The University of Nottingham

A major new report involving experts at The University of Nottingham says that smoking in people with mental health conditions is neglected by the NHS.

Smoking and Mental Health, led and co-authored by Professor John Britton and colleagues from the UK Centre for Tobacco Control Studies based at the University, says that much of the substantially lower life expectancy of people with mental disorders relates to smoking, which is often overlooked during the management and treatment of their mental health condition.

The report has been produced jointly for the Royal College of Physicians (RCP) and Royal College of Psychiatrists (RCPsych).

Professor John Britton, who is chair of the RCP’s Tobacco Advisory Group, said: “As the prevalence of smoking in the UK falls, smoking is increasingly becoming the domain of the most disadvantaged in our society, particularly those with mental disorders. That smoking prevalence has remained so high in this group, especially among those with severe disease, is a damning indictment of medical practice and public health policy.

“It is time for a radical change in our approach to smoking in mental health care provision, to make non-smoking the norm, and significantly enhance life expectancy and quality among millions of people.’

One in three of the UK’s 10 million current smokers has a mental disorder. 20 per cent of the general population smokes, but around 40 per cent of people with mental health disorders smoke, and this figure is even higher in those with more severe mental health problems. Those with mental disorders also smoke more cigarettes, are more addicted to nicotine, and find it harder to quit, than those without.

The report says it is likely that the high prevalence of smoking accounts for much of the substantially lower life expectancy of people with mental disorders, some 10 yearsor more. Smoking also reduces quality of life, exacerbates poverty, increases drug requirements to control symptoms, and adds to social stigma in this group.

Smokers with mental disorders are just as likely to want to quit as those without. They are more likely to be heavily addicted to smoking, to believe it will be difficult to quit, and are much less likely to succeed in any quit attempt. Many are discouraged by mistaking the symptoms of nicotine withdrawal for those of underlying mental disorder; however, stopping smoking improves mental health in the longer term.

Doctors, nurses and other health professionals are missing opportunities to help smokers with mental health problems to quit. Smokers with mental health problems are more likely than other smokers to receive support to quit from their GP, but this reflects the increased frequency of their consultations. Over the course of a year, only half of smokers with mental disorders are advised to quit and around one in 10 receive prescriptions of medicines such as NRT, bupropion or varenicline that can help them to quit. This suggests that much more could be done to encourage uptake of cessation support, or the use of medicinal nicotine to reduce harm from smoking.

People treated in specialist mental health settings are the most disadvantaged when it comes to the provision of cessation services. While heavy smokers often reduce consumption due to the smoke-free setting, studies have shown that there is a ‘culture’ of smoking, and some light or moderate smokers will actually smoke more due to boredom, stress or as a means of socialising. Healthcare staff are often complicit in maintaining this culture, for example by prioritising supervision of smoking breaks rather than promoting a smoke-free policy.

Although all NHS mental health trusts in England have now implemented smoke-free policies, lack of monitoring makes it difficult to evaluate their effectiveness. Resources allocated to enforcing smoke-free policies, including those that would ensure the provision of adequate behavioural and pharmacological support (such as staff training and provision of NRT), are often lacking, and there are complex barriers to the implementation of effective tobacco dependence treatment in mental healthcare settings. Resources that could be used to help smokers to quit are often channelled primarily into enabling smoking, through the provision of smoking shelters and staff-supervised smoking breaks.

In addition to the human cost of premature death and disease, the total overall estimated cost to the NHS of diseases caused by smoking in people with mental disorders based on financial year 2009/10 was £719 million, from an annual estimated 2.6 million avoidable hospital admissions, 3.1 million GP consultations and 18.8 million prescriptions. Reductions in smoking prevalence could also save up to £40 million on psychotropic drugs, many of which are required in lower doses among non-smokers.

The report makes the following key recommendations:

• Smoke-free policy is crucial to promoting smoking cessation in mental health settings.
• All healthcare settings used by people with mental disorders should therefore be completely smoke free.
• Smokers with mental disorders using primary and secondary care services, at all levels, should be identified and provided routinely and immediately with specialist smoking cessation behavioural support, and pharmacotherapy to relieve nicotine withdrawal, promote cessation and reduce harm.
• Commissioners should require mental health service settings to be smoke free, and to provide support for cessation, temporary abstinence and harm reduction.
• Service indicators, such as the primary care Quality Outcome Framework (QOF) and Commissioning for Quality and Innovation (CQUIN), should measure and incentivise cessation, not just delivery of advice to quit.
• All professionals working with or caring for people with mental disorders should be trained in awareness of smoking as an issue, to deliver brief cessation advice, to provide or arrange further support for those who want help to quit and to provide positive (ie non-smoking) role models. Such training should be mandatory.
• Research funding agencies should consider encouraging and investing in research to address this major cause of ill-health, and health inequalities, in British society.

Cancer Research UK provided additional funding to support the systematic reviews and new data analyses in the report.