CHAPEL HILL - Reports of violence, abuse and blatant neglect in North Carolina mental health treatment facilities demand appropriate responses. However, government leaders, mental health providers and citizens may be overlooking a more subtle but significant instance of neglect.

Few realize that 44 percent of cigarettes smoked in the United States are smoked by people with mental illness and substance use disorders (as reported in JAMA, the Journal of the American Medical Association, in 2000). High rates of smoking (two to four times higher than in the general population) and the large number of cigarettes consumed per day help to explain this staggering statistic.

As we envision ways to create safer and healthier environments for staff and residents in mental health settings, strategies to address tobacco use and dependence must be part of the plan.

For most of us, "tobacco-free" is an increasingly accurate descriptor of our lives. Hospitals, schools, work places and recreational areas are becoming tobacco-free, inside and out. In North Carolina, the majority (77 percent) of the population does not smoke. More than half of those who do smoke have tried to quit in the past year.

Seven over-the-counter and prescription medications are available to help people quit. Tobacco users have access to a free telephone counseling service (N.C. Quitline, 1-800-784-8669) as well as numerous Web sites, cessation programs, support groups and self-help materials.

Even in the most supportive environment, overcoming addiction is a tremendous struggle. Unfortunately, tobacco use is still the norm in many mental health residential facilities. (Smoking is now banned inside, but not outside, state mental hospitals.)

High rates of smoking among both staff and residents, the absence of formal training for staff in smoking cessation and the lack of adequate cessation treatment (counseling and medication) for residents make quitting extremely difficult.

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WIDESPREAD FAILURE TO ADDRESS THIS ADDICTION IN THOSE WITH MENTAL HEALTH DISORDERS is frequently portrayed as a compassionate approach. Family members and service providers argue that quitting is simply not a priority. Cigarettes serve as a reward, a source of comfort, a way to cope with stress and the only good thing in the lives of people who suffer tremendously. Nicotine improves their mood and social skills, and it may help people with schizophrenia reduce some of the symptoms associated with their disease.

These compelling reasons, in addition to the power of addiction, help to explain why many people with mental illness smoke.

While the needs of the mentally ill and concerns of their caregivers are certainly valid, smoking is not the solution. Not only does it cause significant morbidity and mortality in this population, but it is also associated with increased psychiatric problems.

For example, people with schizophrenia who smoke exhibit more positive symptoms of their disease such as hallucinations and delusions. Moreover, smoking actually interferes with the treatment of mental illness because it alters the way many drugs are metabolized, including psychiatric medications. As a result, smokers require significantly more medication than non-smokers to achieve the same effect.

In addition, evidence does not support the belief that people in substance abuse treatment who want to quit are placing their overall stability and recovery in jeopardy. In fact, participating in a smoking cessation program may actually facilitate abstinence from other substances. Families and providers need to understand that more and more people with mental illness and substance use disorders want to quit smoking. With appropriate treatment, they can succeed.

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COMPREHENSIVE CESSATION PROGRAMS ARE BEING DEVELOPED IN HOSPITALS across the state and the 2008 Clinical Practice Guidelines for Treating Tobacco Use and Dependence provides an excellent, evidence-based treatment manual.

Psychiatrists and other mental health providers can begin by educating themselves about the most effective approaches for treating nicotine addiction in their patients, including management of medications and withdrawal symptoms. Directors of residential facilities can review their current policies regarding tobacco use: Are residents given access to counseling and medication? Are staff trained to help residents quit? Does the social and physical environment support cessation? Family members can serve as essential sources of support and encourage their loved ones to seek additional help.

Given the hazardous nature of cigarettes, we simply cannot turn a blind eye to smoking in people with mental illness and substance use disorders. A truly compassionate response acknowledges the enormous challenges they face and supports them in quitting anyway, for the sake of their lives.

(Katie Patsakham is program associate with the UNC Nicotine Dependence Program in the Department of Family Medicine at UNC-Chapel Hill.)

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