Cigarette Smoking, Insurance Coverage Appears Linked in Those With Mental Health, Substance Use Disorders

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

Despite an overall decline in smoking in the US over the past 50 years, people with mental health and substance abuse disorders (MH/SUD) have shown less reduction in smoking than people without MH/SUD.

A recent study analyzed smoking and insurance coverage trends 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 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 among those with MH/SUD.

“We hypothesized that insurance expansion would have a larger effect on insurance coverage among those with MH/SUD compared to those without MH/SUD; and that increased insurance coverage would be associated with improved smoking outcomes among those with MH/SUD,” wrote the authors of this study.

The data for this study were obtained from 2008 to 2019 records from the National Survey on Drug Use and Health, an annual cross-sectional survey. There was a total of 448,762 respondents to the survey, aged 18 to 64 years.

Outcome variables were measured by recent cigarette use and past-year health insurance coverage.

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

Across 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%).

Additionally, adults with MH/SUD were more likely 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 health insurance for at least 10 out of the 12 months before survey completion (76.0% vs. 80.4%).

Having health insurance for at least 10 of the 12 months prior to being surveyed was strongly associated with a reduction in the likelihood of any 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 recent smoking abstinence (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 compared with adults without MH/SUD.

In 2018 to 2019, that difference had shrunk 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) larger increase in coverage for those with MH/SUD (10.4 points; 95% CI, 9.0-11.8) than those without MH/SUD (6.2 points; 95 % CI, 5.4-7.0).

The authors suggest that the associations between insurance coverage gains and smoking outcomes may be accounted for by factors not examined in this analysis, including reduced financial stress, alleviation of adverse social detriments, and increased utilization of care.

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

Additionally, given that the NSDUH is a point-in-time cross-sectional survey and area-level variables were not available, the authors could not establish a causal relationship between ACA insurance expansion and the investigated outcomes.

“A substantial 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 wrote.


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. Addiction. Published online November 17, 2022. doi:10.1111/add.16052

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