East Tennessee State University
Reduction of Smoking
Rate among Psychiatric
Patients in Tennessee
Master’s in Public Health: PUBH 5907
Sonali Kumari
Spring
2012
Executive Summary
Tobacco use is the leading cause of preventable premature death and disease in the United States.
Mental disorders are strongly related to smoking behaviors and smoking prevalence is two to four
times higher in mentally ill and substance abusers as compared to the general population. This study
strives to assess smoking and quit rates among adult population in Tennessee and the accessibility
and availability of resources for smoking cessation in psychiatric population. The primary source of
data is National Health Interview Survey 2009 as a proxy for the state of Tennessee. The results
show that 40.7% of the respondents who mentioned that they had depression/anxiety/emotional
problems causing difficulty with activity were current smokers and 21.6% were former smokers. This
shows a high rate of smoking among psychiatric patients as compared to general population. 50% of
sample adults who mentioned alcohol/drug/substance abuse problem causing difficulty with activity
were current every day smoker as compared to 34.4% of sample adults with
depression/anxiety/emotional problems who were current every day smoker. Smoking rate is higher
in people who abuse alcohol/drug and other substances than people with depression/anxiety and
other emotional problems. Sample adults who mentioned other mental
problems/ADD/Schizophrenia causing difficulty with activity had a smoking rate of 47.9% with 39.6%
every day smoker and 8.3% some day smoker and a former smoking rate of 18.8%. These findings
show a high rate of smoking among adults with mental illness.
-1-
Table of Contents
Introduction
4
Educational goals and objectives
4-5
Background
5-9
Mental health and mental illness
Tobacco and mental illness
Significance of study
10-11
Tobacco cessation
Tobacco industry
Tennessee
12-23
Prevalence of smoking in Tennessee
Poor mental health days in Tennessee
Smoking laws in Tennessee
Mental health facilities in Tennessee
Model of study
23-26
Study design
26-29
Results
29-32
Limitations of study
32
Discussion
32-33
Conclusion
34
Tables
35-46
References
47-50
-2-
Introduction
Tobacco dependence among people with mental illnesses contributes to increased morbidity and
mortality that are preventable. The issue of smoking in mentally ill population is largely ignored and
not treated. The question here arises “Why do people with mental illness smoke more than the
general population?” According to researchers, biological and psychosocial factors reinforce nicotine
use in this population. In the past, smoking was used as a positive reinforcement in the psychiatric
inpatient units and has been integrated in the psychiatric culture. The properties of nicotine further
contribute to smoking in mentally ill. Nicotine increases alertness; elates mood; helps relaxation and
stress; might have an anti-depressant effect; might reduce negative symptoms like hallucinations;
reduced levels of anti-psychotic induced parkinsonism like tremors, slowed movements, rigidity,
postural instability; relieve boredom and provide a framework for those with few daily activities; and
improve social interaction. (1) At the same time, nicotine is an addiction drug (2) (3), which is even
stronger than substances of abuse such as heroin and cocaine (4).
Educational Goals and Objectives
Goals:
The primary goal of this study is to assess the smoking and quit rates among psychiatric patients and
improve theirhealth status through appropriate interventions.
Objectives:
1. Assess smoking and quit rates among adult population in Tennessee.
-3-
2. Explore resources available for smoking prevention and cessation among psychiatric patients
in Tennessee.
3. Examine the utilization of smoke free policy in psychiatric facilities in Tennessee.
Background
Mental Health and Mental Illness
Mental health is one of the leading indicators of the health status of a population. Healthy People
2020 aim to “Improve mental health through prevention and by ensuring access to appropriate,
quality mental health services”.(5) A healthy mind helps to make a person physically healthy and
improves the daily functioning to an optimal level. Mental Health has been defined by World Health
Organization as “a state of well-being in which the individual realizes his or her own abilities, can
cope with the normal stresses of life, can work productively and fruitfully, and is able to make a
contribution to his or her community.”(6) Mental illness is defined as “collectively all diagnosable
mental disorders” or “health conditions that are characterized by alterations in thinking, mood, or
behavior (or some combination thereof) associated with distress and/or impaired functioning.”(7)
The American Psychiatric Association (APA) developed mental illness diagnostic categories; the
Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) is
the current version of this system. Another system, the WHO International Classification of Diseases,
10th Revision, Clinical Modification (ICD-10-CM), defines mental illness categories that are similar
but not identical to those in the DSM-IV-TR. Previous DSM and ICD versions have not been
completely congruent, and APA is developing a fifth edition of the DSM (DSM-V) that will coordinate
better with future editions of ICD. Mental illnesses as recognized by Diagnostic and Statistical
Manual, 4th edition of the APA (DSM-IV) (8) include depression, anxiety disorders like phobias,
obsessive compulsive disorders, psychotic disorders, bipolar disorders and dementias (Table 1).
-4-
Table 1: Mental Illnesses
Diagnosis
Mood Disorders
Definition
Major Depressive Disorder: Presence of sad mood, diminished interest in
activities that used to be pleasurable, weight gain or loss, psychomotor
agitation or retardation, fatigue, inappropriate guilt, difficulties
concentrating, as well as recurrent thoughts of death for five or more days
for a continuous period of at least two weeks.(9)
Bipolar disorders: Patients experience episodes of mania and depression.
Mania is defined by elevated, unrestrained, irritable mood, which can
manifest as exaggerated self importance, grandiosity, sleeplessness, racing of
thoughts, pressurized speech, and tendency to engage in activities with a
high potential for adverse consequences.(10)
Seasonal Affective Disorder: Occurs in winter, patients crave for
carbohydrates rich food, overeat and oversleep.
Anxiety disorders
Excessive and unrealistic worry about everyday tasks or events, or may be
specific to certain objects or rituals like anxiety, phobias, simple phobia,
social phobia, agoraphobia, panic disorder, obsessive compulsive
disorders.(11)
Psychotic disorders: Dysregulation of thought processes specifically schizophrenia which has
symptoms of delusion-false beliefs, hallucinations-visual or auditory
Schizophrenia
information not actually present or not apparent to others. Schizoaffective
disorders which are a combination of schizophrenia and mood
disorders.(12)Types of Schizophrenia: Paranoid type, disorganized type,
catatonic type, catatonic excitement and catatonic stupor.
Somatoform
Disorders
Physical symptoms in the absence of physical cause.
Hypochondriasis: Excessive, unnecessary concern for personal health. Minor
symptoms are perceived as major / serious disorder.
Conversion Disorder: Serious sensory or motor symptoms like paralysis,
blindness in the absence of any physical cause.
Body Dysmorphic Disorder: Obsession with ugliness of body part like
distorted nose even after undergoing many reconstructive surgeries.
Dissociative
Disorders
Loss of ability to integrate a person’s normal conscious and psychological
functioning into coherent representation of one’s identity.
Dissociative Amnesia: Sudden loss of ability to recollect personal information
like name, address, profession.
Dissociative Fugue: Loss of memory and move to new place with a new
identity, new name, new family, new profession.
Dissociative Identity Disorder: Multiple personality, each with individual
-5-
name, speech pattern, hair style, memory.
Dementia
Cognitive disorders typically characterized by memory impairment, as well as
marked difficulty in the domains of language, motor activity, object
recognition, and disturbance of executive function – the ability to plan,
organize, and abstract. Alzheimer’s disease is the most common form; others
are vascular dementia, Lewy body dementia, frontotemporal dementia,
Huntington’s disease, and Creutzfeldt-Jakob disease.(13)
Childhood Disorders
Autism: Kids are oblivious to others, have inclination for non social objects,
social isolation, little or no response to stimuli with self stimulating behavior.
Attention Deficit Disorder: Inability to focus, impulsive, distractive,
hyperactive.
Eating Disorders
Associated with fear of putting on weight.
Anorexia nervosa: Distortion of body image, excessively thin with extreme
measures to lose weight.
Bulimia nervosa: Binge eating followed by purging, weight normal.
Mental health disorders are the leading causes of disability in the United States (U.S.) and Canada,
contributing to 25% of life lost to disability and premature mortality.(14) National Institute of Mental
Health estimates that in any given year 13 million American adults have serious debilitating mental
illness.(15) Suicide was the 11th leading cause of death in the United States in the year 2010.(16)
People with serious mental illness die 25 years prematurely and the leading causes of death are
cancer, respiratory and lung diseases, heart and cerebrovascular diseases.(17) The leading causes of
death in the mentally ill population is similar to that of the general population, but people with
mental illness face more challenges in accessing health services than the general population.
Tobacco and Mental illness
Tobacco use is the leading cause of preventable premature death and disease in the U.S., the
number of deaths attributed to smoking is 443,000 annually including 49,400 deaths per year from
second hand smoking.(18) According to the Surgeon General Report (2006)” there is no risk-free
-6-
level of exposure of secondhand smoke”. Smoking affects almost all the organs of the body. Smoking
causes inhalation of a complex mixture of chemical compounds which cause adverse effects through
DNA damage, inflammation, and oxidative stress. These effects lead to cardiovascular and
pulmonary damage, cancer and addiction. These adverse health outcomes are directly dependent on
the level and duration of exposure.(19) Despite the adverse health outcomes of smoking among
mentally ill patients, smokefree laws in mental health facilities are not implemented in all the states
of U.S.
Mental disorders are strongly related to many risk behaviors like smoking, physical inactivity, alcohol
drinking to name a few. Smoking prevalence is two to four times higher in mentally ill and substance
abusers as compared to general population.(20) Based on study by Dr. Laser, people with mental
disorders smoke approximately 44.3% of all U.S. tobacco consumption.(20) Since this population
smokes nearly half of the cigarettes produced, it is estimated that 200,000 smokers with mental
illness and substance use will die each year. So this population experiences increased death rates
and physical consequences as compared to the general population.(21) Rate of cancer,
cardiovascular and respiratory diseases in schizophrenia patients is double as compared to age
matched controls due to the highest rate of smoking in this subgroup.(22) Depression is also
associated with increased risk of smoking. Smokers experience increased (29%) frequency of daily
depressive symptoms as compared to nonsmokers (19%).(23) They also experience increased
psychiatric symptoms, hospitalizations, and require larger doses of drugs.(24) Tobacco induces liver
enzyme Cytochrome P450, thereby lowering the blood levels of drugs and increasing the cost of
treatment. Tobacco smoking increases the metabolism of psychiatric drugs, thereby increasing the
dose of drug required for satisfactory action and increasing the cost of treatment.
Biological and psychosocial factors explain high incidence of smoking in mentally ill population. Likely
biological factors are greater genetic vulnerability, increased susceptibility to progress from tobacco
use to dependence, subjective feeling of pleasure, or decreased symptoms of psychiatric disorder.
-7-
According to self-medication theory, cigarette smoking may be considered a self-medication to
resolve the problems of depression, loneliness, anxiety, boredom, and other insecurities in this
vulnerable population. Smoking may seem to alleviate these symptoms but the reality is the
prevention of withdrawal symptoms which positively reinforces them to smoke.(25) Tobacco use in
adolescents is greatly associated with other substance uses and possibly precedes the development
of psychiatric disorder. Adolescents with many life and family stressors are more likely to become
tobacco dependent.(26)
Despite a decline in overall smoking rate in U.S. since 1970, smoking in mentally ill group remains
unevenly high.(27) Analysis of data obtained from National Comorbidity Study Replication (U.S. NCSR) conducted in 2001-2003 and National Health Interview Survey (NHIS) conducted in 2007 data
revealed that 19.7% of the U.S. adult civilian non-institutionalised population had amental illness in
the 12 months prior to the survey (95% CI: 18.9%–20.6%). Amongthose adults with a mental illness,
40.1% were current smokers (95% CI: 37.6%–42.7%) which was almost doublethe 21.3% smoking
prevalence in adults with no 12-month mental illness (95% CI: 20.1%–22.5%). Currently in the year
2012, smoking prevalence in adults with no 12-month mental illness is 19.3%.(28) People with
mental illness represented 31.7% of current smokers (95% CI: 29.5%–33.8%), or 16.1 million people
out ofan estimated total 51.0 million adult smokers in the U.S. In contrast, only 15.1% of people who
had never smokedhad a mental illness in the 12 months prior to the survey (95% CI: 13.8%–16.4%).
Smoking rates were highestamong those with substance use disorders, where aroundtwo-thirds of
sufferers were current smokers. In the U.S., 45.1% of adults with affective disorderssmoked (95% CI:
41.1%–49.2%), and 37.6% of adults withanxiety disorders smoked (95% CI: 34.6%–40.7%),
comparedwith 21.3% of adults with no 12-month mental disorder (95% CI: 20.1%–22.5%).(29)
-8-
Significance of Study
Tobacco Cessation
Studies have revealed that mentally ill patients are as likely to want to quit smoking as the general
population with comparable quit rate.(30) Acton et al studied a sample of 205 outpatient psychiatric
patients with mixed diagnosis and found that motivation in quit in their patient samples was similar
to that of U.S. population samples. In the clinic sample, 29% were in pre-contemplation (versus
37%–42% inpopulation samples), 43% were in contemplation (versus 39%–47%), and 28% were in
preparation (versus 16%–20%). Smoking is a concern in people with mental illness as they are more
likely to die from adverse effects of smoking than due to the mental condition.
Literature on smoking and mental illness does not provide an accurate statistics on the smoking and
quit rates in people with mental illness. There is no solid foundation for exemption of mental health
facilities from smoke free laws. This study aims to explore the smoking and quit rates and the
availability of resources for smoking cessation for psychiatric patients in Tennessee. Even though the
percent of people smoking in Tennessee has declined from 30.8% in 1990 to 22% in 2010,
Tennessee’s ranking did not improve. In contrast people with poor mental days in Tennessee have
risen from 2.9 in 2000 to 3.8 in 2010. This demonstrates a decreased quality of life among the
general population.
Tobacco Industry
-9-
Tobacco/nicotine has been excluded and then included in the category of addictive substances over
the past 50 years. These definitions of addictive substances were developed in the mid-20th century
at the committee of World Health Organization (WHO) and the US Surgeon General’s Advisory
Committee (SGAC). The selection these definitions were largely influenced by scientist with
collaboration with the tobacco industry. In the 1964 SGAC report, tobacco was classified as
“habituation” due to the influence by scientist with ties to tobacco industry. In 1997, it was agreed
upon that tobacco was addictive. (31)
The Joint Commission on the Accreditation of Healthcare Organizations (JCAHO), proposed a
nationwide ban on smoking in the health care facilities based on the harmful effects of secondhand
smoking on the patients, hospital staff and visitors as it jeopardized hospital’s health care mission.
Due to revolt by patient advocacy group, JCAHO exempted psychiatric and drug treatment facilities
from smoking ban. (32)
Tobacco use among mentally ill patients is promoted due to several contributing factors. According
to the self-medication hypothesis, tobacco is an essential self medication for these patients. Tobacco
industry has supported this myth by funding research and publishing articles in its favor. Thus,
tobacco industry is targeting this population group and marketing their tobacco products.(33) Also, it
is assumed that mentally ill patients do not participate in smoking cessation programs and are least
interested to quit smoking with a low quit rate and are not successful. Contrary to these
assumptions, there is no evidence that tobacco improves the health of mental patients. In fact
nicotine transiently enhances mood and concentration and leads to addiction with continued usage.
It increases the metabolism of drugs thus reducing their effectiveness leading to increase dose
requirement and more hospitalization rate.
Tennessee
- 10 -
Tennessee is located in the Southeastern United States and is the 36th most extensive and 17th most
populous of the 50 states. Tennessee’s second largest city and capital, Nashville has a population of
626,144 and the largest city, Memphis has a population of 670,902. The state of Tennessee is
geographically and constitutionally divided into three grand divisions: East Tennessee, Middle
Tennessee and West Tennessee. According to United States Census Bureau the population of
Tennessee was 6,403,353 on July 1, 2011, a 0.90% increase since 2010. The center of population of
Tennessee is located in Rutherford County, in the city of Murfreesboro.
Prevalence of Smoking in Tennessee presented in Figure 1:
The percent of smoking has declined from 30.8% in 1990 to 22% in 2010 with a slight rise in 2008
(24.3%). Tennessee ranked 41 in 2010 as compared to 31 in 1990.(34) Even though the percentageof
smoking in the population has reduced, Tennessee’s ranking has rather worsened as compared to
other states.
Figure1: Prevalence of Smoking in Tennessee.
- 11 -
35
Prevalence of Smoking in Tennessee
Percent of Population
30
25
20
15
10
5
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
0
Year
Poor Mental Health Days in Tennessee presented in Figure 2:
Poor Mental Health Days means the number of days in the previous 30 days when a person indicates
their activities are limited due to mental health difficulties. This is a general indication of the
population’s ability to function on a day-to-day basis.
The number of poor mental health days has risen from 2.9 in 2000 to 3.8 in 2010 and ranking has
gone from 21 in 2000 to 41 in 2010.(35) Poor mental health days have consistently increased
indicating the worsening quality of life of the population.
Figure 2: Poor mental health days in Tennessee
- 12 -
Poor Mental Health Days
4
Days in the Previous 30 days
3.5
3
2.5
2
1.5
1
0.5
0
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Year
Even though, the health status ranking of Tennessee has improved from 42 to 39 in 2012, the
number of poor mental health of the people has risen contributing to stress and greater vulnerability
to smoking and other substance abuse.
Smoking Laws in Tennessee:
On June 11, 2007, Governor Phil Bredesen signed the Tennessee Non-smoker Protection Act into
law. According to this law, smoking is prohibited in most enclosed public places, including health
care facilities with a few exceptions.
An important note here is that Health care facilities are defined as “an office or institution providing
care or treatment of diseases, whether physical, mental, or emotional, or other medical,
physiological, or psychological conditions. This definition shall include all waiting rooms, hallways,
private rooms, semiprivate rooms, and wards within health care facilities.”
- 13 -
Tennessee Department of Health and Department of Labor and Workforce Development have the
power to enforce the law. Anyone who knowingly smokes in a no-smoking area has to pay a civil
penalty of $50. Any business that does not comply with this policy will be subject to the following:

For a first violation in a twelve-month period, a written warning from the Department of
Health or the Department of Labor and Workforce Development

For a second violation in a twelve-month period, a civil penalty of $100

For a third or subsequent violation in a twelve-month period, a civil penalty of $500
This law passed by Governor Phil Bredesenon 2007, addresses the significance of keeping health
care facilities including psychiatric health care facilities smoke free. Thus, abstinence from smoking
in patients admitted to health care facilities would facilitate smoking cessation for the time period
they are admitted, as initial phase of quitting is the most difficult with high urge to smoke.
Mental Health Facilities in Tennessee:
There are two sets of psychiatric health facilities in Tennessee – those run by the Department of
Mental Health and those run by private facilities. The Tennessee Department of Mental Health
runs five regional mental health institutes (RMHIs) as presented in Fig 3. The RHMIs provide
inpatient psychiatric services for adults and admissions are on an emergency and involuntary
basis. Region I serves twenty four counties, Region II twenty eight counties, Region III eighteen
counties, Region IV twenty four counties and Region V one county (Table 2).(36) Private
psychiatric health facilities are presented in Table 2.(37)
Tennessee Department of Mental Health
The Tennessee General Assembly created the department on March 13, 1953, upon
recommendation of then Governor Frank Clement to provide services to persons with mental illness
and mental retardation. In 1973, under the Comprehensive Alcohol and Drug Treatment Act, the
- 14 -
General Assembly gave the department responsibility for developing programs for treating and
preventing alcohol and drug abuse. In July 1991, the Division of Alcohol and Drug Abuse Services was
transferred to the Department of Health and, in February, 2007, back to TDMH.Beginning in 1978,
the department was charged with licensing facilities that provide services to persons with mental
retardation, mental illness, and alcohol and drug abuse. The responsibility for management and
operation of the Division of Mental Retardation Services was transferred to the Department of
Finance and Administration by executive order in 2002. The department’s name was changed to the
Tennessee Department of Mental Health and Developmental Disabilities in 2000 as a result of a
comprehensive revision of the mental health and developmental disability law. The law revision also
expanded the department’s licensure authority from only facilities or agencies to include services,
effective March 1, 2001. Beginning March 1, 2002, revision of the law expanded eligibility for direct
services to persons with developmental disabilities, other than mental retardation. In 2003, the
department celebrated its 50th anniversary.On January 15, 2011, the department's name was
changed to the Tennessee Department of Mental Health. The responsibility for Developmental
Disabilities was transferred to the Department of Intellectual and Developmental Disabilities.
Currently, TDMH is the state’s mental health and substance abuse authority. Its mission is to plan for
and promote the availability of a comprehensive array of quality prevention, early intervention,
treatment, and rehabilitation services and supports based on the needs and choices of individuals
and families served. The department is responsible for system planning, setting policy and quality
standards, system monitoring and evaluation, disseminating public information and advocating for
persons of all ages who have mental illness, serious emotional disturbance, or substance abuse
disorders. TDMH annually assesses the public's needs for mental health, substance abuse, and
recovery service supports. Title 33 of the Tennessee Code Annotated requires that functions of
TDMH be carried out in consultation and collaboration with current or former service recipients;
their families, guardians, or conservators; advocates; providers; agencies; and other affected
persons and organizations. A planning and policy council advises the department about plans,
- 15 -
policies, legislation, service system needs, and budget requests. A majority of the council’s
membership must be service recipients or members of their families.
Divisions and Offices of TDMH
1. Division of Alcohol and Substance abuse services: The Division of Alcohol and
Drug AbuseServices, serves as the single state authority for receiving and administering
federal block grant funding from the U.S. Department of Health and Human Services,
Substance Abuse and Mental Health Services Administration. State funding for alcohol and
drug abuse services is also administered by the division.
2. Division of Clinical Leadership: The Division of Clinical Leadership assists TDMH
service recipients by providing clinical oversight of the TennCare Partners Program and
conducting clinical research.
3. Division of Planning, Research and Forensics: The Division of Planning, Research
& Forensics oversees and coordinates general mental health policy development and
implementation throughout the department and for service areas. The responsibility for the
development of public mental health policy is accomplished through staff assigned to the
various stages of development.
4. Division of Mental Health Services: The Division of Mental Health Services helps
devise and implement services for special populations in Tennessee, including Children, and
others.This Division is responsible for developing, expanding and monitoring a
comprehensive continuum of services for citizens of Tennessee across the lifespan, who are
at risk of developing or have been diagnosed with serious emotional disturbance, or serious
and persistent mental illness. These populations include but are not limited to children and
youth and the elderly.
5. Office of recovery services: The Office of Recovery Services, in the Division of Mental
Health Services, oversees support, employment/education, transportation and
- 16 -
housing/homeless services, promoting recovery for persons diagnosed with mental illness
and co-occurring disorders.
6. Office of consumer affairs and peer support services: The Office of Consumer
Affairs and Peer Support Services, in the Division of Mental Health Services, helps promote
the interests of TDMH service recipients through training, promotion and advocacy by
assisting with access to service and supports. The office has developed a program for Peer
Specialist training and certification.
7. Division of Hospital services: The Tennessee Department of Mental Health operates
five (5) Regional Mental Health Institutes (RMHIs) which provide in-patient psychiatric
services for adults. Most RMHI admissions are on an emergency involuntary basis. The
RMHIs provide psychiatric services based upon the demonstrated and emerging best
practices of each clinical discipline, and are fully accredited, certified and licensed.
8. Office of communication: The Office of Communications assists media organizations
with inquiries and research-related questions and coordinates statewide overcoming stigma
efforts. The office is also responsible for the authorization, design and printing of all
department publications, manages the Web site, and monitors Web mail for media and
consumer inquiries.
9. Office of general counsel: The Office of General Counsel provides representation,
advice and assistance to the Commissioner's Office, the departmental divisions and the
regional mental health institutes in legal and administrative proceedings, and oversees
HIPAAcompliance and policy development. The Office of Licensure and Review is now under
the Office of General Counsel.
10. Office of licensure, review and investigations: The Office of Licensure, Review &
Investigations is responsible for protecting Tennesseans who need mental health,
developmental disability, alcohol and drug abuse, and personal support services by applying
the department's licensure rules.
- 17 -
Fig 3: Tennessee Regional Mental Health Institutes
Source: Tennessee Government Department of Mental Health
- 18 -
Table 2: Tennessee Regional Mental Health Institutes
Regions
I
II
III
IV
V
RMHI
Lakeshore
Mental
Institute, Knoxville, TN
Counties Served
Health Anderson, Blount, Campbell,
Carter,
Claiborne,
Cocke,
Grainger, Greene, Hamblen,
Hancock, Hawkins, Jefferson,
Johnson, Knox, Loudon, Monroe,
Morgan, Roane, Scott, Sevier,
Sullivan, Unicoi, Union and
Washington
Moccasin Bend Mental Health Bedford, Bledsoe, Bradley, Clay,
Institute, Chattanooga, TN
Coffee, Cumberland, DeKalb,
Grundy,
Fentress,
Franklin,
Hamilton,
Jackson,
Lincoln,
Overton,
Macon,
Marion,
McMinn, Meigs, Moore, Pickett,
Polk, Putnam, Rhea, Sequatchie,
Smith, Van Buren, Warren and
White
Middle Tennessee Mental Health Cannon, Cheatham, Davidson,
Institute, Nashville, TN
Dickson, Giles, Hickman, Houston,
Humphreys, Marshall, Maury,
Montgomery,
Robertson,
Rutherford, Stewart, Sumner,
Trousdale, Williamson and Wilson
Western Mental Health Institute, Benton,
Carroll,
Chester,
Bolivar, TN
Crockett, Decatur, Dyer, Gibson,
Fayette,
Hardeman, Hardin,
Haywood, Henderson, Henry,
Lake, Lauderdale, Lawrence,
Lewis, Madison, McNairy, Obion,
Perry, Tipton, Wayne and
Weakley
Memphis
Mental
Health Shelby
Institute, Memphis, TN
Source: Tennessee Government Department of Mental Health
Smoking cessation efforts by TDMH
The Tennessee Department of Mental Health (TDMH) along with the OASIS Center highlights
National Kick Butts Day by unveiling a state-wide art project in the Legislative Plaza that displays 172
pairs of shorts to illustrate the lives of Tennesseans cut short due to tobacco use. Kick Butts Day is a
national event that works to engage children and youth nationwide in learning about the negative
- 19 -
impacts of tobacco use.Over the past year, the Tennessee Youth Prevention Working Group,
comprised of staff from three state agencies including Mental Health, Health, and the Office of the
Attorney General has worked with tobacco retailers across the state to remind them of both the
health and legal risks associated with selling tobacco to minors. “Kick Butts Day serves as a great
reminder to our young people about the risks of tobacco use as well as to tobacco retailers about
their responsibility regarding minors,” said TDMH Commissioner Doug Varney. “Research shows
that those who start smoking at a young age form stronger addictions. By only selling tobacco
products to customers over 18, tobacco merchants help ensure that Tennessee complies with
federal law and reduces the overall number of youth smokers.”
Facts from www.tobaccofreekids.org about Tennessee youth and tobacco:

Most individuals with an addiction to cigarettes started smoking before they turned 18 years
old.

Tennesseans under the age of 18 will purchase and consume over 16.8 million packs of
cigarettes this year.

Approximately 7,600 young people in Tennessee become new youth smokers each year.

Approximately 412,000 of today’s Tennessee children will become smokers and nearly
132,000 of them will die prematurely from tobacco related causes.
"Decades of research have proven the devastating impact of smoking on our bodies and our
health. Our best advice to Tennesseans of any age is to never start smoking,” said Tennessee Health
Commissioner John Dreyzehner, MD, MPH. "For those who do smoke, we urge you to talk with your
health care provider about ways to quit, and to take advantage of the free Tennessee Tobacco
QuitLine counseling service at 1-800-QUIT-NOW for added support."The Tennessee Tobacco
QuitLine is a state wide, free tobacco cessation treatment program made possible through the
Department of Health. There is no charge to callers for services, and callers have unlimited access to
a “quit coach” through the QuitLine. This service is available to teens as well as to adults.
- 20 -
Table 3: Private Psychiatric Health Facilities in Tennessee
Name
Location
County
Indian Path Pavilion
Kingsport
Lakeside Behavioral Health System
Memphis
Parkridge Valley Hospital
Chattanooga
Parthenon Pavilion
Nashville
Peninsula
Knoxville
Knox county
Peninsula Hospital
Louisville
Blount county
Peninsula Village
Louisville
Blount county
Ridgeview Psychiatric Hospital and Center
Oak Ridge
Valley Hospital
Chattanooga
Woodridge Hospital
Johnson city
Source: Psychiatric Hospitals and Medical Centers.
Parthenon Pavilion: Parthenon Pavilion at Centennial Medical Center – the oldest and largest
private psychiatric facility in Middle Tennessee, Nashville -- was established in 1971 based on the
belief that mental illness is treatable in a supportive, therapeutic environment. It has a long history
of helping individuals with mental illness and chemical dependency lead fulfilling and productive
lives. Fully licensed and accredited, Parthenon Pavilion is a comprehensive psychiatric hospital
committed to providing easy access to superior quality mental health services.As the only psychiatric
hospital in the state connected to a tertiary medical center, Parthenon Pavilion is able to provide a
full continuum of mental health and medical services.Parthenon Pavilion offers help and hope for
individuals age 18 or older. Programs address a broad range of psychiatric illnesses, including:
depression, bipolar and psychotic disorders; mood and anxiety disorders; alcohol and drug abuse;
dissociative disorders; Alzheimer’s disease and other geriatric illnesses. Parthenon Pavilion’s
multidisciplinary team responds to each patient’s situation with a tailored plan of care that may
- 21 -
include individual psychotherapy, group and/or family therapy, medication management and other
services. Each program emphasizes assessment, treatment and aftercare to enhance quality of
life.Parthenon Pavilion stands on a firm foundation of excellence built and maintained by
experienced team of psychiatrists, nurses, clinical pharmacists, counsellors, social workers, case
managers, patient advocates, dieticians and certified adjunctive therapists.
Woodridge Hospital: Woodridge Hospital is located in Johnson City Tenn., and offers variety of
therapeutic treatments. It provides mental health and chemical dependency services for children,
adolescents and adults. It offers a wide range of services, including behavioral health, cardiology,
childbirth, emergency, fitness, home care, hospice, neurology, oncology and radiology services. The
hospital also provides occupational health, orthopedic and pastoral care, pulmonary and
rehabilitation services, surgery, women’s health and wound care. Its rehabilitation services assist
patients with brain injury, stroke, amputation, spinal cord and orthopedic injuries, burns and
rheumatologic impairments, neurological and neuromuscular problems. Woodridge Hospital is
operated by the Mountain States Health Alliance. Its outpatient treatment services are designed for
individuals who are dealing with a psychiatric or substance abuse.
Model of Study
The construct used in most studies of readiness or motivation for cigarette abstinence is
derivedfrom the stages of change model (DiClemente et al. 1991, Prochaska et al. 2001, Velicer &
Prochaska 1999). This model posits five stages of change in quitting smoking. These are
(a)precontemplation—a person has no intention of quitting smoking in the foreseeable
future,defined as the next six months; (b)contemplation—a person is contemplating stopping
smoking in the next six months, but not the next 30 days; (c)preparation—a person intends tostop
smoking in the next month and has made at least one quit attempt in the past year; (d )action—a
- 22 -
person has quit smoking for less than six months; and (e) maintenance— a person has quit smoking
for six months or longer. The model itself is broader than the stages alone, including both
motivational aspects (stages of change, situational temptations) and cognitive aspects (processes of
change, pros and cons of change). However, stages are generally accepted as a measure of
motivation.
This study would best fit in the Mc Leroy’s Social Ecology Model. This model explains how
environment affects a behavior and vice versa, that is, the relationship between the individual and
the physical environment. The components of this model are Intrapersonal, interpersonal,
institutional, community and public policy as presented in Table 3.
- 23 -
Table 4: Mc Leroy’s Social Ecology Model
1.
Components
Characteristics
Intrapersonal
Focuses on individual characteristics like knowledge,
attitude and skills. We can increase awareness about
adverse effects of nicotine through education,
campaigns, counseling.
2.
Interpersonal
Social support from family, friends and coworkers would
motivate smoking cessation in this population and build
self-confidence and self-efficacy which are vital
components of quitting.
3.
Institutional
Includes formal and informal rules of institutions like
smoke-free campus. Making the whole campus smokefree would help this population to not smoke during the
course of their stay in the hospital. The initial phase of
quitting is the most difficult with high urge to smoke.
4.
Community
Includes social networks, churches, neighborhood
support. This vulnerable population would benefit
greatly from the community support.
5.
Public Policy
Policy development, advocacy and analysis in smoke
free area and health care facilities. This is the most
powerful tool to reduce the smoking rate. This would
also measure compliance with the smoke free laws.
- 24 -
Overall, Social ecology model focuses on individual and the social environmental factors as targets
for health promotion interventions. It assumes that appropriate changes in the social environment
will produce changes in the individual. This model provides insight into smoking cessation efforts at
different levels. The key to smoking cessation in mentally ill population lies in educating them about
the adverse effects of smoking and providing support at all levels including family, friends; making
the resources available to them and integrating it into our policy.
Study Design
Data Source:
National Health Interview Source (NHIS)
The National Health Interview Survey (NHIS) is the Nation’s primary source of general health
information for the resident civilian noninstitutionalized population. NHIS is conducted by the
National Center for Health Statistics (NCHS), a component of the Centers for Disease Control and
Prevention, U.S. Public Health Service, Department of Health and Human Services. In accordance
with specifications established by NCHS, the U.S. Bureau of the Census, under a contractual
relationship, participates in the planning for NHIS and the collection of data. NHIS has continuously
collected data since 1957. This continuous data collection has administrative, operational, and data
quality advantages because fieldwork can be handled on a continuous basis with an experienced,
stable staff. NHIS provides estimates on health indicators, health care utilization and access, and
health-related behaviors for the U.S. resident civilian noninstitutionalized population. Summary
reports and reports on special topics for each year’s data are prepared by NCHS Division of Health
Interview Statistics for publication in Series 10 of the Vital and Health Statistics publications series.
In these reports, basic NHIS survey estimates are published annually for various population
subgroups. These subgroups include those defined by age, sex, race, family income, census region
- 25 -
(Northeast, Midwest, South, and West), place of residence (central city of a metropolitan area,
metropolitan area but not in a central city, and nonmetropolitan areas), and other domains covered
on the particular NHIS statistic. The basic module contains three components: the family core, the
sample adult core, and the sample child core. The family core component collects information on
everyone in the family. Information collected in the family core component includes household
composition and sociodemographic characteristics. It also includes basic indicators of health status
and utilization of health care services. From each family in the survey, one sample adult and one
sample child (if any children under age 18 are present) are randomly selected, and information on
each is collected with the sample adult core and the sample child core questionnaires. Because some
health issues are different for children than for adults, these two questionnaires differ in some
items, but both collect basic information on health status, health care services, and behavior.
For this study, data was taken from the 2009 person and sample adult component which includes
measures of smoking and level of psychological distress. There were total 301,362,048.0 persons
and 27,731 sample adults in the 2009 NHIS.
As the study consisted of publicly available data, no institutional ethics approval was required.
For this study, national data was used as proxy for the state of Tennessee as TN specific data could
not be imputed. Data was supplemented with BRFSS data and qualitative data from the Tennessee
department of mental health and private institutes like Woodridge Hospital and Parthenon Pavilion
conducted through phone interviews.
Measures:
Demography
- 26 -
Total number of people who participated in the 2009 NHIS survey is distributed on the basis of age,
sex, race and marital status in the study. There were a total of 301,362,048 persons who completed
the survey.
Tobacco Use
In the NHIS 2009 sample adult population, smokers are identified from responses to the questions
“Are you a current every day smoker?, Are you a current some day smoker?, Were you a former
smoker?, Never smoked, Smoker current status unknown, and unknown if ever smoked.” Further
questions pertinent to smokers were asked. To ascertain the level of smoking, detailed questions
were asked to current smokers. Current smokers were asked “Number of cigarettes smoked in a day,
number of days smoked in the past 30 days.” Additional questions were targeted at attempts to quit
smoking in the past 12months as to “attempt quitting smoking for more than a day in the past
twelve months.”
Mental Illness
The American Psychiatric Association (APA) developed mental illness diagnostic categories based on
symptoms observed by a health professional or reported by the patient; the Diagnostic and
Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) is the current
version of this system. Another system, the WHO International Classification of Diseases, 10th
Revision, Clinical Modification (ICD-10-CM), defines mental illness categories that are similar but not
identical to those in the DSM-IV-TR. Previous DSM and ICD versions have not been completely
congruent, and APA is developing a fifth edition of the DSM (DSM-V) that will coordinate better with
future editions of ICD.
NHIS employs Kessler 6 scale, which is a short measure of non-specific psychological distress. It does
not assess specific mental disorder but non-specific psychological distress. This scale was specifically
designed to be sensitive to the upper 90th – 99th percentile range of population distribution of
mental disorders. Within this range it has high discrimination. NHIS measures included
- 27 -
“Depression/Anxiety/Emotional problems causing difficulty with activity, Alcohol/drug/substance
abuse problem causing difficulty with activity, other mental problem/ADD/Bipolar/Schizophrenia
causing difficulty with activity.” Depression/anxiety/emotional problems include neurotic disorders,
personality disorders, and other nonpsychotic mental disorders, excluding alcohol and drug related
problems and developmental problems. Any mention of “alcohol,” “drugs” (or specific drug types),
or substance abuse is included under Alcohol/drug/substance abuse problem causing difficulty with
activity.
Psychological distress (Kessler - 6 Psychological Distress Scale)
Surveys use the Kessler-6 psychological distress scale to screen for psychological distress
experienced by persons with anxiety and mood disorders. The Kessler-6 scale asks respondents
about the frequency with which they have experienced six manifestations of psychological distress,
which include feeling 1) nervous, 2) hopeless, 3) restless or fidgety, 4) so sad or depressed that
nothing could cheer the respondent up, 5) that everything is an effort, and 6) worthless. Responses
are "all of the time," "most of the time," "some of the time," "a little of the time," and "none of the
time." Scoring of individual items is based on a 4-point scale according to increased frequency of the
problem, yielding a total six-item score ranging from 0--24. A score of ≥13 indicates serious
psychological distress. Serious psychological distress as defined by the Kessler-6 score is highly
associated with anxiety disorders and depression but does not identify a specific mental illness.
Results
NHIS 2009 survey was carried out over a US population of 301,362,048.0. Age stratification of total
participants is shown as proportions (Table 5). The subjects were 49% males and 51% females (Table
6). 80.5% of the participants were White, 13.4% Black, 4.8% Asian and 1.4% other race groups (Table
- 28 -
7). 19.1% of the respondents were under 14 years of age, 40.8% married with spouse in household,
0.8% married with spouse not in household, 4.4% widowed, 6.4% divorced, 1.6% separated, 21.5%
never married, 5.3% living with partner, and 0.3% unknown marital status (Table 8).
As the sample design is a stratified cluster sample, the method used was Taylor series
approximation. Among the sample adult population, 15.4% (95% CI: 14.9-15.9) were current every
day smoker, 4.7% (95% CI: 4.5-5.0) current some day smoker, 21.9% (95% CI: 21.3-22.5) former
smokers, and 57.5% (95% CI: 56.8-58.3) never smoked (Table 9). 29.4% of current smokers smoked
1-5 cigarettes in a day, 28.4% smoked 6-10 cigarettes in a day, 9.2% smoked 11-15 cigarettes in a
day, and 24.2% smoked 16-20 cigarettes in a day (Table 10). On an average 91.2% of smokers
smoked 1-20 cigarettes in a day and 8.8% smoked >20 cigarettes in a day. 3.8% did not in the past 30
days, 22.6% smoked 1-5 days, 18.5% smoked 6-10 days, 20.8% smoked 11-15 days, 15.3% smoked
16-20 days, 5.2% smoked 21-25 days, and 10.9% smoked 26-30 days in the past 30 days (Table 11).
47.2% of the current smokers tried quitting smoking for 1+ days in the past 12 months and 52.7% did
not try (Table 12).
40.7% of the respondents who mentioned that they had depression/anxiety/emotional problems
causing difficulty with activity were current smokers and 21.6% were former smokers (Table 17). This
shows a high rate of smoking among psychiatric patients as compared to general population. 50% of
sample adults who mentioned alcohol/drug/substance abuse problem causing difficulty with activity
were current every day smoker as compared to 34.4% of sample adults with
depression/anxiety/emotional problems who were current every day smoker (Table 18). Smoking
rate is higher in people who abuse alcohol/drug and other substances than people with
depression/anxiety and other emotional problems. Sample adults who mentioned other mental
problems/ADD/Schizophrenia causing difficulty with activity had a smoking rate of 47.9% with 39.6%
every day smoker and 8.3% some day smoker and a former smoking rate of 18.8% (Table 19).
- 29 -
Both NHIS and optional modules of BRFSS use the Kessler-6 scale to identify persons who
experienced psychological distress during the 30 days before the survey. NHIS data indicate that in
2009, 3.2% of respondents experienced serious psychological distress (Table 16). BRFSS included the
Kessler-6 in the optional mental illness and stigma module during 2007 (administered in 35 states,
the District of Columbia, and Puerto Rico) and 2009 (16 states). Among participating states,
prevalence estimates were similar in 2007 (4.0%) and 2009 (3.9%). These BRFSS estimates are higher
than NHIS estimates, which might be a result of the limited geographical coverage of BRFSS,
differences in survey design and methods, question placement, and context. As in NHIS, women
were more likely to have serious psychological distress than men, and rates were highest among
adults aged 45--54 years and non-Hispanic blacks (Table 16). BRFSS data for state-specific prevalence
of serious psychological distress during 2009 indicate that, like depression, prevalence varied among
states, ranging from 1.9% in Utah to 9.4% in Tennessee. The prevalence of serious psychological
distress was generally highest in the southeastern states.
Prevalence of serious psychological distress among adults aged ≥ 18 years in the state of Tennessee
according to Behavioral Risk Factor Surveillance System, United States, 2009, was 9.4% with a 95%
Confidence Interval was (7.7 – 11.6), total number of 2,216.
The NHIS sample size (approximately 10,000) is not sufficient to provide reliable state-level
estimates for most states. Although the database does not identify respondents' state of residence,
state-level estimates can be produced for more populous states by requesting state identifiers
through the CDC National Center for Health Statistics (NCHS) Research Data Centers.
In Tennessee, 20.1% of adults smoke as compared to national rate of 17.2% (Table 20). 21.7% of
males (US 19.1%) and 18.6% of females (US 15.1%) smoke in Tennessee (Table 20). The percent of
smokers in Tennessee are high in comparison to the national rate.
For mental illness, Tennessee uses Severe Persistent Mental illness (SPMI), based on four criteria:
diagnosis, severity of functional impairment, duration of functional impairment, need for services to
- 30 -
prevent relapse which are determined through CRG assessment. The data uses current DSM-IV-TR
diagnosis excluding substance abuse and developmental disorders. Tennessee state mental
authority served 69.3% of adults with SMI in the age group 21-64 yrs as compared to 63.5% served
by United States (Table 22).
Limitation of Study
The main limitation of the study was the lack of state specific quantitative data. For this reason,
national data was used as a proxy. Further efforts should be taken to measure state specific data on
mental illness and smoking to increase the accuracy of the study.
Discussion
The figures from NHIS survey show high rate of smoking among adults with mental illness. Findings
also show increasing level of smoking with increasing level of psychological distress. Although
smoking rates have been declining in the United States, findings demonstrate large proportion of
smokers who suffer from common mental disorders. The proportion of people with mental illness
who smoke was highest among young adults. People with substance abuse disorders have the
highest rate of smoking. Those with anxiety and comorbid substance abuse disorder also have very
high smoking rate. These groups present particular challenges for tobacco control.
Due to insufficient release of data by TDMH, a co-relation between Smoking and mental health could
not be established for the state of Tennessee. Tennessee Department of Mental Health, Top to
Bottom review has recommended to develop an online data book to make mental health outcome
and substance abuse data more accessible. Tennessee does not have special programs to promote
smoking cessation in mentally ill population like some other states. The tobacco cessation toolkit for
Mental Health providers was developed by the University of Colorado at Denver and Health Sciences
- 31 -
Center, Department of Psychiatry to help with smoking cessation in persons with mental illness. This
tool kit contains a variety of information and step by step instructions to assess readiness to quit,
possible treatments and Colorado community resources.
Tennessee state Medicaid program provides coverage of tobacco dependence treatments for any
tobacco dependence treatment, NRT gum, NRT patch, NRT nasal spray, NRT inhaler, NRT lozenges,
Varenicline (Chantix), Bupropion (zyban), Group counseling and Individual Counseling (Table 21).
Tennessee offers free Tobacco QuitLine counseling service at 1-800-QUIT-NOW. The law prohibits
selling or distribution of tobacco products to persons under the age of 18 years or purchase of
tobacco on behalf of a person less than 18 years of age.
In the current health care system, tobacco dependence treatment is delivered in conjunction with
other health care at health care facilities, medical clinic or offices, and hospitals; through programs
and services that tobacco users seek out like quitlines and community cessation programs; and
sometimes through referrals between these programs and services (Fig 2). Tobacco users with
serious mental illness and/or substance use have very rate of smoking and have the most difficulty
quitting. These smokers need to have tobacco dependence treatment integrated directly into their
mental health or substance use care and if needed, coordinated with primary care providers.
Health Care
Settings
Community
Cessation
Programs
Referral
Quitlines
- 32 -
Fig 2: Delivery of tobacco dependence services
Conclusion
NHIS data confirms high rate of smoking among people with mental illness and people with higher
levels of psychosocial stress consume higher number of cigarettes. Efforts should be made to reduce
smoking rate, morbidity and mortality associated with mental illness and reduce inequality in health
outcomes by targeting tobacco control efforts at this population of smokers. It is possible that
reducing the incidence of common mental health problems might reduce the incidence of smoking.
Moreover, it is possible that helping people with depression and anxiety problems to find alternative
ways of coping and to understand the consequences of nicotine withdrawal for their symptoms, may
be helpful strategies for reducing smoking rates. Population based methods are required as the
majority of smokers with mental illness are not in contact with mental health facilities. Market
segmentation studies and the development of brands and campaigns for tailored market segments is
a common tool of marketing which may help in efforts to combat smoking related harm.
- 33 -
Table 5: Age
Age
Distribution (%)
0-10
15.1
11-20
13.7
21-30
13.8
31-40
13.1
41-50
14.5
51-60
12.9
61-70
8.8
71-80
5.2
81-85+
2.9
Total
100
Table 6: Sex
Distribution (%)
Frequency
Male
49.0
147,660,324.0
Female
51.0
153,701,724.0
TOTAL
100.0
301,362,048.0
Sex
- 34 -
Table 7: Race
Distribution (%)
Race
Frequency
White
80.5 242,528,713.0
Black
13.4
40,318,314.0
Asian
4.8
14,327,375.0
All other race groups
1.4
4,187,646.0
Total
100.0 301,362,048.0
Table 8: Marital Status
Marital Status
Distribution (%) Frequency
Under 14 years
19.1
57,436,905.0
Married - spouse in household
40.8
122,828,620.0
Married - spouse not in household
.8
2,475,542.0
Widowed
4.4
13,168,350.0
Divorced
6.4
19,279,121.0
Separated
1.6
4,726,225.0
Never married
21.5
64,654,349.0
Living with partner
5.3
15,919,726.0
Unknown marital status
.3
873,210.0
Total
100
301,362,048.0
- 35 -
Table 9: Smoking Status
Smoking status
Distribution (%) Confidence Interval (95%) Frequency
Current every day smoker
15.4
(14.9-15.9)
4,273
Current some day smoker
4.7
(4.5-5.0)
1,305
Former smoker
21.9
(21.3-22.5)
6,069
Never smoker
57.5
(56.8-58.3)
15,956
Smoker, current status unknown .0
(0.0-0.1)
13
Unknown if ever smoked
.4
(0.3-0.5)
115
TOTAL
100.0
--
27,731
- 36 -
Table 10: Number of cigarettes a day for all current smokers
No. of cigarettes
Distribution (%)
Frequency
1-5
29.4
1618
6-10
28.4
1574
11-15
9.2
514
16-20
24.2
1333
21-25
1.2
67
26-30
3.5
198
31-35
0.3
16
36-40
2.4
133
41-45
0.1
3
46-50
0.2
10
51-55
0.0
2
56-60
0.2
10
61-65
0.0
0
66-70
0.0
2
71-75
0.0
0
76-80
0.0
1
81-85
0.0
0
86-90+
0.0
2
Refused
0.1
8
Don’t know
0.7
37
Total
100.00
5528
- 37 -
Table 11: Number of days smoked in the past 30 days
No. of days
Distribution (%)
Frequency
0
3.8
50
1-5
22.6
294
6-10
18.5
242
11-15
20.8
271
16-20
15.3
200
21-25
5.2
68
26-30
10.9
143
Refused
0.2
2
Don’t know
2.7
35
Total
100
1305
Table 12: Tried quitting smoking 1+days in the past 30 days
Distribution (%)
Frequency
Yes
47.2
2,632
No
52.7
2,937
Refused
0.0
2
Not ascertained
0.0
2
Don’t know
0.1
5
Total
100
5,578
- 38 -
Table 13: Depression/Anxiety/Emotional problems causing difficulty with activity
Distribution (%)
Mentioned
7.8
Not mentioned
90.9
Refused
.2
Not ascertained
.2
Don't know
.9
TOTAL
100.0
Confidence Interval (95%)
Frequency
(7.3-8.4)
781
(90.3-91.4)
9,081
(0.1-0.3)
22
(0.1-0.3)
19
(0.7-1.1)
88
---
9,991
Table 14: Alcohol/drug/substance abuse problem causes difficulty with activity
Distribution (%)
Confidence Interval (95%)
Frequency
Mentioned
.0
(0.0-0.1)
2
Not mentioned
98.7
(98.4-98.9)
9,860
Refused
.2
(0.1-0.3)
22
Not ascertained
.2
(0.1-0.3)
19
Don't know
.9
(0.7-1.1)
88
TOTAL
100.0
---
9,991
- 39 -
Table 15: Other mental problems/ADD/Bipolar/Schizophrenia causes difficulty with activity
Distribution (%)
Mentioned
.5
Not mentioned
98.2
Refused
.2
Not ascertained
.2
Don't know
.9
TOTAL
100.0
Confidence Interval (95%)
Frequency
(0.4-0.6)
48
(97.9-98.5)
9,814
(0.1-0.3)
22
(0.1-0.3)
19
(0.7-1.1)
88
---
9,991
- 40 -
Table 16: Prevalence of serious psychological distress among adults aged ≥ 18 years, by socio
demographic characteristics – Behavioral Risk Factor Surveillance System, United States, 2009
Characteristics
Sex
Age Group
Distribution (%)
Confidence Interval (95%)
Frequency
Male
3.5
3.0 – 4.0
33,434
Female
4.4
4.0 – 4.8
54,558
18 – 24
3.1
2.1 – 4.5
2,592
25 - 34
4.0
3.2 – 4.9
7,329
35 – 44
3.8
3.2 – 4.5
11,930
45 – 54
4.9
4.3 – 5.6
17,925
≥55
3.7
3.3 – 4.2
47,668
White, non-Hispanic
3.5
3.2 – 3.9
68,335
Black, non-Hispanic
5.4
4.5 – 6.4
8,410
Other, non-Hispanic
3.1
2.3 – 4.1
6,507
Hispanic
5.3
4.2 – 6.7
3,886
3.9
3.6 – 4.3
87,992
(yrs)
Race/Ethnicity
Total
Data from 16 States, Kessler 6 score of ≥ 13
- 41 -
Table 17: Depression/anxiety/emotional problem causes difficulty with activity in relation to
smoking status, NHIS 2009
Mentioned
Not
Refused
mentioned
Not
ascertained
Don’t
Total
know
14.8 18.5
13 1,846
Current every day
smoker
34.4
269
17.2
1,558
18.2
4
10.5
2
Current some day
smoker
6.3
49
4.1
375
4.5
1
10.5
2
Former smoker
21.6
169
28.6
2,601
18.2
4
31.6
6
21.6 28.0
19 2,799
Never smoker
37.3
291
49.6
4,501
59.1
13
47.4
9
58.0 48.7
51 4,865
Smoker, current
status unknown
.0
0
.0
4
.0
0
.0
0
.0
0
.0
4
Unknown if ever
smoked
.4
3
.5
42
.0
0
.0
0
.0
0
.5
45
Total
100.0
781
100.0
9,081
100.0
22
100.0
19
Color coding:
<-2.0
<-1.0
<0.0
>0.0
>1.0
>2.0
5.7
5
4.3
432
100.0 100.0
88 9,991
Z
N in each cell: Smaller than expected Larger than expected
- 42 -
Table 18: Alcohol/drug/substance abuse problem causes difficulty with activity in relation to
smoking status, NHIS 2009
Mentioned
Not
Refused
mentioned
Not
ascertained
Don’t
Total
know
14.8 18.5
13 1,846
Current every day
smoker
50.0
1
18.5
1,826
18.2
4
10.5
2
Current some day
smoker
.0
0
4.3
424
4.5
1
10.5
2
Former smoker
.0
0
28.1
2,770
18.2
4
31.6
6
21.6 28.0
19 2,799
Never smoker
50.0
1
48.6
4,791
59.1
13
47.4
9
58.0 48.7
51 4,865
Smoker, current
status unknown
.0
0
.0
4
.0
0
.0
0
.0
0
.0
4
Unknown if ever
smoked
.0
0
.5
45
.0
0
.0
0
.0
0
.5
45
Total
100.0
2
100.0
9,860
100.0
22
100.0
19
Color coding:
<-2.0
<-1.0
<0.0
>0.0
>1.0
>2.0
5.7
5
4.3
432
100.0 100.0
88 9,991
Z
N in each cell: Smaller than expected Larger than expected
- 43 -
Table 19: Other mental problem/ADD/Bipolar/Schizophrenia causes difficulty with activity in
relation to smoking status, NHIS 2009
Not
Refused
mentioned
Mentioned
Not
ascertained
Don’t
Total
know
14.8 18.5
13 1,846
Current every day
smoker
39.6
19
18.4
1,808
18.2
4
10.5
2
Current some day
smoker
8.3
4
4.3
420
4.5
1
10.5
2
Former smoker
18.8
9
28.1
2,761
18.2
4
31.6
6
21.6 28.0
19 2,799
Never smoker
33.3
16
48.7
4,776
59.1
13
47.4
9
58.0 48.7
51 4,865
Smoker, current
status unknown
.0
0
.0
4
.0
0
.0
0
.0
0
.0
4
Unknown if ever
smoked
.0
0
.5
45
.0
0
.0
0
.0
0
.5
45
Total
100.0
48
100.0
9,814
100.0
22
100.0
19
Color coding:
<-2.0
<-1.0
<0.0
>0.0
>1.0
>2.0
5.7
5
4.3
432
100.0 100.0
88 9,991
Z
N in each cell: Smaller than expected Larger than expected
Table 20: Tennessee Smoking statistics, State health facts, 2010
Tennessee (%)
United States (%)
Percent of adults who smoke
20.1
17.2
Percent of
adults who
smoke by
gender
Percent of
adults who
smoke by race
Male
21.7
19.1
Female
18.6
15.1
White
21.1
17.4
Black
18.1
19.1
60.8
59.0
60.3
57.9
61.3
60.2
Percent of smokers who attempt
to quit smoking
Percent of
Male
smokers who
attempt to quit Female
smoking by
gender
- 44 -
Table 21: TN State Medicaid program coverage of Tobacco Dependence Treatments by type of
coverage, state health facts, 2011
Program
Medicaid covers any TobaccoDependence treatment?
NRT Gum
NRT Patch
NRT Nasal Spray
NRT Inhaler
NRT Lozenges
Varenicline (Chantix)
Bupropion (zyban)
Group counseling
Individual Counseling
Tennessee
Yes
United States
49+ DC Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
48+ DC Yes
48+ DC Yes
43 Yes
42 Yes
41+ DC Yes
48+ DC Yes
49+ DC Yes
29+ DC Yes
37+ DC Yes
Table 22: Demographic Characteristics of Adults with SMI and Children with SED Served by the
State Mental Health Authority, FY 2010, Tennessee
Total Served
State
US
Demographics
N
%
N
%
0-12
17,083
13.5%
671,820
14.9%
13-17
13,722
10.9%
592,653
13.1%
18-20
5,754
4.6%
193,305
4.3%
21-64
87,534
69.3%
2,872,320
63.5%
65-74
1,848
1.5%
126,699
2.8%
75 and over
329
0.3%
64,761
1.4%
Age Not Available
2,162
0.0%
Age Total
126,270
100.0%
4,523,720
100.0%
Female
71,705
56.8%
2,319,948
51.3%
Male
54,565
43.2%
2,198,389
48.6%
Gender Not Available
5,383
0.1%
Gender Total
126,270
100.0%
4,523,720
100.0%
American Indian/Alaskan
233
0.2%
50,122
1.1%
Native
Asian
391
0.3%
64,835
1.4%
Black/African American
28,400
22.5%
939,974
20.8%
Native Hawaiian/Pacific
10,351
0.2%
Islander
White
89,142
70.6%
2,719,273
60.1%
Hispanic or Latino Race
1,123
0.9%
44,180
1.0%
Multi-Racial
44
0.0%
101,892
2.3%
Race Not Available
6,937
5.5%
593,093
13.1%
Race Total
126,270
100.0%
4,523,720
100.0%
Hispanic or Latino Ethnicity
524,785
12.2%
Not Hispanic or Latino
3,283,010
76.3%
Ethnicity
Ethnicity not available
-
-
497,786
11.6%
Ethnicity Total
-
-
4,305,581
100.0%
- 45 -
References
(1) Nichols M. Evil Twins: Smoking and Mental Illness, Part 1. 2008.
(2) United States. Public Health Service. Office of the Surgeon General. The Surgeon General's Report
on Nutrition and Health. 1988;88-50210.
(3) Hadii MM, MariaElena G, Stanton G. The Nature, Scope, and Development of the Global Tobacco
Control Epistemic Community. American Journal of Public Health 2011;101:2044-2054.
(4) Nicotine Addiction in Britain. A report of the Tobacco Advisory Group of the Royal College of
Physicians. 2000.
(5) Healthy People 2020. Mental Health and Mental Disorders. 2012; Available at:
http://healthypeople.gov/2020/topicsobjectives2020/overview.aspx?topicid=28. Accessed January,
2012.
(6) World Health Organization. Strengthening Mental Health Promotion. Geneva, World Health
Organization (Fact sheet no. 220). 2001.
(7) U.S. Department of Health and Human Services. Mental Health: A Report of the Surgeon General.
Rockville, MD: U.S. Department of Health and Human Services; Substance Abuse and Mental Health
Services Administration, Center for Mental Health Services, National Institutes of Health, National
Institute of Mental Health. 1999.
(8) Centers for Disease Control and Prevention. Mental Illness. 2011; Available at:
http://www.cdc.gov/mentalhealth/basics/mental-illness.htm. Accessed November, 2011.
(9) American Psychiatric Association. Quick Reference to the Diagnostic Criteria from DSM-IV. 1994.
(10) Centers for Disease Control and Prevention. Mental Health: Bipolar Disorder. 2011; Available at:
http://www.cdc.gov/mentalhealth/basics/mental-illness/bipolar.htm. Accessed November, 2011.
(11) Centers for Disease Control and Prevention. Mental Health: Anxiety. 2011; Available at:
http://www.cdc.gov/mentalhealth/basics/mental-illness/anxiety.htm. Accessed November, 2011.
- 46 -
(12) Centers for Disease Control and Prevention. Mental Health: Psychotic Disorders. 2011; Available
at: http://www.cdc.gov/mentalhealth/basics/mental-illness/psychotic.htm. Accessed November,
2011.
(13) Centers for Disease Control and Prevention. Mental Health: Dementia / Alzheimer's Disease.
2011; Available at: http://www.cdc.gov/mentalhealth/basics/mental-illness/dementia.htm.
Accessed November, 2011.
(14) World Health Organization. The world health report 2004: Changing history. Annex Table 3:
Burden of disease in DALYs by cause, sex, and mortality stratum in WHO regions, Estimates for 2002.
2004;A126-A127.
(15) Kessler R, Chiu W, Demler O. Prevalence, severity, and comorbidity of twelve-month DSM-IV
disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry 2005 June;62(6):617627.
(16) National Institutes of Health, National Institute of Mental Health (NIMH). NIMH strategic plan
(revised 2008) [Internet]. Bethesda, MD: NIMH; 2008. 2010; Available at:
http://www.nimh.nih.gov/about/strategic-planning-reports/index.shtml. Accessed October, 2011.
(17) Colton C, Manderscheid R. Congruencies in Increased Mortality Rates, Years of Potential Life
Lost, and Causes of Death Among Public Mental Health Clients in Eight States. Prev Chronic Dis
2006:A42.
(18) Centers for Disease Control and Prevention. Smoking-Attributable Mortality, Years of Potential
Life Lost, and Productivity Losses—United States, 2000– 2004. 2008;57(45).
(19) U.S. Department of Health and Human Services. How tobacco smoke causes disease: The
biology and behavioral basis for smoking-attributable disease. 2010.
(20) Lasser K, Boyd J, Woolhandler S, Himmelstein D, Cormick D, Bor D. Smoking and Mental Illness A
Population-Based Prevalence Study. JAMA 2000:2610.
- 47 -
(21) Brown S, Inskip H, Barraclough B. Causes of the excess mortality of schizophrenia. British Journal
of Psychiatry 2000;177:217--217.
(22) Stroup T, Gilmore J, Jarskog L. Management of medical illness in persons with schizophrenia.
Psychiatric Annals 2000;30(1):35-40.
(23) Sanderson C, Feng S, Canar J, McGlichey F, Tercyak K. Social and behavioral correlates of
cigarette smoking among mid-Atlanta Latino primary care patients. Cancer Epidemiol, Biomark&Prev
2005;14:1976.
(24) Desai H, Seabolt J, Jann M. Smoking in patients receiving psychotropic medications:
Apharmacokinetic perspective. CNS Drugs 2001;15(6):469-494.
(25) Williams J, Ziedonis D. Addressing tobacco among individuals with a mental illness or an
addiction.
(26) Gil A, Vega W, Turner R. Early and mid-adolescence risk factors for later substance abuse by
African Americans and European Americans. 2002;117 (Suppl.
(27) King B, Dube S, Kaufmann R, Shaw L, Pechacek T. Vital signs: Current cigarette smoking among
adults≥18 years - United States, 2005-2010.
. MMWR 2011;60(35):1207-1212.
(28) CDC. Vital signs, Centers for Disease Control and Prevention. 2012; Available at:
http://www.cdc.gov/VitalSigns/. Accessed 02/02, 2012.
(29) Lawrence D, Mitrou F, Zubrick S. Smoking and mental illness: results from population surveys in
Australia and the United States.
(30) Hall S, Prochaska J. Treatment of Smokers with Co-Occurring Disorders: Emphasis on Integration
in Mental Health and Addiction Treatment Settings.
(31) Sarah G, Pamela M. Meanings & Motives Experts Debating Tobacco Addiction. American Journal
of Public Health 2008;98(10):1793-1892.
- 48 -
(32) Prachaska J. Smoking and Mental Illness-Breaking the link. 2011;365(22):196-198.
(33) Prochaska J, Hall S, Bero L. Tobacco use among individuals with schizophrenia: What role has
the tobacco industry played? Schizophr Bull 2008;34:555-567.
(34) United Health Foundations. America's Health Rankings. Available at:
http://www.americashealthrankings.org/Measure/2010/TN/Prevalence%20of%20Smoking.aspx.
Accessed 08/20, 2011.
(35) United Health Foundations. America's Health Rankings. Available at:
http://www.americashealthrankings.org/Measure/2010/TN/Poor%20Mental%20Health%20Days.asp
x. Accessed 08/20, 2011.
(36) Tennessee Government. Department of Mental Health. Available at:
http://tn.gov/mental/mhs/mhs2.html. Accessed 08/20, 2011.
(37) Psychiatric Hospitals and Medical Centers. Psychiatric Hospitals and Medical Centers. 2011;
Available at: http://www.theagapecenter.com/Hospitals/Psychiatric.htm#Tennessee. Accessed
11/30, 2011.
- 49 -