Ten years ago, the American Psychiatric Association (APA) released its practice guideline for the treatment of patients with nicotine dependence, providing strategies for behavioral health practitioners to address tobacco dependence.1 Since then, new medications for tobacco dependence have become available, financial incentives (i.e., through greater third-party reimbursement) for treatment have increased, and both patient and staff interest on this topic has grown.
Yet a great opportunity to expand tobacco-dependence treatment and create more smoke-free workplaces remains. Most public and private mental health and addiction services do not provide tobacco-dependence treatment, although model programs exist and new clinician resources are available. External pressure from state governments or accrediting bodies has motivated some organizations to become tobacco-free settings; in others, leaders have been motivated by the desire to do the right thing. And people have become more aware that smoking is more prevalent among those with behavioral health disorders, and that most patients with behavioral health disorders die from tobacco-related diseases.
This article updates readers on this topic and presents ten reasons behavioral health practitioners should treat tobacco dependence.
Ten Reasons for the Field's Involvement
Treating tobacco dependence saves lives and improves quality of life. With 50% of smokers dying from their tobacco use, quitting is the most important action to improve health and reduce morbidity and mortality. Smoking remains the leading preventable cause of death in the United States and, sadly, most individuals with mental illnesses will die from tobacco-caused diseases.2
Individuals with serious mental illnesses have a reduced life expectancy and, in general, receive poorer healthcare. Much of the excess morbidity is attributable to diseases with modifiable risk factors, including tobacco dependence, obesity, diabetes, and hyperlipidemia.3,4 A ten-year study of elevated coronary heart disease risk in patients with schizophrenia demonstrated that tobacco smoking was the major causal risk factor, even after controlling for factors such as weight and body mass index.5
The danger of environmental tobacco smoke (ETS), a class 1A carcinogen, to nonsmokers has been a primary motivator of making public places smoke-free. Unfortunately, many residential group homes, treatment programs, and social clubs for the behavioral health population continue to allow smoking, thereby exposing nonsmoking patients and staff to ETS.
Quitting tobacco improves smokers’ quality of life beyond reducing disease risk. For example, tobacco use is very costly. In one study, smokers with schizophrenia were found to spend at least one-third of their monthly disability income on cigarettes.6 Smoking also complicates mainstream community reintegration. Smokers have less discretionary income to spend on clothing and housing. Smokers may be less likely to obtain employment and housing since many employers and landlords prefer nonsmokers.
Treating tobacco-dependence is cost- effective and saves healthcare dollars. Treating tobacco dependence is one of the most cost-effective treatments in all of medicine. Tobacco-dependence treatment interventions are less costly than other routine medical interventions, such as treatment of high blood pressure and screening mammography. Across all types of tobacco treatment interventions, the estimated cost per smoker is $165.61,7 and tobacco-dependence treatment can be easily integrated into mental health and addiction treatment.
Tobacco use is costly to society. The total annual public and private healthcare expenditures from smoking-related disease and disability exceed $75 billion. Annual Medicaid payments total more than $23 billion, half of which are paid by states. California, in fact, experienced substantial savings in healthcare costs after implementing a statewide comprehensive tobacco-control program. For every $1 spent on the California program, the state reduced healthcare costs by $3.60,8 a figure insurers and employers would be wise to recognize.
Treating tobacco dependence improves employee productivity and health. Smokers have higher absenteeism and reduced job productivity relative to nonsmokers. Smokers take on average three smoke breaks per day, lasting approximately 39 minutes; this translates to 21 days of lost time per year.9 Employees who smoke have higher hospitalization rates and outpatient healthcare costs than nonsmokers and typically take longer to recover from illness and injury.9
Although employers have a vested interest in reducing tobacco use among employees, only 20% of employers cover tobacco-dependence treatment. Cost analyses have shown that providing tobacco-dependence treatment to employees is cost-effective and that over time this benefit actually can generate financial returns for employers in four ways: reduced healthcare costs, reduced absenteeism, increased productivity, and reduced life insurance costs.10 Tobacco- cessation interventions provided through the workplace are readily accessible and provide a network for social support.