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  5. Behavioral Health & Tobacco Use

Behavioral Health & Tobacco Use

Barriers for Quitting Amongst People who have Behavioral Health Conditions

  • People with behavioral health conditions who smoke want to quit and have a better chance to quit when they have access to treatment.1
  • Many mental health treatment facilities do screen for tobacco use, but less than half provide treatment to help people with behavioral health conditions to quit smoking.2,3
  • Mental health professionals are less likely to discuss about quitting due to misperceptions about the patient’s willingness to quit.4
  • People with behavioral health conditions might feel pressure from thoughts of stigma, which could encourage them to start or continue to smoke.5

Behavioral Health and Tobacco Use Rates

  • It is estimated that 35% of people who smoke cigarettes have a mental health condition and account for 38% of all U.S. adult cigarette consumption.6
  • Despite the national cigarette smoking rate being 14% overall among adults, it is 23% for individuals with a behavioral health condition .6
  • The nicotine dependency rate for individuals with behavioral health conditions is 2-3 times higher than the general population.7
  •  (Combine with Behavioral Health and Tobacco Use Rates) Lifetime smoking rates are higher in patients who are diagnosed with a behavioral health condition compared to adults with no behavioral health condition.8
  • Adults who have a behavioral health condition over the past year are more likely to have ever used a cigarette (53.6%) compared to adults who did not have a behavioral health condition over the past year (36.4%)9
  • 70 to 85% of individuals with schizophrenia use tobacco.10
  • Individuals with a diagnosis of post-traumatic stress disorder (PTSD) are about 22% more likely to be current smokes than individuals without PTSD.11
  • Among people who currently smoke with a lifetime history of depression, anxiety, anxiety with depression or major depression, they smoke more cigarettes, smoke more frequently and have a higher level of dependence.12              
  • Individuals with social anxiety are more likely to engage in heavy smoking and are less likely to successfully quit in comparison to individuals without social anxiety, depression, and other substance use disorders.13The presence or history of depression is associated with greater smoking severity and poorer smoking outcomes.14
  • Major depressive disorders are associated with an earlier age of cigarette smoking, greater dependence on nicotine, higher nicotine withdrawal scores, greater cravings, and higher Carbon Monoxide levels during cessation treatment.14

Morbidity and Mortality

  • People who smoke and have a serious behavioral health condition have increased risk of dying from cancer, lung disease, and cardiovascular disease15 and account for more than 200,000 of the 520,000 tobacco-related deaths each year.17
  • Individuals with a serious behavioral health condition die about 15 years earlier than individuals without serious mental illness who never smoke.18
  • About half of deaths among those hospitalized for schizophrenia, depression, or bipolar disorder are from causes linked to smoking.17

Tobacco and Substance Use

  • More than 80% of youth with substance use disorders report current tobacco use, most report daily smoking, and many become highly dependent, long-term tobacco users.19
  • Individuals with alcohol use disorders smoke at rates between 34 and 80%; people with other substance use disorders smoke at between 49 and 98%.20
  • The prevalence of past-month cigarette use (56.7%) among adults with a past-year illicit drug and alcohol use disorder.2
  • Addiction to nicotine is the most common form of substance use in people with schizophrenia.21

Overall, daily cigarette smoking declined between 2005 and 2014 among people with behavioral health conditions or substance use disorders (from 29.4% in 2005 to 24.2% in 2014).20

  • People who currently smoke cigarettes in the past month were more likely than those who were not nicotine dependent to have engaged in alcohol use (62% vs. 54%), binge alcohol use (43% vs. 22%), and heavy alcohol use (15% vs. 5%) in the past month.22

Morbidity and Mortality

  • Tobacco use causes more deaths among individuals receiving substance use treatment than alcohol or other substance use.2351% of deaths were the result of tobacco-related causes, which is double the rate found in the general population.24
  • One study found that most deaths among those with a history of opioid-related disorders were from tobacco or alcohol-related causes and not directly caused by drug use.25

Recovery

  • 70 to 80% of individuals receiving substance use disorder treatment have expressed an interest in tobacco cessation.26
  • the adjusted prevalence of lifetime cessation was lower among those with past-year bipolar disorder (29.2%), dysthymia (33.5%), panic disorder (33.5%), agoraphobia (36.3%), generalized anxiety disorder (36.5%), posttraumatic stress disorder (36.7%), major depressive episode (36.8%), and specific phobia and social phobia (39.7% each)9
  • Participation in smoking cessation efforts while engaged in substance use treatment has been associated with a 25% greater likelihood of long-term abstinence.27

  1. CDC Vital Signs. Vital Signs: Adult Smoking Focusing on People with Mental Illness [PDF - 3.2 MB]. Vital Signs. February 2013. https://www.cdc.gov/vitalsigns/pdf/2013-02-vitalsigns.pdf. Accessed Feb 25, 2022.

  2. Marynak K, Vanfrank B, Tetlow S, Mahoney M, Phillips E, Jamal A, et al. Tobacco Cessation Interventions and Smoke-Free Policies in Mental Health and Substance Abuse Treatment Facilities—United States, 2016. MMWR Morb Mortal Wkly Rep. 2018;67(18):519-23. DOI: http://dx.doi.org/10.15585/mmwr.mm6718a3.

  3. Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. Tobacco Cessation Services. The N-SSATS Report. September 19, 2013. https://www.samhsa.gov/data/report/tobacco-cessation-services. Accessed Feb 25, 2022

  4. Brown, CH, Medoff D, Dickerson FB, Fang LJ, Lucksted A, Goldberg RW, et al. Factors Influencing Implementation of Smoking Cessation Treatment Within Community Mental Health Centers. J Dual Diagn. 2015;11(2): 145-50. DOI: 10.1080/15504263.2015.1025025

  5. Centers for Disease Control and Prevention, Substance Abuse and Mental Health Services Administration, National Association of County Behavioral Health & Developmental Disability Directors, National Institute of Mental Health, The Carter Center Mental Health Program. Attitudes Toward Mental Illness: Results from the Behavioral Risk Factor Surveillance System. Centers for Disease Control and Prevention; 2012. Accessed Feb 25, 2022. https://sprc.org/online-library/attitudes-toward-mental-illness-results-from-the-behavioral-risk-factor-surveillance-system/.

  6. Centers for Disease Control and Prevention. National Center for Health Statistics. National Health Interview Survey, 2017. Analysis performed by the American Lung Association Epidemiology and Statistics Unit using SPSS software.

  7. Schroeder SA, & Morris CD. Confronting a neglected epidemic: Tobacco cessation for persons with mental illnesses and substance abuse problems. Annu Rev Public Health. 2010; 31: 297-314.

  8. Smith PH, Mazure CM, McKee SA. Smoking and mental illness in the US population. Tob Control. 2014; 23(0): e147-e153.

  9. Smith PH, Chhipa M, Bystrik J, Roy J, Goodwin RD, McKee SA. Cigarette smoking among those with mental disorders in the U.S. population: 2012–2013 update. Tobacco Control 2020b;29(1):29–35.

  10. Ziedonis DM, Hitsman B, Beckham JC, Zvolensky M, Adler LE, Audrain-McGovern J. Tobacco use and cessation in psychiatric disorders: National Institute of Mental Health report. Nicotine Tob. Res. 2008: 10, 1691–1715.

  11. van den Berk-Clark C, et al. Association between posttraumatic stress disorder and lack of exercise, poor diet, obesity, and co-occuring smoking: A systematic review and meta-analysis. Health Psychology. 2018; 37(5):4-7-16.

  12. Tosclair, A & Dube SR. Smoking among adults reporting lifetime depression, anxiety, anxiety with depression and major depressive episode, United States, 2005-2006. Addict. Behav. 2010; 35(5): 438-443.

  13. Cougle JR, Zvolensky MJ, Fitch KR, Sachs-Ericcson NS. The role of comorbidity in explaining the associations between anxiety disorder and smoking. Nicotine Tob Res. 2010; 12(4): 355-364.

  14. Soone S, Nunes EV, Jiang H, Tyson C, Rotrosen J & Reid MS. The relationship between depression and smoking cessation outcomes in treatment-seeking substance abusers. Am J Addict. 2010; 19(2): 111-118.

  15. Callaghan RC, et al. Patterns of tobacco-related mortality among individuals diagnosed with schizophrenia, bipolar disorder, or depression. J Psychiatr Res. 2014; 48:102–10.

  16. Prochaska J, Das S, Young-Wolff K. Smoking, Mental Illness, and Public Health. Annu Rev Pub Health. 2017, 38:165-85.

  17. Tam J, Warner KE, Meza R. Smoking and the Reduced Life Expectancy of Individuals with Serious Mental Illness. Am J Prev Med. 2016; 51(6):958-66.

  18. Hall SM, Prochaska JJ. Treatment of smokers with co-occurring disorders: emphasis on integration in mental health and addiction treatment settings. Annu Rev Clin Psychol. 2009; 5:409-31.

  19. University of California San Francisco Smoking Cessation Leadership Center. Behavioral Health. https://smokingcessationleadership.ucsf.edu/behavioral-health. Accessed May 2, 2018.

  20. U.S. Department of Health and Human Services. Eliminating Tobacco-Related Disease and Death: Addressing Disparities—A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2024.

  21. Cuffel BJ & Chase P. Remission and relapse of substance use disorder in schizophrenia: Results of a one-year prospective study. Journal of Nervous and Mental Disease 1994; 182(6):342–348.

  22. Substance Abuse and Mental Health Services Administration. Results from the 2017 National Survey on Drug Use and Health: Detailed Tables, Table 6.34B. 2018.

  23. Hurt RD, Offord KP, Croghan IT, Gomes-Dahl L, Kotke TE, Morse RM, et al. Mortality following inpatient addictions treatment. Role of tobacco use in a community-based cohort. J Am Med Assoc. 1996; 276(10): 1097-103.

  24. Hurt RD, Offord KP, Croghan IT, Gomes-Dahl L, Kotke TE, Morse RM, et al. Mortality following inpatient addictions treatment. Role of tobacco use in a community-based cohort. J Am Med Assoc. 1996; 276(10): 1097-103.

  25. Veldhuizen S, Callaghan RC. Cause-specific mortality among people previously hospitalized with opioid-related conditions: A retrospective cohort study. Ann Epi. 2014; 24:620-4.

  26. McClure EA, et al. Characterizing smoking, cessation services, and quit interest across outpatient substance abuse treatment modalities. J Subst Abuse Treat. 2014; 46(2):194-201.

  27. Prochaska JJ, Delucchi K, Hall SM. A meta-analysis of smoking cessation interventions with individuals in substance abuse treatment or recovery. Journal of Consulting and Clinical Psychology. 2004; 72(6):1144–56.

Page last updated: January 6, 2025

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