Health Care Reform Will Help Smokers with Severe Mental Illness to Quit

Changes brought about by health care reform are making it easier to help people with severe mental illness to quit smoking. This population traditionally has not received much smoking cessation assistance, according to Adam O. Goldstein, MD, Director of the University of North Carolina Tobacco Prevention and Evaluation Program.

“Half of all cigarettes in the United States are consumed by those with consistent and severe mental illness,” says Dr. Goldstein. “People who don’t have mental illness are quitting at a higher rate, and tend to be lighter smokers than people who are mentally ill.”

Although people with severe mental illness want to quit smoking at the same rate as other smokers, there is a bias against treating these patients, he notes. “There is the assumption that they don’t want to quit, and they won’t be successful. But the research shows they can quit at a similar rate as other smokers, and they are as interested in quitting.”

The best smoking cessation treatment for people with severe mental illness, as with all smokers, is a combination of smoking cessation medications, along with intensive behavioral treatment, he says. “It’s not enough to treat for six to eight weeks and then withdraw support,” Dr. Goldstein states. “You wouldn’t do that for other chronic conditions. You need to treat for extended periods—six to eight months—and dealing with relapse is part of the effort. With that type of extended treatment, we should see a doubling or tripling over the success rate of what we’ve seen in the last few decades.”

One of the reasons why people with severe mental illness often do not get help in quitting smoking is that it is not usually addressed by psychiatrists or in residential facilities, he says. But as mental health is increasingly incorporated into primary care as part of health care reform, this is likely to change, he adds. “There will be less of a barrier between what primary care physicians do and what mental health providers do.”

Health care reform changes are making it easier for providers to receive reimbursement not only for smokers with mental illness, but for all patients who smoke, Dr. Goldstein remarks. Five years ago, very few health plans would have reimbursed health care providers for smoking cessation counseling, unless someone had a smoking-related disease. Now Medicare provides coverage for smoking cessation counseling. Medicaid programs provide some coverage for counseling and medications, as do most health plans, he notes.

New voluntary guidelines that stem from health care reform are also encouraging health care providers to focus on smoking cessation, he observes. Guidelines written by the Joint Commission, which accredits and certifies more than 19,000 health care organizations and programs in the United States, call for hospitals to screen all inpatients who are 18 or older, provide cessation treatment for smokers while they’re hospitalized, and follow up with them within 30 days of discharge. Unlike the earlier measures, the new guidelines do not target a specific diagnosis. Many people believe these guidelines will soon become mandatory, according to Dr. Goldstein.

Another set of recommendations, known as meaningful use guidelines, also have implications for tobacco cessation services. These guidelines are part of a federal initiative that provides incentives to hospitals and health care providers who can show they are using electronic health record technology in ways that can be measured significantly in quality and quantity.

These meaningful use guidelines call on doctors to report data on three core quality measures: patient blood-pressure level, tobacco use status and adult weight screening and follow-up provided by the health care provider. All eligible hospitals and physicians are required to screen all patients 13 years of age and older for tobacco use. “Under these guidelines everyone from dermatologists to psychiatrists are collecting and utilizing data about patients’ smoking and giving them resources to help them quit—it’s a huge step forward, since many health care practices were not doing this,” says Dr. Goldstein.

Yet another health care change that is likely to have a major impact on smoking cessation services is Medicare’s decision to incentivize hospitals to reduce readmission rates for pneumonia, heart failure and heart disease. “If patients are readmitted within 30 days the hospital suffers penalties,” he explains. “Since smoking and secondhand smoke are risk factors for all three conditions, hospitals will have to care dramatically about the smoking status of patients and their families in a way they never have before.”

For information on the University of North Carolina Nicotine Dependence Program’s resources for implementing comprehensive tobacco use treatment services, visit

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    Elaine Keller

    March 11, 2012 at 4:15 PM

    Dr. Goldstein is on the right track regarding chronic conditions, but he doesn’t take it far enough.
    What happens when you begin treating someone for hypothyroidism and then have them stop taking levothyroxine? Their symptoms return with a vengeance.

    But what if you slowly wean them off levothyroxine? Their symptoms return, bur at a slower pace. Then, when treatment stops altogether, the symptoms return with a vengeance. Hypothyroidism is a chronic condition that requires ongoing treatment.

    Many people who smoke are self-medicating chronic underlying conditions. The scientific literature shows that people with chronic depression, attention deficits, memory problems, and those who are being treated for schizophrenia have much lower rates of cessation than the rest of the population. Let’s think for a moment about why that is true.

    The scientific literature also shows that nicotine helps to improve mood, concentration, and attention and also helps to alleviate side-effects of anti-psychotic medications. It stands to reason that those who have a chronic condition that is helped by nicotine will be impaired when they give up nicotine.

    It doesn’t matter whether the nicotine-dependent person tapers down for six to eight weeks or for six to eight months. When nicotine intake stops, relapse follows. Sometimes relapse begins even earlier, when the process of tapering down triggers relapse because symptoms are not being controlled adequately.

    The Institute of Medicine’s 2001 report, “Clearing the Smoke,” stated, “Indeed, it has been predicted that even with the most intensive application of the most effective programs for abstinence and cessation, at least 10 percent to 15 percent of adults in the United States would continue to smoke.” The 2007 report by the Tobacco Advisory Group of the Royal College of Physicians, “Harm reduction in nicotine addiction: Helping people who can’t quit” pointed out that some people will never be able to give up all use of nicotine. The authors went on to say stated, “If nicotine could be provided in a form that is acceptable and effective as a cigarette substitute, millions of lives could be saved.”

    Pharmaceutical nicotine products are a start, but they are often ineffective as a cigarette substitute. The FDA has purposely kept the nicotine dosage low in these products, in the belief that this will prevent new addictions. Millions of people have escaped from smoking by switching to a smoke-free alternative such as low-nitrosamine snus (a type of moist snuff), dissolvable tobacco products, or smoke-free electronic ‘cigarettes’.

    “Clearing the Smoke,” had another important message: “… the best way for those who already smoke to minimize their health risks is to quit promptly.” This makes sense because the faster you can help smokers to stop inhaling smoke, the less irreversible damage will be done to their bodies. Encouraging inveterate smokers to switch to a much less hazardous alternative would be a life-saving course of action.

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