Taking a Deep Breath, Smoking Cessation and Diagnosed Mental

8/3/2019 Taking a Deep Breath, Smoking Cessation and Diagnosed Mental

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Taking a deep breath

Smoking cessation and

diagnosed mental health

problems

Dr Kam DhillonHead of Research


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Smoking and Mental Health

In the general population adult tobacco use is in decline,

more so since the ban.

However, cessation rates are 2 to 3 times lower for people

with mental health problems.

No appreciable reduction in tobacco consumption among

people with mental health problems.

People with diagnosed mental health problems have highrates of smoking.


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Smoking and the brain

Within 10 seconds of inhaling tobacco smoke, nicotinereaches the brain and acts on specific neurons and

releasing noradrenalin and dopamine that act as

stimulants. This can lead to improved mood, concentration,

decreased anxiety and stress.This is more illusionary than real. Withdrawal symptoms

kick in and are relieved by more smoking. Over time

tolerance goes up and more nicotine is needed for normal

state.Cravings feel stressful and smoking feels relaxing - self

medication is established.


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Stress and anxiety

420,000 people reported stress at a level that was making

them ill.

47% of people with Generalised Anxiety Disorder smoke.

Self-medication hypothesis is a strong explanation, but

sources of anxiety are also beyond the nicotine withdrawal

symptoms.

People with eating disorders say that the strongestmotivation for smoking was coping with stress and anxiety.


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DepressionMany epidemiological studies link clinical depression with

smoking.

Long term nicotine exposure may have a causal influence

on depression Vs shared environmental or genetic factors

predispose to both smoking and depression.

Previous smoking history increases the risk of depressive

symptoms and depression.

For women, smoking increases the risk of major

depression by 93% (Pasco et al, BJP, 2008).56% of people with depression diagnoses smoke and

smoke earlier in the day, harder to quit and more likely to

relapse.


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SchizophreniaPeople with schizophrenia diagnoses are more likely to

smoke (88%) and smoke more heavily, particularly ifstaying in psychiatric settings.

They smoke early on in the day and find it harder to stop.

The are more likely to have smoking related illness

accounting for other relevant risk factors.

Reasons for high nicotine consumption may include

start younger, co-morbidity with other drug use, culture of

inpatient wards and boredom.Nicotine consumption reduces the negative symptoms of

schizophrenia, due to increased dopamine further self-

medication. Dopamine pathways not absolutely clear.


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Alzheimers disease

AD is the most common form of dementia.

400,000 affected in UK.

Neuro-protective effect? nicotine appears to alleviate theneurological impairment associated with the disease, may

delay the onset.

Other research indicates that smoking increased the risk

of AD.An under-researched area.


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Smoking cessation and mentalhealthAround 50% of smokers with mental health problems

would like to quit.

However, cessation rates remain 2 to 3 times lower for

people with mental health problems.

People with mental health problems get less support thanother quitters.

They tend to be living in environments where smoking is a

norm.

They refuse voluntary psychiatric admission if forced to

stop smoking.

They leave psychiatric settings earlier if stopped from

smoking.


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Psychological approaches to

cessationPsychological approaches widely available now.

Counselling is effective, both individual and group, with

different intensity and duration (1,3, 6 session).

CBT shown to be effective for smokers with depression

and schizophrenia.

The need to acknowledge and be mindful of mental healthdiagnoses in the therapeutic process is important

practitioners need to work with their professional

accountability and ethics in mind.


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Pharmacological approaches

Nicotine Replacement Therapy, anti-depressants and

other medication has proved to be successful for

cessation, but more applied research needed.

NRT has been effective in psychiatric in-patient settings

but higher strength patches may be needed.

Smokers with depression have had positive outcomes

with Buproprion (Zyban), but needed prescriptions beyond

the usual 8 weeks.


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Combined approaches

Combined psycho-pharmo interventions have been shown

to be the most effective (i.e. NRT, CBT and MI).

Studies have shown positive results for smokers with

depression, where 10 weeks of CBT addressed the

depression too.

Sustained release Zyban, combined with CBT had

significant positive cessation results for smokers with

schizophrenia.


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Smoking ban in England Tobacco kills around 87,000 people annually in England

alone (Smoke free England One year on, DH, July2008).

Compliance to the legislation has been high.

Local NHS Stop Smoking services have had a 20%

increase in demand. We do not know how people with mental health problems

have fared since the smoking ban.

People are smoking outside psychiatric settings, like

others in other clinical settings.

GPs now minded to record smoking prevalence and

PCTs asked to increase prescribing of stop smoking

products, encourage more smoke-free work places and

target high risk groups (DH, 23rd September 2008).


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Strategies for working with smokers

with mental health problemsRecognise that the traditional approaches do not work as

there appears a different and stronger relationship with

nicotine.

Explore with people this relationship with nicotine

employ CBT oriented strategies with greater flexibility

combination approaches successful keep mental health

in the foreground, accounting for different vulnerabilities.

Confidence building and stress management activities are

helpful.

Be aware of your capabilities and scope of work and refer

to and work with other professionals.


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http://www.mentalhealth.org.uk

Taking a Deep Breath, Smoking Cessation and Diagnosed Mental

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