Study: 44% of cigarettes are smoked by people with mental disorders or substance abusers
Author: Authorities are unable or unwilling to fight smoking among these groups
Addiction treatment population smoking rates are nearly 70%, says author
Some drug treatment programs reward patients with cigarettes, author reports
Editor’s Note: Joseph Guydish is professor of medicine and health policy at the University of California, San Francisco, where his research concerns access, delivery and organization of substance abuse treatment services, treatment effectiveness and adoption of new treatments into practice settings.
Since the first surgeon general’s report on smoking in 1964, smoking among U.S. adults has decreased from 40% to 20.6%. However, smoking remains high in some groups.
A frequently cited paper in the Journal of the American Medical Association reported that people with either a mental disorder or substance abuse problem consume 44% of all cigarettes smoked in the U.S.
Our efforts to address smoking in these populations is anemic.
I’ve talked with colleagues about this issue at the National Institute on Drug Abuse, the National Cancer Institute, the Center for Substance Abuse Treatment and the Centers for Disease Control and Prevention. Most are sympathetic and interested, but they are either unable or unwilling to provide national leadership to address smoking in these populations.
I’ve talked with colleagues in tobacco control, some of whom are world leaders here at my university, but most have many competing priorities.
Now the Food and Drug Administration, with its regulatory authority over tobacco products through the Family Smoking Prevention and Tobacco Control Act, is taking on issues of flavored tobacco products, e-cigarettes and new warning labels.
Will these efforts reach vulnerable populations where smoking rates are highest?
My research focuses on people receiving drug abuse treatment. According to the National Survey on Drug Use and Health, this population totals about 4 million people each year. For 30 years, papers have noted the high rate of smoking among drug treatment clients.
There are clinical guidelines to address smoking in this population.
There are policy statements, like that of the American Public Health Association, supporting tobacco treatment in these settings. This group of smokers has been exposed to surgeon general reports, state and federal tobacco tax increases and regulatory policies prohibiting smoking in public places, workplaces and bars and restaurants.
Nevertheless, while smoking has decreased in the general population, smoking rates in addiction treatment populations are near 70% and show little change over time.
A year ago, I had a call from the father of a young man who was enrolled in a residential drug abuse treatment program. During his visits, the father noticed that the program gave a carton of cigarettes to residents every two weeks, as a reward for progress.
He was concerned about this policy because of the health risks associated with smoking. He contacted the program administration, who said that they had to choose their battles, and they did not choose to address smoking.
This parent was reasonable and measured on the phone. He did not want to antagonize the program because his son was doing well there. He did not think that everyone must stop smoking. But he thought the program could discourage smoking, rather than directly supporting it.
This is where the smokers are.
They are in our addiction treatment programs, in our mental health treatment programs and in our criminal justice system. All are disenfranchised and stigmatized populations. Many receive services in our public health sector, and smoking rates are high and unyielding to prior tobacco control efforts.
Inaction on smoking in these populations is systemic, reaching beyond the individual smoker to the treatment programs, the state agencies that pay for those programs and the national agencies that set and shape treatment priorities.
There are some bright spots, notably state agencies in New York and Oregon, that are aggressively addressing smoking in these populations. There’s also the Smoking Cessation Leadership Center, which works with state and professional leadership groups.
These efforts, representing local successes, pale in comparison to the scope of smoking in vulnerable populations.
It is time now for national leadership, direction, priority and funding to better address smoking in substance abuse, mental health and criminal justice populations. And I call on the various health and regulatory agencies and the field of tobacco control to do so.
If we want to further reduce prevalence of smoking in the United States, we must come to where the smokers are.
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The opinions expressed in this commentary are solely those of Joseph Guydish.