Smoking and Mental Illness Statistics 2026: Cessation Rates in Schizophrenia, Bipolar Disorder, and Depression

People living with severe mental illness (SMI) — including schizophrenia, bipolar disorder, and major depressive disorder — face a disproportionate burden from tobacco use. Smoking rates among people with SMI are two to four times higher than in the general population, and the gap in life expectancy between people with SMI and the general population is substantially explained by tobacco-related cardiovascular and respiratory disease. Understanding the latest smoking and severe mental illness statistics 2026 is the essential first step toward changing that picture — for clinicians, patients, and carers alike.

For decades, smoking was informally tolerated — even inadvertently facilitated — in mental health settings, based on the misplaced assumption that helping people with SMI quit was too difficult or clinically risky. The data from the landmark EAGLES trial and subsequent real-world studies have dismantled that assumption. Effective, safe cessation treatment is available, and the psychiatric population stands to gain more from quitting than almost any other group.

SMI Smoking Prevalence: Condition-by-Condition Data

According to the National Institute on Drug Abuse (NIDA), adults with mental illness or substance use disorders account for approximately 40% of all cigarettes consumed in the United States, despite representing a much smaller share of the adult population.

Schizophrenia

Schizophrenia carries the highest smoking prevalence of any psychiatric diagnosis. NIDA data places the rate between 70% and 85%, compared with approximately 11–15% in the general US adult population. A Scientific Reports study drawing on comparative data across diagnoses found a schizophrenia smoking prevalence of 18.5% in their clinical sample — but this reflects hospital clinic populations where rates are moderated by treatment engagement. In community and inpatient cohorts, the 70–85% figure is consistently replicated.

Bipolar Disorder

Between 50% and 70% of people with bipolar disorder smoke, according to NIDA. A peer-reviewed comparative prevalence study (Scientific Reports, 2017) found smoking rates in bipolar disorder were not significantly different from those in schizophrenia, with both substantially elevated compared with major depressive disorder.

Major Depressive Disorder (MDD)

Smoking prevalence in major depressive disorder is elevated relative to the general population, but lower than in schizophrenia and bipolar disorder. The Scientific Reports study cited above found 10.6% prevalence in their MDD clinical sample; US population-based studies consistently find rates of approximately 25–40% among people with active depression, compared with the general adult population rate of approximately 11–15%.

Sources: NIDA; Scientific Reports 2017; PMC meta-analysis 2025.

Why Smoking Rates Are Higher in SMI

The elevated rates are not coincidental. Several reinforcing mechanisms drive them:

• Neurobiological: self-medication of symptoms. In schizophrenia, nicotine transiently improves sensory gating deficits and alleviates some negative symptoms by modulating dopamine and acetylcholine pathways — providing genuine short-term symptom relief that reinforces use.
• Pharmacological interaction. Many antipsychotic medications cause dopaminergic side effects (including anhedonia and akathisia) that nicotine partially masks, making the reinforcement loop stronger.
• Social and environmental factors. Smoking has historically been normalised — and sometimes inadvertently facilitated — in inpatient and community mental health settings. Peer smoking rates in these environments are high.
• Socioeconomic factors. People with SMI experience higher rates of poverty, unemployment, and social exclusion — all of which correlate with higher smoking rates and lower access to cessation support.
• Reduced health literacy and cessation support access. Quit messaging, pharmacotherapy, and behavioural programmes are often less accessible to people navigating mental health care systems.

Understanding these drivers matters for cessation planning: the bidirectional relationship between smoking and mental health means that quitting must be approached with care, appropriate medication, and psychological support tailored to the person’s psychiatric context.

Cessation Rates by Psychiatric Diagnosis

Cessation rates in SMI populations are lower than in the general population — but they are not negligible, especially with pharmacotherapy.

Unaided quit rates

Unaided (cold turkey) quit rates for people with SMI are low. This reflects both the neurobiological dependency factors described above and the reduced access to cessation support. For context, unaided quit rates in the general population over 12 months are already low — below 5% in most studies. In schizophrenia, unaided sustained abstinence rates are thought to be lower still.

With pharmacotherapy: EAGLES schizophrenia subgroup

In the EAGLES schizophrenia spectrum subgroup analysis (Psychiatric Services, 2021), varenicline roughly doubled continuous abstinence rates at weeks 9–12 compared with placebo among people with schizophrenia. Absolute abstinence rates were lower than in the non-psychiatric arm of the trial, but the relative benefit of varenicline over placebo was preserved.

Depression subgroup

People with major depressive disorder generally have higher cessation rates than those with schizophrenia when offered pharmacotherapy and support. The EAGLES trial found broadly consistent relative treatment effects across psychiatric subgroups, with varenicline consistently outperforming bupropion, nicotine patch, and placebo.

Source: Anthenelli et al., The Lancet, 2016.

The EAGLES Trial: What the Safety Data Shows

The EAGLES trial (Evaluating Adverse Events in a Global Smoking Cessation Study) was a double-blind, randomised, placebo-controlled trial funded by Pfizer and GlaxoSmithKline and published in The Lancet in June 2016. It enrolled 8,144 smokers across 140 centres in 16 countries, of whom 4,116 had a clinically stable psychiatric disorder (including schizophrenia, bipolar disorder, MDD, and anxiety disorders).

What the trial measured

The primary endpoint was a composite of moderate and severe neuropsychiatric adverse events: depression, suicidal ideation, anxiety, aggression, abnormal dreams, and others. The study was specifically designed to address the warnings that had been placed on both medications based on post-marketing case reports — warnings that had reduced prescribing and deterred smokers with mental illness from accessing the most effective cessation pharmacotherapy.

Key safety results

• No significant difference in the primary NPAE composite endpoint between varenicline, bupropion, and placebo in the psychiatric cohort.
• No significant difference in suicidal ideation or behaviour attributable to active treatment vs placebo.
• Varenicline produced the highest abstinence rates of any treatment arm in both psychiatric and non-psychiatric participants.
• Neuropsychiatric adverse events did occur in all groups — including placebo — reflecting the underlying psychiatric burden. The key finding was that active treatments did not increase rates above placebo.

“Clinicians can have more confidence in prescribing these medications to smokers with stable psychiatric disorders,” the authors concluded. Read the full quit smoking success rates by method for a broader comparison of cessation approaches.

Medication Options and Contraindications

Varenicline (Chantix/Champix)

Varenicline is a partial agonist at nicotinic acetylcholine receptors. The EAGLES trial established its neuropsychiatric safety profile in stable psychiatric populations. It remains the most effective single pharmacotherapy for smoking cessation. Patients must consult their prescriber about potential interactions with antipsychotic medications.

Bupropion (Zyban/Wellbutrin)

Bupropion is an antidepressant that also reduces nicotine cravings via dopaminergic and noradrenergic mechanisms. Bupropion is contraindicated in people with:

• A history of seizures or conditions that lower seizure threshold
• Current or prior anorexia nervosa or bulimia
• Current use of MAOIs (requires a washout period)
• Abrupt alcohol or benzodiazepine withdrawal

These contraindications are clinically significant in psychiatric populations and must be reviewed before prescribing. Bupropion was already used as an antidepressant in some patients with MDD, and dose adjustments may be needed.

Nicotine Replacement Therapy (NRT)

NRT — patches, gum, lozenges, spray, and inhalers — does not carry psychiatric contraindications and is often the first-line choice when there is uncertainty about medication safety. Combination NRT (patch plus fast-acting form) outperforms single-form NRT. See the best NRT options compared for dosing guidance.

Combination approaches

Combining pharmacotherapy with behavioural support consistently produces higher quit rates than medication alone. Specialist mental health smoking cessation services — where the counsellor understands psychiatric medication and symptoms — are the most effective setting for people with SMI.

Does Quitting Smoking Worsen Mental Health Symptoms?

A widely held clinical concern — and a common reason smokers with SMI are not offered cessation support — is that quitting might destabilise psychiatric conditions. The evidence does not support this concern.

A large meta-analysis (Taylor et al.) found that smoking cessation was associated with reduced depression, anxiety, and stress, with improvements in positive affect and quality of life. Effect sizes were comparable to those of antidepressant treatment. This held true for people with depression, anxiety disorders, and mixed mental health diagnoses.

Nicotine withdrawal does cause temporary mood disturbance — irritability, anxiety, and low mood in the first one to two weeks. This can be distinguished from recurrence of psychiatric illness by its timing (onset within 24–72 hours of quitting, peak at 3–5 days, resolution within 2–4 weeks) and its pattern. Nicotine replacement therapy significantly reduces withdrawal-related mood disturbance.

Understanding the nicotine withdrawal timeline helps patients and carers distinguish withdrawal symptoms from psychiatric relapse — an important distinction for maintaining motivation through the first two weeks.

Practical Cessation Support for People with SMI

People with SMI are just as motivated to quit smoking as the general population, but face structural barriers that require tailored support. Evidence-based recommendations include:

• Integration into mental health care. Cessation support delivered within existing mental health appointments — rather than requiring a separate referral chain — significantly increases uptake.
• Longer treatment courses. Standard 12-week pharmacotherapy courses can be extended for people with SMI, who may take longer to achieve stable abstinence.
• Monitoring of psychiatric medication levels. Smoking induces cytochrome P450 1A2 enzymes, which metabolise several antipsychotics (including clozapine and olanzapine). Quitting smoking can increase blood levels of these medications by up to 50%, potentially requiring dose reductions. Prescribers should monitor this closely.
• Peer support and supported housing. Smoking rates in supported accommodation are high; group-based cessation within these settings has been shown to be effective.
• Digital support tools. Apps that provide 24/7 craving support can supplement clinical care, particularly for managing cravings between appointments. The iQuit app offers AI-powered coaching and health milestone tracking that can support people with SMI through cessation.

For the broader picture of what happens in the body and mind after quitting, see the complete health recovery guide. And for data on how quitting improves mental health outcomes across the general population, read quitting smoking and depression: understanding the connection.

Frequently Asked Questions