People with mental or substance use disorders are more than twice as likely to smoke as people without them, and are more likely to die of a smoking-related illness than of their behavioral health condition. Yet many of them want to quit and can, although they may need more intensive help. Quitting lowers the risk of smoking-related disease and may improve mental health and recovery from drugs and alcohol.
To see how treatment centers handle tobacco, CDC and the Substance Abuse and Mental Health Services Administration (SAMHSA) analyzed two 2016 national surveys of facilities: the National Mental Health Services Survey (12,136 mental health facilities analyzed) and the National Survey of Substance Abuse Treatment Services (14,263 substance abuse facilities), covering the United States, including Puerto Rico.
What facilities offered
| Practice | Mental health facilities | Substance abuse facilities |
|---|---|---|
| Screened patients for tobacco use | 48.9% | 64.0% |
| Offered cessation counseling | 37.6% | 47.4% |
| Offered nicotine replacement therapy (NRT) | 25.2% | 26.2% |
| Offered non-nicotine quit medications | 21.5% | 20.3% |
| Smoke-free campus (no smoking indoors or out) | 48.6% | 34.5% |
Screening was the most common practice, and counseling the most common treatment. But a smoke-free campus often came without help to quit: among facilities with one, 57.3% of mental health and 39.4% of substance abuse facilities did not report offering counseling, and 67.6% and 65.7% respectively did not report offering NRT.
A wide range between states
- Counseling in mental health facilities ranged from 20.5% in Idaho to 68.2% in Oklahoma; in substance abuse facilities, from 26.9% in Kentucky to 85.0% in New York.
- Smoke-free campuses ranged from 19.9% (Idaho) to 77.7% (Oklahoma) among mental health facilities, and from 10.0% (Idaho) to 83.0% (New York) among substance abuse facilities.
- Fewer than half of mental health facilities were smoke-free in 31 states; fewer than half of substance abuse facilities were in 43 states, DC and Puerto Rico.
Mental health treatment facilities with smoke-free campuses, by state, 2016. Image from CDC’s report.
Substance abuse treatment facilities with smoke-free campuses, by state, 2016. Image from CDC’s report.
Why treatment lags
- Priorities: some providers have seen quitting smoking as secondary to treating the behavioral health condition, or feared it would worsen symptoms or threaten recovery. The latest evidence does not support those fears — though patients should be monitored, because smoking speeds the breakdown of some psychiatric drugs and doses may need adjusting after quitting.
- Beliefs: some providers think their patients cannot or will not quit. Many can, and benefit from proven treatments.
- Money: few incentives, and reimbursement problems.
- Industry: the tobacco industry once opposed smoke-free psychiatric hospitals, gave cigarettes to mental health facilities and funded research claiming patients needed tobacco to self-medicate.
What is working
New York required tobacco-free campuses in state-funded or state-certified substance abuse programs and let Medicaid cover unlimited quit attempts a year. Oklahoma dropped copays and prior authorization for Medicaid quit treatment, and required substance abuse and state-contracted mental health facilities to go tobacco-free, deliver proven quit treatment and document quitline referrals. A 2016 national action plan aimed to cut smoking among people with behavioral health conditions from 34% in 2015 to 30% by 2020.
Tobacco and other addictions
Smoking in adolescence is linked to later drug dependence, and animal studies suggest nicotine exposure in youth raises susceptibility to other addictive substances, including opioids. Nicotine and opioid addiction reinforce each other, while quitting smoking is associated with long-term abstinence after opioid treatment — so tobacco prevention and treatment belong in any strategy against substance abuse.
Limits: the data were self-reported by facilities, counted every facility equally regardless of size, and could not show whether treatments were used or whether policies covered e-cigarettes. The report adds that tobacco-free policies covering every product, including e-cigarettes and smokeless tobacco, support quitting and remove secondhand exposure.
Sources
Based on Marynak K, VanFrank B, Tetlow S, et al., "Tobacco Cessation Interventions and Smoke-Free Policies in Mental Health and Substance Abuse Treatment Facilities — United States, 2016," MMWR Vol. 67, No. 18, CDC; a work of the United States government in the public domain. Maps from the same report.
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