Pat Salber
First posted 7/27/11 on The Doctor Weighs In
Judith Prochaska has written a very interesting commentary about smoking and mental illness that appeared in the July 21, 2011 issue of the New England Journal of Medicine (NEJM). The point of the article is that we in the health professions have failed to aggressively address smoking in people with mental illness. She posits that it is because of five prevailing myths about smoking and mental illness. She provides evidence to dispel those myths in every instance.
Myth #1: Tobacco is a useful self-medication for people with mental illness
It shouldn’t be a surprise to learn that our friends in Big Tobacco have played a role in promulgating this myth by funding research and presentations supporting this hypothesis. In fact, the industry has a long and rich historyof manipulating research to reach its goal of selling more and more cigarettes to more and more people. One of industry’s main strategies was to create confusion to counter the increasing body of evidence about tobacco’s adverse health impact. Just read this quote from a 1969 Brown and Williamson document:
“Doubt is our product since it is the best means of competing with the ‘body of fact’ that exists in the mind of the general public….”
When the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO – now the Joint Commission) proposed a national ban on smoking in hospitals, the tobacco industry opposed it. Ultimately, psychiatric and drug treatment facilities were exempt from the ban because patient advocates argued in favor of tobacco’s “therapeutic and calming effects” – psychiatric patients, they said, would revolt, if denied their cigarettes! There is no substantiation of this claim and, in fact, according to Prochaska, psychiatric hospitals that banned cigarettes did not have increased behavioral problems as a result. Probably the most damning statement in this commentary is that tobacco companies purposefully marketed cigarettes to people with mental illness…we already know they have no shame when it comes to pushing these addicting substances on individuals not well prepared to resist (think adolescents).
Myth #2: People with mental illness are not interested in smoking cessation
Evidence in the commentary suggests that people with mental illness are as likely to want to quit smoking as those without such diagnoses (20-25% of smokers report they intend to quite within the next 30 days and another 40% say they intend to do so within the next 6 months).
Myth #3: People with mental illness cannot quit smoking
Simply not true, per Prochaska. With therapy that includes smoking cessation medications when indicated, people with mental illness are able to quit and do so at about the same rates as the general population.
Myth #4: Smoking cessation efforts interfere with recovery from mental illness
Five randomized studies found that smoking cessation didn’t worsen depression or PTSD, nor did it lead to psychiatric hospitalization or increase use of alcohol or illicit drugs.
Myth #5: Smoking cessation is a low priority when treating individuals with acute psychiatric symptoms
Yeah, but we (the health professionals) made it a low priority. In the face of evidence that people with psychiatric disorders are more likely to die from tobacco-related disease than from their mental health problems, this is simply not acceptable. We have been treating psychiatric patients differently from the way we treat other individuals. And, we have done so at the peril of our patients.
It is long past time to do something about the disparity in the way we address smoking cessation in people with mental illness compared to the way we address this serious health in all other folks. The lethality of cigarette smoking is no longer in question. Cigarettes kill. Long term abstinence from cigarettes is possible, particularly when health professionals provide support and medications, when indicated. Smoke-free environments are healthier than smoke-filled rooms and they reduce temptation/opportunity to smoke when applied in institutionalized settings such as hospitals and outpatient facilities.
I second Dr. Prochaska’s closing statement: It is time to make effective cessation treatments readily available to all smokers.
Pat Salber MD MBA is a former Chief Medical Officer of a national health plan, and now advises health plans on medical management.
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