National Alliance on Mental Illness
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(800) 950-NAMI; firstname.lastname@example.org
An important new source of funding for public programs serving adults with severe mental illnesses will soon be available to states. These resources are being made available to state governments through a $206 billion settlement reached on November 23, 1998, between 46 state attorneys general and the tobacco industry (Florida, Minnesota, Mississippi and Texas had previously settled their cases and thus did not participate in this settlement). The settlement is based on numerous lawsuits filed by the states to recover Medicaid funds spent over the years to treat low-income persons with tobacco-related illnesses.
The global settlement provides little, if any, restrictions on how states can spend their share of the settlement. Thus, there are no restrictions preventing all of the participating states from directing these funds to existing, or new, programs serving adults with severe mental illnesses. Already, several states have either made the decision to direct tobacco settlement proceeds to mental illness treatment, or had state officials publicly support the same. For example, Arizona recently committed to use $76 million of its future tobacco receipts to replace the state's aging, underfunded and unsafe psychiatric hospital. In Rhode Island, the state's new Lt. Governor has gone on record in support of using tobacco funds for mental illness treatment.
The purpose of this memorandum is to provide NAMI advocates with a few arguments that can be made for investing these new resources into the public mental illness treatment system in your state. While some governors have already put forward specific plans on how to spend their share of the global tobacco settlement, others are still developing ideas. However, even in cases where governors have made specific commitments, approval by the legislature is still needed. The public process by which these decisions are made should provide NAMI advocates with the opportunity to make the case for investment in treatment and supports for people with severe mental illnesses. If nothing else, the debate should provide an opportunity for NAMI advocates to continue delivering the message to public officials that serious mental illnesses are treatable brain disorders.
The Link Between Tobacco and Smoking-Related Illness
In seeking to make the case of using these funds for mental illness treatment, services, and supports, NAMI advocates are likely to be most successful by developing a link to the original basis of the state initiated lawsuits; i.e., the link between tobacco, disease, and state Medicaid expenditures to treat sick smokers. However, this linkage need not be explicit. For example, some governors have already declared interest in spending their settlement funds on child care programs, health prevention programs, and initiatives to keep children from smoking.
While nearly all of these spending plans are related to tobacco and public health, none are directly linked to state dollars that have already been spent to treat Medicaid recipients with smoking-related illnesses. In fact, a case can be made that leaving settlement proceeds in the state treasury to replace previously spent Medicaid funds would be the most logical use for these funds. Of course few, if any, elected officials are willing to resist the temptation to spend state revenues not derived from direct taxation on pressing public needs. Thus, there are likely to be important opportunities for advocates to make the case for investment in new or existing state and local programs if there is a link to tobacco and smoking-related illness.
Severe Mental Illness and Tobacco
A review of the medical and public health literature by the NAMI policy staff has found considerable evidence indicating both that adults with severe mental illness have higher rates of smoking, and that the symptoms of brain disorders such as schizophrenia and major depression are linked to tobacco use. The following points are supported by the existing science and research.
1. Adults with severe mental illnesses smoke at a rate higher than the general population. Evidence: a) chronic schizophrenia patients smoke at a rate that approaches 90% (Lohr & Flynn, "Smoking and Schizophrenia" Schizophrenia Res, 8:93-102, 1992),
b) while testing a new drug for smoking cessation, a 1988 study found that 42 to 71 smokers (60%) in the study had a history of major depression, while the best available data suggests that lifetime smoking rates for the general community are around 18% (Kessler, McGonagle, Zhao, Nelson, Hughes, Eshleman, Wittchen, Kendler, "Lifetime and 12-month prevalence of DSM-III psychiatric disorders in the U.S.: Results from the National Comorbidity Survey," Archives of General Psychiatry, 51:8-19, 1994).
c) patients coming to a medical center for treatment for a variety of psychiatric conditions, including depression, were more likely to be smokers than the general population (Hughes, Hatsukami, Mitchell, Dahlgren, "Prevalence of smoking among psychiatric outpatients," American Journal of Psychiatry, 143:993-997, 1986).
d) In a study on smoking cessation, 31% of those smokers with no history of psychiatric illness were able to stop smoking for more than 1 year, and 28% of those individuals with either no psychiatric history (or no psychiatric history except for depression) were able to quit; among those with a lifetime history of major depression, less than 14% of smokers were able to stop (Glassman, Helzer, Covey, Cottler, Stetner, Tipp, Johnson, "Smoking, smoking cessation and major depression," JAMA 264:1546-1549, 1990).
e) Individuals with schizophrenia in the U.S. smoke over 10 billion packs of cigarettes each year, at a cost of over $20 billion (Torrey, Surviving Schizophrenia, 3rd Edition, 1995).
2. There is mounting evidence that smoking is a form of self-medication for individuals with schizophrenia in that nicotine appears to reduce anxiety and sedation and improve concentration in some people.
a) Nicotine is known to affect the receptors for many brain neurotransmitters and to promote the release of dopamine, serotonin, acetylcholine, and norepinephrine - of which are related to serious brain disorders such as schizophrenia (Surviving Schizophrenia, 3rd edition, pp. 250-253, 1995).
b) Studies of smokers with schizophrenia reveal that smoking can transiently improve specific brain functioning, including auditory sensory gating, that are known to be impaired by the disease (Surviving Schizophrenia, 3rd edition, pp. 250-253, 1995).
c) Studies have also shown that smoking decreases side effects of antipsychotic medications such as stiffness and tremors (Surviving Schizophrenia, 3rd edition, pp. 250-253, 1995).
d) There are nicotine receptors in the brain and many scientists believe that these are related to schizophrenia (Surviving Schizophrenia, 3rd edition, pp. 250-253, 1995).
e) Nicotine has been shown in some studies to decrease the blood level of antipsychotic medications by increasing the excretion by the kidneys; smokers with schizophrenia are known to require higher doses of antipsychotic medications than non-smokers, although a direct link to increased kidney excretion has not been found yet (although a study of Tourette's disease reported that nicotine potentiated the effects of haloperidol in decreasing tics) (Surviving Schizophrenia, 3rd edition, pp. 250-253, 1995).
The arguments cited above are not intended to constitute the sole justification for using tobacco settlement funds for mental illness treatment and community supports. In fact, some of the most persuasive arguments are not necessarily supported by the current scientific literature (at the same time, they are not disproven either). For example, the personal experience of many NAMI advocates is that many consumers started smoking while they were residents in public psychiatric hospitals. This occurred as a direct result of being provided cigarettes at no cost during a long-term involuntary placement in a state hospital. Such experiences have inevitably led to a lifetime habit of heavy smoking and nicotine addiction that, for many consumers, is simply too difficult to break. While there is scarce scientific literature or surveys on this phenomenon, it is a powerful argument to make in seeking a share of tobacco settlement funds; i.e., that the state bears responsibility for any ongoing addiction to tobacco.
At the same time, it is also important to recognize that the scarcity of scientific research on severe mental illness and smoking raises a number of questions. According to Dr. Torrey, the medical literature does not yet support a higher incidence of lung cancer among individuals with schizophrenia. In Surviving Schizophrenia he notes that it is "one of the intriguing mysteries about this disease . . . that the lung cancer rate in schizophrenia appears to be lower than the general population, not higher." Torrey goes on to note that "there has been speculation whether antipsychotic medication might in some way be protective and account for this, but this explanation seems unlikely since at least two studies reported a lower lung cancer rate in schizophrenia before antipsychotic drugs were introduced" Surviving Schizophrenia, 3rd edition, p. 253.
For more information on the tobacco settlement or state spending on mental illness treatment and services, please contact either Clarke Ross (703-312-7894) or Andrew Sperling (703-516-7222) of the NAMI Policy Staff.