Introduction
Tobacco use is a problem of current interest as it directly affects various significant indexes, such as morbidity and mortality rates. Although smoking is dangerous for anyone to a certain extent, it is an even more severe problem for individuals with mental health disorders. They can be more susceptible to tobacco, and it is often more challenging for them to stop smoking. Different studies address that problem and either nominate possible solutions or share information concerning the attempted ones. This paper’s purpose is some of those studies, including several scholarly articles. This work is designed to summarize the existing evidence of the problem, its strengths and weaknesses, gaps and limitations, and consider how that evidence may help further discussion.
Nicotine Dependence and Consequences of Tobacco Use
First of all, it is essential to address tobacco cessation itself because it is profound not only for mentally ill people, but many smokers cannot quit and suffer various health issues because of nicotine. For instance, recent research by the World Health Organization (WHO, 2017) explains the mutual relationship between tobacco use and oral diseases, accentuating that oral health programs should be a priority for tobacco interventions. The main reason is that oral health professionals contact young smokers most often and have enough time with their patients to advise smokers to quit (WHO, 2017). However, WHO (2017) also states that oral health professionals do not usually discuss nicotine habits with patients, which causes a “lack of integration of tobacco cessation interventions with oral health programs.” Therefore, because of a lack of skills and knowledge about tobacco cessation, it is challenging to provide tobacco cessation interventions.
Another vital health care service is oncology care, which has a strong correlation with tobacco use. Kaiser et al. (2018) report that tobacco use is a significant risk factor and the leading cause of several types of cancer. The authors state that tobacco cessation has effective behavioral and pharmacological treatments for tobacco cessation; still, for some reasons, they are not widely used in the setting of oncology treatment (Kaiser et al., 2018). Thereby, considering how smoking can affect cancer prognosis and considering the cost of oncology treatment, treating tobacco dependence should be a severe part of cancer treatment.
Other studies show that smoking does not only cause various health issues, but it directly affects some parts of people’s bodies, as well. For instance, the most recent studies by Logtenberg et al. (2021) provide strong evidence that smoking many cigarettes on a daily basis decreases hippocampal volume. According to Logtenberg et al. (2021), “structural variation in subcortical brain regions has been linked to substance use, including the most commonly used substances nicotine and alcohol.” This study is additional proof that smoking, along with alcohol, can be a cause of reducing subcortical brain volume (Logtenberg et al., 2021). Considering the topic under discussion, the research mentioned above is crucial because anything causing brain problems may also be a reason for a mental health illness.
The next thing that this work should consider is the methods currently used in tobacco cessation attempts and the actual status of their effectiveness. For example, Momin et al. (2017) have observed the use of tobacco cessation interventions based on population, namely state quitlines and interventions based on the Web, promoted by the National Comprehensive Cancer Control Program (NCCCP) and National Tobacco Control Program (NTCP). The observation followed nearly 8000 smokers, with half of them being quitline users and the other half being Web-intervention users “to ascertain the prevalence of 30-day abstinence rates seven months after registering for smoking cessation services” (Momin et al., 2017). Thus, this work may guide clinicians, containing recommendations and techniques for tobacco cessation intervention and providing an evidence base appropriate for decision making.
Regarding the research described above, a question might appear addressing the level of the health care system that should be a priority for implementing tobacco cessation intervention. Furthermore, smoking may be a cause of many different health issues, as has been described in the previous literature mentioned in this paper. For example, the work of Zijlstra et al. (2021) refers to the primary health care system, monitoring a referral aid developed for expediting the use of smoking cessation interventions and potentially increasing the number of successful quit attempts. The authors state that “the results of this study aim to provide insight into the effectiveness of an intervention which is aimed at promoting the use of more evidence-based smoking strategies,” and they also mention that they will be reporting the status of said effectiveness in later papers (Zijlstra et al., 2021). Although the study seems very promising, there is still not enough information to make definite conclusions, and further exploration is required.
Some more efficient studies provide evident results, as well. For example, Barnes et al. (2021) performed an audit to assess the current smoking status and the effectiveness of offered interventions. According to the results, half of the people involved in the audit were smokers, and most of them had notes regarding their smoking status in their medical records (Barnes et al., 2021). Subsequently, three-quarters of smokers were briefly advised on cessation, and Nicotine Replacement Therapy (NRT) was offered to half of them; still, only a third of smokers involved in the service had a prescription for NRT in their medication chart (Barnes et al., 2021). Another similar audit performed by Mohamed & Bader (2021) in telephone reviews resulted in generally positive feedback, but the study itself does not provide any definite conclusions. Although the outcomes described above may have numerous possible reasons, most of them are certainly lack of knowledge, low confidence in delivering cessation interventions, and conversations that have taken place but have no records.
Current Research Status on Mental Health Disorders
The following essential point in researching the topic under discussion is to consider the existing data regarding the specific health conditions involved. In this case, with mental health disorders being that particular condition, it is necessary to understand this particular group of health issues before addressing tobacco cessation under the circumstances. For instance, Romain et al. (2020) report that people with different mental illnesses have a 2 to 3 times higher mortality rate than the other population, and their life expectancy is reduced by 15 to 25 years. The authors also state that lifestyle features of mentally ill people, including tobacco dependence, make a significant contribution to the mortality rate increase (Romain et al., 2020). Therefore, the broad specificity of mental health problems should be an essential factor when treating such issues as tobacco dependence.
That is why many studies are concerned with connections between patients’ lifestyles and their mental conditions, including the correlation between tobacco dependence and mental health disorders. According to the research of Harris et al. (2019), which involved observation of 421 adults experiencing homelessness, different lifetime diagnoses such as schizophrenia, depression, posttraumatic stress disorder, bipolar disorder, illicit substance, and others, in many cases, were associated with increased tobacco use. At the same time, “a lifetime diagnosis of depression was associated with an increased likelihood of a past 3-month tobacco cessation attempt, while illicit substance use was associated with a lower likelihood of a cessation attempt” (Harris et al., 2019). Thus, mental health disorders affect not just tobacco use but cessation attempt as well.
Certain studies make more confident statements regarding the correlation between tobacco use and mental health. For example, Carpenter et al. (2019) state that adults with various mental health illnesses have a higher smoking rate and are more dependent on nicotine; it is more difficult for them to quit smoking than those who do not suffer from any mental health conditions. The authors have made those conclusions after examining the results of a tailored quit-line program offered by Texas Tobacco Quit Line, which consisted of 12 weeks of combination tobacco replacement (nicotine gum and patches) and coaching calls (Carpenter et al., 2019). Three hundred eleven participants of the program had severe mental illnesses and high rates of co-morbidity, and outcomes of early cessation showed high quit rates for participants (Carpenter et al., 2019). However, a small selection size among low response rates does not allow us to make definitive conclusions, and more studies would be required to examine the efficacy of that program.
The Specificities of Tobacco Use for Mentally Ill People
The studies described above may prove that tobacco use and mental health issues have a mutual interconnection in most cases. Various mental conditions may both increase tobacco use if a mentally ill individual has dependence already and be a reason for that dependence. Although specific experiments have been performed to find a solution to the problem, and they have given encouraging results, there is still a need to explore the field deeper to understand better how to help people with mental illnesses stop smoking.
There are numerous studies addressing tobacco cessation issues for people with mental health conditions, all of them conducted by different specialists and health care practitioners. For instance, Taylor et al. (2020) claim that people with anxiety or depression smoke at twice as high rates as the general population; however, they also should have higher motivation to quit because stopping smoking might improve a person’s mental health in size, potentially equal to taking antidepressants. The authors “draw on evidence-based methods such as cognitive-behavioral therapy (CBT) and outline approaches that healthcare professionals can use to integrate these methods into routine care to help their patients stop smoking” (Taylor et al., 2020). The study does not fully cover the field of mental health issues. However, it still addresses the most common ones, such as depression and anxiety, to use CBT principles to help mentally ill people who are tobacco-dependent understand the relationship between that dependence and mental health.
However, there are much worse mental health conditions called severe mental illnesses (SMI), which are often associated with smoking. Sharma et al. (2018) examined the attitudes and practices toward smoking cessation for people with SMI using an online cross-sectional survey of 267 Australian health practitioners. As Sharma et al. (2018) report, “most practitioners (77.5%) asked their clients about smoking and provided health education (66.7 %) but fewer provided direct assistance (31.1%-39.7%).” Additionally, many mental health professionals hold misconceptions that may negatively affect smoking cessation interventions; those professionals report “a lack of time, training and confidence as main barriers to addressing smoking in their patients” (Sheals et al., 2016). The results reveal the gaps in the health care system, which is a most severe offense, considering the status of nicotine-dependent people with SMI and softer forms of mental illnesses.
The study mentioned above is not the only one addressing the smoking dependence of people with SMI. Heron et al. (2020) report that “the SCIMITAR+ trial was commissioned to evaluate the effectiveness of a bespoke smoking cessation intervention for people with severe mental ill-health compared with usual services.” The bespoke survey included 22 participants, who are National Health Service (NHS) healthcare providers, and all of them offered tobacco cessation support; still, not all services were streamlined, which means people received counseling from one organization and medication from another (Heron et al., 2020). This trial exemplifies a need for services that provide behavioral support and tobacco replacement therapy for people with SMI.
Considering the current pandemic situation caused by COVID-19, smoking becomes an even more complex issue for people with SMI, as tobacco use may lead to more severe COVID-19 outcomes. Peckham et al. (2021) examined smoking patterns of individuals with SMI before and after the pandemic outbreak, reporting increased smoking rates, although some people have quit. Therefore, mental health services should act swiftly to mitigate possible risks and be ready for any turn of events.
Moreover, tobacco use leads not only to health issues but also to financial ones, especially when it comes to mentally ill people, considering that they have higher dependence rates, as was shown in previously mentioned studies. Salt & Osborne (2020) estimate the number of people with mental health disorders pushed into poverty by nicotine dependence is around 130000 in England only. Furthermore, Elisseou & Rahuja (2021), who have conducted a questionnaire to assess the implementation of the Smoke-Free Policy by NHS on acute adult mental health units, claim that “smoking is the single largest preventable cause of ill health and premature mortality in England.” There is a secretariat for the Mental Health & Smoking Partnership, which “aims to reduce the inequality in smoking rates between people with mental health conditions and the wider population” (Salt & Osborne, 2020). Although that goal is reasonable, it is geographically limited, and health care systems’ primary concern should be not just reducing the inequality in smoking rates, but reducing the smoking rates themselves, as well.
Another approach for collecting data through a survey is questioning not professionals or the patients themselves but certain third parties who are somehow connected to the smokers and care for their cessation, too. For example, Bailey et al. (2016) conducted a cross-sectional survey with carers of a mentally ill person to explore their expectations of smoking cessation intervention. According to the results of that survey, “the majority of carers expected smoking cessation treatment to be provided by all services catering for people with a mental illness” (Bailey et al., 2016). These results illustrate that nicotine dependence is not always a concern of only one person. Potentially, the tobacco dependence of an individual, including mentally ill ones, may lead to mental health problems for a person who cares about them, which in turn may cause such a person to start smoking, too.
Exceptional Consequences of Tobacco Use and Significance of Cessation
One of the most dramatic outcomes of a mental health illness is a suicidal attempt, which demands the health care system to explore whether there is a mutual connection between nicotine dependence, mental illnesses, and suicidal ideation. For instance, if an individual smokes and is mentally ill, and these factors affect suicidal ideation, the chances of a fatal outcome are significantly higher. Harrison et al. (2020) claim that cigarette smoking and suicidal attempts are indeed associated; still, their research aimed to examine that association has not resulted in clear evidence that smoking has a causal effect on suicidal attempts. Nevertheless, it is vital to explore that field further, so the health care system can prevent such outcomes as suicide.
That leads to the next essential part of tobacco cessation interventions – social support, which is crucial as personal motivation and medical attention. Both people who try to quit smoking and mentally ill people need to be supported by their family, friends, and close people to bear the troubles more efficiently and for their treatment to be more effective. The study of Soulakova et al. (2018) examines the role of behavioral interventions and social support in the effectiveness of smoke-quitting attempts. The research involved the Tobacco Use Supplement to the Current Population Survey conducted in the US, which showed that smokers who relied on their friends and family were more intended to quit than those who did not (Soulakova et al., 2018). Moreover, it is accentuated that “these associations were similar for both sexes, all age groups, and nicotine dependence levels” (Soulakova et al., 2018). The research results illustrate the significance of social support for people who endeavor to quit smoking, especially if they are mentally ill. However, it might be reckless to rely only on friends and family on such weighty matters.
Conclusion
Summarizing the evidence of the problem of tobacco cessation among individuals with mental health disorders presented in this work, one can make certain conclusions. First, almost every considered research reveals higher rates of smoking among mentally ill people, which is the most practical argument that there is an association between mental health disorders and tobacco dependence. Second, many researchers and professionals actively explore this field to collect more data and find more effective ways of helping mentally ill people to quit smoking. Third, the geographic spread of review studies indicates that the problem under discussion is addressed worldwide, which increases the odds of making more significant discoveries soon. Fourth, there have been many surveys conducted and many experiments performed, and some of them have been successful, but most of the studies raise new questions and require further investigation. The essential point of the literature review is that the problem is serious to a great extent, and it should be one of the primary concerns of the world health care system.
References
Bailey, J., Wye, P., Stockings, E., Bartlem, K., Metse, A., Wiggers, J., & Bowman, J. (2016). Smoking cessation care for people with a mental illness: Family carer expectations of health and community Services. Journal of Smoking Cessation, 12(4), 221-230. Web.
Barnes, K., & Westmoreland, R. (2021). Assessing the delivery of smoking cessation interventions in adult inpatients. BJPsych Open, 7(1), 311-311. Web.
Carpenter, K. M, Nash, C. M., Vargas-Belcher, R. A., Vickerman, K. A., & Haufle, V. (2019). Feasibility and early outcomes of a tailored quitline protocol for smokers with mental health conditions. Nicotine & Tobacco Research, 21(5), 584–591. Web.
Elisseou, A., & Rahuja, S. (2021). To assess implementation of trust policy (smoke free policy) on an acute mixed mental health ward setting. BJPsych Open, 7(S1), S78-S79. Web.
Harris, T., Winetrobe, H., Rhoades, H., & Wenzel, S. (2019). The role of mental health and substance use in homeless adults’ tobacco use and cessation attempts. Journal of Dual Diagnosis, 15(2), 76-87. Web.
Harrison, R., Munafò, M., Davey Smith, G., & Wootton, R. (2020). Examining the effect of smoking on suicidal ideation and attempts: Triangulation of epidemiological approaches. The British Journal of Psychiatry, 217(6), 701-707. Web.
Heron, P., McCloud, T., Arundel, C., Bailey, D., Ker, S., Li, J., & Gilbody, S. (2020). Standard smoking cessation services in sites participating in the SCIMITAR trial for people with severe mental ill health. BJPsych Bulletin, 44(1), 6-11. Web.
Kaiser E. G., Prochaska J. J., & Kendra M. S. (2018). Tobacco cessation in oncology care. Oncology, 95(3), 129-137. Web.
Logtenberg, E., Overbeek, M., Pasman, J., Abdellaoui, A., Luijten, M., Van Holst, R., & Treur, J. (2021). Investigating the causal nature of the relationship of subcortical brain volume with smoking and alcohol use. The British Journal of Psychiatry, 1-9. Web.
Mohamed, F., & Bader, M. (2021). Audit of inpatient smoking cessation advice. BJPsych Open, 7(1), 92-93. Web.
Momin, B., Neri, A., Zhang, L., Kahende, J., Duke, J., Green, S., & Stewart, S. (2017). Mixed-methods for comparing tobacco cessation interventions. Journal of Smoking Cessation, 12(1), 15-21. Web.
Peckham, E., Allgar, V., Crosland, S., Heron, P., Johnston, G., Newbronner, E., & Gilbody, S. (2021). Investigating smoking and nicotine dependence among people with severe mental illness during the COVID-19 pandemic: Analysis of linked data from a UK Closing the Gap cohort. BJPsych Open, 7(3), 86. Web.
Romain, A. J., Trottier, A., Karelis, A. D., & Abdel-Baki, A. (2020). Do mental health professionals promote a healthy lifestyle among individuals experiencing serious mental illness? Issues in Mental Health Nursing, 41(6), 531-539. Web.
Salt, V., & Osborne, C. (2020). Mental health, smoking and poverty: Benefits of supporting smokers to quit. BJPsych Bulletin, 44(5), 213-218. Web.
Sharma, R., Meurk, C., Bell, S., Ford, P., & Gartner, C. (2018). Australian mental health care practitioners’ practices and attitudes for encouraging smoking cessation and tobacco harm reduction in smokers with severe mental illness. International journal of mental health nursing, 27(1), 247-257. Web.
Sheals, K., Tombor, I., McNeill, A., & Shahab, L. (2016). A mixed‐method systematic review and meta‐analysis of mental health professionals’ attitudes toward smoking and smoking cessation among people with mental illnesses. Addiction, 111(9), 1536-1553. Web.
Soulakova, J., Tang, C., Leonardo, S., & Taliaferro, L. (2018). Motivational Benefits of Social Support and Behavioural Interventions for Smoking Cessation. Journal of Smoking Cessation, 13(4), 216-226. Web.
Taylor, G., Baker, A., Fox, N., Kessler, D., Aveyard, P., & Munafò, M. (2020). Addressing concerns about smoking cessation and mental health: Theoretical review and practical guide for healthcare professionals. BJPsych Advances, 27(2), 85-95. Web.
World Health Organization. (2017). WHO monograph on tobacco cessation and oral health integration. Author.
Zijlstra, D., Muris, J., Bolman, C., Elling, J., Knapen, V., & De Vries, H. (2021). A referral aid for smoking cessation interventions in primary care: Study protocol for a randomized controlled trial. Primary Health Care Research & Development, 22, E22. Web.