MANDEVILLE, La. — Annelle S., 64, who has paranoid schizophrenia, took an urgent drag on a cigarette at a supervised outdoor smoke break at Southeast Louisiana Hospital.
"It's mandatory to smoke," she explained. "It's a mental institution, and we have to smoke by law."
That was 18 months ago, and Annelle's confusion was understandable. Until recently, Louisiana law required psychiatric hospitals to accommodate smokers — unlike rules banning smoking at most other health facilities. The law was changed last year, and by March 30, smoking is supposed to end at Louisiana's two remaining state psychiatric hospitals.
After decades in which smoking by people with mental illness was supported and even encouraged — a legacy that experts say is causing patients to die prematurely from smoking-related illnesses — Louisiana's move reflects a growing effort by federal, state and other health officials to reverse course.
But these efforts are hardly simple given the longstanding obstacles.
Hospitals often used cigarettes as incentives or rewards for taking medicine, following rules or attending therapy. Some programs still do. And smoking was endorsed by advocates for people with mental illness and family members, who sometimes sued to preserve smoking rights, considering cigarettes one of the few pleasures patients were allowed.
New data from the Centers for Disease Control and Prevention shows that the nearly 46 million adults with mental illness have a smoking rate 70 percent higher than those without mental illness, and consume about a third of the cigarettes in the country, though they make up one-fifth of the adult population.
People with psychiatric disorders are often "smoking heavier, their puffs are longer and they're smoking it down to the end of the cigarette," said William Riley, chief of the Science of Research and Technology Branch at the National Cancer Institute. With some diagnoses, like schizophrenia, rates are especially high.
A report by the National Association of State Mental Health Program Directors said data suggested that people with the most serious mental illnesses die on average 25 years earlier than the general population, with many from smoking-exacerbated conditions like heart or lung disease.
Now more treatment facilities are banning smoking, with some finding it easier than expected. Others still allow it, usually outside on their grounds during scheduled times. About a fifth of state hospitals are not smoke-free, a survey issued in 2012 by the State Mental Health Program Directors association found. Occasionally, hospitals that banned smoking have reinstated it to avoid losing patients.
Moreover, smoking is so deeply ingrained that smoke-free hospitals can only dent the problem; many patients are now hospitalized only for short stints and resume smoking later.
New research suggests scientific underpinnings for some of the affinity, said Dr. Nora D. Volkow, director of the National Institute on Drug Abuse. Nicotine has antidepressant effects and, for people with schizophrenia, helps dampen extraneous thoughts and voices, she and other experts said.
Other chemicals in cigarette smoke set off a perilous cycle, causing some medications to be metabolized faster, making them less effective and allowing symptoms to return. Because patients feel sicker, they may seek even more comfort from nicotine. "You may think, 'Well, I need to smoke more,' " said Dr. Steven Schroeder, a professor of health and health care at the University of California, San Francisco.
Then, as smoking increases, "blood levels of their medication go down, and they end up back in the hospital," said Judith Prochaska, an associate professor of medicine at Stanford University's Prevention Research Center.
Socially, smoking provides "cover rituals for patients having psychiatric symptoms," said Dr. Rona Hu, medical director of the acute psychiatric inpatient unit at Stanford Hospital in Palo Alto, Calif. "You tamp the box, you kind of play with the lighter, you can exhale and look into the middle distance and not look like you're hallucinating."
Dr. Thomas R. Frieden, director of the C.D.C., said hospitals had historically resisted going smoke-free, fearing it would interfere with treatment. "In my very first job as an aide in a psychiatric hospital," he said, "if patients behaved better they got additional cigarettes."
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