Tobacco use and its treatment among young people in mental health settings: a qualitative analysis

Nearly all adults who smoke start smoking before the age of 26, making tobacco use a pediatric problem (U.S. Department of Health and Human Services, 2012). In the United States, each year, over a million adolescents become regular users of tobacco (Stevens, Barron, Ledbetter, Foarde, & Menard, 2001). The decline in youth smoking during the 1990s has stalled, and the Surgeon General’s 2012 report on smoking among adolescents called for greater attention to this national epidemic (U.S. Department of Health and Human Services, 2012). According to recent U.S. surveys, 23% of high school students and 36% of young adults aged 18–25 use tobacco, the latter being the highest smoking rate among all age groups (Centers for Disease Control and Prevention, 2012; Substance Abuse and Mental Health Services Administration, 2010). Smoking rates are further elevated among youth with psychiatric disorders such as attention deficit, conduct disorder, depression, anxiety, and alcohol or illicit drug dependencies (Mermelstein, 2003). A study of adolescent psychiatric inpatients found that 60% were current smokers with 40% smoking a pack or more daily (Ramsey, Brown, Strong, & Sales, 2002). Another study reported that half of 14- to 17-year olds with anxiety symptoms and two thirds of those with depressive symptoms used tobacco (Dudas, Hans, & Barabas, 2005). The reciprocal also is true. Youth who smoke are at increased risk of developing mental illness compared with nonsmokers, including major depressive disorder, agoraphobia, generalized anxiety disorder, and panic disorder (Chang, Sherritt, & Knight, 2005; Choi, Patten, Gillin, Kaplan, & Pierce, 1997; Hanna & Grant, 1999; Johnson et al., 2000). Decreasing youth smoking is imperative for addressing chronic use and the incidence of tobacco-related illnesses (Al-Delaimy, White, & Pierce, 2006). With a median age of smoking initiation at 14 years (U.S. Department of Health and Human Services, 1988), the typical adolescent smoker will smoke for 18 years if male and 22 years if female (Giovino, 1999). Smoking during adolescence is predictive of health problems at age 30, including respiratory ailments, neurobehavioral and cognitive problems, and general malaise (Brook, Brook, Zhang, & Cohen, 2004). Tobacco-related health consequences also may emerge relatively early as suggested by findings of significant respiratory problems among heavy smoking youth in addictions treatment programs (Myers & Brown, 1994). Tobacco use can complicate psychiatric treatment, increasing the metabolism of some antipsychotic and antidepressant medications (Zevin & Benowitz, 1999). In prospective studies, tobacco use is one of the strongest predictors of suicidal behavior in youth and adults, even after controlling for depressive symptoms, other substance use, and prior suicidal behavior (Breslau, Schultz, Johnson, Peterson, & Davis, 2005; Oquendo et al., 2004). In regions where smoking is greatly restricted, heavy smokers with mental illness may find it difficult to participate socially, leading to isolation (Prochaska, Fletcher, Hall, & Hall, 2006). A Healthy People 2020 objective for the nation is to decrease the adolescent smoking rate to 16% (U.S. Department of Health and Human Services, 2010). Without intervention, few adolescent smokers stop smoking on their own (Mermelstein, 2003). Although an estimated 51% of high school smokers report a quit attempt in the past year (Centers for Disease Control and Prevention, 2010), only about 4% are successful (Zhu, Sun, Billings, Choi, & Malarcher, 1999). One-year abstinence success rates are even lower (2%) among adolescents with co-occurring addictive disorders (Myers & MacPherson, 2004). Adolescent preventive service guidelines recommend clinicians regularly assess and treat tobacco use with their patients (American Medical Association, 1997; American Academy of Pediatrics, Committee on Substance Abuse, 2001). Yet, a minority of child and adolescent psychiatrists report consistently asking about smoking, advising their patients to quit, assessing readiness to quit, offering assistance, or arranging follow-up with cessation efforts, referred to as the 5 A’s of tobacco treatment (Price, Sidani, & Price, 2007; Upadhyaya, Brady, Wharton, & Liao, 2003). A recent review of predictors of cessation in adolescent and young adult smokers concluded from the sparse literature that tobacco treatment interventions will remain less than optimally effective until there is a solid evidence base on which to develop interventions (Cengelli, O’Loughlin, Lauzon, & Cornuz, 2012). None of the studies reviewed focused on youth with mental health concerns. Further, the outpatient mental health setting has not been examined as a venue for treating youth tobacco dependence. Research is needed to better understand the smoking behavior of adolescents and young adults with co-occurring psychiatric disorders and the viability of delivering tobacco treatment in outpatient psychiatry settings. This study obtained formative data from patients and clinicians to guide development and delivery of a tobacco cessation program for transitional age youth (aged 16–24) with co-occurring psychiatric disorders. The World Health Organization (1989) defines youth as spanning 15–24 years of age. Transitional age youth are further defined as young people between the ages of 16 and 24 who are at risk and in need of coordinated services during the developmental transition from adolescence to young adulthood (Kenney & Gilis, 2009).