From the Editor

The waiting room was filled with patients to see, so I concentrated on his history of alcohol misuse and opioids, and I glossed over his nicotine use. But does the path to sobriety in fact start with smoking cessation?

In a new JAMA Psychiatry paper, Michael J. Parks (of the National Institutes of Health) and his co-authors attempt to answer that question. They looked at whether smoking cessation increased sustained remission from substance use disorder (SUD) over time. They describe a longitudinal survey cohort study of more than 2 600 participants from the United States, followed for four years, finding that quitting cigarettes increased the odds of recovery from other SUDs by 30%. “In this cohort study, smoking cessation was linked to better SUD recovery outcomes, and it could improve overall health among the millions of US adults with a current SUD.” We discuss the paper and its implications.

In the second selection from The New England Journal of Medicine, Simon Gilbody (of the University of York) and his colleagues write about the challenges of tobacco in low- and middle- income countries. They note that 80% of tobacco users are in such countries, yet cessation programs aren’t prioritized, particularly absent for those with mental health conditions. “Therapeutic nihilism (the belief that no intervention will work) impedes change and is unjustified in this instance.”

And, in the third selection from JAMA Oncology, Dr. Chadi Nabhan (of the University of South Carolina) writes about his patient and lung cancer. He describes the incredible draw of tobacco – including as a way for his patient to cope with loneliness and isolation. “The cigarette was more than a source of nicotine.”

DG

Selection 1: “Cigarette Smoking During Recovery From Substance Use Disorders”

Michael J. Parks, Carlos Blanco, MeLisa R. Creamer, et al.

JAMA Psychiatry, October 2025

Despite declines in cigarette smoking, smoking remains the leading preventable cause of morbidity and mortality in the US. Disparities in smoking also persist – certain subgroups smoke at disproportionately high rates, particularly individuals with nontobacco substance use disorders (SUDs). Individuals with SUDs also have a disproportionately high likelihood of dying from tobacco-related causes. There are renewed calls to treat tobacco use, particularly smoking, among those with SUDs. However, tobacco use is undertreated and often untreated in health facilities that treat SUDs, as treatment professionals may consider smoking a low priority. Recent estimates show there are 48.5 million people in the US with an SUD in the past 12 months, and 35.8% of those with an SUD currently smoke…

Previous research shows that smoking cessation is associated with improved outcomes for SUDs. However, most studies are from population samples with data collected at least 20 years ago or from treatment studies, and few studies examine how change in smoking status is related to SUD recovery over time using recent, nationally representative samples. Research designs that can account for confounding factors (eg, randomized clinical trials that isolate the experimental effect of smoking on SUD recovery) are typically not feasible at the population level, but quantitative methods applied to population-based data can approximate experimental conditions that remove the influence of confounders across individuals.

So begins a paper by Parks et al.

Here’s what they did:

  • They did a cohort study “among a nationally representative cohort of US adults with history of SUD from the PATH (Population Assessment of Tobacco and Health) Study” – an ongoing, nationally representative, longitudinal study which included participant interviews.
  • Inclusion criteria: having an SUD in their lifetime and having a change in recovery status over the study period.
  • Analyses included adults (aged ≥18 years) in the wave 1 cohort (recruited in 2013/2014) assessed annually over 4 years. The sensitivity analyses also included the second cohort (recruited in 2016/2018).
  • Main outcome: SUD recovery. This was assessed “via the Global Appraisal of Individual Needs–Short Screener SUD subscale, measured as high lifetime SUD symptoms (4-7 symptoms) and zero past-year symptoms (sustained remission) or high lifetime SUD symptoms with any past-year symptoms (current substance use or SUD).”

Here’s what they found:

  • A total of 2 652 individuals with 9 088 observations were assessed.
  • Demographics. Most participants were male (58.1%) with a mean age of 39.4 years; a majority identified as White (63.1%).
  • Smoking & substance status. Current smoking was the most common smoking status (47.2%), followed by former smoking (44.3%) and never smoking (8.5%). Those in recovery for SUD versus not were roughly equal (48.4% vs. 51.6%).
  • Smoking & substance. “Within-person change from current to former smoking was positively associated with SUD recovery: year-to-year change to former cigarette use was associated with a 30% increase in odds of recovery (odds ratio, 1.30…), accounting for time-varying covariates and between-person differences.”
  • Time. The association remained significant in an analysis that lagged the recovery outcome and main smoking predictor by a year (OR, 1.43) and was also confirmed in a nationally representative cohort assessed from 2016/2018 to 2022/2023 (OR, 1.37).

A few thoughts:

1. This is an interesting study with a practical question, published in a major journal.

2. The main finding in a sentence: “within-person change from current to former smoking was associated with recovery from other SUDs.”

3. The authors see clear clinical implications. “This study’s finding that smoking cessation was associated with recovery from nontobacco SUDs can be used to help justify incorporating smoking cessation treatment into virtually all SUD treatment.”

4. The above summary doesn’t well capture the authors efforts to reduce noise, with both a sensitivity analysis and the use of a second cohort.

5. Tobacco may not gather the attention of opioids and other substances, but the morbidity and mortality remain high. Smoking cessation should always be a priority. But is it the key to fuller sobriety? The authors argue yes. But how do we understand this? Did smoking cessation build confidence and engage patients in care? Were they simply individuals who were more likely to quit – and started with tobacco? 

6. Like all studies, there all limitations. The authors note several, including the reliance on self-report data. And there is the larger problem: the reliance on retrospective data. Though the main result is interesting, the study isn’t fully persuasive.

The full JAMA Psychiatry paper can be found here:

https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2837251

Selection 2: “The Epidemic of Tobacco Harms among People with Mental Health Conditions”

Simon Gilbody, Garima Bhatt, and Krishna P. Muliyala

The New England Journal of Medicine, 13 December 2025

Throughout the world, people with mental health conditions experience poorer physical health and live shorter lives than the general population. In many cases, poor health and early death are driven by tobacco use. People with mental illness consume 44% of all cigarettes in Western countries, and nearly 80% of tobacco users reside in low- and middle-income countries (LMICs), which also face high burdens of both mental illness and tobacco-related diseases. Although tobacco use is decreasing worldwide in most subpopulations, it remains persistently high among people with mental health conditions.

So begins a paper by Gilbody et al.

They remind us of the problems of tobacco. “People with mental health conditions are about 2 to 3 times as likely to smoke as members of the general population. This disparity contributes substantially to a 10-to-20-year reduction in life expectancy for people with severe mental illness. Cardiovascular disease, respiratory illness, and cancer are strongly linked to smoking and are leading causes of premature death among people with mental health conditions.”

Yet they warn of the soft bigotry of low expectations. “Therapeutic nihilism (the belief that no intervention will work) impedes change and is unjustified in this instance. Some mental health care workers see smoking as inevitable in their patient population and believe that attempts to help patients quit are futile. But many people with mental illness who smoke want to quit and can successfully do so. Nearly 1 billion people live with a mental disorder, and approximately 82% of them live in LMICs. Nevertheless mental health continues to receive limited attention and funding in countries’ health strategies.”

They make several suggestions:

Management of tobacco and other substances

“People with mental health conditions are often more heavily dependent on nicotine than other tobacco users and often experience more intense cravings and withdrawal. Trials have shown that such symptoms can be managed with intensive support, longer-term engagement, and dosage adjustments. Managing nicotine dependence alongside other dependencies complicates cessation but should not be seen as a barrier.”

Consideration of antipsychotics

“Tobacco smoke can affect the metabolism of antipsychotic medications such as clozapine and olanzapine. Quitting smoking may necessitate dosage adjustments, requiring careful monitoring. Guidelines are available for managing these interactions and dose adjustments, and ultimately, quitting may have the benefit of reduced antipsychotic dosage requirements.”

Prioritization of care and laws

“Although treatments such as nicotine replacement therapy are free with a prescription in the United States and the United Kingdom, cessation medications may be unavailable or unaffordable in many countries. There is often a shortage of trained personnel to deliver cessation services. Access to cheap tobacco products in countries that have not implemented smoke-free laws or the recommended price and tax measures exacerbates the problem for people with mental illness: tobacco products remain affordable and available, including as single cigarettes sold by informal vendors.”

They note innovative approaches in LMICs. “Task-shifting models, whereby lay health workers deliver mental health or cessation advice, represent a promising way forward. Mobile health tools, mass media campaigns, and tobacco taxation can reduce tobacco use but must be paired with targeted support for high-risk groups. For example, India’s National Tobacco Quit Line Services provide telephone-based counseling in multiple regional languages; its National Tele-Mental Health Program allows people to seek help for mental health conditions and substance use by telephone, toll-free; and e-learning modules hosted by the National Institute of Mental Health and Neurosciences Digital Academy support capacity building.”

A few thoughts: 

1. This is an excellent paper.

2. They also note the “research gap.” Tobacco, after all, is used differently in different parts of the world. “In high-income countries, manufactured cigarettes, pipes, e-cigarettes or vapes, heated tobacco products, and oral nicotine pouches predominate. The products used in LMICs are more diverse, encompassing smoked products (hand-rolled bidis, hookahs, kreteks) and smokeless forms (gutka, khaini, naswar, paan with tobacco, chewing tobacco, etc.), each associated with a distinct nicotine delivery system, gender dynamics, and sociocultural meanings.”

3. They present a big agenda. It’s worth noting the need for a big agenda; after all, the vast majority of tobacco users are in low and middle-income countries.

The full NEJM paper can be found here:

https://www.nejm.org/doi/full/10.1056/NEJMp2500491

Selection 3: “The Cigarette”

Chadi Nabhan

JAMA Oncology, 4 December 2025  Online First

I was at his wife’s funeral when she died 3 years ago. I recall when he shared the news of her breast cancer recurrence with me and how devastating this was on the entire family. He was a smoker, and he started smoking more often after her death. Frequently, I would see him with a cigarette in his hand. We have had our share of exchanges with me preaching him to stop smoking, because tobacco could kill you, and with him smiling back confused as to why I kept trying to offer unsolicited advice that he would never follow.

For him, the cigarette was much more than tobacco and smoke. It was a quiet companion, faithfully available through the hardest years, past and present. It was rhythmic and oddly provided structure to an otherwise aimless day.

So begins a paper by Dr. Nabhan.

“After his wife’s death, his children visited often. He shared with me that with time, the frequency of these visits became less. Life is busy and it gets busier. His world that was once filled with laughter and conversations, became emptier and lonelier. Since his wife’s passing, the rooms of his house had grown silent, punctuated only by the soft scratch of a match striking or a lighter flickering and the gentle draw from his cigarette. I continued to lightly urge him to quit every opportunity I got and would tell him that I was worried for his health. I once offered him a pamphlet on tobacco harms, with only the kindest intentions. He would always listen, would nod politely, would smile and express gratitude for my attempts, but then would explain that he could not bring himself to abandon the comfort his companion provided.”

It notes that the patient is diagnosed with cancer, but declines treatment. “‘I am not afraid of the treatment, and I know it may make me live longer. But the fact is that I am also not afraid from dying,’ he told me quietly as he puffed from a cigarette in his right hand. ‘It’s just that I don’t see the point anymore. She was my world, and my world has been gone for a while now.’”

The author tries to persuade him. “I used all what I had learned in over 20 years of oncology experience to change his mind. I tried to reason that life could still hold a meaning, that recovery might bring new joys or help him rediscover purpose. But nothing could fill the void left by her absence and filled by his loneliness.”

He notes the problem of loneliness and its implications on cancer care.

  • Loneliness. “In a 2023 review, up to 50% of older adults felt lonely.” 
  • Outcomes. “Studies have shown that these are linked to negative disease outcomes, including higher mortality rates and worse mental and physical health. A 2024 longitudinal analysis revealed that cancer survivors experiencing more severe loneliness had a much higher risk of death compared to those who were socially connected, with an adjusted hazard ratio of 1.67 for those most isolated.” 
  • Psychological implications. “The emotional toll of loneliness also affects coping, sleep, and overall quality of life for patients with cancer.”

“It cuts deeper than physical ailments, tearing apart the very fabric of hope that keeps the human spirit resilient.”

He wonders what more could be done. “As I read his obituary, I pondered whether he would still be around had we all succeeded in combatting his loneliness. How many more patients had endured the same? The bigger question that haunted me was the solution. How do we combat loneliness as oncologists and as a society?”

A few thoughts:

1. This is a moving essay.

2. In the second selection, Gilbody et al. discuss “therapeutic nihilism” in low- and middle- income countries. Is this true in more affluent nations, as well?

3. In a society where families are increasingly spread out across cities – or even continents – how do we combat the loneliness of modern life?

The full JAMA Oncology paper can be found here:

https://jamanetwork.com/journals/jamaoncology/article-abstract/2842594

Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.