By David Joel Miller.
Nicotine – The killer drug.
Off all the drugs out there, legal or illegal one drug alone accounts for the bulk of the drug related deaths each year. That drug is Nicotine and the predominant ways it gets into your body is by smoking or second-hand smoke.
We have known for 50 years or more that Tobacco and smoking were harmful to our physical health but we are only now seeing the extend of the connection between smoking and other societal problems such as mental illness and homelessness.
For every one person that dies of an illegal drug Nicotine kills 200 people. That is not an argument for legalizing other drugs. We have seen highly publicized drug deaths recently from illegal drugs. Heroin and prescribed Opiates can kill quickly and with alcohol in the blood stream the overdose death rate sores.
Deaths from tobacco happen far more slowly. There is a gradual progression of a variety of diseases before the final death.
What we have been overlooking in all of this is the significant connection between mental illness, other drug addiction and smoking. Mental health treatment providers have been slow to recognize the connection and slower yet to attempt any form of smoking cessation treatment with the mentally ill clients.
While in withdrawal from Nicotine clients can become agitated, restless and harder to manage. Providers have suggested that they needed to work on the “bigger” issues of drug withdrawal, alcoholism, depression and other mental disorders.
What has been missing from this approach is a clear view of the ways in which Nicotine may be causing and maintaining a mental illness.
Research studies have suggested that between 44% and 50% of all the cigarettes consumed in America are smoked by those with a mental, emotional or behavioral health diagnosis (a DSM diagnosable condition.) Researchers have detailed the efforts of the Tobacco companies to market to the mentally ill (Prochaska, Hall, & Bero, 2008; Lasser et al., 2000; Apollonio & Malone, 2005, cited in Wigand, 2009.)
One consequence of the heavy smoking by the mentally ill is that they commonly live twenty years less than those without a long-term mental illness.
Despite the apparent connection between Nicotine and the creation and maintenance of mental illness most providers have been reluctant to include smoking cessation in their programs.
This connection between smoking and mental health issues is particularly problematic among women. Jessup Et al. on their study of women smokers reported “Smokers had significantly higher rates of Post Traumatic Stress Disorder (PTSD), past year depression and anxiety, suicidality, past year substance abuse, and co-occurring disorders.
Jessup further reports that women who smoke two packs per day are more than twice as likely to suffer from Major Depression. Those with Post Traumatic Stress Disorder were 4-5 times more likely to be heavy smokers. In this study smoking women were much more likely to be unemployed than nonsmokers and even if they lived with a partner the smokers were more likely to not have enough money to meet their basic needs.
The connection between smoking, drug and alcohol use disorders and mental illness has been reported in study after study.
Those disorders that seem to be highly correlated include substance use disorders, PTSD, Depression, Anxiety disorders and Psychosis. There have been some suggestions that smoking has helped those with serious mental illness manage their symptoms, even though this is at the cost of a shortened lifespan. The research seems to report that smokers report more not fewer symptoms of mental illness. The “smoking solution” is making symptoms worse not better.
This connection between smoking, mental illness and a substance use disorder also resulted in increased rates of unemployment, no medical insurance and a high need for treatment. Those at the highest need of physical health services were the least likely to be receiving those services other than through free programs or hospital emergency rooms.
Studies have also reported that smokers are twice as likely to have had recent thoughts of suicide as non-smokers.
One difficulty with adding smoking cessation treatment to substance abuse, mental health and co-occurring treatment programs is that the majority of people in treatment are in the stage of change we call “precontemplative” meaning they had not even thought about quitting. For this group the most effective intervention may be education about the connection between smoking and their other co-occurring issues.
We are hopeful that the expansion of health care will result in more services for those who have co-occurring disorders and that smoking cessation treatment may be included in those services.
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