Smoking

1
Smoking Mental Health The Research
Lisa McNally Chartered Health Psychologist
Wandsworth PCT Hon. Lecturer in Tobacco Addiction
St Georges, UL
2
Smoking Mental Illness
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Smoking Prevalence

• Psychiatric patients are twice as likely to smoke
  as the general population (El-Guebaly Hodgins,
  1992).

People with mental health disorders who live in
institutions exhibit rates of smoking in excess
of 70 (Meltzer et al., 1996)
One survey estimated that 45 of all cigarettes
smoked by individuals with a psychiatric disorder
(Lasser et al. 2000)
While general smoking rates are falling not so
among psychiatric populations (McCloughen, 2003).
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Smoking Prevalence (Meltzer, 1995)
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Why do psychiatric patients smoke so much?

• There are a number of theories concerning the
  higher rates of smoking among mental health
  patients

• Mediating role of social deprivation
• Self medication

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Social Deprivation
Smoking is higher among lower SES groups. This
is a major determinant of the gap in life
expectancy between those most in need and those
most advantaged. (DoH, 1997)
Low SES, in turn, is independently associated
with increased mental health problems (Raul et
al., 2001)
While deprivation is probably a factor, research
shows that smoking is associated with mental
health problems even after controlling for SES
(Farrell et al., 2001). So other factors must be
involved
7
Self Medication
Schizophrenic smokers (more so than other
diagnostic groups) reported that their smoking
was self-medicating and they reported alleviating
positive symptoms (Lawn et al. 2002)
There is evidence that smoking can transiently
alleviate some positive symptoms of schizophrenia
(such as diminished suppression of
auditory-evoked P50 response) (Dalack et al
1998).
Studies have found that smoking may also reverse
some of the adverse side effects of antipsychotic
treatment (Levin, 1996) as does NRT (Anfang
Pope, 1997).
8
Impact of Smoking among Mental Health Patients
Smoking-related fatal diseases are more prominent
among mental health patients than in the general
population (Brown et al. 2000)
Those with mental illness are often the least
capable of coping with the devastating medical
illnesses caused by smoking (Boyd and Lasser,
2001)
Concerning mental health - smoking predicts
subsequent onset of depression (Wu et al, 1999).
and anxiety disorders (Johnson et al., 2000). .
Smoking exaccerbates stress (Parrot, 1989) state
anxiety (West and Hajek, 1997) and sleep
disorders (Htoo, 2004) all of which will be
detrimental to most mental health conditions.
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Smoking Cessation
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Exclusion from Intervention
Up until recently, there has been relatively
little smoking cessation research among
psychiatric patient groups (Health Development
Agency, 2004).
A major recent review of the research on hospital
based smoking cessation (Rigotti et al., 2003)
considered a wide range of health care areas but
excluded psychiatric patients.
However, people with mental health problems are
susceptible to the same smoking related illnesses
as anyone else. (Not to mention mental health and
social impact).
11
Surveys indicate that around 50 of smokers with
mental health problems in Britain want to quit
(Meltzer et al , 1995 and 1996, McCreadie,
2003).
People with mental illnesses have reported
feeling excluded from mainstream stop smoking
programmes (Freidli and Dardis, 2002).
Within mental health care, it is often assumed
that people with mental health difficulties are
not interested in health promotion initiatives
(Seymour, 2003). (RETAD survey).
Indeed, smoking is often reinforced within the
culture of psychiatric care. (Mester et al.,
1993) (Willemsen et al., 2004).
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Effects of Interventions A Review
In a systematic review we examined the nature and
impact of smoking cessation interventions among
people with a history of, or current, mental
health problems.
We searched MEDLINE, PSYCH-INFO, EMBASE, CINAHL
and the Cochrane Controlled Trial databases, as
well as reference sections and peer
recommendations.
In total, 21 studies were included in the review
13
The studies reviewed focused almost exclusively
on out-patients.
The most common, definable form of psychosocial
treatment was cognitive behavioural therapy.
Among the studies offering pharmacological
intervention 8 studies (38) offered NRT and 5
(24) offered Bupropion.
14
Treatment effects comparable with general
population
Among the studies reviewed there was evidence
that smoking cessation interventions can be
effective among people with mental health
problems.
Abstinence rates immediately post-treatment
ranged 10 up to 72, with a mean rate of 40.
At six months, the most common follow up point,
abstinence rates were lower, ranging from 10 to
46 and with a mean of 20.
15
There is evidence that people with mental health
problems may lower rates of quitting success
without cessation support.
But, all 4 studies that compared active cessation
support for participants with depression to
healthy controls found greater treatment
effects among participants in the depression
sub-group.
This pattern was found for both psychosocial and
pharmacological treatments.
16
A place for Zyban?
Of the six studies that randomly allocated
additional pharmacological treatment to a
psychosocial programme, all reported a
significant and positive effect on abstinence.
There was strong evidence that the addition of
Bupropion to psychosocial interventions may be
particularly beneficial.
eg - George et al. (2002) reported a 50
post-treatment abstinence rate among those also
treated with 300 mg of Bupropion compared to only
12.5 abstinence among those given placebo.
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Detrimental effects of Intervention?
In general, there seems to be little evidence of
any detrimental effects of psychosocial cessation
interventions (or cessation per se) on
psychiatric symptoms.
Similarly, no studies providing data on the
influence of pharmacological interventions on
psychiatric symptoms reported any detrimental
effects.
Rather, two studies reported positive effects of
Bupropion on symptom severity among schizophrenic
patients and one found that Nortriptyline reduced
negative affect among depressed patients.
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Reccomendations for Intervention

• Be flexible and offer choice!There is no clear
  evidence supporting any one type of psychosocial
  treatment in mental health settings. All can be
  effective. So why be prescriptive? A
  person-centred approach that emphasises choice
  can enhance control!

2) Use NRT! Pharmacological supplements
enhance efficacy of all forms of intervention.
Many mental health patients are very
nicotine dependant.
3) The main challenge is increasing access!
Think about home visits, NRT prescription via
CMHTs, and group treatments. The
starting point should be widespread, routine
brief intervention in wards / clinics.
4) Collaborate! Use the expertise of mental
health clinicians train up at all levels of
intervention. Promote ownership of the
smoking cessation work within the mental health
trust!
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Smoke Free Policy
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Background
The white paper on public health, Choosing
Health, makes clear that by the end of 2006 the
NHS will be smokefree (DH, 2004).
There is a widespread perception that psychiatric
settings are one of the most difficult hospital
settings within which to implement smoking
restrictions (HEA, 1999)
A large survey in 2001 found that most MH trusts
had designated smoking areas and prohibited the
sale of tobacco, but none had outright bans (HDA,
2001).
21
Staff Concerns
Compared to general medical staff, mental health
staff are far more reluctant to introduce smoking
policies, particularly in in-patient settings.
(RETAD Survey)
Surveys suggest that there is often apprehension
that introducing policies would be unworkable and
/ or lead to discipline problems or an increase
in aggression (Hempel et al , 2002 Quinn, Inman
and Faddow, 2000).
Most mental health staff think that patients
should be allowed to smoke in designated areas
(Stubbs et al, 2004).
22
The Research Evidence
There has been relatively little work on the
effects of going smoke free in mental health
settings we have to look abroad for evidence.
We searched MEDLINE, PSYCH-INFO, EMBASE, CINAHL
and the Cochrane Controlled Trial databases, as
well as reference sections and peer
recommendations.
15 studies were included in the review
23
Ward disruption was examined in a number of ways.
Indices included aggressive acts (verbal
physical), prn medication and patients absconding.
Staff attitudes to smoking policies over time
were also examined.
As was the extent to which NRT provision and
training in withdrawal support was in place.
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Effects of Smoking Bans on Ward Disruption
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Effects of Smoking Bans on Staff Attitudes
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Provision of Cessation Support
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Provision of Cessation Support Disruption
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Recommendations
Reassure! There is evidence that ward disruption
does not usually increase beyond an initial
settling in period, and often, improvements can
occur. Make this known!
Cessation support make step 3 step 1!The
evidence suggest that providing training in
cessation support, and making NRT available, will
make life easier for all. This needs to be in
place before the policy!
Consult and involve!Dont hand down policy
without consultation MH clinicians specialist
experience will improve policy if tapped into
(the same goes for patients). Allow exemption
policy to vary across services and be determined
in-house (subject to central approval).
Take note of what happens!Gain ongoing feedback
from all involved and then use it! A review of
what has happened after a period of time can
benefit your own trust, and others following your
lead (especially London).