1. Smoking and mental health

2. Smoking Kills’ (DoH 1998) Sought to tackle the issue of smoking Aimed help at the least well off Start with those who smoke the most

3. Saving Lives: Our Healthier Nation (DoH 1999) Increased mortality due to  respiratory illness  cancer  coronary heart disease Intrinsic link with smoking activity

4. National Service Framework for Mental Health (DoH, 1999) Specialist services when mental health problems co-exist with  Substance misuse  Co-morbidity  Dual diagnosis

5. World Health Organization (2000) Smoking harms physical health, but it has links to mental health as well Tobacco dependence is a psychiatric disorder (DSMIV)  In fact, it is the most prevalent, most deadly, and most treatable of all psychiatric disorders It has a high co-morbidity with other mental health problems

6. Dr Ann McNeill’s review of the literature (2001) Over 70% of this group smoke People who live in institutions are particularly vulnerable About half these smokers want to quit.

8. Smokefree policies in Mental Health Trusts The smokefree policy can be seen as supportive of patients with mental health problems in that both their physical and mental health are being addressed by health professionals Many mental health patients who smoke say they have never received advice to stop from a health professional

10. Dependence and cessation Why am I so sad?

11. The more miserable is your life the more likely you will be to smoke the more nicotine per cigarette you will be getting the more difficult it will be to quit  Dependence  Salience of any reward  Difficulty in achieving hard goals

12. Dependence and cessation Psychiatric patients tend to smoke more heavily than general population Cessation rates in this group are lower than in general population

13. Smoking rates by mental health problem

14. Smoking rates for people with psychotic illnesses living in institutions

15. Psychiatric morbidity & smoking, 2000

16. Smoking and psychiatric morbidity: 2000 data Never smokers Ex- smokers Current smokers Heavy smokers 0 10 20 30 40 50 60 70 80 % prevalence General population Adults with a psychotic disorder ONS, 2002; GHS, 2002

17. High smoking rates in psychiatric patients could be: A non-specific effect of socio-economic deprivation and stress For dependent smokers, quitting requires coping resources and perseverance Achieving hard goals is generally more difficult if you suffer from a psychiatric disorder (or if your life is, for whatever reason, generally miserable)

19. Other explanations: The effects of stress Smokers experience  higher stress levels  lower quality of life  much higher incidence of mental disorders At the same time, they cite stress relief as the major benefit of smoking

20. Other explanations: Effect of psychiatric medication Most psychiatric drugs have unpleasant side effects Heavy smoking can counteracts drug side- effects Stopping smoking can aggravate them, unless the dose is lowered

21. Other explanations: Self-medication Tobacco withdrawal may temporarily increase depression Stopping smoking does not aggravate schizophrenia or increase depression episodes Does smoking correct neurotransmitter defects (MAO, dopamine, serotonin)?

22. Dopamine and Monoamine Oxidase Using brain imaging technology smoking was seen to decrease monoamine oxidase B an enzyme that breaks down dopamine

23. Dopamine and Monoamine Oxidase This results in increased dopamine levels in the brains of smokers Further re-enforcing the brains reward pathway

24. Do mental health problems cause smoking? Depression and generalised anxiety predict onset of smoking in adolescents Relationship between nicotine and neurotransmitters Nicotine alleviates some positive and negative symptoms eg P50 gating effect

25. Link with negative symptoms Paired stimuli 0.5 sec apart Schizophrenics do not inhibit response to 2nd stimulus Nicotine and cigarettes can transiently reverse this deficit

26. Stress - Two conflicting explanations Smoking helps coping, poor mental health in smokers is due to individuals prone to stress finding smoking a useful self-medication Smoking generates stress, e.g. via central effects or via withdrawal discomfort during inter- cigarette intervals. The perceived calming effect is a misinterpreted withdrawal relief

27. Key question What happens to anxiety and stress levels when people stop smoking? Increase: Smoking was self-medication Decrease: Smoking made matters worse

28. Initial studies Several studies reported that smoking precedes mental health problems, although the link can go the other way as well Cohen and Lichtenstein 1990: After quitting, stress goes down Carey et al. 1993: Self-quitters less stressed than continuing smokers. 15% PP quit

29. Later studies In a study with 81% abstinence at 1 week, anxiety levels decreased below baseline (West and Hajek, 1997) Patients on antidepressant medication, in those who quit for 4 weeks, depression decreased (McRobbie, Mihaescu and Hajek 2002)

30. Latest evidence Large cohort of cardiac in-patients At baseline, future quitters and non-quitters reported the same stress levels and stress relief from smoking In quitters stress went down significantly (Hajek and Taylor 2002)

31. Can smoking harm mental health? Smoking seems to increase negative emotional states overall Stopping smoking improves mood A hypothesis needs to be taken seriously that in vulnerable individuals at least, smoking may contribute to psychiatric morbidity

32. Conclusions Individuals who are subject to higher levels of distress, whether because of personal characteristics or situational factors, are more likely to seek out and have greater difficulty terminating, behaviours that provide rapid and reliable rewards even though the long- term effects of these behaviours may be deleterious Robert West and Martin Jarvis

33. Conclusions If this interpretation is correct then interventions that reduced distress associated with mental disorder would be expected to increase the likelihood of success at stopping smoking It is may also be important in health promotion messages to alert smokers to the fact that smoking damages mental as well as physical health Robert West and Martin Jarvis