Overview

Smoking persists as a significant public health issue in contemporary society, with far-reaching consequences for both physical and mental health. People with mental health issues are disproportionately affected by smoking, experiencing both higher rates of smoking and greater difficulty in quitting than the general population. Smoking is a biopsychosocial issue, meaning there are biological, psychological, and social factors which all contribute to an individual’s smoking patterns. By understanding more about the relationship between smoking and an individual’s mental health, we will be better equipped to understand exactly which strategies are most effective in reducing smoking rates, especially for those with mental health issues as they are less likely to quit independently.¹ It’s crucial that people with mental health issues have the support they need to quit smoking, as chronic smoking can not only exacerbate mental health issues, but also introduce severe physical health problems such as respiratory disorders, lung cancer, and cardiovascular diseases.²

Recently, the term ‘mental health’ has become common in the contemporary lexicon, with increased awareness amongst the general public, especially in the workplace and education systems. People can struggle with their mental health for various reasons, even without meeting the criteria for a clinical diagnosis. According to the NHS, mental health describes an individual’s emotional, psychological, and social well-being. This means that mental health is a multifaceted state with consequences spanning quality of life, productivity, decision-making, and much more. This highlights the necessity for a functioning society to maximise and take care of the mental health of the population. One such way to do so includes reducing smoking rates.³

This article explores the smoking rates of individuals with mental health disorders and the impact of smoking on mental health. This article also examines the obstacles faced by this demographic when trying to quit smoking, as well as strategies for addressing these challenges.

Factors influencing smoking rates

Social and environmental factors

Peer pressure

Peer pressure is the tendency for people to act differently due to the influence of the people around them; peer pressure is particularly influential for adolescents and young adults. The desire to fit in, be accepted, or appear mature can lead individuals to adopt smoking habits, especially if smoking is the norm in their social circle. Peer pressure might disproportionately affect people with mental health issues because people with poor mental health report increased feelings of isolation, a weaker self-identity and greater anxiety.⁴ All these feelings may predispose them to be more vulnerable to peer influence due to the desire to belong and alleviate some of their negative feelings. Hence if they are often surrounded by smokers, they may be more likely to succumb to peer pressure and therefore begin or continue smoking.

Media representation

The portrayal of smoking in movies, television shows, and advertisements can glamorise smoking and influence public perceptions.⁵ Smoking is often presented as an effective coping mechanism for mental turmoil, which can make smoking more appealing to those who are struggling mentally. People with poor mental health may also be more likely to seek out media in which the focus is a character with poor mental health,⁶ so seeing a character they perceive to be similar to themselves cope by smoking may resonate more strongly with someone in this demographic than with someone with better mental health who doesn’t relate to this character.

Psychological factors

Stress relief

Many individuals smoke as a way to cope with stress. Nicotine can produce temporary feelings of relaxation and relief from psychological stress, making smoking feel like a quick and accessible stress relief.⁷ Again, people with poor mental health disproportionately seek ways to alleviate stress (especially harmful coping mechanisms), therefore may be more likely to use smoking as a method of self-medication.

Mental health disorders

Nicotine has short-term psychoactive effects that can temporarily alleviate symptoms of mental health disorders by increasing levels of dopamine in the brain, providing a reinforcing effect.⁸ Mental health disorders are often associated with impulsivity and poor decision-making skills,⁹ leading to an increased likelihood of smoking initiation and increased difficulty quitting. People with depression also report struggling to imagine the future and therefore have little regard for the future,10 including the long-term negative consequences of smoking which often act as an effective deterrent for most other populations.

Weight control

Some evidence suggests that smoking helps control weight by reducing appetite.¹¹ This perception may promote smoking initiation among individuals concerned about body image.

Genetics

The dopamine system

Dopamine is a neurotransmitter responsible for experiences of reward, pleasure, and motivation.¹² Genetic variations can cause reduced numbers of dopamine receptors in the brain, making these individuals experience less reward naturally.¹³ For these people, because their natural reward system is compromised, nicotine feels more rewarding because there is a greater difference in dopamine levels before and after smoking for this population. Such abnormalities in the dopamine system are also linked to depression,¹⁴ explaining why depression and smoking often coexist.

Impact of smoking on mental health

Immediate and short-term effects

Most smokers report the immediate effects of nicotine as beneficial, providing temporary relief from stress, anxiety, and depressive symptoms.

Immediate cognitive effects of smoking include increased alertness and concentration shortly after smoking due to nicotine's stimulating properties.¹⁵

Long term effects

Increased risk of depression

According to a study by Fluharty et al. (2017), there is a significant correlation between smoking and the development of depressive symptoms. Chronic smoking causes changes in the brain which diminish its ability to produce its own dopamine, contributing to depressive symptoms when nicotine is not present and therefore creating a reliance on nicotine to feel normal.

Exacerbation of symptoms

Individuals with various preexisting mental health conditions may experience worsening of their symptoms with chronic smoking.¹⁶

Additionally, nicotine can interfere with the effectiveness of psychiatric medications, resulting in a worse mental health prognosis.¹⁷

Cognitive decline

Smokers are at a higher risk of developing cognitive impairments and Alzheimer's disease compared to non-smokers. Research suggests that smoking causes vascular damage and oxidative stress which adversely affects brain health and function.¹⁸ Certain forms of dementia can be caused by vascular abnormalities and their consequences, such as vascular dementia which often follows strokes which may be caused by vascular damage from smoking. Dementia is a very distressing condition which often has a negative impact on an individual’s mental health due to confusion and stress.

Barriers to smoking cessation

People suffering from poor mental health may find it more difficult to stop smoking. This can be for various reasons, including the following:

Psychological barriers

People struggling with their mental health can experience significant psychological barriers to quitting smoking; as mentioned previously, some people smoke to self-medicate mental health disorders, so people with mental health problems may feel unprepared to quit smoking without an alternative coping mechanism due to the fear of symptoms returning. People may also fear the withdrawal symptoms of quitting smoking. Additionally, people suffering from body image may fear the weight gain that is associated with quitting smoking, due to their appetite returning which they believe was suppressed through smoking.

Social and environmental barriers

Social support deficits

Individuals with poor mental health typically have smaller or less supportive social circles. Many people quit smoking due to the impact smoking has on their interpersonal connections and receive support from their social circles to prevent relapse, and people with the lowest rates of smoking relapse tend to be those with supportive social networks. This can mean that individuals with poor mental health are less likely to try stopping smoking, and tend to be less successful when they do try. Additionally, smokers are more likely to associate with other smokers, and research has shown that the greater the proportion of smokers in one’s social circle, the less likely they are to successfully quit.¹⁹

Stigma

Many people may feel the pressure of the dual stigma associated with both mental health issues and smoking. This stigma can cause feelings of shame, making people who are struggling less likely to seek out guidance and support with quitting due to the fear of being judged.²⁰

Institutional barriers

Healthcare system

People with mental health disorders can face barriers to accessing healthcare, including smoking cessation programs. This may be due to financial constraints - mental health issues are more common in those of a lower socioeconomic status.²¹ Additionally, in deprived areas, there may be a lack of resources and trained professionals. People with mental health issues may also experience difficulties navigating the healthcare system alone and may experience discrimination or stigma from healthcare workers, deterring them from seeking care.

Strategies to reduce smoking

Nicotine replacement therapy 

Nicotine replacement therapy has various forms such as patches, gum, or lozenges. These do not contain harmful tar-like cigarettes but help to manage withdrawal symptoms and reduce cravings by providing a low-level concentration of nicotine over a longer period of time. The intention is for people to eventually come off nicotine replacement therapy, although many stay on this therapy for extended periods of time. Regardless, it is still safer than regular cigarette smoking.

Non-nicotine medications

Medications such as bupropion and varenicline can reduce smoking by blocking the nicotinic acetylcholine receptors, so nicotine can’t bind, blocking the effects of nicotine and making smoking less appealing. Bupropion can also help manage depressive symptoms by increasing the concentration of dopamine available in the brain.

Individual counselling

Counselling can assist individuals with developing a quitting strategy, managing stress, and navigating challenges associated with their mental health condition, instead of having to cope alone.

Group therapy

Support groups create a sense of community, which is valuable for individuals who feel isolated in letting them know that they’re not alone. Group therapy can provide peer support and practical tips for quitting smoking coming from people with lived experience.

Combined treatment

Combining psychological treatments such as counselling with pharmacotherapy ensures a holistic approach to smoking cessation, meaning that both the psychological and biological components of smoking are addressed.

Summary

Smoking is one of the greatest preventable causes of morbidity and mortality worldwide, creating a significant public health burden and concern, though smoking rates have been on the decline in recent decades. Awareness of mental health problems has also been on the rise in the past decade, as part of this it is important to understand the harmful health behaviours that people may use to cope with mental health difficulties. There is a two-way relationship between smoking and mental health: people experiencing mental health difficulties may be more likely to smoke, either to cope with their mental health condition or due to a third factor such as low socioeconomic status or poor social support which increases the likelihood both of smoking and experiencing mental health problems. In addition to this, smoking may cause or exacerbate mental health problems through mechanisms such as damaging the dopamine reward system in the brain. Therefore, it is important to consider strategies to reduce smoking, increase cessation, and prevent relapse in populations at risk of or already suffering from mental health issues. Such strategies may include counselling, nicotine replacement therapy or other pharmacological interventions, improved social support (e.g. group therapy), or even a combination of these.