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8/3/2019 Taking a Deep Breath, Smoking Cessation and Diagnosed Mental
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Taking a deep breath
Smoking cessation and
diagnosed mental health
problems
Dr Kam DhillonHead of Research
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Smoking and Mental Health
In the general population adult tobacco use is in decline,
more so since the ban.
However, cessation rates are 2 to 3 times lower for people
with mental health problems.
No appreciable reduction in tobacco consumption among
people with mental health problems.
People with diagnosed mental health problems have highrates of smoking.
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Smoking and the brain
Within 10 seconds of inhaling tobacco smoke, nicotinereaches the brain and acts on specific neurons and
releasing noradrenalin and dopamine that act as
stimulants. This can lead to improved mood, concentration,
decreased anxiety and stress.This is more illusionary than real. Withdrawal symptoms
kick in and are relieved by more smoking. Over time
tolerance goes up and more nicotine is needed for normal
state.Cravings feel stressful and smoking feels relaxing - self
medication is established.
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Stress and anxiety
420,000 people reported stress at a level that was making
them ill.
47% of people with Generalised Anxiety Disorder smoke.
Self-medication hypothesis is a strong explanation, but
sources of anxiety are also beyond the nicotine withdrawal
symptoms.
People with eating disorders say that the strongestmotivation for smoking was coping with stress and anxiety.
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DepressionMany epidemiological studies link clinical depression with
smoking.
Long term nicotine exposure may have a causal influence
on depression Vs shared environmental or genetic factors
predispose to both smoking and depression.
Previous smoking history increases the risk of depressive
symptoms and depression.
For women, smoking increases the risk of major
depression by 93% (Pasco et al, BJP, 2008).56% of people with depression diagnoses smoke and
smoke earlier in the day, harder to quit and more likely to
relapse.
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SchizophreniaPeople with schizophrenia diagnoses are more likely to
smoke (88%) and smoke more heavily, particularly ifstaying in psychiatric settings.
They smoke early on in the day and find it harder to stop.
The are more likely to have smoking related illness
accounting for other relevant risk factors.
Reasons for high nicotine consumption may include
start younger, co-morbidity with other drug use, culture of
inpatient wards and boredom.Nicotine consumption reduces the negative symptoms of
schizophrenia, due to increased dopamine further self-
medication. Dopamine pathways not absolutely clear.
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Alzheimers disease
AD is the most common form of dementia.
400,000 affected in UK.
Neuro-protective effect? nicotine appears to alleviate theneurological impairment associated with the disease, may
delay the onset.
Other research indicates that smoking increased the risk
of AD.An under-researched area.
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Smoking cessation and mentalhealthAround 50% of smokers with mental health problems
would like to quit.
However, cessation rates remain 2 to 3 times lower for
people with mental health problems.
People with mental health problems get less support thanother quitters.
They tend to be living in environments where smoking is a
norm.
They refuse voluntary psychiatric admission if forced to
stop smoking.
They leave psychiatric settings earlier if stopped from
smoking.
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Psychological approaches to
cessationPsychological approaches widely available now.
Counselling is effective, both individual and group, with
different intensity and duration (1,3, 6 session).
CBT shown to be effective for smokers with depression
and schizophrenia.
The need to acknowledge and be mindful of mental healthdiagnoses in the therapeutic process is important
practitioners need to work with their professional
accountability and ethics in mind.
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Pharmacological approaches
Nicotine Replacement Therapy, anti-depressants and
other medication has proved to be successful for
cessation, but more applied research needed.
NRT has been effective in psychiatric in-patient settings
but higher strength patches may be needed.
Smokers with depression have had positive outcomes
with Buproprion (Zyban), but needed prescriptions beyond
the usual 8 weeks.
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Combined approaches
Combined psycho-pharmo interventions have been shown
to be the most effective (i.e. NRT, CBT and MI).
Studies have shown positive results for smokers with
depression, where 10 weeks of CBT addressed the
depression too.
Sustained release Zyban, combined with CBT had
significant positive cessation results for smokers with
schizophrenia.
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Smoking ban in England Tobacco kills around 87,000 people annually in England
alone (Smoke free England One year on, DH, July2008).
Compliance to the legislation has been high.
Local NHS Stop Smoking services have had a 20%
increase in demand. We do not know how people with mental health problems
have fared since the smoking ban.
People are smoking outside psychiatric settings, like
others in other clinical settings.
GPs now minded to record smoking prevalence and
PCTs asked to increase prescribing of stop smoking
products, encourage more smoke-free work places and
target high risk groups (DH, 23rd September 2008).
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Strategies for working with smokers
with mental health problemsRecognise that the traditional approaches do not work as
there appears a different and stronger relationship with
nicotine.
Explore with people this relationship with nicotine
employ CBT oriented strategies with greater flexibility
combination approaches successful keep mental health
in the foreground, accounting for different vulnerabilities.
Confidence building and stress management activities are
helpful.
Be aware of your capabilities and scope of work and refer
to and work with other professionals.
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http://www.mentalhealth.org.uk