The case for going smokefree in mental health

1
The case for going smoke-free in mental health

• Smoke-free London, 26th October 2006
• Dr Jonathan Campion
• Specialist Psychiatry Registrar
• St Georges Psychiatry Training Scheme
• Roehampton Community Mental Health Team Queen
  Marys Hospital, London

2
Overview

• Context of smoking
• Smoking and mental disorder
• Reasons for higher smoking rates in those with
  mental illness
• Impact of smoking on physical health of mentally
  ill
• Smoking and different psychiatric conditions
  depression/anxiety/psychosis
• Interactions between smoking and medication
• Effect of smoking cessation on mental health
• Barriers to smoke-free mental health settings
• Smoke-free policy works in mental health settings
• Exempting mental health from smoke-free
  legislation
• Reasons for exempting mental health
• Benefits of smoke-free mental health services
• Conclusions
• References

3
Context of smoking

• 5 million deaths worldwide from tobacco
  consumption in 2006 (WHO, 2006)
• Projected 10 million deaths annually by 2020 with
  70 occurring in developing countries
• Smoking largest single cause of preventable
  illness and premature death in UK
• 106,000 people dying of smoking caused diseases
  in 2002 (DOH, 2006)
• one in five deaths in UK attributable to
  smoking.
• 10,000 deaths each year in the UK attributable
  to passive smoking (Jamrozik, 2005)
• RCP (2000) estimated cost in UK in 1997 80
  billion

4
Smoking and mental disorder

• Smoking significantly associated with increased
  prevalence of all psychiatric disorders (Farrell,
  2001)
• Probability of any mental disorder in smokers
  double that in non-dependent individuals (22.4
  versus 12.2)
• Heavier and more dependent than general
  population (McNeill, 2004)
• Complex relationship between mental illness and
  smoking

5
Smoking as a mental disorder

• Nicotine dependence most prevalent, deadly and
  most treatable of all psychiatric disorders,
  fulfilling the core criteria for mental disorder
  
• a clinically significant behavioural or
  psychological syndrome or pattern that occurs in
  an individual and that is associated with present
  distress or disability or with a significantly
  increased risk of suffering death, disability or
  an important loss of freedom not merely an
  expectable and culturally sanctioned response to
  a particular event
• Nicotine dependence - chronic illness, typically
  persisting for decades once established and with
  very low rate of remission 2 annually

6
Possible reasons why people with mental health
problems smoke more

• Causative particularly with anxiety disorders
• Deprivation association with cigarette smoking
  and mental health problems
• Environment
• Higher rates of smoking in people in institutions
  cf community
• Highest rates in homeless sleeping rough
  (Meltzer, 1996)
• Psychiatric hospitalization can lead non-smokers
  to become smokers (Lawn, 2002)
• Result of distress
• Those in greater distress - greater
  difficulty stopping behaviour providing rapid and
  reliable rewards despite harmful long-term
  effects of these behaviours
• Reinforcement of smoking behaviour
• Related to lax smoking policies
• Media vulnerability
• People with mental health problems may be
  more vulnerable to misleading messages about
  tobacco promoted by the tobacco industry (Boyd
  and Lasser, 2001).
• Interaction between nicotine dependence and
  symptoms

7
Smoking more deadly than suicide

• 1 in 2 smokers in general population die 15 years
  early and 1 in 4 smokers die 23 years early
  (Doll, 2004)
• Heavy passive smoking associated with 50-60
  increased risk of coronary heart disease (Whincup
  et al, 2004)
• 86,500 deaths from smoking in England compared
  with
• But smoking frequently overlooked by mental
  health professionals despite much greater levels
  of smoking.

8
Consequence of more smoking in psychiatric
patients

• Patients with schizophrenia 20 reduced life
  expectancy
• compared with the general population
  (Hennekens et al, 2005)
• Substantially greater risk of premature death
• smoking related diseases compared to general
  population (McNeill, 2004)
• 10x death rate from respiratory disease (McNeill,
  2001)
• most of the cause of excess natural mortality of
  community mental health populations (Brown et al,
  2000)
• Death toll from smoking among those with mental
  health problems
• far outweighs the 10 lifetime risk of suicide
• both risks are susceptible to treatment
  intervention
• only suicide reduction has been identified as a
  health gain target.

9
Smoking and depression

• Higher rates of smoking
• twice as likely to smoke compared with no
  neurotic disorder.
• More depression/suicide
• clear relationship between degree of smoking/
  nicotine dependence and number of neurotic
  symptoms (Coultard, 2000)
• smokers within non-clinical population more
  depressed and anxious (Gilbert, 1995)
• higher rates of depression
• experience more severe depression
• more suicidal ideation/ higher suicide rates
  (Wilhelm, 2004)
• History of depression associated with
• depression after cessation (Wilhelm, 2004)
• no increase in smoking cessation failure (Hitsman
  et al, 2003).

10
Nicotine and anxiety

• Increased anxiety among smokers in general
  population studies (Coultard, 2000)
• Smoking increases risk of certain anxiety
  disorders
• during late adolescence and early adulthood
  (Johnson 2000)
• Increased risk of first panic attack
• increased risk of first occurrence of panic
  attack (Breslau et al, 1999) with reduced risk of
  panic disorder after smoking cessation
• Link between anxiety and starting smoking
• Generalised anxiety/ social anxiety predict
  uptake of smoking (Sonntag et al, 2000
• Smoking associated with mood lability
• leading to heightened feelings of stress/
  depression in many smokers (Parrott, 2006).

11
Smoking and psychosis

• Higher rates of smoking (Jochelson et al, 2006)
• 70 smoking rates
• in those with schizophrenia or affective
  psychosis in survey of psychiatric institutions
  (Meltzer 1996)
• 64 smoking rates
• in those with probable psychosis were
  smokers compared with 29 without psychosis
  (Coultard 2000)
• Majority wanted to stop (Jochelson et al, 2006)
• Tax revenue reflecting financial burden
• People with schizophrenia generated 139m in
  tax revenue a year (McCreadie 2000)

12
Smoking and schizophrenia

• Heavy smoking associated with
• more severe psychotic and schizophrenic illness
• poorer outcomes
• more frequent hospital admissions (Aguilar et al,
  2005 Corvin et al, 2001)
• typical vs atypical antipsychotic medication
  (Barnes et al, 2006)
• smoking not associated with positive, negative
  cognitive and mood symptoms in schizophrenia
  (Barnes et al 2006) .
• Smoking to self-medicate symptoms of illness/
  side effects
• smoking stimulates dopamine (Le Houezec, 1998)
• smoking reduces level of medication
• Greater reinforcement of nicotine in those with
  schizophrenia
• nicotine more reinforcing in schizophrenia since
  stimulates subcortical reward system and
  prefrontal cortex
• both areas hypofunctional in schizophrenia
  (Chambers et al, 2001)
• ability to trigger dopamine release in mesolimbic
  reward centres might mean
• smoking one of few possible reinforcers to
  overcome anhedonia of schizophrenia and
  depression (Watkins et al, 2000)

13
Interactions between nicotine and medication

• Induction of liver enzyme P450-1A2 (CYP1A2) by
  smoking
• responsible for activation of some
  pro-carcinogens and for metabolizing many drugs
• Smokers prescribed higher doses of antipsychotic
  medication
• increased metabolism of antidepressant and
  antipsychotic medication
• Diazepam, haloperidol (partial), olanzapine
  (partial), clozapine, mirtazapine (partial),
  tricyclics (Bazire, 2004)
• reduction in plasma levels of up to 50 (Ziedonis
  et al 1994 Wilhelm, 2004)
• Development of toxicity after cessation
• smokers stable on any drug metabolised by CYP1A2
• cessation can cause toxic levels of drug in their
  blood over a matter of days as less drug
  metabolised (Zullino et al, 2002)
• Reduction in antipsychotic drug may be needed
• f stopping smoking (Hughes, 1993)
• If starts smoking, previous therapeutic plasma
  levels of drugs can drop as enzyme induction
  occurs and therefore require increased medication
• Smoking as a clinical issue
• Need for close monitoring of attempts to
  stop smoking and this being addressed as a
  clinical issue

14
Smoking cessation and those with mental illness

• Smoking is a recognised drug dependence
• But dirty syringe equivalent, most deadly form of
  nicotine delivery
• Smokers with mental health problems want to quit
• From surveys in the UK, around half of
  smokers with mental health problems have
  expressed a desire to quit (Jochelson et al,
  2006)
• Health benefits of cessation
• Stopping smoking at the age of 50 halves
  the risk while stopping at the age of 30 avoided
  almost all of it (Doll, 2004)
• But smoking frequently overlooked by mental
  health professionals
• mental health patients less likely to be offered
  health promotion intervention such as smoking
  cessation.
• Consistent with reports of poor physical health
  of mental health patients.

15
Effect of smoking cessation on mental health

• Anxiety reduction or withdrawal relief?
• Although smokers report that smoking calming
  them, reflects relief of withdrawal symptoms such
  as restlessness and irritability
• Smoking chronically anxiogenic rather than
  anxiolytic
• Increased anxiety among smokers in general
  population studies.
• Anxiety decreases following first week of
  abstinence (West et al, 1997)
• Ex-smokers fewer neurotic disorders than current
  smokers (Haukkala et al 2000)
• Perceived stress levels reduce on stopping
  smoking and increase again following relapse to
  smoking (Cohen and Lichtenstein 1990)
• depression after cessation (Wilhelm, 2004)
• Psychological problems decline after cessation
• significantly in smokers who stopped smoking
  for 6 months (Mino et al, 2000)
• Smoking cessation does not exacerbate psychotic
  illness No clear evidence (Smith, 1999)

16
Treatment for smoking cessation

• Harm reduction
• Nicotine replacement therapies least harmful
  nicotine delivery systems available
• Cost effective intervention
• Effect of NRT on symptoms
• NRT reduces total withdrawal discomfort,
  irritability and anxiety with some evidence for
  an effect on depressed mood and craving (West and
  Shiffman, 2001).
• Bupropion effective for smoking cessation
• in those with major depression, alcoholism
  (Hayford et al, 1999) and schizophrenia (Evins et
  al, 2005)
• Application of interventions to mental health
• Smoking cessation interventions used in the
  general population can be implemented in
  psychiatric outpatient settings (Hall et al,
  2006).

17
Other treatments for smoking cessation

• Longer term
• Bupropion/ relapse prevention extended use of
  bupropion for relapse prevention effective for
  smokers with/ without major depression (Cox et
  al, 2004).
• Bupropion and nortriptyline aid long term smoking
  cessation
• Assist with dysphoria during withdrawal and
  prevent relapse
• but selective serotonin reuptake inhibitors do
  not (Hughes et al, 2004)
• Psychological/ lifestyle/ group
• Psychological and lifestyle strategies e.g.
  motivational interviewing, relaxation exercises
  and mood charts, assist in mood regulation
• Staged care interventions for depressed
• Cognitive-behavioural treatment tailored
• Specialised group therapy programmes and (NRT)
  have been shown to be effective in people with a
  diagnosis of schizophrenia

18
Barriers to smoke-free settings

• Concern about increased aggression
• Common concern of staff although no increase
  found and fewer adverse effects than staff
  anticipated
• Concern about deterioration in mental health
• No clear evidence for smoking cessation
  exacerbates psychotic illness (Smith, 1999)
• or that it causes depression or anxiety
• No-smoking policy in psychiatric clinics, even
  when this leads to withdrawal symptoms has no
  negative effect on mental illness (Haunstein et
  al, 2002)
• Smoking culture
• 54 of staff believed smoking with patients
  created therapeutic relationships (Stubbs 2004).
  
• Majority of staff did not favour a smoking ban
• High levels of smoking among psychiatric nursing
  staff (DOH Consultation, 2005)
• Staff more difficulty with total bans since
  smoked during breaks (Hempel et al, 2002)
• Smoking appears to be currently tolerated and
  accepted for those with mental illness
• Lack of smoking cessation support for staff
• (NIMHE review in South West, 2005)

19
Smoke-free policy works in mental health settings

• Simple, consistent policy more effective
• Simple smoking policies
• applied in consistent way to all patients in
  inpatient psychiatric settings
• more effective than selective or gradually
  introduced bans (Lawn and Pols, 2002)
• partial smoking bans ineffective (Leavell et al,
  2006)
• Need for consistency and planning
• Success of smoking bans in psychiatric units
  depends upon
• consistent approach across management and
  clinical staff
• education of staff and patients about impending
  ban (Lawn and Pols, 2002)
• No increase in patient aggression
• in 75 per cent of all study sites regardless of
  the type of ban
• in 90 per cent of sites imposing a total ban
  (Lawn and Pols, 2002 El-Guebaly et al, 2002).
• No effect on mental illness (Haunstein et al,
  2002)

20
Proposal to exempt MH units from smoke-free
legislation

• For mental health units, the Department of Health
  proposed that
• any exemption from smoke-free legislation
  will be limited to premises that provide
  long-term accommodation.
• Long-term in relation to residential
  accommodation in a mental health unit defined as
  accommodation occupied for more than 6 months.
• Other proposed exemptions are care homes and
  prisons

21
Six month cut off

• Why six months?
• Half inpatient for more than 6 months
• 46 of psychiatric inpatients in 2006 were
  inpatients for longer than 6 months (Mental
  Health Act Commission, 2006)
• large proportion of mental health settings would
  be exempt
• Difficulty for staff
• Create great difficulty with enforcement by
  staff who would have to apply different
  principles to different patient groups
• Arbitrary
• Proposal to exempt those units where
  patients remain for more than six months appears
  arbitrary.

22
Partial exemption and health inequality

• Smoking causes inequality
• Smoking responsible for half the
  difference in survival to 70 years of age between
  social class I and V (Wanless, 2004)
• Mental illness and inequality
• those with mental illness experience
  health inequality 10 year lower life expectancy
• Higher rates of smoking exacerbate health
  inequality
• already experienced by those with mental
  illness
• Inequality reduction
• effective smoke-free policy will significantly
  improve health in populations with
  disproportionate levels of inequality
• Smoke-free policy key part in addressing physical
  health needs of those with mental health problems
  which are worse in part due to higher levels of
  smoking.
• Exemption would worsen health inequality
• for people with mental health problems compared
  to other groups included in the Health Act
• thereby discriminate against them on account of
  their illness

23
Reasons for not going smoke-free?

• Unnecessarily cruel
• Unfair since cannot leave and smoke as others can
• Human rights especially those detained under the
  mental health Act

24
Human Rights Perspective

• Health of others
• Human Rights Act only individual freedom to act
  when their actions not endangering others
• Equal need to protect the human rights of
  non-smoking staff and patients.
• Health of others already legally protected
• Rights of non-smoking staff and patients
  protected by Health and Safety at Work Act
• Employers have legal duty to protect both
  patients and staff from tobacco smoke.  
• Discrimination of rights of those with mental
  illness
• Rights of those with mental illness will be
  discriminated against under the Disability
  Discrimination Act if less access to smoke-free
  environments and treatments compared to rest of
  NHS and public places under the Health Act
• Services risk a stigmatising presumption that
  psychiatric patients unable to stop smoking.
• Alcohol/drug rules on wards not a human rights
  breach
• Mental Health patients not allowed to drink
  alcohol or use illicit drugs in mental health
  units
• Not argued as a breach of their human rights.

25
Other arguments

• Their place of residence. Countered by legal
  requirement to protect non-smoking staff and
  patients under the Health and Safety at Work Act
• Patients will refuse to be admitted

26
Benefits of smoke-free mental health services

• Inequality reduction
• those with mental illness experience
  disproportionate levels of health inequality
• Smoking cessation could reduce this inequality.
• Improved physical health and life expectancy
• Improved well-being
• Smokers in non-clinical population more
  depressed/ anxious than non-smokers (Gilbert,
  1995).
• Psychological problems decreased in smokers who
  stopped for 6 months (Mino, 2000).
• Anxiety reduces in first week of abstinence
  (West, 1997).
• Patients experienced increased sense of self
  esteem/ mastery following ban (Cooke, 1991)
• Protection of non-smoking staff and patients
• Part of comprehensive health promotion strategy
• Smoke-free services would help address this area.
  
• Part of addressing wider health promotion agenda
  including nutrition, physical activity

27
Part of a health promoting environment

• Smoking affects psychiatric treatment by
• negatively influencing well-being and psychiatric
  symptoms
• increasing the doses of required medication
• causing physical ill-health
• Smoking is a chronic illness
• by considering smoking as a chronic illness in
  all mental health settings, more active
  intervention in health settings would be offered
• Smoke-free environments would include
• the provision of help with nicotine withdrawal
• monitoring of medication after smoking cessation
• prevention of weight gain through encouraging
  healthy diet and activity.
• long- term strategies, combination of medication
  with psychosocial interventions, and integration
  into the overall patient management with the aim
  relapse prevention
• Introducing a comprehensive smoke-free policy
• significantly improve health and well-being in
  populations with disproportionate levels of
  inequality
• therefore play key part in addressing physical
  health needs of those with mental health
  problems.

28
Conclusions 1

• Smoking is largest single cause of preventable
  illness in the UK
• Mentally unwell smoke significantly more and
  therefore at greater risk
• Psychiatric treatment affected by
• negatively influencing well-being and psychiatric
  symptoms
• increasing the doses of required medication
• significantly causing physical ill-health
• Half of smokers with mental illness want help to
  give up
• but less likely to receive help
• Smoking cessation treatment is effective
• Smoking anxiogenic not anxiolytic
• Improved mental health after cessation

29
Conclusions 2

• Comprehensive smoke-free policies are successful
• Initial introduction in flexible and pragmatic
  way
• supported by greatly increased accessibility to
  advice and support in stopping smoking
• then progressing to a smoke-free policy without
  exemption.
• No evidence for increased aggression or
  deterioration of mental health after introduction
  of smoke-free policy in mental health settings
• Improved health and well-being
• in populations with introduction of
  effective smoke-free policy
• Addressing inequality
• Smoke-free policy key part in addressing
  disproportionate levels of inequality and
  physical health needs of those with mental health
  problems.
• Exempting mental health units from smoke-free
  laws would worsen existing health inequalities
  for people with mental health problems

30
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