Smoking and mental health

Mental Health: have you been affected by the recession? We would welcome your views.

Introduction

This leaflet is for anyone who has a mental health problem and is worried – or just curious – about:

• how smoking affects your body
• how smoking affects your mental health
• how to stop smoking

“I feel so much healthier overall after stopping smoking a year ago. I also have much more money to do things that I wasn’t able to afford while I was smoking. The doses of my medication have also come down a lot.”  

Introduction

If you have a mental health problem and smoke, you may feel that there's nothing you can do about it. This isn't true. Many people with mental health problems stop smoking - and feel better and live longer. You have the same right to help with this as anyone else.

What's in it for me if I stop smoking?

• You'll probably feel much healthier and better in yourself.
• You may be able to reduce the amount of medication you take.
• It 's the single most powerful way of improving your health – and living longer.
• If you stop smoking 10 cigarettes a day, you'll save more than £1000 a year.
• You'll be able to get much fitter.

And if I don't ….. ?

• If you have a mental health problem, you probably smoke more than other people – so your smoking is even more likely to harm you.
• You are more likely to be one of the 100,000 people in the UK each year who are killed by smoking.
• You are more likely to die early  - you will live on average, about 10 years less than you would have done if you did not smoke. However, half of smokers die 15 years earlier than they should while a quarter die 23 years earlier.
• You are more likely to have breathing problems, heart disease, diabetes and many kinds of cancer (not just lung cancer).

Mental health and smoking

If you have a mental illness, you are more likely to smoke. 42% of all cigarettes smoked in England are by people with mental health problems.

The more you smoke, the more likely you are to:

• develop a mental illness – but it's unclear why
• feel anxious or depressed
• think about suicide - and to go on to commit suicide
• use more drugs and alcohol – which can make a mental health problem worse.

Overall, if you have a mental health problem and smoke, you are more likely to have poor general health – it's one of the main reasons why people with a mental health problem tend to die younger.

• If you stop smoking, you can feel better, be healthier and live a lot longer
• You have the right to help with stopping smoking

Other problems with smoking

• Men can find it difficult to get an erection.
• Women tend to:
  • find it hard to get pregnant
  • have a more difficult pregnancy
  • have babies who are less healthy and have a lower birth weight.
• It harms non-smokers who breathe other’s smoke.  
• It's expensive.
• If your health is poor, you may not be able to do things you want to – work, for example.
• Most public places don't allow smoking - so you can find yourself shut out from  things you might want to do.

Isn't it too late to stop?

No. Even if you have smoked since your teenage years:

• If you stop smoking before the age of about 35, you will live nearly as long as people who have never smoked.
• If you stop smoking before the age of 50, you will be half as likely to die from smoking-related diseases as someone who carries on smoking.

How will I feel if I stop smoking?

• Probably much healthier and better in yourself.
• A few people feel worse for a short time after stopping. This does get better but you may need some extra support if you are finding it hard.  
• You may cough more for a while after stopping smoking – this is usually temporary, but may last a few months.
• You may put on weight – but you can control this with exercise and a healthy diet.
• You'll be able to get much fitter.
• You may be able to reduce the amount of certain medication you take by up to half.
• Proud that you have done something that will give you a healthier, longer life.

How can I stop smoking?

Different people find different things helpful – you need to find what is best for you. Think about:

Self Help

• Read a self-help book
• Do some regular exercise

Help and support from other people

• Get advice from your doctor, nurse or other health care professional – this may be all you need to stop smoking.
• Get help from your local NHS stop smoking service.
• Telephone/ internet support.
• You can get support from a friend, a professional or someone else or a group of other people who are giving up smoking.
• Pair up with a friend who is also trying to stop.
• At first you may find it easier not be around friends who smoke -  but friends and family can give valuable support.
• Some people like acupuncture and hypnotherapy – but clinical trials have not shown that they help.  

Impact of stopping smoking on others

• Think about who else you know who you might help if you stop smoking – like your baby or child.

Finally - don't be discouraged if you start smoking again - many people do, it's all part of learning not to smoke.

Medications

Nicotine replacement therapy (NRT)

This is a way of giving your body the nicotine it craves without using cigarettes. It comes as skin patches, gum or inhalers. It seems to work better if you use a patch together with an inhaler or gum. The patches, gum or inhalers can irritate your skin, mouth, throat or nose, but usually just for a short time. NRT doubles your chance of giving up completely.

Bupropion (Zyban)

This cuts down the craving but can make it hard to sleep and you might experience amxiety. You should not use it if you have had epilepsy (seizures or fits) or bipolar disorder (manic depression). 

Varenicline (Champix)

This cuts down the craving for nicotine – but, if you do have a cigarette, it also cuts down the pleasure you get from it. However, there have been reports that it can make you anxious, depressed, agitated and suicidal as well as give you mood swings and make it hard to sleep, even if you don't have a history of mental health problems.

If you take varenicline and have a mental health problem, you should let your doctor know. If you develop any of he side-effects above, you should stop varenicline and see your doctor immediately.

But I don't think I can stop completely .....

You might feel – especially if you smoke heavily – that you can't stop completely. Don't worry, just:

• Cut down before stopping – you don't have to stop suddenly.
• Keep a diary of when, where and with whom you smoke. This can highlight the times and situations when you are more likely to smoke – so you can plan ways of avoiding them or dealing with them.
• While you are cutting down, you can work out ways of coping without cigarettes
• You can use NRT to help you do this (see above).

OK,  I stop smoking – what about my mental health?

Depression

You may well feel less depressed. A few people do feel more depressed when they stop smoking, so:

• Keep in regular contact with your doctor and (if you have one) key worker or case coordinator.
• Ask if you can have a talking therapy like cognitive behaviour therapy (CBT).

Schizophrenia

• You may find it harder than other people to stop smoking – but your symptoms won't get worse.
• NRT or bupropion can help.
• If you use any of the above medications and go to a support group, you are more likely to give up.

Smoking and Medication

• Smoking can interfere with some medication, so you may have to take a higher dose than you would if you were not smoking.
• So, if you stop smoking, the amount of some medications in your blood can go up, often within a few days. Your doctor may need to reduce the dose of some medications by a quarter in the first week, and perhaps even more in the following three weeks.
• However, if you start smoking again, you will probably need to go back to the old dose of medication.

Some of the medicines affected by smoking include:

• Antidepressants (the older tricyclics such as amitriptyline and the newer mirtazapine)
• Antipsychotics (especially clozapine, olanzapine and haloperidol)
• Benzodiazepines (eg diazepam)
• Opiates (eg methadone).

What about being in hospital?

• Even if you want to carry on smoking, you can't smoke indoors in any mental health unit in the UK.
• Ward staff should be trained to help you to not smoke while you are an in-patient. They can help you to stop smoking, if you want to.
• The ban on smoking in hospitals is part of the drive to improve everybody's physical and mental health.

Mental health services can help you with your mental health – and with other things

Your GP, psychiatrist, care coordinator and anyone else you see in mental health services can help you to:

• improve your physical health
• develop a healthy lifestyle – exercise and eating healthily
• get advice, information, support and, if necessary, medication to stop smoking
• not put on weight after stopping smoking
• make any changes you need to your medication after you stop smoking.

Look after your body and your mind will feel better

You can stop smoking - ask for help - it’s your right

Resources

• NHS Smokefree: NHS Smoking Helpline on 0800 022 4 332
• Free local NHS Stop Smoking Service

References

• Brown S, Barraclough B, Inskip H. (2000). Causes of the excess mortality of schizophrenia. British Journal of Psychiatry. 176: 109.
• Cahill K, Stead L, Lancaster T (2007). Nicotine receptor partial agonists for smoking cessation. Cochrane Database of Systematic Reviews, issue 1, CD006103. Wiley Interscience.
• Campion J, Checinski K, Nurse J, McNeill A (2008). Smoking by people with mental illness and benefits of smoke-free mental health services. Advances in Psychiatric Treatment. 14: 217-228.
• Campion J, Checinski K, Nurse J (2008). Review of smoking cessation treatments for people with mental illness. Advances in Psychiatric Treatment. 14: 208-216.
• Campion J, Hewitt J, Shiers D, Taylor D (2010) Pharmacy guidance on smoking and mental health. RCPsych and RCGP Forum.
• Cuijpers P, Smit F, ten Have M et al (2007). Smoking is associated with first-ever incidence of mental disorders: a prospective population based study. Addiction. 102(8): 1303-9.
• Doll R, Peto R, Boreham J, Sutherland I (2004). Mortality in relation to smoking: 50 years’ observation on male British doctors. British Medical Journal. 328: 745.
• Farrell M, Howes S, Bebbington P et al. (2001). Nicotine, alcohol and psychiatric morbidity. Results of a national household survey. British Journal Psychiatry. 179: 432-7.
• Foulds JGK, Steinberg MB, Richardson D et al (2006). Factors associated with quitting smoking at a tobacco dependence treatment clinic. American Journal of Health Behavior. 30: 400-412.
• Hughes, J.R. (2007) Depression during tobacco abstinence. Nicotine Tob Res. 9:443-6.
• John, U., Meyer, C., Rumpf, H. J., et al (2004) Smoking, nicotine dependence and psychiatric comorbidity – a population-based study including smoking cessation after three years. Drug and Alcohol Dependence, 76, 287–295.
• Malone KM, Waternaux C, Haas GL et al.( 2003). Cigarette smoking, suicidal behavior, and serotonin function in major psychiatric disorders. American Journal Psychiatry. 160(4): 773-9.
• McManus S, Meltzer H, Campion J (2010) Cigarette smoking and mental health in England. Data from the Adult Psychiatric Morbidity Survey. National Centre for Social Research.
• Phelan M, Stradins L, Morrison S (2001) Physical health of people with severe mental illness. British Medical Journal. 322: 433-444.
• Royal College of Physicians and Royal College of Psychiatrists. Smoking and mental health. Report by the Tobacco Advisory Group. London: RCP 2013. Royal College of Psychiatrists: CR178. 
• Taylor D, Paton C, Kapur S (2012) Maudsley prescribing guidelines. 11^th Edition. Informa Healthcare.
• Willi C, Bodenmann P, Ghali WA et al (2007) Active Smoking and the Risk of Type 2 Diabetes. A Systematic Review and Meta-analysis. JAMA. 298(22):2654-2664.

Original authors

Dr Jonathan Campion (Director for public mental health and consultant psychiatrist, South London and Maudsley NHS Foundation Trust)

Dr Ken Checinski (St George’s University London).

We are grateful to the service users who commented on this leaflet and thank Dr David Shiers, Dr Sharon Lawn, Simon Lawton-Smith (Mental Health Foundation) and Aine Duggan (Rethink) for their help.

This leaflet was edited by the RCPsych Public Education Editorial Board.

Series Editor: Dr Philip Timms.

© Illustration by Huw Briscoe www.unfoldstudio.com

This leaflet reflects the best available evidence at the time of writing.

For a catalogue of public education materials or copies of our leaflets contact: Leaflets Department, The Royal College of Psychiatrists, 17 Belgrave Square, London SW1X 8PG. Tel: 020 7235 2351 x 259.

Charity registration number (England and Wales) 228636 and in Scotland SC038369.

Please note that we are unable to offer advice on individual cases. Please see our FAQ for advice on getting help.

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