Cigarette smoking, insurance coverage appear to be associated in people with mental illness and substance use disorders

Policy reforms that expand insurance coverage can play a supportive role in discouraging smoking among adults living with mental health and/or substance use disorders.

Despite an overall decrease in smoking in the US for the last 50 years people with Mental health and substance abuse disorders (MH/SUD) have shown less reductions in smoking than people without MH/SUD.

A Recent study analyzed smoking and insurance coverage trends in US adults with and without MH/SUD and found evidence that improvements in smoking and abstinence outcomes for adults with MH/SUD appear to be associated with increases in health insurance coverage. Since 2014, the Affordable Care Act (ACA) has led to major changes in the US health insurance market that may impact tobacco use by people with MH/SUD.

“We hypothesized that coverage extension would have a greater effect on coverage for individuals with MH/SUD than for individuals without MH/SUD; and that increased insurance coverage would be associated with improved smoking outcomes in patients with MH/SUD,” the study authors wrote.

The data for this study were obtained from records from 2008 to 2019 from the National Survey on Drug Use and Health, an annual cross-sectional survey. A total of 448,762 people between the ages of 18 and 64 took part in the survey.

Outcome variables were measured using recent cigarette smoking and health insurance coverage over the past year.

Comparing pooled data from 2008-2009 and 2018-2019, current smoking rates for adults with MH/SUD decreased from 37.9% to 27.9%, while current smoking rates for adults without MH/SUD decreased from 21.4% 16.3% declined.

In the 2008-2019 study period, adults with MH/SUD were more likely to report current (34.2% vs 19.0%) and daily (24.2% vs 13.5%) smoking. Adults with MH/SUD were less likely to report smoking (8.9% vs. 10.1%).

Additionally, adults with MH/SUD tended to be younger, female, and non-Hispanic White. They were less likely to be Hispanic, non-Hispanic Black, or non-Hispanic Asian. They were also less likely to have had health insurance for at least 10 of the 12 months prior to completing the survey (76.0% vs. 80.4%).

Having health insurance for at least 10 of the 12 months prior to the survey was strongly associated with a reduction in the likelihood of currently smoking (−14.2 points; 95% CI, −14.7 to −13.7) or smoking daily (-12.3 points; 95% CI, -12.8 to -11.8) and an increase in the odds of recent smoking cessation (3.7 points; 95% CI, 3.2-4.3).

In 2008-2009, the adjusted prevalence of coverage for adults with MH/SUD was 6.2 points lower (95% CI, -7.6 to -14.8) compared to adults without MH/SUD.

In 2018 versus 2019, this difference had shrunk to -2.0 points (95% CI, -2.7 to -1.3). This corresponded to a 4.2 points (95% CI, 2.7 to -5.7) greater increase in coverage for those with MH/SUD (10.4 points; 95% CI, 9.0 to -11.8) than for those without MH/SUD (6.2 points; 95% CI, 5.4-7.0).

The authors suggest that the associations between insurance coverage gain and smoking outcomes may be explained by factors not examined in this analysis, including reduced financial burden, alleviation of adverse social disadvantage, and increased use of long-term care services.

Because the NSDUH relies on self-reported and recall-based measures, the authors acknowledge that the data can be prone to bias.

Furthermore, because the NSDUH is a point-in-time cross-sectional survey and variables at the area level were not available, the authors were unable to establish a causal relationship between ACA insurance expansion and the outcomes examined.

“A significant portion of the estimated improvements in smoking and abstinence among patients with MH/SUD was explained by increases in health insurance coverage,” the authors write.


Creedon TB, Wayne GF, Progovac AM, Levy DE, Cook BL. Trends in cigarette use and health insurance coverage among US adults with mental health and substance use disorders. Seeks. Published online November 17, 2022. doi:10.1111/add.16052

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