National Drug Strategy
National Drug Strategy

Comorbidity of mental disorders and substance use: a brief guide for the primary care clinician

4.1.1 Effects of tobacco on mental disorder

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There are many theories about why people with mental disorders have a high rate of tobacco use. Nicotine may help to:

Most of these effects are likely to be caused directly by nicotine. However, for some symptoms such as depression and anxiety, it can be difficult to separate the effects of nicotine from the relief of withdrawal(82-84). While more recent research has enabled separation of withdrawal relief and direct effects of nicotine, nicotine withdrawal at times can present in a similar manner to some of the symptoms of the mental disorder (particularly depression and anxiety). As a result, it can occasionally be misinterpreted by the person with the mental disorder as well as the clinician and must be taken into consideration.

It is also likely that external social and environmental factors contribute significantly to, and account for, the high rates of smoking amongst individuals with mental disorders. These include higher rates of smoking amongst family, friends and within mental health services, the perceived role of smoking in relieving stress and as a coping mechanism, in aiding low self esteem and social mixing, and in dealing with boredom(70, 83). In addition, people with mental disorders may have more difficulty quitting or reducing tobacco use because of limited support from health workers. They may have more difficulty coping with withdrawal symptoms and may lack the support and confidence needed to persist with their quitting efforts.

People with mental disorders have identified other effects of tobacco smoking including barriers to community involvement, accommodation difficulties, stigma and shame, the negative effects on appearance and other people, stained fingers and teeth, the smell of tobacco, and the added stress caused by living with an addiction(85-88).

As well as the serious impact on physical health, many people with mental disorders are spending a significant percentage of their income on cigarettes. As a result they have very little money for food, recreation, public transport, clothing and health care(85, 87, 89, 90).

The affordability of nicotine replacement therapy (NRT) and other treatments may, therefore, be a significant factor in restricting access. While the cost of NRT has been implemented so that it is more economical than continuing to smoke, the cost may be viewed in the same manner that clients perceive costs associated with methadone and buprenorphine dispensing. That is, individuals with mental disorders and substance use disorders are often unable to prioritise aspects of their life which include the inability to budget and rationalise treatment benefits. Therefore, they may perceive the cost of NRT to be prohibitive despite being a cheaper alternative than continuing to smoke.

A history of mental disorders does not necessarily mean, however, that individuals do not wish to quit smoking(91). Evidence also suggests if the above mentioned factors such as demographics, diagnosis and concurrent medication are taken into account, smoking cessation strategies that are effective in the general population can be implemented and are effective at the same time as treatment for mental disorders****(92-101). People with mental health disorders are able to quit smoking if their mental disorder is under control and other psychotropic medication dosing remains stable****(92, 99). Improvements in anxiety and depression have also been observed in those who cease smoking(100).

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