Healthcare neglects effects of smoking among mentally ill people, says report

BMJ 2013; 346 doi: (Published 27 March 2013) Cite this as: BMJ 2013;346:f1987
  1. Jacqui Wise
  1. 1London

A third of cigarettes smoked in Britain today are smoked by people with a mental illness, says a new report that calls on the NHS to deal with the issue urgently.

The report, Smoking and Mental Health, from the Royal College of Physicians and the Royal College of Psychiatrists, says that smoking is becoming the domain of the most disadvantaged people in society: poor, unemployed, homeless, imprisoned, and mentally ill people.1 Life expectancy of people with mental disorders is 10 or more years less than that in the general population,2 and the report says that the high prevalence of smoking accounts for much of this difference.

Whereas the prevalence of smoking in the United Kingdom has fallen substantially over the past 20 years, it has barely changed among people with mental illness. Around 20% of the general population but 40% of people with mental health disorders now smoke, and the proportion is even higher in those with severe problems. People with mental disorders also tend to smoke more cigarettes, are more addicted to nicotine, and find it harder to stop smoking than the general population.

John Britton, chairman of the Royal College of Physicians’ Tobacco Advisory Group, said, “That smoking prevalence has remained so high in this group, especially among those with severe disease, is a damning indictment of medical practice and public health policy. It is time for a radical change in our approach to smoking in mental healthcare provision, to make non-smoking the norm, and significantly enhance life expectancy and quality among millions of people.”

The report says that smokers with mental health problems are just as likely to want to quit as those without. However, they are more likely to be heavily addicted and to believe that it would be difficult to quit and much less likely to succeed in any attempt to stop. Smoking cessation does not exacerbate the symptoms of mental disorders and improves symptoms in the longer term. However, many smokers are discouraged by mistaking the symptoms of nicotine withdrawal for those of the underlying mental disorder.

The report says that much more could be done to help people with mental disorders quit smoking. Over a year, only half of smokers with mental disorders are advised to quit, and only one in 10 receive prescriptions of drugs that could help them stop.

Nicotine replacement therapy is effective in people with mental health disorders but is likely to be needed in higher doses, for longer durations, and with more intensive behavioural support than in the general population. The report says that bupropion and varenicline are both effective in people with mental health disorders but need to be used under close supervision because of concerns about the occurrence of depression and suicidal thoughts.

People treated in specialist mental health settings are the most disadvantaged. The report says that there is a “culture” of smoking in many service settings and that many light or moderate smokers will smoke out of boredom or stress or as a means of socialising. It says that healthcare staff are often complicit in maintaining this culture.

The report calls for:

  • A smoke free policy in all mental healthcare settings

  • Smokers with mental disorders to be identified and provided with smoking cessation support

  • The Quality and Outcomes Framework (QOF) and Commissioning for Quality and Innovation (CQUIN) scheme to measure and incentivise smoking cessation, and

  • Mandatory training in smoking awareness for all professionals working with people with mental disorders.

Louise Howard, professor of women’s mental health at the Institute of Psychiatry at King’s College London, said, “Support for people with mental health problems to stop smoking needs to be prioritised urgently to improve not only the health of this vulnerable group but also the next generation, as smoking is the leading preventable cause of fetal and infant morbidity and mortality. Pregnant women with mental health problems are motivated to stop smoking but are more likely to be smoking through pregnancy than other women.”

The report says that smoking among people with mental disorders costs an estimated £719m a year in avoidable hospital admissions, GP consultations, and prescriptions. Reductions in the prevalence of smoking could also save up to £40m on psychotropic drugs that can be given at lower doses among non-smokers.


Cite this as: BMJ 2013;346:f1987