A proportionally large number of people with mental illness smoke. The smoking rate in the general population is just over 20% (Glassman 1999), while the proportion of people with schizophrenia who smoke may be as high as 90% (Glassman, 1993).

Why Do People With Mental Illness Smoke?

There are many reasons why any individual smokes. On top of the usual reasons people with mental illness may find other good effects from smoking. Positive effects of smoking for people with mental illness, include the following:

* Nicotine increases alertness. This may enhance concentration, thinking and learning. This may be a benefit to people with schizophrenia whose illness or medication leads to cognitive problems.

* Nicotine can help relaxation, and it can also reduce negative feelings such as anxiety, tension and anger. So smoking may help people with mental illness deal with stressful situations.

* Nicotine might have an antidepressant effect. Nicotine stimulates dopamine production in part of the brain and so may help negative symptoms of schizophrenia, such as lack of motivation, lack of energy and flat mood.

* Nicotine may reduce positive symptoms, such as hallucinations for a short period.

* There is some evidence to suggest that smoking is associated with reduced levels of antipsychotic induced Parkinsonism.

* Smoking can help to relieve boredom and provide a framework for the day.

* Smoking can improve social interaction, something that may be of particular benefit to people with negative symptoms.

Why Should Someone With Mental Illness Quit Smoking?

There are many reasons why any individual might want to quit smoking. On top of the usual reasons there are some that may be particularly important to people with mental illness. Negative effects of smoking for people with mental illness, include the following:

* Premature death rates are higher for people with mental illness than for the general population, even after suicides are discounted. Many of these deaths are due to cardiovascular and respiratory problems and smoking is thought to contribute towards this.

* Substances found in tar in cigarettes stimulate enzymes in the liver, which increase the metabolism of some antipsychotics, including clozapine, fluphenazine, haloperidol and olanzapine. This results in higher doses being needed.

* There is some evidence to suggest that smoking may increase some side effects of antipsychotic medication, including akathesia (restlessness) and tardive dyskinesia (slower involuntary movements).

* Smoking puts a heavy financial burden on the smoker, who, as a person with severe mental illness, is likely to be on a low income.

* Heavy smokers may find it difficult to participate in some activities where smoking is not allowed. This adds to social exclusion experienced.

Smoking and Medication

Smoking can have an effect on medication. Substances found in tar in cigarettes stimulate enzymes in the liver, which changes the way the body processes some antipsychotics, including clozapine, fluphenazine, haloperidol and olanzapine. This results in higher doses being needed. It is important to review medication regularly to ensure you are getting the best dose for you.

Smoking can also have an impact on the side effects of medication. There is some evidence to suggest that smoking may increase some side effects of antipsychotic medication, including akathesia (restlessness) and tardive dyskinesia (slower involuntary movements). So by not smoking you may find you have less severe side effects. However, smoking can help some other side effects such as parkinsonism.

Quitting Smoking

Changing habits, especially when addiction is involved, is very difficult and many attempts to stop smoking may be needed. It may be helpful to remember that -

* You can try to get someone to think about it by discussing the disadvantages of continuing and the barriers to quitting. Try to actively encourage quitting and offer support and treatment. Don't let the diagnosis of mental illness be an excuse for not attempting to quit, whilst also acknowledging the beneficial effects of smoking for the person with some types of mental illness.

* Feelings about stopping smoking may be affected by previous attempts to stop. Look at why previous attempts failed and try to find a way of overcoming the problems and the reasons for trying to quit. Try not to be disheartened by failed attempts to quit. Most people trying to quit smoking make many attempts before finally giving up forever.

* Quitting smoking can sometimes lead to psychotic relapse. Be aware of signs of relapse and be prepared to act. Depression may also result from cessation of smoking and should be treated appropriately.

* As smoking habits change the amount of antipsychotic medication needed may also change. This should be carefully monitored.

* Nicotine replacement therapy may help to avoid withdrawal symptoms. This may be particularly important for people with schizophrenia as these withdrawal symptoms may be confused with or exacerbated by symptoms of schizophrenia.

* Cognitive behaviour therapy and participation in self-help groups for people trying to quit smoking can be helpful in the cessation process. Participation in groups with other people with psychotic illness may be of particular value.

Passive Smoking

Passive smoking means breathing in smoke produced by somebody else, eg if you don't smoke but you are in a room with somebody else who is smoking. Passive smoking can aggravate existing health problems such as asthma and it can also cause respiratory disorders and even lung cancer. These health risks of passive smoking can lead to tension between smokers and non-smokers - with smokers wanting and needing to smoke but the non-smokers wanting and needing clean and safe air to breathe.

There are some situations where this tension between smokers and non-smokers can be particularly problematic. For example -

A member of staff working at a day centre develops lung cancer. Many of the clients at the day centre smoke but this member of staff does not. The Health and Safety at Work Act requires employers (the organisation who run the day centre and employ this member of staff) to provide as far as is reasonably possible, a safe environment for employees to work in. The member of staff could sue the employer for failing to provide a safe working environment. However, there are things the employer can do to protect the employees (the staff) whilst still allowing people to smoke. For example, they could provide smoke free areas where staff can take breaks and they can ensure that smoking areas are well ventilated.

Tags: Mental Health, Smoking

About the Author

www.rethink.org
Rethink is the largest severe mental illness charity in the UK. We are dedicated to improving the lives of everyone affected by severe mental illness, whether they have a condition themselves, care for others who do, or are professionals or volunteers working in the mental health field.