There has been a significant decline in cigarette smoking across the United States over the past 50 years, yet this progress is not evenly distributed across populations. Smoking rates remain disproportionately high among individuals with psychiatric illnesses. Psychiatrists, uniquely positioned with both the expertise to treat tobacco use and regular contact with these high-risk patients, are in a pivotal position to address this health disparity. However, a recent Viewpoint article in JAMA psychiatry explains that smoking cessation has not been integrated into psychiatric practice to the extent that it should be.

Indeed, the article reports that 24% of individuals who experienced a major depressive episode in the past year, and 36% of those with a substance use disorder, reported smoking in the past month. This contrasts sharply with the 16% smoking rate of the general population. The disparity is even more pronounced in certain clinical settings: up to 62% of patients with schizophrenia in a large psychiatric hospital system in Maryland were found to be smokers. Indeed, tobacco-related diseases are responsible for approximately half of the deaths among individuals with schizophrenia, bipolar disorder, depression, and various substance use disorders.

Psychiatrists are well-equipped to help patients navigate the challenges of quitting smoking. However, despite the high smoking rates among people with mental illness, the prescribing of smoking cessation pharmacotherapy remains notably low. In 2019, less than 2% of smokers were prescribed varenicline or nicotine replacement therapy, and only 8.4% received bupropion, despite these being effective treatments for smoking cessation. Moreover, it is critical to recognize the overlapping symptomology between psychiatric symptoms and nicotine withdrawal, such as irritability, dysphoria, and anxiety.

The reluctance to prioritize smoking cessation in psychiatric practice may stem from concerns that quitting smoking could destabilize patients' psychiatric conditions. However, evidence suggests that smoking cessation does not worsen, and may even improve, mental health symptoms, including anxiety and depression. By equipping future psychiatrists with the skills and confidence to address smoking cessation, this viewpoint argued that we can help more patients with mental illness avoid the severe health consequences of smoking.

Ultimately, helping patients with psychiatric disorders to quit smoking should be a core responsibility of psychiatrists. By making smoking cessation a priority, we can significantly reduce the burden of tobacco-related illness in this vulnerable population, improving both their physical and mental health outcomes. .

Reference:
Kleinman RA and Barnett BS JAMA Network 2024; online ahead of print. Abstract.