In Australia, while the prevalence of smoking is declining in the overall community, it remains higher among people with mental illness. 1 Compared to both the overall population and to people without mental illness, people with recent mental illness have higher smoking rates, higher levels of nicotine dependence, and a disproportionate health and financial burden from smoking. 2,3
Mental health problems are common within the Australian population: in 2019, 17% of Australians aged 18+ reported that they had been diagnosed with and or/treated for one or more mental illnesses in the past year. 4
People with mental illness have a substantially higher prevalence of smoking and those who smoke tend to smoke more heavily than the overall population. 4 Data from the 2019 National Drug Strategy Household Survey showed that Australian adults who reported having been diagnosed or treated for mental illness in the past year were almost twice as likely to be a current smoker than those who had not been diagnosed or treated in the past year—see Figure 9A.3.1. 5 Daily smokers were twice as likely to have high/very high levels of psychological distress compared with people who had never smoked (25% and 12%, respectively) and were twice as likely to have been diagnosed or treated for a mental health condition (29% and 14%). 6
Smoking prevalence tends to increase alongside the severity of the psychiatric disorder. 7 For example, two Australian studies conducted 10 years apart both found that among people living with psychotic disorders, about 70% of men and 60% of women are smokers. 1, 8 Results from the 2017–18 National Health Survey show a similarly high prevalence of smoking among people with mental disorders, and also show the extremely high prevalence of smoking among those with harmful use or dependence on drugs and schizophrenia-related conditions—see Figure 9A.3.2.
Similarly, smoking—especially daily smoking—is much more common among adults who meet the criteria for alcohol dependence, or who report drinking in ways that could be harmful or hazardous. In 2019, compared with those at low risk, adults who reported drinking alcohol at harmful or hazardous levels were more than twice as likely to report being a daily smoker, while those who met the criteria for alcohol dependence were more than three times as likely to be a daily smoker—see Figure 9A.3.3. 13
International data also show high smoking rates among those with mental illness. Research in the US 14 and the UK 15, 16 has found large disparities between smoking in the overall population and among people with mental illness.
Limited data suggest that smoking appears highly prevalent among young people with diagnoses of mental illness. 17, 18 Australian research in 2017 found that among young people aged 15–25 attending youth mental health services, 29% had smoked in the past week. 19 An earlier Australian study found that in 2013, among young people presenting for primary mental healthcare, 23% of 12–17 year olds, 36% of 18–19 year olds, and 41% of 20–30 year olds reported daily smoking. 20
People with mental illness who smoke also report high levels of consumption. US studies 21, 22 have estimated that while nicotine-dependent individuals with a comorbid psychiatric disorder make up only 7.1% of the population, they consume more than one-third of all cigarettes. Australian research found that in 2019, regular smokers with mental illness smoked an average of about one extra pack per week compared to those without mental illness (117 and 98 cigarettes per week, respectively). 4 Among smokers with severe mental illness, other studies indicate average daily consumption of 30 cigarettes, with a range of 5–80 per day. 23, 24
While the prevalence of smoking has declined over time in the overall community, it remains high among people with mental illness. 1 For example, the prevalence of smoking among Australians with psychotic disorders remained steady at about 67% between 1997 and 2010, while smoking in the total Australian population declined from 26% to 19%. 1 Similarly in the US, several studies have shown growing disparities over time between smoking in the overall population and among people with high levels of psychological distress and serious mental illness. 25-28 As overall smoking rates decline, those with mental illness comprise a greater proportion of the remaining smokers—see Figure 9A.3.4. 29 These findings suggest that tobacco control policies and cessation interventions that have effectively reduced smoking in the overall population may not have been as effective for people with mental illness.
Nonetheless, there are some encouraging trends. Several US studies have shown reductions in smoking prevalence and increased quit rates over time among people with psychological distress and some mental disorders. 30-32 Australian research has found that there was a significant decrease in regular smokers—see Figure 9A.3.5—and significant increases in never smokers and in the proportion of ever-smokers who had quit among people with mental illness between 2004 and 2019. 4
Data from the ABS National Health Surveys similarly suggest some declines in daily smoking prevalence among those with mental illness and substance use problems—see Figure 9A.3.6.
In 2018, mental and substance use disorders were the second leading cause of Australia’s disease burden, behind cancer and equal with cardiovascular disease and musculoskeletal conditions. 36 High smoking rates among people with mental illness contribute to higher levels of tobacco-caused morbidity and mortality. 37 Compared with the overall population, people with mental illness have a disproportionate health and financial burden from smoking. 2, 3 Australian men with mental illness live 15.9 years less and women live 12 years less than those without mental illness, 38 and most of the excess morbidity and mortality is attributable to smoking-related illnesses such as cardiovascular disease, respiratory disease, diabetes, and cancer. 38-40 The gap in life expectancy between those with and without mental illness has also widened over time, largely due to smoking-related diseases. 38 People with mental illness who smoke are far more likely to die from their smoking than as a result of their psychiatric condition. 2, 38 One study found that among people with serious mental illness, those who smoked had a reduced life expectancy of 5–7 years compared with non-smokers. 41
Research in the US estimated that from 2018 to 2060, approximately 484,000 smoking-attributable deaths will occur among adults with depression, but up to 264,000 of those deaths could be avoided with comprehensive tobacco control strategies. 42 Another modelling study estimated that widespread uptake of any cessation treatment (behavioural counselling, pharmacological, or combination) among patients with depression in the US would avert 32,000 deaths and result in 138,000 life-years gained by 2100. 43
People with mental illness and mental health workers often perceive smoking to be helpful in relieving or managing psychiatric symptoms. 7, 44 However, recent evidence suggests that the reverse is true; people who quit smoking may experience improvements in their mental health and quality of life. 44, 45 Smokers with mental illness who quit report lower levels of psychological distress 4 and mental health symptoms 46, 47 than those who continue to smoke. Quitting smoking has a similar sized effect to taking anti-depressants on improving mental health. 48
As well as contributing to poorer health outcomes, smoking can also exacerbate financial stress among people with mental illness. Research in the UK estimated that smoking pushes an estimated 130,000 people with a common mental disorder into poverty per year. 49 In the US, one study found that smokers with depression were more likely than those without depression to experience financial distress and smoking-induced deprivation, with about one-third of smokers with depression foregoing essentials to pay for tobacco. 50 In Australia in 2000, it was estimated that people with a psychotic illness who smoked and were in receipt of a disability support pension spent more than one-third of their pension on tobacco products. Smoking plays an important role in the cycle of poverty and disadvantage experienced by people with mental illness. 51
The mechanisms underlying the relationship between mental health conditions and smoking are complex, and vary between disorders. 52 There are a number of potential explanations for why people with mental health problems are more likely to smoke; risk factors for smoking among the overall population are experienced to a greater degree, and there are also unique factors that contribute to the higher prevalence of smoking. These include:
The self-medication hypothesis suggests that people with mental illness smoke to ease the symptoms of depression, schizophrenia, substance abuse and other disorders, and is the most common explanation for the very high prevalence of smoking among this group. 54, 68 The hypothesis has also been expanded to suggest that smoking can relieve side effects of antipsychotic medication. 57 Smokers with mental illness frequently cite stress and anxiety relief as reasons for smoking, 61 and many erroneously believe that smoking is helpful for relaxation. 17, 19 However, results from recent studies have not supported the self-medication hypothesis 69, 70 (with the exception of ADHD—see Section 9A.3.5.4). The supposed beneficial effects of smoking on stress can be largely attributed to the temporary alleviation of nicotine withdrawal symptoms, which creates the false impression that smoking is relaxing. 71 However, smoking actually increases stress levels overall. 7 Several studies have shown that quitting smoking is associated with reduced depression, anxiety, and stress and improved positive mood and quality of life compared with continuing to smoke among people with psychiatric disorders. 44, 45
A 2015 review of smoking among people with schizophrenia concluded that, despite some enhanced performance for cognitive tasks, smoking appears to be less beneficial on schizophrenic symptomology than generally assumed, while clearly increasing the risk of cancer and other smoking-related diseases responsible for early mortality. 69 Another similarly highlights the lack of evidence for favourable effects on symptoms, but substantially increased health risks among smokers with schizophrenia. 66 Two more recent meta-analyses found strong evidence that smoking is in fact associated with cognitive impairment among people with schizophrenia. 72, 73 Another found evidence for more severe positive symptoms but less severe extrapyramidal side effects (e.g., involuntary muscle contraction, tremors) among people with schizophrenia who smoke compared with those who do not. 74 A 2015 systematic review and meta-analysis concluded that daily tobacco use is associated with increased risk of psychosis and an earlier age at onset of psychotic illness. The authors propose that smoking could have a causal role in psychosis, which further brings into question the self-medication hypothesis. 75 Another systematic review and meta-analysis suggested that smoking, and prenatal smoke exposure, may be an independent risk factor for schizophrenia. 76 Smoking may also increase the risk of other mental illnesses, 77 including anxiety, depression, 7, 78, 79 and bipolar disorder. 80
Another proposed explanation for the higher rates of smoking among people with mental health problems is that they do not want to quit or try to quit. However, Australian and international research has shown that smokers with mental illness are just as likely to attempt to quit and more likely to use cessation support. Nonetheless, they appear to experience less success maintaining cessation than people without mental illness. 4, 16, 81 Although treating tobacco dependence in people with mental illness is challenging, several randomised treatment trials and systematic reviews have documented that success is possible. 82 Smokers with mental illness are able to quit with standard cessation approaches with minimal effects on psychiatric symptoms. 83
Socio-economic status (SES) is inversely related to smoking, such that the prevalence of smoking is substantially higher among lower socio-economic groups. Mental disorders are associated with low incomes and higher levels of debt; 84 thus, there is likely interplay between low socioeconomic status, mental illness, and smoking. In 2011–12, 62% of working age Australians with a mental illness were employed, compared to 80% of those without a mental illness. 85 One study found that smokers with mental illness frequently smoke to combat boredom, and suggested that the higher rates of unemployment among this group may contribute to more frequent experiences of boredom and therefore smoking. 61
Looking at why and how some people resist smoking despite being at-risk can also shed light on potential protective factors. 86 One small study with people diagnosed with mental illness found that strong, negative attitudes to smoking as children that have persisted into adulthood, lasting associations with smoking, a clear sense of ‘self’ separate from peers from an early age, and developing a range of coping strategies and external supports not related to smoking served as protective factors from taking up smoking. 86
People with mental health problems face a number of unique barriers to quitting, including misperceptions regarding the safety of stopping smoking, higher levels of nicotine dependence and withdrawal, lower degree of participation in programs, misperceptions of low motivation to quit, socio-economic factors, and systematic barriers to quitting in mental healthcare settings. A systematic review identified smoking for stress management, lack of support from health and other service providers, the high prevalence and acceptability of smoking in vulnerable communities, and the maintenance of mental health as perceived barriers among those with mental illness. 87 An Australian study of smoking behaviours among institutionalised psychiatric populations found systematic barriers to quitting, including cigarettes being the currency by which economic, social and political exchange took place and complex processes of reinforcement to smoke. Escape from the smoking culture of the settings appeared to be extremely difficult for clients and staff. 88
There is a common misperception within mental health settings that quitting smoking interferes with recovery from mental illness, eliminates a coping strategy, and leads to decompensation in mental health functioning. 82 People with mental illness also report similar concerns, which can hinder quit attempts. 89 However, several major reviews have found that quitting does not lead to deterioration in symptoms of schizophrenia, depression, or severe mental illness, 90, 91 and is in fact associated with improvements in mental health among people with psychiatric disorders. 44, 45 Smoking cessation also does not exacerbate anxiety or PTSD symptoms, or lead to psychiatric hospitalisation or increased use of alcohol or illicit drugs. 55, 92 Indeed, smoking cessation interventions during addictions treatment appear to enhance rather than compromise long-term sobriety. 93 Two studies examining whether the treatment of ADHD can enhance response to smoking cessation intervention found no association overall between abstinence and change in ADHD symptoms, 94, 95 and another found that quitting can reduce anxiety and depressed mood in smokers with ADHD. 96 Quitting is also associated with a decreased likelihood of suicide attempt. 97 Lifetime history of major depression does not appear to be an independent risk factor for failure in smoking cessation treatment. 98
Another common misperception is that people with mental illness do not want to quit, which can lead to a lack of encouragement and support to do so. 99 A review of smoking cessation in inpatient psychiatry settings found that it is rare or often delayed. 100 A study of mental health centres found that the most common barrier to staff implementing smoking cessation treatment was a perceived lack of patient interest in quitting. 101 Although the co-presence of mental illness can make quit attempts more challenging 102 and less successful, 103 smokers with mental disorders are motivated to quit. 4, 104 Studies involving patients recruited from outpatient and inpatient psychiatric settings suggest that they are just as likely as the overall population to want to quit smoking. 55
Further, contrary to common beliefs, greater psychiatric symptoms have been shown to predict greater, not lesser, motivation to quit smoking. 105 In British surveys, about half of smokers with mental illness have expressed an interest in quitting when asked. 106 In the US, 20–25% of smokers with mental illness report that they intend to quit smoking in the next 30 days, and another 40% say they intend to do so in the next six months. 82 Another population-level study in the US found that smokers with mental illness were more likely than those without mental illness to attempt quitting, and just as likely to use cessation treatment. 107 Inpatients with mental health disorders appear to be no less motivated to stop smoking than those without mental health disorders and their use of NRT during hospitalisation is similar. 108 One Victorian study of consumers at a psychiatric disability rehabilitation and support service found that while smoking rates were almost four times higher than the total population, there was high interest in quitting and cutting down. 109 US research found that, among a sample of women with PTSD symptomatology and serious mental illness, readiness and intention to quit smoking was high. 110 Smokers with mental illness cite similar reasons for wanting to quit as the overall population. For example, one study found that health concerns (73%), cost (71%), advice from a doctor (54%), and advice from others (64%) prompted a desire to quit, while social support from family and friends (58%), direction from a doctor (46%), use of NRT (31%), and the advice of friend who had quit (23%) were factors that enabled quitting. 111
Smoking has a disproportionate impact on the mental and physical health of people with mental illness, therefore treating nicotine dependence should be a high priority and form part of routine care. 7 However, progress in the development of cessation treatments for people with mental health problems has traditionally been slow, in part because smokers with a current mental disorder have been excluded from most smoking cessation trials. 112, 113 Given the growing body of evidence showing that quitting is typically not detrimental to psychiatric symptoms and, in fact, appears to improve mental health and wellbeing, 44, 45, 114 cessation should be encouraged and supported among smokers with comorbid mental disorders as it is among smokers in the overall population. 52 However, as with any other stressor, the stress of cessation could temporarily affect symptoms; 55 therefore, monitoring of patients’ psychiatric status during the quitting process is warranted. 52, 115 Nonetheless, people with a mental illness should be offered the same smoking cessation interventions that have been shown to be effective in the overall population, 115, 116 with optimal treatment comprising a combination of behavioural counselling and NRT/pharmacotherapy. 117, 118 Smokers with chronic mental illness can successfully quit with standard cessation approaches, and longer maintenance on pharmacotherapy can reduce the typically high rates of relapse without detrimental effects on psychiatric symptoms. 83 Smokers with mental illness are as motivated to quit as those without mental illness, 4 and despite lower overall success rates, can quit successfully. 104 Integrating tobacco cessation interventions into routine mental health treatment, and providing more intensive intervention when required, forms an important part of reducing the large health disparities between those with and without a mental health problem. 7, 52
An important consideration in treating nicotine dependence is the impact of smoking on psychiatric treatment. Smoking complicates the treatment and course of psychiatric disorders through its profound effect on the metabolism of pharmacotherapies, and is therefore one of the factors that leads to individual differences in drug responses. 52 For example, smoking can interfere with the medications taken for schizophrenia and depression, therefore the doses of some psychotropic medications may need to be decreased following cessation. 116, 119 Patients with mental illness can be offered the same cessation medications as the overall population, 120 but should be monitored closely. The typically higher levels of nicotine dependence among smokers with mental illness mean that larger doses of NRT, combination pharmacotherapy, and a longer duration of therapy may be necessary. 7 Several Australian studies have supported the effectiveness of integrated cessation interventions in community mental health settings. 121, 122 Integrating cessation into mental healthcare can increase screening for smoking and the provision and uptake of cessation advice and support. 123-125 Australian research has also found that cessation support after discharge from an inpatient psychiatric facility was effective in encouraging quit attempts and reducing cigarette consumption up to 6 months post-discharge. 126
In Australia, Quitline is the most accessible behavioural intervention, and research has shown that such services can have positive impacts on smoking cessation among people with mental illness 127 and are just as effective as face-to-face interventions. 128 Many quitline services offer coordinated care with clinicians, and some have introduced monitoring of nicotine withdrawal symptoms and common medication side-effects for people with mental illness. 129 However, although use of quitlines is more common among smokers with mental illness in Australia than among those without, they are underutilised. 4 Interviews with Australian smokers with mental illness revealed that many held negative perceptions about the usefulness of Quitline, highlighting that strategies may be needed that raise awareness about the service. 130 Other Australian research has shown that targeted videos providing smoking cessation information and advice to smokers with mental illness can be well-received and increase knowledge about quitting. 131
Compared to people without depression, people with depression are about twice as likely to be smokers, and are less likely to succeed in quit attempts. 132, 133 Smokers also have significantly higher rates of lifetime depression. 52 Compared to those without depression, smokers with depression are more nicotine dependent, more likely to suffer from negative mood changes after nicotine withdrawal, more likely to relapse, and experience disproportionate morbidity and mortality from smoking-related disease. 132 Evidence suggests that major depression may be a risk factor for progression of nicotine dependence. 134 Depression is also related to psychosocial characteristics that make it more difficult to stop smoking, for example, lower self-esteem and self-efficacy for quitting, and greater likelihood of unemployment, poorer social support networks and poorer physical health. 135
Findings from the Four Country (Canada, US, UK, and Australia) International Tobacco Control Study showed that smokers with depressive symptoms or diagnosis make more quit attempts than people without depression, but they were also more likely to relapse in the first month. 136 Despite this, meta-analyses suggest that a lifetime history of major depressive disorder, in itself, does not predict failure to quit smoking. 98 A 2015 review of depression and smoking concluded that: depressed smokers are motivated to quit; smoking cessation does not exacerbate symptoms of depression; depression does not have a negative impact on smoking cessation outcomes; and the self-medication hypothesis does not account for tobacco dependence and depression co-morbidity. 137 Indeed, a growing body of evidence supports the beneficial role of quitting in reducing depression. 44, 138
A meta-analysis of treatment trials in smokers with depression published in 2010 concluded that NRT was more effective than placebo, and that adding behavioural mood management to cessation counselling improved treatment outcomes. Notably, only three trials included smokers with current depression, therefore the findings were most relevant to smokers with a history of depression. 139 A 2013 Cochrane review evaluated the effectiveness of smoking cessation interventions in smokers with current or past depression. It concluded that adding a psychosocial mood management component to a standard smoking cessation intervention increases long-term cessation rates in smokers with both current and past depression when compared with the standard intervention alone. Bupropion was beneficial for smokers with a history of depression, but there was a lack of evidence regarding its use with smokers with current depression. There was not enough evidence regarding the effectiveness of other antidepressants for quitting in current or past depression, nor for the effectiveness of standard smoking treatments that do not target depression, such as nicotine replacement therapy and psychosocial smoking cessation interventions. 132 A placebo controlled trial published in 2013 found that varenicline significantly increased continuous abstinence among people with depression up to a year, without exacerbating depression or anxiety. 140 Another RCT similarly supported the use of varenicline for smoking cessation among people with depression. While bupropion, NRT, and combination bupropion and NRT were also effective, varenicline led to superior abstinence rates. 141 A 2017 systematic review and meta-analysis concluded that smoking cessation interventions, particularly pharmacological treatments, appear to increase short-term and long-term smoking abstinence in individuals with current depression. 138 A systematic review published in 2021 concluded that:
A recent review also notes that there appears to be a reduction in the concentration of serum levels of common anti-depressants (fluvoxamine, duloxetine, trazodone and mirtazapine) in people who smoke, which likely necessitates careful choice and adaptation of medications based on smoking and smoking cessation. 119
Among people with anxiety disorders, smoking rates appear to range from 31.5% for people with social phobia to 54.6% for people with generalised anxiety disorder. 143 Obsessive-compulsive symptoms are also associated with tobacco dependence severity and greater withdrawal symptoms during quit attempts. 144 Despite the high rates of smoking among those with anxiety disorders, and evidence showing that they are motivated to quit, 145 there is a dearth of evidence regarding effective cessation interventions for this population. 52 A randomised controlled trial published in 2011 found that anxiety diagnoses were common among treatment-seeking smokers and were related to increased motivation to smoke, elevated withdrawal, lack of response to pharmacotherapy, and impaired ability to quit smoking. 146 Another study found that smokers with social anxiety disorder experienced higher levels of craving and urge to smoke during quit attempts, which could explain their worse cessation outcomes. Such smokers would likely benefit from additional treatment aimed at managing or reducing their social anxiety symptoms, and NRT also seemed to help alleviate the relationship between social anxiety and cravings. 147
A subgroup analysis of a large randomised controlled trial examining the effectiveness of pharmacotherapies for smoking cessation in people with anxiety disorders found that they were more likely than those without psychiatric illness to experience neuropsychiatric adverse events during quit attempts, regardless of treatment. Nonetheless, findings supported the use of varenicline for cessation in those with generalised anxiety disorder and panic disorder, and the use of NRT for those with panic disorder. 148 Another paper from the same trial reported that varenicline, bupropion, and nicotine patch are well tolerated and effective in adults with anxiety disorders. Varenicline showed greater effectiveness than bupropion, NRT, and placebo, and combination bupropion and NRT was more effective than placebo. 141
Smoking is associated with suicidal ideation, suicide plan, suicide attempt, and suicide death, 149, 150 but this association is reduced when a person quits. 97 Among people with psychosis, one study estimated that smoking contributed to 21% of suicidal behaviours; 151 reducing consumption may also reduce suicidality in this population. 151 Smoking is also associated with suicide attempts among people with bipolar disorder. 152 Researchers have suggested that smoking should be routinely screened for among people with suicidal ideation. 150, 153
ADHD is one of the most common psychiatric disorders, and is associated with a wide range of impairments and risks into adulthood. 154 Smoking is one such risk, with young people with ADHD beginning smoking earlier, and being two to three times more likely to smoke, compared to those without ADHD. The substantially higher prevalence of smoking persists into adulthood, and adults with ADHD are also less likely to be successful at quitting. 155-157 The risk of smoking also increases with the severity of symptoms. 158, 159
There is a growing body of evidence that stimulant medication, which is a front-line treatment of ADHD, may influence smoking-related outcomes. 155 Nicotine and stimulant medications operate on the same pathways in the brain, and both appear to help alleviate some of the symptoms of ADHD, which may help explain the very high rates of smoking among this group. 160 Research has shown that nicotine is experienced as more pleasurable as reinforcing among young people with ADHD. 161 ADHD medication (i.e., stimulant treatment) reduces smoking rates and smoking withdrawal, therefore early and consistent stimulant treatment of ADHD may reduce smoking risk. 155, 162-164 Bupropion, NRT, and possibly varenicline—approved smoking cessation medications—have also shown efficacy in treating symptoms of ADHD; 162, 165 however, further research is needed to examine its effectiveness in treating comorbid ADHD-smoking. 52 One RCT found that varenicline reduced smoking and withdrawal in smokers with ADHD with high, but not low, hyperactivity/impulsivity symptoms. 166 Non-pharmacological interventions, particularly cognitive-behavioural therapy, also show promise for the treatment of ADHD, and warrant further investigation for supporting cessation among this population. 52 Limited evidence also suggests that financial incentives may be a useful approach for promoting short-term cessation in adult smokers with ADHD. 167
Smoking prevalence among people with substance use disorders is substantially higher than the overall population. 11, 21, 31, 168-175 People with substance or alcohol use disorders also have greater nicotine dependence, lower quitting, and differences in quit attempts and withdrawal symptoms compared with people without such disorders. 176 Many people who successfully overcome their substance use disorder will go on to die from a smoking-related disease. 177 An Australian study examining alcohol misuse among smokers found that smokers were 3.8-fold more likely to have a higher level of alcohol consumption than non-smokers. 178 Many health risks for dual use of alcohol and tobacco are multiplicative rather than simply additive. For example, the risk of oesophageal cancer is greater among heavy alcohol users as a result of alcohol allowing tobacco toxins to penetrate more deeply to basal layers. 179 Similarly, there is evidence that smoking cannabis is a risk factor for many of the same illnesses as tobacco. 180-182 Cannabis poses unique problems for users since it is often mixed with tobacco, potentially inducing double dependence. In 2019, 34% of smokers in Australia reported recent use of cannabis, compared to 8% of non-smokers. 5
Treatment centres for substance use disorders have traditionally not prioritised treating nicotine addiction due to lack of staff training, lack of integration into usual care, and because of the common misperception that quitting may be detrimental to the treatment of alcohol or other drug use. 183-185 Substance abuse counsellors often have limited knowledge of the smoking cessation medications available for those trying to quit 186 and their implementation of tobacco cessation guidelines is inconsistent. 187 A study of staff and management attitudes and practices in Australia found smoking received little systematic attention, with concerns about possible negative impact on other treatments, absence of policy, and lack of training being major impediments. 188 Research in the US found that smokers with a substance use disorder who had undergone addiction treatment were less likely to quit smoking than those who had never received such treatment, possibly due to false beliefs about smoking as a coping strategy and staff attitudes that may discourage cessation. 189 Some centres may even endorse occasional smoking by staff with clients 190 or rely on cigarettes to stabilise mood in their patients. 55, 191
Contrary to staff perceptions, smokers with substance use disorders are motivated to quit. 192 However, despite this motivation to quit, there appears to be a wide variation in readiness to seek help to do so, 55, 93, 191, 193 which may be due to a lack of confidence in or wariness of quitting multiple substances at once. 193 Research in the US showed that when provided with a tobacco free treatment environment, patients with substance abuse and mental illness can and do make the decision to quit tobacco and maintain their abstinence, which in turn helps them to remain sober. 194 While negative affect can hinder quit attempts, patients in an addictions treatment setting can successfully quit smoking regardless of current depressive symptoms. 195 In the US, despite being lower than for people without the disorders, the smoking quit rates for people with alcohol use disorders has increased over time. 31
Perhaps most importantly, smoking interventions and cessation during substance use treatment appear to enhance rather than compromise long-term abstinence from other addictive drugs. 104, 196-199 Including cessation interventions in the course of addiction treatment can reduce consumption, 200 increase the provision of advice to quit, 201 increase use of cessation aids, 170, 200, 202 and increase quit attempts among smokers. 203, 204 A 2015 systematic review of smoking cessation interventions for adults in substance abuse treatment or recovery concluded that NRT, behavioural support, and combination approaches appear to increase smoking abstinence in those treated for substance use disorders. However, the authors note that higher quality studies are needed to strengthen the evidence base. 205 Some research indicates that drug treatment clients can successfully quit smoking at rates similar to the overall population when given access to an intensive intervention. 206 Several studies suggest that varenicline may promote smoking changes 207 and concurrently help reduce heavy drinking in people with alcohol use disorders. 208-211 However, use of bupropion by abstinent alcoholic smokers does not appear to increase long-term smoking cessation. 212 A 2021 meta-analysis concluded that varenicline may promote smoking cessation in people with alcohol dependence, but there was no clear evidence for the use of naltrexone, topiramate or bupropion. 213 For methadone maintenance patients, varenicline 214 and NRT 215 may be effective for promoting tobacco abstinence.
Several studies have explored the role of contingency management (i.e., financial incentives) in promoting abstinence. One study found that contingency management was associated with more short-term abstinence and lowered nicotine addiction among current and former injecting drug users. 216 Several studies have supported the use of contingency management when combined with pharmacotherapies and/or behavioural counselling. 217-219 Contingency management may also promote smoking reduction in more severe substance abusers, such as those in residential services and opioid-maintained patients, 220-222 and also among pregnant women with substance use disorders. 223 Such interventions appear to increase abstinence self-efficacy among residential substance abuse treatment patients. 224 Increasing tolerance for withdrawal and abstinence discomfort, addressing expectations, and increasing motivation may also be important when implementing incentive programs. 225 Other strategies include brief advice plus NRT, which appears to be a cost-effective way to reduce smoking for smokers in residential alcohol treatment, 226 and an Australian study found that a group program showed promise for reducing smoking among people attending residential alcohol and other substance dependence treatment. 227 Digital interventions 228 and quitlines 229 may also be helpful for addressing co-use of tobacco and other drugs.
As with mental health and correction services, public health experts have identified a need for policy and training initiatives to address past neglect of tobacco control issues. 230, 231 Systematic intervention around the 5As framework, tailored to the needs of client groups, would provide a good foundation for this work. Factors promoting smoking cessation programs within substance abuse treatment settings include supportive systems and integration within other treatments, 125 educating providers about the beneficial effects of cessation for their clients, staff training, and encouraging and assisting staff to quit. 191 One study found that an intervention based on organisational change helped to shift the treatment system culture and increase tobacco services in a residential addiction treatment setting. 231 Policies that mandate smoking cessation interventions as part of substance use disorder treatment can increase adoption and implementation. 232
Future clinical research in this area and its translation into practice may be improved by recruiting and retaining a broader range of people with drug dependencies, particularly those who are not currently being reached through mainstream interventions, and by longer-term follow-up. 233 Research as to the role of social bonding around tobacco use and its normalisation in drug treatment settings may be useful in guiding future practice. 193
The prevalence of current smoking in individuals with PTSD is substantially greater than that for the overall population. 234-236 A systematic review found that smokers were about twice as likely to have PTSD than non-smokers in the overall population, and more than one-third of people with PTSD were current daily smokers. 234 Another review concluded that there appears to be a causal relationship between PTSD and smoking that may be bidirectional. PTSD, rather than trauma exposure itself, appears to have a greater influence on a person’s risk of smoking, and specific PTSD symptoms may contribute to smoking and disrupt cessation attempts. 237 Evidence suggests that people with PTSD smoke to cope with negative affect and anxiety, 83, 234, 235 and PTSD is associated with higher levels of consumption (i.e., more cigarettes smoked per day). 238 Nonetheless, evidence suggests that PTSD is associated with more overall quit attempts (albeit with less success), and there has been a decline in smoking among people with PTSD over time. 234
To date, there have been a small number of studies examining smoking cessation interventions in smokers with PTSD. Given their greater difficulty maintaining quit attempts, people with PTSD may benefit from more intensive and targeted interventions, 235 and from proactive outreach to initiate treatment. 239 A systematic review published in 2018 examined integrated, specialised treatments for comorbid smoking—PTSD, including preliminary treatment studies and RCTs in both veteran and general clinical samples. It concluded that mobile technology shows promise for providing effective, lower cost, and wide-reaching PTSD—smoking intervention. There is also evidence to support the integration of smoking cessations aids (e.g., varenicline) and smoking cessation counselling into existing PTSD treatments (i.e., prolonged exposure), particularly for people experiencing elevated PTSD symptom severity. 234
Severe mental illness, or serious mental illness (SMI), are umbrella terms that generally refer to diagnoses of bipolar disorder or schizophrenia. People with SMI generally have very high rates of nicotine dependence and smoking—between 40% and 80%—and people with SMI who smoke have poorer mental and physical health outcomes than those who do not smoke. 240 Nonetheless, evidence suggests that smokers with SMI are motivated to quit and often seek help for quitting. 241 A systematic review published in 2021 of cessation interventions for people with SMI concluded that it is currently unclear which interventions are most effective, including the optimal intensity, duration, and modality of treatment, due to mixed findings and methodological limitations. However, it identified common evidenced-based components across studies that supported smoking cessation and/or reduction, including cessation medications (e.g., NRT, bupropion), motivational enhancement techniques, and cessation education and skills training. 240 A meta-analysis of RCTs published in 2019 concluded that varenicline is effective at 3- and 6-months for people with SMI. While bupropion and NRT showed short-term effectiveness, this was not sustained. 242 The largest RCT to date examining cessation interventions for people with SMI concluded that a tailored combined pharmacological and behavioural approach was effective in supporting short- and long-term quitting. 243, 244
Another review supported the effectiveness of tailored person-based smoking cessation interventions for people with SMI. 245 An Australian RCT found that telephone-delivered smoking cessation support led to significant reductions in cardiovascular disease risk and smoking across 36 months among people with psychotic disorders. 246 Although a number of guidelines have been developed for smoking cessation in people with severe mental illness, a review found that they varied considerably in quality, and many did not adequately describe their methods or report conflicts of interest. 247
People with bipolar disorder are about three and a half times more likely to smoke than the overall population, and have much lower quit rates than smokers without a comorbid condition. 248, 249 Research in the US and Europe has consistently found that the prevalence of smoking is approximately two to three times higher among people with bipolar disorder than in the overall population. 52 In addition to contributing to increased morbidity and mortality, smoking has also been implicated in the progression of bipolar disorder. 250 However, despite these high rates of comorbidity and related morbidity, there is only a modest field of research focusing on smoking among individuals with bipolar disorder. 251 To date, there have only been a small number of clinical studies on cessation interventions among smokers with bipolar disorder. Researchers have highlighted challenges in recruitment and low eligibility rates as significant hurdles to such studies, and have noted that many health professionals remain wary of encouraging cessation among people with bipolar disorder. 249 Nonetheless, recent research has attempted to address this gap.
Schizophrenia is a chronic and severe mental illness that affects about one in 100 people. 259 A meta-analysis of studies from 20 different countries found that people with schizophrenia have more than five times the odds of current smoking than the overall population. 260 Smokers with schizophrenia smoke more heavily and are more nicotine dependent, 261 and extract more nicotine from each cigarette. 262 Tobacco-related conditions are responsible for about half of total deaths in people with schizophrenia. 263 Despite wanting to quit, 264 a recent meta-analysis found that the prevalence of smoking cessation was 15% in schizophrenia patients, compared with 23% in healthy controls. 265 These lower success rates are partly because of the increased level of nicotine dependence among smokers with schizophrenia, and reduced access to treatments. 266 People with schizophrenia also report smoking to manage stress and negative affect, and to maintain social relationships. 59 They may also perceive themselves to be at lower risk of smoking related-disease. 267
Healthcare services have traditionally condoned or encouraged smoking and failed to offer tobacco cessation interventions to patients with schizophrenia, 59 mainly due to beliefs about the benefits of smoking to symptoms, stigma, lack of information, or perceived hopelessness regarding abstinence. 268, 269 However, in recent times there has been considerable interest in developing effective smoking treatment for this population, 52 particularly in light of research showing that smoking is associated with poorer clinical outcomes. 270, 271 Guidelines have been published that include cessation interventions for smokers with schizophrenia, 116 and studies have highlighted that early interventions with young people at risk of psychosis can be effective. 272 Smokers with a psychotic disorder are capable of long-term reduction and abstinence with appropriate intervention and support. 273 Once people with schizophrenia have successfully quit, the use of antipsychotics may need to be reviewed, as tobacco smoke can differentially affect drug metabolism and the effects of antipsychotic medications. 7, 274
A 2013 Cochrane review of interventions for smoking cessation and reduction in individuals with schizophrenia concluded that bupropion increases smoking abstinence rates in smokers, without any deterioration of mental state. Varenicline may also improve smoking cessation rates, but the authors noted a possibility of adverse psychiatric effects, such as increased suicidality. There is some evidence that contingent reinforcement (i.e., monetary rewards) may help people with schizophrenia to quit and reduce smoking in the short term. 269 Building on the Cochrane review, a 2015 systematic review and meta-analysis concluded that while there did not appear to be any adverse psychiatric outcomes, varenicline was not found to be superior to placebo for quitting among people with schizophrenia. 275 Another 2015 review of smoking cessation in people with schizophrenia concluded that the most promising evidence is for bupropion, and that pharmacological interventions do not appear to increase adverse events. It suggested that the lack of evidence for NRT and varenicline may be due to the paucity of research. Behavioural and psychosocial interventions are also promising, particularly when combined with pharmacotherapy. The authors highlight the importance of carefully monitoring antipsychotic levels, and suggest that encouraging physical activity may help to negate potential weight gain and diabetes risk following cessation. 276 A further review of the evidence recommended that people with schizophrenia should receive varenicline or bupropion with or without nicotine replacement therapy in combination with behavioural treatment. Maintenance pharmacotherapy for 1 year appears to improve sustained abstinence rates. 277
Results from a large randomised controlled trial were published in 2016, which found that varenicline was more effective than bupropion and nicotine patch in smokers both with and without psychiatric disorders (including schizophrenia), whereas bupropion and nicotine patch were similarly effective, and both more so than placebo. The authors also examined the safety of the medications, and concluded that they can be used safely by psychiatrically stable smokers; there was no increase in neuropsychiatric adverse events attributable to varenicline or bupropion relative to nicotine patch or placebo. 120 In September 2016, the FDA released a preliminary review of this trial, suggesting a number of problems with the study. The review supported similar conclusions about the relative rates of events: in patients without prior psychiatric history, events did not seem to be more frequent in varenicline, bupropion, or NRT-treated patients than in placebo-treated patients. The review also found that among patients attempting to quit, events were more common in those with psychiatric history than those without, regardless of which treatment they received. Of concern however, was a possible increased risk of neuropsychiatric events in patients with psychiatric history in the varenicline or bupropion group compared to placebo. This trended toward statistical significance, but was not observed in NRT-treated patients. 278
There has also been some interest in the use of electronic cigarettes for smoking cessation among people with schizophrenia; however there is currently only very limited research on their efficacy. 289 See Section 18.7 for further discussion. One review notes that nicotine is likely responsible for the potential role of smoking in the onset of schizophrenia, which should be considered in discussion of e-cigarettes. 290
Medical and mental health professionals have traditionally overlooked the importance of addressing tobacco use with their patients. 54 Smoking is often not asked about or recorded as a standard part of psychiatric assessment, and even when it is, inclusion of smoking cessation in treatment planning is often inconsistent. 54, 291, 292 This may be partly due to the erroneous beliefs held by some mental health workers that smoking is one of the few pleasures clients have, that smoking reduces stress and anxiety, 60, 293 that those with mental illness are not motivated to quit, 99 or that there are more pressing concerns for patients with acute psychiatric symptoms. 82 They may also hold fatalistic views that smoking and failed quit attempts are inevitable. 63
International evidence suggests that cessation support for inpatient smokers by staff is likely to be severely compromised by low levels of knowledge and awareness of tobacco dependence. 294 Several Australian surveys have found strong support for the provision of smoking cessation treatment among mental health service staff; 295, 296 however staff report significant barriers to providing such care. 295 Commonly cited barriers include inadequate resources, cultural norms, client resistance, and lack of training and confidence. 232, 297-301 More experienced staff, and those with tobacco cessation training, are more likely to help their clients quit smoking. 292, 302, 303
Healthcare professionals, including physicians, psychiatrists, and psychologists, have an important role in the recognition and treatment of tobacco use disorders in patients with psychiatric illnesses, and providing cessation treatment for all patients who smoke should form part of routine care. 7, 304, 305 Australians with mental illness who smoke report that mental health professionals are a preferred and trusted source of cessation information. 130 A 2015 systematic review and meta-analysis concluded that while there has been progress, offering smoking cessation advice should receive a higher priority in everyday clinical practice for patients with a mental health diagnosis. 306 Encouraging longitudinal research in the US found that smokers who had seen mental health professionals for mental health problems had higher odds of having made attempts to quit in the past year, and were more likely to have used cessation assistance. 307 However, another longitudinal US study looking only at psychiatrists found that they are screening for tobacco use at declining rates, and the proportion of smokers provided with treatment remains low, 308 and a UK study found that smoking cessation medication prescribing appeared to be declining in primary care. 309 Australian research also found that the provision of cessation interventions in acute psychiatric units is inconsistent and generally suboptimal. 310
As in the overall population, people with mental illness should be given advice and support to quit using the 5As framework. 311 Given that people with mental illness are often highly nicotine dependent, and are more likely to socialise with smokers, more intensive interventions may have greater success. This might involve NRT or other pharmacotherapies, as well as referral to a specialised individual program, such as the Quitline, or a group program. The integration of cessation treatment into existing care by health professionals results in greater engagement, greater use of cessation pharmacotherapy, and increased likelihood of abstinence. 125, 312 An Australian study found that introducing a ’smokers’ clinic‘ to a mental health setting helped those with mental illness to reduce or quit smoking and led to a sustained increase in the delivery of cessation interventions among health professionals. 121 Researchers have developed a comprehensive guide for healthcare professionals to integrate smoking cessation treatment into routine care, and note that by drawing on evidence-based methods such as behavioural support and CBT, smoking cessation can be addressed in a compassionate and respectful manner. 48 Quit Victoria has suggested a number of strategies that mental health services could implement to reduce smoking-related harms, including:
An important part of providing smoking cessation support for those with mental health disorders is for mental health services to develop comprehensive policy on smokefree environments, documenting tobacco use, and continuing support on discharge. This requires leadership from management, staff training, and consistency across services. 314-316 An audit of an Australian psychiatric hospital found that the setting did not conform to current clinical practice guidelines as it often failed to document smoking status, despite nicotine dependence being the most commonly diagnosed psychiatric disorder. 317 Another Australian study of public psychiatric inpatient units found that over one-third of inpatients started smoking during their admission, and that staff often provided cigarettes to patients. Only half of respondents reported that all patients were assessed for smoking status. The study suggests that failure of psychiatric services to provide smoking care is systematic and not related to particular types of services. 318
However, an Australian study published in 2015 found that adherence to smokefree policy in an inpatient psychiatric facility was poor, with more than four in five smokers still smoking, and only about half perceiving staff to be supportive of the policy. 326 Two Australian studies have found that about only about half of psychiatric patients feel positively about bans, 326, 327 while another found that only about one quarter of mental health staff agreed with a total smoking ban. 328 Compliance and enforcement can be challenging in the context of high smoking prevalence and complex needs of patients. 329 Some patients also perceive the restrictions to be a form of punishment. 330 There have been debates regarding the ethics of implementing complete smoking bans in psychiatric hospitals; proponents argue that the ‘smoking culture’ creates disproportionate harm among people with mental illness, while opponents argue that it is unethical to deprive patients of autonomy and impose treatment. 331, 332
Together, evidence suggests that there is a critical need to engage healthcare providers, policy-makers, and mental health advocates in the effort to increase access to:
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