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Taking a deep breath Smoking cessation and diagnosed mental health problems Dr Kam Dhillon Head of Research .

• No appreciable reduction in tobacco consumption among people with mental health problems. more so since the ban. • People with diagnosed mental health problems have high rates of smoking.Smoking and Mental Health • In the general population adult tobacco use is in decline. •However. . cessation rates are 2 to 3 times lower for people with mental health problems.

•This is more illusionary than real. Withdrawal symptoms kick in and are relieved by more smoking. concentration. decreased anxiety and stress.self medication is established. This can lead to improved mood. Over time tolerance goes up and more nicotine is needed for ‘normal’ state. . •Cravings feel stressful and smoking feels relaxing .Smoking and the brain •Within 10 seconds of inhaling tobacco smoke. nicotine reaches the brain and acts on specific neurons and releasing noradrenalin and dopamine that act as stimulants.

•Self-medication hypothesis is a strong explanation.Stress and anxiety •420. . •People with eating disorders say that the strongest motivation for smoking was coping with stress and anxiety. but sources of anxiety are also beyond the nicotine withdrawal symptoms. •47% of people with Generalised Anxiety Disorder smoke.000 people reported stress at a level that was making them ill.

2008).Depression •Many epidemiological studies link clinical depression with smoking. •For women. harder to quit and more likely to relapse. BJP. •56% of people with depression diagnoses smoke and smoke earlier in the day. . •Long term nicotine exposure may have a causal influence on depression Vs shared environmental or genetic factors predispose to both smoking and depression. smoking increases the risk of major depression by 93% (Pasco et al. •Previous smoking history increases the risk of depressive symptoms and depression.

. •The are more likely to have smoking related illness – accounting for other relevant risk factors.Schizophrenia •People with schizophrenia diagnoses are more likely to smoke (88%) and smoke more heavily. particularly if staying in psychiatric settings. co-morbidity with other drug use. Dopamine pathways not absolutely clear. •They smoke early on in the day and find it harder to stop. culture of inpatient wards and boredom. due to increased dopamine – further selfmedication. •Reasons for high nicotine consumption may include – start younger. •Nicotine consumption reduces the negative symptoms of schizophrenia.

•400. may delay the onset. •Other research indicates that smoking increased the risk of AD.Alzheimer’s disease •AD is the most common form of dementia. •An under-researched area. •Neuro-protective effect? – nicotine appears to alleviate the neurological impairment associated with the disease.000 affected in UK. .

•They leave psychiatric settings earlier if stopped from smoking. •People with mental health problems get less support than other quitters. cessation rates remain 2 to 3 times lower for people with mental health problems.’ •They refuse voluntary psychiatric admission if forced to stop smoking. .Smoking cessation and mental health •Around 50% of smokers with mental health problems would like to quit. •However. •They tend to be living in environments where smoking is a ‘norm.

•Counselling is effective. with different intensity and duration (1.3. •The need to acknowledge and be mindful of mental health diagnoses in the therapeutic process is important – practitioners need to work with their professional accountability and ethics in mind. 6 session).Psychological approaches to cessation •Psychological approaches widely available now. •CBT shown to be effective for smokers with depression and schizophrenia. . both individual and group.

but more applied research needed. anti-depressants and other medication has proved to be successful for cessation. but needed prescriptions beyond the usual 8 weeks. .Pharmacological approaches •Nicotine Replacement Therapy. •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).

NRT. •Studies have shown positive results for smokers with depression. combined with CBT had significant positive cessation results for smokers with schizophrenia. . CBT and MI).Combined approaches •Combined psycho-pharmo interventions have been shown to be the most effective (i. where 10 weeks of CBT addressed the depression too.e. •Sustained release Zyban.

encourage more smoke-free work places and target high risk groups (DH. 23rd September 2008). like others in other clinical settings. DH. . • People are smoking outside psychiatric settings.000 people annually in England alone (Smoke free England – One year on. • We do not know how people with mental health problems have fared since the smoking ban.Smoking ban in England • Tobacco kills around 87. • Compliance to the legislation has been high. July 2008). • Local NHS Stop Smoking services have had a 20% increase in demand. • GPs now minded to record smoking prevalence and PCTs asked to increase prescribing of stop smoking products.

Strategies for working with smokers with mental health problems •Recognise that the traditional approaches do not work as there appears a different and stronger relationship with nicotine. •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. •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. .mentalhealth.http://www.