Abstract
Tobacco and nicotine use threaten mental and physical health, particularly during adolescence and among people with mental health conditions. Adolescent nicotine exposure may affect neurodevelopment and is associated with dependence and psychological difficulties. In adults, smoking is disproportionately prevalent in psychiatric populations and contributes to preventable disease and premature death. Perceived stress relief often reflects temporary relief of nicotine withdrawal, reinforcing dependence. Many people with mental health conditions want to quit, and effective treatments are available. Evidence suggests cessation can improve mental health, yet misconceptions about psychiatric destabilization and treatment effectiveness limit access. Persistent under-treatment compounds the disproportionate burden of physical illness already experienced by this population. Integrating cessation into routine mental healthcare is essential to reduce this avoidable inequity.
Keywords: tobacco; nicotine; mental health; adolescence; smoking cessation; psychiatric disorders; health inequities.
1. Introduction
Tobacco use remains a leading preventable cause of death. Beyond cardiovascular, respiratory and oncological disease, it is closely intertwined with psychological distress, substance dependence and social disadvantage. [7,8]
The relationship is complex and bidirectional. Mental health difficulties may increase smoking initiation and persistence, while dependence, withdrawal and tobacco-related harms can contribute to distress. Observational associations require cautious interpretation because shared vulnerabilities and reverse causation may influence findings. [10]
Two priorities follow: preventing nicotine dependence during adolescent brain development and improving cessation care for adults with mental health conditions. Both require addressing clinical misconceptions and fragmented services that limit access to effective treatment.
Although many could benefit substantially from quitting, adults with mental health conditions often receive less cessation assistance than other tobacco users. Closing this gap requires treating dependence as a clinical priority alongside psychiatric symptoms and other health needs. [7]
2. Nicotine and the Developing Adolescent Brain
Adolescence involves substantial maturation of neural systems supporting reward, emotional regulation, learning, and executive function. The prefrontal cortex continues developing into early adulthood. Nicotine acts on nicotinic acetylcholine receptors and influences neurotransmitter systems involved in attention, motivation, and learning. Repeated exposure promotes neuroadaptation, tolerance, craving and dependence, which can emerge before daily use is established. Products delivering nicotine efficiently, including electronic cigarettes containing nicotine salts, can facilitate repeated exposure. [2,9]
Experimental research and human studies suggest particular vulnerability during adolescence, with reported effects on reward processing, attention, learning, memory, and anxiety-related behaviors. However, human findings are heterogeneous, and some mechanistic evidence comes primarily from animal studies. Further human research remains necessary. [2,3]
Adolescent nicotine use is associated with depression, anxiety, psychological distress, and other substance use. Dependence and withdrawal can contribute to irritability, low mood, and concentration difficulties. Reliance on nicotine to regulate unpleasant emotions may limit opportunities to develop other coping strategies. Reported cognitive and behavioral effects vary by outcome and study design. [2,3,9,10]
Shared vulnerabilities, including adverse childhood experiences, impulsivity, family and social environments, and pre-existing psychological difficulties, may contribute to both nicotine use and mental health problems. These factors complicate interpretation of observed associations. Studies need to consider baseline mental health, patterns of exposure, other substance use, and the possibility of reverse causation. [2,3,9,10]
These associations do not establish that nicotine alone causes later psychiatric disorders. Nevertheless, the combined evidence supports prevention and developmentally appropriate cessation support. Clinicians should ask about all tobacco and nicotine products. Long-term psychiatric evidence for newer products remains incomplete; this uncertainty does not establish safety.
3. Tobacco Use and Mental Health Conditions in Adults
Smoking is disproportionately prevalent among people with schizophrenia, bipolar disorder, recurrent major depression and substance use disorders. Contributing factors include socioeconomic disadvantage, chronic stress, social isolation, severe dependence and the historical normalization of smoking in some psychiatric settings. [7]
Smoking may precede psychiatric illness, follow its onset or coexist through shared vulnerabilities. Associations with depression, schizophrenia and bipolar disorder are well documented, although causal pathways remain debated. [10]
Some people report improved concentration or reduced distress after smoking. These perceptions do not establish that smoking treats the underlying disorder: dependence and withdrawal can themselves generate symptoms attributed to psychiatric illness. [7]
Perceived short-term improvements can therefore coexist with a dependence cycle that creates additional distress between cigarettes. Recognizing this pattern helps clinicians discuss smoking without dismissing patients’ experiences or minimizing their psychiatric symptoms.
Overlapping difficulties, including other substance use, poverty, housing instability and limited healthcare access, should inform treatment planning. Cessation support should remain available while these needs are addressed, with nicotine dependence treated within routine mental healthcare.
4. Smoking and Perceived Stress Relief
Many people feel calmer after smoking, reinforcing the belief that it relieves stress. This experience partly reflects nicotine dependence. As nicotine levels decline between cigarettes, withdrawal can cause anxiety, irritability, restlessness, low mood and difficulty concentrating. Smoking temporarily relieves this discomfort, which may be interpreted as relief from everyday stress. Repeated withdrawal and relief reinforce dependence. [4,7]
People who smoke also face genuine psychological, social and economic stressors. Nicotine may briefly affect attention or arousal, but smoking does not resolve the sources of chronic stress.
A Cochrane review of 102 studies involving more than 169,500 participants found that quitting was associated with improvements in anxiety, depression and mixed anxiety–depression symptoms compared with continued smoking. Certainty ranged from very low to moderate across these outcomes, reflecting study limitations and possible confounding. The findings challenge the assumption that smoking is needed to maintain psychological wellbeing. [4]
Clinical conversations should distinguish temporary withdrawal discomfort from longer-term outcomes. Explaining that withdrawal symptoms are generally time-limited, and offering treatment to manage them, can support informed quit attempts.
This distinction matters when patients interpret early anxiety or low mood as evidence that quitting is harmful. Preparing them for withdrawal and reviewing symptoms over time can help separate transient discomfort from persistent psychiatric needs.
5. Physical Disease and Premature Mortality
People with serious mental illness experience high rates of cardiovascular and respiratory disease, cancer, and other preventable illnesses. Tobacco contributes substantially to this burden. Life expectancy is often approximately 10–20 years shorter than in the general population, although estimates vary by diagnosis, population and healthcare setting. Tobacco-related disease contributes alongside suicide, other substance use, socioeconomic disadvantage and barriers to physical healthcare. [7]
This mortality gap also reflects inadequate screening, underdiagnosis, undertreatment and fragmented care. It cannot be attributed solely to psychiatric symptoms or illness severity.
Cessation reduces future cardiovascular and respiratory risks and should be a core component of efforts to prevent premature mortality. This priority extends to people with depression, anxiety and substance use disorders, whose physical health needs can be obscured by competing clinical demands.
Addressing tobacco use therefore belongs within coordinated physical and mental healthcare, with preventive screening and treatment of existing disease continuing alongside cessation support.
6. Motivation to Quit and Effective Treatments
Many people with mental health conditions want to quit, make repeated attempts, and benefit from accessible, tailored treatment. Assuming that they are uninterested or unable to succeed can prevent effective care. [7]
WHO’s 2024 clinical guideline recommends behavioral and pharmacological interventions for adults who use tobacco. Options include individual, group, or telephone counseling and medicines such as nicotine replacement therapy, varenicline, and bupropion, selected according to clinical circumstances and availability. [1]
A 2026 systematic review and network meta-analysis included 74 randomized controlled trials involving 11,023 participants with schizophrenia, bipolar disorder, severe major depression or post-traumatic stress disorder. Compared with placebo or minimal care, varenicline increased long-term abstinence by an estimated 10 additional people per 100 treated and bupropion by approximately five per 100. Nicotine replacement therapy improved short-term abstinence; combined pharmacological and behavioral approaches may provide additional benefit. The review found little or no difference in depressive symptom scores with these medicines, although certainty varied by outcome. [5]
These findings support offering treatment with individualized assessment, monitoring and shared decision-making. Evidence remains less extensive for some populations and clinical circumstances. [5,6]
Treatment plans should reflect the person’s preferences, previous quit attempts and current needs. A psychiatric diagnosis alone should not exclude a patient from support, and difficulty quitting should prompt continued assistance rather than assumptions that treatment cannot work.
Medication interactions require attention. Polycyclic aromatic hydrocarbons in tobacco smoke induce CYP1A2, which metabolizes medicines including clozapine and olanzapine. Stopping combustible tobacco can increase their concentrations and cause adverse effects. The treating team should anticipate this change, monitor clinical response, and assess dose adjustment. Nicotine replacement therapy does not reproduce the enzyme-inducing effect of tobacco smoke. [7]
7. Barriers Within Mental Health Services
Cessation is frequently neglected because of modifiable clinical and institutional barriers. [5,7]
- Fear of psychiatric destabilization: Withdrawal may cause temporary symptoms, but evidence does not support routinely postponing treatment on this basis. Individual monitoring remains important.
- Doubts about effectiveness: Clinical trials show that people with severe mental illness can benefit from cessation treatment.
- Competing priorities: Acute symptoms, complex medication regimens and limited consultation time can displace tobacco care despite its importance for long-term health.
- Institutional culture: Smoking may be normalized, while responsibility for cessation is assigned elsewhere rather than shared across mental health and primary care teams.
- Limited training and access: Professionals may lack practical cessation skills, referral pathways or access to medications.
Services can address these barriers through staff training, clear protocols, accessible treatments and coordinated follow-up. Treatment should be routinely offered, with timing and intensity adapted to patient preferences, psychiatric stability and immediate clinical needs. Recording tobacco use should lead to an offer of support and a documented follow-up plan.
Clear professional responsibilities are also necessary: referral to another service should be accompanied by coordination and continued involvement from the mental health team. Ongoing support can help patients make further attempts.
8. Integrating Cessation Into Mental Healthcare
Psychiatrists, psychologists, nurses, primary care professionals and addiction specialists have complementary roles in cessation care. Routine encounters provide opportunities to ask about tobacco and nicotine use, offer brief advice, assess readiness, discuss treatment and arrange follow-up. Patients who are not ready to quit should continue receiving motivational support and future opportunities for treatment. [1,7]
Institutions and policymakers should incorporate tobacco dependence treatment into service standards, professional training, medication access policies and quality indicators. Monitoring should extend beyond recording tobacco use to assessing treatment access and sustained abstinence. [1]
A diagnosis should never become a routine barrier to the cessation support offered to other adults using tobacco.
For adolescents, prevention and early intervention can reduce dependence during a vulnerable developmental period. For adults with mental health conditions, improving access to cessation care can reduce avoidable physical illness and premature death. [7,9]
Treating nicotine dependence as part of comprehensive, person-centered care requires a sustained change in clinical culture. Accessible, integrated cessation treatment is essential to protect health, improve quality of life and advance equity in mental healthcare.
References
- World Health Organization. WHO clinical treatment guideline for tobacco cessation in adults. Geneva: World Health Organization; 2024. https://www.who.int/publications/i/item/9789240096431.
- Colyer-Patel K, Kuhns L, Weidema A, Lesscher H, Cousijn J. Age-dependent effects of tobacco smoke and nicotine on cognition and the brain: a systematic review of the human and animal literature comparing adolescents and adults. Neurosci Biobehav Rev. 2023;146:105038. doi: 10.1016/j.neubiorev.2023.105038.
- Elatfy A, Vrahimis S, Conti A, Baldacchino A. Chronic tobacco smoking and neurocognitive impairments in adolescents and young adults: a systematic review and meta-analysis. Front Psychiatry. 2024;15:1384408. doi: 10.3389/fpsyt.2024.1384408.
- Taylor GMJ, Lindson N, Farley A, Leinberger-Jabari A, Sawyer K, te Water Naudé R, et al. Smoking cessation for improving mental health. Cochrane Database Syst Rev. 2021;3(3). doi: 10.1002/14651858.CD013522.pub2.
- Bekkering GE, Detraux J, López-López JA, De Hert M, Evins AE, Vanhove AC, et al. Smoking cessation for people with severe mental illness: systematic review and network meta-analysis. BMJ Med. 2026;5(1). doi: 10.1136/bmjmed-2025-002190.
- Anthenelli RM, Benowitz NL, West R, St Aubin L, McRae T, Lawrence D, et al. Neuropsychiatric safety and efficacy of varenicline, bupropion, and nicotine patch in smokers with and without psychiatric disorders (EAGLES): a double-blind, randomised, placebo-controlled clinical trial. Lancet. 2016;387(10037):2507–2520. doi: 10.1016/S0140-6736(16)30272-0.
- Royal College of Physicians, Royal College of Psychiatrists. Smoking and mental health. London: Royal College of Physicians; 2013. Disponible en: https://www.rcp.ac.uk/resources/smoking-and-mental-health/.
- World Health Organization. WHO report on the global tobacco epidemic, 2023: protect people from tobacco smoke. Geneva: World Health Organization; 2023. Disponible en: https://www.who.int/publications/i/item/9789240077164.
- Jenssen BP, Walley SC, Boykan R, et al; AAP Section on Nicotine and Tobacco Prevention and Treatment, Committee on Substance Use and Prevention. Protecting children and adolescents from tobacco and nicotine. Pediatrics. 2023;151(5). doi: 10.1542/peds.2023-061806.
- Burke C, Freeman TP, Sallis H, Wootton RE, Burnley A, Lange J, et al. Associations of cannabis use, tobacco use, and incident anxiety, mood, and psychotic disorders: a systematic review and meta-analysis. Psychol Med. 2024;54(15):4287–4301. doi: 10.1017/S0033291724002587.
Dr. Eduardo Bianco
Director, Addiction Training Program for Health Professionals (ATHP), Frank Foundation.
Coordinator, Nicotine Addiction and Tobacco use Treatment Initiative (NATTI)