The smoking patient: Should we intervene?

By Garland Y. DeNelsky, Ph.D.
January 1, 2008 - Last updated: May 31, 2011

As the session ended, the psychologist and the patient rose simultaneously and started moving toward the door. With one smooth motion, the patient reached into her purse, retrieved a package of cigarettes and took one out. She said her goodbyes and hurriedly walked away, apparently eager to exit the building and light her cigarette.

The psychologist thought, “Should I bring up her smoking and the need for her to quit at our next session? Would that prove too stressful for her? Does she actually need her smoking as a means of helping her cope? And, of course, I must remember that she came to me for help with her emotional problems, not her smoking. What should I do?”

This psychologist was facing the type of issues frequently associated with clients who smoke. And many clients do: A large-scale survey by Karen Lasser, M.D., and her associates found the smoking rates of patients with mental and emotional problems roughly double that of the general population (41 percent versus 21 percent). Individuals diagnosed with bipolar disorder have even higher rates of smoking (61 percent). Persons abusing or dependent upon alcohol have similarly high rates of smoking (56 percent) as do other chemically dependent persons (68 percent). Extrapolating their results to the U.S. population, these researchers estimate that people with diagnosable mental illness comprise nearly half of the total tobacco market in the U.S.!

It should come as no surprise that psychiatric patients who smoke have markedly elevated rates of cancer, heart disease, chronic obstructive pulmonary disease and all the other diseases associated with tobacco use and that their lives are substantially shortened by their tobacco use. But the damages of tobacco use are not limited to such physical disorders. One survey found a positive relationship between smoking and suicidality in psychiatric patients. Evidence is also accumulating that smoking may actually be a cause of teen depression.

Are patients with mental health and substance abuse disorders really capable of quitting? Or are we asking too much of them to even try? Do they need the addictive substance in tobacco – nicotine – as a means of helping them cope?

Those who manufacture tobacco products would have you answer, “yes,” to the issue of patients’ need for tobacco. Internal documents from the tobacco industry show that at least one tobacco manufacturer conducted marketing studies targeting psychologically vulnerable consumers. The studies implied that smokers used nicotine to treat symptoms of depression, for “mood enhancement,” for “anxiety relief,” to “cope with stress” and to “gain self-control.” The marketing effort also suggested that smoking “helps perk you up” and “helps you think out problems.”

A recent review of the “smoke to cope” literature portrays a rather more complex relationship between stress and smoking. Although most smokers do report that cigarettes help them relax, several studies indicate smokers are more anxious overall than nonsmokers.

Indeed, while the effects of nicotine seem to have a subjective calming effect to the smoker, the effects of tobacco are anything but calming on the body’s physiology, resulting in almost instantaneous rises in heart rate and blood pressure.

Even more startling are the findings that former smokers who maintain complete nicotine abstinence for at least six months report significant reductions in overall stress levels. These findings suggest that nicotine-dependent smokers smoke on a regular basis to cope with the withdrawal symptoms experienced when nicotine levels drop between cigarettes.

Smoking seems to be both a major contributor to stress and a conditioned response to negative moods. While quitting smoking may temporarily increase a person’s stress level, over the long haul, no tobacco translates into less stress. Knowing that one is no longer engaging in the deadly behavior of smoking is stress reducing in itself.

So quitting smoking results in not only reduced morbidity and mortality but also in reduced stress among persons with emotional and substance abuse problems. But are patients with emotional problems or substance abuse disorders capable of quitting? Lasser and her colleagues found some interesting results here.

They found that nearly one third of smokers with mental illness were able to quit smoking. If they abstained from drugs and alcohol they had cessation rates about equal to people without mental illness. “This finding should encourage us to help our patients with mental illness to quit smoking, especially given that persons with mental illness are at high risk for smoking related deaths” said Danny McCormick, M.D., one of the co-authors of this landmark study.

Thus it turns out that patients with emotional problems and substance disorders are indeed capable of quitting and when they quit they not only become healthier physically they also are likely to report less stress in their lives. There may be other benefits as well. As noted above, preliminary results suggest that smoking may be a causative factor in some mental disorders.

It is becoming increasingly well documented that when people quit smoking – and stay quit – they experience increased feelings of well-being as well as improved self-esteem. They are also more likely to engage in other positive behaviors such as exercising regularly and eating healthier. In short, the long-term effects of smoking cessation are positive, both physically and emotionally.

Ex-smokers typically need significantly lower dosages of medications than when they were smokers. Smokers more quickly metabolize psychoactive (and many other) medications, lowering the blood levels of these medications.

When former smokers abstain from tobacco, medication blood levels increase and there is a risk of over medication and increased side-effects if the medication dosages are not appropriately adjusted. This is true with many antipsychotics and some antidepressants and antianxiety medications. It is also true with many non-psychoactive medications. The bottom line: When smokers quit, they typically need less medication to achieve the same effects. And when it comes to medications, less is almost always better.

What about the argument that since the patient did not come seeking help with quitting smoking, perhaps the psychologist should not initiate discussion of this topic? If in the course of therapy with a patient, you learn that the person is unknowingly ingesting a powerfully poisonous food supplement, is it not your duty as a health care provider to alert the patient to this danger and urge her or him to stop?

In the case of smoking, the patient is inhaling over 4,000 poisons, including over 50 known carcinogens! Should you sit silently by and watch your patient commit slow suicide?

When, then, should psychologists bring up smoking cessation with their clients? While timing is important, and there are no clearly established guidelines, sooner is better than later. Bring up the issue in a positive, non-confrontative fashion, pointing out both the physical and emotional benefits to be derived from quitting. Express your confidence that your clients are indeed capable of quitting (even if you are not completely sure).

Become aware of the smoking cessation resources that are available in your community, including the North American Quitline Consortium, an association of telephone quitlines available at little or no cost to smokers in all 50 states, the District of Columbia (1-800-QUITNOW) and all 10 provinces in Canada (see website for phone numbers – Help your patients find the resources they need to assist them in the process of quitting.

Above all, be patient and non-judgmental. Most people require multiple attempts – and some time – before they quit and stay quit. There are no “failures” unless the smoker – or the person providing health care services – gives up and stops trying to achieve cessation. Reinforce even small steps that patients take along the journey to quitting. Remember that quitting smoking is one of the most precious and lasting gifts that persons can give to themselves. Become part of this superb, life-preserving process.

Eventually, both you and your patient will be thankful that you did.


Lasser, K, Boyd, J. W, Woolhandler, S, Himmelstein, D. U., McCormick, D., Bor, D. H. (2000). “Smoking and mental illness: A population-based prevalence study.” Journal of the American Medical Association, 284 (20), 2606-2610.

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