Opinion: Tobacco use and mental illness — an overlooked dual burden

The COVID-19 pandemic compelled the world to acknowledge mental health struggles more than ever before, especially among youth. By the time a 2021 JAMA Pediatrics study examined the pandemic’s toll on children and adolescents, the reported prevalence of anxiety and depression had doubled prepandemic estimates. But many others are suffering too. Data show an epidemic of loneliness among seniors grew worldwide amid lockdowns and quarantines, and LGBT+ people globally experienced increased rates of poor mental health.

Newly published material from the Tobacco Atlas — an online resource that examines the tobacco epidemic and offers proven solutions — demonstrates an association between mental health and smoking. The atlas cites a 2017 study that found that the prevalence of smoking among adults with any mental illness in the United States was 33.3%, compared to 20.7% for those without mental illness. That translates to millions of people experiencing the dual burden of mental illness and tobacco use. There hasn’t been nearly enough research around the world into the way these epidemics overlap, but the implications of extrapolating the U.S. statistics are a concern.

To combat this underattended comorbidity, public health experts must cut across specialties and connect smart tobacco-control interventions with treatment for mental health. And the advocates for tobacco control and for mental health will need to work together to lobby for broadly protective policies, such as more aggressive taxation and smoke-free mental health facilities. These efforts could ease compounding health burdens for millions and lessen the costs associated with their care. Action is both morally imperative and economically sound.

Here are five ways governments, advocates, and those on the front lines of care and counseling can address tobacco use and mental health.

Smart cessation strategies

One effective way to deliver smoking cessation support is to go directly through health care workers that tobacco users already interact with, such as disease diagnosticians, obstetricians and gynecologists, primary care doctors, and behavioral health practitioners. This approach builds on the trust that many people hold in health care providers, who can advise smokers to stop and actively direct them to supportive resources and/or counseling. This proactive integration, combined with government investment in national quit lines, free or affordable nicotine replacement therapies, and incisive mass-media messaging, can help wean millions off products that boost corporate profits at the expense of health.

Smoke-free mental health facilities

It’s increasingly common for restaurants, hotels, office buildings, and other heavily trafficked public spaces to prohibit tobacco use on their premises. But paradoxically, many psychiatric units within hospitals make exceptions for their patients. The thinking goes that permitting mental health patients to smoke on the grounds of care facilities preserves their personal autonomy. But a truly patient-centered strategy would be to ban smoking in and around mental health facilities, while at the same time training staff to discuss tobacco use and its multiplying harms with patients. Patients should be offered cessation tools including access to nicotine replacement therapies as an off-ramp to quitting.

Taxes, taxes, taxes

Public health advocates must repeat the mantra “taxes save lives” when faced with resistance to excise tax hikes and higher corresponding purchase prices. Creating cost-prohibitive barriers to tobacco products has been proven to precipitate especially sharp declines in youth smoking. As the Tobacco Atlas recently charted, taxes per pack of cigarettes in New Zealand rose steadily from 2009-19, and the prevalence of smoking among youth in that time was nearly halved. Adult usage lessened as well, though not as dramatically.

Mapping mental illness in low- and middle-income countries

As is so often the case, residents of low- and middle-income countries bear a disproportionate burden of poor health outcomes as mental health treatment and tobacco control remain overlooked and underfunded. The Oxford Textbook of Social Psychiatry observes that 80% of those living with a mental health disorder reside in LMICs, yet there is a stubbornly large gap in treatment relative to higher-income nations. Meanwhile, 80% of the planet’s smokers aged 15 and above reside in LMICs. Something has to give.

Communities and integration are the way forward

In its 2022 World Mental Health Report, the World Health Organization wisely stated that mental health and substance use are linked, and advocated for a community-based approach to overall health care that trains and empowers trusted messengers within communities to serve as mental health providers. India’s Health Activity Program has put this into practice and witnessed tremendous trial success. And in Syria, researchers are hard at work adapting cessation methods to suit Middle Eastern populations, accounting for a range of psychological and physiological factors. Those efforts ought to be applauded, funded on an ongoing basis, and encouraged to be collaborative across sectors and transparent about their results. Integrating community-level interventions that can be scaled up with population-level strategies such as smart taxation is the winning combination to address the inequitable impact that tobacco use can have on those with mental health challenges.

There’s no single solution to cure mental health or tobacco use. But there are well-established methods for driving down tobacco consumption and easing the burden of mental illness. We just need to apply them vigorously and without delay, or else risk ruining another opportunity missed.

Visit www.tobaccoatlas.org to learn more.