Newfoundland and Labrador Smokers’ Helpline

1-800-363-5864

mental health and addictions

For healthcare providers:

Information and Resources to Help Individuals with Mental Health and Addictions Issues Quit Tobacco​

People with mental illness and addictions have been identified as a priority group under the Provincial Tobacco Reduction Strategy, since the health, social and financial impacts of tobacco use are higher for this group.

Although smoking rates in the general population have decreased over the years, there continues to be high rates of smoking among people with mental illness and addiction.

For example:

Smoking rates are 2-4 times higher among people with mental illness than in the general population[1]. People with addictions also have higher smoking rate[1].

50-90% of individuals with mental illness or addiction are tobacco dependent[2].

Smoking rates vary depending on the type of mental illness or addiction[3].

Smoking rate of populations of individuals with:

Bipolar Disorder – 51-70%
Depression – 36-80%
Anxiety Disorders – 32-60%
Schizophrenia – 62-90%
Alcohol Abuse – 34-93%

Individuals with mental illness and addiction also tend to smoke more cigarettes per day than the general population[1].

Alcohol and drug abuse are strongly associated with high rates of smoking.  Of individuals in addictions treatment, 80-98% smoke[4].

One of every two people who smoke will die due to smoking related illnesses[5] and individuals with mental illness and/or addiction are disproportionately affected by tobacco-related disease and death[1].

Individuals with mental illness and addiction may die up to 25 years earlier than individuals in the general population; most of these deaths are attributable to tobacco use[6].


[1] CAN-ADAPTT. (2011). Canadian Smoking Cessation Clinical Practice Guideline. Toronto, Canada: Canadian Action Network for the Advancement, Dissemination and Adoption of Practice-informed TobaccoTreatment, Centre for Addiction and Mental Health

[2] Williams, J.M. & Ziedonis, D. (2004). Addressing tobacco among individuals with a mental illness or an addiction. Addictive Behaviors 29, 1067-1083.

[3] Morris, C., Waxmonsky, J., May, M., Giese, A., Martin, L.(2009). Smoking cessation for persons with mental illnesses: A toolkit for mental health providers. Denver, Colorado: University of Colorado, Department of Psychiatry

[4] Baca, C.T., & Yahne, C.E. (2009). Smoking cessation during substance abuse treatment: What you need to know. Journal of Substance Abuse Treatment, 36, 205-219.

[5] World Health Organization. (2001). Regulation of nicotine replacement therapies: an expert consensus. Copenhagen: World Health Organization.

[6] Prochaska, J.J. (2010). Failure to treat tobacco use in mental health and addiction treatment settings: A form of harm reduction? Drug and Alcohol Dependence 110, 177-182.

Tobacco use is a complex addiction involving physiological and psychological response components. It can be very challenging to quit. Only 3-5% of individuals who try to quit without support (i.e. counselling), nicotine replacement therapy, or cessation medications are successful in quitting.

Individuals living with mental illness and/or addictions may experience additional challenges in their journey to quit smoking. For instance, in addition to experiencing withdrawal symptoms when trying to quit smoking, people with mental illness have unique neurobiological features which can complicate these symptoms and make it more difficult to quit[1].

Furthermore, some individuals with mental illness may be more affected by nicotine withdrawal. For example, one withdrawal symptom is increased heart rate which can trigger an attack in people who suffer from panic attacks[2] making it more difficult for them to quit.

People with mental illness experience a list of risk factors for tobacco use. These individuals are more likely to[3]:

  • Have a lower socioeconomic status.
  • Be surrounded by others who smoke.
  • Experience homelessness.
  • Lack medical insurance and;
  • Lack access to resources that could help them quit.

 
The financial costs of smoking affect quality of life. People with mental illness who are addicted to tobacco may spend up to 27% of their income on tobacco addiction while struggling to afford food or other essential daily needs[4].

Additionally, some people with mental illness may have reduced social functioning and use smoking to cope with boredom and loneliness or use it as a way to connect with others [5].

Components in tobacco smoke increase the metabolism of some antidepressants and antipsychotic medications resulting in lowered levels of medication in the blood. When a person quits, the levels of drug in the person’s blood may increase significantly and dosages may need to be adjusted.

Individuals with mental illness and/or addictions may drink a lot of coffee and caffeine levels can rise when quitting smoking, thus caffeine levels should be monitored[4].


[1] Morris, C., Waxmonsky, J., May, M., Giese, A., Martin, L.(2009). Smoking cessation for persons with mental illnesses: A toolkit for mental health providers. Denver, Colorado: University of Colorado, Department of Psychiatry.

[2] Williams, J.M. & Ziedonis, D. (2004). Addressing tobacco among individuals with a mental illness or an addiction. Addictive Behaviors 29, 1067-1083.

[3] Weir, K. (2013). Smoking and mental illness. American Psychological Association, 44(6), 36.

[4] CAN-ADAPTT. (2011). Canadian Smoking Cessation Clinical Practice Guideline. Toronto, Canada: Canadian Action Network for the Advancement, Dissemination and Adoption of Practice-informed TobaccoTreatment, Centre for Addiction and Mental Health

[5] Morris, C., Waxmonsky, J., May, M., Giese, A., Martin, L.(2009). Smoking cessation for persons with mental illnesses: A toolkit for mental health providers. Denver, Colorado: University of Colorado, Department of Psychiatry

People with mental illness may smoke because they feel it alleviates some of the symptoms they experience from their illness and reduces the side effects of medication.  This effect is short term, lasting only a few minutes until nicotine levels in the body drop once again. For example, for individuals living with depression, smoking can create positive feelings triggered by the release of dopamine in the brain[1].  Dopamine is often lower in patients with depression so they may smoke as a way of temporarily creating those feelings of euphoria or positive emotion. The inhalation of nicotine triggers the brain to switch off its own biological mechanism for making dopamine, and after a period of time decreases its natural supply.

Chemicals in cigarette smoke increase the metabolism of some antidepressants and antipsychotic medications resulting in lowered levels in the blood. When an individual quits smoking, the levels of drug in the person’s blood may increase significantly and doses may need to be adjusted[2].


[1] Mental Health Foundation. (2007). Smoking and mental health: Why people smoke and how to quit. London: Mental Health Foundation.

[2] CAN-ADAPTT. (2011). Canadian Smoking Cessation Clinical Practice Guideline. Toronto, Canada: Canadian Action Network for the Advancement, Dissemination and Adoption of Practice-informed TobaccoTreatment, Centre for Addiction and Mental Health

Although overcoming addiction to tobacco can be challenging for anyone who smokes and even more challenging for individuals with mental illness and addiction to other drugs, success is possible.  Research clearly shows that individuals with mental illness and addictions can quit and achieve all of the benefits of living smoke free.

Overall, research indicates that individual and group counselling strategies that are successful in the general population are also effective for persons with mental illness and addictions. The most effective approach to quitting is through a combination of nicotine replacement therapy (NRT) or other medication supported by counselling[1].

All persons with mental illness and addictions can and should be encouraged to use the full range of cessation medications, including NRTs unless medically contraindicated[1].

Individuals with mental illness and addictions often have higher levels of addiction and smoke more heavily, thus they generally benefit from more intensive treatment. For example[1]:

  • an increased number of counseling sessions
  • longer duration of treatment
  • higher doses of NRT or medication
  • a combination of smoking cessation medications.

Here are some recommended strategies to encourage and support people living with mental illness and addictions to become smoke free.

Counselling

  • Remind the person that quitting smoking is a process. Many people require multiple quit attempts before they are successful in staying smoke free.
  • Focus on small steps. The client may not be ready to set a quit day, cutting down before quitting may be more realistic. Switching from daily to non-daily use has also been found to be an effective first step.
  • Address misconceptions about smoking and fears about quitting.
  • Reassure the person that while you are encouraging them to take action to quit smoking, no one will force them to quit. A person may feel that smoking is an area of their life that they can control, so it is important that they are also in control of their quit plan. Respect the person’s decision on whether or not they smoke, and simply provide them with resources, information and support to help them when they are ready.
  • Provide simple key messages. Lower cognitively functioning clients may have difficulty processing abstract concepts. Keep the focus on identifying a clear reason to quit and on planning specific strategies to deal with cravings and triggers. Gradual pacing, visual aids and repetition are helpful.
  • Review past experience with quit attempts. This may help identify what was helpful in the past and will help the individual better prepare for obstacles.
  • Offer tips on coping strategies to deal with stress.
  • Incorporate resources which illustrate the tangible effects of tobacco use, such as the carbon monoxide monitor, and the rewards of quitting, such as the Savings Calculator. These tools promote key messages and may increase motivation to quit.
  • Promote group programs to people who report they enjoy smoking while socializing. Group programs offer support from peers who may help overcome feelings of isolation. Having a client co-facilitate along with a staff member has been a strategy that has worked well in other smoking cessation groups.
  • Include messages about smoking cessation within other programs that address health and wellness.


Quit-Smoking Medications

  • Adjust use of NRT products to best meet individual needs. Individuals do not have to strictly follow NRT doses recommended by the manufacturer. To manage withdrawal symptoms, it is safe to use the product more frequently and for a longer time than recommended in product inserts.
  • Use different NRT products at the same time, if needed. This is safe and can lead to higher success rates. For example, use of the nicotine gum and patch at the same time.
  • Refer patients to their local pharmacist for more information on NRTs.
  • Remind the person about the importance of counselling in combination with NRT or cessation medications.
  • Ensure medication side effects are monitored closely. Components in tobacco smoke increase the metabolism of some antidepressants and antipsychotic medications resulting in lowered levels of medication in the blood.  When a person quits, the levels of drug in the person’s blood may increase significantly and dosages may need to be adjusted.

 


[1]CAN-ADAPTT. (2011). Canadian Smoking Cessation Clinical Practice Guideline. Toronto, Canada: Canadian Action Network for the Advancement, Dissemination and Adoption of Practice-informed Tobacco Treatment, Centre for Addiction and Mental Health

Myth: People with mental illness cannot quit smoking OR do not want to quit.

Fact: People with mental illness are just as concerned about the health risks associated with smoking as other people who smoke and many are interested in receiving information on quit smoking services and resources[1]. There are effective supports to help individuals with mental illness to be smoke-free.

Myth: Quitting smoking will harm mental illness recovery or treatment plans.

Fact: Many studies have concluded that quitting smoking does not worsen psychiatric symptoms or negatively impact mental illness recovery. In fact, quitting has been linked to very positive outcomes for those with mental illness[2].

Myth: Smoking can be useful for people with mental illnesses because they use it to self-medicate, therefore lessening the symptoms of these illnesses.

Fact: Research shows that people with schizophrenia who smoke experience increased psychiatric symptoms, need higher medication doses and have an increased number of hospitalizations[3].  In addition, chemicals in cigarettes smoke interfere with the effectiveness of some psychotropic medication used to treat mental health conditions[2].

Myth: Quitting smoking will negatively impact treatment for other addictions.

Fact: Involvement in quit-smoking initiatives while in treatment for other substance abuse issues is associated with a 25% greater likelihood of long-term abstinence from alcohol and other drugs, while continued smoking is associated with worse drug outcomes[4][5].


[1] Els, C. & Kunyk, D. (2008) Management of tobacco addiction in patients with mental illness.  Smoking Cessation Rounds, 2(2).

[2] Morris, C., Waxmonsky, J., May, M., Giese, A., Martin, L.(2009). Smoking cessation for persons with mental illnesses: A toolkit for mental health providers. Denver, Colorado: University of Colorado, Department of Psychiatry

[3] Centre for Addiction Research of British Columbia (CARBC). (2006). Tobacco reduction in the context of mental illness and addictions: A review of the evidence. Vancouver, British Columbia: Provincial Health Services Authority

[4] Baca, C.T., & Yahne, C.E. (2009). Smoking cessation during substance abuse treatment: What you need to know. Journal of Substance Abuse Treatment, 36, 205-219.

[5] Prochaska, J.J., Delucchi, K., Hall, S.M. (2004). A meta-analysis of smoking cessation interventions with individuals in substance abuse treatment or recovery. Journal of Consulting and Clinical Psychology, 72(6), 1144 – 1156.

The Provincial Tobacco Reduction Strategy states that all people in contact with the health care system that smoke should be encouraged to quit and supported in their efforts; this includes individuals with mental illness and other addictions.

All health care providers and community organizations are in a position to address the issue of tobacco use with individuals who smoke and to offer support to help them quit.

Health care providers need to offer individuals ways of coping and assist them in developing strategies specific to that individual. This includes education on the effects of smoking and offering resources available in the community, such as the Newfoundland and Labrador Smokers’ Helpline.

The Smokers’ Helpline offers a variety of materials, resources, and training to support your work in smoking cessation. The CARE Fax Referral Program provides a simple and convenient tool to connect individuals with effective, evidence-based services to help them become smoke free. For more information, visit the CARE Fax Referral Program or call 1-800-363-5864.

Many people who smoke are already aware that tobacco use is having a negative impact on their health.  They expect healthcare providers to intervene.  Studies even show that talking to individuals about their smoking actually enhances the rapport between patients and healthcare providers.

Mental Health And Addictions Services

Important Links

Websites of the Regional Health Authorities and the Government of Newfoundland and Labrador have up-to-date information for you. Along with regional services, there are many mental health and addictions services that are provincially available:

 ‘In An Emergency’
 Help Lines and Navigator
 Online Supports
 Counselling Options
 Hospital Care
 Treatment Centres
 Opioids and Naloxone
 Mental Health Promotion and Addiction Prevention
 Housing Services
 Resources for Physicians and Service Providers

For quick access to service descriptions and referral forms please visit the website for your region:

Labrador-Grenfell Health: http://www.lghealth.ca/index.php?pageid=513
Central Health: http://www.centralhealth.nl.ca/mental-health-addictions-services/
Western Health: http://www.westernhealth.nl.ca/home/health-topics-main/
Eastern Health: http://www.easternhealth.ca/WebInWeb.aspx?d=1&id=2106&p=74
Government of NL: http://www.gov.nl.ca/health-and-wellness

Also, Bridgethegapp.ca includes a provincial Service Directory and online supports.