Smoking is tied to a wide variety of health problems and in vulnerable populations – including individuals with mental illness and/or low socio-economic status – those problems can get far more complicated, according to new research from the University of Vermont College of Medicine.

Diann Gaalema, Ph.D., UVM assistant professor of psychiatry, is the lead author of two separate research reviews involving those populations. One, published online this month in the journal Tobacco Regulatory Science, looked at the effects of reduced-nicotine cigarettes on smokers who suffer from psychiatric conditions known as “affective” disorders. These include depression, bipolar disorder, anxiety and post-traumatic stress disorder.

The federal Food and Drug Administration has had the authority, since 2009, to require a reduction in nicotine content in cigarettes, intending to make them less addictive and decrease smoking rates. However, regulatory research rarely examines the consequences of such a change on people with serious mood problems, who, according to Gaalema and her study co-authors from Brown University, tend to make up a large portion of the people who smoke.

“Smoking prevalence rates among individuals with mood disorders are two- to three-fold higher than those in the general population,” the authors report. “In addition, smokers with affective disorders are more likely to be nicotine dependent, initiate daily smoking earlier, and smoke more cigarettes per day than those without psychiatric comorbidity.”

In the short term, Gaalema found, smokers with these disorders suffer from more severe withdrawal symptoms and amplified mood problems when they no longer are receiving nicotine. Long-term, though, “both their anxiety and depressive symptoms seem to improve,” she says.

While smoking is unhealthy, nicotine has mood-controlling abilities, Gaalema explains. If a national measure to cut nicotine takes place, people with these disorders would need options – medications, other safer sources of nicotine, or behavioral support – to help them gradually step down to low or no nicotine, suggests Gaalema, who conducts research in the Vermont Center on Behavior and Health (VCBH) at UVM.

“It’s going to be important to have the support in place for this population,” she says.

A separate review, published by Gaalema and VCBH colleagues in April in Preventive Medicine, tracked smokers who suffered serious cardiac events such as heart attacks and heart surgery and the rates at which they were referred to, attended and completed a cardiac rehabilitation program. Smokers did get referred by their doctors for cardiac rehab more often than nonsmokers but were less likely to show up for and much less likely to finish the exercise regimen, the study found.

“Smokers drop out like crazy,” Gaalema says.

Smoking exacerbates heart trouble, so smokers need the rehab more than others. At the same time, smoking rates are higher in low-income populations, as are incidences of diabetes and obesity – all of which make it harder for these patients to devote themselves to exercise, Gaalema says. “Medically, it might be taking a backseat to other concerns.”

Social and economic pressures get in the way for low-income patients, who often have multiple jobs and care for other family members, leaving little time for a program that offers long-term, but not immediate, benefits.

For example, says Gaalema, “the patient caring for her mother with cancer, who has a pending foreclosure on her house and needs to show up in court on Monday or she’s going to jail – that’s the person who has too much social and other stuff going on to focus on her heart health.”

In an effort to encourage attendance among this population, Gaalema is working with colleagues Philip Ades, M.D., professor of medicine and director of cardiac rehabilitation and preventive cardiology, and Stephen Higgins, Ph.D., professor of psychiatry and VCBH director, on a long-term study of how financial incentives influence low-income heart patients’ participation in cardiac rehab. In September, she and Ades plan to present their findings at the American Association of Cardiovascular and Pulmonary Rehabilitation conference in Washington, D.C.