Cigarette smoking and insurance coverage appear to be associated with those with mental health and substance use disorders

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

Gross though Reduction in smoking In the United States for the past 50 years, people with B Psychological health and substance use disorders (MH/SUD) showed a lower reduction in smoking than subjects without MH/SUD.

a A recent study Analyzing trends in smoking and insurance coverage among US adults with and without MH/SUD, finding evidence that improvements in smoking and abstinence outcomes for adults with MH/SUD appear to be associated with increased health insurance coverage. Since 2014, the Affordable Care Act (ACA) has driven significant changes in the US health insurance market that may affect tobacco use among those with MH/SUD.

We hypothesized that expansion of insurance would have a greater effect on insurance coverage among those with MH/SUD than among those without MH/SUD; and that increased insurance coverage would be associated with improved smoking outcomes among those with MH/SUD. this study.

Data for this study was obtained from 2008 to 2019 records from the National Survey on Drug Use and Health, an annual cross-sectional survey. There were a total of 448,762 survey participants, ranging in age from 18 to 64 years old.

Outcome variables were measured using recent cigarettes and health insurance coverage in 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% to 16.3%.

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

In addition, adults with MH/SUD were more likely to be younger, female, and non-Hispanic. 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 out 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 lower likelihood of either current smoking (-14.2 points; 95% CI, -14.7 to -13.7) or daily smoking (-12.3 points); 95% CI, -12.8 to -11.8), and an increase in the likelihood of having recently quit smoking (3.7 points; 95% CI, 3.2–4.3).

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

In 2018 to 2019, that spread narrowed to -2.0 points (95% CI, -2.7 to -1.3). This amounted to a 4.2 point (95% CI, 2.7 to -5.7) greater increase in coverage for those with MH/SUD (10.4 points; 95% CI, 9.0–11.8) than for those without MH/SUD (6.2 points; 95% CI, 5.4–7.0).

The authors suggest that associations between insurance coverage gains and smoking outcomes may be explained by factors not examined in this analysis, including reduced financial stress, mitigation of negative social harms, and increased utilization of care.

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

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

“A large proportion of the estimated improvements in each smoking and abstinence outcome for those 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. addicted. Published online November 17, 2022. doi: 10.1111 / add.16052

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