Discussion

During 2019–2020, the prevalence of current cigarette smoking remained high among adults with mental health conditions. Overall, the proportion of current smoking among adults with AMI was approximately 67% higher than among those without AMI. Disparities in current smoking among subpopulations with mental health conditions were similar to disparities in current smoking among adults without mental health conditions, albeit with generally higher current smoking prevalence ^[9]. Previously reported higher prevalence of current smoking among subpopulations of adults with mental health conditions are still apparent, including among adults aged 26 to 64 years; those who are lesbian, gay, or bisexual (LGB), or non-Hispanic AI/AN; have less than a high school diploma; have an annual income below the federal poverty threshold; are uninsured; live in a rural area; or have been arrested and booked in the past 12 months. Between-state variations also exist. These findings suggest it is possible that adults with mental health conditions may continue to experience greater smoking initiation or barriers to successful smoking cessation.

Several possible factors related to smoking cessation could be associated with high smoking prevalence among adults with mental health conditions. Barriers to providing smoking cessation services exist in mental health care settings and among mental health clinicians, including misconceptions about the effect of smoking on behavioral health conditions and their treatment ^[4]. More than half of psychiatric providers believe their patients are not interested in quitting; in contrast, among a sample of adults who smoked and were hospitalized with mental illness ^[4], almost 2 of 3 participants were interested in quitting, suggesting that adults who smoke and have mental illness are motivated to quit ^[12]. Smoking cessation is associated with reduced depression, anxiety, and posttraumatic stress disorder (PTSD) symptoms, whereas continued smoking is associated with elevated levels of anxiety and depressive symptoms ^[4,13]. An additional barrier to reducing cigarette smoking among adults with mental health conditions who are treated in mental health facilities is a lack of tobacco-free grounds. As of January 1, 2022, 14 states required tobacco-free grounds for most mental health facilities ^[14]. These results are based on legal requirements made in each state. Additional behavioral health facilities can and do take voluntary action on creating tobacco-free grounds ^[14]. Adults with mental health conditions may have more severe dependence on commercial tobacco and nicotine than those who do not have a mental health condition, so intensive interventions that use a range of evidence-based cessation services, including pharmacotherapy and counseling, are important to improve cessation success ^[5]. Recent studies have found declines in cigarette smoking among adults with mental health conditions, although not to the same extent as among adults without mental health conditions ^[8,10].

Current smoking was high among adults of all racial and ethnic groups with AMI relative to no AMI. However, the greatest difference among adults with and without AMI was seen among Hispanic and non-Hispanic AI/AN adults. Cigarette smoking among Hispanic adults tends to be lower than among other racial and ethnic groups ^[9]. We found a larger disparity in current smoking among Hispanic adults with and without AMI than previously reported ^[2]. It is unclear why smoking is more prevalent among Hispanic adults with AMI, although this finding is partially supported by findings that indicated use of mental health services — as a general proxy for psychiatric comorbidity — was significantly associated with smoking among a small group of Hispanic adults ^[15].

Historically, non-Hispanic AI/AN adults have had among the highest rates of cigarette smoking (not including traditional ceremonial tobacco use) of all racial and ethnic groups in the US ^[16]. We found current smoking estimates were twice as high among non-Hispanic AI/AN adults with AMI than among those without (53% vs 26%), with almost 1 of 2 non-Hispanic AI/AN adults with a mental health condition reporting current smoking ^[16]. Although the sample size for non-Hispanic AI/AN adults was small, we found that those with serious psychological distress had one of the highest rates of cigarette smoking of all demographic groups. non-Hispanic AI/AN adults may have experiences of current and historic trauma, including PTSD, high rates of violent victimization, and overall higher rates of mental health conditions compared with other racial and ethnic groups ^[17]. These factors, in addition to past policies that have led to mistrust of government services and care, such as removal from their land, high rates of poverty, barriers to appropriate health care and mental health services, and an already high prevalence of current smoking may be related to the high prevalence of current smoking among non-Hispanic AI/AN adults who have mental health conditions ^[17,18]. Trauma-informed care and culturally appropriate smoking cessation resources for non-Hispanic AI/AN adults may be important considerations when developing or providing cessation interventions for this population.

Smoking prevalence is high in the US among adults who identify as LGB. In 2020, current smoking prevalence was 16.1% among LGB adults, compared with 12.3% among those who identified as heterosexual ^[9]. Our results are consistent with these findings. The tobacco industry has historically advertised heavily and promoted commercial tobacco products to the LGB community, especially in bars and clubs ^[19]. High prevalence of commercial tobacco use among LGB adults suggests that these strategies were successful ^[19]. Adults in the LGB and other sexual orientation and gender identity minority communities may experience stress caused by concealment of sexual orientation and expectation of rejection and may be more likely to be subjected to bullying, all of which have the potential to cause or exacerbate mental illness ^[20,21]. Through these internal and external stressors, a person may turn to coping mechanisms, which could include smoking ^[20]. To help reduce cigarette smoking among LGB adults with mental health conditions, access to mental health care providers with appropriate knowledge of LGB health and with the use of evidence-based cessation interventions could help reduce this disparity ^[21].

Adults who were arrested and booked in the last 12 months and reported AMI, serious mental illness, mild or moderate mental illness, serious psychological distress alone, major depressive disorder alone, or both were among those with the highest prevalence of current smoking in our study. Almost 3 out of 4 people who had been arrested and had serious mental illness or major depressive disorder reported current smoking. The act of being arrested can adversely affect a person, regardless of whether they are convicted or sentenced ^[22]. An arrest could result in a label of “criminal,” which can limit a person’s opportunities and increase or exacerbate stress ^[22]. In turn, this may lead to stress-coping behaviors such as smoking ^[22]. People in prisons and jails are disproportionately affected by mental illness, with more than 50% experiencing mental illness in any given year ^[23]. Collaboration between criminal justice, public health, and mental health researchers could provide opportunities for further research into managing mental illness and reducing cigarette smoking among those who are incarcerated, adoption of smoke-free jails and prisons, and resources such as providing mental health care and access to smoking cessation services to people immediately upon incarceration ^[23].

Our study generally found lower levels of cigarette smoking among adults with the assessed mental health conditions compared with previously reported estimates ^[6–9]. However, our study was not designed to examine significant changes in cigarette smoking among these populations over time. The use of different sources of data ^[9] and use of different methodologies to calculate estimates may also contribute to variations in reported estimates ^[8]. Future examination of estimates among this population over time using the same sources of data are warranted to accurately detect trends and point out increases or decreases in cigarette smoking prevalence.

State-level estimates of current smoking were consistent with, but generally lower than, previous findings ^[2]. Commercial tobacco and smoke-free laws and policies vary by state and locality, and approximately 40% of the US population are not covered by comprehensive smoke-free laws for workplaces, restaurants, and bars ^[24]. Smoke-free policies have been shown to reduce cigarette consumption, increase cessation attempts, and increase rates of successful cessation ^[25]. Additionally, states have variable mental health care systems — for example, 55% of US counties do not have a practicing psychiatrist — as well as inconsistent commercial tobacco-related regulations, including varying reimbursement rates for providing smoking cessation services ^[26,27]. The results of our study suggest that, although smoking prevalence by state among adults with AMI is lower than previously reported, there is still room for improvement.

Very limited information exists on smoking prevalence by state among people with AMI or other mental health conditions. The results of a study conducted in New York State indicated that tobacco retailer density was independently and positively associated with smoking among adults with comorbid diabetes and serious mental illness ^[28]. The authors’ reported that smoking cessation support was readily available in the state mental health system, yet many patients continued to smoke ^[28]. Some populations may benefit from further commercial tobacco–related protections and public health interventions, such as equitable implementation of comprehensive commercial tobacco control policies, improved integration of smoking cessation interventions into mental health treatment facilities, and other population-specific approaches.

Limitations

The findings of our study are subject to limitations. First, mental health conditions in the past year and current smoking are self-reported and may be affected by self-report and social desirability bias. Race and ethnicity may be related to underestimates of mental health conditions. Lower prevalence of depression among non-Hispanic Black and Hispanic adults than among non-Hispanic White adults may reflect self-report differences rather than true differences ^[29]. However, estimates for AMI, serious mental illness, and mild or moderate mental illness were based on a previously developed statistical model that was itself based on responses to the Kessler Psychological Distress questions ^[11] and depression-related questions — not just a yes/no indicator question — which may have helped limit self-report bias. Second, NSDUH does not include adults in its sampling frame who were, at the time of survey, institutionalized, incarcerated, or on active military duty; therefore, results cannot be generalized to these populations. However, a weighted count of 1,570,874 adults in the 2019–2020 NSDUH reported on AMI in the past year and reported an overnight stay in a hospital for mental health treatment by a positive response to the question, “During the past 12 months, have you stayed overnight or longer in a hospital or other facility to receive treatment or counseling for any problem you were having with your emotions, nerves, or mental health? Please do not include treatment for alcohol or drug use.” Therefore, NSDUH may capture results from some people with a prior history of brief institutionalization. Lastly, we were unable to make statistical comparisons in state-level current smoking prevalence among adults with and without AMI because of restrictions on unweighted state data. Strengths of this study include providing updated national estimates of current smoking among noninstitutionalized adults with mental health conditions in the past year and state-level estimates of current smoking among adults with AMI.

Conclusion

Current cigarette smoking remains higher among adults with AMI, serious psychological distress, and major depressive disorder than among those without AMI, especially among adults who are Hispanic, non-Hispanic AI/AN, or LGB and populations experiencing poverty, lack of health insurance, or were arrested and booked in the past year. Our study adds further evidence that adults with mental health conditions may be disproportionately affected by multiple external factors that lead to ongoing high prevalence of current smoking. The findings from this article contribute to our knowledge of cigarette smoking disparities, especially among adults with mental health conditions and cigarette smoking by US state. Addressing cigarette smoking among adults with mental health conditions may require interventions that can reduce barriers particular to this population, in addition to the equitable implementation of well-established comprehensive commercial tobacco prevention and control strategies. Population-specific approaches could include education on evidence-based practices for treating people who smoke and have a mental health condition, increasing the number of smoke-free mental health treatment facilities, and improving access to cessation services, particularly within the criminal justice system.