While tobacco use slowly drops among the general population, a startling 41 percent of persons with mental illness in Kentucky use tobacco, according to a 2013 study by the Centers for Disease Control. An increasing number of mental health advocates and providers are calling for tobacco treatment programs specially designed for people with chronic mental and behavioral health conditions.

“There is a culture of tobacco use that has been pervasive in behavioral health populations and we are strongly trying to address that,” says Chizimuzo Okoli, Ph.D., an associate professor at the University of Kentucky College of Nursing.

Research suggests that people with behavioral health issues die on average 10 to 25 years earlier than those without mental illnesses and substance use disorders. Okoli adds, “So if you look at a death certificate, you’re not going to see that somebody died from schizophrenia or bipolar disorder, but it isn’t uncommon to see… problems like smoking and substance use.”

Okoli directs the Tobacco Treatment Services and Evidence-Based Practice at Central Kentucky Recovery Center (CKRC), located at Eastern State Hospital in Lexington. This winter, he supervised an eight-week smoking cessation course specifically designed for persons with mental illness.

“There are many theories about why people with substance use disorders, mental illnesses, behavioral conditions, use tobacco, and one theory is the self-medication theory,” Okoli says.

“One example is how individuals with schizophrenia have some challenges” in being able to ignore extraneous noises and concentrate on more prominent stimuli, such as someone else talking. Persons with schizophrenia can struggle with this, “but while they’re smoking,” they can actually concentrate, Okoli explains.

The nicotine in cigarettes also serves as an axiolytic, a substance that relieves anxiety, Okoli adds.

While smoking may help persons with mental illness relieve anxiety and ease some of the neural effects of their condition (such as lack of concentration), its destructive impact on human physiology affects them just as severely as it does any other segment of the population.

Furthermore, persons with mental illness are at high risk of having their medication dosage affected, Okoli says. He explains: The tar in smoking gets into the bloodstream and reduces the effectiveness of the medications. Because of this, people typically need higher doses to overcome the tar effect. After smoking cessation (and tar is reduced) many find they don’t need such high doses to get the same effectiveness.

Debunking Myths About Smoking and Mental Illness

Okoli says that there have been many myths about persons with mental illness that in past years discouraged health care providers from addressing their tobacco use.

“They just can’t quit, that’s one big myth I’ve encountered from different providers,” he says. “But the evidence says they can – it may take longer durations, more intensive therapy, but they are able to achieve cessation.”

Other common assumptions, according to Okoli, are that cigarettes offer persons with mental illness one of the few pleasures they have, making them more reluctant to stop, and that if they do quit they are more prone to relapse than the general public.

These myths are eroding, however, due to greater education and research. According to one study Okoli cites, more than 50 percent of persons with behavioral challenges actively want to quit smoking. And other studies have shown that persons undergoing treatment for their mental illness can quit using tobacco concurrently.

Bridgehaven’s Holistic Approach to Mental Health Services

Celebrating its 60th anniversary this year, Bridgehaven Mental Health Services in Louisville is an integral part of the region’s provider network, offering a wide variety of programs to its members.

Ramona Johnson, APRN, CS, the CEO of Bridgehaven, says that the organization’s mission is still the same as it was 60 years ago: “Providing the best quality, evidence-based, community-based services to people who have mental illness, with the goal being recovery.”

Improving physical health is now part of that mission. In recent years, Bridgehaven started the Bridges to Health Clinic with a grant from the Humana Foundation. That clinic has expanded to offer health and wellness services promoting exercise, healthy eating, and diabetes education and monitoring.

“Our approach is very holistic,” Johnson says, adding “It’s hard to be mentally healthy without being physically healthy.”

As part of its Bridges to Health Clinic, Bridgehaven staff supervised a smoking cessation course using the Freedom From Smoking model created by the American Lung Association, a popular model nationwide.

Brad Leedy, MSSW, who oversees the Humana Foundation grant for the clinic, says that over the past year and a half, eight members at Bridgehaven who took the Freedom From Smoking class quit smoking — although not all of them quit immediately after finishing the class.

Two others have substantially cut down on their cigarette smoking. Members made their decisions based on financial necessity, health concerns, to spend more time with family members, and other reasons.

Success Story: Arlan

Arlan, a smoker since age 15, has been attending Bridgehaven on and off since age 18 and regularly since his late twenties. Since his return, he’s made remarkable improvement in dealing with bipolar disorder and in his general health. As a graduate of Bridgehaven’s cognitive enhancement therapy (CET) course, he’s developed sharper skills in concentration and social interaction, and after taking the facility’s Freedom From Smoking class and joining the YMCA through its Bridges to Health program, he quit using tobacco in spring 2015.

Now approaching his three-year smoke-free anniversary, Arlan is a counterpoint to the myth that people with mental illness can’t and won’t quit smoking. He has made strides in managing bipolar disorder, and he’s been able to keep his desire to smoke under control as well.

“I still want to smoke every now and then, but I don’t,” he says. “A couple nights ago, I felt like smoking, and I said, ‘You know how easy it would be for me to just go out there and get a pack of cigarettes and smoke? But I just can’t do it.”

Building a Tailored Smoking Cessation Program

Bridgehaven staff are currently consulting with Okoli to adapt a smoking cessation model for use at Bridgehaven. This new program is based on Okoli’s initial work at Eastern State Hospital but will tweak some of its features – expanding to 16 weeks for example, and also structured to serve an outpatient population. It uses some of the same features as a Freedom From Smoking course but is far more tailored to help persons with mental illness.

For example, persons with schizophrenia, bipolar disorder, and other mental illnesses may need to take higher doses of smoking medications and have longer durations of treatment, Okoli explains. They also require specific behavioral therapy to help promote coping and relapse prevention skills.

This model was first put into practice in Vancouver, British Columbia, by Okoli and Dr. Milan Khara. There, it was embedded into an outpatient program and had great success, resulting in a quit rate of around 40 percent among those who completed the full course.

Going forward, Okoli believes that his tobacco cessation course will be most effective when held in a facility that offers comprehensive outpatient services to a group of members who attend regularly. Bridgehaven offers an ideal setting to incorporate this more targeted, expanded model.

This KET article is part of the 2018 Smoking and Health Initiative, funded in part by the Foundation for a Healthy Kentucky.