Time for action on smoking and mental illness

Dr Mark Ragg offers a five point plan for reducing the current high rate of smoking among people with mental illnesses.

The first report card of the National Mental Health Commission makes fascinating reading. It’s refreshing to see an agency talking so much about people, rather than numbers, and taking so much effort to tell stories that we as readers can understand. It’s a report that’s been developed with an eye to having an impact, not just meeting obligations.

It’s missing quite a bit. Like reporting against actual performance by national, state and territory governments. It’s a broad brush report by a new body that has impressive breadth of vision, but will have to develop more depth of analysis by next year.

But one of the key points to come from A Contributing Life, the 2012 National Report Card on Mental Health and Suicide Prevention is the focus on the physical health of people with mental illness. The report card says people with serious mental illness die 10-32 years earlier than they should, largely from suicide, cardiovascular disease and cancer. Personally, I think the order should be shifted, with heart disease top of the list. But that’s not so important.

What is important is that smoking gets a good run in the report. Now if you’re reading this, there’s a good chance you don’t smoke. While policy is largely a middle class profession, smoking has lost its cachet and has become an addiction of the marginalised.

Reducing smoking in marginalised groups is the next big thing in tobacco control. That includes a focus on people who are Aboriginal, or homeless, or in prison, and it particularly includes those with a mental illness. People with a mental illness smoke more than others, with about 60 per cent those with a psychotic illness like schizophrenia being regular smokers. The rate among the highest socioeconomic group is 13.4 per cent.

Socioeconomic disadvantage, susceptibility to external influences, in some cases susceptibility to addiction, deliberate targeting of the vulnerable by tobacco companies … all play a part. But so, too, do the years of neglect when some doctors and nurses gave people with mental illness cigarettes, and others failed to give even the simplest of advice. Do you smoke? How about quitting? That advice – known in the trade as a brief intervention – works. The rest of us have heard that message repeatedly since the 1960s, but many people with mental illness have never been asked.

But times, thankfully, are changing, with many health groups and some governments sharpening their focus. In different ways, in different jurisdictions, people are starting to act.

Here are five important approaches that work.

1. Ensure that everybody with mental illness has good access to support to quit smoking.

In the community, this means having GPs, pharmacists, allied health professionals, people in the social welfare sector and quitlines up to speed. In hospitals, it means making sure doctors, nurses and others think to offer both psychological support and nicotine replacement therapy to people coming off cigarettes, even if briefly. It also means encouraging the Australian Government to broaden its subsidies of nicotine replacement therapy as much as possible. A consistent approach, wherever people with mental illness bump into the healthy and welfare systems, would be ideal.

2. Ensure it is clear that all hospitals in Australia, including psychiatric hospitals, are smoke-free.

This takes some effort. Many psychiatric hospitals have gone smoke-free, successfully, while others have found it difficult. The consistent message from the research in this area is that conversion to smoke-free requires good planning, close involvement of staff and full implementation, without exceptions. Exceptions provide grounds for dispute.

3. Ensure that everybody knows this before they go to hospital.

Difficulties arise when people going to hospital, and their families and carers, think smoking is allowed. If everybody knows in advance that it is not, problems diminish. It will take time to get the message through, but a community education campaign and clear signage are two important ingredients.

4. Ensure buy-in from psychiatrists, nurses, GPs, social workers, community workers and others in the mental health sector.

Attitudes are evolving. Ten years ago, most would have thought it okay to offer their clients or patients a cigarette, or even to have a smoke to establish rapport. Now, most would think it isn’t.

But health professionals and others need support to develop the confidence and skills to back the changing attitudes. Professional development is important across both public and private sectors.

5. Give consumers a strong voice.

The initial drive in Australia to reduce smoking among people with mental illness came from people with mental illness. How come, said a group of smokers with mental illness in Adelaide, we don’t get the same support to quit as others?

It was a good question. They were offered support, with excellent results (see People with mental illness can tackle tobacco, Australian and New Zealand Journal of Psychiatry. 2010:44(11):1021-1028). Over time, NGOs and governments have become involved for a number of reasons, ranging from altruism to occupational health and safety concerns.

In the end, there’s a single question to answer.

Given that smoking imposes such a huge financial and health burden on people who are already deeply disadvantaged, how could we not act?

 Dr Mark Ragg is director of RaggAhmed, a health and communications consultancy, and Adjunct Senior Lecturer in the School of Public Health at the University of Sydney. While receiving no current funding, he has previously been funded for work in this area by Cancer Council NSW and the NSW Ministry of Health and Cancer Institute NSW.