Smoking, smoke-free policies and mental disorder

The importance of addressing tobacco smoking among people with mental disorder is now well recognised, and increased research activity, policy initiatives and widespread endorsement ^1-3 raise hopes that, in the UK, progress and change are underway. As presented in more detail than this article allows, elsewhere the evidence shows that people with mental disorder are not only substantially more likely to smoke, but also smoke more heavily than people without a mental disorder, ^{Reference Williams and Ziedonis4,Reference Meltzer, Gill, Hinds and Petticrew5} thus consuming over 40% of all cigarettes smoked in the UK ^{Reference McManus, Meltzer and Campion6} - a figure as staggering as it is worrying. As one would expect, morbidity and mortality because of smoking-related conditions, such as cardiovascular and respiratory disease, are elevated accordingly, adding to the burden of excess premature deaths and life years lost as a result of other causes in this disadvantaged population. ¹ Most worrying, however, is the circumstance that despite this and the fact that people with mental disorder can be as motivated to address their smoking as people without, ^{Reference Siru, Hulse, Khan and Tait7} smoking remains deeply entrenched in the culture of mental health settings, and is rarely addressed in clinical practice - often because of the belief that it fulfils therapeutic functions with regard to certain symptoms of some mental disorders, and out of reluctance to interfere with patients' ‘choice to smoke’ (although the term ‘choice’ in the context of using a substance as addictive as heroin may arguably be ill chosen). There are other reasons for the persistent failure to support smokers with mental disorders to equally good standards as smokers without that are too many and too complex to discuss here in detail and that are documented elsewhere. ^{Reference Lawn8-Reference Pols and Lawn11}

Be that as it may. The recently published Royal College of Physicians and Royal College of Psychiatrists' report on smoking and mental disorder, ¹ as well as the National Institute for Health and Care Excellence (NICE) guidance on smoking cessation in secondary care including mental health settings ² mark, one would hope and trust, the dawn of a new area. Mental health trusts are now expected to provide prompt, comprehensive and evidence-based on-site support to help smokers quit or maintain temporary abstinence in completely and strictly smoke-free mental health settings. It is important to note that this expectation goes decidedly beyond the standard most mental health trusts fulfil in the context of the smoke-free legislation that came into force under the Health Act 2006. Although many mental health trust policies drafted to comply with the Act stipulate smoke-free trust premises, the reality tends to look different: although indoor spaces are now, with greater or lesser success, kept smoke free, it is the norm to see patients smoke on trust grounds, near entrances, in courtyards or on balconies, and to observe staff spending time (that could and should arguably be used for more constructive purposes) facilitating smoking breaks (or ‘fresh air breaks’, as they are sometimes called) for in-patients who are smokers. ^{Reference Ratschen, Britton and McNeill9,Reference Ratschen, Britton, Doody and McNeill12}

Anecdotally, the discontent of staff and patients with how smoking and not smoking are currently being handled in many mental health settings appears ubiquitous. Less clear is what to do about it - and how to fulfil the expectations of the new NICE guidance, which are, compared with the current status quo, high and, some would argue, in places short of being accompanied by clear practice recommendations that would enable trusts to fulfil them in a straightforward manner. Although there is probably good reason to argue that policies and procedures to deal with alcohol on in-patient units could be usefully extrapolated to cover smoking, seeing as both are legal substances that are not to be consumed on trust premises, it seems that the comparison or even likening of the two is not always perceived as wholly intuitive, and so the call for clear guidance on how to deal with smoking in particular remains. The problem is that a strong evidence base that would confidently suggest how best to eliminate smoking and treat tobacco dependence in mental health in-patient settings (where no exemptions from the policy are allowed) is missing. There is some evidence, but it is limited, ^{Reference Cormac, Brown, Creasey, Ferriter and Huckstep13-Reference Lawn and Campion15} sometimes referring to small studies with particular parameters (such as high secure forensics) and not always taking into account the complexities some mental health settings are facing - one size does, as so often, not necessarily fit all. It also indicates that more research into effective ways of supporting acutely ill in-patients who smoke and have mental disorder to quit or temporarily abstain from smoking is needed, and that existing approaches need to be tailored and adapted to the setting. ² In short, creative ways of thinking are required, and the author of this article believes that e-cigarettes could play a part in it.

E-cigarettes, smoke-free policy and mental disorder

How could e-cigarettes be of particular value in mental health settings? Many trusts are currently confronted with what must feel like a conundrum: there is all the good will to make mental health settings completely smoke free, to offer smokers gold standard support, to work towards closing the gap between smokers with mental disorder and smokers without by changing the persistent smoking culture in these settings - and yet, there is not much wisdom as to how to achieve this. It is true that, generally speaking, treatments for tobacco dependence that work for the general population (i.e. a combination of pharmacotherapy and behavioural support) also work for people with mental illness, ^{Reference Banham and Gilbody18} although certain caveats with regard to the use of bupropion and varenicline apply. ^{1,Reference Banham and Gilbody18} However, the evidence supporting this stems from clinical trials that recruited particular subgroups of smokers with mental disorder: those who were stable, usually living in the community (a standard inclusion criterion for research in this area) and who were, above all, willing to address their smoking and consent to being part of smoking research in the first place. Every clinician working with people with mental disorder on acute adult mental health in-patient units on a daily basis knows that there is a huge difference between their patients and the recruits in these studies.

Pilot research on in-patient units has demonstrated that the mantra of offering NRT and specialist smoking cessation advice in everyday practice results in modest success rates in terms of service uptake and smoking cessation or abstinence. ^{Reference Parker, McNeill and Ratschen14} Nicotine replacement therapy products, although generally effective and doubling success rates for smoking cessation compared with no use of pharmacotherapy, ^{Reference Stead and Lancaster19} are undoubtedly products of limited popularity - whereas it should be noted that mental health professionals' often sceptical stance, probably based on misconceptions with regard to their use in the context of mental disorder, ^{Reference Ratschen, Britton, Doody, Leonardi-Bee and McNeill20} do a disservice to the products and needs to be addressed. It is, however, conceivable that to smokers admitted to a mental health in-patient unit in an acute state of crisis, NRT may seem like yet another medication, and one whose administration may not be entirely intuitive or without pitfalls. The need to administer frequently and regularly if a heavy smoker (with likely underdosing resulting in limited effectiveness and quick dissatisfaction with the product) and potential difficulties associated with use, such as chewing techniques for the gum, side-effects of the nasal spray and unpleasant taste of the products, may just be enough to prevent success in acute mental health settings - where patients' motivation and resources to address smoking are likely to be fluctuating. It is probably fair to say that what mental health trusts are currently facing - albeit undoubtedly and rightly in the name of health promotion and equality - is the somewhat daunting prospect of enforcing entirely smoke-free trust premises, while trying to offer the majority of their patients treatment for cessation or temporary abstinence that they might not want to use. To complicate matters and intensify apprehensions that may or may not prove justified, there are added concerns over introducing inequalities between formal and voluntary patients in terms of the ability to access tobacco (off trust premises), over the loss of voluntary patients (feared and anecdotally reported to become reluctant or unwilling to admit themselves to in-patient units when not able to smoke), and over escalations relating to strict policy enforcement (for example through body searching for smoking paraphernalia on (re-)entering the ward).

Would it not be wonderful if there was something on offer that people really liked? Something they could use in the same way they use cigarettes, that was, however, relatively safe (and appropriately licensed), something they might find at least quite attractive and had perhaps used in the past, that substituted for their normal cigarettes for their time on the ward, and that may, as a by-product, result in substantial reduction or cessation of tobacco use in the long term? Perhaps e-cigarettes could be just that. Although still limited, the evidence for the general population suggests that e-cigarettes could serve as an effective cessation aid, ^{Reference Bullen, Howe, Laugesen, McRobbie, Parag and Williman21} and a pilot study of smokers with schizophrenia who were not willing to quit showed that e-cigarette use substantially decreased cigarette consumption over 12 months, without significant side-effects or a negative impact on the symptoms of schizophrenia. ^{Reference Caponnetto, Auditore, Russo, Cappello and Polosa22} And would it not seem promising to inform a patient on admission (and before, where possible) that tobacco use is not allowed on trust premises, but that they could use e-cigarettes instead, should they prefer or would like to add it to the offer of standard smoking cessation treatment with NRT and behavioural support - more promising than seizing cigarettes and offering standard treatment only? Bearing in mind the circumstance that the risks of exposure to second-hand e-cigarette vapour have not been thoroughly assessed, patients could be asked to use e-cigarettes in their private rooms or outdoors only. Both formal and voluntary patients could use the devices, through greater acceptability and popularity perhaps at least partly removing the issue of voluntary patients continuing tobacco smoking off trust premises and re-entering the ward smelling of cigarettes, and perhaps carrying paraphernalia with them. Granted, not all challenges or potential problems would suddenly be solved. For example, risk assessments would need to consider how to handle issues relating to devices that require regular charging would need to be addressed (perhaps by prescribing the use of e-cigarettes with non-rechargeable batteries only?), or how to address any potential fire risks.

Commissioning of (licensed) products along the lines of NRT is another example of discussions likely to ensue. Still, on reflection, short of hailing e-cigarettes as revolutionary devices for mental health in-patient settings, it is probably reasonable to state that they could change the way smoking and smoke-free policies are handled, and help trusts and clinicians with solving the conundrum they find themselves confronted with. It certainly seems worth a try, and worth some research. Indeed, some trusts in the country are already incorporating e-cigarettes in their smoke-free policies, and it will be important to share and learn from each others' experience along the way of what will hopefully become a major avenue towards health promotion in mental health settings.