Smoking cessation and reduction in people with chronic mental illness

The last decade has seen a rapid growth in what we know about smoking and mental health. What is more, as the evidence has grown, so has the optimism. Reviews such as that by Tidey & Miller (2015) are now quite rightly highlighting the potential of people living with mental illness to quit successfully without risk to their long term psychological well-being. Treatment elements ranging from structured behavioural support, pharmacotherapy and emerging technologies such as e-cigarettes have all been shown to have positive effects in this group.

Despite this positive evidence, however, smoking within mental healthcare settings remains extremely prevalent. For example, a recent survey by Public Health England (2015) revealed smoking rates of 64%, three times higher than the UK adult smoking rate. Therefore, if we know so much about how to help people with mental illness quit, why has this prevalence not reduced?

For the answer we need to acknowledge that stop smoking treatment can not be considered in isolation from the context in which it is delivered. For as long as there has been research interest in smoking and mental health, there has been the view that the ‘smoking culture’ within mental healthcare settings is one of the most important barriers to successful cessation. Lawn & Pols (2005), for example, saw smoking as representing an “entrenched process that has been central to the history of mental institutions over the past three centuries”. Smoking related interventions and policy have in the past been significantly less popular among mental health staff than other health care professionals (McNally et al., 2006) and it has also been observed that mental health staff have often used cigarettes in order to appease or engage patients (Mester et al. 1993) and in this way, utilized it as a ‘clinical tool’.

More recently, however, it can be argued that that the place of smoking in the culture of mental healthcare has diminshed. For example, a recent study by Kulkani et al (2014) found that vast majority of mental healthcare staff in their sample did not feel that addressing patients’ smoking would have an adverse impact on the therapeutic relationship (86.7%), or that quitting smoking during treatment for their mental disorder would have a negative impact on their recovery (81.4%).

Unfortunately however, also notable in this study was that less than half (48.3%) of the respondents felt that addressing smoking was within their remit of responsibility as a mental health professional. Therefore, while it may be true that smoking is less a part of the mental healthcare ‘culture’ as it once was, we have still not arrived at the point where mental healthcare staff see smoking cessation as relevant to their role. Until this happens, quit smoking support will never become routine in mental healthcare settings and the high prevalence of smoking among people using these services will not fall.

Making this happen will require a varied, whole system approach. For example, Kulkani et al (2014) highlighted the importance of making smoking cessation training available to staff, while NICE (2013) made clear the role that commissioners can play by including smoking cessation within mental heathcare provider’s contracts and performance indicators.

In conclusion, when it comes to supporting people with mental health conditions to quit smoking, it is true that we know a lot more than we did. However, it’s less clear that we are actually doing a lot more than we did. The technology is there, and attitudes have changed. But until system-wide action is in place, this particular health inequality will remain alive and well.

References

Kulkarni M, Huddlestone L, Taylor A, Sayal K, Ratschen E. (2014) A cross-sectional survey of mental health clinicians’ knowledge, attitudes, and practice relating to tobacco dependence among young people with mental disorders. BMC Health Services Research. 14:618. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4251854/

Lawn, S. J. and Pols, R. G. (2005) Smoking Bans In Psychiatric Inpatient Settings? A Review of the Research, Australian and New Zealand Journal of Psychiatry, 39, 874-893. http://anp.sagepub.com/content/39/10/866.long

McNally, L; Oyefeso, A; Annan, J; et al. (2006) Journal of Public Health, Volume 28, Number 3, 15 September 2006, pp. 192-196(5) http://jpubhealth.oxfordjournals.org/content/28/3/192.long

Mester R, Toren P, Ben-Moshe Y, Weizman A. (1993) Survey of smoking habits and attitudes of patients and staff in psychiatric hospitals. Psychopathology; 26:69-75. http://www.ncbi.nlm.nih.gov/pubmed/8321895

National Institute for Health and Care Excellence (2013) Smoking cessation in secondary care: acute, maternity and mental health services [Guidance PH48] https://www.nice.org.uk/guidance/ph48

Public Health England (2015) Smoking cessation in secure mental
health settings. https://www.gov.uk/government/uploads/system/uploads/attachment_data/fil...

Tidey JW, Miller ME. (2015) Smoking cessation and reduction in people with chronic mental illness. BMJ: 351 http://www.bmj.com/content/351/bmj.h4065