People with depression and anxiety are the heaviest smokers in the country but their doctors and mental health specialists don't ask them to quit due to concern that if they try to quit smoking their mental disorders will get worse. 

Between 40 to 80 percent of people with mental illness are daily smokers, depending on the disorder, compared to less than 20 percent of people who don't have problems with mental illness, according to research. The mentally ill also smoke more cigarettes per day -- often up to two packs. They have a disproportionately high rate of tobacco-related disease and mortality, such as cardiovascular disease or cancer, with a correspondingly heavy financial burden to the health-care system.

The mentally ill receive tobacco treatment on only 12 percent of their visits to a psychiatrist and 38 percent of their visits to a primary care physician. 

Doctors erroneously believe mental disorders will worsen if they take away a person's tobacco.  But that is just a myth, says Brian Hitsman, assistant professor of preventive medicine at Northwestern University Feinberg School of Medicine.

This population's tobacco use and dependence need to be treated, he said, and he has designed and published what he calls the first comprehensive, evidence-based plan for psychiatrists, psychologists and other mental health providers to help their patients quit smoking.  It appeared in the Canadian Journal of Psychiatry.

"These doctors and mental health specialists focus on their patients' psychiatric health and lose track of their physical health," said Hitsman, who is also a health psychologist. "Tobacco cessation gets a lot of attention, but we leave out a population that smokes the majority of all the cigarettes.  Not a single study shows that symptoms get worse."

He examined 13 randomized clinical trials that measured psychiatric symptoms during smoking cessation treatment. Seven studies showed that psychiatric symptoms actually improved during smoking cessation treatment, and six showed no changes. 

Another problem is mental health professionals believe tobacco is not a real addiction compared to other drug addictions. 

"The perception is patients need tobacco because it's their only source of pleasure and helps them feel better," Hitsman said. "There is very little evidence, though, that smoking cigarettes serves to self-medicate emotional symptoms."

There is evidence from a few studies, however, that when mental health providers insert smoking cessation treatment into the mental health treatment plan, they can help their patients quit or cut down. 

"They find if you take advantage of the relationship with the counselor and insert smoking cessation counseling into treatment that you enhance quit rates," Hitsman said. 

His tobacco cessation plan combines cognitive behavioral therapy, pharmacotherapy and motivational counseling to help the patient quit. Hitsman also has identified several treatment medications that may further facilitate quitting for this population. 

People with mental disorders do have a harder time quitting than the general population, Hitsman acknowledged, but said newer studies show it is possible to enhance the chance of success with this approach. Even if patients simply reduce their smoking, they are much more likely to quit successfully at a later date. 

To help motivate the patient, the counselor highlights the benefits of quitting, the personal costs of smoking and the barriers to cessation success. "It gets the person in a problem-solving mode, at the basis of which is a solid relationship with the counselor," Hitsman said.

Tobacco dependence also needs to be treated as a chronic disease, Hitsman believes. "We know that treatment provided for a longer duration substantially increases the abstinence rates of people without mental disorders," he noted. "Smokers with mental illness may be especially likely to benefit from extended or maintenance tobacco treatment."