The lived experiences of tobacco use, dependence, and cessation: insights and perspectives of people with mental illness.
Abstract: Even as the rate of smoking in the U.S. population overall has decreased dramatically during the last four decades, people with mental illness continue to use tobacco at alarmingly high rates. In the last two years, national initiatives have developed to address smoking within this population, yet there has not been an attempt to understand the perspectives of people with mental illness themselves regarding the role tobacco plays in their lives. This grounded theory study, based on focus group interviews with 26 individuals with various smoking statuses receiving outpatient mental health services, attempted to develop a theory to understand this high prevalence from the perspectives of people with mental illness. The article explores the experiences of people with mental illness related to never smoking, smoking, and quitting; the role of tobacco use for people with mental illness; the other forces that promote or discourage tobacco use; and the tensions and complexities in understanding the "problem" of tobacco use in this population. It concludes by highlighting directions for future research, policy considerations, and the important role social workers can play in addressing this significant cause of health disparities.

KEY WORDS: mental health; mental illness; smoking cessation; tobacco
Article Type: Report
Subject: Mental health (Research)
Smokers (Health aspects)
Smokers (Psychological aspects)
Smoking cessation programs (Health aspects)
Author: Solway, Erica Singer
Pub Date: 02/01/2011
Publication: Name: Health and Social Work Publisher: National Association of Social Workers Audience: Academic; Professional Format: Magazine/Journal Subject: Health; Sociology and social work Copyright: COPYRIGHT 2011 National Association of Social Workers ISSN: 0360-7283
Issue: Date: Feb, 2011 Source Volume: 36 Source Issue: 1
Topic: Event Code: 310 Science & research
Product: Product Code: 8000142 Antismoking Programs NAICS Code: 62142 Outpatient Mental Health and Substance Abuse Centers
Geographic: Geographic Scope: United States Geographic Code: 1USA United States
Accession Number: 251086510
Full Text: Although smoking rates among the overall population have declined dramatically since the 1960s, when Surgeon General Luther Terry first announced that smoking was deleterious to health (Schroeder, 2005), smoking rates among people with mental illness remain extremely high (Lamberg, 2004). People with serious mental illness (SMI), commonly referred to as "mental health consumers," have been found to live 25 fewer years on average than do people in the overall population, and this disparity in longevity has been found to be a result of preventable and treatable causes of disease, disability, and death such as smoking (Colton & Manderscheid, 2006; Lutterman et al., 2003; Parks, Svendsen, Singer, & Foti, 2006). Estimates suggest that individuals with mental illness or substance use disorders smoke 44.3 percent of the cigarettes consumed in the United States (Lasser et al., 2000). In fact, tobacco addiction is the most common cooccurring disorder for people with SMI (Ziedonis, Williams, & Smelson, 2003). Approximately 200,000 of the 443,000 people who die prematurely from smoking each year are people with mental illness or substance use disorders (Schroeder, 2009;Williams & Ziedonis, 2004).

Studies indicate that individuals with mental illness or addictions are two to three times more likely to be tobacco dependent than are individuals in the general population (Ziedonis & Williams, 2003). Numerous physiological, social, and cultural factors can contribute to these high rates, including the fact that mental health providers often have limited training in addressing tobacco use and sometimes assume that people with mental health problems cannot quit smoking or that symptom management should take precedence over preventive health measures (Williams & Ziedonis, 2004).Tobacco use is typically ignored or even encouraged in mental health settings and is not deemed a disorder like other mental illnesses or addictions (Williams & Ziedonis, 2004).

Overall, it appears that a complex combination of biological, psychological, and social-cultural factors lead to the high tobacco use and addiction rates among people with mental illness (Schmitz, Kruse, & Kugler, 2003). Several biological hypotheses exist regarding the high rates of tobacco use in this population, although questions remain about causation in the association between nicotine dependence and psychiatric comorbidity. It is possible that there are separate, specific causal mechanisms behind the association between smoking and mental disorders and that between mental disorders and smoking (Schmitz et al., 2003). Furthermore, it is possible that people who have difficulty coping with stress, anxiety, and depression are more susceptible to nicotine dependence, as it may temporarily relieve feelings of tension. Yet such a dependency may create a vicious cycle, because the inability to quit smoking is itself stressful and can lead to greater anxiety (Schmitz et al., 2003). In terms of social and cultural factors, smoking has become an accepted and integral part of the culture in mental health and substance abuse treatment centers and is often considered a common collective social practice within these settings.

QUITTING SMOKING AND MENTAL ILLNESS

Be that as it may, studies suggest that people with mental illness can quit smoking and have high motivation to do so. Prochaska et al. (2004) found that almost 80 percent of depressed smokers wanted to quit, and nearly one in four were ready to quit in the next month. Individuals do not need to be free of mental illness symptoms to quit (Schroeder, 2009), and research suggests that individuals being treated for depression can quit smoking without adversely affecting their mental health (Prochaska et al., 2007). The overall rates of quitting among people with mental illness are substantial, but they remain lower than that in the population overall (el-Guebaly, Cathcart, Currie, Brown, & Gloster, 2002).

In 2007, the National Mental Health Partnership for Wellness and Smoking Cessation was established to bring together leading organizations in mental health and smoking cessation to address tobacco use among people with mental illness (Smoking Cessation Leadership Center, 2009). The partnership's initiatives are led by and based on the perspectives of leaders in the fields of mental health and smoking cessation. Building on the limited extant research, this article examines the perspectives of people with mental illness themselves regarding smoking and quitting to more effectively create strategies and interventions at the micro, meso, and macro levels that will help people with mental illness to quit smoking. Specifically, the primary aim of this article is to explore the question: What are the experiences of mental health consumers around choosing to smoke, trying to quit, and quitting, and what can be learned from these experiences in the development of smoking cessation initiatives for people with mental illness?

METHOD

I conducted focus group interviews with people with mental illness, broadly defined as adults currently receiving outpatient mental health services. The participants were recruited through the adult and older adult programs at a social service agency that provides treatment and support to people living with SMI. All participants were currently receiving outpatient mental health services from this agency and living in the community. On the basis of the diagnoses of clients served by this agency, nearly all participants in these focus group interviews had received diagnoses of SMI, including schizophrenia and bipolar disorder. Moreover, participants also described experiences of depression, anxiety, and pain. The focus of this study was on the perspectives of those receiving outpatient mental health services given that institutional smoking policies can strongly dictate the experiences around tobacco use for people receiving care and residing within a facility. The University of California, San Francisco's Committee on Human Research (the institutional review board) granted approval for this study in June 2007, and the project was also reviewed and approved by the recruitment site's research committee.

Four focus groups and one individual interview lasting about 1.5 hours each were conducted during a two-week period in July and August 2008. The groups were organized according to current smoking status; there were two groups for current smokers (individuals who had smoked within the past month [one group also included one individual who used only smokeless tobacco]), one for former smokers (individuals who had not used tobacco in at least the previous month, though the average time quit was several years), and one for never smokers (individuals who had smoked less than 100 cigarettes in their lifetime). Although the intent was to organize another focus group for individuals trying to quit smoking, recruitment presented a particular challenge for this group: Seven people called me expressing interest in the group, were deemed eligible to participate, and signed up to attend this group, but only one person ultimately showed up. Thus, the one person who chose to attend this group participated in an individual interview.

A total of 26 individuals participated in one of the five groups (10 women and 16 men). Participants ranged in age from 41 to 82 years, with an average age of 62 years. This relatively high average age was a result of the fact that recruitment was most successful among individuals receiving services from the older adult division of the social service agency (which serves all individuals 55 years and older). Information on the demographics of study participants is presented in Table 1.

The focus groups were guided using a unique, nonstandard semistructured interview protocol that I designed and pretested. The focus group interviews and the individual interview were digitally recorded and transcribed verbatim. To identify who was speaking during the group sessions, I asked participants to state their first name or a pseudonym before making a comment. Participant observation was also conducted during each group and at the agency sites where these individuals received services. I was able to observe some of the programs participants were involved in and observe the relationships participants had with one another and with agency staff outside the focus group setting. From August 2007 through August 2009, I also attended groups and events offered in the community, including a smoking cessation education group that included people with mental illness, conferences on mental health and tobacco cessation, and planning meetings for the National Mental Health Partnership for Wellness and Smoking Cessation. These opportunities to observe people with mental illness in the treatment environment as well as to observe leaders in the fields of tobacco use and mental illness discussing ways to address this topic allowed for the development of a deeper and more comprehensive understanding of this issue and served, in some cases, to confirm or disprove findings identified through data analysis, especially given that focus group interviewees had diverse demographic backgrounds and experiences related to their mental illness and tobacco use.

This study was designed using grounded theory methodology (Charmaz, 2006; Clarke, 2005), a technique developed by Glaser and Strauss (1967). Grounded theory allows for the generation of a theory of a process that is grounded in data obtained from interviews and observations with participants who have experienced that process. When using grounded theory, a researcher must attempt to set aside theoretical notions that might bias interpretation of the information being collected. Data collection and analysis were ongoing and iterative. The transcripts were read closely, and segments of text were compared with one another (Clarke, 2005; Glaser & Strauss, 1967; Morse et al., 2009; Strauss & Corbin, 1990). Throughout the data collection and analysis process, I coded to capture emergent issues and processes, constructed maps, compared transcripts, and engaged in memo writing and theory development, as described by Clarke (2005) and Charmaz (2006).

The present research used constructivist grounded theory (Charmaz, 2009), a perspective that is based on the assumption that knowledge rests on social construction. This form of grounded theory "assumes a relativist epistemology, sees knowledge as socially produced, acknowledges multiple standpoints of both the research participants and the grounded theorist, and takes a reflexive stance" (Charmaz, 2009, p. 129). Constructivists are able to "enter participants' liminal worlds of meaning and action in ways classical grounded theorists do not" and are able to locate participants' meanings and actions in larger social structures and discourses of which participants may be aware or unaware (Charmaz, 2009, p. 131). This approach to grounded theory, although similar to Strauss and Corbin's (1990) conception to the approach in many ways, also allows for more flexibility and places greater emphasis on "the views, values, beliefs, feelings, assumptions, and ideologies of individuals than on the methods of research" (Creswell, 2007, p. 65). In this study, I analyzed the data and the emergent themes in consideration of the larger social structures and discourses in the areas of mental health and tobacco control.

In qualitative research, a key aim is to achieve saturation--a point where the same perspectives on a phenomenon are being voiced by participants and no new findings are emerging. In the tradition of grounded theory, 26 is an appropriate sample size if saturation is achieved. In the focus group interviews with former smokers and never smokers, it was clear by the conclusion of the groups, on the basis of continued emergence of related themes and issues, that these perspectives had been fully taken into account. For example, the final focus group was conducted to more fully understand the experiences of current smokers and those thinking about quitting given the high likelihood that people with mental illness would fall into these categories. By the end of the final group--whose members were all current tobacco users, including an individual who used smokeless tobacco and some participants who were thinking about quitting--the same themes had emerged as from the other groups, which demonstrates that saturation was achieved in this study.

As a social worker, public health practitioner, and sociologist, I came to this research with a broad understanding of and interest in health promotion strategies for people with mental illness. Before conducting this research, I had limited theoretical knowledge of the perspectives of people with mental illness related to tobacco use and, thus, was able to set aside theoretical notions that might bias my interpretation of these data.

LIVED EXPERIENCES OF MENTAL HEALTH CONSUMERS

This article examines the socially constituted realities around tobacco use for people with mental illness and "how smoking fits into the lived experience of people's lives, embedded in the (sub)cultural contexts in which they live, work, and play" (Poland et al., 2006, p. 62). Several codes and categories emerged from the focus group discussions around tobacco. In this article, I organize these findings into four major categories: (1) the lived experiences of never smoking, smoking, and the process of quitting; (2) the role of tobacco use for people with mental illness; (3) other forces influencing tobacco use from the perspectives of mental health consumers, including institutional smoking policies; and (4) tensions and complexities in addressing smoking in this population.

NEVER SMOKING, SMOKING, AND THE PROCESS OF QUITTING

Never Starting to Smoke

Given the staggering rates of smoking among people with mental illness, it is interesting and useful to explore why some mental health consumers never start using tobacco in the first place. Those who never smoked described spending much of their time growing up either around nonsmokers or around smokers who experienced tobacco-related conditions. These nonsmokers described being very committed to their own health and making health-promoting activities a top priority, and when asked about smoking, they focused on the health consequences of tobacco use. In the words of a nonsmoking participant, "I see what my mother went through being diagnosed with cancer, having one lung taken.... That's mainly why I never smoked, because I seen the effects of it."

Nonsmokers described a desire to respect the rights and desires of smokers while also attempting to protect themselves and their rights and desires to avoid the harmful effects of exposure to secondhand smoke. For example, one nonsmoker described how he could empathize with smokers because of his understanding of addictions and his experiences with their own "weaknesses." At the same time, several nonsmokers mentioned that they do not want to put their own health at risk, an important concern given that many rived in close vicinity to smokers in group homes and other group riving arrangements.

Smoker Perspectives and Attitudes about Tobacco

Alternatively, smokers themselves described what led them to tobacco use. Many started smoking at a young age because their family members or friends smoked. In the discussion in these focus groups, there was less emphasis on physical health and a greater focus on the need and the opportunity for escape that cigarettes provide. Several smokers described the ability to forgo cigarettes when they are out of sight but noted that they experience intense cravings as soon as they feel upset, anxious, or are around another person who is smoking. Many current smokers described the physical act of having a cigarette as extremely enjoyable and as a unique form of relaxation. They noted that these perceived benefits of tobacco use outweighed the negative health effects*

Thinking about Quitting

As I organized and conducted the final three focus groups and then analyzed the data, it became readily apparent that there was something truly unique about identifying as "trying to quit." Seven of the 11 individuals who participated in the current smokers groups expressed a strong desire to quit and spent considerable amounts of time "thinking about quitting." This demonstrates that there is an important difference between "trying to quit" and "thinking about quitting." As I reread the transcripts, it became evident that "trying to quit" assumes a commitment to quitting, whereas "thinking about quitting" allows for various levels of readiness to quit and is better understood as an openness to the idea of quitting contingent on one's own belief about one's ability to take on the challenge. The one person who did ultimately attend the trying to quit group was unique in that she described an extremely strong and urgent desire to quit as a result of increasing tobacco-related health concerns, which also led to concerns about her pride and appearance. Her doctor said that she would be required to use an oxygen tank by her next appointment if her breathing problems did not improve. She said.

Motivating Quitting

Similar to the one participant in the trying to quit focus group, the smokers described mounting health concerns as the essential factor in motivating them to quit. If the health problems they experienced were diagnosed by a doctor and were believed to be a result of or exacerbated by smoking, people started to consider the possibility of quitting. For example, one current smoker said, "I'm trying to give it up. I've got asthma, emphysema, bronchitis, heart condition, and high blood pressure. I ain't got no business with it [tobacco]."

Although their health concerns overall were not necessarily as chronic or debilitating, former smokers also noted that they were motivated to quit as a result of health problems or potential health problems. For example, one participant expressed that he was "somewhat grateful" he had bronchitis because it provided him with a reason to quit:

For others, the health effects experienced by family members and friends also served as a motivation. According to one former smoker, "I knew the problems. They killed my dad, and they were having an effect on me, so I says, 'Well, you know, it's probably time to quit,' and I quit." Some participants also expressed motivation to quit as a result of nonhealth-related factors, including fear of causing a fire and cigarettes no longer being enjoyable.

Overcoming Obstacles to Staying Quit

Many of the current smokers and those who had quit experienced significant barriers to preventing relapse and continuing to live tobacco-free. For some participants, smoking provided a perceived sense of control over their emotions. As a result, when they attempted to quit, it became harder to handle and manage their feelings. For example, a former smoker described his attempts at quitting:

Also, the sheer magnitude of the process of trying to quit appeared too large and insurmountable for some people to grasp, particularly for those who had heard how challenging it was for family members and friends to quit and for those who could not conceive of life without cigarettes. One participant, for example, mentioned that he had been told in a cessation education and support group that "the withdrawal symptoms are as bad as from heroin, there's just no way around it. It's hard to do it," and that made him question his ability to quit.

The one person who participated in the thing to quit focus group noted that because she is on Medi-Cal [California's Medicaid program], she was required to complete a program that allowed her access to free nicotine replacement therapy (NRT). Although she strongly wanted to quit and was going through the necessary steps in preparation, she said, "If you got to go through all that [taking a course] then ... I'd rather just keep smoking. But it's not as accessible as it should be if you want somebody to try it." Other current smokers who were thing to quit also expressed disappointment and frustration in their experiences using NRT, lamenting the high costs and poor accessibility they associated with it. Many participants used NRT, specifically the patch--while receiving inpatient treatment, for example--but then immediately went off it when returning to the community because they continued to crave cigarettes while using it, because they did not know how to use it, or because they did not know where to find NRT at an affordable price.

Garnering Will Power and Inner Strength

A common theme in all groups was the notion that quitting ultimately required will power, inner strength, and the right frame of mind. Smoking was described as "a state of mind," focusing on the psychological aspects of addiction rather than the physiological aspects, and many former smokers recalled quite simply setting their mind on quitting and then never smoking again (quitting "cold turkey"). Current smokers who had experienced relapse said they "really have to put [their] minds to it," placing the blame on themselves and their own lack of will power and mental toughness. Several participants associated their mental health conditions with an inner weakness and a propensity for failure and, thus, felt that their likelihood of quitting was low, their mental illness being evidence that they did not have "what it takes" to he successful.

"Seeing What It's Like" and Relapsing

When participants discussed relapsing and returning to smoking days, weeks, months, years, and sometimes decades after quitting, they described the desire to experience the pleasure of a cigarette again and to "see what it was like" to smoke without "feeling addicted." Many participants made it their goal to still enjoy cigarettes, on occasion, while also having "control over" their tobacco use. Yet in their search for this control to manage their smoking, people soon found themselves addicted again. Participants described the power and the positive feelings they associated with the first cigarette, and "then after that, it was all downhill." Five participants mentioned that in realizing that the thrill of the first cigarette would not return, they were able to quit again within a couple of months, but many others continued smoking.

Accomplishing after Quitting

It is noteworthy that all participants in the former smokers groups fondly described what quitting smoking allowed them to accomplish. One participant said that she could assert herself and "get along better" after quitting. Another said that in graduate school, when she no longer had the distraction of fumbling for a cigarette, she was able to more readily focus on her assignments. In general, former smokers described awareness that cigarettes were a distraction from achieving life goals and said that quitting had numerous other benefits along with improved health.

THE ROLE OF TOBACCO USE FOR MENTAL HEALTH CONSUMERS

Participants also described the role that tobacco use plays or played in their lives. In particular, there were three broad ways in which participants described their smoking intersecting with their mental illness: (1) as a tool for managing stress; (2) as a facet of their striving to be "a part of" something and coping with feelings of exclusion and difference; and (3) in fulfilling a desire for calm, comfort, and support and relieving symptoms of withdrawal.

Managing Stress: Feeling like a Prisoner

Most current smokers mentioned that smoking helped them to cope with the stressors or daily obstacles and demands in their lives associated with their mental illness. This stress was derived from numerous, and in some cases interconnected, cultural, social, physical, physiological, and financial factors. The stress of being ill and learning to cope with mental illness and its attendant concerns and managing the health problems associated with smoking and the stressors associated with school, caregiving, military service, and money took a substantial toll on many participants. One participant noted that unlike "the average person," people with mental illness have a "constant state we're trying to just maintain." Several people mentioned that they live in fear of their mental illness getting worse and, as a result, tend to focus on maintaining their current mental health, when things are good, at all costs. Maintaining one's mental health typically required regular and consistent use of psychiatric medications. One participant described how his reliance on medications makes him feel like a prisoner:

Similarly, another participant described how the unpredictability of her mental health and the fear of the unknown contributed to daily stress that is unique to people with mental illness:

Participants described how cigarettes create a sense of comfort that helps to reduce this stress. In the words of a current smoker,

In feeling trapped by the limited number of things they could do, participants spoke of smoking as providing a rare opportunity to exercise their rights, sense of independence, and freedom of choice. A current smoker said, "I want to keep smoking because I believe in individual freedom, and even though the whole world is down on cigarettes, I want to be able to smoke."

Being "A Part Of"

Furthermore, participants noted that tobacco use is a result of feeling excluded and misunderstood. Several participants noted that they smoke to relieve feelings of isolation. According to a former smoker,

This participant articulated the ways in which she strived for inclusion, avoided separation, and negotiated difference in her own life. She described a sort of hierarchy of normalcy. As a result of her mental illness, she felt marginalized and, thus, relegated herself to part of the fringe. Her "toolkit" analogy suggests that smoking becomes an easy and accessible method for feeling included until one has other "hammers" at one's disposal.

Creating Comfort

As a consequence of the tensions, worries, and complexities in their lives, the participants described longing for calm and tranquility. Although many recognized that smoking created a "false sense of comfort," they still found it effective in helping them to manage their emotions and feel at ease. For example, one participant described how cigarettes could prevent an anxiety attack:

In a similar manner, others said that cigarettes calmed unwanted or difficult thoughts and feelings. Smoking allowed people to avoid taking things too personally, reduce excessive worry, and even manage hallucinations. One participant related how she turns to cigarettes when experiencing auditory hallucinations:

For some participants, particularly during stressful times, cigarettes served as a friend and a reliable source of social support. One former smoker said that "cigarettes [were] the only way I was going to get through.... They were my friends, and they pulled me through."

Finally, cigarettes were described as a source of comfort because they could eliminate the discomfort of withdrawal. Many of the participants felt that their desire to smoke ultimately came down to feeding their addiction to nicotine. Some participants described these cravings or addictions as something that is "not your fault, you're just born with it," which created a feeling "like you're going to die if you don't have them [cigarettes]."

FORCES INFLUENCING TOBACCO USE FOR MENTAL HEALTH CONSUMERS

Participants described marketing/economic, cultural, and political forces that shaped their decisions to smoke and to quit. These included the influences of the tobacco industry, changing norms around smoking, and institutional smoking policies and culture change in psychiatric hospitals.

"Being Brainwashed" by the Tobacco Industry or Mental Health Consumers as Tobacco Consumers

Participants were aware of "being brainwashed" as a result of the advertising tactics used by the tobacco industry. They recalled events in which they obtained free cigarettes and received coupons by mail, and they illustrated examples of ways in which the industry attempted to create a positive image of smoking by associating it with popular household brand names. It is interesting to note that although participants did not discuss the ways they were targeted by the tobacco industry because of their mental illnesses, they described feeling targeted as "consumers" because of gender, level of income, and military service.

Changing Norms and "Social Smoking"

Although the tobacco industry has targeted smokers and potential smokers for as long as it has existed, changes in cultural norms and values and shifts in the social, political, and economic climate have created powerful grounds for people to start or quit smoking. Participants noted that smoking lost its appeal within their social networks. Although many noted that they started smoking to fit in and feel comfortable in social situations, they described how changes in norms and values eventually created an image of smoking as a risky and unpopular behavior, which transformed it into a barrier to socialization. One former smoker described this shift in social norms around tobacco:

It is interesting to note that although smoking continues to be seen as a social activity, most of the current smokers mentioned that they typically smoke alone and prefer it that way. Only one participant, who preferred to smoke while gambling in casinos, described herself as a "social smoker."

It is rather unsurprising that nonsmokers saw the shift to smoke-free policies as a positive change, one person even describing it as "like a dream come true." It is noteworthy though, that current smokers overall were also pleased with the many changes in norms and social policies that limit smoking, seeing these changes as an opportunity to protect themselves from the dangers of secondhand smoke and a potential motivation to quit.

Institutional Smoking Policies and Culture Change in Psychiatric Hospitals

Historically, cigarettes were used as a reward for good behavior and as a way to relate to staff in psychiatric settings. Now, the culture change around tobacco use is also evident in psychiatric hospitals. Although initially excluded from Joint Commission on Accreditation of Healthcare Organizations (now simply known as the Joint Commission) standards requiring hospitals to be smoke free (Shmueli, Fletcher, Hall, &, Prochaska, 2008), psychiatric hospitals are increasingly creating policies to protect patients and staff (Parks & Jewell, 2006; Shmueli et al., 2008). One participant recounted being given cigarettes by guards during regular designated smoke breaks while receiving care in a hospital nearly 30 years ago. These days, another participant noted, when receiving care in a smoke-free hospital, you cannot smoke at all during your treatment: "Not only are they trying to deal with whatever they're being 5150'd [involuntarily psychiatrically held] for, but they're trying to deal with the fact that they can't get up in the morning and have a smoke."

In general, participants seemed to support these changes in hospitals. The major critique of this shift in policies was that, in some cases, NRT was not provided to ease the symptoms of withdrawal:

For some, as indicated in this quote, NRT was not provided during their hospital stays. In other situations, people were "given" the patch or gum while being treated in an inpatient setting but were not provided with education regarding how NRT works or how to use it safely if they were fortunate enough to have access to it on returning to the community. Moreover, some participants noted that their cigarettes were taken away at admission but were returned at discharge without any recommendation or discussion about quitting. Overall, many smokers receiving care in smoke-free inpatient settings felt that smoke-free policies presented a missed opportunity. Lack of access to NRT in the hospital or education about its proper use in the community ultimately lowered their confidence in their ability to quit and led many to return to smoking immediately after discharge.

TENSIONS AND COMPLEXITIES IN ADDRESSING SMOKING AMONG MENTAL HEALTH CONSUMERS

A final theme that emerged from analysis of the focus group interviews was the tensions and complexities that exist in addressing smoking cessation among people with mental illness. In some cases, focus group participants described these tensions explicitly, whereas sometimes they were inferred or arose through participant observation. The tensions discussed in the focus groups included opinions about the possibilities and probabilities of recovery, the role of psychiatric medications in influencing smoking, the financial cost of tobacco use and quitting, and the hierarchy of health concerns for people with mental illness.

Recovering as the Exception to the Rule

A conscious shift has occurred in the mental health community from a focus on maintenance to an emphasis on wellness and recovery (Solway, 2009). Yet, when asked how they felt about their prospects for recovery, many participants focused on the perceptions of others. Several participants stated that they felt that others had given up hope and did not expect them to recover. One participant said he felt that, as a society, we are more likely to believe in the rehabilitation of "ex-cons and people who have broken the law" than the idea that people with mental illness can return to and lead a full, ordinary life. Some participants expressed that cigarettes actually helped to reduce or make more tolerable the feelings of hurt and disappointment that come with this realization. They subsequently expressed their own diminished sense of hope regarding their chances for a "normal" future. For example, although they found the stories of other people with mental illness who had gone on to lead exemplary lives as doctors and lawyers inspiring, they saw these success stories as "exceptions to the rule."

"Mixing Up" Medications and Smoking

Several participants felt strongly that certain psychiatric medications, although effective for addressing the symptoms of their mental illness, also contributed to their smoking. Although participants tended not to talk with their providers about this connection between medications and tobacco use, they were made aware of the relationship through their own experiences and the experiences shared by others. The person who attended the trying to quit focus group said she knew of many people who were struggling in their efforts to quit and who felt, like her, that "somehow the medication and the smoking is mixed up. Like ill could get off this ]medication used to treat bipolar disorder], I could stop smoking." This resulted in great frustration given the participant's understanding of her need for her medication. She noted that her medication made her feel like she was "living in a fog," which made her "want to smoke more cigarettes" to relieve the fog. Eventually, this participant found it necessary to reconcile her strong desire to quit with the realization that "I'm going to have to be on that medication so that's--that's a given." She described her frustration in being caught in this quandary: "It's just like you think you going to die if you don't have them [cigarettes], you know, and you know you might die if you do."

Paying for Tobacco

Whereas nonsmokers commonly mentioned the high price of cigarettes as a deterrent to smoking, most former and current smokers, although they did not have high incomes, appeared relatively unconcerned by the rising cost of cigarettes. Although some said that they would quit if the price of a cigarette went up to a certain point, they found that even when the price did increase beyond it, they would continue. Others just accepted the fact that cigarettes would continue to spiral up in price, and so price did not serve as a motivation for quitting. Some participants reasoned that smoking is a "lifestyle," and spending money on tobacco is just like spending money on other things for one's enjoyment, like new clothes or travel, regardless of the cost. One current smoker said, "Come on, you're going to spend it on something anyway, so what--why not get something that makes you feel good?"

Yet these same participants noted that NRT, which costs approximately the same amount as cigarettes, was prohibitively expensive. Although they wanted to quit and were interested in trying different aids to help, they felt they could not afford these medications, nor could they successfully overcome the barriers to receive free or discounted NRT. In cases in which participants could no longer afford their brand of cigarettes, they would first try switching to a less expensive brand or would purchase "singles" for a quarter. In more extreme cases, when money was tight and cravings intense, participants described their willingness to endure behaviors they found self-degrading, humiliating, or unwise like "gutter sniping dirty cigarettes" [smoking used cigarettes found on the street] .They noted that although they were concerned about picking up germs from others, this was a behavior they would not choose to engage in if they were not poor, addicted, and experiencing withdrawal symptoms. It was apparent that quitting was not an obvious option, even when people could no longer afford to smoke.

Creatively Maneuvering through the Health Hierarchy

Finally, one of the greatest tensions experienced by mental health consumers is what can be called the health hierarchy. The health hierarchy illustrates the dangers of smoking as compared with the risks of other behaviors that people with mental illness may also choose, or feel encouraged or compelled, to engage in. The participants described engaging in complex, personalized analyses and calculations to determine the ways in which various behaviors might benefit or hinder their own health and well-being. Then they would decide where smoking falls within this hierarchy.

For some participants, largely those who had never smoked or who quit, smoking was seen as a major health concern that they considered more unhealthy and damaging than most other behaviors. Thus, smoking was placed near the top of their constructed health hierarchy. For others though, specifically current smokers, tobacco use was considered "a lot better than other habits." Many current smokers noted they were likely to pick up another habit that could be "just as bad as smoking" if they quit. Current smokers constantly compared their own smoking with others' behaviors that they saw as equally or even more problematic and burdensome than smoking, including gaining weight, getting numerous tattoos, shopping excessively, hoarding, and using marijuana. In particular, gaining weight presented a significant concern. Participants felt that smoking decreased their appetite and was, therefore, effective for weight management and that quitting would inevitably result in overeating and a host of other complications. As one participant said,

At least six participants, including those who identified as former smokers, hinted that they smoked marijuana as a substitute for cigarettes. The actual number could be substantially higher as participants were not specifically asked about marijuana use. One participant said that when he started to smoke marijuana, he thought, "this is great, I don't smoke cigarettes," whereas another commented, "if you're smoking pot, still--you're smoking, it's the same as cigarettes." Participants noted that marijuana served as a social activity, and they saw it as less harmful to their health, less addictive, and more socially acceptable than tobacco.

DISCUSSION

This study indicates that tobacco use among people with mental illness is a result of complex personal and social experiences and phenomena that shape the opportunities and motivations for smoking and quitting. By and large, each participant, regardless of his or her smoking status, saw cigarettes as an effective and available coping tool for finding relief from pain, grief, anger, and sadness as well as fulfilling the needs to fit in, feel supported, and avoid withdrawal. Smoking among people with mental illness represents a layering of stigma in which the stigma associated with mental illness is coupled with the stigma associated with smoking. The overarching themes that emerged from the present data were that smoking provides individuals with mental illness with perceptions of normalcy and belonging and feelings of control. The need to avoid feeling different and the desire to fit in resulted in the decision to smoke, even if it meant fitting in with "the fringe" rather than the mainstream population. The drive to create a sense of control through smoking stemmed from the lack of control individuals felt they had over their lives as a result of their illnesses and the lack of control over the intense stress they experienced on a daily basis and within their social relationships. Ultimately, people began to think about quitting and attempted to quit if and when smoking failed to meet those needs or when they were made aware of serious health concerns and chose to take action.

Seven of the 11 individuals who participated in the focus groups for current smokers described a desire to quit, which is consistent with the 70 percent of people with mental illness who want to quit described in previous research (Lucksted, McGuire, Postrado, Kreyenbuhl, & Dixon, 2004). Although current smokers said that smoking helped improve their mood, anxiety, and concentration, this may have been because they did not recognize that they were using tobacco to prevent or treat the unpleasant symptoms of withdrawal (Williams & Ziedonis, 2004). It is interesting to note that although research indicates that a multicomponent program that combines NRT with motivational enhancements and relapse prevention is most effective, most former smokers described quitting cold turkey (Schroeder, 2009).

The present study is unique in that it included focus group interviews with people with mental illness of various smoking statuses. The results were in some cases similar, yet also different from the results of the two previously published qualitative studies on this topic that included only current smokers with mental illness. Lawn, Pols, and Barber (2002) interviewed 24 people living in the community with various mental illnesses and attempted to make comparisons on the basis of diagnosis. Similar to the results described here, they found that participants had little hope of recovery, saw cost as a main barrier to NRT use, and noted that their health care practitioners rarely asked about their smoking. Unlike the present research, Lawn et al. also found that the participants saw smoking as part of their identity and as a way to differentiate themselves from family and friends, and they viewed smoking and its health consequences as a method for ending the despair they experienced. Esterberg and Compton (2005) applied the transtheoretical model to the smoking behaviors of 12 people (average age of 25 years) with first-episode and chronic schizophrenia-spectrum disorders who received inpatient care. Many participants emphasized the perceived benefits of smoking. Esterberg and Compton also found that there were differences between first-episode patients and chronic patients in that those hospitalized for the first time demonstrated less insight into their smoking and had a lower perceived dependence on nicotine.

Future Research

Future research should continue to explore the themes that arose from this research on the perspectives of people with mental illness. For example, the participants in this study noted from their personal experiences that certain medications may trigger cravings for tobacco. Campion, Checinski, Nurse, and McNeill (2008) found that individuals on typical antipsychotics smoke less when switched to an atypical antipsychotic with fewer side effects, but this effect requires further study. Also, people with mental health problems, or what the tobacco industry calls the "psychologically vulnerable," have been targeted as desirable, "downscale" consumers, as indicated by internal tobacco industry documents (Apollonio & Malone, 2005; Lasser et al., 2000). The role of the tobacco industry in encouraging tobacco use among people with mental illness deserves further attention, especially as it relates to the experiences of smoking and quitting for mental health consumers. Moreover, additional research should be conducted on how to help people with mental illness who are thinking about quitting to actually try to quit smoking. Another area for potential research is in examining the psychiatric hospitals that have been successful in developing and enforcing smoke-free policies and the alternatives to smoke breaks integrated into the daily programming and activities. Finally, people with mental illness tend to be dependent on limited, fixed incomes, and cigarettes can take up 27 percent to 36 percent of their monthly budget (Mechanic, Bilder, & McAlpine, 2002; Steinberg, Williams, & Ziedonis, 2004). Although many of the focus group participants stated that they did not find it challenging to pay for cigarettes, further research should examine the financial, health, and social implications of quitting for people with mental illness. Indeed, the implication of this work is that without fully understanding the perspectives of people with mental illness themselves, efforts to address tobacco use in this population will achieve limited success.

Limitations

The participants in this study represent a nonrandom sample of people with mental illness living and receiving outpatient services in a large urban area--one with a particularly well-developed antitobacco culture. I made no attempt to determine whether the insights of people with mental illness are similar to or different from the experiences of smokers and nonsmokers without mental health conditions. The results presented here are based on the views of a small purposive sample of participants and participant observation, but given the diversity among participants in gender, ethnicity, age, and level of education and the fact that saturation was achieved in this study, these findings are likely applicable to other people with mental illness. Finally, a current smoker was defined as someone who had smoked within the last 30 days, and a former smoker was defined as an individual who had not used tobacco within the past month. Abstinence from smoking in the previous month does not ensure that a person has or will quit for good, but abstinence of a month or longer was actually rare for many focus group members, and the ability to quit for even several weeks at a time demonstrates an ability to overcome many of the barriers associated with quitting.

CONCLUSION

A culture that supports tobacco use in mental health settings coupled with poor access to preventive health care and an oppressive treatment system creates a fertile ground for neglect of smoking and the feeling among mental health consumers that they lack the ability to quit. For many current smokers, cigarettes are an enjoyable choice and a pleasurable distraction from the drudgery of and unpredictability associated with managing their mental illness and an activity that they see as having benefits that outweigh its potential risks and the risks associated with other behaviors. Former smokers described the important influence that tobacco had in their lives and the ways in which their lives changed for the better after quitting. The conversation with nonsmokers suggests that although mental health consumers may live in a world in which their mental health is considered central, physical health, for many, is of great importance too, and many mental health consumers consistently strive for improved health and wellness. Those thinking about quitting who desperately hoped to live tobacco free demonstrated the challenges of trying to quit and the ways in which structural and systemic forces influence achievement of this goal.

Policy Implications

There are several ways in which changes in policy could better support people with mental illness in trying to quit smoking. Policy should support the creation of tobacco-free environments in community-based mental health programs for people with mental illness receiving outpatient mental health services similar to the policies that have created tobacco-free psychiatric hospitals. Moreover, Medicare and state Medicaid programs should cover pharmacotherapy and counseling to encourage quit attempts for all people, including those with low incomes, older adults, and people with disabilities. On the macro level, policies that support the integration of mental health and primary care services can help to support people with mental illness in engaging in health-promoting behaviors. Prochaska, Hall, and Bero (2008) asked, "Might it be that the mentally ill are the largest remaining group of smokers, not because they need to smoke, but rather because they are among the last to be treated?" (p. 562). The creation of policies and practices that remove barriers to cessation treatment and support will help to give people with mental illness the opportunities they need and the desire to quit for good.

An Important Role for Social Workers

This article suggests that although living with a mental illness may present unique challenges to quitting smoking and living tobacco free, people with mental illness have a strong desire to quit smoking and strive to live the healthiest life they can. Social workers can play an important role in addressing tobacco use among people with mental illness, helping to lower rates of morbidity and mortality and improve quality of life. Furthermore, although people with mental illness may have a strong desire to quit, mental health clinicians are less likely than other providers to ask about their smoking status or provide cessation counseling (Himelhoch & Daumit, 2003; Prochaska et al., 2004). One of the simplest ways to make a difference is to practice "ask, advise, refer": ask about tobacco use; advise your client to quit; and refer him or her to local resources for additional information and support, including the national toll-free quitline (1-800-QUIT-NOW) which provides telephone-based counseling and information on cessation from trained experts. Social workers can also serve as valuable advocates in securing low-cost NRT and in developing support groups for people working toward quitting.

Thirty percent to 35 percent of staff in mental health facilities smoke, making rates of smoking among staff considerably higher than those in the overall population (Bernstein & Stoduto, 1999; Parks & Jewell, 2006). Social workers who smoke should also use the free quitline services so that they can serve as role models for their clients who are trying to quit. Ultimately, the present research demonstrates that although people with mental illness aspire to optimum health, they do not necessarily see wellness and recovery as real possibilities in their lives. We, as social workers, can play a critical role in making health, longevity, and quality of life a reality for people with mental illness by addressing tobacco use and providing unwavering support and education for those thinking about quitting and during attempts to quit and live tobacco free.

Original manuscript received November 24, 2009

Final revision received April 16, 2010

Accepted June 22, 2010

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Erica Singer Solway, PhD, MPH, MSW, is program director, Older Adult Day Support Center/Community Integration Services, Family Service Agency of San Francisco, 1010 Gough Street, San Francisco, CA 94121; e-mail: esolway@fsasf.org. The author acknowledges assistance from Steven Schroeder and Catherine Spensley and support from the Anselm L. Strauss Fund, the Centers for Disease Control and Prevention (Public Health Dissertation Award R36), the Smoking Cessation Leadership Center, and the University of California, San Francisco (Graduate Student Research Award).
I have some vanity. I don't want to be walking
   around pulling an oxygen thing but what choice
   do I have--have I given him by my smoking?
   And by, you know, whatever, my unwillingness
   or just not being able to get myself to stop,
   you know.


I got bronchitis, and the doctor said that if I
   kept smoking I would get chronic, as opposed
   to what I had, acute bronchitis. So that was
   enough. I just gave my cigarettes away, and that
   was the last of it.


Well, I've quit for periods of time. Several months
   at a time a bunch of different times. I think part
   of it has to do with managing my emotions.
   ... If you want to calm down, you smoke one;
   if you want to perk up, you smoke one. Like
   someone said something and I felt insulted, so
   I--this last time, about two months ago--so I
   went and bought a pack of cigarettes.


Well, you're kind of like a prisoner in a way,
   because you have to have this medicine. Without
   the medicine ... it would be horrible. So, you
   know, they pacify us, they give me medicine
   here once a week, and without it, I can't do
   anything.


I think, in general, we are under more stress
   than Public Citizen 101, the regular person that
   just gets up in the world and goes out every
   day. When I wake up in the morning, I have
   to wonder, "Is this going to be a bipolar day?"
   I have to wonder that as I go to my medicine
   cabinet to get my toothbrush ... "am I going
   to be manic today? Am I going to just be able
   to take my Depakote and make it through?"
   The average person doesn't do that. The average
   person just gets up and brushes their teeth, you
   know what I'm saying?


Well, when you're a mental health consumer,
   there's a lot of things that you'd like to do that
   you can't do, and it's frustrating ... and cigarettes
   pretty much curb appetites for a lot of things. So
   if I don't have anything but a pack of cigarettes
   in my room, I can handle stuff.... So cigarettes
   at least can take away--can create a fantasy that
   you're okay.


I feel that mental health patients are made to
   feel apart from rather than a part of society and
   culture. So when you're on the periphery or
   pushed to the periphery like that, you're isolated
   and made to feel alone. So you pick up whatever
   tools you can find if you're on edge to try to
   feel a part of and make yourself a part of. Well,
   if you don't fit in with the general population
   anymore, then you look for what the fringe
   population is doing, and the fringe population
   is smoking.


When I was stressed, cigarettes would relax
   me. When I would start to have the start of
   an anxiety attack but not quite go into one, I
   would feel like if I got a cigarette quick enough,
   it could take me out of going all the way to an
   anxiety attack. So I felt they were very helpful
   in that sense. They could somehow ground me
   and relax me.


You'll be edgy, and the cigarette takes some of
   the edge off.... Like you sit there and try to
   calm yourself and talk yourself into saying that,
   no, you're not hearing nothing or you're not
   seeing nothing, but you are, so you're going to
   keep smoking.


I went in the military, and everybody smoked ...
   whenever you took a break, you could socialize
   because there was a group of smokers, and
   you all went in a group.... All of a sudden, the
   bars became healthy and you couldn't smoke
   in the bars anymore.... All of a sudden, I was
   the only one smoking, and I was the only one
   that was smelling of it on my clothes, and I was
   noticing that people were reacting to me and
   I didn't want to be the odd man out anymore.
   ... Finally, one day, that just got to me where I
   said, "What am I doing it for?" I started doing it
   to socialize, and now it's not working anymore
   for what I do it for.


So, say someone goes in for 5152, a 14-day
   hold, and they're a smoker, can I go up to the
   counter on the second day and say, "Give me a
   Nicorette patch"? No, there's no alternative. I'm
   stuck there for 14 days, and I'm being denied
   my cigarettes when I could have just come in
   from smoking two packs a day the day before,
   and they don't offer you any alternative.... If
   they gave you the Nicorette for the two weeks
   you're in there, by the time you got out, you'd
   be a nonsmoker.


Well, I noticed that she's [a friend] getting bigger
   and bigger, and I don't want--I have enough
   problem with my weight now, and it's like too
   hard on my knees. So I don't want to do something
   that's going to make me eat all the time.
   But I know that I'm going to be wanting to
   have something in my mouth, and hard candy
   may not do it."


Table 1: Demographics of Study Participants (N = 26).

Demographic                             Percentage
Variable and Category              n     of Total

Smoking status
  Former smoker                     7       27
  Trying to quit                    1        4
  Never smoker                      7       27
  Current tobacco user (a)         11       42

Gender
  Male                             16       62
  Female                           10       38
Race
  White                            14       54
  Black                            10       28
  Hispanic                          1        4
  Biracial                          1        4
Education
  Some high school                  3       12
  High school graduate              4       15
  Some college/associate degree    11       42
  College graduate                  4       15
  Master's degree                   4       15

(a) Eleven current tobacco users participated in the focus
group interviews. These 11  people participated in one of
two groups (six in one group and five in the other).
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