Enhancing Tobacco Harm Reduction through Holistic Approaches

By Cheryl K. Olson

“I firmly believe a lot of us, people like me, are self-medicating, pure and simple,” says Skip Murray. A Minnesota-based tobacco harm reduction specialist, Murray began smoking at age 10. She was diagnosed initially with autism and attention deficit/hyperactivity disorder (ADHD) and later with depression, anxiety and post-traumatic stress disorder (PTSD) as well. She vapes to manage her symptoms.

Brian King, director of the U.S. Food and Drug Administration’s Center for Tobacco Products, has called for greater focus on health equity. One group he cited as disproportionately affected by smoking is people living with mental health conditions. If you’re among this crowd, you are more likely to smoke (and smoke heavily) and less likely to quit compared to the general population.

Plenty of research details this serious disparity. Among U.S. adults scored as having serious psychological distress (SPD) in the National Health Interview Survey, nearly 40 percent smoked. That’s compared to 13 percent of people without SPD. Of all cigarettes consumed by U.S. adults, nearly one-third are smoked by someone with a mental illness.

A new analysis of Population Assessment of Tobacco and Health survey data found that among adults ever diagnosed with psychosis, 41 percent had used any kind of tobacco in the past month, and 31 percent had smoked. Having multiple mental health conditions is linked to higher smoking rates.

The disparity is growing. U.S. national surveys find that smoking rates for those with mental health diagnoses are either stagnant or are declining more slowly compared to the general population. In particular, smoking rates for black and Hispanic adults experiencing serious psychological distress have not budged in years.

What stands in the way? How can we better support tobacco harm reduction for people with mental health needs and persuade mental health professionals to take smoking seriously?

A Culture of Smoking

Historically, mental health care systems tolerated or even encouraged a smoking culture. Smoking breaks helped build relationships between patients and providers. Cigarettes were used as rewards for “good” behavior or for complying with treatment.  

Studies find that mental health professionals frequently believe that their patients who smoke aren’t interested in quitting. Or that giving up cigarettes is too much to take on when also dealing with mental illness. Many therapists view smoking as not part of their turf but belonging to the physical health side of things.

Amid the stresses and crises of mental health practice, granting lower priority to smoking cessation may seem practical. But ignoring cigarettes costs their patients years, even decades, of life. A recent editorial in the British Journal of General Practice called smoking the single biggest contributor to the seven-year to 25-year reduced life expectancy for people with mental health conditions.

“To ignore their smoking, and only focus on their mental health, in the long run harms their overall health,” says Murray. “Why aren’t we looking at why they smoke? Do they not have healthcare, a home, enough food?”

“I’m more than my mental illness,” she continues. “We need to treat the whole person.”

Another barrier to encouraging smoking cessation has been lack of research on, and provider knowledge about, effective interventions. People with schizophrenia are at highest risk for earlier death, and their rates of smoking are especially high. Randomized trials suggest that smoking cessation medications are not risky for them to use. The issue is not safety but effectiveness.

For example, a large Canadian community-based smoking cessation study found that many people with schizophrenia who smoke want to stop. They were as able as others to reduce their smoking but much less successful at quitting altogether.

For people living with mental health conditions, as with the general population of people who smoke, there is an urgent need for more effective cessation approaches. A 2002 commentary titled “Smokers with Schizophrenia Will Benefit From More Flexible Treatment Approaches” put it this way: “New and creative NRTs [nicotine-replacement therapies] and pharmacological and psychosocial interventions are needed to compete with the high reinforcement value of smoking.”

Today, we have nicotine alternatives undreamed of in 2002, including e-cigarettes.

A Role for Vaping?

In a 2017 review on Smoking, Mental Illness and Public Health, Stanford researchers wrote that “Additional data are needed to more fully understand the long-term potential of [e-cigarettes] for harm/harm reduction, particularly in vulnerable groups of smokers, including those with mental illness.”

Six years later, many in public health are unfortunately still on the fence about whether vaping causes or reduces harm. We now have high-certainty evidence from a respected Cochrane review of research that vaping works better than NRT to help people quit smoking.

But what evidence do we have for persons with mental illness in particular? The studies summarized in the Cochrane review either didn’t mention mental health or specifically excluded people with conditions such as depression, anxiety and psychosis from participating.

More often than not, even the newest studies on helping people with mental illness quit smoking ignore the existence of vaping and other non-NRT nicotine options. However, evidence from recent population surveys that give results for people with mental health conditions suggests that vaping merits a closer look.

A 2023 report analyzed data on people reporting depression and anxiety from the 2018 and 2020 Four Country Smoking and Vaping Surveys. The authors state, “It appears that smokers with depression are motivated to quit smoking but were less likely to manage to stay quit and more likely to be vaping if successfully quit.”

A 2020 English population survey report by Brose and colleagues found that smokers with mental health problems were just as likely as others to successfully quit smoking if they tried. People who had ever had a mental health diagnosis were nearly four times more likely to choose vaping over nonprescription NRT (37 percent versus 9.8 percent) when making quit attempts—more than the sample overall. The authors suggest that “e-cigarettes used in quit attempts currently are more likely to positively affect inequalities than other smoking cessation interventions,” especially if their reach among people with mental health problems can be increased.

Wanted: Better Studies

Caponnetto and Polosa have summarized the results of some small but promising studies, involving first-generation or second-generation e-cigarettes, to help people with schizophrenia spectrum disorders stop smoking. Vaping showed potential as an acceptable substitute even among people with severe mental illness who don’t intend to quit smoking. Are larger studies in the research pipeline?

A 2021 research letter in JAMA Psychiatry describes registered clinical trials looking at e-cigarettes to reduce or stop smoking. Just eight of the 66 ongoing or completed trials recruited individuals who smoke who have a psychiatric condition. The authors note that very few studies (and no completed ones) tested “newer e-cigarette devices that are designed to deliver nicotine more similarly to cigarettes.” They call for more, higher quality studies. We’ll keep an eye out.

Ways to encourage harm reduction after inpatient mental health treatment also need more study. A 2023 U.K. study by Shoesmith and colleagues in Nicotine & Tobacco Research describes the development of a complex behavior change intervention to follow discharge from a smoke-free mental health stay. You have to dig into the supplemental material to find that mental healthcare worker training in use of e-cigarettes is part of the recommended intervention.

We need more research to better understand what may block or encourage people with mental health conditions from trying and switching to vaping. A 2017 study analyzed discussions on Reddit by people with mental illness about motivations and limitations associated with vaping. Self-medication was a common theme.

One person who reported PTSD and anxiety wrote, “For me, vaping is pretty much the same as smoking, in terms of how it helps me calm down and handle stress.”

Many wrote on Reddit about the importance of education about and support for vaping from friends, family and online communities. Informed mental health professionals could likely play a critical role in saving lives. A U.K. study found that among people who have used tobacco, those with serious mental distress are more likely to have inaccurate harm perceptions of nicotine and nicotine products, including vaping.

“A Clear and Definite Message”

A U.K. government-funded community interest company, the National Centre for Smoking Cessation and Training, just released a much-needed guide to vaping for health and social care professionals. The guide states that “some people from disadvantaged groups may vape for temporary abstinence (e.g., at work or while in a mental health inpatient setting) before deciding to switch completely.” Also, “it is important that people from disadvantaged groups receive a clear and definite message that vaping is much less harmful than smoking.”

Some mental health professional associations have endorsed vaping, however grudgingly or conditionally. For example, the Royal Australian and New Zealand College of Psychiatrists issued a sensible e-cigarette position statement in 2018 (due for updating soon). Acknowledging the high smoking prevalence and low quit rates among people who live with mental illness, they say that “e-cigarettes and vaping devices may provide a less harmful way to deliver nicotine to those who are unable or unwilling to stop smoking tobacco.”

The college would like more data on vaping’s long-term health effects and on switching success. However, “This does not justify withholding what is, on the current evidence, a lower-risk product from existing smokers while such data is collected.”

The position of the U.K. Royal College of Psychiatrists is similarly pragmatic. Vaping devices, they note, have become the most popular real-world quit-smoking aid. Although using neither is preferable, “using an EC [electronic cigarette] is always better than smoking a cigarette.”

By contrast, a 2022 position statement on vaping products from the American Psychiatric Association does not mention harm reduction. They focus only on potential risks to youth.

Knowledge can flow the other way, from patient to mental health professional. Murray received counseling for a year from a therapist who was initially highly skeptical of vaping. “She was one of those who believed that nicotine causes cancer and depression,” Murray recalls.

After seeing the difference in Murray’s focus when she had forgotten her vape at work and gone without nicotine for hours, the therapist became curious. “That’s when we figured out that nicotine helps my ADHD,” Murray says. Upon request, she shared published studies on nicotine and mental health with her therapist.

Adds Murray, “It was cool to meet somebody who was willing to look at information and think about if what they believed was actually true.”