OP-ED

Smoking and Mental Illness

At last weeks Health 2.0 Conference Maggie Mahar, author of HealthBeatBlog got more than a little feisty about Al Waxman’s suggestion that we make people with bad health behaviors pay more. She said that 95% of smokers had some form of mental illness, and therefore we were punishing the mentally ill. Really? Read on for Maggie’s explanation (lifted at her request from a comment elsewhere).Matthew Holt

According to the New England Journal of Medicine,

“The link between smoking and anxiety also helps explain why smoking is so strongly correlated with mental illness. “smoking rates have been reported to be over 80 percent among persons suffering from schizophrenia, 50 to 60 percent among persons suffering from depression, 55 to 80 percent among alcoholics, and 50 to 66 percent among those with [other] substance-abuse problems.”

Poverty is highly correlated with smoking because poverty is stressful. U.S. soldiers also smoke in greater numbers than the population as a whole–even if they didn’t smoke before joining the army The NEJM reports:

“Serving in the military is a risk factor for smoking even for those who did not start smoking prior to the age of 18. Smoking is the number-one health problem for vets,” says Dr. Steven Schroeder, former President of the Robert Wood Johnson Foundation, where he focused on smoking cessation.  “And reports are showing that many US soldiers serving in Iraq are turning to smoking to relieve their stress.”

At the  Health 2.0 conference, Al Waxman asked the audience how many thought that smokers should be “penalized” for smoking, presumably by paying more for insurance. I pointed out that the vast majority of adult smokers are poor; many suffer from some form of mental illness.Do we really want to punish people who are living in poverty and are mentally ill?

How about soldiers returning from Iraq who have become addicted to smoking and, in many cases are also suffering from post-traumatic stress? Should we “penalize” them? The irony,of course, is that because the majority of adult smokers are poor they can’t pay higher insurance premiums. The original Senate Finance bill would charge smokers twice as much for insurance, but the majority will qualify for full or partial subsidies, so taxpayers will wind up paying the “penalty.” More importantly, rather than punishing smokers we could help them stop smoking. We actually know how to help people quit.

“If we want to cut the number of premature deaths, we might put more emphasis on smoking cessation clinics,” says Dr. Steve Schroeder. who directs the Smoking Cessation Leadership Center at UCSF. “Smoking shortens smokers’ lives by 10 to 15 years, and those last few years can be a miserable combination of severe breathlessness and pain.”

44.5 million Americans still smoke.

“Smoking is increasingly concentrated in the lower socioeconomic classes and among those with mental illness or problems with substance abuse,” Schroeder adds. “Understanding why they smoke and how to help them quit should be a key national research priority. Given the effects of smoking on health, the relative inattention to tobacco by those federal and state agencies charged with protecting the public health is baffling and disappointing.”

We don’t put money into smoking cessation for two reasons: first, smoking cessation clinics aren’t  profitable. Secondly, as smoking becomes concentrated among the poor, those with money and power have lost interest in the problem. Yet Kaiser Permanente of Northern California has shown that we can help smokers. When Kaiser implemented a multi-system approach to help smokers quit, Schroeder reports that

“the smoking rate dropped from 12.2% to 9.2% in just 3 years. Of the current 44.5 million smokers, 70% claim they would like to quit. Assuming that one half of those 31 million potential nonsmokers will die because of smoking, that translates into 15.5 million potentially preventable premature deaths. Merely increasing the baseline quit rate from the current 2.5% of smokers to 10% — a rate seen in placebo groups in most published trials of the new cessation drugs — would prevent 1,170,000 premature deaths. No other medical or public health intervention approaches this degree of impact. And we already have the tools to accomplish it.”

Rather than focusing solely on medicine and medical care, Schroeder is committed to strategies that would improve public health. In the U.S. there is a sharp division between the two, with public health always the poor relation.

“It’s harder, because there’s stigma attached to it,” Schroeder explains. “There’s a sense among some that if a large portion of the nation’s population is obese or sedentary, drinks or smokes too much, or uses illegal drugs, that’s their own fault or their own business.We often get a double-standard question.”

Critics who object to investing more in programs that could help drug addicts and alcoholics, ask: Well, don’t many of these people relapse?

“Yes, of course,” Schroeder responds. “But is it worth treating pancreatic cancer, which has a 5 percent survival rate, at most? Yes. So the odds of successfully treating drug abuse or alcoholism are actually better than in many of the serious illnesses that society, without question, wants us to treat.”

Schroeder is right: When allocating health care dollars, we eagerly spend far more on cutting-edge drugs that might give a cancer patient an extra five months than on drug rehab clinics that could make the difference between dying at 28 and living to 68”. But Schroeder fears that we are going to continue to focus on cutting edge acute care–while ignoring public health:

“It is arguable that the status quo is an accurate expression of the national political will,” he writes, ” …a relentless search for better health among the middle and upper classes. The pursuit is also evident in how we consistently outspend all other countries in the use of alternative medicines and cosmetic surgeries and in how frequently health ‘cures’ and ‘scares’ are featured in the popular media. The result is that only when the middle class feels threatened by external menaces (e.g., secondhand tobacco smoke, bioterrorism, and airplane exposure to multidrug-resistant tuberculosis) will it embrace public health measures. In contrast, our investment in improving population health — whether judged on the basis of support for research, insurance coverage, or government-sponsored public health activities — is anemic.”

Maggie Mahar is an award winning journalist and author. A frequent contributor to THCB, her work has appeared in the New York Times, Barron’s and Institutional Investor. She is the author of  “Money-Driven Medicine: The Real Reason Why Healthcare Costs So Much,” an examination of the economic forces driving the health care system. A fellow at the Century Foundation, Maggie is also the author the increasingly influential HealthBeat blog, one of our favorite health care reads, where this piece first appeared.

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24 replies »

  1. I’m a smoker and I really hate when people stare at me when I light up. It’s an unpleasant feeling because it’s my own right to smoke and why bother? But in the end, I also feel it’s not easy for people to have second hand smoke either.

  2. There should be more of a public effort to prevent smoking in the first place. I only see health care entities reaching out to their smoking patients, because they have to, for either political or economic reasons. What if they coordinated their efforts with other organizations (non-profits) within the community and focused on prevention for everyone. Frequent TV and radio spots, where families could actually talk about it in the open. Instead, it’s all very hush hush and only spoken in terms of what to do after the fact. We still have a ways to go to move from a treatment mentality to a prevention mentality.
    These programs aren’t very glamorous, but they can be highly effective.

  3. I have found the answer to be Torch Electronic Cigarettes. I have “Smoked” aka vaped in restaurants, bars, malls and even at work. NO TOBACCO, and nothing is ignited. I get the nicotine that I CHOOSE (this is America, right), without first or secondhand smoke, no smell. Considerate to the non-smoker and the environment.
    Torch is even save to use around medical oxygen. http://www.torchcigarettes.com

  4. hm. anecdotally, i’d say that a far smaller percentage of smokers is mentally ill than suggested above. but i’d suggest, anecdotally, that it’s the other way around: a very high percentage of the mentally ill self-medicate with tobacco.
    as a very young person riding the greyhound, i used to apply that logic by intentionally sitting in the non-smoking section of the bus. every time i’d arrived late and had to sit with the smokers, i had hassle. never in the non-smoking section. my mother, one of the heaviest smokers i’ve ever known (she was not mentally ill — she was a nurse [hm. another study?]), thought this was very clever thinking.
    now that all public transport in the u.s. is non-smoking, it’s harder to pick a good place to sit.

  5. Actuallly, obese people also don’t cost us as much as
    slim people.
    It’s true that their health problems begin earlier, but
    they are also more likely to die quickly of heart attacks, strokes . . .
    Like the smokers they don’t live long enough to develop some of the diseases that kill you slowly–Alzheimer’s, etc.
    Bottom line: If you’re slim and do all things in moderation, you run a real risk of outliving your mind.
    I fear that this will be the fate of many baby-boomers.
    Finally, Nate– I agree with arb.
    You really should be grateful to the liberals– especially those who grew up in the 1960s.
    Without us, you’d still be eating squishy Tip-Top white bread and listening to Truly Terrible music.

  6. Nate, honey – a world without liberals or a world without conservatives for that matter – would be a world without balance. Don’t you get that each side needs the other – like McCartney needed Lennon from going to pop musicky. Do try to see the good in this system (not perfect, but better than many others). I don’t want to live in a U.S. that proscribes a single way of being. I think they tried that in the Third Reich, the USSR, and other places, and found out it’s not so good for people, societies or the world in general.
    It really is a good thing not to own other people, and that women are gaining in their earning power and that big industry isn’t allowed to pay their workers in scrip that can only be used to trade for goods at the company store at inflated prices and that they are supposed to provide safe working environments and that World War II was won and I could go on and on.
    I promise you, that just as I benefit from so-called conservative policies, you, right now are benefiting from so-called liberal policies and would be outraged if those policies were rescinded. Civil discourse is good. Do try to think for yourself. It is amazing. There are many ways to be right (pun intended).
    And, one more thing to add to the list of items that cause higher insurance premiums – it is well known that owning a gun increases substantially the risk of injury from guns. Therefore, it follows that gun owners must pay more for insurance. It’s only fair, after all. (and motorcycle owners, too).

  7. Has anyone seen a study showing Republicans smoke more than Democrats? Experientially it seems that way, and fits with the mental illness theory.
    Outlaw nicotine, legalize marijuana.

  8. Michael Millenson (who was an excellent moderator of the panel) and Everyone–
    I’m terribly sorry if I said that 95% of smokers suffer from mental illness. My mistake. I should have simply said that the vast majority of adult smokers in the U.S are poor, and a very large percentage of Ameicans who suffer from mental illness also spoke.
    I’m very embarassed that I got the percentage wrong because, when writing my blog, I’m very careful about facts and numbers.
    My bad. My only excuse: I hadn’t prepped for talking about smoking before coming to the conference- (didn’t think it would come up) – so I’m afraid I quoted numbers from memory.
    This is the article about smoking and menal illnes that I was thinking of — by Dr. Steven Schroeder, former head of the Robert Wood Johnson Foundation who ran the very successful smoking cessation clinic at UCSF for about ten years:
    “few are aware that smoking is concentrated among people with mental illness, often compounded by substance-abuse disorders such as alcoholism. Go to most Alcoholics Anonymous meetings, and the room will be so full of smoke that you can cut it with a knife. Ask the members, and they will tell you that it was much easier to stop drinking than to stop smoking. Indeed, nicotine, the addictive component of tobacco smoke, is as habituating as cocaine or heroin, and it has a similar effect on chemical receptors in the brain.
    “The facts about smoking and mental illness are stark. Almost half of all cigarettes sold in the United States (44 percent) are consumed by people with mental illness. This is because so many people who have mental illnesses smoke (50 to 80 percent, compared with less than 20 percent of the general population) and because they smoke so many cigarettes a day — often three packs. Furthermore, smokers with mental illness are much more likely to smoke their cigarettes right down to the filters.”
    Again, I’m sorry that I had the numbers wrong. .
    But, in the end, it seems to me that the percentages matter less than the larger facts:
    Most people don’t realize that such a large share of people suffering from mental illness smoke.
    And most people don’t know that smoking is so concentrated among the poor.
    If these facts were better known, I doubt that most Ameiricans wouldlwant t “penalize” smokers.
    Also, as Gregory points out: when it comes to health care: smokers do not cost us more than other Americans.
    Smokers die much earlier–as do people who are obese.
    They don’t live long enough to suffer from the many long-term chronic diseases that the rest of
    us will suffer from: many cancers, Alzheimers, etc.
    Thus, when it comes to consuming healthcare dollars, smokers, obese Americans–and poo rAmericans- cost us much less.
    Did you know that, on average, poor Americans die y\6 years sooner than affluent Americans.?

  9. so Rick your saying the issues blind people are forced to deal with are the same as those that choose to smoke, just want to be clear where you stand. Not sure it’s really funny, it is actually quit offensive to the blind to marginilse what they deal with like that, but your are entitled to your opinion

  10. Folks, read carefully: 80 or 90 or whatever percent of those with mental illness smoking is NOT the same thing as saying 95 percent of those who smoke have mental illness.
    If there were 10 people in the country with mental illness, and all of them smoked, it would not mean that 100 percent of smokers had mental illness.
    You remember this from Philosophy 101: All politicians are liars. John is a politician. John is a liar is NOT the same as All politicians are liars. John is a liar. John is a politician.

  11. Nate’s funny. He thinks if you tell a blind person to just make better decisions, they can see, and if an amputee were more virtuous, they would grow a new leg.

  12. “We don’t put money into smoking cessation because smoking cessation clinics aren’t profitable.”
    Likewise, in cancer medicine, no pharmaceutical trial ever followed whether patients smoked during their clinical trials, despite dosing themselves daily with cigarettes with hundreds of chemicals in them. There’s no profitability in that.
    According to research by Dr. Carolyn Dresler, the addition of nicotine inhibits the ability of a chemo drug to induce apoptosis by 61%. If that is the case, a medical onoclogist should care if it was being ingested during treatment. Again, there’s no profitability in that.
    Most have emphasized the role of the primary healthcare provider in providing smoking cessation advice to cancer patients, whereas the specialist (medical oncologist) should be dealing with the health problems resulting from the smoking as the patient faces imminent interventions. Don’t expect the drugs companies to do that!

  13. before liberals minorites weren’t crammed in ghettos
    before liberals insurance was affordable
    before liberals child rapist weren’t heros
    let me get to the point the world would be a much nicer place without liberals

  14. Oh yes, Nate….
    And before liberals only white men that owned property could vote. And before liberals people could own other people. And before liberals women were paid almost nothing for the same work a man did, if at all allowed to work. And also before liberals people with disabilities had no chance for a normal life. And before liberals people of different sexual orientation were ostracized and worse.
    And it worked just fine for thousands of years…..
    And the point is…????

  15. Smoking saves health care dollars. Smokers die young, and relatively inexpensively. Smoking isn’t an economic problem for medicare. Bossing people around with incentives rarely works out the way you would like. Pay people to stop smoking, and you will only encourage more smoking.
    Google Charles Murray and smoking for the miriad problems with do-gooder behavior modification or read his classic:”Losing Ground”. A sociology best-seller. I am not even kidding.
    Besides, at some level, all of our health problems, starting with obesity are mental health issues.

  16. “We should penalize obese people as well.”
    Before liberals outlawed underwriting we did exactly that, and to a degree still do in individual and small group. In Life and disability it is a considerable factor.
    “Next we should penalize sick people that don’t comply with treatment plans.”
    Again before liberals we did, it was called co-insurance, get more care pay more money, before Ted Kennedy and his HMOs it was extremely effective at controlling cost.
    “Then, we can start looking at folks that consistently drive 15 miles above the speed limit.”
    Again we already do, get a ticket for driving 15 over your insurance goes up.
    “We should penalize people that don’t go to college”
    Lost you here, college doesn’t increase your earning potential or chances to be successful in life, being intelligent or dedicated enough to complete college is what leads to success, you mixed up your chicken and egg, typical liberal mistake when discussing the faux advantages to higher education.
    As a liberal you retort with the typical solution, let me and big government tax you for it. I have a really simple solution, be responsible for your own decisions and care. It worked for thousands of years. Don’t insure what doesn’t need insured. If you live a healthy life your less likely to need to buy care, if you want to be a gluten then it will cost you, minus the government surcharge your so apt to include.
    At the conference I attended last week a wellness program presented some sample results they achieved. At one firm they dropped smoking from 85% of the group to 13%, it was a low wage employer, blue collar. Everyone wanted to know how they achieved such amazing results, was it covering laser treatment, multiple chances at what ever program? No the main driver was the owner outlawed smoking anywhere on the property, as people didn’t have time to leave property, smoke, and come back during breaks, they quit.
    I have sent the same thing in CA and OH when they passed anti smoking laws, when it became inconvenient people stopped. This whole argument from MM is BS. Poor people smoke because they have the time and money. In fact the amount of money they spend on their smoking habit would be more then enough to take them out of poverty if they tried. A pack a day will buy you health insurance, or a working car, or a better apartment.
    There are some with true mental illness, not one of the disorders de jour they come up with every couple months, that need help for their mental illness, allowing them to smoke doesn’t help that. Troops in battle are the other exception where you can understand why they took it up but that doesn’t justify it or mean we should accept it. If a solider is tough enough to get through boot camp and one or more tours they can beat smoking.

  17. I still don’t see anything to support the claim that 95% of smokers have some form of mental illness.
    That 80% of schizophrenics smoke doesn’t mean that 80% of skoders are schizophrenic (duh).

  18. There is difference between penalizing someone through the judicial system for their individual choices and having people pay for the burden they place on others. When one’s actions affect others, the argument that they are victimless is no longer valid.
    Let people smoke, let them over eat. Sure. Those are individual choices. But don’t make others pay for the consequences.

  19. There is no room for zealotry in Medicine. Anti-smoking zealots for example can be cruel.
    But there IS some room for individual responsibility and a lot MORE room for insitutional responsibility.
    Dr. Rick Lippin
    Southampton,Pa

  20. Perhaps we should penalize all those individuals who were not born from the “optimal” gene pool. If we all only had better parents…. Let’s just start at birth with a genetic profile and then penalize those whose profile deviates from the norm. Or force genetic profiling in utero and then we could penalize those with termination. It would save so much money, wouldn’t it?
    Haven’t we walked down this road before and found we didn’t like it?

  21. For all the enlightened folks that deem it worthy to “penalize” smokers where health insurance is concerned, let me take this modus operandi to its logical conclusion.
    We should penalize obese people as well. Maybe the size of the penalty should be proportional to the person’s weight, or more scientifically, BMI. Want to avoid the penalty? Quit wolfing down all those Big Macs. Never mind that you would be hard pressed to find one obese person who would not rather be slim and many of them are fighting and losing the battle on a consistent basis.
    Next we should penalize sick people that don’t comply with treatment plans.
    Then, we can start looking at folks that consistently drive 15 miles above the speed limit. Maybe add a little extra if you do most of your driving on highways and particularly if you drive a cheap unsafe clunker.
    We should also penalize drinking in general, not just alcoholism. It should be a sliding scale, with weighted values for wine, beer and hard drinks.
    We should penalize people that don’t go to college and definitely those that drop out of high school, because lack of education may lead to smoking, obesity, and driving cheap cars.
    We could be proactive and penalize parents that let their kids watch too much TV, with all those sugary adds and lack of exercise. That would fall under “fostering obesity”.
    We should also penalize people that work too much and hold stressful jobs.
    Basically, we should create a standard person profile, approved by insurance companies and other Wall Street stakeholders, and penalize any deviation from the sanctioned model.

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