The first time she tried to stop smoking, April Vargas pulled off the nicotine patch she had been wearing for less than an hour and lit a cigarette. On the second attempt, she tossed her tobacco in a dumpster. She was smoking again the next day.
To a longtime smoker, Vargas’s struggle to quit might sound familiar. But the 52-year-old from Worcester may have added factors working against her: She has severe anxiety and depression.
Adults with mental illness are far more likely to smoke, putting them at greater risk for health problems and a shortened life, a report released last month by the Centers for Disease Control and Prevention found.
While a national anti-smoking campaign and the ever-increasing cost of cigarettes have dramatically lowered overall smoking rates in the United States over the past 50 years, more than a third of people with mental illness smoke — 36 percent between 2009 and 2011, compared with 21 percent of people with no mental illness.
The report does not include people who struggle with substance use but have no other mental illness. When that group is included, smoking rates are even higher.
Some mental health specialists say people with certain disorders may be genetically predisposed to nicotine addiction or see cigarettes as a means of easing nerves and staying focused. Some fear that, without cigarettes, they would need to increase their medications.
“They rely on the cigarettes to soothe their symptoms — what the medications don’t,” Vargas said. The cigarettes help in “handling what they don’t know how to handle.”
People with mental illness may be less able to navigate the health care system to get to the doctors, support groups, or cessation tools that can help them quit. And, despite the significant health risks, many doctors or therapists have seen smoking as a problem that is secondary to managing symptoms of schizophrenia or depression.
Years ago, cigarettes were a pervasive part of mental health treatment, a mode of socializing at group homes and a reward given for good behavior at inpatient facilities.
“I think it’s really important to recognize that some people learned to smoke in hospitals,” said Dr. Ken Duckworth, medical director for the National Alliance on Mental Illness.
While smoking is prohibited today in nearly all mental health facilities, with many banning it even from the grounds outside, Duckworth said that the history of cigarettes in treatment has led some who work in mental health to be less aggressive in urging patients to quit.
“That’s part of how the culture plays into the reality,” he said.
But that culture may be changing. State and federal laws are pushing hospitals and doctors to pay more attention to the medical needs of people with mental illness, investing in changes that could save the health care system money in the long run. Some say it’s about time.
“Why have we been waiting for this all along? We don’t know,” said Bruce Bird, chief executive of Vinfen, a nonprofit that provides community-based services for people with mental illness and developmental disabilities. “But it’s finally here.”
The evidence has been clear for years that people with mental illness have far higher rates of physical illness than the general population. Duckworth began studying the issue in the 1990s, when he was medical director for the state Department of Mental Health.
In 2001, the agency completed a report documenting those disparities. Among the most alarming figures was that heart disease killed the department’s clients between ages 25 and 44 nearly seven times as often as in the state’s overall population.
The study helped to prompt a national examination of medical disparities for the mentally ill. The National Association of State Mental Health Program Directors published a report in 2006 with this alarming statistic: People with serious mental illness die about 25 years earlier than the general population.
While suicide accounted for about 30 percent of the difference, most of the disparity was attributed to medical conditions, such as heart and lung disease. The group cited smoking as a major risk factor, along with poor nutrition and lack of exercise.
Duckworth called the high smoking rates highlighted in the CDC’s report a public health crisis, but a preventable one. “I think there is an opportunity here,” he said.
Others see it, too. Starting in 2009, the Department of Mental Health asked every person referred to the agency about their smoking history and offered cessation counseling.
“When people start paying attention to the needs of individuals with mental illness, it’s important and it’s significant,” said Commissioner Marcia Fowler.
She is optimistic that a health care cost control law, signed last summer by Governor Deval Patrick, that mandated a review of how to improve mental health care in the state could help.
Groups outside of government are focused on the issue, too.
Genesis Club is part of a network of clubhouses for people with mental illness, funded by the state and with private donations. While they provide some addiction recovery services, the clubhouses have historically operated outside of the health care system, focusing on job skills, education, housing, and support services.
Around the same time that the state was looking at health disparities, the Worcester clubhouse started looking at members’ broader well-being.
Obesity was a major problem, said Executive Director Kevin Bradley. When it affected members’ stamina or ability to stand for more than a short period, it also limited their chances of finding employment.
The clubhouse began taking members to work out at a nearby gym. Five years ago, leaders there worked with the University of Massachusetts to develop a program focused on nutrition, exercise, and smoking cessation that has become an example for groups around the world that use the clubhouse model.
Vargas, a member of the Genesis Club, smoked three packs a day when she joined the Healthy Living program two years ago. She struggled to walk the mile and a half from her apartment to the clubhouse.
“I’d huff and puff,” she said. “My breathing was out of control.”
Vargas tries to never miss the group’s weekly meeting. She’s learned how to eat healthier and gotten the encouragement she needed to lose about 100 pounds. Walking is getting easier, she said. “When it feels good in my legs and in my steps, it makes me walk even faster.”
The course has taught her about the dangers of smoking, including interactions with her medication. She said learning how secondhand smoke can affect her miniature dachshund and her grandchildren has been a motivator.
Two years ago, members decided to prohibit smoking on the club’s grounds. Small groups still gather on the sidewalk outside, but losing the social atmosphere of the smoking patio, where there was always a crowd, has helped, Vargas said.
Last week at Genesis Club, Vargas exhaled into a carbon monoxide meter, to measure how much of the gas was in her breath — a proxy for how much had entered her blood through smoking. When she started Healthy Living, she said, she clocked in at 68 parts per million, close to the level that could set off a home alarm. (A non-smoker would register in the low single digits.) Her eyes widened as the screen flashed her latest reading: 22 parts per million.
Later, she described her progress like this: “Breathtaking.”
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