Mental Health and Nicotine
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People with mental health conditions have shorter life expectancies than those without them. Although many factors contribute to this reality, some behaviors that increase the risk of early death are manageable—including smoking. The difference in life expectancy between people with mental health conditions who smoke and those who do not is stark. Smokers with serious psychological distress lose approximately 15 years of life compared to never-smokers without, while never-smokers with serious psychological distress lose about five years.
The relationship between smoking and mental health conditions is multifaceted; however, one of the main reasons people continue to smoke is a physical dependence on nicotine. Smoking is the most common—and most harmful—way to consume nicotine. While most research on smokers with mental health conditions does not isolate the effects of nicotine, researchers are increasingly considering how reduced-risk products that deliver nicotine without combustion (e.g., e-cigarettes, nicotine pouches) might help these individuals quit or reduce the harm from smoking.
Smoking, Quitting, and Mental Health Conditions
About half of people who smoke will experience mental health conditions in their lifetime. The reverse is also true, as people with mental health conditions smoke at higher rates than those without. While 15.8 percent of people without a past-year mental health condition smoked, 28.2 percent of people with a mental health diagnosis smoked during the past month. Additionally, people with mental health conditions tend to smoke more cigarettes and have greater nicotine dependence than people without these challenges. In fact, although they only make up about 23 percent of the population, individuals with mental health conditions smoke about 40 percent of all combustible cigarettes consumed by adults in the United States.
U.S. smoking rates have decreased significantly; however, the same decreases have not been observed among people with mental health conditions. Although mental health conditions do not decrease people’s motivation to quit smoking, individuals with mental health conditions successfully quit at lower rates and return to use at higher rates.
Many factors contribute to the higher smoking rates and lower quit rates among people with mental health conditions. Evidence suggests that smokers with mental health conditions experience stronger withdrawal symptoms and less interest in alternative sources of pleasure when quitting. Although studies show that quitting smoking can improve symptoms of mental health conditions, the perception that smoking reduces stress and other negative feelings or medication side effects can discourage quit attempts. One survey of psychiatrists found that almost half thought patients’ other problems were more immediate than their smoking, while 22 percent believed that cessation exacerbates mental health symptoms. Psychiatrists often do not provide treatment referrals or help in quitting. Some studies suggest that people with mental health conditions smoke to self-medicate their symptoms, which could make it more difficult to quit. Finally, smoking and mental health conditions share socioeconomic risk factors, many of which are associated with lower quit rates.
Existing Smoking Cessation Tools
People with mental health conditions have typically been excluded from smoking cessation studies, leaving questions about the effectiveness of nicotine replacement therapy (e.g., nicotine patches) and pharmaceutical treatments (i.e., varenicline and bupropion). One study that combined data from multiple analyses found no placebo-controlled clinical trials that evaluated long-term (greater than six months) cessation outcomes from nicotine replacement therapy alone among people with serious mental illness. A similarly designed study found that both pharmaceutical treatments for smoking cessation could be used safely by people with severe mental illness and were more effective than no treatment at all. Quitlines—another cessation tool—are generally underutilized; however, one study showed that a specialized quitline for mental health patients was more effective at helping them quit. Because people with mental health conditions smoke at higher rates than the overall population, further evaluation of existing and novel quit strategies for this population is necessary.
Alternative Nicotine Delivery Methods
Smoking is no longer the only way to consume nicotine. Products like e-cigarettes expose people to fewer harmful chemicals than combustible cigarettes while still allowing them to use nicotine. As with combustible cigarettes, researchers have noted associations between e-cigarette use and poor mental health—particularly among young people. But no causal relationship has been established between e-cigarette use and developing a mental health condition. One review of studies that assessed how helpful or harmful e-cigarettes are for people with mental health conditions found that e-cigarette use was not associated with greater dependence on nicotine or increased psychiatric symptoms. The high nicotine dependence and low quit rates among people with mental health conditions has led some to suggest that the harm-reduction potential of these products could be particularly beneficial for this population.
Across studies and populations, evidence suggests that e-cigarettes are more effective than nicotine replacement therapy at helping people quit smoking. While few studies have assessed e-cigarettes’ ability to help people with mental health conditions quit or reduce their smoking, most of those that exist show positive or neutral outcomes. One trial compared the effectiveness of e-cigarettes and nicotine replacement therapy for smoking cessation among people with mental health conditions, finding that the products performed similarly. However, participants rated e-cigarettes as more acceptable and were more compliant with their use compared to nicotine replacement therapy. Overall, participants using e-cigarettes decreased the number of combustible cigarettes smoked more than those using nicotine replacement therapy.
Another small study evaluated the acceptability of e-cigarettes among people with serious mental illness. This study found that e-cigarette use helped participants decrease the number of combustible cigarettes smoked without increasing nicotine dependence. Participants also found e-cigarettes similarly appealing and satisfying compared to combustible cigarettes.
Conclusion
The relationship between nicotine and mental health conditions is complex. Since smoking is much more prevalent and quit rates much lower among people with mental health conditions, we must consider all avenues to help this population quit or reduce their combustible cigarette consumption. It is imperative to continue evaluating the role of lower-risk nicotine products in accomplishing this goal.