Australians with mental health conditions are more than twice as likely to be smokers as the general population. About 22% of people with a mental health condition smoke daily compared to a national rate under 13%. And the more severe your illness, the more likely you are to smoke. For example, about 60-70% of people with psychotic conditions such as schizophrenia smoke.
We don’t have clear evidence for why this is the case, but there are several theories. These include that people with mental health conditions may smoke to self-medicate or to cope with social exclusion. People with mental health conditions are also more likely to have lower levels of education and higher levels of unemployment, which are accepted risk factors for smoking.
Despite huge gains in getting Australians to quit since the turn of the century (22% of Australians smoked in 2001), people with a mental illness appear to have been left behind. They are a big group to overlook. More than 4 million Australians are living with mental health conditions, including anxiety, depression and psychosis.
Why it matters
People with mental health conditions are at a much higher risk of chronic physical conditions, and more likely to die prematurely as a result. People with severe mental health conditions are at risk of dying from heart conditions and cancer 10 to 15 years earlier than the rest of the population. Smoking is undoubtedly contributing, being a key risk factor for heart disease, stroke, cancer and a range of other conditions.
Some health professionals may have put smoking in the “too hard basket” for certain patients with complex or urgent health needs. But there is good evidence people with mental illnesses want to quit smoking, that they are capable of quitting, and that smoking causes stress rather than relieving it. Research also shows quitting does not exacerbate poor mental health, but rather improves it.
Help people quit in hospital
Imagine a health professional telling you to keep smoking to help manage your disease. Until as recently as late last century, this was the case for some people being cared for in psychiatric facilities. There are even reports of patients entering hospital care as non-smokers only to be discharged later with the potentially lethal habit. While a culture of smoking is no longer encouraged in mental health facilities and hospitals, in some it is not actively discouraged.
People with severe mental health problems may spend time in an Australian hospital which is meant to be smoke-free. But are they really free of tobacco smoke? Despite nearly every Australian hospital having a smoke-free policy, we know implementation and enforcement have been patchy.
We need to do more to enforce smoke-free policies and use these as an opportunity to help patients quit. Research shows total smoking bans in mental health facilities help people quit when they are supported with appropriate nicotine-dependence treatment.
While a smoke-free environment will hopefully remove temptation, hospital stays also give health professionals an opportunity to discuss smoking with patients. This can include whether the patient wants to quit, how they want to do it, and what sort of therapies are available to help them with the process.
Post-discharge support is also crucial. All patients should be referred to services such as Quitline when they leave hospital.
Promote quitting in all mental health services
We know 4 million people with mental health conditions are much more likely to smoke, but only a small proportion of them need psychiatric hospital care. Other mental health services, including general practice clinics, should promote the benefits of quitting if they are not doing so already.
People with mental health conditions want to improve their physical health and address risk factors causing ill health. However, mental health providers often don’t see this as their job while they concentrate on improving a patient’s mental health.
Given we know quitting smoking will improve patients’ mental health, it’s important all services embed brief models of preventive care into their standard practice. Proven, effective strategies assess the patient’s nicotine dependence, offer personalised advice and assistance, and provide referral to behaviour change supports. These strategies are simple and don’t take much time.
A trial at a mental health service in New South Wales has offered mental health clients the opportunity to discuss their lifestyle with a nurse “coach” who gave advice and support for issues such as smoking, diet and physical activity. Evaluations of this model undertaken so far demonstrate it is popular with patients, inexpensive and can be effective.
We need to do better
People living with mental health issues are interested in improving their own physical health, but quitting smoking isn’t easy. Just like everyone else, people with mental health conditions need help and support.
Despite this need, there is a reported unwillingness or ambivalence among some mental health practitioners to address risk factors such as smoking among their patients, and there is no systematic approach in services to provide support to quit smoking.
Health practitioners and services have a critical role to improve health overall. Helping people to stop smoking is still the best thing we can do to support a longer, healthier life.
The fifth National Mental Health Plan, as well as state and territory plans, call for more action to prevent early death and chronic disease among people with mental health conditions. Combating smoking is essential to achieving this goal, and should be incorporated into the provision of care for this population at all levels.