The sample (N=685) was largely female (67%), aged 26 to 50 years old (67%), and non-Hispanic Caucasian (89%). Less than a third (31%) had a 4-year college degree; another 34% reported some college coursework without a degree; 43% reported household income ≤ $25,000/year. Average age of bipolar disorder diagnosis was 26 (SD=11) years. At the time of survey completion, respondents’ mental health treatment included medication (91%), psychotherapy (56%), and support groups (18%). A few respondents (9%) were not receiving any mental health treatment, in several cases attributed to lack of insurance. A total of 595 respondents finished the survey (87%). Survey finishers and non-finishers (n=90) did not differ on smoking status, intention to quit, or any of the measured demographic or mental health variables (all comparisons, p-value > .10).
Most participants (87%) were current smokers; 13% were ex-smokers. Current and ex-smokers did not differ on demographic characteristics with the exception that ex-smokers were significantly older, χ2(5
)= 19.78, p=.001 than current smokers. Age of diagnosis, F(1,553)=0.52, p=.471, did not differ by smoking status nor did type of mental health treatment; however, current smokers rated their current mental health symptoms as significantly more debilitating than ex-smokers (). The sample began smoking at a mean age of 17 years (SD=6) and smoked a median of 7 years prior to being diagnosed with bipolar disorder; 83% started smoking prior to receiving a diagnosis of bipolar disorder. Most current smokers smoked daily (92%) and averaged 19 cigarettes/day (SD=11).
Mental Health Symptoms at the time of Survey Completion: Current Smokers (n=519) and Ex-Smokers (n=69)
Among current smokers, 48% reported smoking to treat their mental illness; 7% said smoking made their symptoms worse and 22% reported smoking “gets in the way of living the life that I want.” Nearly all respondents (96%) stated it was somewhat important (10%), important (7%) or very important (79%) that they be in good mental health when they try to quit smoking. Less than a third reported that a psychiatrist (27%), therapist (18%), or case manager (6%) had recommended they quit smoking and several reported discouragement to quit from mental health providers. Nevertheless, 74% of current smokers expressed a desire to quit; 93% had made at least one lifetime quit attempt; 65% tried to quit in the past year; and 48% currently planned to quit smoking. Current intent to quit smoking was unrelated to current mental health symptoms, χ2(3)= 5.50, p=.139.
Current smokers reported a median of four lifetime-quit attempts. Reasons for relapse to smoking in a prior quit attempt were stress (74%), craving cigarettes (26%), and tobacco use by family and friends (21%). Smokers planning to quit (n=256 of 528) intended to use cessation medication either alone (38%) or with psychosocial support (18%), such as individual or group counseling, physician advice, or a quitline; 12% intended to quit with psychosocial support alone; and 32% planned to quit “cold turkey” (i.e., without any medication or support).
Among respondents who did not wish to quit smoking (n=145 of 567), 97% acknowledged that tobacco use is harmful to their health. Smokers unmotivated to quit, however, were less influenced by the negative aspects of smoking (). Specifically, compared to smokers planning to quit, smokers unmotivated to quit were significantly less concerned about the health consequences of smoking for themselves (38% vs. 92%) or friends and family (19% vs. 46%), the financial costs of cigarettes (17% vs. 65%), and the pervasiveness of restrictions on where you can smoke (3% vs. 23%), all group comparisons significant at p-value < .05. The most highly rated barrier to quitting was the pleasure of smoking, identified by 69% of unmotivated to quit smokers. Additionally, 35% reported concerns that stopping smoking would make their mental illness worse and 17% did not believe they could quit. Notably, nearly a third (32%) of unmotivated to quit smokers said they would want to quit smoking if their mental health improved.
Factors Rated as Important in the Decision to Quit Smoking among Smokers Planning (n=422) and Not Planning to Quit (n=145)
Ex-smokers (13% of sample) had been quit a median of 2.7 years (range: <1 month to 29 years). Nearly half (48%) quit “cold turkey”, 46% used cessation medications either with (7%) or without (39%) psychosocial support, and 4% quit with psychosocial support alone. Those who quit cold turkey had quit less recently (median = 3 years) than those who reported using a cessation aid (median = past year), Mann-Whitney U = 465, p=.049.
Asked how they maintain abstinence from tobacco, 46% of ex-smokers identified support from family and friends and 43% engaged in wellness strategies such as exercise, healthy diet, and meditation. Few (12%) reported encouragement from healthcare providers to stay quit. The median and modal number of times that ex-smokers attempted to quit before they were successful was five. Most ex-smokers (64%) rated their mental health as poor or fair at the time they successfully quit smoking. The majority (54%) reported no adverse effects of quitting on their mental health symptoms, 18% reported temporary worsening of mental health symptoms that resolved, 21% reported a harder time controlling symptoms, and 7% reported the development of new mental health symptoms (e.g., anxiety, rage). At the time of the survey, 57% of ex-smokers described their mental health as in recovery compared to 40% of current smokers ().
Of the full sample, most respondents recommended promotion of cessation medications (78%) and behavioral approaches (68%) for quitting smoking and 45% recommended support through quit-lines1
or groups. Compared to current smokers, ex-smokers were more likely to recommend use of motivational strategies (57% vs. 35%, χ2(1
)= 11.52, p=.001).
DBSA is a peer support network with members sharing advice and encouragement. Ex-smokers diagnosed with bipolar disorder are a unique resource with insights and personal experiences in the struggle of quitting a powerful addiction while managing mental illness. When ex-smokers were asked what kind of information would be most useful in helping someone with mental illness stop smoking, several themes emerged (). Specifically, advice centered on emphasis of the negative consequences of smoking, the benefits of quitting, and cognitive-behavioral and pharmacologic strategies for quitting.
Ex-smokers’ Advice to Help Someone Living with Mental Illness Stop Smoking