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• Posted July 5, 2023

Program Helps Folks Battling Mental Illness Beat Another Foe: Smoking

Dr. Richard Stumacher's coworker at Northwell Health in New York City used to smoke to curb her severe anxiety, and tried multiple times to stop.

"She went through the program and she would quit, and then she would fall off, and we would always support her,"said Stumacher, who specializes in pulmonary disease and critical care medicine. "And I saw her in the hallway just a few months ago and she hugged me out of nowhere. I'm like, 'Hey, what's going on?'"

She told Stumacher it was her five-year anniversary of not smoking. "It took her a long time, but she got there,"he said.

Just 11.5% of Americans currently smoke cigarettes, according to the U.S. Centers for Disease Control and Prevention. But within that population, the CDC found that those with feelings of severe psychological distress or those who were diagnosed with depression were far more likely to smoke.

Thankfully, a new study found that people with serious mental illness who were offered medication and counseling to quit smoking had a 26% success rate after 18 months, compared to 6% in a control group. This included successful weight management, which is often a reason smokers are hesitant to quit.

Dr. Gail Daumit, vice dean of clinical investigation at Johns Hopkins Medicine in Baltimore, is first author of the study, published recently in the journal JAMA Psychiatry. She said it was critical to study smoking among those with mental illness because it could save lives.

"We also know that these individuals have a very, very high mortality rate compared to the overall population,"Daumit said. "They're three times more likely to die and they're dying 10 to 20 years earlier, mostly from medical conditions like cardiovascular disease and cancer. Of the causes, every cardiovascular risk factor is increased; obesity, high blood pressure, diabetes, those are all increased, but the main contributor to premature death in people with serious mental illnesses is tobacco smoking, hands down. And so it's a huge, huge problem."

To make matters worse, quitting is even harder for this population.

"People who have serious mental illness like schizophrenia or bipolar disorder, major depressive disorder, there's a very high propensity of smokers because nicotine is a neurotransmitter, it's a neurochemical,"said Stumacher, who was not part of the research. "And although they don't know it, smoking actually helps regulate their disease."

Therefore, he said, it can be difficult to get smokers with serious mental illnesses to quit.

"I used to do smoking cessation in the Bronx and I had a lot of patients that were able to successfully quit hard drugs like heroin or crack or alcohol,"Stumacher said. "Every single one of them told me that it was much harder to quit cigarettes than any of those other drugs."

The researchers knew going in that smokers with mental illness were more likely to quit if they had both medication and behavioral counseling.

But what was novel at the time of the study was that they took participants who were both interested in quitting immediately, within the next 30 days, and also those who were interested within six months, who had not previously been included in smoking studies.

Importantly, the authors found that there wasn't a significant difference in quitting rates between those who said they wanted to immediately stop smoking and those who were more hesitant. And it is now common practice for doctors to offer smoking cessation tools to anyone at any time.

But there still are reasons why smokers might not want to quit.

"We also know that a lot of times people are hesitant to quit smoking because they may gain weight because it's an appetite suppressant,"explained Daumit. "So what we did with this study, which was really, really innovative, is that as part of the counseling for smoking cessation, we included weight management principles. You didn't have to be overweight to come into the study at all, but we included weight management principles like healthy eating"¦And we also included exercise as part of the intervention as well."

The researchers found that participants didn't significantly gain weight in the intervention group when compared to the control.

As for next steps, Daumit hopes the study can serve as a model to help others quit smoking.

"I think that our study, on top of the existing literature, has shown that smoking cessation treatment for people with serious mental illness is usable, acceptable, it works, and that's great,"she said.

But to scale this kind of community-based program will require more resources and federal policies, Daumit said.

"This is a very important issue that's affecting people's length and quality of life," she added.

More information

The U.S. Centers for Disease Control and Prevention has more on smoking rates in the United States.

SOURCES: Richard Stumacher, MD, pulmonary disease and critical care medicine, Northwell Health, New York City; Gail Daumit, MD, MHS, professor, medicine, and vice dean, clinical investigation, Johns Hopkins Medicine, Baltimore; JAMA Psychiatry, July 5, 2023