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Mental health and smoking: a holistic approach to giving up

Joyce Borgs
PGDip
Smoking Cessation Specialist
Consulting Trainer in Applied Suicide Intervention Skills Training
Manager
Mind Aberystwyth

We all know that smoking is bad for our health and we are becoming more accepting of the relationship between physical and mental health. So how can primary care nurses support individuals experiencing mental distress to give up smoking and improve their general wellbeing?

We have come a long way in our attitudes towards smoking cessation and mental health, as reflected in the health and wellbeing agenda and the demand for a more integrated and holistic approach to health and keeping healthy.

Tobacco use is the biggest cause of premature death in the UK. One in two long-term smokers will die prematurely as a result of smoking – half of these in middle age. Estimates show that around 114,000 people in the UK are killed by smoking every year, accounting for one fifth of all UK deaths.1

While general smoking rates are falling, this is not the case among the psychiatric populations, who suffer poor health as a consequence.2 Smoking rates for people from this group tend to be, on average, twice as high as those for the general public.3

Smokers with a mental health problem also tend to smoke more heavily and be more dependent than smokers without mental health problems. One study showed that 51% of individuals with a schizophrenia diagnosis and 50% of those with a bipolar affective disorder smoked over 20 cigarettes a day, compared to only 8% of the general population.3 This results in smoking-related fatal diseases being more prominent among individuals experiencing mental health problems than among the general public.

Smoking has a big impact on all parts of an individual's life. The following factors are all linked and interact with one another.

  • Mental health. In contrast to popular belief, smoking exacerbates stress, state anxiety and sleep disorders. All of these are detrimental to most mental health conditions. Anxiety levels fall significantly after successfully giving up smoking for one week.4 A research review found that smokers reported above-average stress before smoking, rather than below-average stress after smoking.5 Individuals smoke mainly to avoid the stress that nicotine depletion causes.
  • Social health. Having a mental health concern isolates people; this is exacerbated by changing attitudes towards smokers and having to go outside when socialising in cafes and pubs.
  • Financial health. In a US study, it was estimated that a smoker with schizophrenia spends just over one third of their weekly income on cigarettes.6 This money is not available to be spent on food, heating, socialising or leisure activities, which could help to improve quality of life. As a consequence, physical and mental health might suffer.
  • Medication. Smokers on antipsychotic medication are often prescribed higher doses than nonsmokers on the same medication. This might be because smoking increases the speed at which the medication gets metabolised. This can impact on the person's perception of how ill they are and affect their self-esteem.

About half of smokers with mental health problems in Britain are interested in giving up smoking, but this group has reported feeling excluded from mainstream stop-smoking programmes, or that health promotion campaigns are not directed towards them.7

Case study
Adrian, aged 38, is a large and shy man who has a long and enduring mental illness. He came to Mind Aberystwyth's smoking cessation service with his support worker to see if he could be helped to give up smoking. Adrian has been smoking since he was 11 years old. He is now starting to feel stressed because his GP and his family would like him to give up for health reasons. He suffers from repeated lung infections and coughs a lot. He does not know where to start with giving up; he has tried by himself but has never managed to go without a cigarette for more than a few hours.
 
When Adrian first arrives at the service he does not make eye contact with anyone and come across as agitated, stressed and shy. After the first session, to which he brings his support worker, he comes by himself. Together we do an analysis of his wellbeing and of how ready he is to give up. Then he chooses his medication and we make another appointment before his quit date to go over how he can use his medication and talk about motivation. Adrian has contact with the service for over three months, during which time he relaxes a lot and starts coming to the drop-in with a friend. He also joins our swimming session.

Adrian says about his quit attempt: "Giving up has totally transformed my life! I don't cough at all any more, I am less stressed and can think more clearly now – it is like a fog has lifted. I couldn't have done it without this service. I feel you understand my mental health problems and that I can talk about them, which has helped a lot."

After five months, Adrian has gone back to smoking. Although he is disappointed, he is also proud that he gave up for such a long time. This period of abstinence has given him the opportunity to make positive changes in his life. He has invested in his social life and takes more exercise, as well as eating more healthily. Adrian also knows that he can come back to the service at any time if he wants to try again, something he thinks will happen because he now knows he can do it and has proven to himself by not smoking for five months.

Mind Aberystwyth clinic
Mind Aberystwyth's Health and Wellbeing Centre has been operating a unique and successful Holistic Smoking Cessation clinic for people like Adrian, who are experiencing the effects of mental distress, including family, friends and carers (see Table 1).

[[Table 1 smok]]

As well as using nicotine replacement therapy in the clinic, we look at the whole of the individual rather than just their smoking behaviour. All aspects of wellbeing are assessed together with the client, and we look at what works well for the individual and what is causing them stress, directly or indirectly (see Figure 1). Emotional distress predisposes people to lapse, so we need to look at stress management and coping skills, and how we, or others, can support these.8 Motivational interviewing techniques are employed throughout sessions to maximise the client's ownership of their quit plan.

[[Fig 1 smok]]

When someone experiencing mental distress gives up smoking, a major stressor is removed and the opportunity is created for other positive changes to happen. By giving up smoking a "breathing space" is created to look at other parts of life that need changing. The individual becomes more aware of their wellbeing and has extra motivation, which they can use as a catalyst for other positive change. So, even if the client does start smoking again, there may have been some lasting positive changes that have taken place in their lives.

The emphasis is on the process rather than the outcome. The client will feel that they have benefited from the help they received, even if they start smoking again. This will support future quit attempts. For the clinician there is the sense of empowering the client; by maintaining the emphasis on wellbeing the clinician avoids overidentification with outcomes, which can, in turn, have the effect of reducing the tendency to become battle-weary.

Mind Aberystwyth provides a unique setting for this work. As a health and wellbeing centre it offers a range of therapeutic activities five days a week alongside its "food and mood" drop-in. Here, people can purchase an affordable, healthy, local and mainly organic lunch. Activities on offer include yoga, swimming, arts and crafts, cooking, walking and confidence-building classes. The stop-smoking service refers clients to activities within the organisation to help with exercise and stress.

We are flexible in terms of how much time we can give people for appointments, and all our staff have received training in brief intervention and are available to talk to clients during non-smoking-related sessions or on the phone. We have the experience and expertise to take people's mental health issues into account, which is something our smoking cessation clients rate highly. The service is perceived as more accessible to them – it gives people a sense of security and lowers their stress levels. We work closely with other support agencies where possible. We have found that clients who are helped by their CPN or support worker benefit tremendously.

How can mainstream smoking cessation services apply this knowledge?
The challenge is making your service more accessible to this marginalised and excluded sector of society. A starting point would be to develop links with local organisations in both voluntary and statutory sectors who support this group. Knowledge of mental health issues and how these affect the life of the individual is essential. Extra time will need to be made available for appointments due to the increased need of
these clients.

Mind Aberystwyth offers training sessions in the use of their holistic model for mainstream smoking cessation specialists. To find out more, email: training@mindaberystwyth.org or telephone Joyce Borgs: 01970 626 225.

References
1. Action on Smoking and Health (ASH). Factsheet No 2. Smoking statistics; illness and death. London: ASH; 2002. Available from: http://old.ash.org.uk/html/factsheets/html/fact02.html
2. McCloughen A. The association between schizophrenia and cigarette smoking: a review of the literature and implications for mental health nursing practice. Int J Mental Health Nurs 2003;12:119–29.
3. NHS Health Development Agency (HDA). Smoking and patients with mental health problems. London: HDA; 2004. Available from: http://www.nice.org.uk:80/niceMedia/documents/smoking_mentalhealth.pdf
4. West R, Hajek P. What happens to anxiety levels
on giving up smoking? Am J Psychiatry 1997;154:1589–92.
5. Parrot AC. Stress modulation over the day in cigarette smokers. Addiction 1995;90:233–44.
6. Shiffman S, Paty JA, Gnys M, Kassel JA, Hickcox M. First lapses to smoking: within-subjects analyses of real-time reports. J Consult Clin Psychol 1996;64:
366–79.
7. Brown C. Tobacco and mental health: a literature review. Edinburgh: ASH Scotland; 2004. Available from: http://www.ashscotland.org.uk/ash/files/tobacco%20and%20mental%20health.pdf
8. Shiffman S, Waters AJ. Negative affect and smoking lapses: a prospective analysis. J Consult Clin Psychol 2004;72:192–201.