Smoking and mental health
Mark Allen
Specialist Health Improvement Practitioner
Contents
• Health effects of smoking
• Tobacco addiction
• Links between mental health and smoking
• Smoking cessation
• Very brief advice and referral
• 10 million adults smoke cigarettes in Great Britain = 19.5%
prevalence
• Half of all regular cigarette smokers will eventually be killed by
their addiction (ASH 2013, Factsheet)
• Every year, over 100,000 smokers in the UK die from smoking
related causes (ibid.)
• Main cause of preventable morbidity and premature death in
England (NICE, 2008 Guidelines PH10)
Health benefits of stopping smoking
1. US Department of Health and Human Services (2006)
Tobacco addiction
Physical
Psychological
Social
Physical
 Nicotine dependence
Psychological
 Habit/Cues and Triggers
 Beliefs about benefits
 Low mood, stress, anxiety
Social/cultural
 Friends, family, colleagues, neighbours
Smoking and mental
health
Rationale for addressing smoking
and mental health
• Smoking is responsible for the largest proportion of the excess
mortality of people with a mental disorder (DoH, 2011)
• Motivation to stop is high – 50% of smokers with MH problems say
that they want to stop (Phelan et al, 2013)
Smoking prevalence
• General population = 21%
• Common mental disorder = 32%
• Psychosis = 40%
• Alcohol dependence = 46%
• Illicit drug dependence = 69%
• Inpatient schizophrenia = 70%
McManus et al, 2010 , Kumari & Postma, 2005 and Jochelson and Majrowski, 2006
Bi-directional link
• Evidence that long-term smoking is associated with the onset and
worsening of depression and anxiety (Pasco 2008; Johnson 2000)
Why higher smoking prevalence in MH?
• Genetics?
• Deprivation
• Self-medication of MH symptoms – belief that smoking helps with
stress, anxiety and low mood
• Smoking actually increases symptoms
Effect of stopping smoking on
mental health
• In the short term, nicotine withdrawal can include low mood and
anxiety, however,
• “Smoking cessation is associated with reduced depression,
anxiety, and stress and improved positive mood and quality of life
compared with continuing to smoke. The effect size seems as large
for those with psychiatric disorders as those without. The effect
sizes are equal or larger than those of antidepressant treatment for
mood and anxiety disorders.” (Taylor et al. BMJ, 2014)
• Doses of some medicines can be reduced, especially Clozapine
Reduction of rehospitalisation risk
Smoking cessation treatment may decrease rehospitalisation risk:
“The findings support initiation of motivationally tailored tobacco
cessation treatment during acute psychiatric hospitalization. Psychiatric
severity did not moderate treatment efficacy, and cessation treatment
appeared to decrease rehospitalization risk, perhaps by providing
broader therapeutic benefit.”
(Prochaska et al., 2013)
Smoking cessation
Smokers want and expect to be asked about their smoking (Conroy et
al.2005)
Smokers are up to 4 x more likely to stop with support and treatment
from a stop smoking service (DH 2011)
Stop smoking services
• 1:1 or group support; weekly appointments
• In GP practices, pharmacies, community settings
• Combination of medication and behavioural support
• Nicotine replacement therapy (NRT) – patches, gum, etc.
• Champix or Zyban – prescription medications which act on the part of the
brain involved in nicotine addiction
Stop smoking medicines
Electronic cigarettes
• Electronic cigarettes deliver nicotine by heating and vapourising a solution
of nicotine, propylene glycol and/or glycerol, plus flavours
• 2.1 million UK adult users in 2014
• Generally considered significantly less harmful than smoking; no tobacco,
no combustion
• Used as an aid to quitting or cutting down; nearly 2/3rds electronic
cigarette users are smokers and 1/3rd are ex-smokers
• Health professionals can give advice that they are likely to be significantly
less harmful than smoking, and stop smoking services should be open to
electronic cigarette use in people keen to try them
NCSCT (2014) Electronic cigarettes
Very brief advice on smoking
ASK (and record)
“Do you smoke?”
ADVISE
“Did you know the best way to stop is with support and medication? With
these you are up to four times more times likely to stop.”
ACT
“Would you like me to refer you to Smokefree South Gloucestershire? They
can book you an appointment with a Stop Smoking Practitioner for free
support and medication.”
Referral
Royal Colleges of Physicians and Psychiatrists
2013 Report
- Only a minority of people with mental disorders receive effective
smoking cessation interventions
- Smokefree policy is crucial to promoting smoking cessation in mental
health settings
- Smokers with mental disorders using primary and secondary care
services, at all levels, should be identified and provided routinely and
immediately with specialist smoking cessation behavioural support, and
pharmacotherapy to relieve nicotine withdrawal, promote cessation and
reduce harm
- All mental health professionals should be trained in awareness of
smoking as an issue, to deliver brief cessation advice, and to provide or
arrange further support for those who want help to quit
Partnership possibilities
- Review Smokefree Policy for staff and service-users
- Support available for staff to stop smoking
- Routinely ask and record smoking status
- Refer to Smokefree South Gloucestershire
- Provide in-house support; medications (NRT, Champix, Zyban) and
support (free training available from Smokefree South Gloucestershire)
(- Harm reduction approaches?)
- Champions, peer support
Smokefree South Gloucestershire
01454 865502
smokefree@southglos.gov.uk