The United States has just observed its annual Mental Health Awareness Month. Another year and another awareness month have gone by with little attention paid to the many people who both live with a mental health condition and smoke.
On average, people with a mental illness die up to 25 years younger than the general population, and many die from smoking-related chronic diseases. Tobacco-related diseases contribute to approximately 53 percent of deaths among people living with schizophrenia, 50 percent among people with depression, and 48 percent among people with bipolar disorder. It’s estimated that somewhere over 20 percent of people in the US live with a mental illness. But this population smokes almost half of all the cigarettes sold around the country each year. It’s past time that we prioritized their health.
Smoking rates are extremely high among people with a range of mental health conditions. But there is conflicting evidence on the relationship between smoking and depression, for example: While some studies find that depression leads to smoking, others indicate that smoking leads to depression. But it’s worth noting that many people start smoking during adolescence, often a turbulent time of life. And adolescents with depressive symptoms are more likely to start smoking than those who are not depressed.
Adults self-medicating with nicotine need safer alternatives to smoking to improve their physical health.
What’s more, nicotine, the main psychoactive compound in tobacco, has shown promise in helping some people with mental illnesses, such as those suffering from late-life depression (LLD) and major depressive disorder. However, adults self-medicating with nicotine need safer alternatives to smoking to improve their physical health.
As the nicotine market changes and vaping has increased in popularity, scientists are also exploring the relationship between vaping and depression. A recent study published by Drug and Alcohol Dependence found that vaping in adolescents did not lead to the development of depression symptoms. The study found instead that 14-year-olds who already had elevated depression symptoms had a faster rate of progressing to heavier use of vapes.
There has for years been a public outcry about youth use of vapor products, labeled an “epidemic”—a term even the US Food and Drug Administration (FDA) no longer uses. In the 2021 National Youth Tobacco Survey, 43.4 percent of adolescents who “currently” vape (used in past 30 days) cited anxiety, depression and stress as reasons for doing so. That amounts to 1.3 million adolescents illegally using vapes to self-medicate mental health conditions.
There is an unbalanced focus on youth vaping while mental health issues are neglected. Millions of youths live with determinants of poor mental health, such as poverty, bullying, poor housing, sleep deprivation, food insecurity, isolation, abuse, and lack of health care. These issues existed long before nicotine vapor products hit the US market. It would be welcome if a fraction of the efforts devoted to cracking down on teen vaping were redirected to addressing these inequities.
Smoking—which costs almost half a million US lives each year—is being both sidelined and conflated with the most effective route to smoking cessation.
Similarly, smoking by people of any age—which costs almost half a million lives each year in the US—is being both sidelined and conflated with the most effective route to smoking cessation.
At this year’s Addiction 2023 conference, Dr. Smita Das, a psychiatrist at Stanford University, gave a presentation about smoking and vaping. A tweet by Chris Palmer, MD, with more than 52,000 views, showed one of her slides: “Cigarettes and Vaping. Causing more morbidity and mortality than alcohol and all other drugs combined.”
While technically true, the statement is dangerously misleading. It would also be true if the slide said, “Cigarettes and Coffee. Causing more morbidity and mortality than alcohol and all other drugs combined.” It is smoking that causes morbidity and mortality, not vaping or coffee.
In a recent article, Dr. Das talked about mental health, smoking, and vaping. She pointed out that two-thirds of people who smoke long-term will die from smoking-related causes. She also observed that because vaping doesn’t involve combustion, if a person switches from smoking to vaping, “health harms will be reduced.” That is the accurate way to compare smoking and vaping.
Conflating the two—as her slide did, and many other influential figures have done in the US, despite the FDA’s acknowledged continuum of risk—can easily confuse people into believing they are equally harmful. That can be a fatal mistake for someone who smokes.
Americans living with mental illness must not continue to be left behind in terms of well-informed access to safer alternatives to smoking.
Misinformation certainly deters people with mental illnesses from switching to a safer alternative. For example, Military Medicine published a study in 2021 of US veterans receiving services at a mental health and substance use disorder clinic. It found that 36 percent of study participants falsely believed vaping was as harmful as smoking.
In 20 years, the United Kingdom has seen little change in smoking prevalence among people living with a mental illness. But unlike the US, the UK is on a mission to change that statistic: Its Swap to Stop program will give out free vape starter kits to one million people who smoke. Local authorities are empowered to decide which populations to prioritize—and that should certainly include people with mental health conditions, in line with past pioneering work in the country to bring vapes to mental health hospitals.
Globally, the health of millions of people could be improved if other countries followed the UK’s lead. Americans living with mental illness must not continue to be left behind in terms of well-informed access to safer alternatives to smoking.
Photograph by lil artsy via Pexels