Original Investigation |

Trends in Smoking Among Adults With Mental Illness and Association Between Mental Health Treatment and Smoking Cessation

Benjamin Lê Cook, PhD, MPH1; Geoff Ferris Wayne, MA1; E. Nilay Kafali, PhD1; Zimin Liu, MA2; Chang Shu, BS3; Michael Flores, MPH4
[+] Author Affiliations
1Harvard Medical School/Cambridge Health Alliance, Department of Psychiatry, Cambridge, Massachusetts
2College of Economics and Management, Southwest University, Chongqing, People’s Republic of China
3Harvard School of Public Health, Department of Epidemiology, Boston, Massachusetts
4Brown University, Providence, Rhode Island
JAMA. 2014;311(2):172-182. doi:10.1001/jama.2013.284985.
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Importance  Significant progress has been made in reducing the prevalence of tobacco use in the United States. However, tobacco cessation efforts have focused on the general population rather than individuals with mental illness, who demonstrate greater rates of tobacco use and nicotine dependence.

Objectives  To assess whether declines in tobacco use have been realized among individuals with mental illness and examine the association between mental health treatment and smoking cessation.

Design, Setting, and Participants  Use of nationally representative surveys of noninstitutionalized US residents to compare trends in smoking rates between adults with and without mental illness and across multiple disorders (2004-2011 Medical Expenditure Panel Survey [MEPS]) and to compare rates of smoking cessation among adults with mental illness who did and did not receive mental health treatment (2009-2011 National Survey of Drug Use and Health [NSDUH]).The MEPS sample included 32 156 respondents with mental illness (operationalized as reporting severe psychological distress, probable depression, or receiving treatment for mental illness) and 133 113 without mental illness. The NSDUH sample included 14 057 lifetime smokers with mental illness.

Main Outcomes and Measures  Current smoking status (primary analysis; MEPS sample) and smoking cessation, operationalized as a lifetime smoker who did not smoke in the last 30 days (secondary analysis; NSDUH sample).

Results  Adjusted smoking rates declined significantly among individuals without mental illness (19.2% [95% CI, 18.7-19.7%] to 16.5% [95% CI, 16.0%-17.0%]; P < .001) but changed only slightly among those with mental illness (25.3% [95% CI, 24.2%-26.3%] to 24.9% [95% CI, 23.8%- 26.0%]; P = .50), a significant difference in difference of 2.3% (95% CI, 0.7%-3.9%) (P = .005). Individuals with mental illness who received mental health treatment within the previous year were more likely to have quit smoking (37.2% [95% CI, 35.1%-39.4%]) than those not receiving treatment (33.1% [95% CI, 31.5%-34.7%]) (P = .005).

Conclusions and Relevance  Between 2004 and 2011, the decline in smoking among individuals with mental illness was significantly less than among those without mental illness, although quit rates were greater among those receiving mental health treatment. This suggests that tobacco control policies and cessation interventions targeting the general population have not worked as effectively for persons with mental illness.

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Trends in Smoking Rates Among Individuals With and Without Mental Illness, Mental Health Treatment, or Botha

Error bars indicate 95% confidence intervals. A, Analysis included individuals with (median, 4091 [range, 3633-4319]) and without (median, 16 363 [range, 15 009-18 355) probable mental illness. P < .01 at 2010 and P < .05 at 2011. B, Analysis included individuals with (median, 2515 [range, 2353-2729]) and without (median, 17 909 [range, 16 259-19 992]) treatment linked to a mental health diagnosis. P < .05 at 2010 and 2011. C, Analysis included individuals with (median, 2333 [range, 1981-2522]) and without (median, 17 669 [range, 16 254-19 692]) severe psychological distress or probable depression. D, Analysis included individuals with (median, 1180 [range, 1126-1400]) and without (median, 19 232 [range, 17 516-21 343]) neurotic/anxiety disorder. P < .05 at 2011. E, Analysis included individuals with (median, 1499 [range, 1388-1601]) and without (median, 18 899 [range, 17 203-21 115]) depressive disorder. P < .10 at 2011. K-6 indicates Kessler 6-Item Psychological Distress Scale; PHQ-2, Patient Health Questionnaire 2.aMental health treatment included individuals who received outpatient care or a prescription drug for a mental health diagnosis.

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