Smoking and mental health - NCSCT

Smoking cessation interventions for individuals with mental disorders 5
5.3 Cutting down on smoking, and other harm reduction
strategies
Promoting smoking reduction as an option for those who do not wish to attempt
abrupt cessation has been controversial due to concerns that cutting down may
provide false reassurance of reduced hazard, and perpetuate smoking by
postponing a definitive quit attempt. For various reasons, including heavier
smoking of the reduced number of cigarettes (compensation) and the
exposure–response relationships between smoking and disease, the health benefits
accrued from cutting down are likely to be disproportionately low in relation to
reductions in the number of cigarettes smoked. A recent systematic review
concluded that a substantial reduction in smoking seems to have a modest health
benefit, although the long-term effects of smoking reduction are uncertain. 48
However, smoking reduction does yield substantial benefits in the general
population by increasing the likelihood of a definitive quit attempt in the
future. 49,50 Encouraging smokers to use NRT to cut down on smoking without a
commitment to quit doubles the likelihood of a successful quit attempt. 51 Harm
reduction strategies, 52 by which people who are otherwise unlikely or unwilling
to quit are encouraged to substitute smoked tobacco with alternative sources of
nicotine for long-term use, therefore offer substantial potential to prevent harm
from smoking by both directly reducing the amount of smoke inhaled and
making complete cessation more likely. This approach, which in addition to NRT
embraces the potential of substitution using alternative nicotine devices such as
electronic cigarettes, is endorsed in draft guidance from NICE 53 due for final
publication in May 2013. Given the high levels of dependence on smoking and
low perceived likelihood of quitting outlined in Chapter 2, harm reduction has
evident major potential as a means to promote smoking cessation, and support
smoke-free policies, in mental health settings. This potential is to date highly
under-researched, and evidence on the effectiveness of harm reduction in SMI is
currently limited, however, to analyses of secondary outcomes in a heterogeneous
range of cessation studies 35–38,54,55 summarised in the following sections.
5.3.1 Behavioural interventions
A study of a specialist smoking programme for SMI comprising 3 weeks of
motivational enhancement therapy and 7 weeks of psychoeducation, social skills
and relapse prevention training, compared with standard group therapy to
achieve reductions in the numbers of cigarettes smoked, reported no difference
in change in mean exhaled CO relative to baseline over 3 months. 29 This suggests
that any reduction in cigarette consumption (which was not reported in the
study) had been counterbalanced by compensatory smoking. Cigarette
consumption was reduced, however, in a study of eight sessions of motivational
interviewing and cognitive–behavioural therapy, which increased the likelihood
© Royal College of Physicians 2013 89