A time to quit Experiences of smoking cessation support among people with severe mental illness Curtis Sinclair Centre for Mental Health Contents Acknowledgements 3 Executive summary 4 1 Introduction 5 2 Why are people with severe mental illness less likely to quit? 7 REPORT 3 What commitments have been made and what targets have been set? 9 4 What works for smoking cessation in people with severe mental illness? 13 A time to quit 5 How should services be organised and delivered? 19 6 How does this project fit into the picture? 23 7 The experiences of people with severe mental illness of smoking cessation 29 8 What do people with severe mental illness want from smoking 30 cessation services? 9 What support do services currently provide, and what challenges and 19 opportunities do they face? 10 Conclusions 22 References 31 Appendix 30 2 Centre for Mental Health Acknowledgements This project has been commissioned by the VCSE Health and Wellbeing Alliance (HWA), a partnership between the Department of Health, NHS England, and Public Health England, and 20 national voluntary sector organisations and consortia. The Alliance aims to bring the voice of the voluntary sector and people with lived experience into national policy making, to promote equality, and to reduce health inequalities. The Association of Mental Health Providers, Centre for Mental Health, and Rethink Mental Illness, REPORT as members of the Mental Health Consortium, are leading on this project alongside HWA partners Friends, Families and Travellers, LGBT Hero on behalf of The National LGB&T Partnership, and Race Equality Foundation. Together, we have carried out extensive engagement with people with lived A time to quit experience, the VCSE sector, the NHS, local government and academic bodies. This will culminate in the production of a suite of resources. Input for this report was gratefully received from Emma Bailey, Andy Bell, Emma Bray, Jabeer Butt, Paul Cilia La Corte, Rosie Fox, Josie Garrett, Michelle Gavin, Dania Hanif, Gabriella Hasham, Ian Howley, Samir Jeraj, Hannah Lewis, Andrew Mills, Kathy Roberts and Jo Wilton. We also thank the individuals who participated in interviews and focus groups, and who otherwise contributed to this project. Their insights, which we have used in this report, have given us important insights into the issues they face as well as potential solutions. 3 Centre for Mental Health Executive summary The aim of this report is to introduce There is evidence from research that what practitioners, commissioners and policymakers helps people with severe mental illness to to some of the key themes and evidence quit smoking is broadly similar to that for the around the needs of people with severe mental general population, including behavioural illness and what is known about successful techniques, medication and help from peers, approaches to smoking cessation. families and friends. REPORT Based on the first-hand experiences of service People with severe mental illness would like users and published research, it brings into more help to quit smoking, including help focus some of the challenges and complexities to find the right time for them, holistic and A time to quit of this subject, and it provides a starting point personalised support, access to the full range for those looking to provide more effective of effective therapies, support from social smoking cessation support to people with networks and incentives to reduce or quit severe mental illness. The primary focus is smoking. on smoking cessation in the community, but To help them to do this, it is important that inpatient and residential settings are also health professionals are trained in how to discussed. support people with severe mental illness in People with severe mental illness have very smoking cessation techniques, for psychiatric much higher rates of smoking than the general medication to be adjusted when people stop population, and those who do smoke are more smoking, and for ongoing help to be offered to likely to be heavy smokers. An estimated 50% sustain quit attempts. of deaths of people with severe mental illness are from smoking-related illnesses. Yet rates of wanting to quit are about the same as for the general population. There are numerous barriers to people with severe mental illness quitting smoking. These include myths about the risks of giving up smoking to mental health and perceptions that it will be more difficult for someone with a mental illness. This sometimes stops health professionals from offering help to people who might want to quit smoking. 4 Centre for Mental Health 1. Introduction People with severe mental illness have in life expectancy between current smokers significantly poorer physical health than the with severe mental illness and never-smokers general population. This includes a higher risk without severe mental illness (Tidey & Miller, of cardiovascular disease, various cancers, 2015; Tam, Warner & Meza, 2016). There is metabolic conditions and, ultimately, reduced widespread recognition that this inequality life expectancy (Chang et al., 2011; Chesney, is unacceptable and must be addressed (RCP, Goodwin & Fazel, 2014). Smoking contributes 2013; Passey & Bonevski, 2014; ASH, 2016; REPORT disproportionately to these health inequalities. Firth et al., 2019). People with severe mental illness are more likely to smoke than the general population Definition of terms A time to quit (RCP, 2013; Szatkowski & McNeill, 2015) and Severe mental illness to smoke more heavily (Szatkowski & McNeill, 2015); and some people with severe mental Severe mental illness refers to psychological illness may be at increased risk of smoking- problems that are often severe enough to related illness compared to the general seriously limit a person’s ability to work and population, even after adjusting for clinical and do day-to-day activities. It includes, but is demographic factors (Krieger et al., 2019). not limited to, severe and enduring psychotic disorders, personality disorders and mood However, people with severe mental illness are disorders. often found to be as motivated as the general population to stop smoking (Szatkowski & Diagnosable eating disorders are also widely McNeill, 2015) but, historically, have not recognised as severe mental illnesses; however, received the same benefits from smoking owing to the special clinical considerations of cessation programmes (Cook et al., 2014). As weight management in these cases, they will not a result, the prevalence of smoking in people be included in this report. with severe mental illness is falling at a slower rate than in the general population, leading Smoking cessation to increasingly unequal health outcomes (Dickerson et al., 2017; NHS Digital, 2018). Of most interest to this literature review are interventions that result in an individual It has been estimated that 50% of deaths of stopping smoking completely and permanently. people with severe mental illness are due to However, harm reduction options, which lead tobacco-related illnesses and that smoking to lower smoking rates, will also be considered, may account for two-thirds of the difference especially as a means to an end of abstinence. 5 Centre for Mental Health 2. Why are people with severe mental illness less likely to quit? This section will focus on factors relating to the unsuccessful quit attempt (McDermott et al., individual. External factors, such as the design 2013). Therefore, the relationship between and delivery of smoking cessation interventions perceived failure, relapse, anxiety, motivation, and the attitudes of clinicians, will be discussed and a perception of quitting as difficult is in a later section of this report. complex. REPORT Level of addiction Impact of smoking on mental health There is evidence that some smokers with It is often believed that people with severe A time to quit severe mental illness may be more dependent mental illness smoke because it helps them on nicotine compared to the general population. to manage their symptoms. The evidence The evidence of this association comes mainly supporting this hypothesis is weak (Smith, from people with schizophrenia diagnoses Homish, Giovino & Kozlowski, 2014; Sharma, (Freeman et al., 2014; Scott et al., 2018). A Gartner & Hall, 2016; Prochaska, Das & Young- UK population-based study found that quit Wolff, 2017). It is possible that this belief, attempts in people with common mental health irrespective of the evidence, could affect the conditions were less likely to be successful likelihood of an individual making a successful than those among the general population, but quit attempt via its effect on their confidence this association disappeared when adjusted for in their ability to stop smoking. Educational heavy smoking (Richardson, McNeill & Brose, approaches that dispel misconceptions 2019). This suggests that the more heavily a combined with nicotine replacement therapy person smokes, the lower the likelihood that (NRT) to reduce the effects of nicotine a quit attempt will be successful. However, withdrawal may be helpful. Notably, smoking in understanding this relationship, it may cessation has been shown to be associated be important to note that a retrospective with reduced depression, anxiety and stress, analysis of 1,604 smokers from the general and improved positive mood and quality of life population found that smoking intensity did compared with continuing to smoke (e.g., Taylor not independently predict the likelihood of et al., 2014). However,