Smoking neglected in people with mental health conditions, leading to premature death

A major new report from the Royal College of Physicians (RCP) and Royal College of Psychiatrists (RCPsych) says that smoking in people with mental disorders is neglected by the NHS. Smoking and mental health 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.

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

Change long overdue

Although the prevalence of smoking in the UK has fallen substantially over the past two decades, among people with mental disorders it has barely changed.  Three Royal College Presidents – Sir Richard Thompson (RCP), Sue Bailey (RCPsych) and Lindsey Davies (Faculty of Public Health) say in their Foreword to the report that this is an indictment of UK public health policy and clinical service provision, and an area where change is long overdue:

As smoking becomes less prevalent in our society, so the need to identify and reverse failures of health policy and service provision for those who remain dependent on tobacco smoking becomes more urgent. This report calls for radical changes in the prioritisation, service provision and prevention of this major cause of premature death and disability in people with mental disorders.

The report says it is likely that the high prevalence of smoking accounts for much of the substantially lower life expectancy, some 10 years or more, of people with mental disorders. Smoking also increases risk of physical illness and long-term conditions, 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, but they are more likely to be heavily addicted, to believe it will be difficult to quit, and 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.

Download key recommendations from Smoking and mental health.

Missing opportunities

Doctors, nurses and other health professionals in both primary and secondary care are missing opportunities to help smokers with mental disorders to quit. Smokers with mental disorders are now 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 only one in ten receive prescriptions of medicines such as Nicotine Replacement Therapy (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 in many service settings, and some light or moderate smokers will actually smoke more due to boredom, stress or as a means of socialising in service settings. Healthcare staff are often complicit in maintaining this culture, for example by prioritising supervision of smoking breaks rather than promoting a smoke-free policy.

Provision of adequate support

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.

Key recommendations of the report

  • 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.

Professor Louise Howard, Professor of women’s mental health, Institute of Psychiatry, King’s College London, said:

Support for people with mental health problems to stop smoking needs to be prioritised urgently to improve not only the health of this vulnerable group but also the next generation, as smoking is the leading preventable cause of fetal and infant morbidity and mortality - pregnant women with mental health problems are motivated to stop smoking but are more likely to be smoking through pregnancy than other women.

Dr Jonathan Campion, director for public mental health and a contributor to the report, said:

Smoking is the largest preventable cause of death and health inequality in the UK. However, much higher rates of smoking occur among the almost one in four of the population affected by mental disorder at any one time. People with mental disorder are therefore a large proportion of overall smokers and experience much greater levels of smoking related harm and associated inequalities. Reducing the levels of smoking in those with mental disorder is one of the most effective ways to reduce the health inequalities they experience.

Sarah Woolnough, Cancer Research UK's executive director of policy and information, said:

This report is a strong reminder that urgent action is needed to support smokers to quit whatever their circumstances, and especially those who are more vulnerable or in need of specialist help. Increasingly we're seeing the most disadvantaged in society continuing to smoke, including those with mental health conditions. It's vital that staff being asked to help break the addiction of tobacco are given adequate training and support. This report offers many useful ways to reduce the burden of smoking in mental health settings. We hope they’ll be implemented as a priority. Smoking remains the biggest preventable cause of cancer death, responsible for around 60,000 cancer related deaths in the UK each year.

Notes to editors

* In view of concerns over the occurrence of depression, suicidal thoughts, suicide attempts and completed suicides in patients taking varenicline, the RCGP and RCPsych recommend that both varenicline and bupropion be used under close, coordinated supervision by health professionals, especially in the first 2–3 weeks of therapy, that family members and caregivers be alerted to the potential for adverse effects, and that varenicline or bupropion be discontinued immediately in the event of any cause for concern.