Photo: Michael Macor, The Chronicle
Joe Alaniz smokes along San Pablo Ave. in San Pablo, Calif. on Tues. Sept. 6, 2016. California’s proposition 56, the cigarette initiative is passed would add $2 to a pack of cigarettes which would go to health-care programs, smoking prevention and research.
One of the great public health triumphs of the past century has been the steady decrease in cigarette smoking. Yet there is one group that has not benefited from this progress: persons with mental illness.
Today, smoking rates among adults in the United States are at a modern low of 15.1 percent, and California, which at 11.7 percent has the second-lowest state smoking rate, has led the way with early action on tobacco taxation and clean indoor air laws. Had smoking rates persisted at the rate they were in 1964, 8 million more Americans would have died from smoking-related illnesses.
Persons with mental illnesses, such as depression, bipolar disease, schizophrenia and chronic anxiety, as well as those with substance-use disorders including alcohol abuse or heroin addiction, smoke at rates two-to-three times the national average. Not only that, they smoke more daily cigarettes.
As a consequence, smokers with mental illnesses consume 40 percent of all cigarettes sold in this country, despite accounting for only about 20 percent of the population. Heavy smoking comes with a huge cost — persons with mental illness die 10 to 15 years earlier than the general population and most of those premature deaths are from smoking-related illnesses such as heart disease, lung cancer, stroke, and chronic lung disease.
For too long, smoking among persons with mental illnesses was tolerated and even encouraged because of many misperceptions: Smoking alleviates psychiatric symptoms; smokers with mental illnesses don’t want to stop smoking; even if they want to quit they won’t be able to; they deserve the pleasure from smoking to counteract the pain of their illnesses; and quitting exacerbates the underlying mental health condition. These myths were perpetuated by too many mental health professionals, and were abetted by the tobacco industry and well-intended families and friends.
Now we know different. Most smokers with mental illness do want to quit, and many are able to do so. Much of the “pleasure” of smoking a cigarette comes from avoiding withdrawal from its addictive component — nicotine. And rather than worsening symptoms, a recent review has shown that when persons with chronic depression or anxiety stop smoking, their symptoms actually improve.
Despite California’s low rate of smoking, because of its large population, the state has more smokers than any other state, including smokers with mental illnesses. We can do much better in helping Californians with mental illness stop smoking and improve their health — and all Californians have a role to play.
First, the recent $86.4 million state budget increase for behavioral health services should provide resources focused on smoking cessation among persons with mental illness. This has been a neglected area.
Second, clinicians caring for persons with mental illness — both in public and private settings — should identify smokers and encourage them to seek treatment.
Third, administrative barriers to receive appropriate smoking-cessation assistance, including counseling and medications, should be removed.
Fourth, achieving this goal should be a priority for all who work in the health care system, as well as the many committed advocates concerned about the well-being of those with mental illness.
Finally, every Californian who knows a smoker living with mental illness — a family member, friend, classmate or coworker — should encourage them to have a conversation with a health-care provider about how to quit. One important and underused resource is the free California Smokers Helpline (800-NOBUTTS).
It is time to recognize the existence of this hidden epidemic and try to correct it. The health of millions of Californians would benefit.