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Published Online: 28 March 2013
Smoke alarm: mental illness and tobacco
The Lancet
The dramatic decline in smoking rates in the UK and other countries in
recent history is an achievement to be proud of. Millions have led
happier and healthier lives as a result. But not everyone has
benefited. Since 1993, smoking prevalence in the UK as a whole has
fallen by a quarter, but among people with mental health disorders, it
has hardly changed at all. Smoking and mental health, a joint report
by the Royal College of Physicians and the Royal College of
Psychiatrists released on March 28, speaks of a group left behind by
progress.
Using data derived from the Health Survey for England, the Adult
Psychiatric Morbidity Survey, and The Health Improvement Network, the
report estimates that, of 10 million smokers in the UK, up to 3
million have evidence of a mental health disorder. People with
longstanding mental health problems are around twice as likely to
smoke as are people without such disorders. These figures speak of a
huge unmet need. The association between high rates of smoking and the
foreshortened lives of people with mental illness (at least 8 years
for men, and 10 years for women, according to one recent UK study) is
not coincidental. To take a more optimistic perspective, the report
identifies a possible way to further reduce population smoking levels.
If the authors are correct, a substantial proportion of smokers will
be in regular contact with primary care and community mental health
care. Furthermore, although people with mental health disorders are
more likely to be heavily addicted to cigarettes than are individuals
without mental health problems, they are no less likely to want to
quit. Therefore, consistent, effective anti-smoking advice and smoking
cessation services added to the current package of mental health care
could yield great rewards for patients and the health system. If just
25% of people with mental health disorders stopped smoking, there
would be a gain of 5·5 million undiscounted life-years in the UK.
To claim these rewards will require a close analysis of the reasons
why people with mental health disorders take up smoking, and why they
continue to smoke. Some factors may be related to mental illness
itself. Common genetic pathways might increase the risk of both mental
health disorders and smoking. Smoking could, for some patients, be an
attempt to reduce symptoms such as depression and anxiety; agitation
resulting from the absence of cigarettes might be misattributed to
mental illness, not nicotine withdrawal. People with mental health
disorders who smoke are more likely than members of the general
population to anticipate difficulty quitting, and are less likely to
succeed in an attempt to quit. This issue might in part be due to the
negative cognitions and motivational problems associated with both
mood and psychotic disorders. So it is possible that more effective
treatment of mental health disorders will have a knock-on effect on
quit rates.
There are, however, other reasons why smoking has not substantially
fallen in people with mental health disorders over the past two
decades. These reasons are reflective less of the neurobiological
intricacies of mental illness, and more of the ongoing marginalisation
of people with mental illness. It may be assumed by health-care staff
that smoking cessation will exacerbate mental health disorders, or
that cessation measures used in the general population will simply not
work. Neither assumption is true. Mental health settings, such as
inpatient units, may have a culture of smoking, with cigarettes
facilitating social interaction, or serving as currency or reward.
Smoke-free policies must therefore not be implemented in a
half-hearted fashion, but in the context of a comprehensive,
supportive policy for smoking reduction and cessation. The cigarette
break must not be the event around which inpatient life revolves.
Coordination between primary and secondary care services will also be
essential to implement effective smoking cessation programmes for
people with mental health disorders. If the current UK situation in
which mental health and social care trusts are separated from acute
hospital trusts continues, it is up to professionals in different
disciplines to build and maintain clear lines of communication. The
fact that Smoking and Mental Health bears the signatures of the
Presidents of the Royal College of Physicians, the Royal College of
Psychiatrists, and the Faculty of Public Health gives cause for hope.
Caring for a patient's mental health needs and neglecting his or her
physical health is not acceptable. Low expectations of the desire and
motivation to stop smoking in a person with a mental health disorder
are a reminder of the paternalistic nature of too much of medicine's
past. A substantial reduction in tobacco use among people with mental
illness is a major challenge—and a great opportunity—for the future.
Full-size image (15K) Science Photo Library
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