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Behavioral Health & Tobacco Use

Behavioral Health and Tobacco Use Rates

  • It is estimated that 35 percent of cigarette smokers have a behavioral health disorder and account for 38 percent of all U.S. adult cigarette consumption.1
  • Despite the national cigarette smoking rate being 14 percent overall among adults, it is 23 percent for individuals with a behavioral health disorder.1
  • The nicotine dependency rate for individuals with behavioral health disorders is 2-3 times higher than the general population.2

Tobacco and Mental Health

  • Lifetime smoking rates are higher in patients who are diagnosed with major depression disorder (59%), bipolar disorder (83%), or schizophrenia and other psychotic disorders (90%)3 compared to 32 percent among adults with no mental illness.4
  • Individuals with schizophrenia are addicted to nicotine at rates that are up to three times greater than the general population.5
  • 70 to 85 percent of individuals with schizophrenia use tobacco.6
  • Individuals with a diagnosis of post-traumatic stress disorder (PTSD) are about 22 percent more likely to be current smokes than individuals without PTSD.7
  • Among current smokers with a lifetime history of depression, anxiety, anxiety with depression or major depression, they smoke more cigarettes, smoke more frequently and have a higher level of dependence.8
  • Individuals with social anxiety are more likely to engage in heavy smoking and are less likely to successfully quit in comparison to individuals without social anxiety, depression, and other substance use disorders.9
  • The presence or history of depression is associated with greater smoking severity and poorer smoking outcomes.10
  • Major depressive disorders are associated with an earlier age of cigarette smoking, greater dependence on nicotine, higher nicotine withdrawal scores, greater cravings, and higher Carbon Monoxide levels during cessation treatment.10

Morbidity and Mortality

  • Smokers with serious mental illness have increased risk of dying from cancer, lung disease, and cardiovascular disease11 and account for more than 200,000 of the 520,000 tobacco-related deaths each year.12
  • Individuals with serious mental illness die about 15 years earlier than individuals without serious mental illness who never smoke.13
  • About half of deaths among those hospitalized for schizophrenia, depression, or bipolar disorder are from causes linked to smoking.12

Tobacco and Substance Use

  • More than 80 percent of youth with substance use disorders report current tobacco use, most report daily smoking, and many become highly dependent, long-term tobacco users.14
  • Individuals with alcohol use disorders smoke at rates between 34 and 80 percent; people with other substance use disorders smoke at between 49 and 98 percent.15
  • Addiction to nicotine is the most common form of substance use in people with schizophrenia.16
  • Current cigarette smokers in the past month were more likely than those who were not nicotine dependent to have engaged in alcohol use (62% vs. 54%), binge alcohol use (43% vs. 22%), and heavy alcohol use (15% vs. 5%) in the past month.17

Morbidity and Mortality

  • Tobacco use causes more deaths among individuals receiving substance use treatment than alcohol or other substance use.18
  • 51 percent of deaths were the result of tobacco-related causes, which is double the rate found in the general population.19
  • One study found that most deaths among those with a history of opioid-related disorders were from tobacco or alcohol-related causes and not directly caused by drug use.20


  • 70 to 80 percent of individuals receiving substance use disorder treatment have expressed an interest in tobacco cessation.21
  • Participation in smoking cessation efforts while engaged in substance use treatment has been associated with a 25 percent greater likelihood of long-term abstinence.22


  • Sources
    1. Centers for Disease Control and Prevention. National Center for Health Statistics. National Health Interview Survey, 2017. Analysis performed by the American Lung Association Epidemiology and Statistics Unit using SPSS software.
    2. Schroeder SA, & Morris CD. Confronting a neglected epidemic: Tobacco cessation for persons with mental illnesses and substance abuse problems. Annu Rev Public Health. 2010; 31: 297-314.
    3. Kalman D, Morissette SB, George TP. Co-morbidity of smoking in patients with psychiatric and substance use disorders. Am J Addict. 2005;14(2):106-123.
    4. Smith PH, Mazure CM, McKee SA. Smoking and mental illness in the US population. Tob Control. 2014; 23(0): e147-e153.
    5. Cuffel BJ & Chase P. Remission and relapse of substance use disorder in schizophrenia: Results of a one-year prospective study. Journal of Nervous and Mental Disease 1994; 182(6):342–348.
    6. Ziedonis DM, Hitsman B, Beckham JC, Zvolensky M, Adler LE, Audrain-McGovern J. Tobacco use and cessation in psychiatric disorders: National Institute of Mental Health report. Nicotine Tob. Res. 2008: 10, 1691–1715.
    7. van den Berk-Clark C, et al. Association between posttraumatic stress disorder and lack of exercise, poor diet, obesity, and co-occuring smoking: A systematic review and meta-analysis. Health Psychology. 2018; 37(5):4-7-16.
    8. Tosclair, A & Dube SR. Smoking among adults reporting lifetime depression, anxiety, anxiety with depression and major depressive episode, United States, 2005-2006. Addict. Behav. 2010; 35(5): 438-443.
    9. Cougle JR, Zvolensky MJ, Fitch KR, Sachs-Ericcson NS. The role of comorbidity in explaining the associations between anxiety disorder and smoking. Nicotine Tob Res. 2010; 12(4): 355-364.
    10. Soone S, Nunes EV, Jiang H, Tyson C, Rotrosen J & Reid MS. The relationship between depression and smoking cessation outcomes in treatment-seeking substance abusers. Am J Addict. 2010; 19(2): 111-118.
    11. Callaghan RC, et al. Patterns of tobacco-related mortality among individuals diagnosed with schizophrenia, bipolar disorder, or depression. J Psychiatr Res. 2014; 48:102–10.
    12. Prochaska J, Das S, Young-Wolff K. Smoking, Mental Illness, and Public Health. Annu Rev Pub Health. 2017, 38:165-85.
    13. Tam J, Warner KE, Meza R. Smoking and the Reduced Life Expectancy of Individuals with Serious Mental Illness. Am J Prev Med. 2016; 51(6):958-66.
    14. Hall SM, Prochaska JJ. Treatment of smokers with co-occurring disorders: emphasis on integration in mental health and addiction treatment settings. Annu Rev Clin Psychol. 2009; 5:409-31..
    15. University of California San Francisco Smoking Cessation Leadership Center. Behavioral Health. Accessed May 2, 2018.
    16. Cuffel BJ & Chase P. Remission and relapse of substance use disorder in schizophrenia: Results of a one-year prospective study. Journal of Nervous and Mental Disease 1994; 182(6):342–348.
    17. Substance Abuse and Mental Health Services Administration. Results from the 2017 National Survey on Drug Use and Health: Detailed Tables, Table 6.34B. 2018.
    18. Hurt RD, Offord KP, Croghan IT, Gomes-Dahl L, Kotke TE, Morse RM, et al. Mortality following inpatient addictions treatment. Role of tobacco use in a community-based cohort. J Am Med Assoc. 1996; 276(10): 1097-103.
    19. Hurt RD, Offord KP, Croghan IT, Gomes-Dahl L, Kotke TE, Morse RM, et al. Mortality following inpatient addictions treatment. Role of tobacco use in a community-based cohort. J Am Med Assoc. 1996; 276(10): 1097-103.
    20. Veldhuizen S, Callaghan RC. Cause-specific mortality among people previously hospitalized with opioid-related conditions: A retrospective cohort study. Ann Epi. 2014; 24:620-4.
    21. McClure EA, et al. Characterizing smoking, cessation services, and quit interest across outpatient substance abuse treatment modalities. J Subst Abuse Treat. 2014; 46(2):194-201.
    22. Prochaska JJ, Delucchi K, Hall SM. A meta-analysis of smoking cessation interventions with individuals in substance abuse treatment or recovery. Journal of Consulting and Clinical Psychology. 2004; 72(6):1144–56.

    Reviewed and approved by the American Lung Association Scientific and Medical Editorial Review Panel. Last reviewed February 14, 2019.

    Page Last Updated: May 13, 2019

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