Although public health interventions have resulted in decreased smoking rates in the United States general population over the last 50 years, smokers with mental illness have not benefited as greatly from these efforts. Smoking rates in individuals with a mental illness or addiction are at least double the rates of tobacco use in the general population (Lasser et al. 2000
; Lawrence et al. 2009
). Some estimates are that two-thirds of current cigarette smokers have a past or present mental health or substance abuse disorder and there is evidence that this group consumes a sizeable portion of the tobacco sold in the United States (Lasser et al. 2000
; Grant et al. 2004
). Individuals with mental illness suffer many consequences of tobacco use with 25 years of life expectancy lost with excess mortality particularly from cardiovascular disease (Brown et al. 2000
, Miller et al. 2006
The continued high prevalence of smoking among the mentally ill is likely related to several factors and one may be lack of access to cessation services. There is evidence that smokers with mental illness have less access to tobacco dependence treatment across the health care spectrum, but particularly in the behavioral health setting (Peterson et al. 2003
; Montoya et al. 2005
; Friedmann et al. 2008
). Barriers to addressing tobacco in mental health settings include undervaluing tobacco addiction as a problem, behavioral health professionals and systems have been slow to change despite recommendations that they treat tobacco, a lack the knowledge about evidence-based treatment for tobacco dependence and lack of hope and advocacy among consumers and mental health advocates (Williams et al. 2009b
). Recent publications corroborate past findings. A study by Ashton et al. (2010)
found that only 26% of mental health staff raised the issue of tobacco use with patients, often or as part of the assessment. A study by Johnson et al. 2010
found that psychiatric hospital staff are resistant to smoke-free policy and continue to believe that tobacco is a therapeutic for patients.
Smoking cessation services, when available, are typically brief, localized to primary care or public health settings, and serve mainly the highly motivated smoker ready to quit. There is evidence that those with mental illness experience barriers in accessing health care due to disorganized lifestyles and difficulty communicating needs; this makes it likely that they face similar barriers when trying to access community based tobacco treatments. In addition, smoking cessation specialists may have limited experience and knowledge about helping smokers with mental illness (Pbert et al. 2007
). Individuals with mental illness have an increased vulnerability to tobacco use, developing dependence, and experiencing difficulty quitting tobacco (Breslau et al. 2004
; Hagman et al. 2008
; Lasser et al. 2000
) which warrants a specialized treatment approach. For example, certain mental illnesses are associated with heavy smoking, failed quit attempts, and early relapse back to smoking after a quit attempt (de Leon et al. 2002
; Beckham 1999
; Niaura and Abrams 2001
; Anda et al. 1990
; Glassman 1993
). National treatment guidelines recommend that all smokers should be offered counseling and pharmacotherapy, and given that smokers with a mental illness tend to be heavier smokers, these recommendations should be followed more aggressively in this population, not less (Fiore et al. 2008
Paradoxically, although tobacco treatment has traditionally not been offered in behavioral health settings, this sector of health care is well-suited to deliver it (Williams and Ziedonis 2006
) and may offer advantages compared to primary care if barriers can be overcome. Behavioral health professionals have experience and training in the treatment of other addictions and are skilled to deliver behavioral therapies, and even group therapy for treating tobacco. As tobacco dependence is a chronic, relapsing condition, behavioral health providers have many opportunities to intervene. Most clients resume stable functioning and remain in behavioral health treatment for years. Individual office visits are also longer than in primary care. Integrated models have been successful for other co-occurring addictions (Drake and Mueser 2001
; SAMHSA 2002
) and would likely succeed for tobacco treatment as well. Perhaps most importantly, smokers endorse wanting their mental health center, counselor or psychiatrist to help them to quit smoking (Williams et al. 2010b
). Since a combination of factors contribute to tobacco use in this population, it also makes sense that interventions take a comprehensive approach. Recognition of complex biological, psychological and behavioral characteristics as well as social and environmental factors may be critical in adequately assessing the needs of the population and delivering optimal treatments.
At this time, little is being done for mentally ill smokers at the national level through mental health or public health systems. Tobacco control resources dedicated to, or targeting, this group remain scarce or non-existent. Few models have emerged that address smoking among the mentally ill in a comprehensive way. However, in New Jersey, we have focused on helping smokers with mental illness for more than a decade through a variety of initiatives. Each initiative has contributed to the development of a comprehensive model for Mental Health Tobacco Recovery in New Jersey (MHTR-NJ) that has the overarching goal of improving tobacco cessation for smokers with mental illness.
Consistent with Center for Disease Control (CDC) recommendations for Best Practices for Tobacco Control (2007)
, several interdependent elements are necessary to meet the goal of improving tobacco cessation in a population. Important steps involve engaging patients, professionals and the community to increase buy-in that addressing tobacco is important. We have sought to increase demand for tobacco treatment services for mentally ill smokers while simultaneously educating mental health professionals in evidence-based treatments so that patients can seek help in their usual behavioral health care setting. It is imperative to change accepted norms and influence the culture of behavioral health care by developing tobacco policies that restrict use and require assessment and treatment of tobacco dependence. Peer services that offer hope and support to smokers are essential. Working with mental health advocacy groups will encourage them to advocate for greater access to tobacco treatment resources including counseling and medications to and help bring greater systems change. With these larger networks in place, cessation programs have a greater chance to meet the needs of the mental health community and become sustainable.
Each of the policy or cessation initiatives described addresses the two core goals of this model: 1. To increase demand for tobacco cessation services among mentally ill smokers and 2. To help more smokers with mental illness to quit. Both of these goals are extremely important if we are to reduce smoking prevalence and tobacco-caused morbidity and mortality in the mentally ill since both reduced access to treatment and reduced success at quitting likely contribute to elevated prevalence of tobacco use.
Although building consumer demand for evidence-based tobacco cessation products and services helps all smokers, there have not been focused efforts to reach populations of smokers with mental illness despite high tobacco use and low use of evidence-based treatments. Removing barriers to accessing treatment by disseminating clinical practice guidelines and increasing treatment capacity are essential (Orleans and Phillips 2007
). Many smokers do not know about effective treatments and cannot differentiate these from unproven treatment aids and over-the-counter herbal remedies (Bansal et al. 2004
). Bringing services to smokers where they are is also increasingly recognized as a needed strategy to increase tobacco treatment utilization and an important part of the MHTR-NJ model. In addition to increasing access and awareness of services, it is important that treatments are effective in preventing relapse back to smoking and are sufficient in intensity and duration to meet the needs of patients.
Each of the elements described in the MHTR-NJ model has been implemented with pilot outcomes in feasibility and/or effectiveness and revised with feedback from stakeholders. The model based initiatives have brought together academics, clinicians, administrators and mental health consumers to develop tobacco programming and policy that has been tested in a real world environment. The MHTR-NJ model focuses on smokers who receive services in the behavioral health system of care (i.e. with serious mental illness, SMI) although we acknowledge the additional contributions that community tobacco and primary care providers make in treating mental illness which are beyond the scope of this report. We have been admittedly less focused on prevention, although we agree that preventing the next generation of mentally ill people from starting to use tobacco, especially as they experience their first episode of mental illness, is laudable and could also emerge as a result of the culture change we hope to influence ().
Model of mental health tobacco recovery in New Jersey
The specific initiatives of the MHTR-NJ model can be conceptualized as having a focus in the community (at the level of the consumer, family member or advocate), in the clinical treatment setting (at the level of the provider or clinician) or in the environment (at the level of the agency or larger mental health system), although considerable overlap exists. A continuation between community and treatment setting is desirable as it creates a bridge to bring tobacco users into treatment and has implications for continued community support before and after treatment has been completed. The model also demonstrates the intersection between the environment, the treatment setting and the community in addressing tobacco. When these three elements come together we can expect the greatest success in increasing demand for tobacco services and helping more mentally ill smokers to quit. The components working alone will have local results, however; the synergy between components can be expected to produce enhanced results. Below we describe each element of the MHTR-NJ model.