Smoking Cessation Interventions for Individuals with Severe Mental Illness
Discussion Paper
Canadian Mental Health Association
Ottawa Branch
JUNE 2010
Donna Pettey MSW, RSW
CMHA Ottawa
PhD Student, Population Health, University of Ottawa
2
Executive Summary
While tobacco use remains the leading preventable risk factor for mortality and morbidity in
Canada (Patra, Rehm, Baliunas & Popova, 2007, p. 228), the overall smoking prevalence rate of
Canadians has decreased substantially from 50% of the population in 1965 to less than 18% in
2008 (Health Canada, 2010). However, up to 85% of the severely mentally ill 1 continue to use
tobacco products (Harris, Parle & Gagne, 2007), and 40% of individuals smoke more than 40
cigarettes a day (Horsfall, Cleary, Hunt & Walter, 2009, p. 25). This has contributed to such an
astounding inequitable distribution of negative health outcomes that it is now estimated that
individuals with severe mental illness die 25 years earlier than the general population, with 60%
of these deaths due to cardiovascular and respiratory disease (Parks, Svendsen, Singer, & Foti,
2006). For individuals with schizophrenia, heart disease is now associated with 25 to 30 years
premature mortality (Kilbourne et al., 2009, p. 555). In response to this alarming health
outcome information, CMHA Ottawa conducted a client smoking prevalence and nicotine
dependency survey in May 2010. Of 639 clients surveyed, 445 or 70% reported that they were
currently smoking tobacco and 63% scored as having a ‘high’ or ‘very high’ level of nicotine
dependence (see Appendix A). Given the appalling inequitable health outcomes for this
population that are specifically attributable to smoking, there is a health system imperative to
finally address tobacco use.
Recommendations
The advantage of developing recommendations to address smoking cessation for those with
severe mental illness is that incredibly successful population health intervention strategies do
exist, they have just never been provided to this population as part of any concerted strategy, and
as the strategies currently exist, they do not accommodate this population. Beyond the actual
direct intervention strategies though, there are also a variety of systemic, educational, and
attitudinal issues within the psychiatric care system that must be concurrently addressed as part
of a comprehensive intervention. One means to address this broad deficit is to‘ scale up’ this
population health intervention with particular sensitivity to the population at risk.
Recommendation #1
Given that most individuals with severe mental illness receive the majority of their health system
contact from the mental health system (Ziedonis et al., 2003), tobacco use treatment needs to be
integrated as part of routine care in the mental health system. Existing attitudinal barriers where
tobacco use is not only considered normalized behaviour but necessary to mange symptoms or
reduce the likelihood of both psychiatric and substance abuse relapse, will need to be reconciled
through the education of mental health care practitioners.
Recommendation #2
Due to the high levels of tobacco dependency within the mental health service provider group,
system support must be provided here as well, as the likelihood of assessing and treating tobacco
addiction is not only related to many of these attitudes or beliefs, but to the actual smoking status
of the provider (Johnson et al., 2009).
1
Severe mental illness is defined as individuals who have been diagnosed with an Axis I diagnosis such as
schizophrenia, bipolar disorder or severe depression and who require long-term intensive support and treatment to
facilitate recovery.
3
Recommendation #3
The actual dose and intensity guidelines for smoking cessation interventions must be adjusted to
reflect the needs of those with high levels of nicotine dependence. Standardized guidelines for
prescribing increased nicotine replacement therapy options, with training and support for
practitioners, would reduce the existing bureaucratic barriers to appropriately serving this
population. Additionally, psychosocial interventions need to be provided with the intensity
required to respond to the support needs of this population, beyond the typical 8 or 12 week
support group format.
Recommendation #4
Related to this, is that for heavily addicted populations, harm reduction approaches need to be
explored. This could include such options as counselling a reduction in the total number of
cigarettes smoked with the attendant health and financial burden benefits and enabling the long
term use of nicotine replacement therapy, similar to methadone maintenance for opiate addiction.
Recommendation #5
While nicotine replacement therapy is the ‘gold standard’ for treating nicotine addiction, it is
cost prohibitive for any population living in poverty. This is a medical intervention that needs to
be available through Provincial health care plans and additionally, provided to community and
hospital mental health programs that work with this population.
Recommendation #6
At a legislative level, the existing smoke-free bylaws governing health institutions need to be
extended and enforced for psychiatric services. An excellent toolkit, “Tobacco-Free Living in
Psychiatric Settings” has been developed by the National Association of State Mental Health
Program Directors (NASMHPD, 2007). This provides a best-practise guide for preparing,
implementing, monitoring and following up on the commitment to a tobacco-free facility and is
an excellent example of both vertical and horizontal integration activities necessary for the
sustainability of smoking cessation in this particular environment. Unfortunately, no equivalent
provider group exists in Canada to guide such a process, although with the appropriate political
will and clinical leadership to develop the ‘institutional standards’, this process could certainly
still be applied locally, Provincially and Nationally.
Recommendation #7
Emerging research that expounds the benefits of nicotine for any marginalized population needs
to be closely scrutinized, challenged, and questioned as to who is actually benefiting from the
outcome of the research. A new research and evaluation agenda needs to be developed that
monitors the state of tobacco use for this population and begins to systematically evaluate
population health interventions as they become more accessible to this population. Alternative
harm reduction intervention options need to be part of this research platform.
Summary
The Substance Abuse and Mental Health Service Administration (SAMHSA) in the U.S. has
stated “people with serious mental health problems deserve to live as long and healthy lives as
other Americans” (SAMHSA, 2010). Hopefully, the same sentiment can be expressed for
Canadians with serious mental health problems.
4
Background
Tobacco use constitutes a modern day epidemic. It is projected that by 2015 tobacco will kill
fifty percent more people than HIV-AIDS and that ten percent of all deaths globally will be
attributable to tobacco (Mathers & Loncar, 2006, p. 2021). In Canada, more than 37,000 people
will die this year due to tobacco use and up to half of all current smokers will die before their
seventieth birthday unless they quit (Health Canada, 2010). Tobacco use is associated with
numerous cancers as well as cardiovascular and respiratory diseases (Baliunas et al., 2007) and
remains the leading preventable risk factor for mortality and morbidity in Canada accounting for
over twelve percent of the total disease burden (Patra, Rehm, Baliunas & Popova, 2007, p. 228).
Despite these sobering figures, incredible gains have been made in the Canadian public health
arena over the past four decades to reduce tobacco use and the attendant negative health
consequences. Not only has the overall smoking prevalence rate of Canadians decreased
substantially from fifty percent of the population in 1965 to less than eighteen percent in 2008,
but other measures that predict severity of tobacco related harm such as number of cigarettes
consumed by smokers and levels of nicotine dependence, have also decreased (Health Canada,
2010).
Clearly by most standards of analysis, tackling tobacco use is a population health intervention
success story, yet troubling revelations regarding those who continue to smoke reveal the
inadequacies of current practise in addressing tobacco use. Nowhere is this more evident than
with the population of individuals with severe mental illness where up to eighty-five percent of
the severely mentally ill continue to use tobacco products (Harris, Parle & Gagne, 2007), and
forty percent of individuals smoke more than forty cigarettes a day (Horsfall, Cleary, Hunt &
Walter, 2009, p. 25). This has contributed to such an astounding inequitable distribution of
negative health outcomes that it is now estimated that individuals with severe mental illness die
twenty-five years earlier than the general population, with sixty percent of these deaths due to
cardiovascular and respiratory disease (Parks, Svendsen, Singer, & Foti, 2006). For individuals
with schizophrenia, heart disease is now associated with twenty-five to thirty years premature
mortality (Kilbourne et al., 2009, p. 555). A Canadian study that examined mortality rates
among the homeless and marginally housed (predominantly individuals with mental health and
substance use disorders) concluded the probability of survival to age 75 for those living in the
marginal housing environments was 32% for men and 60% for women compared with 51% and
72% respectively for those in even the lowest Canadian income percentile. The largest
differences in the mortality rates were for smoking related heart and respiratory diseases.
(Hwang, Wilkens, Tjepkema, O’Campo & Dunn, 2009, p. 1 of 9).
CMHA Ottawa conducted a client smoking prevalence and nicotine dependency survey in
May 2010. Of 639 clients surveyed, 445 or 70% reported that they were currently smoking
tobacco. Of the 307 smokers who completed the Fagerstrom Test for Nicotine Dependence
(Heatherton, Kozlowski, Frecker & Fagerstrom, 1991), 63% scored as having a ‘high’ or ‘very
high’ level of nicotine dependence. A summary of the survey results can be found in Appendix
A.
5
Smoking Cessation as a Population Health Intervention
David Kindig (2007) defines population health simply as “health outcomes and their
distribution in a population” (p.141) but he is careful to note the importance of examining which
determinants and/or interactions may have produced these outcomes and how this ultimately
shapes health inequities (p. 144). Typically, population health interventions aim to address
health inequities by identifying the underlying ‘ingredients’ (such as physical environment,
gender, or economic status) that factor in the determination of one’s health and to then improve
the health status of the entire population through the provision of ‘upstream’ policy and program
development. Tobacco use is an excellent example of a behaviour that requires a population
health intervention as “in the context of tobacco control, there is widespread agreement that
effective action requires a comprehensive, ecological intervention approach that targets multiple
systems and employs multiple strategies” (Richard et al., 2004, p. 410).
In Canada, measures to address tobacco have evolved over time and reflect this socioecological approach. Richard, Potvin, Denis & Kishchuk (2002) describe three ‘generations’ of
approaches to address tobacco use:
• Micro or first generation interventions that focused on smoking cessation by targeting
individual behaviour
• Meso or second generation interventions that moved into the community realm by
focussing on prevention and the overall population as well as the high risk ‘smokers’
group.
• Macro or third generation interventions that “redefined the notion of comprehensive
tobacco control programs by putting a greater emphasis on macro-environmental factors
and by initiating actions to influence public and private policies and regulations” (p. 398).
These macro or system level interventions include demand reduction strategies such as
legislation that guides taxation and price control, label warnings and marketing restrictions;
supply reduction legislative strategies such as prohibiting the sale of tobacco to minors and
addressing the issues related to the illegal tobacco trade; and legislative measures that protect
against exposure to second hand smoke in public places, workplaces, and even in private places
such as vehicles transporting children (von Tigerstrom, 2008).
This described evolution of distinct generations or transition points of interventions plots the
trajectory of how tobacco control has ‘taken hold’ and become embedded in Canadian public
health culture. As a population health intervention, the taxation of tobacco has demonstrated, for
example, that by altering the ‘dose’ of the intervention or amount of taxation, smoking
prevalence patterns can be modified (Stephens, Pederson, Koval, & Macnab, 2001) and that the
reach of this intervention can be particularly effective in discouraging the purchase of tobacco
products (Carpenter & Cook 2008; Auld, 2005). While this multi-system comprehensive
approach has produced impressive outcomes and has resulted in a dramatic modification of
smoking behaviour (Health Canada, 2010), one of the challenges of a population health approach
is that particular subpopulations may remain marginalized from the intervention.
6
Smoking Cessation for the Mentally Ill
While smoking rates have consistently declined over the past forty years in the general
population, why would up to eighty-five percent of individuals with severe mental illness
continue to smoke? Both neuropsychiatric and psychosocial factors are most frequently cited in
the literature, specifically the neurobiological vulnerabilities of the “receptor populations that
respond to nicotine” (Leonard et al., 2001, p. 561), theories of stress and reduced coping
capacity and the “hypothesis that the association between schizophrenia and tobacco smoking is
relatively independent of sociocultural factors” (Leon & Diaz, 2005, p. 136; Diaz, Veasquez,
Susce & Leon, 2008). However, other factors or ‘causal pathways’ need to be considered in
order to explain why in both in-patient and community settings, individuals with serious mental
illness are less likely to even be offered information or support to address their tobacco use
(Johnson et al., 2009). Hall and Prochaska (2009) identify a range of individual and system
factors that help to explain why this vulnerable population continues to smoke at alarming levels,
specifically that the “prioritization of mental health treatment, lack of an appreciation of the
health effects of cigarette smoking, and beliefs among clinicians that persons with mental illness
are not able or willing to quit have contributed to a culture in many treatment settings that
accepts and ‘normalizes’ cigarette smoking” (p. 411). While first generation smoking cessation
interventions targeted smokers, clearly, smokers with severe mental illness were not just
neglected, they were deliberately absolved from the requirement to quit. Similarly, in terms of
the more ‘second generation’ population level or preventative measures, these pervasive beliefs
and attitudes have continued to marginalize access to treatment for this population. While the
multi-system approach to tobacco control measures provide an excellent example of successful
scaling up of a population health intervention, what has occurred in relation to smoking cessation
for the mentally ill highlights how a lack of horizontal scaling up (little evidence of expansion or
consistent replication of the intervention for this population) and vertical integration of the
intervention throughout the health system, can create health inequity.
The psychiatric treatment system has in fact, a long and troubling relationship with tobacco
use including a longstanding practise (that continues to this day) of providing cigarettes as
rewards for positive behaviour and treatment compliance. The ‘father’ of psychoanalysis
Sigmund Freud, continued to smoke until his death (despite thirty-three operations for cancer of
the jaw) and in modern day psychiatry, psychiatric residents and psychiatrists report higher
smoking rates than other health specialists and are less likely to treat tobacco addiction than
other health providers (Hall & Prochaska, 2009, p. 411). Similarly, a recent Canadian study that
examined community mental health care practitioner attitudes and practises toward smoking
cessation for mentally ill clients revealed a higher level of smoking amongst the practitioners
than in the general population and again, that these staff were less likely to engage in
conversation with clients about their tobacco use (Johnson et al., 2009, p. 293).
An additional factor that will influence whether or not mental health clients are being
exposed to possible smoking cessation treatment is the associated interest or belief by the mental
health system provider groups that addressing tobacco use is even part of their role. For
example, psychiatrists have been found to provide cessation counselling during only twelve
percent of visits with their patients as opposed to general health physicians where the rate is
thirty-eight percent of visits. (Ziedonis, et al. 2008. p. 1693). In examining mental health
7
practitioner attitudes, Johnson et al. (2009) were able to demonstrate that “providers who
perceived that they did not have the time or resources to engage in cessation activities and did
not think it was part of their role were less likely to engage in smoking cessation activities.
Similarly, providers who indicated clients were not interested in stopping, were less likely to
engage in cessation activities” (p. 294). This aspect of suspected motivation is also at the core of
a health system that systematically neglects to offer treatment with the assumption that
individuals with mental illness are not interested in, or capable of, quitting. Research has
demonstrated however that smokers with psychiatric disorders have similar levels of expressed
desire to quit or reduce smoking as the general population (Hall & Prochaska, 2009, p. 414;
Moeller-Saxon, 2008). Further, a review of twenty-four studies assessing the effectiveness of
smoking cessation for this population found that at the twelve month follow-up, quit rates were
only marginally lower as compared to the general population suggesting “that conventional
attitudes about persons with mental illness being able to quit smoking need to be modified” (elGuebably, Cathcart, Currie, Brown, & Gloster, 2002, p. 1168).
Part of challenging these conventional attitudes is addressing a pervasive belief that smoking
provides a singular source of pleasure for clients who have few material comforts (National
Association of State Mental Health Program Directions (NASMHPD), 2007). There are also
persistent beliefs that quitting smoking will worsen the symptoms of mental illness and interfere
with the ability to maintain abstinence from alcohol or drugs (Hall & Prochaska, 2009).
Research in this area indicates however, that smoking cessation interventions do not endanger
abstinence (Currie, Nesbitt, Wood & Lawson, 2003) and do not increase schizophrenic
symptomology (Hall & Prochaska, 2009, p.421).
It is clear that smoking cessation as a population health intervention has limited reach for
individuals with severe mental illness. In the U.S., clinical guidelines for smoking cessation
within this population have been produced (U.S. Department of Health and Human Services,
2008) but “implementation of these recommendations in mental health and addiction treatment
settings has been slow” (Hall & Prochaska, 2009, p. 413). Even with stringent smoking in the
workplace legislation now in place, thirty percent of Canadian hospitals continue to have
separate smoking policies for psychiatric patients (Bardell & Brown, 2006). In most residential
treatment programs for substance abuse treatment, smoking remains essentially unrestricted
(Currie et al., 2002) and only ten percent of these treatment facilities in Canada reported
providing on site smoking cessation treatment (Hall & Prochaska, 2009, p.412). In the U.S.,
only forty-one percent of state psychiatric facilities are smoke free (NASMHPD, 2007, p. 15)
and while staff safety and fear of escalation of violence is often sited as a rationale for lenient
smoking regulations in psychiatric hospitals, research has demonstrated that facilities that
continue to permit smoking have significantly higher incidents of conflict related to smoking
than non-smoking facilities (Lane, Werdel, Schacht, Ortiz & Parks, 2009; Harris et al., 2006).
In Canada, while there are widely accepted population health intervention smoking cessation
guidelines for the general population, little attention has been paid to the dose and intensity of
the intervention that will be required for this population. Smoking cessation intervention
programs recommend a combination therapy of pharmacological intervention including nicotine
replacement therapy (NRT) which comes in the form of patches, inhalers, lozenges, and gum,
psychotropic medications such as Champix and Zyban, and psychosocial interventions.
8
Psychosocial interventions include individual and group counselling that address a broad range
of issues related to smoking behaviour and most programs consist of eight to twelve weekly
sessions. There are many challenges with this standard approach in meeting the smoking
cessation needs of a population with serious mental illness. In considering nicotine replacement
therapy, there are two main considerations. First and foremost, the therapy itself is cost
prohibitive as NRT is not routinely paid for as part of a drug plan for individuals receiving social
assistance (in Ontario, recipients of the Ontario Disability Support Plan or Ontario Works).
Once again, the reach of this particular intervention for this population and indeed for any
population living in poverty, is limited.
Additionally, there are few guidelines concerning the actual ‘dose’ of nicotine replacement
therapy required for this population. While it is well documented that individuals with severe
mental illness are extremely ‘heavy’ and ‘efficient’ smokers (Harris et al., 2007; Dixon et al.,
2007), the actual medical directives for NRT are for populations that do not typically have such
extreme levels of dependence and the recommended dosage and titration schedules will not
necessarily be appropriate, as individuals may require long term NRT support beyond the typical
treatment protocol. “Although it has been established that combining medications or
recommending increased NRT doses when indicated is safe and effective, it is considered by
Health Canada as ‘off label’ use. This creates a barrier for professionals who work with clients
who are heavily dependent on smoking, due to lack of knowledge, and availability of specific
guidelines. For heavy smokers who attempt to quit using inadequate pharmacotherapy, this can
lead to frustration and decreased confidence to make another quit attempt” (A. Bradfield, N.P.,
Canadian Mental Health Association, personal communication, April 16, 2010). Intensity of
psychosocial intervention is an additional concern as, given what is known regarding
psychosocial interventions for this population in addressing other substance use disorders
(Cleary, Hunt, Matheson, Siegfried & Walter, 2007), this population is likely to require longterm support beyond the life of most eight to twelve week programs which again, may influence
not only professional interest in providing treatment to this particular cohort but could in fact
defy most program mandates.
While at a direct and system population health intervention level there are clear disparities in
how accessible smoking cessation strategies remain for this population, the third generation or
macro level interventions that utilize legislative measures to facilitate demand reduction
strategies may also have an inequitable effect on this population. Increasing tax on cigarettes for
a population that continues to smoke may not have the same reach for a population with such
ingrained levels of dependence and indeed, studies have found that individuals with serious
mental illness have reported tobacco use as a ‘core need’ above food (Ziedonis et al., 2008, p.
1704). Since this population has clearly continued to use tobacco, these individuals end up
experiencing considerable economic harm as smoking imposes an inequitable and substantial
financial burden on those with restricted incomes (Johnson et al, 2009, p. 290;Steinberg,
Ziedonis, Krejci & Brandon, 2004, p. 206). Beyond the need to purchase taxed cigarettes, this
financial burden can drive individuals to purchase contraband cigarettes where two hundred
cigarettes packed loosely in a plastic Ziploc bag can be purchased for under twenty dollars as
opposed to the current (Ontario) cost of over eighty dollars for legally purchased cigarettes. The
tax ‘disincentive’ has less effect on individuals who are poor, who are heavy smokers and “the
widespread availability of contraband cigarettes can undermine the effectiveness of this policy,
9
negate the intended health benefits of tobacco taxation and reduce taxation revenues” (Luk,
Cohen & Ferrence, 2007, p.1). Finding sources for contraband cigarettes is easier than finding
smoking cessation interventions that pay for nicotine replacement therapy.
In summary, the current population health intervention approach to address smoking cessation
has limited reach and an inadequate dose and intensity response to meet the needs of those with
severe mental illness. This has contributed to what Frohlich & Potvin (2008) have identified as a
pooling or concentration of risk for this vulnerable population.
Nancy Krieger suggests that “effective action to curb tobacco use and social disparities in
tobacco-related diseases requires integrated, multifaceted campaigns that are relentlessly honest
about who gains and who loses from the status quo (Krieger, 2008, p. 227). Contemplating who
gains and who loses in relation to the smoking behaviours of the mentally ill is an instructive
place to begin. It has now been determined that individuals with mental illness comprise 44.3%
of the U.S. tobacco market (Lasser et al., 2000, p.2608), accounting for 39 billion dollars in
annual sales (Hall & Prochaska, 2009. p.411). Clearly, there is a lot to be gained by the tobacco
industry in having this population remain dedicated and committed customers. The relationship
between the tobacco industry and the mentally ill, while critical for a comprehensive
understanding of this issue, is not addressed in this discussion paper but has been explored in the
literature (Prochaska et al., 2008; Bero, 2003; Vagg & Chapman, 2005; Apollonia & Malone,
2005).
Recommendations: Scaling up Smoking Cessation Interventions for the Mentally Ill
By examining the prevalence of smoking related mortality and morbidity within this
population, it is clear that a host of ‘casual pathways’ are at work. It has truly resulted in a
catastrophic public health ‘perfect storm’ of a vulnerable population, a severely addictive
product and a heavily invested corporate interest, left to interact relatively unfettered for over
four decades. Clearly, given the astounding inequitable health outcomes for this population that
are specifically attributable to smoking, there is a health system imperative to finally address
tobacco use.
The advantage of developing recommendations to address smoking cessation for those with
severe mental illness is that incredibly successful population health intervention strategies do
exist, they have just never been provided to this population as part of any concerted strategy, and
as the strategies currently exist, they do not accommodate this population. Beyond the actual
direct intervention strategies though, there are also a variety of systemic, educational, and
attitudinal issues within the psychiatric care system that must be concurrently addressed as part
of a comprehensive intervention. One means to address this broad deficit is to‘ scale up’ this
population health intervention with particular sensitivity to the population at risk. Scaling up is
defined as “deliberate efforts to increase the impact of successfully tested health innovations so
as to benefit more people and to foster policy and programme development on a lasting basis”
(World Health Organization, 2009). The ‘scalability’ of this intervention strategy could be a
specific challenge as the previously documented barriers to addressing tobacco use in this
population are ingrained and after decades of practise, have resulted in a highly nicotine
dependent population combined with a highly disengaged health system. The institutionalization
10
of smoking cessation interventions will never occur for this population without attention to
vertical and horizontal scaling up. Vertical scaling up “refers to the policy, political, legal,
regulatory, budgetary or other health systems changes needed to institutionalize the innovation”
(WHO, 2008, p. 30) and horizontal scaling up refers to the expansion and replication of the
intervention (WHO, 2008, p. 34). These aspects of vertical and horizontal integration contribute
to the sustainability of the intervention, specifically when practises become engrained through
the ‘routinization’ of procedures within organizations and by setting institutional standards at
the system levels of governance (Pluye, Potvin & Denis, 2004).
Recommendations
Given the variety of barriers identified within the mental health system to address tobacco use,
clearly, many changes will need to occur:
Recommendation #1
Given that most individuals with severe mental illness receive the majority of their health system
contact from the mental health system (Ziedonis et al., 2003), tobacco use treatment needs to be
integrated as part of routine care in the mental health system. Existing attitudinal barriers where
tobacco use is not only considered normalized behaviour but necessary to mange symptoms or
reduce the likelihood of both psychiatric and substance abuse relapse, will need to be reconciled
through the education of mental health care practitioners.
Recommendation #2
Due to the high levels of tobacco dependency within the mental health service provider group,
system support must be provided here as well, as the likelihood of assessing and treating tobacco
addiction is not only related to many of these attitudes or beliefs, but to the actual smoking status
of the provider (Johnson et al., 2009).
Recommendation #3
The actual dose and intensity guidelines for smoking cessation interventions must be adjusted to
reflect the needs of those with high levels of nicotine dependence. Standardized guidelines for
prescribing increased nicotine replacement therapy options, with training and support for
practitioners, would reduce the existing bureaucratic barriers to appropriately serving this
population. Additionally, psychosocial interventions need to be provided with the intensity
required to respond to the support needs of this population, beyond the typical 8 or 12 week
support group format.
Recommendation #4
Related to this, is that for heavily addicted populations, harm reduction approaches need to be
explored. This could include such options as counselling a reduction in the total number of
cigarettes smoked with the attendant health and financial burden benefits and enabling the long
term use of nicotine replacement therapy, similar to methadone maintenance for opiate addiction.
Recommendation #5
While nicotine replacement therapy is the ‘gold standard’ for treating nicotine addiction, it is
cost prohibitive for any population living in poverty. This is a medical intervention that needs to
11
be available through Provincial health care plans and additionally, provided to community and
hospital mental health programs that work with this population.
Recommendation #6
At a legislative level, the existing smoke-free bylaws governing health institutions need to be
extended and enforced for psychiatric services. An excellent toolkit, “Tobacco-Free Living in
Psychiatric Settings” has been developed by the National Association of State Mental Health
Program Directors (NASMHPD, 2007). This provides a best-practise guide for preparing,
implementing, monitoring and following up on the commitment to a tobacco-free facility and is
an excellent example of both vertical and horizontal integration activities necessary for the
sustainability of smoking cessation in this particular environment. Unfortunately, no equivalent
provider group exists in Canada to guide such a process, although with the appropriate political
will and clinical leadership to develop the ‘institutional standards’, this process could certainly
still be applied locally, Provincially and Nationally.
Recommendation #7
Emerging research that expounds the benefits of nicotine for any marginalized population needs
to be closely scrutinized, challenged, and questioned as to who is actually benefiting from the
outcome of the research. A new research and evaluation agenda needs to be developed that
monitors the state of tobacco use for this population and begins to systematically evaluate
population health interventions as they become more accessible to this population. Alternative
harm reduction intervention options need to be part of this research platform. Smith & Petticrew
(2010) also note the importance of acknowledging that the evaluations of such complex
population health interventions will require incorporating a range of concepts, methodologies
and perspectives beyond the “‘one size fits all’ adopted by many within public health” (p. 6). In
reflecting on population health smoking cessation interventions for vulnerable populations,
Frohlich (2008) underscores the need for participatory strategies that include vulnerable
populations in the evaluation process as well (p. 881).
Summary Comments
In recognition of the disparity in life expectancy of individuals with severe mental illness, the
Substance Abuse and Mental Health Service Administration (SAMHSA) in the U.S. has ‘scaled
up’ and launched the ‘10x10 Wellness Campaign’, with the stated objective of reducing the
mortality rate of those with mental illness by 10 years in 10 years by promoting and adopting a
range of ‘wellness’ and recovery oriented initiatives, the first one being a concerted focus on
tobacco use in this population. As they state “people with serious mental health problems
deserve to live as long and healthy lives as other Americans” (SAMHSA, 2010). Hopefully, the
same sentiment can be expressed for Canadians with serious mental illness. Currently, there are
no National champions here and the health system is almost four decades behind in providing
appropriate smoking cessation interventions for this population. Why do up to eighty-five
percent of people with severe mental illness smoke? Because in many ways, as a society we
allowed the tobacco industry to protect their most lucrative market and as a health care system,
we remained complicit, accommodating and disinterested.
12
References
Apollonio & Malone. (2005). Marketing to the marginalized: tobacco industry targeting of the
homeless and mentally ill. Tobacco Control 14:409-415.
Auld, MC. (2005). Causal effect of early initiation on adolescent smoking patterns. Canadian
Journal of Economics; 38(3):709-734.
Bardell & Brown. (2006). Smoking inside Canadian acute care hospitals. Canadian Respiratory
Journal, 13(5):266-272.
Baliunas, Patra, Rehm, Popova, Kaiserman & Taylor. (2007). Smoking-attributable mortality and
expected years of life lost in Canada 2002: Conclusions for prevention and policy.
Chronic Diseases in Canada 27(4):154-162.
Bero, L. (2005). Tobacco industry manipulation of research. Public Health Reports. 120(2):200208.
Bero, L. (2003). Implications of the tobacco industry documents for public health and policy.
Annual Review of Public Health, 24:267-288.
Cleary M, Hunt GE, Matheson SL, Siegfried N, Walter G. (2007). Psychosocial interventions for
people with both severe mental illness and substance misuse. Cochrane Database of
Systematic Reviews, Issue 4. Art. No.: CD001088. DOI:
10.1002/14651858.CD001088.pub2
Carpenter C, & Cook PJ. (2008). Cigarette taxes and youth smoking: new evidence from
national, state and local Youth Risk Behavior Surveys. Journal of Health Economics
2008;27(2):287-299.
Currie, Nesbitt, Wood & Lawson. (2003). Survey of smoking cessation services in Canadian
addiction programs. Journal of Substance Abuse Treatment, 24:59-65.
Diaz, Velasquez, Susce & Leon. (2008). The association between schizophrenia and smoking:
Unexplained by either the illness or the prodromal period. Scizophrenia Research,
104:214-219.
Dixon, Medoff, Wohlheiter, DiClemente, Goldberg, Kreyenbuhi, Adams et al. (2007). Correlates
of severity of smoking among persons with severe mental illness. The American Journal
of Addictions, 16:101-110.
el-Guebaly, N., Cathcart, J., Currie, S., Brown, D. Gloster, S. (2002). Smoking cessation
approaches for persons with mental illness or addictive disorders. Psychiatric Services,
53(9):1166-1170.
Frohlich & Potvin. (2008). The inequity paradox: The population approach and vulnerable
populations. American Journal of Public Health, 98(2):216-221.
Frohlich. (2008). Is tobacco use a disease? Canadian Medical Association Journal, 179(9):880882.
Hall & Prochaska. (2009). Treatment of smokers with co-occurring disorders: emphasis on
integration in mental health and addiction treatment settings. Annual Review of Clinical
Psychology, 5:409-431.
Harris, GT., Parle, D. & Gagne, J. (2007). Effects of a tobacco ban on long-term psychiatric
patients. Journal of Behavioural Health services & Research 34(1):43-55.
Health Canada (2010). Retrieved April 7th 2010 from
http://www.hc-sc.gc.ca/hc-ps/tobac-tabac/res/news-nouvelles/risks-risques-eng.php
Heatherton, Kozlowski & Fagerstrom. (1991). The Fagerstrom test for nicotine dependence: a
13
revision of the Fagerstrom Tolerance Questionaire. British journal of Addiction, 86:111927.
Horsfall, J., Cleary, M., Hunt, G., & Walter, G. (2009). Psychosocial treatment for people
with co-occurring sever mental illnesses and substance use disorders (dual diagnosis): A
review of Empirical Evidence. Harvard Review of Psychiatry, 17(1):24-34.
Hwang, S, Wilkens, R., Tjepkema, M., O’Campo, P., & Dunn, J. (2009). Mortality
among residents of shelters, rooming houses, and hotels in Canada: 11 year follow-up
study. British Medical Journal, doi:10.1136/bmj.b4036.
Johnson, Malchy, Ratner, Hossain, Procyshyn, Bottorff, Groening, Gibson, et al. (2009).
Community mental healthcare providers attitudes and practices related to smoking
cessation interventions for people living with severe mental illness. Patient Education
and Counselling. 77:289-295.
Kilbourne, Morden, Austin, Ilgen, McCarthy, Dalack & Blow. (2009). Excess heart-diseaserelated mortality in a national study of patients with mental disorders: identifying
modifiable risk factors. General Hospital Psychiatry, 31:555-563.
Kindig, D. (2007). Understanding population health terminology. The Millbank
Quarterly, 85(1):139-161.
Krieger, N. (2008). Proximal, distal, and the politics of causation: what’s level got to do with it?
American Journal of Public Health, 98(2):221-230.
Lane, Jr., G.M., Werdel, M. B., Schacht, L., Ortiz, G, and Parks, J. (2009). Smoking
polices and practices in state psychiatric facilities: Survey results from 2008. Alexandria,
VA:National Association of State Mental Health Program Directors Research Institute,
Inc. (NRI).
Lasser, Boyd, Woolhandler, Himmelstein, McCormick & Bor. (2000). Smoking and mental
illness A population-based prevalence study. Journal of the American Medical
Association. 284(20):2606-2610.
Leon & Diaz. (2005). A meta-analysis of worldwide studies demonstrates an association between
schizophrenia and tobacco smoking behaviors. Schizophrenia Research, 76:135-157.
Leonard, Adler, Benhammou, Berger, Bresse, Drebing, Gault et al. (2001). Smoking and mental
illness. Pharmacology, Biochemistry and Behavior, 70:561-570.
Luk, Cohen & Ferrence. (2007). Contraband Cigarettes in Ontario. The Ontario Tobacco
Research Unit Retrieved April 14, 2010 from
http://www.otru.org/pdf/special/special_nov_2007.pdf
Mather, CD & Loncar, D. (2006). Projections of global mortality and burden of disease from
2002 to 2030. PLoS Med 3(11):e442.
Moeller-Saxon, K. (2008). Cigarette smoking and interest in quitting among consumers at a
psychiatric disability rehabilitation and support service in Victoria. Australian and New
Zealand Journal of Public Health, 32(5):479-481.
National Association of State Mental Health Program Directors. (2007). Tobacco-free living in
psychiatric settings. Retrieved April 14, 2010 from
http://www.nasmhpd.org/general_files/publications/NASMHPD.toolkitfinalupdated9070
7.pdf
Parks, Svendsen, Singer & Foti. (2006). Morbidity and mortality in people with serious mental
illness. National Association of State Mental Health Program Directors. Retrieved
February 25th 2010 from www.nasmhpd.org
14
Patra, Rehm, Baliuna & Popova. (2007). Substance attributable morbidity and mortality changes
to Canada in a epidemiological profile: measurable differences over a ten-year period.
Canadian Journal of Public Health, 98(3):228-234.
Pluye, Potvin & Denis. (2004). Making public health programs last: conceptualizing
sustainability. Evaluation and Program Planning, 27:121-133.
Prochaska, Hall & Bero. (2008). Tobacco use among individuals with schizophrenia:
What role has the tobacco industry played? Schizophrenia Bulletin, 34(3):555–567.
Richard, Lehouxb, Bretona, Denis, Labried & Le´onarde. (2004). Implementing the ecological
approach in tobacco control programs: results of a case study. Evaluation and Program
Planning 27:409–421.
Richard, Potvin, Denis & Kishchuk. (2002). Integration of the ecological approach in tobacco
programs for youth: A survey of Canadian public health organizations. Health
Promotion Practice, 3(3): 397-409.
Smith & Petticrew. (2010). Public health evaluation in the twenty-first century: time to see the
wood as well as the trees. Journal of Public Health, 32(1):2-7.
von Tigerstrom, B. (2008).Tobacco control and the law in Canada in Public Health Law and
Policy in Canada (2nd Edition) Bailey, Caulfield & Ries (eds) LexisNexis Canada Inc:
p.247-300.
Steinburg, Ziedonis, Krejci & Brandon. (2004). Financial implications of cigarette smoking
among individuals with schizophrenia, Tobacco Control, 13(2):206-208.
Stephens, Pederson, Koval, & Macnab. (2001). Comprehensive tobacco control
policies and the smoking behaviour of Canadian adults. Tobacco Control, 10:317-322.
Substance Abuse Mental Health Services Administration. (2010) 10x10 Wellness Campaign
retrieved April 14th 2010 from
http://www.promoteacceptance.samhsa.gov/10by10/default.aspx
United States Department of Health and Human Services. (2008). Treating Tobacco Use and
Dependence: 2008 Update. Retrieved April 11th 2010 from
http://www.surgeongeneral.gov/tobacco/treating_tobacco_use08.pdf
Vagg & Chapman. (2005). Nicotine analogues: a review of tobacco industry interests Addiction,
100:701-712.
World Health Organization. (2008). mhGAP : mental health gap action programme : scaling up
care for mental, neurological and substance use disorders. Retrieved April 14th 2010
from http://www.who.int/mental_health/mhgap_final_english.pdf
World Health Organization (2009). Nine steps for developing a scaling up plan. Retrieved April
14th 2010 from
http://www.expandnet.net/PDFs/Nine%20Steps%20for%20Developing%20a%20Scaling
%20up%20Strategy.pdf
Ziedonic, Williams & Smelson. (2003). Serious mental illness and tobacco addiction: A model
program to address this common but neglected issue. The American Journal of the
Medical Sciences. 326(4): 223-230.
Ziedonic, Hitsman, Beckman, Zvolensky, Adler, Audrain-MrGovern, Breslau, et al. (2008).
Tobacco use and cessation in psychiatric disorders: Natonal institute of mental health
report. Society of Research on Nicotine and Tobacco, 10(12):1691-1715.
15
APPENDIX A
16
Results from the Smoking Survey (Fagerström Test)
CMHA, Direct Service
May, 2010
Respondents
Answer
Respondent
Non-respondent (No
contact)
All clients
Total Percent
639
89.37%
76
715
10.63%
100.00%
Smokers (Respondents = All clients contacted)
Answer
Total Percent
Smoker
445
69.6%
Non-smoker
194
30.4%
Respondents 639 100.00%
CMHA Direct Service
Smoking Survey Results
n=639
Non-smoker
30%
Smoker
70%
Surveys completed (Respondents = All known smokers)
Answer
Total Percent
Smoker’s who filled out survey 307
69.0%
Smoker’s who did not fill out
survey
138
31.0%
Respondents
445 100.00%
17
Gender Ratio for known smokers (Respondents = All known smokers)
Gender
Total Percent
Male
283
63.6%
Female
161
36.2%
Transgender
1
0.2%
Respondents 445 100.00%
Age Range for known smokers (Respondents = All known smokers)
Age group
18-24
Gender
Total Percent
Female
2.92%
13
Male
6.52%
29
25-44
Female
71
15.96%
Male
131
29.44 %
45-54
Female
58
13.03%
Male
84
18.88%
Transgender
1
0.22%
55+
Female
19
4.27%
Male
39
8.76%
65+
Female
0
0.00%
Male
3
0.67%
Respondents
All
445 100.00%
CMHA Direct Service - Smoking Survey
Age Range by Gender
n=445
35%
29.4%
30%
25%
20%
18.9%
16.0%
13.0%
15%
5%
8.8%
6.5%
10%
4.3%
2.9%
0.0% 0.7%
0.2%
18-24
25-44
45-54
55+
Male
Female
Male
Female
Transgender
Male
Female
Male
Female
Female
Male
0%
65+
18
Diagnostic Category for known smokers (Respondents = All known smokers)
Diagnostic Category
Schizophrenia and other Psychotic
Disorder
Mood Disorder
Anxiety Disorder
Other
Respondents
Total Percent
216
150
38
41
445
48.54%
33.71%
8.54%
9.21%
100.00%
*Other = Combination of: Disorder of Childhood/Adolescence, Dissociative Disorders,
Impulse Control Disorders not elsewhere classified, Mental Disorders due to General Medical
Conditions, Delirium, Dementia, and Amnesiac and Cognitive Disorders, Personality Disorders,
Adjustment Disorders, Somatoform Disorders, Substance Related Disorders, and Unknown.
CMHA Direct Service
Smoking Survey Respondent Diagnostic Category
n=445
50%
45%
40%
35%
30%
25%
20%
15%
10%
5%
0%
49%
34%
9%
Schizophrenia
and other
Psychotic
Disorder
Mood Disorder Anxiety Disorder
9%
Other
19
Smokers in Concurrent Disorder Groups (Respondents = All known smokers)
*Note: Of the 154 participants in the Concurrent Disorder program, 114 of them smoke.
Survey Respondents that are in the Concurrent Disorder Program
In Concurrent Disorder
Group
Number Percent
Don't Smoke
22
16%
Smoke
114
84%
Total
136
100%
CMHA Direct Service - Smoking Survey
Clients who are in the Concurrent Disorder
Program
n=136
Don't Smoke
16%
Smoke
84%
Survey Responses (n=307): Fagerström Test
1. How soon after you wake up do you smoke your first cigarette? (Respondents =
Smokers who completed survey)
CMHA Direct Service - Smoking Survey
How soon after you wake up do you smoke your
first cigarette?
n=307
60%
50%
57%
40%
30%
32%
20%
10%
6%
5%
0%
Within 5 minutes
5 to 30 minutes
31 to 60 minutes
After 60 minutes
20
2. Do you find it difficult not to smoke in places where you shouldn’t, such as in church or
school, in a movie, at the library, on a bus, in court or in a hospital? (Respondents =
Smokers who completed survey)
CMHA Direct Service - Smoking Survey
Do you find it difficult not to smoke in places where
you shouldn't?
n=307
Yes
42%
No
58%
3. Which cigarette would you most hate to give up; which cigarette do you treasure the
most? (Respondents = Smokers who completed survey)
CMHA Direct Service - Smoking Survey
Which cigarette would you most hate to give up?
n=307
80%
70%
60%
74%
50%
40%
30%
25%
20%
0.3%
10%
0%
The first one in the
morning
Any other one
No Answer
4. a) How many cigarettes do you smoke each day? (Respondents = Smokers who
completed survey)
CMHA Direct Service - Smoking Survey
Estimated number of cigarettes
n=69
Average number smoked is 23
Lowest
3
Highest
50
21
CMHA Direct Service - Smoking Survey
How many cigarettes do you smoke each day?
n=307
40%
35%
38%
30%
30%
25%
20%
22%
15%
10%
11%
5%
0%
10 or fewer
11 to 20
21 to 30
31 or more
4. b) Estimated # of cigarettes: (Respondents = Smokers who completed survey)
Answer
Value Percent
Lowest
3.00
0.3%
Highest
50.00
1.3%
Average
23.16
Respondents
307
100.00%
*Note: Only 69 individuals specified the number of cigarettes smoked.
CMHA Direct Service - Smoking Survey
Estimated number of cigarettes smoked
n=69
(Average # smoked 23)
26-50 cigarettes
30%
3-15 cigarettes
38%
16-25 cigarettes
32%
5. Do you smoke more during the first few hours after waking up than during the rest of
the day? (Respondents = Smokers who completed survey)
CMHA Direct Service - Smoking Survey
Do you smoke more during the first few hours after
waking than during the rest of the day?
n=307
No
48%
Yes
52%
6. Do you still smoke if you are so sick that you are in bed most of the day, or if you have a
cold or the flu and have trouble breathing? (Respondents = Smokers who completed
survey)
22
CMHA Direct Service - Smoking Survey
Do you still smoke if you are so sick that you are in
bed most of the day, or if you have a cold or the flu?
n=307
No
33%
Yes
67%
7. a) Scoring (Respondents = Smokers who completed survey)
Score
Total Percent
0
6
1.9%
1
3
1.0%
2
10
3.3%
3
22
7.2%
4
28
9.1%
5
43
14.0%
6
54
17.6%
7
54
17.6%
8
44
14.3%
9
33
10.7%
10
10
3.3%
Respondents 307 100.00%
7. b) Dependency level (Respondents = Smokers who completed survey)
Answer
0-2 Very Low
Dependence
3-4 Low Dependence
5 Medium Dependence
6-7 High Dependence
8-10 very High
Dependence
Respondents
Total
Percent
19
50
43
108
6.2%
16.3%
14.0%
35.2%
87
307
28.3%
100.00%
23
CMHA Direct Service - Smoking Survey
Dependency Level
n=307
40.00%
35.00%
35%
30.00%
28%
25.00%
20.00%
15.00%
16%
10.00%
5.00%
14%
6%
0.00%
0-2 Very Low
3-4 Low
Dependence Dependence
5 Medium
Dependence
6-7 High
8-10 very High
Dependence Dependence
8. Do you live or are you currently staying someplace that limits when and where you are
allowed to smoke? (for example, a hospital, shelter, supervised boarding home).
(Respondents = Smokers who completed survey)
Answer
Total
Yes
102
No
201
No Answer
4
Respondents
307
Percent
33.2%
65.5%
1.3%
100.00%
CMHA Direct Service - Smoking Survey
Do you live or are currently staying someplace that
limites when and where you are allowed to smoke?
n=307
No Answer
1%
No
66%
Yes
33%
24
9. Desire to quit (Respondents = Smokers who completed survey)
Answer
Total Percent
I currently smoke/use tobacco and I do not want to quit in
the next 6 months
150
48.9%
I am seriously considering quitting in the next 6 months,
but not in the next 30 days
58
18.9%
I am interested in drastically reducing the number of
cigarettes I currently smoke (reduce by half or more), but
am not interested in quitting totally
56
18.2%
I am interested in quitting smoking/tobacco use in the
next month, and I would be interested in any assistance I
could get
35
11.4%
No Answer
8
2.6%
Clients interested in quitting (total)
149
48.53%
Respondents
307 100.00%
CMHA Direct Service - Smoking Survey
Desire to Quit
n=307
50%
45%
Do not want to quit in the next 6
months
49%
40%
Seriously considering quitting
in the next 6 months
35%
Interested in drastically
reducing the number of
cigarettes
30%
25%
Interested in quitting
smoking/tobacco use in the
next month. & in any assistance
I could get
No Answer
20%
19%
15%
18%
10%
11%
3%
5%
0%
Desire to Quit
25
10. How much money on average, would you estimate you spend every month on
cigarettes? (Respondents = Smokers who completed survey)
Amount spent
$10-99
$100-199
$200+
No Answer
Respondents
Total
Percent
94
102
34
77
307
30.6%
33.2%
11.1%
25.1%
100.00%
CMHA Direct Service - Smoking Survey
How much money on average would you estimate
you spend every month?
n=307
35%
30%
31%
33%
25%
25%
20%
15%
10%
11%
5%
0%
$10-99
$100-199
$200+
No Answer