Smoking and mental health - NCSCT

Smoking cessation interventions for individuals with mental disorders 5
concerns that interventions effective in the general population are either not
effective, or too difficult to use, or contraindicated in smokers with mental
disorders; and use of tobacco as a means to build or control relationships
between health professionals and patients. 18–23 These and other aspects of
smoking cessation intervention in mental health secondary care settings will be
addressed in detailed NICE guidance scheduled for publication later in 2013, but
the management of smoking in the great majority of people with mental
disorders, whose care is delivered outside the secondary care setting, remains an
area of relative uncertainty.
However, the underlying mechanisms of addiction, and hence the principles of
treating tobacco dependence, are common to all smokers and therefore provide
a basis for treatment approaches that may simply need to be tailored to the
special considerations for use in people with mental disorders. This chapter
therefore addresses the application of smoking cessation and harm reduction
interventions in people with mental disorders by drawing in particular on the
available evidence for people with SMI provided by a recent (2010) systematic
review of randomised controlled trials by Banham and Gilbody, 24 supplemented
by reviews of treatment in schizophrenia by Tsoi et al 25,26 and other relevant
studies published since 2010. The rationale adopted is that, in the absence of
evidence to the contrary, smoking cessation interventions that are effective in
the general population of smokers, and in people with SMI, are also likely to be
so in those with the more common mental disorders. Examples of innovative
approaches to improving service provision for people with mental disorders are
also provided.
5.2 Cessation interventions for severe mental illness
Interventions evaluated in randomised controlled trials in people with SMI
typically comprise specially designed individual or group behavioural
programmes delivered in combination with pharmacotherapy, most commonly
NRT and/or bupropion. 24 To date there has been little evidence published on the
use of varenicline in this group. 27 Trials in SMI also tend not to involve long
follow-up periods, so evidence for long-term efficacy is scarce. Evidence on
cessation interventions in general, and specific considerations in SMI, are
summarised in the following sections.
5.2.1 Behavioural support
In the general population, meta-analyses of trials comparing multi-session
intensive behavioural support with brief advice have reported odds ratios (ORs)
for cessation of 1.56 (95% confidence interval (CI) 1.32–1.84) for individual
support, 2.04 (95% CI 1.60–2.60) for group support 5,6 and 1.64 (95% CI
© Royal College of Physicians 2013 85