The Overlooked Smoking Crisis in Mental Health, and How Vaping Could Help

People living with serious mental illness remain one of the groups most severely affected by cigarette smoking—and one of those least well served by conventional tobacco-control strategies.

While smoking has declined dramatically across many developed countries, prevalence among people with schizophrenia, bipolar disorder and other serious mental illnesses remains disproportionately high.

UK public-health data have estimated smoking prevalence at around 40% among people with serious mental illness, while people with mental health conditions overall are almost 2.5 times as likely to smoke as the general population. Smoking is also considered a major contributor to the 10-to-20-year life-expectancy gap experienced by people with poor mental health.

Against that background, growing evidence suggests that tobacco harm reduction—including vaping and other smoke-free nicotine alternatives—deserves a much larger role in mental health care.

The disparity is particularly pronounced among people with schizophrenia spectrum disorders (SSD). A newly published scoping revie? in Frontiers in Psychiatry notes that smoking rates among people with schizophrenia remain around two to four times those seen among people without psychiatric disorders, with nicotine dependence also typically more severe. Smoking contributes to cardiovascular and respiratory disease and tobacco-related cancers in a population already experiencing substantially elevated premature mortality.

The reasons are complex. Nicotine may temporarily influence attention and cognition, while smoking can become intertwined with managing boredom, stress, social isolation and psychiatric symptoms. Unemployment, deprivation and institutional cultures can further reinforce smoking. Meanwhile, people with serious mental illness have historically been less likely to receive effective cessation support, despite evidence that their desire to quit is comparable to that of other smokers. This matters because simply telling people to stop smoking has never worked.

The 2026 Frontiers review examined studies published between January 2020 and February 2026 involving vaping among people with schizophrenia spectrum disorders or broader serious mental illness. Only three studies, reported across four publications and involving 323 participants, met the criteria—an important reminder that this remains an emerging evidence base. Nevertheless, the researchers found that vaping interventions appeared feasible and acceptable and produced preliminary evidence of substantial reductions in cigarette consumption and exposure to tobacco-related toxicants. Benefits appeared more sustainable when access to devices was combined with behavioural support.

One reason vaping may work particularly well for heavily dependent smokers is that it replaces more than nicotine. Patches deliver nicotine but do not reproduce the sensory and behavioural features of smoking. Vaping retains hand-to-mouth movement, inhalation, throat sensation and the ability to regulate nicotine intake throughout the day. For smokers whose cigarette use is deeply embedded in daily routines, these characteristics may make switching more acceptable. That could be particularly valuable for people with serious mental illness, who often have higher nicotine dependence and have struggled with previous quit attempts.

One of the clearest signals came from a 2021 pilot study involving 40 adults with schizophrenia spectrum disorders who smoked but had no intention of quitting or reducing their cigarette consumption. Participants received high-nicotine e-cigarettes for 12 weeks. By the end of the intervention, 40% had stopped smoking cigarettes, while 92.5% had either quit or reduced their cigarette consumption by at least half. Median cigarette consumption fell from 25 cigarettes per day to six. At 24 weeks, 35% remained abstinent from cigarettes.

The study was small and lacked a control group, so the figures should not be interpreted as definitive cessation rates. Nevertheless, the results demonstrate something important: even smokers with schizophrenia who were initially uninterested in quitting were willing and able to substantially replace cigarettes with a non-combustible product.

A larger randomised study led by Sarah Pratt produced similarly encouraging evidence among smokers with serious mental illness who had previously been unable to quit. Providing e-cigarettes produced substantial reductions in both cigarettes smoked per day and exhaled carbon monoxide compared with assessment alone. During the eight-week intervention, 19–22% of participants receiving vapes reported smoking no cigarettes, compared with none in the control group. Nicotine dependence did not increase, and any reported side effects were minor.

These findings are consistent with the much larger evidence base in the general smoking population. The latest Cochrane living systematic review analysed 104 studies involving more than 30,000 adults and concluded that nicotine e-cigarettes help more people stop smoking for at least six months than conventional nicotine replacement therapy.

The Royal College of Physicians similarly concluded in its 2024 evidence review that e-cigarettes remain an important tool for reducing death, disability and health inequalities caused by tobacco. Importantly, quitting smoking does not appear to worsen mental health—the concern that has historically made some clinicians reluctant to intervene.

A major systematic review published in the BMJ found that people who stopped smoking experienced reductions in anxiety, depression and stress alongside improvements in psychological quality of life compared with people who continued smoking. The pattern was similar in people with and without psychiatric conditions. That challenges the assumption that cigarettes provide a net psychological benefit to people experiencing mental illness.

For smokers who can stop completely using varenicline, NRT, behavioural therapy or other established interventions, those options should remain available. Indeed, evidence indicates that both varenicline and bupropion can help people with schizophrenia quit, without clear evidence in clinical trials that they worsen psychiatric symptoms. The problem is that no single treatment works for everybody.

Tobacco harm reduction offers another route: if complete nicotine abstinence is not currently achievable, eliminate the combustion first. Cigarette smoke—not nicotine itself—causes most smoking-related disease. Vapes avoid burning tobacco and therefore eliminate exposure to tar and carbon monoxide while substantially reducing exposure to numerous other toxicants. The NHS consequently describes vaping as likely to be far less harmful than smoking and recommends it as one option for adults trying to quit. Other smoke-free options, including nicotine pouches and traditional NRT, could similarly expand choice for people who find inhaled products unsuitable.

Another important clinical consideration is that switching from smoking to smoke-free nicotine products such as vapes or nicotine pouches may require the reduction of certain psychiatric medications, particularly clozapine and olanzapine. This is because chemicals in tobacco smoke—not nicotine—speed up the metabolism of these medicines. When smoking stops, drug levels can rise, so clinicians may need to monitor patients and reduce medication doses where appropriate. This would, of course, be a very positive factor for patients on such medications since these come with a number of unpleasant side effects. Therefore, with appropriate medical supervision, tobacco harm reduction can be safely integrated into psychiatric care and should not be viewed as a barrier to helping people move away from combustible cigarettes; quite the contrary.

The emerging evidence suggests mental health services should stop treating smoking as an unavoidable feature of serious psychiatric illness. Rather than insisting on a single cessation pathway, services could offer behavioural support alongside vaping, NRT and approved cessation medicines, allowing patients to choose an approach compatible with their circumstances and preferences. NICE already recommends offering smokers a choice of interventions based on previous experience, health and social circumstances.

People with serious mental illness have been disproportionately exposed to cigarettes for decades. Tobacco harm reduction provides an opportunity to narrow that inequality by meeting smokers where they are and offering alternatives capable of satisfying nicotine dependence without exposing them to the deadly products of combustion. For a population in which traditional approaches have repeatedly fallen short, safer nicotine alternatives should not be regarded as a last resort. They should be considered part of the mainstream effort to reduce preventable disease and premature death.

https://www.vapingpost.com/2026/03/03/nicotine-addiction-isnt-one-size-fits-all-genetics-brain-science-and-mental-health-differences-shape-dependance/