Two summary documents take stock of the consequences of smoking on mental health and highlight the importance of quitting smoking. Among young people and adolescents, e-cigarettes are suspected of having the same types of consequences on mental health as smoked tobacco.

Two out of three people suffering from severe mental health problems are smokers, twice as many as the rest of the population.[1]. They are also significantly more likely to develop addictions to other products. These observations have led to various interpretations, depending on the era and point of view, which are now being revised in light of the latest scientific publications.

Persistent prejudices among health professionals

It has long been accepted – and sometimes still is among health professionals – that people suffering from severe mental disorders (bipolar or psychotic disorders) relieve some of their symptoms with tobacco, in a more or less conscious self-medication approach. In addition, these people have more difficulty breaking out of the addictive cycle and smoking, which may have led to them being granted more indulgence and permissiveness, in particular via exemptions from the smoking ban in healthcare establishments. These considerations, which may have been fueled by research funded by the tobacco industry, are now disproved.[2].

To counter these preconceptions, the European branch of the World Health Organization (WHO) has just published a fact sheet summarizing the main data associating smoking and mental health.[3]. It appears that while tobacco use can sometimes temporarily mask certain psychiatric symptoms, it actually increases many symptoms, particularly those of depression, anxiety, stress and attention deficit hyperactivity disorder (ADHD). When they are not already present in young smokers, symptoms of stress, anxiety and depression can in fact be rapidly induced by smoking and nicotine withdrawal; these symptoms, which are in fact linked to withdrawal, are temporarily relieved by tobacco use, leading to a feeling of well-being and pleasure, before withdrawal returns and traps smokers in a withdrawal/consumption cycle.

Smoking among people with severe mental disorders is complicated by serious health consequences. It is one of the main causes of their reduced life expectancy of fifteen to twenty years, and of five to ten years in people with less serious mental disorders. It also has the effect of metabolizing antipsychotic treatments more quickly and reducing their effectiveness.

Quitting smoking may reduce anxiety-depressive symptoms

For people suffering from severe mental disorders, quitting smoking is accompanied by better mental health, reduced symptoms of stress, anxiety, depression and ADHD, and more generally better health.[4]Smoking cessation may combine drug and non-drug interventions to achieve better outcomes.[5]Once this withdrawal has been achieved, the dosages of antipsychotic medication can then be reduced, and with them the adverse effects linked to them.

Anti-smoking protection measures, such as smoking bans, should be systematically applied in mental health institutions in order to protect both caregivers and patients; they also prevent patients from being placed in a "different" status that dissociates them and separates them from the rest of the population. Deploying smoking cessation assistance programs and raising awareness among psychiatric caregivers on this topic would thus have the effect of significantly improving both the working conditions of care teams and the overall health of patients. Among other protective measures, increases in the price of tobacco are considered a relevant lever for this type of patient, who live in very precarious situations and are very sensitive to the price argument. The introduction of a specific health warning on tobacco products for mental disorders could be considered.

The tobacco industry's attitude is far from neutral towards people suffering from mental disorders, who have been the subject of highly targeted marketing. Manufacturers have thus made numerous contacts with mental health professional organisations, sometimes in the form of financial contributions or donations and deliveries of "first price" cigarettes.[6]They have also fueled the prejudices surrounding psychiatric patients, whether by funding research that perpetuates certain myths.[7] (as if tobacco could relieve certain symptoms) or by opposing measures banning smoking in specialist healthcare establishments.

E-cigarettes and youth mental health

On a related topic, the American organization Truth Initiative published a summary report in September 2021[8] on the influence of nicotine and e-cigarettes on the mental health of young people, whose conclusions are very close to those of WHO-Europe. Although the causality between them remains to be clarified, most of the findings observed on the action of tobacco on mental health seem to be also verified with electronic cigarettes. The use of e-cigarettes would thus have the effect of aggravating the symptoms of depression[9] and ADHD[10]. The rapid delivery of nicotine by e-cigarettes and the high nicotine levels found in these products could be the cause of the consequences of vaping on the psyche and brain development of young people, according to a mechanism similar to that of smoked tobacco. The hypothesis of a link between depression and vaping would also involve traces of metal particles contained in e-liquids.[11].

The belief that tobacco relieves symptoms of stress and anxiety is very common among young users, and is also transposed to vaping products; it would constitute a factor in the initiation of vaping for 81% of young people and would be a factor in maintaining vaping for 50% of regular users.[12]The tobacco industry appears to be one of the driving forces behind this belief, which it has perpetuated for decades by showcasing the relaxing effect of tobacco in its advertisements and associating it with the notion of pleasure; this already old strategy has since been updated around electronic cigarettes.[13], British American Tobacco and Philip Morris International are communicating extensively on the themes of well-being – and health. The search for psychological benefits and well-being is indeed one of the driving forces behind the search for sensations and the regulation of one's mood by products[14], which characterizes the most fragile young people and those most likely to turn to psychoactive products. Manufacturers maintain these inclinations in their communications targeting young people, whom they seek to capture and retain. The influence of this marketing and the relief of nicotine withdrawal symptoms by e-cigarettes would explain why young regular vapers are more likely to believe in the relaxing and anxiolytic effects of electronic cigarettes than young non-vapers.

The health crisis linked to COVID-19 has significantly worsened the moral situation of young people that could already be affected before this crisis. A study has shown that symptoms of severe depression and anxiety doubled during 2020 in the 18-24 age group, affecting up to 56,000 of them.[15]E-cigarette manufacturers have not failed to seize this opportunity to communicate extensively with young people via social networks, on the themes of well-being and stress relief.

A majority of young vapers intend to stop using e-cigarettes

A 2014 meta-analysis showed that symptoms of stress, anxiety, and depression significantly decreased when people quit smoking, and recent research suggests that the same would be true when they quit vaping. Programs like This is Quitting, promoted by the Truth Initiative, are encouraging young people to quit vaping in large numbers.[16]. The testimonies collected by a research report that a majority of young regular vapers intend to stop the electronic cigarette, that a third of them made an attempt to stop in the past year and that 15% intend to stop in the next month.[17].

Other measures to protect young people can be considered and are recommended by Truth Initiative. They include:

• a ban on all flavours, including menthol, in all tobacco and nicotine products;
• restricting marketing, including on social media, and access to e-cigarettes to adults who want to quit smoking tobacco;
• the Food and Drug Administration's (FDA) limitation of nicotine levels delivered by e-cigarettes, in order to reduce their addictiveness;
• greater transparency from the FDA regarding its decisions and approval processes for electronic devices;
• the FDA's ban on online sales of e-cigarettes and all tobacco products, and on any sales that are not made face-to-face;
• a significant increase in local, state or federal taxes on e-cigarettes to discourage their purchase by young people and encourage them to quit

  Keywords: mental disorders, mental health, youth, e-cigarette, anxiety, nicotine, FDA

©Generation Without Tobacco

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  [1] Tobacco use and mental health conditions. A policy brief. Copenhagen: WHO Regional Office for Europe; 2020. [2] Is smoking cessation beneficial for people with mental illness, and can they quit?, Tobacco Control Playbook, published June 8, 2017, accessed November 17, 2021. [3] Tobacco use and mental health, WHO Regional Office for Europe, 2021, accessed 17 November 2021. [4] Pagano ME, Delos-Reyes CM, Wasilow S, Svala KM, Kurtz SP. Smoking cessation and adolescent treatment response with comorbid ADHD. J Subst Abuse Treatment 2016;70:21–27. [5] Desai HD, Seabolt J, Jann MW. Smoking in patients receiving psychotropic medications. CNS Drugs 2001;15:469–94. [6] Is smoking cessation beneficial for people with mental illness, and can they quit?, Tobacco Control Playbook, published June 8, 2017, accessed November 17, 2021. [7] Prochaska JJ, Hall SM, Bero LA. Tobacco use among individuals with schizophrenia: what role has the tobacco industry played? Schizophr Bull 2008;34:555-567 [8] Colliding Crises: Youth Mental Health and Nicotine Use, Truth Initiative, September 2021, accessed November 17, 2021. [9] Lechner WV, Janssen T, Kahler CW, et al. Bi-directional associations of electronic and combustible cigarette use onset patterns with depressive symptoms in adolescents. Preventive Medicine 2017;96:73-78. [10] Bierhoff J, Haardörfer R, Windle M, et al. Psychological risk factors for alcohol, cannabis, and various tobacco use among young adults: a longitudinal analysis. Substance Use & Misuse 2019;54(8):1365-75. [11] Obisesan OH, Mirbolouk M, Osei AD, et al. Association between e-cigarette use and depression in the behavioral risk factor surveillance system, 2016-2017. JAMA Network Open 2019;2(12):e1916800-e00. [12] Many young people turn to nicotine to deal with stress, anxiety and depression, but don't know it may be making them feel worse, Truth Initiative, published October 7, 2021, accessed November 17, 2021. [13] How e-cigarette brands are trying to link vaping with mental health, Truth Initiative, published September 17, 2021, accessed November 17, 2021. [14] Addictions, From pleasure to dependence, INSERM, updated September 11, 2020, consulted November 17, 2021. [15] Racine N, McArthur BA, Cooke JE, et al. Global Prevalence of Depressive and Anxiety Symptoms in Children and Adolescents During COVID-19: A Meta-analysis. JAMA Pediatrics 2021;175(11):1142-1150. [16] This is quitting, Truth Initiative, accessed November 17, 2021. [17] Cuccia A, Patel M, Amato M, Stephens D, Yoon S, Vallone D, Quitting e-cigarettes: Quit attempts and quit intentions among youth and young adults, Preventive Medicine Reports, Vol. 21, March 2021, 101287. National Committee Against Smoking |