Cigarette smoking among psychiatric out-patients

The dangers of cigarette smoking are well recog nised, and a number of public health measures designed to reduce the level of smoking have been introduced over the past 20 years. These measures have been fairly successful, and there has been a steady decline in the prevalence of cigarette smoking in the UK over the period 1972-1988 (Officeof Popu lation Censuses and Surveys, 1990). A number of studies have shown a higher prevalence of cigarette smoking among psychiatric patients (Hughes et al, 1986); however, the majority of these have been of highly selected populations, or have failed to control for factors such as age, sex, socioeconomic status and alcohol abuse, all of which are known to affect the prevalence of smoking. This study compared the prevalence of cigarette smoking among a hetero geneous group of psychiatric out-patients with that of the general population with control for these confounding variables.

The dangers of cigarette smoking are well recog nised, and a number of public health measures designed to reduce the level of smoking have been introduced over the past 20 years. These measures have been fairly successful, and there has been a steady decline in the prevalence of cigarette smoking in the U K over the period 1972-1988(Officeof Popu lation Censuses and Surveys, 1990. A number of studies have shown a higher prevalence of cigarette smoking among psychiatric patients (Hughes et al, 1986); however, the majority of these have been of highly selected populations, or have failed to control for factors such as age, sex, socioeconomic status and alcohol abuse, all of which are known to affect the prevalence of smoking. This study compared the prevalence of cigarette smoking among a hetero geneous group of psychiatric out-patients with that of the general population with control for these confounding variables.

The study
Two hundred consecutive attenders at a general adult psychiatric out-patient clinic at a district gen eral hospital were asked to complete a questionnaire about their smoking habits. The questionnaire was a copy of that used in the 1988 General Household Survey, and was self-administered, except in the case of 11 patients who were illiterate and were helped by the reception staff. Cigarette smokers were identified as those who answered yes to the question: "Do you smoke cigarettes now?". Further questions enquired into the smoking history, demographic details and attitudes to smoking, x2 analysis was used to com pare the responses of the patient group with the results from the 1988 General Household Survey (Office of Population Censuses and Surveys, 1990).
One hundred and ninety-one patients completed the questionnaire (94 male and 97 female). The mean age of the men was 45.3 years (C.L. 42.5-48.0 years), the women were slightly older at 54.2 years (C.L. 51.5-56.9 years). The patients were drawn from a predominantly mining community, with an excess of manual workers, (x: = 24.9, d.f. = 5, P<0.01). The level of unemployment was extremely high, with only 32% of the men and 23% of the women of working age in work at the time of the study. The prevalence of cigarette smoking among the psychiatric patients was about one and a half times that of the general public, both among the men (50% v. 33% x2= 8-2, d.f.= l, P<0.01) and the women (42% v. 30% x2= 4.9, d.f.= I, P<0.05). The higher prevalence was present in all age groups and socioeconomic classes, and remained when those with a history of substance abuse had been excluded from the figures. The mean duration of smoking was 28.3 years (C.L. 12.1-44.5 years).
An interesting finding was that while similar numbers in each group had smoked at some time in their lives, significantly fewer of the psychiatric patients had managed to give up smoking (25.5% v. 16.5% x2= 6.6, d.f. = l,/><0.01). This difference was especially marked among the men. Just over half of the group expressed concern about the dangers of cigarette smoking, and a similar proportion claimed to have seriously tried to give up smoking at some time in the past.

Comment
The results of this study almost certainly represent a real difference in the smoking behaviour of psychi atric patients compared to the general public, and confirm similar findings from the USA (Hughes el al, 1986). The patients were all living in the community at the time of the study; the findings cannot therefore be attributed to the effects of institutionalisation. It is possible that the patients were drawn from a community with an atypical pattern of smoking; however the prevalence of cigarette smoking in the East Midlands is actually slightly lower than the national average (Wald Ã©tal, 1988).
The health risks posed by cigarette smoking exceed those of a number of other problems of substance abuse that are regarded as the province of the psy chiatrist. These risks can be greatly reduced by stopping smoking (Friedman et al, 1981). This is something that the patient group seemed to have failed to do. There are a number of possible expla nations of this finding; however, one hypothesis would be that cigarette smoking is not regarded as being an important problem in people with serious psychiatric illness and it is therefore ignored.
Knowledge of a patient's smoking behaviour is also important to the psychiatrist at an individual level as it may complicate assessment and treatment.
Smoking can reduce anxiety, while abstinence may produce symptoms such as anxiety, irritability and overeating. Nicotine is a powerful drug with effects on neurotransmitter systems and on the action of psychotropic drugs. General practice studies have demonstrated that a relatively brief intervention by the doctor can lead Brown to a significant reduction in the level of smoking (Russell et al, 1979). The psychiatrist is well placed to make such an intervention. All the patients in this study were well enough to understand simple advice and instructions. Cigarette smoking is highly danger ous behaviour, both to the smoker and on occasions to others, such as the victims of fires caused by dis carded cigarette ends. I would argue that we have a responsibility to offer help in this area, and that we should also give some thought to our responsibilities as role models.