Tobacco And Mental Health - Essay - English literature - Carol Brown, Essays (high school) of English Literature

Download Tobacco And Mental Health - Essay - English literature - Carol Brown and more Essays (high school) English Literature in PDF only on Docsity!

TOBACCO AND MENTAL HEALTH:

A LITERATURE REVIEW

By

Carol Brown, ASH Scotland

August 2004 ASH Scotland, Edinburgh

• 1. ASH SCOTLAND TOBACCO AND INEQUALITIES PROJECT................... CONTENTS
• 2. CONDUCTING THE LITERATURE REVIEW ..............................................
• 3. TOBACCO AND MENTAL HEALTH: SETTING THE SCENE .....................
  • 3.1 Tobacco and health................................................................................
  • 3.2 Mental health..........................................................................................
  • 3.3 Developing appropriate services ............................................................
• 4. TOBACCO USE AND MENTAL HEALTH..................................................
  • 4.1 Smoking prevalence.............................................................................
  • 4.2 Explanations for high smoking prevalence ...........................................
  • 4.3 The effects of smoking .........................................................................
• 5. CHALLENGES OF STOPPING SMOKING ...............................................
  • 5.1 General Challenges..............................................................................
  • 5.2 Attitudes of service users .....................................................................
  • 5.3 Attitudes of service providers ...............................................................
  • 5.4 Mental health culture ............................................................................
  • 5.5 Impact on symptoms ............................................................................
  • 5.6 Medication issues.................................................................................
• 6. APPROACHES TO CESSATION AND TOBACCO CONTROL.................
  • 6.1 General approaches.............................................................................
  • 6.2 Tailored approaches.............................................................................
  • 6.3 Tobacco policies...................................................................................
  • 6.4 Recommendations ...............................................................................
• 7. CONCLUSIONS.........................................................................................
• 8. APPENDIX – MENTAL HEALTH IN SCOTLAND ......................................
  • 8.1 Defining mental health and well-being..................................................
  • 8.2 Mental illness: symptoms, causes and treatments ...............................
    • Depression..............................................................................................
    • Anxiety disorders ....................................................................................
    • Schizophrenia, bipolar disorder and other psychoses ............................
    • Substance use disorders ........................................................................
  • 8.3 Mental illness prevalence and profiles..................................................
• 9. GLOSSARY ...............................................................................................
• 10. REFERENCES ........................................................................................

the previous tobacco and inequalities projects are available from ASH Scotland, both in hard copy and on-line.

Literature reviews and briefing papers are available in relation to tobacco and ethnicity, mental health and older adults. ASH Scotland is currently writing a report on current services and resources in Scotland in relation to each of these themes and a report on the current tobacco and inequalities needs assessment work will be available later in the year.

For more information please see our website: http://www.ashscotland.org.uk/inequalities/index.html

Or contact us at:

Action on Smoking and Health (Scotland) Tobacco and Inequalities Project 8 Frederick Street Edinburgh EH2 2HB

Tel. 0131 225 4725

Fax. 0131 225 4759

Email. [email protected]

2. CONDUCTING THE LITERATURE REVIEW

One of the focal points of the third phase of ASH Scotland’s Tobacco and Inequalities project is the development of community-based initiatives to tackle tobacco use among people with mental health difficulties in Scotland. A detailed understanding of attitudes, beliefs, values and behaviours in relation to tobacco use is required in order to develop appropriate strategies to tackle its usage - such as prevention campaigns, tobacco education and smoking cessation services.

A literature review was undertaken to find out more about the pertinent issues in relation to tobacco use among adults with mental health difficulties in Scotland. Reading through existing research, policy documents and other texts uncovered key themes and revealed gaps in the knowledge base.

The literature review encompassed both desk and library-based searches, using the following processes:

• Noting details of relevant literature and contacts as they came to light (over a period of twelve months, beginning in May 2003 and ending in June 2004).
• Searching the ‘mental health’ section of the ASH Scotland library.
• Using information from references at the end of relevant existing texts.
• Bibliographic database keyword searches (using terms such as mental illness, mental health, psychiatric, depression, schizophrenia, bipolar, anxiety and tobacco or smoking). The ‘wildcard’ feature was employed - the stem of a word followed by * - to broaden the searches (e.g. smok, depress, psychia*). The main database searched was the National Library of Medicine’s PubMed http://www.ncbi.nih.gov/entrez/query.fcgi, which includes citations from MEDLINE and many life science journals.
• Keyword internet searches, using the Google search engine http://www.google.com, to find web-based information.
• Focused searches on appropriate websites (such as the homepages for ASH Scotland, NHS Health Scotland, the Scottish Executive and the Health Development Agency).
• Using relevant information posted on the Globalink (‘on-line tobacco control community’) news and discussion forum http://www.globalink.org

Due to time and resource constraints it was not possible to conduct detailed meta-analyses or to scrutinise the methodology of studies in detail. This literature review does not therefore make any judgements on the rigour of the research that is referred to. However, as far as possible, information is presented about the sample and methods used to give context to any research that is cited.

The literature searches uncovered numerous articles related to smoking and mental health. Common themes were the high prevalence of smoking among people with mental illness and investigations of the relationship between tobacco use and mental health. A number of articles looked at tobacco

3. TOBACCO AND MENTAL HEALTH: SETTING THE SCENE

3.1 Tobacco and health

Improving the health of Scotland’s population is the goal of several policies and is addressed by many services and initiatives. Smoking is identified as a key public health concern.

Tobacco use is the single biggest preventable cause of ill-health and premature death in Scotland and a major cause of health inequalities. Scotland has an estimated 1.4 million smokers, representing more than one third of the adult population (Scottish Executive, 2000). In Scotland around 13,000 people die every year from tobacco-related diseases, including heart disease and many cancers (Callum, 1998). There are also serious health risks associated with passive smoking (ASH Scotland, 2004). Smoking-related illnesses cost the NHS (National Health Service) in Scotland an estimated £200 million per annum (Scottish Executive, 2004a).

There is a strong correlation between smoking and deprivation. People on low income are more likely to smoke cigarettes and are more likely to smoke more cigarettes per day on average. Statistics from 1998 revealed that 49% of men and 43% of women from the most deprived areas of Scotland were smokers, compared to an overall national average of 34% of men and 32% of women (Scottish Executive, 2000).

Smoking prevalence is significantly higher among people with mental health problems than among the general population (McNeill, 2001). Surveys reveal consistently higher smoking rates among people with all categories of mental health problems than in the general population, with highest rates found in people with a diagnosis of psychosis (Meltzer et al , 1995). Surveys on residents in British psychiatric institutions found that over 70% of patients were current smokers (Meltzer et al , 1996).

The need for action to tackle tobacco use, to improve the health of Scottish people, is outlined in the following documents:

• The Scottish Executive’s Tobacco Control Action Plan (Scottish Executive, 2004b) takes forward a commitment to review national control policy and to set out a new plan for action. This report describes actions that give most help to disadvantaged communities, where the highest rates of smoking are found. The actions in the plan are set out in four broad categories: Prevention, Provision of Services, Passive smoking (second-hand smoke) and Protection and Controls. It recommends that smoking cessation services should specifically address the needs of groups such as people with mental health problems and members of ethnic minorities, who may be difficult to engage in services and not necessarily catered for by traditional health or workplace settings.

• ASH Scotland and NHS Health Scotland’s Reducing Smoking and Tobacco-Related Harm – A Key to Transforming Scotland’s Health (NHS Health Scotland and ASH Scotland, 2004) makes recommendations about further action that should be taken in Scotland to reduce ill-health caused by tobacco. The document examines smoking trends in Scotland; looks at the most up-to-date evidence about tobacco-related harm and how it can be reduced; and considers current prevention, control and treatment policies and services in Scotland. It notes that smoking rates are extremely high among socially excluded groups, such as people with mental health problems and that smoking may be increasing among some ethnic minorities.
• The 2003 Scottish White Paper Improving Health in Scotland – The Challenge lists tobacco as a major risk factor and a focus for activity under four themes (early years, teenage transition, the workplace and communities) (Scottish Executive, 2003a).
• The 2001 Cancer in Scotland: Action for Change and 2002 Coronary Heart Disease and Stroke Strategy for Scotland acknowledge that these diseases are national clinical priorities. They recognise that illness and death associated with these diseases can be prevented and outline a commitment to improving lifestyles and targeting priority groups. National targets to reduce smoking are reiterated (Scottish Executive, 2001 and 2002).
• The 1999 Scottish Public Health White Paper Towards a Healthier Scotland stresses a commitment to reducing smoking and states initial targets for smoking reduction in three target areas - young people, pregnant women, adult smokers (Scottish Office, 1999)
• The 1998 UK White Paper on tobacco Smoking Kills emphasises the major health risks of smoking and sets targets to reduce smoking rates among young people and pregnant women, and to provide more support for adult smokers who want to quit (Department of Health, 1998).

As a result of the recommendations in these documents there has been a rapid development of smoking cessation (‘stop smoking’) services in Scotland in recent years. There are now dedicated services helping smokers to quit in every Health Board Area. Such services are a core element of a comprehensive approach to tobacco control to improve the health of Scotland’s population.

3.3 Developing appropriate services

The policy, legal and guidance documents presented above are not intended to be an exhaustive list, but rather an introductory overview of the key legislative frameworks relevant for professionals working to provide services (including health promotion and smoking cessation) for people with mental health problems.

Professionals wishing to provide smoking cessation and tobacco education initiatives should be encouraged to create detailed profiles of the population living in their area in order to inform appropriate approaches to tobacco education and smoking cessation.

Factors such as age, gender, social class, occupation, income, education, family and social networks, ethnicity, religion, housing and place of residence can impact on an individual’s way of life, tobacco use, health status and access to services.

Different approaches may be appropriate for adults of different ages, for men and for women, for people from minority ethnic communities, for people living on their own who may be feeling isolated and lacking in social support, or for people with different needs, such as those with mental illness, disabilities or functional impairments.

It is equally useful for those involved in planning, developing and providing tobacco services to have an understanding of mental health and to be aware of the influence that mental illness can have on a person’s lifestyle and physical health. However, it is also important not to stereotype or make assumptions about people who are experiencing mental illness. People with mental health problems are not a homogenous group and their interests, needs and wishes vary as widely as those of the general population.

For further information on mental health , including definitions of the terminology and an overview of the prevalence, symptoms, causes and treatments of some common mental illnesses, please refer to the appendix at the end of this document.

4. TOBACCO USE AND MENTAL HEALTH

4.1 Smoking prevalence

Smoking is so common that tobacco is not often thought of as a mental health issue. However, smoking prevalence is significantly higher among people with mental health problems than among the general population (McNeill, 2001). The 1993 Psychiatric Morbidity Survey revealed higher smoking rates among people with all categories of mental health problems than in the general population (Meltzer et al , 1995).

The highest rates were found in people with a diagnosis of psychosis (Meltzer et al , 1995). For neurotic disorders, there was a clear relationship between smoking and the number of neurotic symptoms, as measured by clinical scales (Meltzer et al , 1995).

These findings were confirmed in a more recent national study of psychiatric morbidity among 8000 people in the general UK population, which found that people with neurotic disorders (e.g. depressive episodes, phobias, obsessive compulsive disorder) were twice as likely to smoke as those with no neurotic disorder. Having more than one neurotic disorder was associated with heavier smoking (Coultard et al , 2000). In general, a greater severity of mental illness is associated with higher rates of smoking.

A survey on residents in British psychiatric institutions - including hospitals, care homes, hostels and group homes - showed that people with mental health disorders who live in institutions have particularly high rates of smoking (Meltzer et al , 1996). In this survey about 74% of people with schizophrenic disorders, 74% with neurotic disorders and 70% with affective psychosis (including mania and bipolar disorder) were current smokers. These figures are significantly higher than statistics on smoking in the general Scottish population, which suggest that around one third of adults smoke (34% for men and 32% women) (Scottish Executive, 2000).

In a study on cardiovascular risk in 102 people with schizophrenia living in the community in south west Scotland (rural Nithsdale and urban Partick, Glasgow), 70% of those surveyed were smokers (McCreadie, 2003). In other studies on people with mental illness living at home, smoking prevalence was 56% among those with depressive episodes, 55% amongst people with panic disorder and 47% among those with a generalised anxiety disorder (Meltzer et al , 1995). Although tobacco use may be lower among people with mental illness living at home than they are for people living in institutions, the rates are nonetheless higher for people with identified mental health problems than they are in the general population.

Elevated smoking rates among people with schizophrenia, bipolar disorder, panic disorder and depression have been observed in other countries (Lerena et al , 2003; Murphy et al , 2003; Uzun et al , 2002; de Leon et al , 2002; Gonzalez-Pinto et al , 1998), with the interesting possible exception of Japan,

While cannabis use may not be a cause of schizophrenia as such, it is believed that excessive use can precipitate the illness in vulnerable cases (Scottish Association for Mental Health, 2003b). Likewise, cannabis may give rise to depression. One study on 14 to 15 year olds in Australia showed that weekly cannabis use was associated with a two-fold increase in depression at the age of 20, and daily use associated with a five-fold increased risk of depressive illness, (although regular users in the study were more likely to have suffered depression or anxiety at the start of the study) (Patton et al , cited in The Point, Scottish Association for Mental Health, 2003b). The relation between cannabis, tobacco and mental illness should be borne in mind by those providing tobacco education and cessation services.

Other issues

A final matter to consider in relation to tobacco use and mental health concerns professionals working in the field. The first issue is smoking among psychiatric nurses. Although it is difficult to find any recent, large scale studies on the prevalence of smoking in mental health professionals, one survey from the early 1990s found that psychiatric nurses had a smoking prevalence rate twice that of other nurses (Gubbay J, 1992). Anecdotal evidence also suggests that many psychiatric nurses smoke. This is issue should be taken into account when addressing smoking and mental health.

The second issue is that of exposure to environmental tobacco smoke (passive smoking) for professionals working with mental health service users. Mental health workers include doctors, nurses, care-givers, counsellors, support workers and auxiliary staff. Workplaces include hospitals, supported residential accommodation, rehabilitation centres, day care services and client’s own homes. Due to the high levels of smoking amongst mental health service users, many mental health staff are exposed to other people’s smoke in the course of their work. Indeed, patients and other service users are also frequently exposed to second hand smoke. This issue is pertinent when planning appropriate tobacco control interventions.

4.2 Explanations for high smoking prevalence

Several suggestions have been forwarded to account for the high rates of smoking among those with mental health difficulties. Most controversially, it has been hypothesised that smoking could actually cause mental illness (see McNeill, 2001 pp14-15). Although few accept this explanation, there ‘ is some evidence to suggest that smoking can affect the body in such a way as to increase vulnerability to some mental health disorders ’, particularly anxiety syndromes (McNeill, 2001: 15).

More widely accepted explanations for the high prevalence of tobacco use amongst those experiencing mental illness include deprivation and social exclusion, smoking as a coping mechanism or a form of self-medication, the environment and culture of mental health services, and lack of information or support to encourage quitting. Each of these is discussed in detail below.

Personal circumstances and coping mechanisms

A clear inverse relationship between smoking prevalence and social class has been demonstrated in the overall population, with smokers in more deprived socio-economic groups having higher rates of tobacco use (Scottish Executive, 2000). There are higher rates of severe mental disorder among the most deprived sectors of society, which correlates with the high smoking prevalence. It is also worth noting that some people living with chronic mental illness may experience a reduction in their income due to unemployment or other changes to work patterns arising as a direct result of their condition.

People experiencing mental illness and poverty can feel isolated from wider society. Smoking is often used as a ‘coping mechanism’ to help deal with the stresses of living with mental illness or financial hardship (McNeill, 2001), or as a means of control in an otherwise uncontrollable environment. It has also been suggested that some people experiencing mental illness may be inclined to take risks (including risks to their health), because they feel that life is not worthwhile (Murphy et al , 2003).

Self Medication

Tobacco can be used as a type of self-medication, to counter stress and the effects of anxiety, depression or psychosis. Nicotine is thought to alleviate some of the positive and negative symptoms of mental health problems 1 , and may help ease some side effects associated with anti-psychotic medications (McCloughen, 2003; McNeill, 2001, Patkar 2002). It has also been suggested that nicotine could have antidepressant effects (Patkar, 2002; Strasser, 2001).

In one study on 59 smokers with schizophrenia, many cited relaxation and calming nerves as reasons for their tobacco use (Glynn and Sussman, 1990). Some respondents identified specific psychiatric issues as having an influence on their tobacco use, for example that they smoked in response to hallucinations or as a way of reducing the side effects of medication (Glynn and Sussman, 1990).

Although many smokers say that smoking helps to relieve stress, studies indicate that tobacco does not confer real benefits in terms of stress control. Smoking induces a cycle. It stimulates an immediate more relaxed, alert state; but this then gives way to withdrawal symptoms, increased cravings, and agitation; which then leads to further smoking to calm this anxiety. One review summarising the findings from 4 published studies into the relationship between cigarette smoking and stress found that there was a repetitive cycle of mood reversals associated with tobacco use, and that smokers gain little advantage from cigarettes, but smoke mainly to prevent nicotine depletion (Parrot, 1995).

(^1) Positive symptoms are things ‘added’ to a person’s experiences, such as delusions and

hearing voices, while negative symptoms (also known as deficit effects) are things ‘removed’ from a person, including withdrawal and lack of motivation.

Another study on psychiatric inpatients found that smoking provided structure and activity in a day which might otherwise be empty of pastimes (Van Dongen, 1999). These kind of stories are commonly told by people who have an inside knowledge of life in psychiatric institutions, either as staff or patients.

Lack of cessation advice and support

Another explanation for high smoking rates is that people with mental health difficulties are less likely than the general population to give up smoking. This could be because individuals with mental health problems find it more difficult to quit, or because they are less likely to be offered appropriate information or support to help them change their tobacco usage. This is discussed in detail later in section 5on the challenges of cessation.

To sum up, the relationship between smoking and mental illness is complex and multifaceted. Tobacco use varies with the nature and severity of the mental illness. Smoking prevalence can be explained by a combination of psychoanalytical, environmental, socio-economical, personality, medical and neurological factors (McCloughen, 2003).

4.3 The effects of smoking

Physical Health

People with mental health problems are susceptible to the same smoking related illnesses as anyone else – such as cardiovascular and respiratory diseases and cancers – which can lead to long-term and chronic disabilities, and are a cause of many deaths. However, studies show that smoking related diseases, particularly respiratory disorders and heart disease, are more common in people with severe mental illness than among the general population (Seymour, 2003; McCloughen, 2003; Brown, Inskip and Barraclough, 2000). People with chronic mental health problems have a higher risk of premature death than the general population, partly because their physical health is often neglected (Seymour, 2003).

In addition to excess mortality, tobacco use affects the general health and well-being of people with mental health difficulties. Smoking can intensify symptoms of both neurotic and psychotic conditions and affects the body in ways that increase vulnerability to some mental health disorders. Smoking can cause an increase in anxiety, by exacerbating stressful feelings, rather than abating them (Long, 2003). In one study, patients with panic disorder who smoke regularly reported significantly more severe and intense anxiety symptoms and social impairment compared to people with panic disorder who did not smoke (Zvolensky, Schmidt and McCreary, 2003).

Smoking also aggravates some symptoms of schizophrenia. For example, people with schizophrenia who smoke have been shown to present more positive symptoms (such as voices, delusion and confusion) and have been shown to have more dyskinetic movements than those who do not smoke (Goff, Henderson and Amico, 1992; Strasser, 2001).

Several studies show that smokers require greater levels of antipsychotic medicines and neuroleptic drugs (which work on the nervous system) than non-smokers. (McCloughen, 2003). This is because both nicotine and tar in cigarette smoke increase the metabolism of certain medications (Ziedonis, 1994; Strasser, 2001) 2. Likewise, smoking increases the side effects of many prescribed drugs.

Another health and safety issue associated with smoking is the risk of burns and fires caused by cigarettes, which is a concern for both for smokers, and for staff of mental health services and carers.

Although some benefits of smoking have been hypothesised (for example as a way of coping with stress and anxiety or to help alleviate impairment in organisation of thoughts), the harmful effects of cigarette smoking vastly outweigh any possible benefits. Indeed, the effects of smoking on the physical health of people with mental health problems are so significant that one commentator has referred to nicotine dependence as ‘the most prevalent, most deadly, most costly, yet most treatable of all psychiatric disorders’ (Hughes, 1999).

Financial implications

In addition to the health implications of tobacco use, smoking can have a serious impact on the financial well-being of people with mental health problems (HDA, 2004). In one study from the USA, smokers with schizophrenia were spending around 30% of their income on cigarettes (Steinberg, Williams and Ziedonis, 2004). People with mental health illness who are on low incomes can spend a large proportion of their budget on cigarettes, meaning less money to spend on things that could improve their quality of life.

To sum up, tobacco use is a significant and potentially preventable cause of ill-health and mortality among smokers with mental health difficulties. Giving up smoking has immediate and long-term benefits. However, quitting is a challenging thing to do and for many reasons smoking cessation is often neglected among people experiencing mental illness. The challenges are discussed in the following section.

(^2) Antipsychotics whose metabolism has been shown to definitely affected by smoking include:

Clozapine (Clozaril), Fluphenazine (Modecate), Haloperidol (Serenace, Haldol) and Olanzapine (Zyprexa). Risperidone (Risperdal) and Quetiapine (Seroquel) appear not to be affected (Strasser, 2001).

were taking), although the smoking culture on psychiatric wards was also cited. The majority said that they found it difficult to relate to information leaflets and advertisements on cessation, and felt that these were not aimed at people with mental health difficulties. There was also a general lack of awareness that Nicotine Replacement Therapy (NRT) was available on prescription.

Another report on mental health service users’ perspectives on physical health noted that people experiencing mental illness may feel excluded from mainstream stop smoking programmes or believe that existing health promotion campaigns are ‘not for them’ (Freidli and Dardis, 2002).

5.3 Attitudes of service providers

Preconceptions about the attitudes and abilities of people with mental illness towards health behaviour change are a further challenge for smoking cessation providers. People experiencing mental illness are seen as a difficult group to engage and it is often (wrongly) assumed that people with mental health difficulties are not interested in wider health promotion initiatives or do not have an insight into their own best interests^3. People with psychiatric disorders are presumed to lack the motivation, cognitive function or insight necessary to control their tobacco use. It is also argued that it would be morally wrong to remove one of life’s pleasures from people who have so much to contend with.

It seems that mental health professionals often miss the opportunity to offer smoking cessation counselling to patients who smoke (Himelhoch and Daumit, 2003). This may be because of low expectations of clients’ desires or abilities to quit, or because staff working in this field perceive the mental health of their patients as the priority, with physical health as a secondary importance.

A study by mental health organisation Mentality looked at information provided by eleven mental health voluntary agencies on smoking cessation relating to mental health service users. Only two of the organisations surveyed had specific information. The remainder stated that they supported non-smoking but did not have any specific information to offer, and commented that they would refer people on to a helpline or other agencies for further advice (Mentality, date unknown). The study concluded that the need for smoking cessation information does not seem to be a priority for the mental health voluntary sector.

Tobacco use might be regarded as a lower priority than other substance use, because cigarettes are not an illegal substance and smoking does not radically impair mental functioning, like alcohol or illicit drugs. Health

(^3) A study by mental health organisationMentality discovered that users did in fact take an

interest in their own physical health, even though this was not always recognised by health and social care professionals or by carers (Seymour, 2003).

promotion may be seen as outside of the mental health remit, and staff may lack the skills, knowledge and training to discuss issues such as smoking.

5.4 Mental health culture

A further issue is the cultural acceptability of smoking in many mental health institutions. Traditionally, psychiatric institutions condoned smoking, by using cigarettes as incentives, rewards or punishments (McNeill, 2001). Smoking is a form of social activity in some mental health establishments and people smoke because there is little else to do.

Anecdotal evidence suggests that some staff even smoke with their patients as a way of social interaction and to facilitate communication (Smokefree London, Mentality and ASH symposium, 2001; Guardian Unlimited, 2001). The fact that many mental health nurses and other caregivers are smokers themselves is a significant issue.

By nature of the job, many psychiatric staff are strong-willed and assertive, and getting them to change their value systems is not an easy task. Involving staff and changing attitudes presents quite a challenge, particularly with regards to introducing tobacco policies and cessation initiatives in mental health institutions and organisations.

It is argued that adults living in mental health institutions should have the right to make choices about their lives. However, this argument seems to refer to the right to smoke, rather than the right to be informed about the risks of smoking or being given the opportunity to change their behaviour; or the right to be protected from environmental tobacco smoke or to breathe smoke-free air.

5.5 Impact on symptoms

There is a fear that mental health symptoms will be exacerbated by attempts to stop smoking. There is concern that the symptoms of nicotine withdrawal, such as irritability, restlessness and depression, could have an impact on mental illness; and that depressive and anxiety symptoms may increase as a result of smoking cessation. The belief that quitting could disrupt treatment and lead to relapse in the client’s condition is a key reason for the neglect of cessation among people with mental illness.

Some studies suggest that smokers with a history of severe neurosis have an increased risk of psychiatric complications after smoking cessation, or are more likely to experience persistent withdrawal discomfort over a longer period of time (Hitsman et al , 2003; Breslau, Kilbey and Andreski, 1992; Covey, Glassman and Stetner, 1998; Covey 1999). Some of these studies also indicate that a history of major or recurrent depressive or anxiety disorders can have a significant negative effect on success at quitting.

However, other research contradicts these conclusions. One study looking at psychosis found that stopping smoking did not appear to exacerbate the