Do population-wide tobacco control approaches help smokers with mental illness?

Introduction

Population-wide tobacco control approaches, such as media campaigns, increasing the cost of tobacco products and smoke-free legislation have been instrumental in encouraging smokers across the community to stop smoking (Scollo and Winstanley, 2012). However, there are still specific groups who smoke at alarming rates and for whom these approaches are far less effective.

People with mental illness are one of these groups and they represent a large percentage of remaining smokers. In 2007, Access Economics (2007) investigated the cost of tobacco use by people living with mental illness and calculated that they consumed 42% of all the cigarettes sold in Australia and paid an estimated AUD2.8 billion per year in tobacco excises. A study in New Zealand found that 33% of all cigarettes were consumed by people who had a mental disorder (Tobias et al., 2008). An Australian study in 2010 found that 66.6% of people with psychotic disorders smoked tobacco. This proportion had not changed significantly since 1997/1998 (Cooper et al., 2012). The smokers in this study were concerned about their tobacco use with over 70% reporting that they had attempted to stop smoking; nearly one-third had tried to quit in the last 12 months (Cooper et al., 2012).

Clearly, the rates of tobacco smoking by people with mental illness continue to be very high and, as a result, they are being left behind the rest of the community. The health and financial consequences of failing to provide effective services to assist smokers with mental illness who want to quit are serious, with smoking contributing to poor physical health and reduced life expectancy (Laursen, 2011).

Although there is clear evidence that smokers with mental illness are concerned about their tobacco use and can quit if effective cessation programmes are provided (Ashton et al., 2013; Baker et al., 2006), tobacco control strategies continue to prioritize population-wide approaches with little investment in initiatives to help those for whom these strategies are ineffective (National Preventative Health Taskforce, 2008). A review of the literature on the effectiveness of the various population-wide approaches found few studies assessed the impact on vulnerable groups, especially people living with mental illness (Greaves et al., 2006). The most commonly used tobacco control policies have both intended and unintended impacts on smokers with mental illness, and these are reviewed in the following sections.

Media campaigns

Few studies have evaluated the impact of media campaigns on the rates of smoking by people with mental illness. Thornton et al. (2011) collected qualitative and quantitative data from 89 people with a diagnosis of schizophrenia or related disorders about their attitudes towards antismoking campaigns. This study found participants had been exposed to the campaigns, had good knowledge regarding tobacco, remembered, understood and were scared by the campaigns, but there was little impact on their actual smoking. Although more research is required, this study, along with the lack of change in the rates of smoking by people with mental illness despite extensive media campaigns over recent years, suggests that these campaigns are not helping mentally ill smokers to quit.

Tobacco price increases

Increasing the price of tobacco has reduced the rate of smoking across the population (Ross et al., 2011) and helped to prevent the uptake of smoking by young people. However, a systematic review of the effect of increased tobacco taxation amongst six population groups who continue to have high rates of smoking found a ‘striking lack of evidence’ about the impact of increased prices on the smoking behaviour of heavy and long-term smokers, smokers with mental illness and Indigenous smokers (Bader et al., 2011).

The high cost of cigarettes is known to affect the health and quality of life of many people with mental illness. Some are unable to afford basic requirements and may choose tobacco over food or secure accommodation, or resort to picking up butts, begging and borrowing (Lawn et al., 2002). Data from the second National Survey of High Impact Psychosis (Morgan et al., 2012) showed that nearly 90% of participants who were smokers lived on welfare benefits, with 82.2% receiving the disability support pension. The smokers in this survey were smoking an average of 21 cigarettes per day; this would cost approximately AUD70.00 per week. A higher proportion of smokers experienced financial difficulty compared to non-smokers and smokers were significantly more likely to report difficulties heating or cooling their home or room, going without meals and having to seek financial assistance from family or friends.

The available evidence therefore suggests that increasing the price of tobacco is unlikely to help smokers with mental illness to stop smoking and may cause other serious health and social difficulties. There are ethical issues involved in increasing tobacco taxation without providing evidence-based programmes to help mentally ill smokers. Despite this obvious problem, recent changes in the Australian Government’s Federal Budget have ensured that the price of tobacco continues to rise, without adequate funding set aside to assist smokers with mental illness.

Smoke-free legislation

Smoke-free legislation prohibits smoking in many public places and worksites, and has been effective in minimizing exposure to passive smoking and reducing smoking rates (National Preventative Health Taskforce, 2008). Many psychiatric hospitals have implemented smoke-free policies to reduce exposure to passive smoking, assist smokers to stop smoking and promote a clear message about the health effects of tobacco smoking. In some settings, smoke-free policies have resulted in important benefits, such as less passive smoking on site, increased provision of nicotine replacement therapy, less social smoking by staff and patients and an increased awareness by staff of the need to help smokers to quit (Hehir et al., 2013).

However, the implementation of 100% smoke-free policies (with smoking prohibited within buildings and grounds) has been challenging in some psychiatric units. Smoke-free policies in acute units can present difficulties for patients who are very unwell and distressed, behaviourally disturbed, uncooperative and lacking insight. Problems have included non-compliance by both staff and patients, patients being distressed and agitated about not being allowed to smoke, increased use of sedation, increased passive smoking at entrances of hospitals and clinics, concern about patients’ safety when smoking off site, increased service avoidance and fire risk as a result of hidden smoking (Kurdyak et al., 2008; Ratschen et al., 2009; Schultz et al., 2011). In addition, 41% of smokers participating in the second National Survey of High Impact Psychosis (2010) reported difficulty not smoking in forbidden places, creating a potential for avoidance of 100% smoke-free services and conflict with those enforcing these rules (Morgan et al., 2012).

There is little research evaluating the impact of smoke-free psychiatric hospitals on smoking cessation. However, a study of 100 patients who were discharged from a smoke-free psychiatric unit found that all resumed smoking within 36 days, with a median time to the first cigarette of 5 minutes (Prochaska et al., 2006). In addition, most people with mental illness live in the community and a survey of hospital admissions calculated that only a small proportion (1.4%) of smokers had a psychiatric admission in the past 12 months. The median duration of inpatient stay was 1 day and 57% of admissions lasted for 2 days or fewer (Lawrence et al., 2011). Both these studies suggest that smoke-free policies in hospitals have a limited effect on sustained cessation and that other strategies are required to help smokers with mental illness.

Clearly, reducing passive smoking in health services, and giving a clear message about the negative health consequences of smoking, is very important for staff, patients and visitors. However, tobacco policies need to be implemented with careful consideration of the risks and benefits involved in each setting. For tobacco policies to be effective in terms of cessation they need to encourage smokers to consider sustained cessation through education, nicotine replacement therapy and linking with longer-term cessation services outside of the hospital setting.

Evidence-based approaches for smokers with mental illness

Smokers living with mental illness are aware of the health effects of tobacco use and are concerned about it. There is evidence that if they are provided with good information and interventions to help them quit, many are able to stop smoking (Ashton et al., 2013; Baker et al., 2006). These studies involved cessation programmes provided by trained staff over several group or individual sessions. Programmes were tailored to the needs of smokers with mental illness, with links to clinical services and additional support and information about managing mental health, goal setting, problem-solving, coping with boredom, stress and sadness and building confidence and coping strategies.

Conclusion

Smokers with mental illness represent a large percentage of smokers, contribute billions of dollars in tobacco tax and suffer the serious health consequences of smoking; however, the available evidence indicates population-wide tobacco control approaches are not effective in helping them to quit. It is time to ensure that effective strategies are used to help them achieve sustained cessation. These strategies should be multifaceted, long term and evidence-based, with a combination of easily accessible services with appropriate smoking cessation pharmacotherapy, specific behavioural counselling, and group, individual and telephone support.

Addressing tobacco use also needs to be incorporated into the everyday practice of all health services for people with mental illness. It needs to be an essential component of the care provided within hospitals, the community, psychosocial rehabilitation, primary health, and accommodation and support services; in both government and non-government services. All health workers, especially mental health workers, require training about helping smokers with mental illness. An ongoing commitment to the funding of smoking cessation programmes is needed. Tobacco control interventions need to be evaluated in terms of the rates of cessation of smokers from the remaining vulnerable and high-risk groups, including smokers living with mental illness.

Tobacco control and mental health services have a shared responsibility for this group of smokers and need to work together to enable them to achieve the same success in quitting smoking as the rest of the community.