Behavioral health patients die from tobacco-related diseases at a much higher rate than the general population. In fact, they are more likely to die from tobacco than mental illness or substance abuse.  In other words, this population smokes a lot, consuming 40% of all cigarettes in the U.S. 
What explanation can be offered for this sad fact? The answer is complex: it includes a combination of treatment apathy, a cloud of myths and misconceptions, policy shortcomings, stigma, and tobacco industry brilliance. While this article won’t go into detail about the industry’s role – sponsoring bogus research, pitching misinformation, and opposing smoking bans in psychiatric hospitals – it will state the nature of the problem, provide relevant data, cite reasons for the disparity, and offer a call to action.
The smoking rate for American adults is now under 17%, down from a high of 57% in 1955. But such progress hasn’t been realized in populations with mental illness or substance abuse. The benefits of the tobacco control movement have reached many Americans, but not all, and striking inequalities exist. For instance, the smoking rate for people with behavioral health conditions is still over 40% and has decreased little over many years. Here are some additional eye-opening research findings:
- Over 65% of clients in treatment for substance use disorders smoke cigarettes, and the rate is as high as 90% for persons with schizophrenia.  
- An 11-year retrospective cohort study of 845 people who had been in addictions treatment found that 51% of them died from tobacco-related causes. 2
- Similarly, about 50% of deaths among people with depression, bipolar disorder, and schizophrenia are attributed to tobacco. 
- Drug users who smoke cigarettes are four times more likely to die prematurely than those who do not smoke. 
- One study found that people diagnosed with schizophrenia spend an average of 27% of their income on tobacco products. 
- Smokers have a 50% greater chance of developing dementia than people who have never smoked. 
- As many as 80% of clients in substance use disorder treatment have expressed an interest in quitting smoking. 4
- Smoking cessation therapies provided during substance use disorder treatment have been associated with a 25% increase in long-term abstinence from alcohol and illicit drugs. 
Thus, not only are people with mental illness and addictions highly likely to smoke, they are also highly likely to want to quit, and those in treatment settings could benefit greatly from cessation interventions. However, it would appear that a behavioral health center can be a dangerous place to hang out – for smokers and nonsmokers alike. One study found 22% of mental health consumers started smoking for the first time in a psychiatric setting.  Some centers still allow smoking as a reward for patient compliance/progress, and it is common for staff and patients to smoke together. Unfortunately, less than half of substance abuse treatment centers in the U.S. offer tobacco cessation services, and only 1 in 4 mental health centers offer this lifesaving care.3 In one study of psychiatry patients who smoke, 82% had attempted to quit, but only 4% reported receiving cessation assistance from a care provider.1 Fortunately, some of these things are changing now as many state psychiatric facilities have recently implemented smoke free policies and begun to help patients quit. Progress, but given the extent of the problem, a long road ahead.
What reasons can be offered for this signal health inequity, given that this is 2016 and the tobacco control movement in the U.S. is a half century old? First, the behavioral health population has always been stigmatized and marginalized, so it is no surprise that this might be a lower priority audience for tobacco cessation initiatives. Additionally, many staff at these centers smoke themselves and may not be supportive of smoke free policies or cessation efforts. Still, there seems to be more to it than this. In one expert commentary on the behavioral health population, the authors state “no other group with such profound evidence of tobacco devastation has been neglected in a similar way”. Could it be that some old, deep-seated myths, originally generated by marketing sleight of hand, are difficult to overcome? For instance:
Myth: Persons with mental illness and substance use disorders can’t quit smoking.
Truth: They can successfully quit at rates similar to the general population.
Myth: Persons with mental illness and substance use disorders don’t want to quit.
Truth: The majority of them want to quit smoking and want information on cessation services and resources. 
Myth: Patients and care providers have more important things to worry about than smoking.
Truth: Like clinical outcomes? The CDC states that smoking is associated with greater depressive symptoms, greater likelihood of psychiatric hospitalization, and increased suicidal behavior. 
Myth: Smoking calms patients down. Without smoking, facilities would be complete mayhem.
Truth: Facilities that do not allow smoking report fewer incidents of seclusion and restraint and a reduction in coercion and threats among patients and staff. 
Myth: Smoking cessation exacerbates poor mental health.
Truth: The positive impact of smoking cessation on anxiety and depression appears to be at least as significant as that of antidepressants. 
So, is tobacco use in the behavioral health population America’s number one health disparity? A good case can be made. In this country, an estimated 16 million behavioral health patients smoke. More will start today in the tobacco use culture of psychiatric settings where they hope to get well. Every year, smoking kills over 200,000 people with mental illness and addictions.  This loss of life is unacceptable.
As a nation, we must implement what we know works to help patients live smoke free – services that are both low cost and high value. To this end, Altarum Institute advocates that all behavioral health facilities:
- Implement and enforce tobacco-free policies covering all buildings and grounds.
- Educate staff about the tobacco-free culture and provide training in tobacco dependence treatment.
- Screen all patients for tobacco use at every clinical encounter and document status.
- Provide treatment services (cessation counseling and medications), as long as is necessary, to all patients who smoke.
Additionally, public health and medical organizations should work together to develop a national action plan for behavioral health/tobacco control, raise awareness of the problem nationally, advocate for tobacco-free buildings and grounds, and share best and promising practices among states.
Behavioral Health and Tobacco webpage, Altarum Institute’s ActionToQuit program.
 Kelly, Deanna L., Et al. (2010). Perception of Smoking Risks and Motivation to Quit Among Nontreatment-Seeking Smokers With and Without Schizophrenia. Schizophrenia Bulletin, Volume 38 Issue 3, Pp. 543-551 Link
 Callaghan RC, Et. Al. Patterns of tobacco-related mortality among individuals diagnosed with schizophrenia, bipolar disorder, or depression. 2014 January, Journal of Psychiatric Research, 48(1): 102-10 Link
 Steinberg, ML, et al., “Financial implications of cigarette smoking among individuals with schizophrenia,” Tobacco Control, 13: 206, 2004.
 Prochaska JJ, Delucchi K, Hall SM. (2004) A meta-analysis of smoking cessation interventions with individuals in substance abuse treatment or recovery. Journal of Consulting and Clinical Psychology, December 72(6):1144-56 Link
 Massachusetts Department of Mental Health's Metro Suburban Area Survey, Mary Ellen Foti, M.D., 1999-2000
 Lasser K, Wesely BJ, Woolhandler S, et. al. Smoking and mental illness: a population-based prevalence study. JAMA. 2000;284:2606-2610
 Prochaska et al. Return to smoking following a smoke-free psychiatric hospitalization. Am J Addiction. 2006; 15(1):15-22.
 Hollen, Vera, et al. (2010). Effects of adopting a smoke-free policy in State psychiatric hospitals. Psychiatric Services, 61(9), 899-904