This study is the first to report the rate of smoking problems in a sample of patients treated by psychiatrists in routine clinical practice and the psychosocial and clinical characteristics of the psychiatric patients who smoke. We found a remarkably low prevalence of current nicotine problems (16.6%) reported by psychiatrists in this sample of psychiatric patients. This prevalence is lower than the lifetime prevalence of smoking reported in the general population (24.0%),20
in persons with a lifetime history of ADM (34.8%), in persons with a past-month history of ADM (41.0%),3
in a sample of psychiatric outpatients (52%),21
and among psychiatric patients at a public mental health hospital (58.9%).2
It is therefore likely that the low prevalence found in this study does not reflect the true extent of the smoking problem among psychiatric patients seen in routine clinical practice. While it is possible that psychiatrists may see a segment of the mentally ill population with lower prevalence rates of nicotine problems, the opposite is more likely, as smoking is associated with more severe illness and psychiatrists tend to see those who are more severely ill.22
Under-reporting is also unlikely because in this research study, there were no incentives to fail to report known nicotine problems. A lack of awareness and making undue assumptions about smoking behavior are more likely explanations of the low level of detection of smoking problems by psychiatrists in their patients.
Another important finding in this study is that less than one-tenth the psychiatric patients who were identified with nicotine problems received treatment for their nicotine problem. This result contrasts with findings from the Medical Expenditure Panel Survey, showing that 57% of smokers who had a routine check-up in the last year were counseled by a physician to stop smoking.23
National health care organizations, recognizing that at least 50% of patients’ health problems are caused by preventable behavioral risks factors, recommend routinely screening patients for behavioral health risks strongly associated with increased morbidity and mortality, including the risk of tobacco use.24
It is likely that the low treatment rate found in this study may be due in part to psychiatrists’ under-reporting/under-detection. It has been recognized that physicians frequently do not document their clinical preventive activities, though from a medico-legal point of view, it is important to document the preventive health care recommendations provided to patients.14
Another possible explanation is that psychiatrists may tend to under-treat their smoking patients. Although it is established that nicotine replacement therapy and bupropion are effective pharmacotherapies for smoking, the questions that arise are if psychiatrists tend to separate the treatment of smoking from the treatment of other psychiatric disorders or if psychiatrists feel that smoking treatment is not part of an overall comprehensive psychiatric treatment plan. Nicotine problems and dependence may appear relatively mild compared to other clinical and psychosocial problems identified in this population and the potential distress related to tobacco withdrawal.
According to our results, the patients with nicotine problems who are more likely to receive treatment are those who are treated in inpatient settings or have a co-morbid, non-nicotine substance use disorder. As health care providers, psychiatrists have a great responsibility to diagnose and treat nicotine problems,6,25–27
and although a recent study failed to prove that physician smoking cessation interventions yield significant gains in long-term quit rates among cancer patients,15
we believe that all psychiatric patients who smoke could greatly benefit from prompt diagnosis and treatment of their nicotine problem. As with any other medical treatment, psychiatric treatment may offer a unique window of opportunity to diagnose and reduce the rates of smoking in this disadvantaged population.
The results of the comparison of psychosocial and demographic characteristics between patients with and without nicotine problems should be interpreted with caution. It is possible that patients who were not recognized by their psychiatrists as smokers were classified as non-smokers, thereby biasing the results; however, the psychosocial and demographic differences between smokers and non-smokers that we found are similar to those previously reported in the scientific literature.2,9
Psychiatric patients who smoke are more likely to be male, with more socially challenging living arrangements (single, divorced, or separated), lower education, and more psychological stressors, including the use of alcohol and other drugs. Smokers also were reported to have worse health status, a higher rate of current and previous psychiatric hospitalization, more severe disability, and poorer treatment compliance than those reported not to smoke. These findings suggest that psychiatric patients who smoke should be paid particular attention, and treating psychiatrists should have the tools to address their multiple psychosocial needs.
Although this study replicates what has been reported in previous literature about the high proportion of schizophrenia and alcohol/substance use disorders among psychiatric patients who smoke, the prevalence of schizophrenia and substance use disorders in our sample is lower (31.6% and 46.1%, respectively) than the rates found in a sample of psychiatric patients at a department of adult mental health in France (66% and 87%, respectively).2
The proportion of patients with the diagnoses with or without smoking problems in our sample was approximately 3:1 for schizophrenia and 4:1 for substance use disorders. The proportion in the sample from France for schizophrenia was 2:1 and 8:1 for substance-related disorders. The differences in these findings may be due to sampling procedures or methods of obtaining the data. However, it may signify that substance-abusing or schizophrenic patients who smoke are more obvious to the psychiatrists or that providers who treat patients particularly with substance use disorders are more trained or skilled in identifying addictions and accurately report those patients who smoke. Moreover, the findings support the need to develop special measures to address the smoking problem of patients with schizophrenia and substance use disorders.
Group comparisons of the source of payment for the current visit (see ) showed that a significantly higher proportion of smokers did not have health insurance, and used public funds as the main source of payment, and the treating psychiatrist was being paid by salary rather than through a fee for service. These findings may reflect the recent trend toward refractory smoking among individuals in lower socio-economic groups or with lower education who have less access to covered health plans and be treated in public settings.28
The results of the multivariate analysis support the hypothesis that psychiatric patients with nicotine problems are more likely to have a psychosocial disadvantage, and much may be explained by the greater likelihood of having lower education and higher prevalence of alcohol/substance use disorders (almost four times), schizophrenia, and depression. It is possible that specific diagnoses or treatments could reinforce smoking behaviors via common biological mechanisms.11
The data used for these analyses have a number of limitations. One of the limitations is that the study is based on the report of psychiatrists about their patients. Consequently, their validity depends on the extent to which psychiatrists accurately reported treatment and practice information. As discussed above, this may in part explain the low rates of smoking problems reported by psychiatrists. Other studies conducted in psychiatric populations that reported higher rates of nicotine problems have collected the data by direct interview of patients. Although clinicians are encouraged to fill out the questionnaires as soon as possible after seeing the patient, there is a risk that clinicians either do not ask about some of the items on the study questionnaire or have recall biases. Finally, because these data are cross-sectional and observational, we are not able to assess whether the increased rate of psychosocial problems among patients who smoke is due to their smoking problem, or if patients smoke to mitigate their psychosocial problems. We may be able to conclude that smoking may represent a marker for patients with greater severity or acuity of illness.
Some of the strengths of the study are that data were collected from a nationally representative sample of psychiatrists, accessing information from a wide range of psychiatric treatment settings, which captures the heterogeneity and complexity of the patients with smoking problems in routine clinical practice in psychiatry. This type of information is unlikely to be captured in clinical trials or other types of population-based research. Furthermore, there is no precedent of a similar study to address this important public health issue.
The results suggest that during routine clinical practice, psychiatrists tend to under-report patients who smoke and under-treat their smoking problem. This is aggravated by the fact that psychiatric patients who smoke have greater psychosocial needs than those who do not. Given that psychiatrists are physicians who provide mental health services, these professionals can play a very significant role in the reduction of smoking among their patients and contribute to solve this important public health problem. Educational programs, perhaps offering additional Continuing Medical Education (CME) bonus points, should be developed to raise the awareness of psychiatrists to diagnose smoking problems in routine psychiatric practice and address the increased psychosocial needs of psychiatric patients who smoke. Education, however, may not be sufficient. Quality improvement strategies that monitor psychiatrist’s performance in this area should be applied more broadly. In addition, financial disincentives positively influencing psychiatrists to identify and treat nicotine problems should be identified, and incentives for improved performance should be developed. Further follow-up studies should be conducted to assess trends in the identification and treatment of nicotine problems by psychiatrists.