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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green cigarettestop smoking helpBonniethornarb Recent comment authors
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green cigarette
Guest

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.

stop smoking help
Guest

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… Read more »

Bonnie
Guest

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

thorn
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thorn

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… Read more »

maggiemahar
Guest

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–… Read more »

arb
Guest
arb

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… Read more »

Margalit Gur-Arie
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Margalit Gur-Arie

Oh but Nate’s friendly insurance companies are on top of the “obesity issue”…. right from the start, nip it in the bud….
http://www.denverpost.com/ci_13530098

Alexander Saip
Guest

Unlike smoking, which is found to have little impact on the nation’s healthcare expenses ( http://www.huffingtonpost.com/2009/04/08/how-much-does-smoking-cos_n_184554.html ), obesity may not be so “cost friendly” ( http://www.medicalnewstoday.com/articles/158948.php ) because it starts affecting our health at a much younger age.

D'cm
Guest
D'cm

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.

maggiemahar
Guest

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… Read more »

Nate
Guest
Nate

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

Michael Millenson
Guest
Michael Millenson

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.

Rick
Guest
Rick

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.

Greg Pawelski
Guest
Greg Pawelski

“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… Read more »

Nate
Guest
Nate

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