Smoking and mental health - NCSCT

Smoking cessation interventions for
5 individuals with mental disorders
5.1 General considerations
Treatments for smokers typically comprise regular behavioural support
combined with nicotine replacement therapy (NRT), or bupropion or varenicline
pharmacotherapy. The effectiveness and cost-effectiveness of these interventions
in the general population of smokers are well established and have been
summarised in an extensive range of Cochrane systematic reviews 1–11 and
guidance from the UK’s National Institute for Health and Clinical Excellence
(NICE). 12,13
As discussed in earlier chapters, the occurrence of symptoms of mental
disorders, especially anxiety and depression, is common in the UK, affecting
almost one in four people at any time, 14 and smoking is particularly prevalent in
this group. For various reasons, however, such as the common practice of
excluding people with mental disorders from randomised trials of drug therapy 15
and the difficulty of recruiting and retaining people with severe mental illness
(SMI) in clinical trials, 16 there is relatively little direct evidence on the
effectiveness of smoking cessation interventions in people with mental disorders,
eg a recent systematic review of smoking cessation in people with depression
identified just 16 studies, only 3 of these recruiting smokers in whom depression
was current. 17 As might be anticipated from the data on levels of dependence
and perceived ability to quit smoking in Chapter 2, the efficacy of the cessation
interventions in the studies included in the review was lower than in the general
population of smokers, but the findings gave grounds to conclude that treatment
strategies of proven effectiveness for the general population, particularly
behavioural support and NRT, are also likely to be effective in people with
common mental disorders. 17
Addressing smoking in mental health settings, and particularly in secondary
care, can pose major challenges, often exacerbated by a culture of acceptance of
smoking. This historic culture is driven by various factors, including: the
population norm of high smoking prevalence; assumptions that smoking
constitutes a form of ‘self-medication’, the discontinuation of which would lead
to exacerbation of symptoms of a mental disorder, or that people with mental
disorders have little interest in stopping smoking or cannot successfully do so;
84 © Royal College of Physicians 2013