Cigarette Smoking and Mental Health 4/26/2018

Rates of cigarette use are higher in persons with mental illness compared with those without mental illness, according to a federal survey conducted by the Centers of Disease Control (CDC) and the Substance Abuse and Mental Health Services Administration (SAMHSA). According to the report, about 1/3 of those with mental illness were current smokers compared with less than 1/4 of the general population. People with mental illness smoke almost 1/3 of all cigarettes consumed in the US. This is due to the higher incidence that has already been discussed, but also because of heavier smoking in persons with mental illness, with an average of 331 cigarettes per month compared with 310 cigarettes per month in the rest of the smoking population. It is important to note that individuals in institutions and those considered to have alcohol and substance use disorders were excluded from the analyses.

It is thought that the higher smoking incidence among those with mental illness is largely due to lower rates of quitting. More than half of smokers without mental illness who have ever smoked have since quit, but among those with mental illness, only 1/3 have ever succeeded in quitting. There are many reasons for this. Many people with mental illness find symptom relief (decreased anxiety, improved mood, distraction from psychotic symptoms) from smoking. Linked to this, many healthcare providers believe that smoking cessation many worsen patients’ mental illness. Cigarettes are used in many inpatient psychiatric hospitals as rewards for good behavior. People with mental illness are more likely to have limited access to health care and lead stressful lives, both of which can also make quitting more difficult. Additionally, many tobacco companies utilize specific marketing strategies directed at people with mental illness.

That is not to say that people with mental illness are not interested in quitting smoking. It is important to provide education and guidance on safe ways to stop smoking as part of general health and wellness. This includes inquiring about smoking habits in patients with mental illness and making smoking cessation one of their treatment goals.

When helping a patient who is taking psychotropic medications stop smoking, it is important to keep certain drug interactions in mind. Tobacco smoke can induce cytochrome P450 1A2, which can increase the metabolism of medications that are substrates of that system. These include:

  • Atypical antipsychotics: olanzapine and clozapine
  • Typical antipsychotics: haloperidol and fluphenazine
  • Tricyclic antidepressants: amitriptyline, clomipramine and imipramine
  • SSRIs: fluvoxamine
  • Anxiolytic medications: propranolol

Therefore if a patient on any of these medications stops smoking (especially if they stop abruptly), it might be important to decrease the dose of medication to avoid overmedication and side effects.

Tobacco use can be a challenging co-morbid medical and lifestyle concern for patients with mental illness. It is important to provide ongoing psychoeducation and motivational interviewing to encourage smoking cessation, keeping in mind replacing the coping strategy that the cigarette use might be providing for the patient.


  1. Mentally Ill Smoke 30% of All Cigarettes. By John Gever, Senior Editor, MedPage Today; From published February 5, 2013.
  2. Cytochrome P450 Drug Interaction Table. Indiana University, Department of Medicine. 2003




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