Doctors Fear Asking Mentally Ill to Quit Smoking

People with mental illnesses such as depression and anxiety are the heaviest smokers in the country, but their doctors are afraid to ask them to quit. They assume that if their patients try to quit smoking, their mental disorders will get worse.

That is a myth, according to Brian Hitsman, a tobacco addiction specialist and assistant professor of preventive medicine at Northwestern University Feinberg School of Medicine. He also is a member of the Robert H. Lurie Comprehensive Cancer Center of Northwestern University.

This population's tobacco use and dependence need to be treated, he said. Hitsman has designed and published the first comprehensive, evidence-based plan for psychiatrists, psychologists and other mental health providers to help their patients quit smoking. His paper appeared in a recent issue of The Canadian Journal of Psychiatry.

"These doctors and mental health specialists focus on their patients' psychiatric health and lose track of their physical health," said Hitsman, who is a health psychologist. "Tobacco cessation gets a lot of attention, but we leave out a population that smokes the majority of all the cigarettes."

Between 40 to 80 percent of people with mental illness are daily smokers, depending on the disorder, compared to less than 20 percent of people who don't have problems with mental illness, according to research. The mentally ill also smoke more cigarettes per day - often up to two packs. They have a disproportionately high rate of tobacco-related disease and mortality, such as cardiovascular disease or cancer, with a correspondingly heavy financial burden to the health-care system.

The mentally ill receive tobacco treatment on only 12 percent of their visits to a psychiatrist and 38 percent of their visits to a primary care physician, Hitsman said.

Doctors erroneously believe mental disorders will worsen if they take away a person's tobacco. "Not a single study shows that symptoms get worse," Hitsman said. He examined 13 randomized clinical trials that measured psychiatric symptoms during smoking cessation treatment. Seven studies showed that psychiatric symptoms actually improved during smoking cessation treatment, and six showed no changes.

Another problem is mental health professionals believe tobacco is not a real addiction compared to other drug addictions.

"The perception is patients need tobacco because it's their only source of pleasure and helps them feel better," Hitsman said. "There is very little evidence, though, that smoking cigarettes serves to self-medicate emotional symptoms."

There is evidence from a few studies, however, that when mental health providers insert smoking cessation treatment into the mental health treatment plan, they can help their patients quit or cut down.

"They find if you take advantage of the relationship with the counselor and insert smoking cessation counseling into treatment that you enhance quit rates," Hitsman said.