient who uses tobacco is identified, advised to quit, and offered scientifically sound treatments.”28 This guideline also calls for systems-level interventions to ensure that tobacco and nicotine use is assessed at every clinical encounter and treated according to current recommendations. Comprehensive smoking interventions by physicians do not tend to reflect what is desirable and effective for counseling patients.28

    To ensure comprehensive smoking interventions, medical practices need to establish a team-based system to implement the following:29

    • Record tobacco-use status as a vital sign.
    • Use electronic health records (EHRs) that include automatic prompts that allow clinicians to screen for tobacco use and nicotine dependence.
    • Define a clear process for assessing interest in quitting, encouraging quitting for those not currently interested, encouraging use of tobacco cessation medications, and following up, as appropriate.
    • Create a system of non-physician members of the health care team (e.g., nurse, health educator) to provide patients with information and support for quitting.
    • Refer patients to the 1-800-QUIT-NOW (1-800-784-8669) Quit Smoking Hotline, the text messaging service SmokefreeTXT (smokefree.gov/tools-tips/text-programs), the quitSTART app (iOS and Android) provided by smokefree.gov, or other counseling resources.
    • Initiate automatic follow-up phone calls by a nurse or health educator to patients who have set a quit date.
    • Create a flow sheet in the patient’s record to summarize past smoking discussions and quit attempts.29

    Integration of Behavioral Health Care Interventions

    Behavioral health care incorporates mental health care, substance abuse care, health behavior change, and attention to family and other psychosocial factors into its umbrella.31 The integration of behavioral health care into primary care is instrumental in effective tobacco dependence treatment.

    The American Academy of Family Physicians (AAFP) encourages family physicians to use interventions drawn from behavioral health care to address tobacco and nicotine dependence. Recommended interventions include motivational interviewing, brief interventions,32 and group visits.33

    The following AAFP resources provide information about the use of motivational interviewing and other behavioral health care interventions in tobacco dependence treatment:

    In addition to AAFP resources, the Smoking Cessation Leadership Center offers a number of tobacco and tobacco cessation-related resources in the area of behavioral health.

    The evidence-based interventions described in these resources can be used with any patient who smokes, not just patients who have a behavioral health disorder. However, counseling and pharmacotherapy must be tailored to the needs of the individual patient. Patients who have a behavioral health disorder will often require more time to prepare to quit, more medical management, more intensive follow up, and closer medication monitoring than other patients.

    Counseling/Behavioral Therapy

    Counseling is critical to the success of tobacco dependence treatment. Both individual and group counseling can be effective to support cessation in patients who have a behavioral health disorder. Intensive behavioral therapy with longer and more frequent sessions is often necessary. Counseling should include problem-solving skills training with specific discussions about what to do in certain situations. Both should also include reassurance that the health care team will provide ongoing support and encouragement.

    Using motivational interviewing and the Five R’s system can also be effective. This system is targeted at patients who use tobacco and are not yet ready to quit. It can motivate change by helping them understand the importance of quitting in personal terms.

    The Five R’s28

    Relevance. Why is quitting relevant to this patient? For example, maybe he or she has had a personal health scare, such as a recent heart attack, or has a child who has asthma.

    Risk. Ask the patient to list negative effects of their tobacco use. These may include short-term risks, long-term risks, and environmental damage.

    Rewards. Ask the patient to list the benefits of quitting. These may include being healthier, saving money, setting a good example, or having better self-esteem.

    Roadblocks. Ask the patient to identify barriers to quitting. Then, talk about ways to address these barriers. For example, if a patient is worried about withdrawal symptoms, ease his or her fears by describing medication options that can help.

    Repetition. The health care team should repeatedly follow up with the patient, keeping in mind that it may take repeated attempts to quit, especially for patients with a behavioral health disorder.28

    Medication Options

    Patients who have a behavioral health disorder are often highly dependent on nicotine. Most will need medication to manage withdrawal symptoms, which will likely be more severe than those in the general population. It is very important to customize pharmacotherapy for these patients. For example, for patients who have a history of inhaling drugs, nicotine nasal spray is not recommended. For patients who have schizophrenia, the nicotine patch has been shown to be highly effective.34,35 A clinician needs to take a patient’s current medications, previous quit attempts, access to affordable medication, and personal preferences into account.

    In particular, physicians need to carefully monitor the dosage and effects of psychiatric medications during quit attempts by patients who have a behavioral health disorder. Since smoking increases the metabolism of some medications, quitting can increase their effects. Since ongoing use of nicotine may modulate psychiatric symptoms and medication side effects, changes in a patient’s smoking status requires close follow up.

    Patients attempting to quit smoking should be encouraged to use appropriate medication, either alone or in certain combinations, unless use is contraindicated, or with patients in a specific population where there is insufficient evidence of effectiveness.28 Seven first-line medications (five nicotine and two non-nicotine) have been approved by the U.S. Food and Drug Administration (FDA), and reliably increase long-term smoking abstinence rates. These include:28

    • Bupropion SR
    • Nicotine gum
    • Nicotine inhaler
    • Nicotine lozenge
    • Nicotine nasal spray
    • Nicotine patch
    • Varenicline28

    See the AAFP Pharmacologic Product Guide: FDA-Approved Medications for Smoking Cessation for precautions, dosing, adverse effects, and other details about these medications.

    Important Notes About Bupropion SR and Varenicline

    Serious neuropsychiatric events (e.g., behavior changes, hostility, agitation, depressed mood, suicidal thoughts, or actions) have been reported by patients who use varenicline or bupropion SR for smoking cessation. Close follow up is recommended.

    The FDA released a safety announcement regarding Chantix (varenicline) and its effects on users who drank alcohol during treatment with Chantix. The announcement states that some patients taking Chantix experienced decreased tolerance to alcohol, including increased drunkenness, unusual or aggressive behavior, or they had no memory of things that happened. The announcement also warned of rare accounts of seizures in patients treated with Chantix.30

    Bupropion SR is contraindicated in patients who have a history of an eating disorder.

    Family Physician's Role

    Approximately 70% of people who use tobacco products see a physician each year,36 so family physicians have the opportunity to make a significant impact on their patients’ tobacco use, including those who have behavioral health disorders.37

    Of the 34.3 million people in the U.S. who smoke cigarettes,38 only 3-5% are able to quit without assistance and support from health care professionals.39 Unfortunately, 68% of smokers who try to quit attempt to do so on their own without using evidence-based tobacco cessation medications or receiving counseling,40 and more than 95% relapse.41 The use of evidence-based programs can more than double success rates.29

    Several surveys of people who are in addiction treatment have shown that 44-80% are interested in quitting cigarettes.8 Despite these rates of people who have a behavioral health disorder expressing a willingness to quit, according to one study of patients with bipolar disorder, only 33% were advised to quit smoking by a mental health provider.42

    This presents an opportunity for family physicians and other health care providers to impact smoking rates and improve the health of patients. One model estimates that if physicians and other health care providers provided annual tobacco counseling to youth and adults, there would be 105,917 fewer smoking deaths.43 Treating tobacco dependence can be one of the most important activities a physician can perform for their patients.8


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