New approaches to smoking and people with mental illness

More people are accepting that people with mental illness have the right to be treated to the same standard of care as people without mental illness, which includes help with a smoking addiction. Mark Ragg reports.

The healthcare system has had a troubled relationship with people with mental illness who smoke. Smoke-free policies in mental health settings were introduced much later than such policies in general health settings in most states. Doctors and nurses have held a diverse range of views, with some ambivalent about helping clients quit and others in clear opposition.

But times are changing. More and more people are accepting that people with mental illness have the right to be treated to the same standard of care as people without mental illness. We spend enormous amounts of time and energy helping others conquer the addiction that is smoking – why shouldn't we help people with mental illness to the same extent?

But in providing such care, many questions arise.

Isn't smoking inevitable in people with mental illness?

No, smoking is not inevitable. In published studies internationally, the prevalence of smoking ranges from 88 per cent ^{(1, 2)} down to 14 per cent ⁽³⁾ in people with schizophrenia. With such a broad range of prevalence, smoking simply cannot be an intrinsic part of mental illness. As well as being an addiction, smoking is a cultural phenomenon – it is more common in places where it is culturally acceptable to smoke.

Do people with mental illness want to quit smoking?

Yes, much the same as people without mental illness. ⁽⁴⁾ Doctors working in the area say that once they start asking their patients about smoking, they are surprised at the number who say things like ‘I’d love to, but nobody’s ever asked before’. Some, shamefully, are discouraged from quitting by mental health professionals.⁽⁵⁾

Can people with mental illness successfully quit smoking?

Yes. In a large US study, 30 to 40 per cent of those who identified themselves as having mental illness said they were ex-smokers.⁽⁶⁾ That survey suggests that many people with mental illness quit successfully, either alone or through standard care. To read success stories, see the NSW Health website and Now I can smell the orange blossoms, a book telling the stories of people with mental illness who have quit successfully.⁽⁷⁾

Will it worsen their mental illness?

There is no evidence to say that people with schizophrenia will have a psychotic episode when they quit, or that people with a history of depression will have another episode when they quit.⁽⁸⁾ It is far more dangerous to keep smoking than to stop. Quitting is the best thing anyone who smokes can do for their health.

People with mental illness who quit smoking should be monitored, but no evidence exists to suggest that quitting smoking causes particular problems. In fact, quitting can lead to a better quality of life for people with mental illness and in some cases, a need for less medication.

Will people with mental illness become violent without cigarettes?

Any person, when quitting smoking, can become tense and irritable. That can happen whether you have mental illness or not.

Research in hospital settings shows that when smoke-free policy is introduced and patients can no longer smoke, there is no increase in violence. ^{(9, 10)} Staff generally find conditions improve, as there are fewer points of negotiation and dispute, and as patients are not repeatedly going through withdrawal as they wait for their next cigarette. This is particularly so if the bans are absolute, rather than partial, and management has taken time and effort to introduce the changes in policy with consultation and appropriate clinical support.

What is the best clinical approach to helping people quit?

The best approach is for all health professionals involved in the care of people with mental illness – nurses, doctors, social workers and others – to take the same approach to smoking as with the general population. Smoking is an addiction that is manageable with clinical support and ongoing care.

Every patient, at every consultation, should be asked if they smoke and advised of the benefits of quitting if they do. Then usual care – motivation, support (behavioural and pharmacological) and referral – applies. Asking is the key.

What about families and visitors?

Families and visitors should know, before arriving at a mental health facility, that it is smoke-free.

Local policies apply for managing visitors who smoke on site or offer cigarettes to patients.

What about nicotine replacement therapy?

Nicotine replacement therapy (NRT) is important. It is more available in some settings than others, but offering NRT to all people with mental illness who enter a healthcare facility is imperative. If people give up smoking suddenly, they are likely to go through withdrawal symptoms, which can compound the feeling of dislocation brought about by hospital admission. NRT will reduce those symptoms of withdrawal and is an essential tool for managing the withdrawal many people face on entering hospital.

NSW Health has recently developed a practical tool for use in hospitals. It is adapted from the work of Renee Bittoun, and offers a flowchart approach to NRT (see illustration of clinical tool). It can easily be used by GPs.

Is more help available?

NSW Health has developed a suite of tools to help clinicians to manage smoking in people with mental illness. The tools cover:

• supporting consumers who are nicotine dependent


• assessing nicotine dependence on admission


• managing nicotine withdrawal in hospital


• the impact of smoking cessation on medications


• nicotine replacement therapy and other medications


• planning for discharge


• managing leave

They are available at the NSW Health website.

Mark Ragg

Dr Mark Ragg is director of RaggAhmed and adjunct senior lecturer in the School of Public Health, University of Sydney. RaggAhmed is working with the Cancer Council NSW on the Addressing Smoking in Mental Health project which is funded by the Centre for Health Advancement, NSW Ministry of Health.

References

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2. Chiles JA, Cohen S, Maiuro R, Wright R. Smoking and schizophrenic psychopathology. American Journal on Addictions. 1993;2(4):315-9.


3. Suarez M, Haydar R, Campo A, Bermudez A, Ayola C. Tabaquismo y trastornos mentales. Acta Medica Colombiana. 1996;21:317-21.


4. Etter M, Mohr S, Garin C, Etter JF. Stages of change in smokers with schizophrenia or schizoaffective disorder and in the general population. Schizophrenia Bulletin. 2004;30(2):459-68.


5. Green MA, Clarke DE. Smoking reduction & cessation: a hospital based survey of outpatients’ attitudes.[see comment]. Journal of Psychosocial Nursing & Mental Health Services. 2005 05;43(5):18-25.


6. Lasser K, Boyd JW, Woolhandler S, Himmelstein DU, McCormick D, Bor DH. Smoking and mental illness: A population-based prevalence study. JAMA. 2000 11/22/;284(20):2606-10.


7. Ashton M, Johnston F, editors. Now I can smell the orange blossom! Adelaide: Department of Health, Government of South Australia; 2011.


8. Ahmed T. Stopping smoking doesn’t make your mental illness worse. Royal Australian and New Zealand College of Psychiatrists Annual Congress; 31 May; Darwin2011.


9. El-Guebaly N, Cathcart J, Currie S, Brown D, Gloster S. Public health and therapeutic aspects of smoking bans in mental health and addiction settings. [Review] [58 refs]. Psychiatric Services. 2002 12;53(12):1617-22.


10. Lawn S, Pols RG. Smoking bans in psychiatric inpatient settings? A review of the research. Australian & New Zealand Journal of Psychiatry. 2005;39:866-85.