The numbers don’t lie, there is a clear link between smoking and mental health, with 30% of smokers having a mental health condition. But is that link because smoking increases an individual’s chance of developing a mental health illness, or do people at a higher risk of mental health illnesses have a greater propensity to smoke than the general public? The simple answer is both, but the researched components that explain the connection between mental health and smoking are diverse and fascinating. This is because mental health is not one thing, but a multitude of different conditions referred to collectively. As such those conditions relate to smoking differently, with the nicotine of cigarettes having differing effects on the brain from person to person.
Smoking numbers in those with mental health conditions are also not following the same downward trend of smoking rates seen in the general population. In the UK, from the mid-1990s to 2017 smoking in the general population dropped from 27% to 14.9%, but in those with a serious mental health illness the number that smoke is 40%, and has remained steady for the past 20 years. On top of this, people with mental health conditions have been proven to smoke significantly more, have increased levels of nicotine dependence, and therefore have higher rates of smoking-related disease compared to other smokers1.
Higher rates of smoking have a huge impact on the overall health of those with mental health conditions. In fact, the higher rate of smoking in those with mental health conditions is the single largest contributor to that group’s 10-20-year reduced life expectancy. This stark effect is often lost when we discuss the short-term effects of cigarettes on the brains of those with mental health conditions.
What we can comfortably say is that smoking has a significant effect on how you interpret and interact with the world, not just immediately after having a cigarette, but throughout the life of a smoker. First, we’ll delve into the science of how smoking a cigarette affects your brain.
What is the physiological impact of smoking on the brain?
Nicotine increases dopamine levels in the brain, stimulating the reward centres and making the person inhaling nicotine feel good. This effect is rapid, with nicotine reaching the brain just 10 seconds after inhalation. The fast feedback loop is the reason smokers feel such an immediate sense of pleasure when smoking.
Over time your body builds a resistance to nicotine, which is the reason it takes more and more of the drug to elicit the same pleasurable effect. This is a key component to what makes nicotine, and cigarettes, addictive.
As nicotine is a stimulant, it has also been proven to improve attention and cognitive performance in some groups, in particular those with ADHD. In fact, it is thought that one of the reasons for a higher than normal rate of smoking in people with ADHD is because they are using cigarettes to self-medicate their symptoms.
Outside of the effects of nicotine, smoking cigarettes is also associated with dementia and dementia-related brain changes, most notably grey matter volume atrophy (the vital part of the brain that contains the neuron cell bodies). This is thought to be due to damage to small blood vessels caused by the chemicals in cigarettes, and is the same reason why smokers are at higher risk of strokes and heart attacks than the general population.
The Relationship between Smoking and Depression:
There is a strong link between smoking and depression, with the smoking rate twice as high in those with depression as opposed to adults without depression.
Dopamine levels are often naturally lower in individuals who have depression, and thus the short term dopamine release caused by nicotine in cigarettes can be used by patients with depression to self-medicate their symptoms. Unfortunately, over time smoking adversely affects the mechanism for making dopamine, meaning whilst it increases dopamine in the short term, in the longer term it leaves smokers with even lower dopamine levels.
This is thought to be the reason why smoking is also associated with severe depression, with further research being done to further define if people with depression are susceptible to smoking, or if smoking is a contributing factor to their depression. Studies have already shown that smoking significantly increases the chance of developing major depression.
The Relationship between Smoking and Anxiety:
Many people believe that they “self-medicate” their stress through smoking. However, the evidence shows that smoking increases anxiety and tension. Nicotine does create an immediate sense of relaxation, which causes those who smoke to believe that their habit promotes relaxation, but this feeling is temporary and soon gives way to symptoms of withdrawal and cravings. Smoking at this point will reduce the withdrawal symptoms but will not reduce anxiety, or deal with any of its underlying causes.
The onset of anxiety can also be a key contributor to why someone begins to smoke in the first place. The initial feeling of relaxation achieved when smoking can then fortify a behaviour in a vulnerable brain that is dealing with an episode of anxiety, and mean that when future episodes occur that person reaches again for a cigarette.
The Relationship between Smoking and Schizophrenia:
People who suffer from schizophrenia have a particularly high rate of smoking, with a prevalence of over 60%. Research has also shown that nicotine may improve attention and short-term memory in sufferers of schizophrenia.
Smoking can also cause some interactions with medications which could be troublesome. Cigarettes and nicotine can increase the speed at which the body breaks down psychotropic drugs. This means that smokers frequently need higher doses of certain drugs, such as Clozapine, than patients who do not smoke to gain the same therapeutic effect. This isn’t necessarily harmful, but in general principles, the lowest doses of necessary medication is probably the best to avoid increased risks of side effects and toxicity of the medication.
Can quitting smoking improve one’s mental health?
The simple answer is yes. Smoking has significant links to a number of mental health conditions, along with causing vascular damage that could lead to cognitive problems in the future.
There is a definite mental health benefit to stopping smoking. If you are replacing cigarettes with a form of nicotine replacement therapy such as vaping, you will still be exposed to the effects of nicotine on the brain. Research on nicotine’s effect on mental health when not part of tobacco cigarettes is still in its infancy, but it is growing fast.
What are the common misconceptions about smoking and relaxation or stress relief?
One of the biggest misconceptions about cigarettes is that they are relaxing. This is because in our own lives, or even in movies and on TV, we see people desperate for a cigarette, then take a first drag and feel immediately calm. This calm is caused by two things, firstly the short term dopamine release in the brain from nicotine, but secondly it is caused by an ending to the stress built up by addictive withdrawal symptoms that are making you feel you need a cigarette. If you can break the cycle of addiction to smoking, that initial stress would not occur, and thus that “stress relieving” effect would not occur.
What measures can be taken to break the cycle between poor mental health and smoking?
Nicotine has a powerful addictive effect. Alongside that, for those who have smoked for a long time, or are regularly surrounded by smokers, there is a large behavioural aspect to smoking that must also be overcome to stop smoking.
Firstly we will address nicotine withdrawal symptoms. The easiest and most effective way to stop smoking is to move on to nicotine replacement therapy. These include nicotine patches, gums, e-cigarettes or vapes, and a number of other formulations. By using a form of nicotine replacement you will not suffer from the same withdrawal symptoms as you are maintaining the amount of nicotine you ingest. There is significant evidence that use of such therapies give people trying to quit smoking a higher chance of succeeding than those who try without them, increasing the chance of quitting by 50-70%.
Secondly, the behavioural aspect of smoking is very important to address. That is why we would always recommend using a stop smoking service when trying to quit. This is because they can offer one-to-one and group support that will help you in your quitting journey.
Lastly, be aware of your triggers. Is it always after a big meal or when you are socialising with friends that you crave cigarettes the most? If that is so, plan ahead when you know those times are coming and ask your friends and family to support you and help to avoid temptation in those difficult moments. Having a good safety-net method of alternative and safer nicotine source such as nicotine replacement therapy is also an important tool to satisfy the physical nicotine cravings.
Quitting smoking is not an easy task, particularly if like a large proportion of the population, you are also suffering with a mental health condition. That being said, the health benefits to stopping smoking are enormous, and more and more people are using the great range of therapies and support available to succeed in their journey to become cigarette free everyday.
The first key to understand is that you are not alone. Friends and family are a magnificent resource for support and drive, and are often a key reason why people want to quit smoking in the first place. Beyond that, there are a number of support services available. Quitline is a wonderful resource in Australia that not only provides smoking cessation counselling, but also has a wide range of information resources to help with quitting. Your GP will also be able to help direct you to local services, and support in the ongoing management of any other medical conditions. Telling your GP that you are trying to quit smoking is particularly important if you are being treated for a mental health condition, as this will allow them to guide you if there are any special precautions that you should take.
Additionally, there is significant research to show that using a nicotine replacement therapy increases your chance of quitting compared to not using one23. Nicotine gum and patches are often recommended to try first, but if you have not been successful with those then using e-cigarettes or nicotine vapes can be a very effective alternative. You will require a prescription to use nicotine vapes in Australia, which can be acquired by certain trained doctors or online at www.quitclinics.com where you will be assessed for your suitability by a specialist.
Lastly, remember that quitting is not easy. Most people require a number of attempts to reach their goal to be cigarette free, but the health benefits are huge. Remember that 1 in 2 smokers will die from a smoking related disease, so the effort of stopping is worth it in the end.