A time to quit

Experiences of smoking cessation support among people with severe mental illness

Curtis Sinclair 19 5 7 9 13 19 29 30

illness? mental severe the picture? into 23 fit 3 4 project 22 31 this 30 and challenges and what provide, currently do services support What face? do they opportunities Conclusions Introduction quit? to likely less illness mental severe with people are Why set? been have targets and what made been have commitments What with in people cessation smoking for works What and delivered? be organised services should How cessation smoking of illness mental severe with people of The experiences smoking from want illness mental severe with do people What services? cessation

Appendix 9 10 References 6 7 does How 8 3 4 5 Executive summary Acknowledgements Executive 1 2 Contents

Centre for Mental Health REPORT A time to quit 2 Centre for Mental Health REPORT A time to quit 3 Acknowledgements We also thank the individuals who participated in interviews and focus groups, and who otherwise and who otherwise groups, and focus in interviews who participated the individuals thank also We us given report, have in this used have we which Their insights, project. this to contributed solutions. potential as well as face they the issues into insights important Paul Cilia La Corte, Rosie Fox, Josie Garrett, Michelle Gavin, Dania Hanif, Gabriella Hasham, Ian Hasham, Gabriella Hanif, Dania Gavin, Michelle Garrett, Josie Fox, Rosie La Corte, Cilia Paul Wilton. and Jo Roberts Kathy Mills, Andrew Lewis, Hannah Samir Jeraj, Howley, the production of a suite of resources. of a suite of the production Jabeer Butt, Bray, Emma Bell, Andy Bailey, Emma from received gratefully report was this for Input Friends, Families and Travellers, LGBT Hero on behalf of The National LGB&T Partnership, and Race and Race Partnership, LGB&T National The of behalf on Hero LGBT Travellers, and Families Friends, lived with people with engagement extensive out carried have we Together, Foundation. Equality in culminate will This bodies. and academic government the NHS, local sector, VCSE the experience, The Association of Mental Health Providers, Centre for Mental Health, and Rethink Mental Illness, Illness, Mental and Rethink Health, Mental for Centre Providers, Health Mental of The Association partners HWA alongside project this on leading are Consortium, Health the Mental of members as national voluntary sector organisations and consortia. The Alliance aims to bring the voice of the of voice the bring to aims The Alliance and consortia. organisations sector voluntary national equality, promote to making, policy national into experience lived with and people sector voluntary inequalities. health reduce and to This project has been commissioned by the VCSE Health and Wellbeing Alliance (HWA), a (HWA), Alliance Wellbeing and Health VCSE the by commissioned been has project This and 20 England, Health Public and England, NHS Health, of the Department between partnership and them, holistic time for sustain quit attempts. quit sustain There is evidence from research that what what that research from evidence is There to illness mental severe with people helps the for that to similar broadly is smoking quit behavioural including population, general peers, and help from medication techniques, and friends. families like would illness mental severe with People help including smoking, quit help to more find the right to range the full to support, access personalised social from support therapies, effective of or quit reduce to and incentives networks smoking. that important is it do this, help them to To to in how trained are professionals health in illness mental severe with people support psychiatric for techniques, cessation smoking stop when people be adjusted to medication to be offered help to ongoing and for smoking,

of rates service of Yet with someone for difficult be more will it smoking to mental health and perceptions and perceptions health mental to smoking that health stops sometimes This illness. a mental who people help to offering from professionals smoking. quit to want might wanting to quit are about the same as for the for as the same about are quit to wanting population. general with people to barriers numerous are There These smoking. quitting illness mental severe up giving of risks the about myths include People with severe mental illness have very very have illness mental severe with People the general than smoking of rates higher much more are who do smoke and those population, 50% An estimated smokers. be heavy to likely illness mental severe with people of deaths of illnesses. smoking-related from are smoking cessation support to people with with people to support cessation smoking is focus The primary illness. mental severe but in the community, cessation on smoking also are settings and residential inpatient discussed. experiences on the first-hand Based into brings it research, and published users and complexities challenges the some of focus point a starting provides and it subject, this of effective more provide to looking those for practitioners, commissioners and policymakers and policymakers commissioners practitioners, evidence and themes the key some of to mental severe with people of the needs around successful about known is and what illness cessation. smoking to approaches The aim of this report is to introduce introduce to is report this of The aim Executive summary Executive

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is and never-smokers but includes, illness It activities. , 2019). et al. et Diagnosable eating disorders are also widely widely also are disorders eating Diagnosable however, illnesses; mental severe as recognised of considerations clinical the special to owing not will they cases, in these management weight report. in this be included cessation Smoking are review literature this to interest most Of in an individual result that interventions and permanently. completely smoking stopping lead which options, reduction harm However, be considered, also will rates, smoking lower to abstinence. an end of to a means as especially in life expectancy between current smokers smokers current between expectancy in life mental severe with & Miller, (Tidey illness mental severe without is There 2016). & Meza, Warner Tam, 2015; inequality this that recognition widespread (RCP, be addressed must and unacceptable is 2014; ASH, 2016; & Bonevski, 2013; Passey Firth terms of Definition illness mental Severe psychological to refers illness mental Severe enough to often severe are that problems and work to ability a person’s limit seriously do day-to-day psychotic and enduring severe to, limited not and mood disorders personality disorders, disorders. , 2019). , 2014). As , 2014). As smoking smoking- of et al. et et al. et the difference the than health , 2011; Chesney, , 2011; Chesney, smoking from of and that et al. et risk increased , 2017; NHS Digital, 2018). 2018). Digital, , 2017; NHS two-thirds for physical poorer be at et al. et may account may It has been estimated that 50% of deaths of of deaths 50% of that been estimated has It due to are illness mental severe with people illnesses tobacco-related to increasingly unequal health outcomes outcomes health unequal increasingly to (Dickerson a result, the prevalence of smoking in people in people smoking of the prevalence a result, a slower at falling is illness mental severe with leading population, in the general than rate benefits the same received (Cook programmes cessation often found to be as motivated as the general the general as motivated be as to often found & (Szatkowski smoking stop to population not have historically, 2015) but, McNeill, demographic factors (Krieger (Krieger factors demographic are illness mental severe with people However, illness the general to compared illness related and clinical for after adjusting even population, (RCP, 2013; Szatkowski & McNeill, 2015) and 2015) & McNeill, Szatkowski 2013; (RCP, & McNeill, (Szatkowski heavily more smoke to mental severe with 2015); and some people People with severe mental illness are more more are illness mental severe with People population the general than smoke to likely life expectancy (Chang (Chang expectancy life contributes Smoking 2014). & Fazel, Goodwin inequalities. health these to disproportionately general population. This includes a higher risk a higher risk includes This population. general cancers, various disease, cardiovascular of reduced ultimately, and, conditions metabolic People with severe mental illness have have illness mental severe with People significantly 1. Introduction

, be

Young- is et al. et & , 2014). One difficult et al. et cannot finding on their confidence as quitting effect psychiatric among that, found mental severe with people to its via

this , 2014). However, attempt the most severe withdrawal symptoms: withdrawal severe the most combined with nicotine replacement therapy therapy replacement nicotine with combined nicotine of the effects reduce to (NRT) smoking Notably, be helpful. may withdrawal be associated to been shown has cessation and stress, anxiety depression, reduced with life of mood and quality positive and improved Taylor (e.g., smoke to continuing with compared al. et illness mental severe with people to generalised further requires that an area and highlights mental the possible specifically, More research. benefits health smoking. when quitting illness symptoms Withdrawal with smokers attempt, a quit When making severe more experience illness mental severe in smokers than symptoms withdrawal nicotine (Smith population the general study US-based experienced groups the following inpatients, 2013). Therefore, the relationship between between the relationship Therefore, 2013). motivation, anxiety, relapse, failure, perceived of and a perception complex. health on mental smoking of Impact severe with people that believed often is It them helps it because smoke illness mental evidence The their symptoms. manage to (Smith, weak is hypothesis supporting this Sharma, 2014; & Kozlowski, Giovino Homish, Das 2016; Prochaska, Gartner & Hall, belief, this that possible is 2017). It Wolff, the affect could the evidence, of irrespective a successful making an individual of likelihood quit Educational smoking. stop to in their ability misconceptions dispel that approaches unsuccessful quit attempt (McDermott (McDermott attempt quit unsuccessful

491 quit of , 2018). A population- study et al. et that found (2019) in a UK , 2014; Scott , Scott 2014; et al. et a telephone- with cessation smoking et al. et , 2018). in quitting confidence with associated et al. et study population-based cohort A UK-based difficult. 2. Why are people with severe mental illness less likely to quit? illness less mental with severe are people 2. Why Perception of quitting as difficult as quitting of Perception successful was success intervention; instead, based strongly (Ni in understanding this relationship, it may may it relationship, this in understanding a retrospective that note to be important the general from 1,604 smokers of analysis did intensity smoking that found population of the likelihood predict independently not than those among the general population, but but population, the general among those than for when adjusted disappeared association this & Brose, McNeill (Richardson, smoking heavy a heavily the more that suggests This 2019). that the likelihood the lower smokes, person However, be successful. will attempt a quit from people with schizophrenia diagnoses diagnoses schizophrenia with people from (Freeman UK health mental common with in people attempts be successful to likely less were conditions Level of addiction of Level with some smokers that evidence is There dependent be more may illness mental severe population. the general to compared on nicotine mainly comes association this of The evidence individual. External factors, such as the design the design as such factors, External individual. interventions cessation smoking of and delivery be discussed will clinicians, of and the attitudes report. this section of in a later This section will focus on factors relating to the to relating on factors focus will section This as and those illness mental severe with smokers a experienced the former that found without an made when they in anxiety increase greater Richardson Richardson common with individuals that found study level than likely more were conditions health mental up giving perceive to population the general

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in rate attending quit meetings. the planned of , 2016; Lum, Skelton, Wynne & Wynne Skelton, , 2016; Lum, Paul Sohal, , 2016; Huddlestone, the 38% in those than lower defined as compliance, as that, a recommendation to led et al. et al. et three-quarters (2018) compared the effectiveness of of the effectiveness (2018) compared the overall 6-month follow-up, least - significantly in success of predictor The strongest without. was quitting at the explore did not the study because However, among compliance of rates the lower for reasons unclear is it illness, mental severe with smokers this address what approach would successfully problem. Boredom severe with people that evidence is There boredom help relieve to smoke illness mental (Peckham a higher do so at Whether they 2018). Bonevski, This unclear. is population the general than rate has finding help should practitioners attempt, quit part of identify to illness mental severe with people boredom relieve to activities meaningful (Peckham 2018). & Ratschen, Compliance Rasmussen in Denmark, based study In a cohort al. et intervention among cessation a smoking illness mental severe and without with smokers respectively). (4,388 and 21,023 individuals, At 29% was illness mental severe with smokers

, 2010]). smokers , 2019). et al. et 124 smokers et al. et of disproportionately social perceived did find that , 2015). , 2019). This literature review review literature This , 2019). benefit would et al. et et al. et by influenced was illness 2016). Those with greater cigarette dependence dependence cigarette greater with Those & Prochaska, Fromont Anzai, (Soyster, Participants with polysubstance misuse polysubstance with Participants illness mental severe more with Those Women participants American African norms, especially those of family and friends and friends family of those norms, especially (Aschbrenner with severe mental illness found that uptake uptake that found illness mental severe with and group medication cessation smoking of therapy with severe mental illness were more likely to to likely more were illness mental severe with (Metse another smoker with live study a US-based Additionally, with severe mental illness had more smokers smokers more had illness mental severe with however, others; than networks in their social study an Australia-based Aschbrenner Aschbrenner on whether people data UK identify any did not Social networks and norms networks Social networks, social through spreads Smoking 2008; & Fowler, (Christakis quitting does as safety of NRT are common [Bobak [Bobak common are NRT of safety mental and nicotine about education and from NRT from the about (misconceptions withdrawal nicotine As a result, it may be that people with severe severe with people be that may it a result, As • • • • • in care and and/or e-cigarettes. smoke- challenge environments smoke-free not should

Providing information and advice for carers, carers, for advice and information Providing and members other household family, visitors hospital smoking stop on and providing Advising these and making pharmacotherapies, in hospital available who people for drug dosages Adjusting smoking stopped have people for in place systems referral Putting who smoke policies smoke-free Developing secondary smoke-free commissioning services and smoking stop to staff Supporting frontline for training smoking stop providing staff. medicines smoking stop alternative activities are in place and promoted, and promoted, in place are activities alternative areas.” outside to access regular including services in communities and primary care, care, and primary in communities services detailed includes 2018). It NG92 (NICE, in authorities local for recommendations smoking stop and providing commissioning health mental with people and lists services of the provision for group a priority as problems interventions. evidence-based CQC it evidence what out set have The CQC around see evidenced to like ideally, would, of implementation that notes It services. inpatient health mental “… inspections on be paid should focus Instead, policies… free adequate by mitigated is a ban whether such or stop to smokers for and support advice the with smoking from abstain temporarily support, and a range behavioural of assistance of whether consider also should Inspections • • • • • • smoking stop guideline for NICE a also is There

than is This less to a smoke- for ambition five-year England Health 2030 (DHSC, 2017). rates smoking reducing Public maternity services maternity Identifying people who smoke and offering and offering who smoke Identifying people support intensive including stop, help to and services, health and mental in acute In brief, the guidance for inpatient services set set services inpatient for the guidance In brief, out by NICE is: • NICE guidelines NICE health mental and maternity acute, Smoking: [PH48] services free future. Its pledges include supporting the supporting include pledges Its future. free and advising cessation smoking for plans NHS’s services, smoking on their stop authorities local groups towards targeting increasing “including need” (PHE, the highest with areas and local 2019). Public Health England Health Public The recent help to action to taking to commits strategy the Government’s achieve mothers and higher risk outpatients (including (including outpatients and higher risk mothers and health mental specialist accessing those access offered are services) disability learning and smoking treatment dependence tobacco to 2019). England, (NHS services cessation The NHS has made a commitment to improve improve to a commitment made has The NHS severe with people for support health physical focuses Plan Term Long The NHS illness. mental general (in patients all that on ensuring and both adults trusts health mental acute, pregnant overnight, admitted and teenagers) 5% of the population. The plan includes pledges pledges includes The plan the population. 5% of with people for esteem’ of ‘parity to in relation conditions. health mental Plan Term Long NHS Government Government Tobacco in its out set has Government The UK England make to an ambition Plan Control by smoke-free defined as 3. What commitments have been made and what targets have been set? have been what targets made and have been commitments 3. What

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three been of all et al. et et al. et to of effective , 2016) found that that , 2016) found The efficacy et al. et , 2016; Roberts , 2016; Roberts the most Yet, , 2017). The large scale scale The large , 2017). smoking for and tolerable et al. et et al. et support. without. or those , 2013; Farholm & Sørensen, 2016). For 2016). For Sørensen, & , 2013; Farholm neuropsychiatric events relative to nicotine nicotine to relative events neuropsychiatric psychiatric with in those or placebo patch disorders cohort, with by differ did not the treatments in efficacy superior being varenicline patch. and nicotine bupropion There are three main pharmacotherapies pharmacotherapies main three are There smoking of the treatment for prescribed (Zyban) bupropion NRT, in England: dependence 2018). Digital, (NHS (Champix) varenicline and a combination as prescribed normally is NRT release slow for patch acting a long i.e. therapy, for gum/lozenge/spray acting and then a quick when needed. use both on their own that shown has Research all other treatments, with and in conjunction efficacious are three illness. mental severe with in people cessation been have varenicline and bupropion In trials, smoking of higher levels with associated and the efficacy NRT; than cessation similar is illness mental severe with in people (Tsoi population in the general that to 2013; Anthenelli 2016; Peckham (Anthenelli trial EAGLES associated not were and bupropion varenicline in moderate-to-severe an increase with been successfully used to improve other health other health improve to used been successfully people among in the short term behaviours Priebe 2012; (Tidey, illness mental severe with al. et counselling Individual population, the general therapy 2017), group Stead, & Lancaster (e.g., 2017), and & Lancaster, Carroll Stead, (e.g., Ordóñez- Matkin, (e.g., counselling telephone all 2019) have Hartmann-Boyce, & Mena offering of methods be effective to shown behavioural smoking recommended widely and most combine that those are interventions cessation support behavioural with pharmacotherapy 2016; & Lancaster, Fanshawe Koilpillai, (Stead, 2017). NICE, Pharmacotherapy

commonly research from a three-step The most one-to-one, are , 2017). There is also some also is There , 2017). et al. et is recommend, methods they severe mental illness? severe What works for smoking cessation in people with with in people cessation works for smoking What support shape of cash incentives, can help to reduce reduce help to can incentives, cash of shape (Tsoi, schizophrenia with in people smoking also have 2013). Incentives Webster, & Porwal 2015; Peckham 2015; Peckham in the reinforcement, contingent that evidence frequency, duration and format of behavioural behavioural of and format duration frequency, has effectiveness and overall interventions & Laffer, Cather (Evins, been established not interventions more often form the backdrop to to the backdrop often form more interventions for a result, As pharmacotherapy. of studies the optimal illness, mental severe with people and cognitive-behavioural. deliveryused these However, telephone. via and group The main psychosocial interventions used in used interventions psychosocial The main motivational educational, are cessation smoking Behavioural interventions Behavioural effective way to stop; and ACT offering help by, help by, offering and ACT stop; to way effective service smoking a stop to referral example, for medication. or prescribing intervention designed to be delivered in as little little in as be delivered to intervention designed and recording establishing ASK 30 seconds: as on the most advising ADVISE status; smoking attempt to quit among the patients who smoke who smoke the patients among quit to attempt the model (VBA), Advice Brief Very (ASH, 2019). of 2013a & 2014). Action on Smoking and Health and Health Smoking on 2013a & 2014). Action mental for guidance published (ASH) have an help them trigger to professionals healthcare services about their smoking status and status their smoking about services (NICE, completely stop to smokers all encourage advice practitioners guidelines, NICE to According health mental accessing people all ask should Starting a conversation and providing and providing Starting a conversation findings or unavailable, limited with and people population the general into be cited. will conditions health mental common studies with people with severe mental illness illness mental severe with people with studies is research where However, possible. wherever general population also works for people with with people for works also population general & Gilbody, (Banham illness mental severe on focus will below The subsections 2010). There is evidence that what works for the for works what that evidence is There 4. five high in the least or relapse; attempt quit who had quit at who smoked higher in the intervention participants was diagnosis SMI preference. and most widely recommended smoking smoking recommended widely and most combine that those are interventions cessation support behavioural with pharmacotherapy & Lancaster, Fanshawe Koilpillai, (Stead, SCIMITAR+, of The trial 2017). 2016; NICE, techniques these an intervention combining are illness, mental severe with people for 1. in Box summarised For the general population, the most effective effective most the population, the general For after an unsuccessful an with , 2019) quit to motivation as twice than more were follow-up the six-month adults et al. et at quitting on participant based support face-to-face but significant, relapse reduced not , 2017). successful was of et al. et was decision motivated-to-quit were significantly Offering NRT before setting a quit date (‘cut down to quit’); to down (‘cut date a quit setting before NRT Offering illness; mental a person’s of in the context smoking of the purpose Recognising 30 minutes); approximately 12 lasting (up to visits house individual Providing additional Providing so that attempt quit a successful of or psychiatrist physician care a primary Informing Making several assessments before setting a quit date; a quit setting before assessments several Making medication can be adjusted accordingly. be adjusted can medication has the final in the proportion of the difference 12-month follow-up, • • • • • • group. health. mental to harmful either intervention was that no evidence was There The chances intervention. the bespoke who received in participants At conditions two Participants were randomised either to treatment as usual (statutory smoking cessation cessation smoking (statutory usual as treatment either to randomised were Participants intervention. the bespoke in the UK) or to cost no direct at available services (22%) and disorder (65%), bipolar schizophrenia were diagnoses common The most (13%). disorder schizoaffective Participants cigarettes a day. The intervention was delivered by a trained mental health smoking cessation practitioner practitioner cessation smoking health mental a trained by delivered The intervention was physician care primary the participant’s and the participant with in conjunction who worked specialist. health or mental pharmacotherapies, cessation smoking of on the range participants advised Practitioners but people with severe mental illness. The adaptations included: The adaptations illness. mental severe with people An intervention from the Manual for Smoking Cessation Training was adapted to cater for for cater to adapted was Training Cessation Smoking for An intervention the Manual from , 2014; Evins , 2014; Evins • Findings • • • • Participants • • • Box 1: SCIMITAR+ trial (Gilbody (Gilbody trial SCIMITAR+ 1: Box intervention? cessation smoking the bespoke was What • period has ended. In trials, maintenance maintenance ended. In trials, period has treatment (Evins illness mental severe with in people rates al. et In this context, maintenance treatment refers refers treatment maintenance context, In this cessation smoking (and tapering) continuing to treatment the initial after pharmacotherapy

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by

, 2018). et al. et to addition e-cigarettes in the general to compared of use in reducing a local with , 2019) compared , 2019) compared behavioural recent e-cigarettes endorsed et al. et than effective more were , 2016; Hickling , 2016; Hickling e-cigarettes interventions RCT with A UK-based harmless. et al. et Lindson- (Begh, cessation complete by accompanied a relatively are small are reduction of use on the research of sessions (one-to-one has England Health , 2019). The SCIMITAR+ trial for people people for trial SCIMITAR+ The , 2019). completely not, however, a licensed medication and are and are medication a licensed not, however, not (Hajek 886 participants e-cigarettes support behavioural by accompanied NRT to clinician) support. E-cigarettes because However, cessation. smoking for NRT e-cigarettes Reviews infancy. in its is research the market, trials, more the need for note the evidence of to continues the technology as especially safety about (PHE, 2018a) and concerns evolve of a paucity currently is there In general, remain. rigorous evidence The illness. mental severe with people support some initial provide does available of the use around (Pratt tobacco Harm reduction designed interventions to refers Harm reduction instead cigarettes, tobacco of the use lower to the health that Given abruptly. stopping of benefits a means as recommended only is it abstinence, an end of to of review A Cochrane 2015). & Aveyard, Hawley reduction-to-quit down who cut people that found population to likely no less were gradually their smoking (Lindson abruptly who stopped those than quit al. et down a ‘cut included illness mental severe with cessation smoking its of part quit’ option as to 1). interventionBox (see E-cigarettes Public aid for cessation smoking reduction a harm as are They (PHE, 2015). population the general

initiated, that found , 2015; reported by et al. et in reduction was smoke-free the benefits study the same Yet, wards follow- six-month both the one- and policies smoke-free despite grounds, ethical issue around removing inpatients’ right right inpatients’ removing around issue ethical & (Woodward controversial remains choose to 2019). Richmond, potential for conversations about behaviour behaviour about conversations for potential were bans if even Finally, place. take to change the enforced, and universally be successfully to change achieved by the smoking ban and, by and, by ban the smoking by achieved change the reduced hidden, more smoking making patients frequently found ways to smoke on smoke to ways found frequently patients hospital the cultural limited had This place. in being and one of policies, patients among motivation increased was staff smoking. stop to MHSP/ASH, 2019). They found that, by 2018, by that, found They 2019). MHSP/ASH, surveyed trusts health the 39 mental 79% of smoke-free comprehensive implemented had Smoking Partnership and ASH carried out out and ASH carried Partnership Smoking (CRUK/ and outcomes uptake on its research Five years after the policy of making mental mental making of the policy after years Five inpatient health and Health UK, the Mental Research Cancer Smoke-free policies Smoke-free pilot called Care2Quit (Aschbrenner, Patten & Patten (Aschbrenner, Care2Quit called pilot & Lukowski, Patten 2018; Brockman, Brunette, 2018). preliminary research has been carried out out been carried has research preliminary to and friends family needed by the skills into a through treatment seek to smokers motivate social network (Aschbrenner (Aschbrenner network social 2017), and Wiggers, & Wye Bowman, Lawn, ups. Additionally, there is some evidence that that some evidence is there Additionally, ups. provided is it if effective be more will support existing the individual’s someone from by (Ford, Clifford Gussy & Gartner, 2013), which 2013), which & Gartner, Gussy Clifford (Ford, a significant demonstrated at smoking There is currently limited evidence in the use use in the evidence limited currently is There found review peer support. systematic A of criteria the inclusion met that one student only Peer support and social support and social support Peer smoking, after stopping week olanzapine, two commonly used antipsychotic antipsychotic used commonly two olanzapine, outcomes clinical Adverse medications… levels in blood increases rapid from arising have smoking stopping after drugs these of recommend guidelines been reported… Clinical 25% around by drugs these of doses reducing the first during and at before levels blood and monitoring until smoking after stopping intervals weekly 2013, p92) (RCP, stabilised.” have levels This applies in particular to clozapine and clozapine to particular in applies This and in non-smokers, to levels blood similar reduce need to smoking stopping of the event effect. this for compensate to used the doses 2013). This has important implications for for implications important has This 2013). when medications those of the prescribing smoking: someone stops to likely therefore are who smoke “Patients achieve to drugs these of need higher doses Links with psychiatric medication psychiatric with Links the reduces smoking that evidence is There (RCP, medications some psychiatric of impact

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of staff was in the UK the benefits to related trained in VBA for smoking cessation (CRUK/ cessation smoking for VBA in trained found has 2019). Other research MHSP/ASH, and nurses health mental 58% of only that Smoking Partnership and ASH (2019) found and ASH (2019) found Partnership Smoking implementing to barriers the biggest one of that policies smoke-free the policies shift the cultural to resistance policy the that a concern (e.g., required relationship therapeutic on their impinges that important therefore is It patients). with health mental of views and the concerns and addressed considered are professionals support to policies of in the implementation cessation. smoking training Staff Physicians of College In 2013, the Royal health mental all that recommended training mandatory receive should professionals brief deliver issues, smoking understand to or signposting support and provide advice, 2013). (RCP, support cessation available to trusts health mental survey of a recent However, staff all 16% were in only that found in England misconceptions mental worsen would quitting (e.g., smoking symptoms). health staff of the attitudes explored also has Research illness mental severe with smokers with working 2016; Shahab, & McNeill Tombor, (Sheals, 2017). & Brose, McEwen Robson, Simonavicius, to found been have professionals health Mental toward attitudes and permissive negative hold people among cessation and smoking smoking health mental to Barriers illnesses. mental with for support effective providing professionals smoking their own included cessation smoking the ‘norm’ as smoking viewing behaviour, and illness, mental severe with people among an important as acts smoking that believing feel the person or helps mechanism coping better. and Health UK, Mental Research Cancer

et , 2018). about advice give et al. et in mental and practice , 2019). This implies that that implies This , 2019). always a third et al. et , 2018). For example, the SCIMITAR+ trial trial SCIMITAR+ the example, , 2018). For , 2012; Szatkowski & McNeill, 2013). More 2013). More & McNeill, Szatkowski , 2012; policy smoke-free 256 family members of individuals with severe severe with individuals of members 256 family prevalent found who smoked illness mental misconceptions about the relationship the relationship about misconceptions For health. and mental smoking between by survey completed an Australian example, There is a widespread perception that smoking smoking that perception a widespread is There severe with people the ‘norm’ among is common also are and there illness, mental Culture, norms and misconceptions norms Culture, policies and guidelines need to be clear, easy to to easy be clear, need to and guidelines policies ignore. to and hard follow identified, only (CRUK/MHSP/ASH, smoking from abstaining 2019; Gilbody health trusts in England found that, on a typical on a typical that, found in England trusts health ask trusts of half only ward, health mental are And when smokers status. smoking about form of pharmacotherapy and safe for use in use for and safe pharmacotherapy of form The survey illness. mental severe with people of varenicline by their primary care physician, physician, care their primary by varenicline effective the most is it that evidence despite still falling short of best practice (Huddlestone (Huddlestone practice best short of falling still al. et prescribed were participants few that found al. although there that, suggests research recent is practice typical been improvements, have compliance with guidelines among primary primary among guidelines with compliance services smoking and stop care, and secondary 2010; McDermott & Ratschen, (McNally Concordance with guidelines with Concordance of levels low found has research In the past, interventions (Huddlestone (Huddlestone interventions that something about the way services are are services the way about something that the undermining is and delivered organised cessation smoking of effectiveness potential clinical trials are often much higher than than higher often much are trials clinical (Cather, world in the real observed those suggests This 2017). & Evins, Cieslak Pachas, It has been noted that the quit rates achieved achieved rates the quit that been noted has It in illness mental severe with people by 5. How should services be organised and delivered? delivered? and be organised should services 5. How

five were of health groups , 2018). Another in mental care health either and were SMI et al. et mental for be to proved focus Seven a having and meta-analysis review produced by Cancer Research UK, Mental Health Health UK, Mental Research Cancer by produced and ASH (2017; Partnership Smoking and Stop some local because that, 2019) notes been decommissioned have Services Smoking is it services, ‘lifestyle’ with or replaced difficult more becoming place. in pathways referral put to services Service co-ordination and integration co-ordination Service mental a severe with people of The majority hospital than rather community receive illness is It the time. of or the majority all for treatment support cessation smoking that vital therefore inpatient between who move people follows (in both directions). services and community A systematic provided who were patients that found RCTs support cessation smoking post-discharge with or reduce their abstinence, maintain to able are those than longer for use, their cigarette (Brose, support with provided not who were 2018). & McNeill, Simonavicius and integration historically, However, not have co-ordination of lack is One barrier straightforward. be responsible who should about agreement physical co-ordinating for (Rodgers settings health in in the ways diversity the increasing is A report jointly offered. are treatments which were conducted with smaller numbers of service service of numbers smaller with conducted were and other stakeholders. users was completed by 27 respondents, primarily primarily 27 respondents, by completed was The second settings. NHS within working who users 37 service by completed survey was as self-reported ex-smokers. or active in greater the issues explore to out carried interviews the surveys. Follow-up depth than

, et al. et , 2017; show to (Whittaker et al. et , 2016). study et al. et smoking initiate to , 2017; Vilardaga , Vilardaga 2017; et al. et , 2019). A systematic review of internet internet of review , 2019). A systematic interventions and app-based messaging other treatments to an add-on of smoking cessation. Focus groups were also also were groups Focus cessation. smoking of their explore to users service with conducted cessation smoking past around experiences survey The commissioner/practitioner support. We collected data from two primary primary two from data collected We and experience lived with people groups: surveys Separate commissioners/practitioners. group, each with conducted were and interviews aspects on different focused questions with 6. How does this project fit into the picture? as al. et to equivalent were they found interventions in terms counselling, and face-to-face telephone (Graham effectiveness of Klein, Lawn, Tsourtos & Agteren, 2019). It has has & Agteren, 2019). It Tsourtos Lawn, Klein, in the general studied extensively been more phone mobile of review A Cochrane population. text in increasing promise showed they that found or on their own delivered either rate, the quit There is interest in using more recent recent more in using interest is There cessation smoking deliver to technology on people focusing Research interventions. stages early in its is illness mental severe with (Naslund staff among confidence Illness, Mental (Rethink conversations cessation 2016). technology Using training is relatively low (Simonavicius (Simonavicius low relatively is training from support initial is There 2019). 2017; ASH, pilot an 18-month UK-based compared education, staff of the effectiveness smoking of capturing in better baseline, to and increased rates, smoking reducing status, 43% of psychiatrists in England had received received had in England psychiatrists 43% of 2019) and (ASH, training cessation smoking health mental advisers, smoking stop among

Centre for Mental Health REPORT A time to quit 14 Centre for Mental Health REPORT A time to quit 15

around by adopted pocket your in self-efficacy that put You of sense quit: them to in motivating factor cost of smoking was highlighted by many as as many by highlighted was smoking of cost a significant makes £10, it that losing about think you “When difference. a big was it months”. However, up for save and can that the interviews one of during suggested a person to smoke), seriously impacted on the impacted seriously smoke), to a person a quit contemplating even that belief person’s unrealistic. was attempt respondents that highlighted The survey data affected health mental their that felt typically The 37). (33 of smoking stop to their ability health their mental that indicated majority (22 of on tobacco their dependence increases respondents of a minority only 37). Conversely, affected health their mental that indicated cessation in smoking engage to their ability to harder it 37) or made (9 of programmes 37). (3 of smoking stop to support access quit to Motivation groups the focus from themes main The two related quitting for typify the motivations that health. physical for and concerns cost to policy the smoke-free Interestingly, one participant reported by only was the NHS The general quit. to factor a motivating being as “…you basically have to do it by yourself; there’s there’s yourself; by to do it have “…you basically on to do it got You’ve there. out much really not own”. your of “fear participants number of a small For further impacted failures” and “past failing” on the person’s uncommon not also was It cessation. smoking smoking that indicate to participants for healthcare up by brought rarely was cessation the by instigated rather but professionals too is quitting that The perception participant. mental severe with a person for challenging health mental by often expressed is illness affect indirectly, may, and this professionals, the likelihood about beliefs own the person’s some participants, for addition, In success. of as such illness, mental severe of symptoms commanding voices (i.e., auditory hallucinations found they smoking, stop to their ability difficult how indicating and self-determination: willpower of smoking cessation smoking The experiences of people with severe mental illness of mental illness severe of people with The experiences 7. provide the right type of support, with many many support, with type of the right provide a great required smoking stop to that insisting deal even contemplating it. contemplating even did not services that felt participants Generally, Several participants said they did not have the have did not they said participants Several about confidence many with Confidence in ability to quit in ability Confidence to discuss quitting in comparison to making making to in comparison quitting discuss to their weight. manage to their diet to changes smoking. smoking. a was smoking that felt participants Many reluctant more often and were choice personal For instance, people felt that there would be would there that felt people instance, For up gave they if socialise to opportunities less Social factors indicated the importance of of the importance indicated factors Social as network their social of part being smokers smoke. to continuing for factor a contributing didn’t think it was possible for me to ever give give to ever me for possible was it think didn’t up”. “Cigarettes would calm me down, I’d experience I’d experience me down, would calm “Cigarettes of a way was it a fag’, think: ‘I need and stress and 60 a day smoking I was stress. with coping “Smoking is quite relaxing, and goes well with well goes and relaxing, quite is “Smoking a break”. yourself to give a way is it alcohol, opportunities for removing themselves from a from themselves removing for opportunities situation: stress and emotions was a common response response a common was and emotions stress the many for also, but, participants amongst and provide boredom alleviate to helped habit A range of views were provided by focus group group focus by provided were views of A range continuing for the reasons explain to attendees manage a method to as Smoking smoke. to Understanding the high rates of of high rates the Understanding smoking related to their experiences of being offered or or offered being of their experiences to related tobacco. smoking quit to support for asking emerged from the lived experience participants, participants, experience the lived from emerged surveys, and completed groups the focus from This section will review the major themes that that themes the major review will section This

needs to difficulties travel the specific understand did not “I think it has to be from health professionals at at professionals health to be from has it think “I then up to give want you don’t time. If the right helpful it find I didn’t to listen. going not you are to give me told just professionals when health you.” support doesn’t that and wrong is it up, inevitable that a person would begin smoking smoking begin would a person that inevitable a relapse. during more once health among knowledge Poor professionals concern expressed participants Generally, by held knowledge of lack the perceived at mental GPs, (e.g., professionals healthcare key about psychiatrists) practitioners, health smoking or undermining in supporting factors illness. mental severe with people for cessation healthcare that perception a common was There providers and their illness mental severe with people of some for Consequently, smoking. for reasons was understanding of lack this participants, with engaging to an impediment as viewed programmes and the cessation professionals a pivotal considered was Timing themselves. engage whether to in determining factor services: cessation smoking being unaccountable (e.g., “Chemist and Doctor and Doctor “Chemist (e.g., unaccountable being to pillar from – passed confused both were enough resources having not GPs or post”), smoking. stop to patients support to available substantial In addition, for service, smoking a stop of the destination too considered is the distance where example, engagement. of the likelihood reduced far, health in mental Relapse stress for a tool as described was Smoking many and groups, the focus in management quitting that a fear about talked participants of a relapse about bring would smoking apprehensive Some were illness. mental directly would varenicline as such drugs that health. their mental of the stability affect relapse health a mental during Conversely, no to little was there that felt some participants smoking maintain them to in helping support almost be to felt was it Rather, abstinence. stop smoking services, healthcare professionals professionals healthcare services, smoking stop

for it find money stop to barrier always you

a significant as “…in practice save to as cited also be difficult can A range of other service rationing issues issues rationing other service of A range was local to cuts funding included These smoking. problems around the use of NRT (e.g., skin skin (e.g., NRT of the use around problems taste): non-adherence, irritation, you itch; make patches that say people “Some work”. really don’t and uncomfortable they’re suggestion that these were being withheld withheld being were these that suggestion be related could and this participants, from (i.e., warning” box “black the previous to dangerous but rare potential communicate as such drugs for designation effects) side outlined several Participants Varenicline. option made available to someone with severe severe someone with to available option made either were participants Many illness. mental pharmacotherapy of range full the of unaware or Varenicline), Buproprion, (i.e., options some was There offered. never were they Access to support to Access access of a lack discussed participants Several their quit support to options of range a full to often the only was NRT instance, For attempt. “I like being healthy, and realised that smoking smoking that realised and healthy, being “I like in problem a health basically and actually is that person that to be want the main…I didn’t want I didn’t health. up my messes deliberately concerns.” health mental to my that to add substantial motivating factors in determining to to in determining factors motivating substantial me stop”. make to attack a heart took quit: “It be a also might concerns health physical These an additional some, are for worry that, of source their mental managing of in the process burden health: for instance, premature death and subsequently and subsequently death premature instance, for “It’s their family: support to there being not can you so family your for well stay to important you”. need they if be there being as cited often were scares Health fags”. fags”. commonly were health physical about Concerns quit. to a reason as participants by raised concerns to in tandem cited often were Family health, on physical smoking of the impact about it for else something up by swallowed gets just but food… example

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Sector

client Public under service a step-down specific for issues of The idea their responsibilities people who share a protected characteristic characteristic a protected who share people who don’t. and those Eliminate unlawful discrimination unlawful Eliminate between opportunity of equality Advance characteristic a protected who share people who don’t and those between relations good or encourage Foster mental illness but also issues faced by, for for by, faced issues also but illness mental A number of communities. LGBTQ+ example, of prescription that requested participants be should NRT, including pharmacotherapy, by (e.g. team health their mental by undertaken a psychiatrist). a smoke-free where hospital, leaving people for a support help to would enforced, was policy discharged. once attempt quit continued Travellers’ and Family Friends, from Evidence the need emphasised also group focus time in invest to services mainstream for Gypsy with and trust relationships developing them enable will This communities. Traveller and fulfil to to: including Duty, Equality • • • “Not making it taboo – realising that there are are there that – realising taboo it making “Not it. This vilifying to stop to smoking, and positives stigma shame or of a feeling create then doesn’t support”. accessing around approach and holistic a personalised Promoting for the opportunity enable would support to a around and ‘open’ dialogue a ‘continued’ the ‘right Furthermore, habit. smoking person’s a with be identified together, quit’ could time to timing that stating survey respondents of third help. accepting not for a reason was and support advice Specialist cessation smoking that felt was it Largely, a specialist by be provided should services of knowledge with severe only not included This groups.

of steps first fits a ‘one size one-to- included identified the need and emotional benefit would approach participants that expressed, of participants group any Therefore, the initial overcoming that cessation services? cessation What do people with severe mental illness want from smoking want from illness severe mental people with What do approaches a quit attempt and better understanding a understanding and better attempt a quit health: mental present person’s information. Many participants expressed a expressed participants Many information. by holistic, more become to services for desire supporting to approach person a whole taking one support, group sessions, psychological/ sessions, one support, group medication, NRT, interventions, behavioural and advice/ reduction, harm vaping, The range of interventions suggested by survey survey by suggested interventions of The range and focus attempt. these enhance to on or helping drawing from qualities. personal Half of survey respondents indicated that that indicated survey respondents of Half determination, (e.g., characteristics personal quit a previous in aiding a factor were willpower) this for giving yourself confidence and allowing allowing and confidence yourself giving for this realistic”. to feel it “I tried to wean myself off and this gave me the me gave this off and myself to wean tried “I recommend could do it. I would I that confidence was to in confidence an increase to led often quitting abstinence: maintain included a range of approaches that some that approaches of a range included clear was What so. less and others helpful found There was a consensus, in terms of the range the range of in terms a consensus, was There of consensus This inadequate. was approach all’ The majority the design to approach a personalised for plan. smoking quit a of and implementation Personalised and holistic approach and holistic Personalised support,non-judgemental and incentivised reduction, support,harm interventions. better support a quit attempt. The themes to be to themes The attempt. a quit support better a personalised need for the are here discussed and advice specialist approach, and holistic from the focus groups and survey, outlining outlining and survey, groups the focus from would that delivery service of aspects key This section explores the emergent themes themes the emergent explores section This 8.

quit identified as were a previous in supporting factor and incentives A quarter of survey respondents indicated indicated survey respondents A quarter of a was and friends family from support that significant attempt. interventions Incentivised Rewards and aid. Goals cessation smoking a useful particularly were achievement for rewards of types these that felt was important. It in services. lacking currently intervention were Support network Support wanting for a reason as mentioned was Family focus the across tobacco smoking quit to Gypsy a from A participant and survey. groups the noted group focus community Traveller and family: their extended of importance life, your in thing important the most are “Family you”. and motivate support can they and people for or low have beneficiaries FFT’s provided that this was supervised by staff with with staff by supervised was this that provided expertise. health mental that is widely available to the general the general to available widely is that healthcare that evident was It population. NRT on offering reliant over were professionals Participants pharmacotherapy. the primary as medication, of the idea open to generally were Access to all smoking cessation cessation smoking all to Access interventions or either unaware were participants Typically, pharmacotherapy of range the full offered not participants was around the failure of services services of the failure around was participants regarding information accessible provide to or no low with people to cessation smoking 45% of literacy. often excluded therefore and are no literacy, smoking. around messages health from considerate of how they offer services in an services offer they how of considerate way and non-stigmatising inclusive digital experiencing are or literacy low have who exclusion. from received we recommendation A key Complementary to this, mainstream services services mainstream this, to Complementary with compliant are they ensure should and Standard Information the Accessible

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benefits identified by an offer to when asked Yet, the potential raised policy, the smoke-free concerning Smoke-free policy Smoke-free areas main two were There professionals so far results mixed had has it that suggesting set should staff that felt was it First, in practice. professionals’ knowledge of this topic. this of knowledge professionals’ One respondent that skill a key as Interviewing Motivational of in professionals health by adopted be could cessation: smoking to relation in trained were we in Australia, “When I worked interviewing cessation/motivational smoking the nurses)”. (all a therapeutic is interviewing Motivational and change behavioural support to approach many that the possibility highlights perhaps possess currently professionals health mental support effectively to skills the necessary would the issue case, In this cessation. smoking skill of a lack than rather application be one of of the experiences However, or knowledge. being not is it that suggest would users service of a lack due to potentially context, in this used time. staff positive and encouraging sign that could enable enable could that sign and encouraging positive within be embedded to or staff teams specialist services. health mental and knowledge Training number of a small only Interestingly, lack that surveyed felt who were professionals smoking offering to a challenge was training of services. cessation or commissioning of the challenges of example people to services cessation smoking providing the with compared illness mental severe with could 18 responses 12 of population, general example (for misconceptions be considered quit”, “links to “harder was it that believing and “patients mood and smoking” between suggests This it”). without so much suffering be limiting may and misperceptions gaps that

the top the NHS authorities fulfil to required one of were landscape, changing identified that pathways referral and opportunities do they face? and opportunities What support do services currently provide, and what challenges and what provide, currently do services What support local financially-challenged Some respondents a 2019) was England, (NHS Plan Term Long comparable substitute to providing the full the full providing to substitute comparable programme. SCIMITAR+ setting up a good nicotine replacement therapy therapy replacement nicotine a good up setting improve to way cheap a relatively is programme a as viewed be cannot but provision service resources the extra providing Conversely, requirements. the programme interest from NHS trusts wanting to introduce a introduce to wanting trusts NHS from interest barrier the main However, programme. similar in involved be the cost to appeared uptake to people with severe mental illness was also also was illness mental severe with people the reported that was It a concern. as expressed of deal a great garnered had study SCIMITAR+ by fund should who around and disagreements for cessation smoking for pharmacotherapy campaigns and awareness”. awareness”. and campaigns services smoking stop of The discontinuation “Services constantly going out to tender every every tender to out going constantly “Services constant issues, staffing causing years, three of national lack and to pathways changes in terms of funding and commissioning, as also also as and commissioning, funding of in terms staff: frontline of the efforts impeding three challenges to providing effective smoking smoking effective providing to challenges three respondents Several services. cessation identified the continually A quarter of all survey respondents felt that that felt respondents survey all A quarter of inefficient Resources and pathways Resources severe mental illness. The emergent themes themes The emergent illness. mental severe policy, the smoke-free training, resources, were vaping. and works, what about uncertainty professionals. More generally, the stakeholder the stakeholder generally, More professionals. further the extant to support provided interviews with people for cessation on smoking literature surveys including staff from VCSE organisations, organisations, VCSE from staff including surveys consultants, health public nurses, GPs, health and mental commissioners, academics, This section summarises the key themes from the from themes the key summarises section This A range survey data. and interviews stakeholder and the interviews to contributed stakeholders of 9.

for and evidence-based policy the smoke-free how environments Smoke-free

additional to is being rolled out in Greater Manchester as as Manchester in Greater out rolled being is programme treatment a comprehensive part of estate). the NHS across offered of an example for access as well away move and addiction tobacco ‘medicalise’ to chosen as completely become to are practice grounds discuss to and confidence the competence have to workforce foster to helping support change been specifically was and hospital day-to-day teams’ smoke. second-hand from Overall 1 in 5 Smokers abstinent at 3 months post discharge post 3 months at abstinent Smokers 1 in 5 Overall quit £183 per Cost secondary care and design individualised treatment plans including beyond discharge beyond including plans treatment individualised and design care secondary upon discharge care primary to plan treatment of handover and robust Standardised all into addiction tobacco of the treatment embed to care secondary within change Culture medical programme this of the delivery support to IT systems initiate the treatment for tobacco addiction with smokers (mandatory training) (mandatory smokers with addiction tobacco for the treatment initiate secondary to admitted smokers for pathway and treatment assessment A standardised Wythenshawe at and implemented been delivered now has which care, to admitted smokers see all to team Nurse Specialist resourced An appropriately Hospitals and public patients, and protecting smoking stop to in their quest smokers supporting all, staff the medical Training All smokers are offered specialist support through motivational interviewing interviewing motivational through support specialist offered are smokers All and behavioural addiction. tobacco for treatments pharmacotherapy from after discharge team a specialist with further appointments offered are smokers All their support. continue to hospital All patients who are admitted to hospital are asked whether they smoke and their smoke whether they asked are hospital to admitted who are patients All (EPR). records patients electronic in the hospitals’ recorded is response of the moment at (NRT) Therapy Replacement Nicotine immediate offered are smokers All admission. that during nicotine for cravings the help alleviate to admission Recent outcomes Recent • • • • • • • • the following: requires the hospital of areas all across effectively CURE of Implementation • • • • • has ‘CURE’ The term must addiction tobacco Treating treatment. disease to choice a lifestyle of the stigma from the hospital. of in every part clinicians all of activity core the of part become the following: and deliver implement to aims CURE About the CURE Project the CURE About tobacco for programme treatment care secondary a comprehensive is project The CURE secondary to admitted smokers active identifying all systematically is heart its At addiction. as well as and other medications, therapy replacement nicotine offering and immediately care discharge. and after the admission of the duration support, for specialist Box 2: The CURE Project - Curing tobacco addiction in Greater Manchester in Greater addiction tobacco - Curing Project The CURE 2: Box a gradual shift in cultural attitudes around around attitudes cultural in shift a gradual 2 (see Box services health in mental smoking a good example of not smoking in restricted in restricted smoking not of example a good that sense a general was there Second, areas. policy the smoke-free

Centre for Mental Health REPORT A time to quit 20 Centre for Mental Health REPORT A time to quit 21

to to

about apply e-cigarette illness; voluntary that about than inpatient from For e-cigarettes. conclusions mental severe of of charging (e.g., smoking reduction a harm considerations as of on the use support to therapy. a single with connected who are needs Care schizophrenia. with special been independently have trials, as NRT e-cigarettes insufficient of about stopping smoking and signposting and signposting smoking stopping about the check as especially other services, to One status. smoking of an assessment includes an incentive operating about spoke stakeholder significantly which users, service for scheme uptake. increased E-cigarettes was there stakeholders, several For and policy, guidance that acknowledgement somewhat was and national, both local contradictory the use endorsed have PHE while instance, of allow do not trusts aid, some NHS cessation grounds. hospital within be used them to and safety Health by raised also were concerns products) stakeholders. is a natural setting for starting a conversation a conversation starting for setting a natural is is never-smokers among smoking identify to findings together run often review type or severity to according difficult Year clinical to opposed interventions Five participants from come have participants from come have it making of uptake preventing their findings in this considered in the NHS settings the findings the findings stratify have and few data follow-up 12 months) than (more long-term include of of about known is helping smokers to quit and not to relapse. to and not quit to smokers helping trials been no placebo-controlled have There on behavioural The literature successful. be most will that programmes of the characteristics cessation and severe mental illness. mental severe and cessation experimental. than rather descriptive are studies the of A majority interventions, as real-world Few evaluated. Less studies Few with people all for suitable equally are interventions whether all unclear is it a result, as illness. mental severe or have homeless who are and people people, young as such populations of The needs on smoking literature in the represented well not are disorders, misuse substance studies Few prevention. relapse explored The meta-analyses and outpatient each. be taken when generalising to other mental illnesses. other mental to generalising when be taken A majority and motivated the research the time of at health mental stable with organisations, sector quit. to A majority • • • • • • • • • • • Box 3: Limitations of the presented evidence evidence the presented of 3: Limitations Box health checks for people with severe mental mental severe with people for checks health check health The physical 30%. around is illness the 60% target Despite physical for average the national View, Forward of failure attached). failure of checks health Physical SCIMITAR study (i.e. using smaller, more more smaller, using (i.e. study SCIMITAR a risk of less with goals intermediate achievable fear of failure was discussed by a number of of a number by discussed was failure of fear the rationale part of and formed stakeholders, in the quit’ approach to down the ‘cut for that is likely to make them feel worse (to be (to worse them feel make to likely is that when another worry add to or fail’) up to ‘set The on recovering. focused entirely are they Interviewees told us that when people feel like like feel when people that us told Interviewees don’t they precarious, is health their mental a task undertaking of the risk take to want Fear of failure of Fear in their Another There is is There someone has mental illness are more likely to have have to likely more are illness mental There networks. in their social smokers and friends their family evidence also is see to likely more are and their clinicians severe with people the norm for as smoking to part in owing (possibly illness mental the relationship about misconceptions These health). and mental smoking between affect negatively may and norms networks that the confidence the affect also may quit; they to ability own mental severe with smokers that likelihood in the general those to compared illness, with support any be offered will population, someone who genuinely by attempt a quit quit. to in their ability believes misconception that may affect quit attempts attempts quit affect may that misconception mental manage to helps smoking that is refuted has Evidence symptoms. health among persists the belief however, this; illness, mental severe with people many clinicians. and their and friends their family belief this sustaining the factors One of with people symptoms: be withdrawal may more experience illness mental severe than symptoms withdrawal nicotine severe symptoms and these population the general mental worsening to misattributed be may psychiatric on some People health. of doses need lower also may medications smoking. quit when they drugs these and norms: networks Social severe with people that some evidence Beliefs about the relationship between between the relationship about Beliefs health: and mental smoking 4. 3.

to Heavy smokers with and with smokers Heavy in their ability confidence less have A common misconception is that that is misconception A common in their ability confidence lower have and one reason for this appears to be that be that to appears this for and one reason they smoking. stop mental health service staff about people’s people’s about staff service health mental quit. to abilities intensity: Smoking lower have illness mental severe without quit, to attempt when they rates success is evidence that people with severe mental mental severe with people that evidence is illness intensity smoking to owing quit, possibly to of the effects about and misconceptions this Some of health. on mental smoking of expectations low to be related also may Motivation and confidence in ability to in ability and confidence Motivation quit: are illness mental severe with people the evidence quit, but to motivated less there However, otherwise. says consistently 10. Conclusion 2. 1. The reasons for higher smoking rates and lower and lower rates higher smoking for The reasons understood. well and not complex are rates quit the from emerge repeatedly that The themes are: our research and from literature further the gap with the general population. population. the general with further the gap the widening to contributing is in turn This the two of expectancies life the between gap been has that – an inequality populations and in unacceptable as recognised widely redress. need of urgent likely to smoke and to smoke more heavily heavily more smoke and to smoke to likely the Although population. the general than in both falling is smoking of prevalence among slowly more fallen has it populations, increasing illness, mental severe with people People with severe mental illness are more more are illness mental severe with People

Centre for Mental Health REPORT A time to quit 22 Centre for Mental Health REPORT A time to quit 23 health and practice and needs in mental best between gaps the specific to Maintenance treatment to reduce the risk of of the risk reduce to treatment Maintenance relapse. Interventions delivered by staff who have who have staff by delivered Interventions mental with people in helping been trained smoking stop to conditions health abrupt of instead attempt quit A phased quit’) to down (‘cut cessation NRT of levels average Higher than to cessation smoking about Education family, by held misconceptions counter especially professionals, and health friends, health and mental smoking around policies Smoke-free support that in ways (implemented services in adjustments including quit, to individuals necessary) where medication psychiatric and family the individual’s of Involvement attempt the quit support to friends • led have historically, that, the myths of Many the disproportionately about acceptance to with in people smoking of high prevalence been dispelled. have illness mental severe with people that demonstrated has Research stop to motivated are illness mental severe the for work that interventions that smoking, and effective, both safe are population general population, this for when tailored especially to lead not does smoking stopping and that However, health. in mental a deterioration even widespread, remain misconceptions smoking and stop staff health mental among and in reported in the literature practitioners report, and there this for collected the data significant are practice. typical adaptations people for cessation smoking of circumstances include: to appear illness mental severe with • • • • • • Key elements of effective practice, and practice, effective of elements Key have , 2016). Another factor that that Another factor Quit rates achieved achieved rates Quit et al. et medication, stop-smoking effective between mental and physical health care. As As care. health and physical mental between short of often falls practice typical a result, practice. best mental illness; compliance with guidelines guidelines with compliance illness; mental integration of a lack is there high; and not is organised. Staff often lack the knowledge the knowledge often lack Staff organised. support effectively needed to and skills severe with in people cessation smoking rate of smoking cessation in the real world, world, in the real cessation smoking of rate in the way is trials, clinical to compared as and implemented are interventions which The implementation of interventions and interventions of The implementation services: of organisation success the lower to contribute to appears attempts for someone to give up smoking up smoking give someone to for attempts (Chaiton completely it is also important to note that in the that note to important also is it quit a number of takes it population general rates of compliance with the treatment the treatment with compliance of rates treatment after relapse of and higher rates But population. the general to compared mental illness are typically much lower than than lower much typically are illness mental factors Two trials. in clinical achieved those lower are this to contribute to appear that Compliance and relapse: and relapse: Compliance severe with people by world in the real Appendix 1 for a more comprehensive list of of list comprehensive a more 1 for Appendix of a range from adapted recommendations reports). but the characteristics of the most effective effective the most of the characteristics but (See unclear are support behavioural of form right support is pharmacotherapy combined combined pharmacotherapy is support right to appears Varenicline support. behavioural with be the most demonstrated that people with severe mental mental severe with people that demonstrated when the smoking stop successfully can illness The way. in the right provided is support right Few of these factors, however, are set in set are however, factors, these of Few interventions Evidence-based stone. 6. 5.

(4), (1), 48 13 , and analysis (2), 115-122. (6), 471-481. 5 , (5), 475-481. 31 , smoking on quitting 28 , [Accessed 23 March 23 March [Accessed BMC Medicine Addiction Research & Addiction Research https://bmjopen.bmj.com/

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The

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Bans in Psychiatric Units: An Issue of Medical Medical of Issue Units: An in Psychiatric Bans Ethics. Systematic Reviews Systematic Smoking R. (2019) E.R. & Richmond, Woodward, A., Gu, text cessation. smoking for (1), 1-19. C., Rodgers, H., Bullen, R., McRobbie, Whittaker, centered design of learn to quit, a smoking quit, a smoking to learn of design centered with people for smartphone app cessation illness. mental serious Vilardaga, R., Rizo, J., Zeng, E., Kientz, J.A., E., Kientz, Zeng, J., Rizo, R., Vilardaga, K. (2018) User- C. & Hernandez, R., Otis, Ries, , 2016) et al. et approaches. and in-reach to be provided to of smoking. stopping of All staff to be trained in Very Brief Advice. Brief Very in be trained to staff All the about be knowledgeable to staff All benefits medical (nursing, training Undergraduate include to professionals) health and allied in the curriculum. dependence tobacco between secondary mental health services, services, health mental secondary between IAPT services, smoking stop care, primary and pharmacies. clear have to services smoking Stop services health mental local with protocols development including support. of models outreach support to England Education Health and its smoking of in the effects training a mental with those among prevalence of methods as well as condition, health in standard reduction harm and cessation clinical nurses, health mental for training occupational psychiatrists, psychologists, and therapists psychological therapists, professionals. health other allied NHS England to develop an appropriate an appropriate develop to England NHS incentivise and promote to CQUIN national tobacco for treatment recommended NICE a mental with people among dependence implemented was (This condition. health England.) NHS by subsequently ensure to Boards Wellbeing and Health local co-ordinated are there support Post-discharge admission. an inpatient after patients be established. to pathways care Clear ensure to in place be put to Systems be shared can information appropriate • • • • in cessation smoking Embedding services health mental training staff health Mental • • approach an integrated Taking • • • • – to a smoke-free funds. being PH48 and PH45, services and financial – human Summary of recommendations for smoking for smoking of recommendations Summary cessation in people with severe mental illness mental with severe in people cessation of a pre-requisite of implementation appropriate policy. provide a short guidance for inspectors of of inspectors for a short guidance provide health mental and community inpatient needed, including is what of settings treatment, dependence tobacco adequate and pharmacotherapy, to access of mental health services to ensure that that ensure to services health mental of to in relation standards NICE delivery of specifically smoking, is commissioned. to (CQC) Commission Quality The Care Mental Health Trust Boards, Clinical Clinical Boards, Trust Health Mental and commissioners Groups Commissioning Health Research Programme, the Medical the Medical Programme, Research Health Research Policy and DH Council Research tackling into research prioritise Programme) a mental with people among smoking condition. health smoking services). smoking the by be made to Commitments Plan. Control Tobacco Health of Department NIHR, Public as (such funders Research Public Health England to ensure these are are these ensure to England Health Public specific and tied to prioritised in contracts be embedded to targets Local severe with people with working services for secondary care, (primary illness mental stop and specialist IAPT care, social care, resources More available. be made be set to targets national Ambitious the England, and NHS government, by and Care Social and Health of Department • Ensuring best practice is standard standard is practice best Ensuring practice • • • • • • (adapted from ASH, 2016 & 2019, and Association of Medical Royal Colleges Medical Royal Association of & 2019, and from ASH, 2016 (adapted in people cessation smoking Making a priority illness mental severe with Appendix 1:  Appendix

Centre for Mental Health REPORT A time to quit 30 Centre for Mental Health REPORT A time to quit 31 evidence- health. those for line medications about be informed to physical to quitting a smoke- to upon admission NRT of first smokers A plan for quitting, or reducing harm, should should harm, or reducing quitting, for A plan the with up in collaboration be drawn user. service Policies to enable timely access to to access timely enable to Policies care in all pharmacotherapy appropriate settings. to access rapid be given to patients All sufficient facility. inpatient free be should varenicline or NRT Combination seen as or quit. down cut to wishing for support part of be a standard to NRT who smokes. anyone and be easy to pharmacotherapy to Access affordable. available. be made to support Peer Carers, friends and family members to be to members and family friends Carers, about and information advice with provided attempt. quit a support to how in service be involved to Carers evaluation. and design development, the about advice be given to smokers All benefits All smoking. stop to ways based the about informed be should smokers All nicotine. of safety relative alternative develop be helped to to People smoking. to activities • Pharmacotherapy • • • • • support Peer • plan Care Involving service users’ support support users’ service Involving network • • Interventions education and Advice • • • initiatives change Behaviour • evidence-based stop-smoking how follow-up. to side- medication stop-smoking How to provide intensive behavioural behavioural intensive provide to How support. What manage to and how expect to effects them tobacco and minimise assess to How symptoms withdrawal carbon and expired-air dependence monoxide of Knowledge optimise to and skills work medicines adherence How to have conversations with smokers smokers with conversations have to How reduce/ to their motivation increase to smoking stop tobacco of the severity assess to How a priority, minimising the number of people people of the number minimising a priority, lost who are Service users to contribute to service service to contribute to users Service and evaluation. design development, be made to users service with Engagement Mental health settings to appoint service service appoint to settings health Mental champions. smoking’ ‘stop user Stop smoking practitioners should be should practitioners smoking Stop cessation smoking around in issues trained health. and mental All services should routinely ask about about ask routinely should services All information. this and record health mental All services should have a mental health health a mental have should services All champion. Staff who smoke to be given support to to support be given to who smoke Staff stop. A member of staff to be appointed as a stop a stop as be appointed to staff A member of champion. smoking competency for mental health staff. health mental for competency include: to and training Education about Knowledge core be a to treatments cessation smoking • • • • • • • • • Involving service users service Involving • • • Embedding mental health in smoking in smoking health mental Embedding services cessation • • Mental health staff involvement staff health Mental • •

policy into translated are into existing systems and collated by by and collated systems existing into a locality. across commissioners wherever be used to researchers Peer possible. to out be carried to review A systematic evidence. in the identify gaps in evaluating be made to Investment interventions. and innovative existing providers, health organisations, Research and bodies professional England, PHE, NHS new that ensure to organisations policy findings research and practice. of smoking status at all assessments, assessments, all at status smoking of smoking to referral automatic including an assessment and services cessation CO including dependence of severity of Monitoring. tobacco of and severity use Tobacco and assessed be routinely to dependence inpatient, receiving patients all for recorded a mental for care or primary community illness. and Survey Morbidity Psychiatric The Adult Disabilities and Learning Health the Mental on smoking data detailed report to Set Data illness. mental severe with in people health and mental status Smoking care in primary be recorded to conditions with and shared consolidated data with local including partners strategic local and CCG. authority be built to status smoking of Recording should mandate that there is recording recording is there that mandate should • of investigation in need Areas • evaluations Practice • practice into research Translating • • • • • quit. to relapse difficult of risk at those for plan reduction harm it finding or are to People in prison People pregnant who are Women and alcohol drugs who misuse People Smokers who do not want to quit quit to want who do not Smokers entirely Ex-smokers facilities in inpatient/residential People inpatient/residential leaving People the community to and returning facilities people Young be smoke-free. to people vulnerable Assessment, Local Authorities to estimate estimate to Authorities Local Assessment, health mental with smokers the number of the and the proportion using conditions services. available services health mental of Commissioners As part of their Joint Strategic Needs Needs Strategic their Joint part of As Provision to be made for: be made to Provision All environments in which care is delivered delivered is care in which environments All to with a mental health condition who do not who do not condition health a mental with want people with out be carried to research More SMI. with Harm reduction to be made available. be made to Harm reduction A specific • • • • • • • • • Research and data and Research collection Data • Populations that may have special special have may that Populations requirements • Smoke-free environments Smoke-free • E-cigarettes • Harm reduction • •

Centre for Mental Health REPORT A time to quit 32 Centre for Mental Health REPORT A time to quit 33 A time to quit Published March 2020 Photograph: istockphoto.com

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