Smoking and insurance coverage appear to be linked in people with mental disorders and substance abuse

Smoking and insurance coverage appear to be linked in people with mental disorders and substance abuse

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

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

A recent study analyzed trends in smoking and insurance coverage among US adults with and without HD/SUD, finding evidence that improved smoking and abstinence outcomes for adults with HD /SUD appears to be associated with increased health insurance coverage. Since 2014, the Affordable Care Act (ACA) has brought major changes to the US health insurance market that may impact smoking among people with HD/SUD.

“We hypothesized that insurance expansion would have a greater effect on insurance coverage among people with HD/SUD compared to those without HD/SUD; and that increased insurance coverage would be associated with better smoking outcomes in people with HD/SUD,” the study authors wrote.

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

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

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

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

Additionally, adults with HD/SUD were more likely to be younger white, 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 health insurance for at least 10 of the 12 months before the end of the survey (76.0% versus 80.4%).

Having health insurance for at least 10 of the 12 months preceding the survey was strongly associated with a reduced likelihood of current smoking (–14.2 points; 95% CI, –14.7 to –13.7) or smoking daily (–12.3 points; 95% CI, -12.8 to -11.8), and an increased likelihood of recent smoking abstinence (3.7 points; 95% CI, 3.2- 4.3).

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

By 2018 to 2019, this gap had narrowed to –2.0 points (95% CI, –2.7 to –1.3). This equates to a 4.2 point increase in coverage (95% CI, 2.7 to -5.7) greater for people with HD/SUD (10.4 points; 95% CI, 9 ,0-11.8) than for those without HD/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 explained by factors not examined in this analysis, including reduced financial stress, reduced negative social harms, and increased use. care.

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

Furthermore, since the NSDUH is a one-time cross-sectional survey and area-level variables were not available, the authors could not establish a causal relationship between the expansion of ACA insurance and the results studied.

“A substantial proportion of the estimated improvements in each smoking and abstinence outcome for people with HD/SUD were explained by increases in health insurance coverage,” the authors wrote.


Creedon TB, Wayne GF, Progovac AM, Levy DE, Cook BL. Trends in Cigarette Smoking and Health Insurance Coverage Among American Adults with Mental Disorders and Substance Abuse. Addiction. Published online November 17, 2022. doi:10.1111/add.16052

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