The Link Between Tobacco Use and Substance Use/Mental Health Disorders

by Brenda Stubbs

I think most people – health providers and patients alike – understand the dangers and overall health risks of tobacco use, even those who currently smoke or use tobacco.

Add substance use or mental health disorders into the mix, and the risk goes up even more, as smoking rates are even higher in these vulnerable populations. Look at the statistics: 90% of women who use opioids, along with 77-93% of patients in treatment for substance use or addiction, and 60-88% of people with mental health disorders – ranging from depression to bipolar to schizophrenia – ALSO SMOKE.

For many people in these populations, smoking may SEEM like the least of their problems – but it is certainly the one problem that may be killing them at higher rates.

People with mental health or substance use problems who also smoke experience more symptoms, more hospitalizations, and typically require more and higher doses of medications during treatment. This is in part due to nicotine and tobacco smoke rendering medications used in treatment less effective. On the flipside, patients receiving treatment for alcohol or drug addiction or mental health disorders who ALSO receive tobacco cessation counseling and treatment have more successful treatment outcomes overall and lower relapse occurrences.

I often hear tobacco cessation specialists say “if you want to help your patients get and stay off other substances, you need to get them off tobacco.” 

Nicotine triggers the same receptors in the brain that are triggered by cocaine, opioids, heroine, and certain other substances. This is why there are so many co-occurring substance use disorders, and why quitting smoking can often help stave off cravings for those other substances. In essence, smoking keeps the door open to triggering these receptors.

In addition, due to its harmful effects on the liver, people who can discontinue tobacco use can often subsequently discontinue their other meds for chronic health conditions such as high blood pressure – including psychotropic meds for mental health conditions.

Now, let’s go a step further and add pregnancy into the mix: All the above still applies to pregnant women, but there are obviously even more specific considerations when it comes to the health of mom and baby. It’s important to note that when we are talking about pregnant women, it is NOT just substance abuse we need to be concerned about, it is ANY substance use.

With regard to pregnancy, smoking is considered the most preventable risk factor for poor birth outcomes – it is a leading cause of preterm birth, low birth weight and SIDS. However, it’s important to note that Fetal Alcohol Spectrum Disorder (FASD), due to alcohol exposure during pregnancy, is a birth defect and also the only preventable cause of intellectual developmental disability, which is essentially permanent brain damage.

So, exposure during pregnancy to nicotine, alcohol, opioids, heroine, and any number of other substances is dangerous for the fetus – all of these substances can shear the placenta and cause a multitude of problems. It’s important for providers to educate their patients on this basic rule:  anything that can get to the mom’s brain can also get to the placenta and in turn can get to the fetus.

Let’s look for a moment at opioid use in pregnancy...
For pregnant women with no history of substance use disorder, prescribing opioids to treat acute conditions is typically okay. The problem is that up to 25% of pregnant women are likely to continue to refill the prescription for pain or mood management – something that is not monitored or regulated enough. 

Chronic opioid exposure during pregnancy changes the balance of neurotransmitters in the neonatal brain – most affected are noradrenaline and norepinephrine – which can result in the baby being born “physically dependent” and with Neonatal Abstinence Syndrome (NAS).

Detox, however, is almost never recommended for pregnant women, as severe withdrawals in the mom can mean a higher risk for complications for the baby, the most severe being fetal demise or stillbirth.

More often, Medication-Assisted Therapy (MAT) or Opioid Treatment Programs (OTP) are the preferred treatment pathways for pregnant women. Even within these types of treatment programs, tobacco cessation specialists say if you can counsel and help the patient to also stop smoking, you will increase the likelihood of a successful treatment outcome, while minimizing NAS and other health risks for the baby and incidence of relapse for the mom.

The American Society of Addiction Medicine issued a public policy statement in recent years that advises addiction treatment programs to: “Integrate evidence-based nicotine addiction treatment into mental health and addiction services…assess for nicotine addiction when they {assess} for other chemical addictions” and “the treatment plan should address nicotine addiction as it would any other addiction.”

So what is the bottom line? Tobacco use, in and of itself, is a major health risk. Combined with substance use or mental health disorders, it can magnify the risks of those conditions. But helping a patient to quit smoking can also improve their chances of abstaining from other substance use that can seriously impact their health or the health of their baby.


American Society of Addiction Medicine (

Marjorie Meyer, MD, OB/GYN, Specialist in Neonatal Impact of Opioid Exposure in Pregnancy

Mary Gillette, MS – GCDHHS: “Tobacco Cessation in Behavioral Health Populations”

Kathy Norins, M.Ed. – Alcohol and Drug Services

Smoking Cessation Leadership Center – Fact Sheets: “The Tobacco Epidemic Among People with Behavioral Health Disorders” and “Drug Interactions with Tobacco Smoke”3/2015.

Revised: October 15, 2015

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