Smoking and mental health - NCSCT

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Smoking and mental health heavy smokers and in those showing a therapeutic response to clozapine. 78–80 Clozapine is the only atypical antipsychotic that consistently improves P50 auditory gating, probably through serotonin (5HT 3 ) receptor antagonism, which increases acetylcholine release, 81 and hence activates nicotinic receptors which reduce the desire to smoke. Conversely, treatment with the older typical antipsychotics, such as haloperidol, has been associated with increased smoking. 79 5.5 Provision of smoking cessation and tobacco dependence treatment for smokers with mental disorders in the UK The UK government’s mental health strategy (No health without mental health) has recently highlighted the need to adress the current higher mortality, lower levels of general health, and lower uptake of mainstream screening and public health programmes by people with mental disorders. 82 The identification of smokers with mental disorders, and provision of support to stop smoking through improved access to appropriate smoking cessation programmes, are described as critical objectives. 82 Smokers with mental disorders can access smoking cessation treatment services through a variety of avenues including their general (primary care) practitioner (GP), services provided by mental health trusts and by self-enrolment with a local NHS SSS. These services, and the challenges that they present, are outlined below. 5.5.1 Primary care As most people with mental disorders are managed in primary care, the role of the GP in providing smoking cessation and harm reduction treatment is crucial. This has recently been acknowledged in the integration of mental health-specific smoking-related outcomes into the Quality of Outcomes Framework (QOF), 83 which is used to measure and incentivise GPs’ performance in the UK. The new indicators reward GPs for documenting smoking status regularly in patients with schizophrenia, bipolar disorder and other psychoses, and for providing smoking cessation advice or referral to an NHS SSS. 83 For the general population, brief advice by a practitioner, defined as the provision of ‘verbal instructions to stop smoking with or without added information about the harmful effects of smoking’, and requiring only 1 or 2 minutes of consultation time, achieves modest effects but is highly cost-effective. 84 Success can be increased by around 40% if more intensive advice is given with reinforcement by CO reading. 84 Although research into the effectiveness of brief and intensive advice for populations with mental disorders alone is lacking, there is no reason to believe that it would not achieve modest success in people with mental disorders, particularly if supported by appropriate prescribing of cessation pharmacotherapy. 96 © Royal College of Physicians 2013
Smoking cessation interventions for individuals with mental disorders 5 Although data from the USA suggest that, in the past, primary care physicians (and indeed many other health professionals) have failed to address 85 or even tacitly encourage smoking, for reasons related to common beliefs and perceptions in terms of its therapeutic value and the risks of cessation for patients’ mental health (‘first things first’; see also sections 5.1 and 6.3), the data in Chapter 2 suggest that, in the UK at least, practice is changing. The revised QOF is likely to have contributed substantially to this, at least in the patient groups specified in the QOF (schizophrenia, bipolar disorder or other psychoses). It is important, however, to ensure that this intervention is delivered to maximum effect and that all smokers, irrespective of co-morbidity, are offered and delivered the maximum level of intervention that they are willing to accept. In line with new NICE guidance, 53 it is also important that smokers who decline help to quit smoking are encouraged to adopt harm reduction strategies. 5.5.2 Specialist mental health settings (secondary care) Specialist inpatient and community mental health services, provided by NHS mental health trusts, should be able to play major roles in addressing smoking, at several levels. First, people with severe mental disorders, many of whom do not access mainstream services (including primary care) regularly, will be in regular contact with these services in the context of the care programme approach, which stipulates the development of a care plan, the identification of a ‘care coordinator’ and an annual review by a consultant psychiatrist. 86 Smoking cessation should be a prominent part of this wider care delivery, in accordance with mental health strategy objectives. 82 Second, there is now clear evidence that patients admitted to inpatient wards tend to change their smoking behaviour by decreasing, increasing or even starting to smoke, 87,88 possibly as a consequence of adapting to inpatient routines and smoking breaks (see Chapter 6, section 6.2). Admission is, however, an opportunity to intervene to reduce smoking, 89 particularly in the context of strong smoke-free policies in British settings. Motivation to stop smoking is similarly high in hospitalised patients with and without a mental disorder, 90 and a Cochrane review of smoking cessation interventions for hospitalised patients found that intensive counselling interventions started during admission and continued for at least 1 month after discharge increased cessation rates (OR = 1.65, 95% CI 1.44–1.90; 17 trials) regardless of admission diagnosis. 15 Third, specialist mental health services are particularly suitable settings in which to provide tailored support through experienced mental health staff, in environments and contexts familiar to service users and with appropriate attention to treatment interactions, and with recognition and appropriate attribution of withdrawal symptoms. © Royal College of Physicians 2013 97
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PDF not for circulation Smoking and
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Contents Members of the Tobacco Adv
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Contents 4.4.3 Attention deficit hy
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Contents 6.4.3 Staff knowledge 122
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Contents 10.5 Tobacco policy and me
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Contributors Anthony Aclet - Specia
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Contributors Jill Williams - Associ
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1 Mental disorders 1.1 What is a me
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Mental disorders 1 1.3 Common menta
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Mental disorders 1 1.4.4 Somatisati
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Mental disorders 1 In addition to s
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Mental disorders 1 not diagnosed un
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Mental disorders 1 Similar to many
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Mental disorders 1 12 Chang CK, Hay
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Mental disorders 1 52 Young S, Toon
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Smoking among people with mental di
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Ethical and legal aspects 9 pose co
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Ethical and legal aspects 9 patient
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10 Summary and conclusions 10.1 Smo
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Summary and conclusions 10 10.4 Smo
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Summary and conclusions 10 although
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11 Key conclusions and recommendati
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Key conclusions and recommendations
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