Art & science |
The synthesis of art and science is lived by the nurse in the nursing act
JOSEPHINE G PATERSON
HELPING PEOPLE WITH SERIOUS
MENTAL ILLNESS TO CUT
DOWN OR STOP SMOKING
Tim Bradshaw and colleagues use case studies to
show how a bespoke intervention, which is being
trialled, can help service users quit their habit
Correspondence
[email protected]
Tim Bradshaw is senior lecturer,
school of nursing, midwifery
and social work, University of
Manchester
Emma Davies is support time
recovery worker, Manchester
Mental Health and Social Care
NHS Trust
Margaret Stronach is community
recovery team clinical lead,
Leeds and York Partnership NHS
Foundation Trust
Katherine Richardson is clinical
studies officer, Tees Esk and
Wear Valleys NHS Foundation
Trust
Laura Hermann is research
assistant, Humber NHS
Foundation Trust
Date of submission
May 20 2013
Date of acceptance
August 23 2013
Peer review
This article has been subject to
double-blind review and has been
checked using antiplagiarism
software
Author guidelines
mhp.rcnpublishing.com
Abstract
The prevalence of smoking in people with serious
mental illness is up to 5.3 times higher than in the
general population and many die prematurely from
smoking-related diseases. There is a need to develop
effective, accessible, acceptable smoking cessation
services that are tailored to this client group.
Scimitar is a flexible, bespoke intervention based
on a traditional NHS smoking cessation model with
a ‘cut down to quit’ option. Cultural factors in mental
health services may still create barriers to service
users giving up smoking, and all mental health nurses
should be trained to provide smoking cessation advice
as part of their routine preparation for practice.
Keywords
Medication interactions, nurse training, serious
mental illness, smoking cessation
TWO RECENT high-profile reports by the Royal
College of Psychiatrists (RCPsych) (2012) and the
Schizophrenia Commission (2012) have highlighted
the inequalities in physical health between people
with serious mental illness (SMI) and the general
population. Individuals with schizophrenia and other
SMIs lose between 15 and 25 years of normal life
expectancy (Tiihonen et al 2009), they are twice as
likely to develop a serious medical condition before
the age of 55 years and they are significantly more
likely to die within five years of diagnosis (Disability
14 March 2014 | Volume 17 | Number 6
Rights Commission 2006). One of the principal
reasons for poor physical health among people
with SMI is the high prevalence of smoking, with
up to 70% being current smokers and half of those
smoking heavily; that is, more than 20 cigarettes per
day (Jochelson and Majrowski 2006).
In a 17-year follow up of 370 community
clients with a diagnosis of schizophrenia,
Brown et al (2010) found that of the 164 (44%) who
had died (mean age of death 57.3 years in men and
65.5 years in women) 81% of deaths were due to
natural causes and only 17% were due to unnatural
causes such as accident and suicides (2% unknown).
And 70% of the deaths from natural causes were
from smoking-related diseases.
Lack of assessment
People with SMI start smoking at a younger age
(Myles et al 2012), they inhale more deeply and
are more addicted to nicotine than smokers in
the general population (de Leon and Diaz 2005).
Yet the recent National Audit of Schizophrenia
by RCPsych (2012) found that only 57% of those
with SMI whose smoking status was assessed
were offered a smoking cessation intervention.
Furthermore, when smoking cessation services are
available, they can be difficult for people with SMIs
to access (Brunette et al 2012). There is a need to
develop effective and accessible smoking cessation
services that are tailored to this client group
(Department of Health 2010).
MENTAL HEALTH PRACTICE
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Art & science | physical health
In this article we describe the development
and evaluation of a bespoke smoking cessation
intervention for people with SMI in a clinical trial.
The delivery of the intervention will be illustrated
with case studies (see panels), and its implications
for the roles of mental health nurses and other
professionals will be discussed.
Considerations when
introducing interventions
In the first systematic review of smoking cessation
interventions for people with SMI, Banham and
Gilbody (2010) examined evidence from ten
randomised controlled trials. The authors concluded
that smoking cessation interventions are about
as effective in people with SMIs as in the general
population, and that for those with a stable
psychiatric condition, they do not result in any
deterioration in mental state.
The types of interventions shown to be effective
are the same as those offered to smokers in
the general population and normally include
a combination of pharmacological treatments,
including nicotine replacement therapy (NRT),
bupropion or varenicline, and individual or group
behavioural support. However, practitioners should
be cautious when helping people with SMIs to give
up smoking, particularly if the client is receiving
atypical antipsychotic medication.
Smoking cigarettes results in increased
breakdown of antipsychotic drugs in the liver and
therefore lower plasma concentrations of the drugs
in the blood. Consequently, when these service
users cut down the number of cigarettes they
smoke, their plasma levels of the antipsychotic may
rise, potentially increasing its action including any
side effects. In some instances, for example, with
olanzapine and clozapine, this situation lowers the
individual’s threshold to seizures.
Therefore when helping people with SMI who are
taking olanzapine or clozapine to reduce or give up
smoking, practitioners should monitor the blood
levels of the drug(s) and adjust doses accordingly.
In the UK, the Royal College of General Practitioners
(RCGP) and the RCPsych Forum (2008) have
produced guidelines for practitioners to help them
manage smoking cessation safely in people with SMI.
Studies show that prescribing pharmacological
agents to help someone give up smoking more
than doubles the likelihood of a quit attempt being
successful (Stead et al 2008), although there are
potential complications for people with SMI. For
example, varenicline has been associated with an
increase in suicidal thoughts (Gunnell et al 2009),
but a recent systematic review examined data from
16 March 2014 | Volume 17 | Number 6
17 studies and concluded that varenicline treatment
was not associated with worsening of psychiatric
symptoms in people with SMI (Cerimele and
Durango 2012). Bupropion has been shown to
lower seizure thresholds, particularly in individuals
with a history of heavy alcohol use (Pesola and
Avasarala 2002), although the review by Banham
and Gilbody (2010) showed no evidence of seizures
having occurred in people receiving bupropion.
This evidence can appear contradictory and
confusing, but it suggests that in most instances
the safest form of pharmaceutical support to offer
to people with SMI is NRT. This can be provided in
various ways (Box 1).
Pilot trial
Scimitar is a pilot randomised controlled trial
funded by the National Institute for Health
Research Health Technology Assessment (NIHR
HTA) Programme (project number 07/41/05).
The goal is to develop and evaluate a bespoke
smoking cessation service specifically tailored for
service users with SMI.
The study aimed to recruit 100 people with SMI
who smoked, from both primary and secondary care
outpatient settings, and randomly allocate them to
either the bespoke smoking cessation intervention
plus usual NHS care, or to usual NHS care alone.
The primary outcome measure is expired breath
carbon monoxide (CO), which was taken at one,
six and 12 months follow up. The study recruited
97 participants, and we are collecting follow-up data
for 12 months. The findings are not presented in this
article but will be published at a later date.
The bespoke smoking cessation intervention is
based on a traditional NHS smoking cessation model
but adapted to meet the needs of individuals with
SMI. Smoking cessation advisers were seconded from
routine NHS and university posts, including a mental
health nurse, a support-time recovery worker and
a research assistant; all had experience of working
with people with SMI. All of the advisers attended
a one-day training course in the standard NHS
Box 1 Formulations used in nicotine replacement
therapy
■■ Transdermal patch.
■■ Spray (oral or nasal).
■■ Gum.
■■ Sublingual tablet.
■■ Inhalator.
■■ Lozenge.
■■ Microtab.
■■ Nasal spray.
MENTAL HEALTH PRACTICE
Case study one
B was a 49-year-old woman with a diagnosis of
paranoid schizophrenia. She had a small social circle
of friends, some of whom smoked. B had tried to quit
smoking five times before using nicotine replacement
therapy (NRT) patches, and her longest duration of
cessation was one year.
Her reasons for quitting were health related and
the cost associated with smoking. She smoked
about 20 cigarettes a day and smoked more in
the morning than the afternoon, indicating a
stronger addiction to nicotine. On initial assessment
her expired breath carbon monoxide reading
was 19ppm (3.7% COHb), indicating that she
was a frequent smoker, mid range between a
non-smoker and dangerously addicted.
B presented as motivated to quit and felt the best way
to do this was to give up cigarettes completely, rather
than follow Cut Down to Quit guidance. She reported
that her main triggers for smoking were drinking
coffee and boredom.
A quit date was set and a plan was developed for
how she would avoid cues for smoking and deal
with cravings. Two weeks later, B quit smoking
and disposed of her smoking-related possessions.
To relieve the boredom associated with smoking
cessation, she used coping strategies such as
colouring cartoon books during the evening and
walking during the day. Her success in quitting was
positively reinforced by the therapist using praise
whenever possible. In addition, B used
self-reinforcement by saving some of the money she
smoking cessation model, qualifying them as level
2 intermediate advisers.
The NHS model normally involves six to
eight meetings between the smoker and the smoking
cessation adviser. At the first session, the person’s
smoking habits are assessed, including how many
cigarettes they smoke per day, their level of
nicotine dependency and their motivation to quit.
A quit date is set – normally two weeks from the
first appointment – and the smoking cessation
adviser devises a collaborative plan with the client
to enhance the likelihood of success. In most
instances this plan will include the prescription of
a pharmacological product to help reduce nicotine
withdrawal effects.
The decision about which smoking cessation
product is selected is also made collaboratively,
MENTAL HEALTH PRACTICE
would normally spend on cigarettes to treat herself
to some new clothes and jewellery.
B also avoided coffee, as this was identified as
major trigger for smoking; instead she ate citrus
fruits and drank peppermint tea. She reported this
had a beneficial effect on the level of craving she
was experiencing. Evidence suggests that high levels
of vitamin C can help to reduce nicotine cravings
(Wastchak and Miller 2003).
To support her attempts to quit, B was prescribed
two methods of NRT delivery – patches and gum.
Patches allow slow release of nicotine, which
can help stave off cravings during the night. This
was supported by gum, which gives a quicker
release during the day; however, B found the taste
quite peppery, and it was difficult to adopt the
recommended technique of chewing and ‘parking’
the gum between her lip and upper gums. If this
technique is not followed, users may feel sick as
the nicotine will go to their stomach and they will
not get the desired release of nicotine into the
bloodstream. In view of this, B was prescribed
an inhalator which allows the release of NRT in
a similar way to drawing on a cigarette, hence
satisfying the behavioural aspect of smoking.
She found this much more beneficial.
B did not smoke for four months but unfortunately,
following an episode of physical illness and severe
family stress, she relapsed and started smoking.
She does however remain motivated to attempt
to quit again in the near future.
based on past experience, level of nicotine
dependency and personal preference. As well as
pharmacological support, the adviser also provides
behavioural support. The smoker’s motivation
to quit is reinforced by using decisional balance
exercises; where the good and bad things about
smoking are considered, and the smoker’s main
reasons for wanting to quit are examined.
Information is provided about common effects of
withdrawal from nicotine, so the smoker knows what
to expect. They are also helped to develop coping
strategies to deal with cravings and to identify
high-risk situations or cues that should be avoided
after they have stopped smoking.
Once the quit date is reached, the smoker is
expected to throw away all their remaining cigarettes
and smoking-related items, such as lighters and
March 2014 | Volume 17 | Number 6 17
Art & science | physical health
Case study two
C was a 50-year-old married man with a
diagnosis of bipolar disorder. He had tried to
quit smoking before, but not in the past five
years. The longest period of cessation had
been three months and he had used patches
and bupropion to achieve this. His main
motive for quitting was health reasons.
C was cautious about receiving nicotine
replacement therapy (NRT) because he
had heard people could get addicted to it.
He was advised that it has been known
for people to use the NRT for longer than
recommended but this would still be far less
harmful than smoking tobacco.
On initial assessment his carbon monoxide
reading was 22ppm (4.2% COHb), which
indicated that he was a moderate smoker.
He reported smoking 75g of rolling tobacco
a week (approximately 25 roll-up cigarettes
per day). C opted for the Cut Down to Quit
option because he thought that stopping
smoking completely would be too stressful
and had not worked for him before;
stress had been identified as a trigger for
his mental illness. He thought that the
last time he stopped smoking the stress
adversely affected his mental health,
and so he chose Cut Down to Quit.
The main barriers to C quitting were
boredom and habit. C was not in paid
employment but was building his own
house, and he used smoking as a reward
during break times, thus positively reinforcing
the habit. He also said that he smoked when
his daughter ‘played him up’, and perceived
nicotine as a stress reducer.
Evidence suggesting that smoking does not
decrease stress but merely staves off nicotine
withdrawal symptoms was discussed with
him (Action on Smoking and Health 2011).
C’s wife did not smoke and she was
motivated to help her husband quit. She
offered to monitor the number of roll-ups he
smoked. His daughter also was encouraging
and delivered positive messages to him every
time he did not smoke.
C managed to cut down significantly to
ten roll-ups per day before deciding he
wanted to set a quit date. He focused on
ashtrays, and then to abstain from smoking.
At each additional visit, CO readings are taken,
and continued abstinence from smoking is
reinforced with praise. The benefits of the smoker’s
new identity as a ‘non-smoker’ are reinforced and
they are helped to develop further coping strategies
for any problem areas they are experiencing.
How the model was adapted As people with SMI
are usually highly addicted smokers, we decided
that in addition to the standard NHS model we
would offer an alternative approach known as
Cut Down to Quit (Wang et al 2008). With Cut
Down to Quit, the smoker is encouraged to set a
target for how many cigarettes they would like to
reduce their daily habit by.
NRT is started while smoking continues, so that
as the smoker begins to cut down they experience
fewer cravings from nicotine withdrawal. The
smoker is then encouraged to reduce the number
of cigarettes they smoke each day, but there is
no obligation to set a quit date, although this may
be achieved later. Other adaptations that we made
to our intervention included offering more than the
18 March 2014 | Volume 17 | Number 6
cutting out all cigarettes that he felt were
‘non-essential’, distracting himself when a
craving came up by chewing on liquorice
root sticks and going for a walk or watching
television/reading a book.
An inhalator was prescribed to address
the behavioural and physical addiction to
tobacco, which C reportedly used to good
effect. However, he did not stay completely
abstinent from tobacco after the quit date.
On assessment it transpired that he was
doing manual labour with a man who
smoked, therefore every break time he was
exposed to cigarette smoke and temptation.
He was now smoking seven cigarettes a day,
but was reassured that as he had cut down
so much this was still a success.
C stated that he was finding quitting quite
stressful and he was not feeling well in his
mental health. Therefore we decided that
a break from the intervention would be the
best course of action. A few months later,
he said that he had found the intervention
useful but no longer felt his mental health
was stable enough to participate.
usual six to eight sessions. Sessions were held at
a venue and time matched to service user choice,
and this often involved visiting them at home.
In view of the potential adverse effects of some
smoking cessation products in people with SMI
in the Scimitar study, we decided that we would
recommend the prescription of NRT, but not
varenicline. The prescription of bupropion was
supported for individuals who requested it.
All professionals involved in the care of people
taking olanzapine or clozapine were given the leaflet
from the Royal Colleges referred to earlier (RCGP
and RCPsych Forum 2008), providing guidance
about dose reduction and monitoring of plasma
levels. Smoking cessation practitioners worked
with the clinical teams to ensure that a plan was
in place before the service user attempted to
reduce cigarette consumption. Smoking cessation
advisers did not prescribe the pharmaceutical
smoking cessation products, but would request the
participant’s GP to do so. To illustrate some of
the issues and complexities involved in the delivery
of the bespoke smoking cessation intervention
in practice, we present three case studies written
MENTAL HEALTH PRACTICE
by the advisers who worked with the individuals
concerned in the community (see panels).
Discussion
Smoking cigarettes is the single most common
cause of premature mortality in the developed
world (Mokdad et al 2004). The prevalence of
smoking in people with SMI is up to 5.3 times
higher than in the general population (de Leon
and Diaz 2005) and is a significant contributory
factor to reduced life expectancy in this group
(Brown et al 2010).
Trying to give up smoking for people with SMI
is difficult; many smoke more heavily, inhale more
deeply and are more dependent on nicotine than
smokers in the general population (de Leon and
Diaz 2005).
There are also cultural factors in mental health
services that may create barriers to service users
giving up smoking (Jochelson and Majrowski 2006).
For example, in the past in the UK, cigarettes were
often used as rewards by mental health nurses when
clients completed desired target behaviours.
Dickens et al (2004) showed that some mental
health nurses were resistant to the implementation
of smoking bans, stating that smoking helped them
to engage service users in therapeutic relationships
and that clients should be allowed to smoke because
it was ‘a comfort’ and that they had ‘nothing
else to live for’ (Jochelson and Majrowski 2006).
Nurses have also argued that if smoking bans
were implemented, levels of untoward and violent
incidents would increase; however, evidence does
not support this (el-Guebaly et al 2002). In fact there
Case study three
D was a 35-year-old man who lived alone. He had a
small circle of friends of whom several smoked. D’s
diagnosis was of depression with psychotic symptoms.
On initial assessment his carbon monoxide (CO)
reading was 49ppm (9.3% COHb), which indicated
he was a heavily addicted smoker.
He reported smoking 60 cigarettes per day and said
he had tried to give up ‘hundreds of times’ and had
tried most of the nicotine replacement therapy (NRT)
products available. His primary reason for wanting
to quit was his fear of developing cancer, and the
secondary reasons were the negative impact he
perceived it had on his mental wellbeing, and the
high cost of smoking.
Initially D was anxious to stop smoking as soon
as possible and requested varenicline to help him,
because he said he knew other people who had found
this helpful. However, in line with the Scimitar study
protocol, the potential adverse effects of this drug were
explained. Therefore D decided to adopt a Cut Down
to Quit approach, although initially he declined NRT,
preferring to try to make changes in his behaviour to
help avoid cues to smoke. These changes included
making his home a smoke-free environment – he
would often smoke when watching TV in the lounge –
and reducing the amount of coffee he drank, because
this was linked to having a cigarette. Distraction
techniques such as going for walks and other forms of
exercise were also discussed.
By the third visit, D had decided that he would like
to have some NRT to support him in cutting down.
MENTAL HEALTH PRACTICE
Having discussed the different types of NRT, his GP
was requested to prescribe an oromucosal spray.
After three months, D had halved his cigarette
consumption to 30 a day through using the spray
and avoiding cues to smoke. He noted becoming
more mindful at this point and had began to ask
himself ‘do I need it?’ before every cigarette.
At the next visit his consumption had increased to
50 cigarettes a day; in this session he was encouraged
to refocus on the reasons why he wanted to give up
and he was reminded to use the NRT as often as he
needed. During the next week he was able to reduce
again to 40 cigarettes a day, and he decided to set
a date to quit completely. It was agreed that on his
quit date he would use the NRT spray as well as the
24-hour patch.
The next week D stopped smoking and reported
that he felt confident in this attempt and was able
to manage his cravings effectively with NRT and
through managing stressful situations that would
usually be a trigger for him to smoke heavily.
In the months that followed, D maintained his
abstinence from smoking and began to reduce
his use of the spray. He used the time he would
normally have spent smoking and the money
saved to join a local gym and began exercising
daily. The intervention consisted of a total of nine
sessions delivered over a period of seven months.
At the end of this time D had maintained his
non-smoking status as confirmed by self-report
and low CO readings.
March 2014 | Volume 17 | Number 6 19
Art & science | physical health
is some evidence that, once smoking is banned,
therapeutic activities on hospital wards may increase
(Jochelson and Majrowski 2006).
The culture of mental health services tends to
support smoking as an acceptable and normal
activity (Lawn 2004, Lawn and Pols 2005), whereas
in UK society more generally it has become less
socially acceptable during the past decade. If we
are to begin to address the inequalities in the
physical health and life expectancy of people with
SMI, mental health service providers need to adopt
positive attitudes towards smoking cessation. They
also need to start encouraging service users to
consider trying to cut down the amount they smoke
or to quit completely (Bradshaw and Pedley 2012).
For those service users who do wish to accept
smoking cessation advice, there is a need to develop
and evaluate interventions that are more acceptable
to people with SMI, such as those we have described
in this article.
Conclusion
We have described the development of a bespoke
smoking cessation intervention that has been
designed specifically to meet the needs of people
with SMI, and we have illustrated its application in
three case studies.
If our bespoke intervention is shown to be
effective in reducing smoking and acceptable
to people with SMI, it may provide a potential
solution to help address their health needs.
Smoking cessation advisers can be trained in
intervention in one day, and it would be possible
to train all UK mental health nurses, and possibly
other professionals, as part of their routine
preparation for practice.
Delivering training at this basic level might
help to change attitudes towards smoking
cessation and provide the critical mass of skilled
workers needed to offer bespoke smoking
cessation advice as part of routine care.
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Conflict of interest
Funding acknowledgement: This
project was funded by the National
Institute for Health Research
[Health Technology Assessment
programme] (project number
07/41/05) and will be published
in full in Health Technology
Assessment later this year
Department of Health disclaimer:
The views and opinions expressed
therein are those of the authors and
do not necessarily reflect those of
the Health Technology Assessment
programme, NIHR, the NHS or the
Department of Health
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MENTAL HEALTH PRACTICE