Friday, December 15, 2006

Raising Cigarette Taxes Fails to Address Nicotine Dependence in People with Severe Mental Illness – Akhil Shenoy

Since 1964, 28 Surgeon General’s reports on smoking and health have concluded that tobacco use is the single most avoidable cause of disease, disability, and death in the United States. Public health interventions have successfully targeted and decreased the overall prevalence of smoking in children and adults. Public health dollars are now being targeted to groups such as young people, racial and ethnic minority groups, and people with low incomes or low levels of education—groups that have been deemed to be at highest risk for tobacco-related health problems (CDC). The US department of Health and Human Services, through the Healthy People 2010 initiatives, have not focused their energies on a group that has at least twice the risk of smoking incidence as the rest of the public; the prevalence of smoking in the severely mentally ill is 40%-80%. The 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions suggested that the approximately 7.1 percent of the U.S. population with a psychiatric illness consumes more than 34.2 percent of all cigarettes (PS). Another study estimates that 44% of all cigarettes consumed are done so by those with severe mental illness. (S)

The current public health initiatives to decrease smoking may have decreased overall cigarette sales but this paper will try to expose, with social and behavioral theory and science, how raising the cigarette tax may not decrease nicotine dependence in the mentally ill. This type of intervention does not consider the more fundamental problems which connect tobacco use to this specific population. It assumes that a seemingly rational choice given to the individual will work in irrational situations. Meanwhile, it ignores the strong theories of labeling and social norms which define the problem of smoking in the mentally ill. Ignoring these problems can be obstacles to traditional treatment of nicotine dependence. Hopefully, it can be shown that such an effort may not work for all smokers and that a directed effort must be taken to stop smoking in the severely mentally ill.
Public health policy continues to expect individuals to make rational decisions regarding smoking cessation. Increasing the cost of tobacco as a measure to deter smoking still relies on the individual to choose to smoke—even though the choice would seemingly be one based on monetary cost as opposed to health cost. Individual level control and decision-making regarding an addictive behavior is far more difficult for someone suffering from mental illness. A cachectic schizophrenic individual, lost in a delusion that cigarettes keep him alive, could forego life-preserving food even if he did not have the money for both. Someone suffering with post traumatic stress disorder may rationalize that smoking as a coping mechanism is worth an ever increasing cost. Still those who are getting adequate disability checks from the state or the Veterans Affairs may not be dissuaded by the rising costs. As a physician I work with a resourceful veteran who would buy cartons of cigarettes on-line and sell packs to others in his apartment building. I see another patient who responded to the increased cost of cigarettes by buying bulk cartons because it seemed to be cheaper; and he ended up smoking more than he did before the tax. We may find that money, as a tool, may mean something different to someone suffering from a severe mental illness. Raising the tax on tobacco as a public health approach calls on our own available heuristic; that a financial burden would dissuade use. This idea may be based on our own familiarization with how we think about and use money.
This type of intervention ignores other fundamental issues which connect tobacco dependence to the severely mentally ill. People suffering with schizophrenia, bipolar disorder, depression, panic disorder and PTSD may be stressed, isolated, and with limited cognition. A powerful paradigm has been built that the mentally ill smoke as a coping mechanism for the extreme stress that they endure (PAB). Those with schizophrenia are thought to smoke in order to mask a deficiency (S). While the label of “mentally ill” can have a positive effect by encouraging patients to seek the appropriate help, it can also promote patients to conform to the deviant behavior of smoking. In describing mental illness, labeling theory shares that individuals would act according to the label that they receive. In this way of thinking, mental illness and smoking can be a self-fulfilling prophecy for some people. (W) It is then rationalized by the patient as an easy coping mechanism to manage the extreme burden of mental illness. Health practitioners and the general public may perpetuate this stereotype. The lens of popular culture portrays the mentally ill as either dangerous, creative or to be pitied—any solution to manage safety, encourage art, and help with their pain may then be seen as acceptable.
Conforming to that label allows the mentally ill to continue to buy cigarettes at increasing prices to help themselves with a troubling existence.
Smoking is the social norm for most people with mental illness. For example, around 80% of schizophrenics smoke cigarettes (PT). Mental illness tends to isolate individuals from the rest of society; in group homes and psychiatric hospitals the social norms are vastly different from that of the rest of society. It is unusual when someone on a psychiatric inpatient unit does not use their smoke break. The smoke break can be a place to connect with someone or something beyond their existence. An intervention to decrease smoking by raising the cost of cigarettes may not be an impetus to stop this basic need. According to Abraham Maslow’s hierarchy of needs, people need safety, love and self-esteem before they can likely problem solve the rising cost of cigarettes (W). All people, including the mentally ill, look to their group to define their identity. Their social norm predicts that an individual will adopt the habits of the group that they belong to (CM). This concept is incredibly salient for a schizophrenic who struggles with loss of ego strength and personal identity. For them, their perceived group identity may be more important than their individual identity. For the severely mentally ill, an external agency raising tobacco costs may be a coalescing factor to stay true to their perceived group and rebuke any push to curb smoking.
Given the level of irrational thinking that lends itself to harmful health and financial choices, one may expect that good psychiatric treatment may help make external disincentives more appealing. A recent study showed that psychotherapy helped half the patients with significant smoking cessation in psychotic disorders (AJP); the cognitive therapy focused on finding concrete coping strategies to replace the tobacco. This is encouraging for psychiatrists as the increased tax can also be taught to be a meaningful concrete reason for some psychotic individuals to quit smoking. Unfortunately, most people with mental illness do not seek help and so there is a large population of people that may not be ready to make such a decision to stop smoking. The co-morbid symptoms of lack of motivation and concrete thinking along with a poor or limited observing ego keep patients from seeking treatment. This is not helped when these sometimes complicated “dual diagnosis” (mental illness and substance abuse) patients are perceived as more difficult and untreatable. Health professional’s social norms of misunderstanding and intolerance about these patients is a barrier to care (DAR). Physicians, nurses and other mental health practitioners model a learned helplessness which demands additional training. Without proper treatment for this population, the expectation for these patients to respond to a coercive campaign with a rational, motivated response is both hollow and unacceptable.
A single intervention may not work for all populations. The mentally ill population is an especially complex and varied group that has not responded to such interventions. Raising the cost of tobacco calls on a sense of self-direction, empowerment, and responsibility which may be impossible for a paranoid schizophrenic. From an economic perspective, the increasing stress of the tobacco burden on this small population enormously underscores the need for a plan which utilizes a power law distribution of resources. From a moral perspective it doesn’t seem fair to expend more resources and energy to helping a minority of the population. Malcolm Gladwell, in talking about helping homelessness, shares that a normal-distribution social policy may seem more morally right but it does not make economic sense (NY). As the largest consumer of tobacco products, the mentally ill would most benefit from resources pointed at smoking cessation. Not all populations fit on a bell curve which respond in ways we can easily expect. The mentally ill may be such a population of people who need a more targeted and nuanced approach.


Psychol Addict Behav. 2006 Sep;20(3):265-78
Am J Psychiatry. 2006 Nov;163(11):1934-42

Drug Alcohol Rev. 2004 Dec;23(4):455-62


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2:18 AM  
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9:32 PM  
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3:33 PM  
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6:17 AM  

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