According to the Centers for Disease Control and Prevention, current smoking rates declined from 45% in 1954 to 15.1% in 2015. This is amazing progress after decades of tireless efforts, and is one of the few quality measures in which the U.S. now leads the world. It’s also a very important health outcome to track, because cigarette smoking is still the leading cause of preventable disease and death in the United States, accounting for more than 480,000 deaths every year.

While this is a wonderful accomplishment, unfortunately, it has not benefited people with mental illness equally, leading to one of the most significant health disparities of our time. In the US, people with mental illness consume more than 40% of all cigarettes smoked by adults: that’s almost 20 billion cigarettes annually. And, according to a 2013 CDC study, 36% of people with mental illness smoke cigarettes.

Smoking is one of the primary causes of premature death and is a significant determinant of morbidity and mortality among this population. And, it has been found that those with serious mental illness die an average of 25 years earlier than those without serious mental illness, and this is often caused by preventable diseases. In the population that I treat, which is people with mental illness and addictions, more than 80% of my patients smoke. In their entire treatment journey, up until now, smoking has been their most neglected addiction.

Tragically, even though tobacco use disorder is considered to be an addiction, very few programs that treat mental illness or addiction address this significant disorder, in conjunction with the mental or substance use disorder, in a meaningful way.

But Sheppard Pratt is one of the few organizations that tackles this problem head-on: Sheppard Pratt maintains non-smoking campuses and provides smoking cessation services to patients on these campuses. And just last year, Sheppard Pratt was able to hire a Smoking Cessation Coordinator, Dr. Rachel Smolowitz, thanks to a generous grant by the Maryland Department of Health and Mental Health Hygiene, who has provided the much-needed focus and discipline to address this important issue in an ongoing manner.

How We Tackle Smoking Cessation

When patients come through our doors, some are ready to quit, some are considering it, and some haven’t even thought about it. The chart below gives you a breakdown of where patients are in their stage of change in regards to smoking. You can see that 30% (those in the precontemplation stage) were in denial of their need to quit; 30% (those in the contemplation stage) were ambivalent about quitting; 37% (those in the preparation stage) wanted to learn more about quitting and asked for advice; and only 3% were already taking steps towards quitting. So, we had our work cut out for us when we began offering smoking cessation services, especially when you compare our patients to the general population; 70% of smokers in the general population want to quit.

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Today, patients are offered individual and/or group counseling for smoking cessation and medications for the treatment of tobacco use disorder during inpatient and day hospital treatment. This counseling serves as a pilot phase for quitting, during which we teach ways of dealing with tobacco use disorder in a controlled environment so that our patients and clients can utilize these interventions upon discharge. We also provide prescriptions for tobacco use disorder as part of the prescriptions that we offer to all patients on our units, as well as referrals for smoking cessation counseling services upon discharge. Ultimately, we strive to apply a proactive, supportive, and guiding counseling style, which has been found to be the most effective at helping patients be successful in quitting. 

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*Patients are offered both a referral to a smoking cessation counseling service as well as a prescription for nicotine replacement therapy (NRT) upon discharge

On December 19, 2016, Sheppard Pratt received notification from the Maryland Resource Center for Quitting Use and Initiation of Tobacco (MDQuit) that  our health system was the recipient of this year’s Fax to Assist Referral Award, which stated that we ‘had the most fax referrals to the Maryland Tobacco Quitline by a behavioral treatment center in fiscal year 2016, and the second highest number of fax referrals in the state overall.’ In addition, they recognized the work of Dr. Rachel Smolowitz, Dr. Faith Dickerson, and the staff at Sheppard Pratt. It makes me proud to be part of a team that is making such great strides in helping our patients to quit smoking, and a health system that takes its mission to address many of the unmet needs of patients with mental illness and addictions seriously.


Sunil Khushalani, M.D., is the medical director of the Adult Service Line at Sheppard Pratt Health System. His primary focus is providing integrated treatment to adult psychiatric patients with co-occurring disorders.

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