Do Patients with Mental Health Problems Find It Hard to Give Up Smoking?
Yes, patients with mental health disorders experience significantly greater difficulty quitting smoking than the general population, with stress and negative affect being the primary precipitants of relapse, but evidence consistently shows that quitting does not worsen—and actually improves—their psychiatric symptoms. 1, 2, 3
The Evidence for Greater Difficulty Quitting
Patients with psychiatric disorders report more severe withdrawal symptoms than those without mental health conditions. 3 The most common precipitator of relapse during previous quit attempts is stress (43.6% of cases), particularly among individuals with depression and anxiety disorders. 2 Smokers with psychiatric illness are especially vulnerable to relapse during times of stress and negative affect, which creates a cyclical pattern that perpetuates tobacco dependence. 2
The mechanisms linking mental health conditions and cigarette smoking are complex and differ across disorders. 4 The prevailing view has been that patients smoke to self-medicate and regulate symptoms associated with their psychiatric disorder—nicotine may improve concentration, cognition, relieve stress and depressive affect, and produce pleasurable sensations through its action on the cholinergic system. 5 However, this creates a paradox where the temporary relief reinforces dependence while ultimately worsening overall mental health outcomes. 4
Critical Reassurance: Quitting Improves Mental Health
A crucial finding that should guide clinical practice: quitting smoking does not exacerbate pre-existing mental illness and is actually associated with improvements in psychological well-being. 1, 3 Meta-analytic evidence demonstrates that smoking cessation is associated with reductions in depression, anxiety, and stress, along with improvements in psychological quality of life and positive affect compared to continued smoking. 6 This effect is similar in both the general population and those with diagnosed mental health disorders. 6
Treatment Gaps in Current Practice
Only approximately one-third (33%) of individuals with bipolar disorder who smoke receive smoking cessation advice from their mental health providers, representing a substantial treatment gap. 7 This undertreatment persists despite evidence that individuals with psychiatric disorders are motivated to quit, with health being the most common motivation (91%), followed by family/social pressures and cost concerns. 2, 5
Evidence-Based Treatment Approach
The recommended treatment combines pharmacotherapy with intensive behavioral counseling—pharmacotherapy alone without counseling may not be better than unaided cessation. 8, 9
Pharmacotherapy Options:
- Combination nicotine replacement therapy (21 mg patch plus short-acting NRT such as 4 mg gum or lozenges) achieves the highest abstinence rate at 36.5% at 6 months. 8
- Varenicline 1 mg twice daily is equally effective and safe in psychiatric populations—it does not increase neuropsychiatric adverse events compared to nicotine patch or placebo in patients with or without psychiatric diagnoses. 7
- Bupropion is also safe and does not worsen psychiatric symptoms. 7, 3
Behavioral Support Requirements:
A minimum of 4 counseling sessions over 12 weeks is essential, with the first session occurring within 2-3 weeks of starting medication. 8, 9 Greater numbers and longer duration of sessions produce a dose-response effect with improved outcomes. 7 High-intensity approaches with weekly counseling for ≥4 weeks have achieved long-term abstinence rates up to 25% in severely dependent smokers. 7
Behavioral interventions should emphasize alternative coping strategies and facilitate mood management, given the vulnerability to stress-related relapse. 2 Motivational interviewing using the 5 A's strategy (Ask, Advise, Assess, Assist, Arrange) benefits all patients, including those ambivalent about quitting. 9
Delivery Modalities:
Both face-to-face and telephone-delivered interventions with combination NRT result in excellent retention and can significantly reduce smoking and cardiovascular risk scores comparably. 1 Quitlines can provide essential behavioral support when in-person counseling resources are limited. 1, 9
Treatment Algorithm for Psychiatric Populations
Initiate combination pharmacotherapy: Start with nicotine patch 21 mg plus short-acting NRT (gum/lozenge 4 mg) OR varenicline 1 mg twice daily based on patient preference. 8, 7
Arrange behavioral counseling: Schedule minimum 4 sessions over 12 weeks, with first session within 2-3 weeks of medication start. 8, 9
Address psychiatric comorbidities: Ensure ongoing mental health treatment is optimized—patients receiving mental health treatment are more likely to successfully quit. 4, 6
Monitor withdrawal versus psychiatric symptoms: Nicotine withdrawal peaks at 1-2 weeks then subsides; distinguish these time-limited symptoms from underlying psychiatric conditions. 8, 3
If initial treatment fails: Switch to a different first-line medication not previously used, or escalate to combination therapy (varenicline + NRT or bupropion + nicotine patch). 9
Common Pitfalls to Avoid
- Do not withhold cessation treatment due to concerns about worsening mental health—the evidence clearly shows quitting improves psychiatric symptoms. 1, 3, 6
- Do not prescribe pharmacotherapy without arranging behavioral counseling—this substantially reduces success rates. 8, 9
- Do not provide insufficient follow-up or allow premature discontinuation—withdrawal symptoms are time-limited and require support through the critical first 2 weeks. 8, 9
- Do not ignore the role of stress management—interventions must specifically address stress as the primary relapse trigger in this population. 2
Special Considerations
Smoking is a leading cause of the 15- to 30-year mortality gap among people with severe mental disorders, making cessation interventions a critical priority. 1 Tobacco-related illnesses are the leading cause of death in patients with psychiatric disorders, with life expectancies reduced by approximately 25 years. 3 The benefits of cessation for both physical and mental health far outweigh any temporary discomfort from withdrawal. 1, 6