Long after losing glamorous image, smoking keeps tight grip on mentally ill

For decades, tobacco companies relied on movie stars and sports heroes to pitch their brands, making cigarettes as much a symbol of sophistication and glamour as limousines and Champagne.

Today, the image is vastly different, with smoking largely a habit of the troubled and the poor. A surprising statistic emphasizes the point: 44 percent of all smokers, according to the most authoritative study on the subject, are mentally ill.

“Smoking has moved from the glamorous to the more marginalized,” said Judith Prochaska, an associate professor of medicine at Stanford Prevention Research Center, referring not just to the mentally ill, but those with “lower income, less status and less education.”

Millions of smokers who were easiest to reach with anti-smoking messages have kicked the habit, leaving what authorities describe as a harder core of smokers with less ability or desire to quit. In particular, the mentally ill might have more trouble handling the distress of nicotine withdrawal than other smokers do. And with the mentally ill accounting for a disproportionate share of current smokers, health officials and advocates face a special challenge in devising anti-smoking strategies.

Smoking rates have declined steeply over the last half-century. In 1965, about 42 percent of American adults smoked, compared with about 18 percent now. But the rate has been stuck there since 2008, and 43 million Americans still puff away.

Smoking remains the nation’s leading cause of preventable disease and death. It is responsible for more than 480,000 premature deaths in the U.S. annually, according to the Centers for Disease Control and Prevention. In addition, a study published last year — based on an evaluation of the deaths of more than 125,000 people who had been diagnosed with schizophrenia, bipolar disorder or depression — blamed half of the fatalities on tobacco.

Research shows that the mentally ill have a harder time quitting on their own. Still, they can succeed when offered the same anti-smoking strategies used in the general population — although often on a more intensive basis — such as counseling, medication and nicotine patches.

Nonetheless, doctors, psychiatrists and counselors have been reluctant to attack this problem, various experts say, for a number of reasons. A major one is a lingering, but dubious, assumption that smoking relaxes the psychologically troubled, especially those with more severe disorders.

Touting supposed benefits of nicotine

A 2007 study co-written by Prochaska documents the role of tobacco companies in promoting this idea. By funding research, lobbying and developing relationships with mental hospitals and psychiatrists, the tobacco giants pushed the notion that nicotine could benefit the mentally ill, and that quitting could worsen their symptoms.

Based on internal industry documents, the paper found that tobacco companies funded research in the 1980s and 1990s aimed at showing that smoking could have beneficial self-medicating effects for schizophrenics, and might reverse what one study termed ‘’certain cognitive deficits.” Many in the mental health community bought into the idea that patients should not be pushed to quit. The study cited letters from psychiatric institutions to tobacco companies asking for donations of cigarettes for patients on grounds that this could decrease their agitation.

And in the early 1990s, when a hospital accreditation commission called for a ban on smoking in all hospitals, some mental health advocacy groups joined with cigarette makers in a successful effort to ease the restrictions for psychiatric institutions.

The National Alliance on Mental Illness -– which now works to help the mentally ill stop smoking – in the past noted that “nicotine may work to reduce [patients’] psychotic symptoms.” Cigarettes or smoking breaks were often used as rewards for good behavior.

Some mental health providers still fear that pressuring those with psychological disorders to quit – and in particular, giving them medication to do so – might upset a psychological balance delicately maintained through a complicated mix of drugs and counseling.

Beyond that, some providers assume that their patients have no desire to stop.

But repeated studies show that the mentally ill, despite facing extra obstacles, can quit, and they feel better once they have. A recent analysis of an array of research found that quitting smoking reduced depression, anxiety and stress for smokers with and without psychiatric disorders.

As health authorities weigh strategies to reduce tobacco-related disease and deaths, the impact on mentally ill smokers has become an important consideration. The 2009 tobacco control law -— the Family Smoking Prevention and Tobacco Control Act — gave the Food and Drug Administration the power to restrict, though not eliminate, nicotine content, if that would reduce smoking’s toll on public health.

Tests with ultra-low nicotine smokes

Some officials and advocates have discussed the possibility of cutting nicotine to levels too low to sustain addiction, easing the way for people who want to quit. Such a rule would pose a threat to the tobacco industry, and trigger ferocious opposition. But before even proposing it, health authorities must determine if the idea is scientifically sound. To that end, a federally funded research project that has cost $32 million over the last four years is examining how ultra-low nicotine cigarettes would affect smoking habits. Clinical trials with experimental cigarettes are being conducted with various groups of smokers, including those with mental illness.

The experimental smokes are not the ‘’light’’ brands that cigarette makers introduced in the 1960s and ’70s as a marketing ploy to keep worried smokers from quitting. The light cigarettes used porous paper and ventilation holes in the filters to dilute the smoke, thus achieving lower tar and nicotine yields in tests with smoking machines. However, by covering the holes with their fingers, inhaling more deeply or lighting up more often, smokers got just as much nicotine and tar as with a regular cigarette.

The new experimental cigarettes contain genetically modified tobacco. The trials have been spread among about a dozen institutions, including the University of Pittsburgh, the University of Minnesota, the University of Calfornia, San Francisco, and the MD Anderson Cancer Center. The study is scheduled to be completed in 2016.

Early findings show that smoking rates decrease within weeks to months after smokers switch to these cigarettes. The upcoming research includes a study next year by Jonathan Foulds, a professor of public health science and psychiatry at Penn State University. He will explore the effects of a gradual reduction in nicotine among smokers with depression and mood disorders.

Meanwhile, Jennifer Tidey, an associate professor at the Center for Alcohol and Addiction Studies at Brown University, is conducting two studies. One will focus on smokers with schizophrenia and the other will involve smokers suffering from depression or anxiety disorders. In her studies, Tidey will switch smokers immediately to the experimental very low nicotine cigarettes.

The cigarettes taste different, “they’re not Marlboros,” Tidey said, but they have “tremendous potential to reach people who aren’t being treated.” Nonetheless, because the health effects of the very-low nicotine cigarettes need to be established, it will probably be years before such cigarettes are available to the public.

What’s key, the experts agree, is that doctors and other health providers put a higher priority on smoking cessation among the mentally ill.

“People are dying from smoking-related illness, and they want to quit,” Tidey said. “Our responsibility is to get treatment to help them quit.”