Nearly half of the cigarettes consumed in the United States are smoked by people dealing with a mental illness, according to the Substance Abuse and Mental Health Services Administration. The federal agency says that rates of smoking are disproportionately higher — a little more than double — among those diagnosed with mental illness than among the general population.
It is widely accepted that the nicotine in cigarettes is highly addictive, but people struggling with mental health issues often turn to cigarettes for reasons that go beyond their addictive qualities. For instance, many people smoke as a coping mechanism to deal with difficult feelings. In addition, despite their negative health effects, cigarettes are still largely viewed by society as an “acceptable” addiction in comparison with other substances.
The reality? “[Smoking] is a devastating addiction and a difficult one to quit,” says Gary Tedeschi, clinical director of the California Smokers’ Helpline and a member of the American Counseling Association. “This clientele [those with mental illness], in particular, need the encouragement and support to go forward [with quitting], and many of them want to, despite what people might think. … To let people continue to smoke because ‘it’s not as bad’ [as other addictions] is missing a really important chance to help someone get healthier.”
To drive home his point, Tedeschi points to a statistic from the 2014 release of The Health Consequences of Smoking — 50 Years of Progress: A Report of the Surgeon General, which says that more than 480,000 people die annually in the United States from causes related to cigarette smoking. Close to half of the Americans who die from tobacco-related causes are people with mental illness or substance abuse disorders, Tedeschi says.
In Tedeschi’s view, the statistics connecting smoking to mental illness are “so obvious that it’s almost an ethical and moral responsibility to help this population quit.”
Part of a package
Ford Brooks, a licensed professional counselor (LPC) and professor at Shippensburg University of Pennsylvania, says he has never had a client walk in to therapy with a primary presentation of wanting to stop smoking.
Tobacco use “is always part of a package” that clients will bring to counseling, Brooks says. In his experience as an addictions counselor, smoking is often piled on top of a laundry list of other challenges that may include alcohol or drug addiction, depression, a marriage that is on the rocks, the loss of a job or financial trouble.
“They’re on the train to destruction, and their nicotine use, in their minds, is on the back end [in terms of importance]. … Is the smoking related to what their presenting issue is? Chances are it probably connects somehow. Don’t be afraid to bring it up,” advises Brooks, co-author of the book A Contemporary Approach to Substance Use Disorders and Addiction Counseling, which is published by ACA.
Tedeschi, a national certified counselor and licensed psychologist, notes that many people who call the California Smokers’ Helpline are struggling with comorbid conditions or mental illness in addition to tobacco use. The phone line is one in a system of “quitlines” operating in each of the 50 U.S. states, the District of Columbia, Puerto Rico and Guam.
For clients struggling with mental health issues, smoking may serve as a coping mechanism to deal with uncomfortable feelings or anxiety, Brooks says. Years ago, when smoking was still allowed in many indoor spaces, Brooks led group counseling in detox, outpatient and inpatient addictions facilities. “When powerful emotions would come up in group, [clients] would fire up cigarette after cigarette to deal with those feelings and quell anxiety,” he recalls.
With this in mind, counselors should help prepare clients for the irritability, anxiety and other uncomfortable feelings they are likely to experience when they attempt to stop smoking cigarettes. “Talk about what it will feel like to be really anxious and not smoke” and how they plan to handle those feelings, Brooks says. “… If a person has anxiety or depression and stops smoking, what initially happens is they could get more depressed or more anxious without nicotine to quell the emotion.”
The counselors interviewed for this article urge practitioners to ask every single client about their tobacco use during the intake process, no matter what the person’s presenting problem is. “If you’re helping them to get mentally and physically healthier, this [quitting smoking] is a very critical part of the overall wellness picture,” Tedeschi says.
Counselors shouldn’t be afraid to ask their clients whether they smoke, says Greg Harms, a licensed clinical professional counselor (LCPC), certified addictions specialist, and alcohol and drug counselor with a private practice in Chicago. “It can feel weird the first couple of times, especially if this is not your area of expertise,” says Harms, who does postdoctoral work at Diamond Headache Clinic in Chicago, an inpatient unit for people with chronic headaches. “A lot of times, clients have heard all the bad stuff about smoking. A lot of them, deep down, they know they’d be better off if they were to quit smoking. They may have failed so many times in the past that they’re discouraged. They might be hesitant to bring it up because this is a counselor and not the [medical] doctor. If you bring it up, more often than not, the client is going to engage with that. Even if they don’t, if it’s not the right time for them, you’ve planted that seed. … It might come to fruition down the road. I’d much rather plant that seed than not say anything at all.”
When Harms was a counseling graduate student, he completed an internship at the Anixter Center, a Chicago agency that serves clients with disabilities. While there, he worked as part of a grant-funded program for smoking cessation for people with disabilities that was spearheaded by the American Lung Association. He also presented a session titled “Integrating Smoking Cessation Treatment with Mental Health Services” at ACA’s 2013 Conference & Expo in Cincinnati.
If a client doesn’t feel ready to begin the quitting process right away, the counselor can put the topic on the back burner to address again once the client has made progress on other presenting problems or has forged a stronger relationship with the practitioner. However, that shouldn’t mean that the topic is off the table completely, Harms says. A counselor should talk regularly with the client about quitting smoking, even if it’s only for a few minutes each session.
“Give them a little nugget of information [about quitting], and then you can focus on what they’re there for,” Harms says. “Help them find ways to deal with their presenting problem, then they’ll trust you. Once they’re in a better place, revisit [the idea of quitting]. We don’t have to address it and get their buy-in during the first session. It would be fantastic if that was the case, but it’s OK if it’s not. In most cases, time is on our side to develop the relationship, plant the seed and revisit it. If the client is not ready, we can harp on [quitting] all we want, [but] it won’t do anything.”
“You really have to take the client’s lead and go at the pace they’re willing,” Harms continues. “Don’t push. Respect their decision. Even if they’re not ready for [quitting], let them know that [you’re] there for them and respect their autonomy to make that decision.”
Positioned to help
Counselors are particularly suited to help clients quit smoking because the profession has an array of tools focused on behavior modification, Tedeschi asserts. Motivational interviewing, cognitive behavior therapy, acceptance and commitment therapy, and other models can be useful in helping clients stop smoking. But techniques from any therapy model that counselors are comfortable using can be adapted to help clients navigate the challenge of quitting, Tedeschi says, especially when combined appropriately with pharmacologic aids approved by the Food and Drug Administration.
“We’re in the business of helping people change. The principles that a counselor uses to help someone understand an issue and begin to make steps toward change apply to smoking cessation as well,” Tedeschi says. “Counselors help people understand their motivation to change and help them come up with a plan to change.”
Harms agrees, noting that in most cases, a counselor will have significantly more time with a client than a medical professional will. Instead of “hitting [the client] over the head” with the dangers of smoking, Harms says, a counselor can afford to focus on the positive, use a strengths-based approach and build on what the client wants to work toward rather than what he or she wants to avoid.
“We [counselors] are so strengths-based. It’s our natural inclination to tell the client, ‘Yes, you’re strong enough to do this,’ rather than [taking] a scare approach,” Harms says. “We can find their strength and have that unconditional positive regard for them, regardless of how long it’s taking. We have the patience to sit with a client as they’re going through [quitting]. We can build that relationship and be a resource.”
Tedeschi recommends that counselors use the “five A’s” to discuss smoking with clients. In this approach, a practitioner should:
- Ask each client about his or her tobacco use
- Advise all tobacco users to quit
- Assess whether the client is ready to quit
- Assist the client with a quit plan
- Arrange follow-up contact to mitigate relapse
Each of these steps is important, but providing support and follow-up as the client begins to quit is particularly critical, Tedeschi says.
“The first week of quitting is the hardest. If [a counselor] waits for a week to talk to the client, you could lose about 60 percent of people back to relapse,” he says. “If someone is able to quit for two weeks, their risk of relapse drops dramatically.”
If clients resist the idea of quitting or do not feel ready to quit entirely, Tedeschi suggests that counselors work with them to stop smoking for one day or even just an afternoon. During this time, have clients monitor how they felt: How was their anxiety level? What were their cravings like? This technique can introduce the idea of stopping and prepare clients for the quitting process, he says.
Brooks recommends using motivational interviewing to help clients make the life change to quit smoking. “Nicotine is a drug, and it’s no different than if [clients] were to say they want to stop drinking. Work with their motivation to identify what they can possibly do for that,” he says.
Part of the quitting process involves clients going through an identity shift, Tedeschi notes. Clients can be behaving as nonsmokers — abstaining from cigarettes — long before they make the mental leap that they are no longer smokers, he says. It is important for clients to make that mental shift from “a smoker who is not smoking” to a “nonsmoker,” Tedeschi says. Counselors need to work with these clients to identify as and accept the nonsmoker label. “As long as someone calls [himself or herself] a smoker, they will be open to turning back to cigarettes,” he explains.
Kicking the habit
Counselors can use the following tips and techniques to better equip clients to meet the challenge to stop smoking.
Set a quit date. This is an important step, but one that clients must take the lead on and choose for themselves, Tedeschi says. Research shows that simply cutting back without setting a quit date isn’t very effective, he adds. The behavioral patterns that often accompany smoking (for example, smoking after eating or taking smoke breaks at work) make it very hard to keep tobacco use at a low level. Setting a quit date creates accountability and is a “sign of seriousness,” he says. At the same time, be flexible. “For some people, it’s just too hard to think about [sticking to a quit date],” Tedeschi says. “For some — especially those who are struggling with other substances — they need to take one day at a time.”
Be aware of psychotropic medications. Counselors should be aware that if clients are taking prescription medicines for anxiety, depression, bipolar disorder or other mental illnesses, their dosages might need to be adjusted as they quit smoking. Nicotine is a stimulant, so it speeds up a person’s metabolism. This means a person who smokes will burn through psychotropic medications faster than someone who doesn’t smoke, Harms explains. Counselors should be certain to talk this through with clients and work with their doctors to modify their dosages, he says. “This is especially noticeable with mood stabilizers. It’s acute with bipolar disorder,” Harms says.
The same holds true with caffeine, Tedeschi notes. After they quit smoking, clients may notice that they get jittery from caffeine and may need to cut back on their coffee intake.
Use cognitive strategies. Counselors can help clients create a list of personal reasons why they want to stop smoking — beyond the health implications, Tedeschi says. The list doesn’t need to be long, but the reasons need to be compelling and motivating enough to carry clients through a nicotine craving. For example, one of Tedeschi’s clients wanted to quit because his young grandson asked him to. As a reminder, the client kept a toy car that belonged to his grandson in his pocket. “When he had a craving [for a cigarette], he would pull [the toy car] out of his pocket, look at it, hold it and squeeze it,” Tedeschi says. “It helped.”
Turn over a new leaf. As they quit smoking, encourage clients to organize, clean and purge their homes and cars of smoking-related materials such as ashtrays, advises ACA member Pari Sharif, an LPC with a practice in Franklin Lakes, New Jersey. That action will help clients turn a new page mentally and start fresh, she says. Sharif also encourages clients to air out their homes and clean their closets so their clothes and furniture no longer smell like smoke.
On a similar note, if clients have a certain mug that they always use to drink coffee while smoking, Harms suggests that they get a new mug. Or if they always stopped at a certain gas station to buy cigarettes, he suggests that they now change where they buy gas.
When cravings strike, breathe. Sharif, a certified tobacco treatment specialist, introduces breathing techniques to all of her smoking cessation clients. She asks these clients to take measured breaths for roughly two minutes, inhaling while slowly counting to four, then exhaling for four counts.
“Instead of the reflex habit to grab a cigarette, take a moment to stop and ask why. Be more in control of yourself and your mind,” she tells clients. “Pause to do breathing and body scanning from head to toe. Ask yourself, ‘What am I doing? Why do I need this [cigarette] to calm down?’ … [Through breathing exercises,] your breath becomes deeper and deeper. Close your eyes. Your body starts relaxing and your anxiety level goes down.”
Sharif also recommends that clients download a meditation app for their smartphones and use a journal to record how they’re feeling when cigarette cravings strike. This helps them log and identify which situations and emotions are triggering their need for nicotine,
Get to the root of it. Asking clients about the circumstances that first caused them to start smoking can help in identifying what triggers their nicotine use and the bigger issues that may need to be addressed through counseling, Sharif says. In some cases, a specific traumatic event or stressor caused the person to start smoking. In other instances, it was a learned behavior because everyone in the household smoked as the client was growing up. “Find out when they started smoking and why,” Sharif says. “Gradually, when they become more aware of themselves, they quit.”
Change social patterns. Cigarettes are often used as a coping mechanism when people experience anxiety in social situations, Harms says, so clients may need to focus on social skills as they start the process of quitting smoking.
“[Cigarettes] are their way to socialize and get out and meet people. If you have social anxiety, you can still go up to someone and ask for a cigarette or ask for a light. It’s programmed socialization,” Harms explains. “It gives you an excuse to be close to people, feel more sociable. If you take away their cigarettes, you’ve got to replace that.”
Brooks agrees, noting that clients who smoke likely have friends who are also smokers. For example, he says, it is not uncommon to see people smoking and talking together outside of Alcoholics Anonymous meetings. Counselors can help clients prepare to avoid situations where smoking is expected and practice asking people not to smoke around them, Brooks says. Counselors can also support clients in creating social networks of people who don’t smoke, including support groups for ex-smokers, he adds.
Break behavioral habits. Similarly, Brooks says, counselors can help clients change the behavioral habits they connect to smoking, such as starting the morning by reading the paper, drinking coffee and smoking a cigarette. Counselors can suggest activities and new rituals to replace the old ones, such as taking a daily walk, he says.
Harms encourages clients to replace their former smoke breaks with “clean air breaks.” They can still take their normal time outside, but instead of smoking, he suggests that they walk around the block, sit and read a book, eat an apple or use their smartphones outdoors. If they had a favorite smoking spot outside, he urges them to find a new place to go instead.
Find comforting substitutes. “The whole ritual of lighting up a cigarette — tapping the pack to pull out a cigarette and flicking the lighter — the behaviors that go with [smoking] can be very comforting,” Harms says. “Sometimes that’s what’s so hard to break — the behaviors that go with it.”
Tedeschi recommends that counselors work with clients to have comforting alternatives ready to go even before the clients attempt to quit smoking. It is hard for people to figure out alternatives in the heat of the moment when a craving strikes, he explains. Tedeschi offers several possible substitutes for consideration: sugar-free gum, beef jerky, cinnamon sticks and even drinking straws cut into cigarette-sized lengths through which clients can inhale and exhale.
If clients are comforted by having something in their hands, Brooks suggests keeping a pen, stress ball or prayer beads nearby. Staying hydrated and carrying a water bottle can also help these clients, Tedeschi adds. Most of all, counselors should work toward the idea of replenishment and filling in where clients feel they are losing something, he says.
Don’t dismiss pharmacotherapy. A wide variety of quitting aids are available, from nicotine patches, lozenges and gum, to prescription pills such as Chantix. The counselors interviewed for this article agree that these stop-smoking aids can be helpful when used alongside counseling. However, Tedeschi says, counselors should work with their clients’ physicians when such medications are being used, or make sure that clients are talking with their physicians. Counselors should also be aware of the potential side affects that these medications can have, such as aggressive behavior.
Brooks notes that none of these options is a magic solution to quit smoking. For example, nicotine gum and other medications can be prohibitively expensive, and some clients can continue to smoke even while using nicotine patches or gum. As for electronic cigarettes, Sharif and Harms agree that they are not a recommended alternative. Electronic cigarettes are carcinogenic, addictive and mimic the “puffing” behavior of regular smoking, Harms notes.
Connect clients with other supports. Counselors should equip clients with resources they can turn to outside of counseling sessions, such as local support groups for ex-smokers or the phone number for their state’s tobacco quitline, Brooks suggests. Nicotine Anonymous (nicotine-anonymous.org) is an ideal resource for clients who are trying to stop smoking, Brooks says. The 12-step method at Alcoholics Anonymous (AA) can also be applied to tobacco use for clients who attend AA meetings already or who don’t have a Nicotine Anonymous support group in their local area, he adds.
Sharif suggests that counselors keep brochures and other information about quitting smoking alongside the materials they might have about depression or suicide prevention in their offices or waiting rooms. It is better for counselors to distribute information that they have vetted themselves rather than having clients search the internet for information on their own, she notes.
Try and try again
On average, it takes a smoker 10-12 attempts to fully quit cigarettes, according to Tedeschi. For that reason, it is imperative that practitioners not give up on clients after their first, second or even 10th try, he stresses.
Quitting smoking is hard, Tedeschi acknowledges, but possible with perseverance. “Don’t be discouraged as a clinician if your client relapses. [Quitting] is definitely not a one-time event; it’s a process. … Relapse prevention is important, but it’s equally important to be ready for the relapse,” he says. “One of the best things a counselor can give a client is that reassurance. Any attempt to quit for any length of time is a success rather than a failure. That’s just the reality of this addiction. As long as they keep trying, they’ll get there. The only failure is to stop trying. The most important message a counselor can give a client is to never give up.”
Statistics: Smoking and mental health
- Roughly 50 percent of people with behavioral health disorders smoke, compared with 23 percent of the general population.
- People with mental illnesses and addictions smoke half of all cigarettes consumed in the U.S. and are only half as likely as other smokers to quit.
- Smoking-related illnesses cause half of all deaths among people with behavioral health disorders.
- Approximately 30-35 percent of the behavioral health care workforce smokes (versus 1.7 percent of primary care physicians).
— Source: U.S. Substance Abuse and Mental Health Administration (see bit.ly/1sEx97a)
- Treatment Strategies for Substance and Process Addictions (2015), a book published by the American Counseling Association, contains a chapter on nicotine addiction (available in print or as an e-book at counseling.org/bookstore).
- A Contemporary Approach to Substance Use Disorders and Addiction Counseling (2015)
second edition, by Ford Brooks and Bill McHenry is also available in print or as an e-book at counseling.org/bookstore.
- The North American Quitline Consortium website (naquitline.org) has a map and information on all the smoking cessation hotlines available in the United States.
- Smokefree.gov has resources for practitioners and clients, including a text message-based cessation program.
- The American Lung Association has a wealth of resources and tools, including online support communities,at lung.org.
- The National Council for Behavioral Health offers tobacco cessation resources at thenationalcouncil.org/topics/tobacco-cessation.
- Mental Health America offers infographics on smoking and mental illness at mentalhealthamerica.net/conditions/smoking-and-mental-illness-quick-facts.
- The article “Smoking Use and Cessation Among People With Serious Mental Illness” was published in the September 2015 issue of the Yale Journal of Biology and Medicine (see bit.ly/2dXCrGf).
- Find out about becoming a certified tobacco treatment specialist via the Association for the Treatment of Tobacco Use and Dependence (attud.org).
Bethany Bray is a staff writer and social media coordinator for Counseling Today. Contact her at firstname.lastname@example.org
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