Behavioral Health & Tobacco Use | American Lung Association

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Behavioral Health & Tobacco Use

Behavioral Health and Tobacco Use Rates

  • It is estimated that 40% of smokers have a behavioral health disorder and comprise 44% of the U.S. tobacco market.1
  • Despite the national cigarette smoking rate being 15% among adults, for individuals with mental illness and substance use disorders, 40% reported smoking tobacco.2
  • The nicotine dependency rate for individuals with behavioral health disorders is 2-3 times higher than the general population.3

Tobacco and Mental Health

  • Lifetime smoking rates are higher in patients who are diagnosed with major depression disorder (59%), bipolar disorder (83%), or schizophrenia and other psychotic disorders (90%).4 Vs. adults with no mental illness, which is 32%.5
  • Individuals with schizophrenia are addicted to nicotine at rates that are up to 3x greater than the general population.6
  • 70%–85% of individuals with schizophrenia use tobacco.7
  • Individuals with a diagnosis of post-traumatic stress disorder (PTSD) have higher rates of smoking (45%) when compared to individuals with no mental health diagnosis (23%).8
  • Among current smokers with a lifetime history of depression, anxiety, anxiety with depression or major depression, they smoke more cigarettes, smoke more frequently and have a higher level of dependence.8
  • Individuals with social anxiety are more likely to engage in heavy smoking and are less likely to successfully quit in comparison to individuals without social anxiety, depression, and other substance use disorders.9
  • The presence or history of depression is associated with greater smoking severity and poorer smoking outcomes.10
  • Major depressive disorders are associated with an earlier age of cigarette smoking, greater dependence on nicotine, higher nicotine withdrawal scores, greater cravings, and higher Carbon Monoxide levels during cessation treatment.10

Morbidity and Mortality

  • Smokers with serious mental illness have increased risk of cancer, lung disease, and cardiovascular disease.11
  • Individuals with serious mental illness die years earlier than individuals in the general population. Smoking and tobacco use are risk factors.12

Tobacco and Substance Use

  • More than 80% of youth with substance use disorders report current tobacco use, most report daily smoking, and many become highly dependent, long-term tobacco users.13
  • Individuals with alcohol use disorders smoke at rates between 34 and 80%; people with other substance use disorders smoke at between 49 and 98% prevalence.14
  • Addiction to nicotine is the most common form of substance use in people with schizophrenia.15
  • Current cigarette smokers in the past month were more likely than those who were not nicotine dependent to have engaged in alcohol use (66% vs. 48%), binge alcohol use (43% vs. 17%), and heavy alcohol use (15% vs. 4%) in the past month.16

Morbidity and Mortality

  • Individuals with substance use disorders who also smoke are four times more likely to die prematurely relative to individuals with substance use problems who do not use tobacco.16
  • Tobacco use causes more deaths among individuals receiving substance use treatment than alcohol or other substance use.17
  • 51% of deaths were the result of tobacco-related causes, at a rate that is 2x the rate found in the general population.17
  • The nicotine dependency rate for individuals with mental illness and/or substance use disorders contributes to 200,000 of the 435,000 tobacco related deaths annually.3


  • Treating tobacco use during substance use treatment increases the likelihood of abstinence from alcohol and substance use by 25%.16
  • 80% of individuals receiving substance use disorder treatment have expressed an interest in tobacco cessation.18
  • Participation in smoking cessation efforts while engaged in substance use treatment has been associated with a 25% greater likelihood of long-term abstinence.14


  • Sources
    1. Lasser K, Wesley B, Woolhandler S. Smoking and mental illness: a population-based prevalence study. JAMA. 2000; 284(20):2606-2610. doi:10.1001/jama.284.20.2606
    2. Substance Abuse and Mental Health Services Administration. The NSDUH report: adults with mental illness or substance use disorder account for 40 percent of all cigarettes smoked. Rockville, MD. U.S. Dept. of Health and Human Services. U.S. Public Health Service. 2013.
    3. Schroeder SA, & Morris CD. Confronting a neglected epidemic: Tobacco cessation for persons with mental illnesses and substance abuse problems. Annu Rev Public Health. 2010; 31: 297-314. doi: 10.1146/annurev.publhealth.012809.103701.
    4. Kalman D, Morissette SB, George TP. Co-morbidity of smoking in patients with psychiatric and substance use disorders. Am J Addict. 2005;14(2):106-123. doi: 10.1080/10550490590924728
    5. Smith PH, Mazure CM, McKee SA. Smoking and mental illness in the US population. Tob Control. 2014; 23(0): e147-e153. doi: 10.1136/tobaccocontrol-2013-051466
    6. Cuffel BJ & Chase P. Remission and relapse of substance use disorder in schizophrenia: Results of a one-year prospective study. Journal of Nervous and Mental Disease 1994; 182(6):342–348. doi: 10.1097/00005053-199406000-00006.
    7. Ziedonis DM, Hitsman B, Beckham JC, Zvolensky M, Adler LE, Audrain-McGovern J. Tobacco use and cessation in psychiatric disorders: National Institute of Mental Health report. Nicotine Tob. Res. 2008: 10, 1691–1715. doi: 10.1080/14622200802443569
    8. Tosclair, A & Dube SR. Smoking among adults reporting lifetime depression, anxiety, anxiety with depression and major depressive episode, United States, 2005-2006. Addict. Behav. 2010; 35(5): 438-443. doi: 10.1016/j.addbeh.2009.12.011
    9. Cougle JR, Zvolensky MJ, Fitch KR, Sachs-Ericcson NS. The role of comorbidity in explaining the associations between anxiety disorder and smoking. Nicotine Tob Res. 2010; 12(4): 355-364. doi: 10.1093/ntr/ntq006
    10. Soone S, Nunes EV, Jiang H, Tyson C, Rotrosen J & Reid MS. The relationship between depression and smoking cessation outcomes in treatment-seeking substance abusers. Am J Addict. 2010; 19(2): 111-118. doi: 10.1111/j.1521-0391.2009.00015.x
    11. Hurt RD, Offord KP, Croghan IT, Gomes-Dahl L, Kotke TE, Morse RM, et al. Mortality following inpatient addictions treatment. Role of tobacco use in a community-based cohort. J Am Med Assoc. 1996; 276(10):1097-103. doi:10.1001/ jama.1996.03530380039029
    12. Druss BG, Zhao L, Von Esenwein S, Morrato EH, Marcus SC. Understanding Excess Mortality in Persons With Mental Illness: 17-Year Follow Up of a Nationally Representative US Survey. Medical Care. 2011;49(6):599–604. doi: 10.1097/MLR.0b013e31820bf86e
    13. Hall SM, Prochaska JJ. Treatment of smokers with co-occurring disorders: emphasis on integration in mental health and addiction treatment settings. Annu Rev Clin Psychol. 2009; 5:409-31. doi: 10.1146/annurev.clinpsy.032408.153614.
    14. University of California San Francisco Smoking Cessation Leadership Center. Behavioral Health. Accessed May 2, 2018.
    15. Cuffel BJ & Chase P. Remission and relapse of substance use disorder in schizophrenia: Results of a one-year prospective study. Journal of Nervous and Mental Disease 1994; 182(6):342–348. doi: 10.1097/00005053-199406000-00006.
    16. Substance Abuse and Mental Health Services Administration. Results from the 2013 National Survey on Drug Use and Health: Detailed Tables, Tables 6.10B and 6.24B. Rockville, MD: Substance Abuse and Mental health Services Administration, Center for Behavioral Health Statistics and Quality, 2014 [accessed 2016 May 18].
    17. Hurt RD, Offord KP, Croghan IT, Gomes-Dahl L, Kotke TE, Morse RM, et al. Mortality following inpatient addictions treatment. Role of tobacco use in a community-based cohort. J Am Med Assoc. 1996; 276(10): 1097-103. doi:10.1001/jama.1996.03530380039029
    18. Prochaska JJ, Rossi JS, Redding CA, Rosen AB, Tsoh JY, Humfleet GL, et al. Depressed smokers and stage of change: Implications for treatment interventions. Drug Alcohol Depend. 2004; 76(2): 143-151. doi: 10.1016/j.drugalcdep.2004.04.017

For quick, downloadable facts:

Download the Mental Health and Tobacco Use Factsheet here.

Download the Substance Use and Tobacco Use Factsheet here.

Learn more:

Statistical analysis methodology of smoking and mental illness.

    Page Last Updated: September 10, 2018

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