Commentary on Banham & Gilbody (2010): The scandal of smoking and mental illness

Abstract

Commentary on Banham & Gilbody (2010):The scandal of smoking and mental illnessa dd_3025 1190..1191 This issue of Addiction contains a meta-analysis of clinical interventions to help people with mental illness stop smoking [1]. Although the number of trials and types of interventions was small and the quality variable, the cautious conclusion is that interventions proven in the general population of smokers are also effective in those with mental illness. One might ask why there is a need to test separately in this population treatments already established in the general population? Is this not just an unnecessary and expensive reinvention of the wheel? It can be justified on at least two counts, both of which point to past failures on the part of health policy makers, tobacco researchers, the pharmaceutical industry and psychiatric institutions and staff.First, smokers with a current or recent mental illness have usually been excluded from participation in trials of clinical interventions, particularly those testing pharmacotherapies. Hence, we have little explicit evidence that these treatments also work for these smokers. This appears to be a case of the manufacturers being overcautious about side effects and drug interactions, or possibly defensive about a group of smokers considered traditionally very hard to help. It is a practice that should end. Drug regulators can act immediately by refusing new trials that exclude people with mental illness, unless the marketing licence is also intended to exclude them on safety grounds. Those with mental illness have not only been neglected in smoking trials. When gauged against need and risk criteria-smoking prevalence (population) and smoke intake (individual)-they appear to have been badly neglected in all areas of tobacco control and smoking cessation policy.Considering prevalence first, de Leon & Diaz, in a comprehensive meta-analysis of 42 studies, found that 62% of people with schizophrenia smoked [2]. The odds of smoking were six times higher than among those in the general population. In those with other mental illnesses the prevalence was 50%. People with mental illness were also found more likely to be heavy smokers, with 40% smoking more than 25-30 cigarettes per day compared with 15% in general population controls. These latter results are corroborated by biochemical measures of smoke intake. In four studies, those with mental illness had saliva or plasma cotinine levels averaging 44% higher than in general population controls [3][4][5][6]. Other studies have shown consistently higher scorers on questionnaire measures of nicotine dependence [3,[7][8][9]. These findings will surprise no clinicians working on psychiatric wards.Against this background of more widespread and hazardous smoking, it is not surprising that those with serious mental illness die about 25 years earlier than others, and are probably more likely to die as a result of their smoking [10,11]. While living, they will rely more often on state benefits and sacrifice a healthier diet and ...

Factors Affecting Smoking Cessation Efforts of People With Severe Mental Illness: A Qualitative Study

“…Recent investigations have explored best practices in providing smoking cessation interventions to people living with severe mental illness (Lasser, 2009;Stapleton, 2010). Results indicate that the combination of pharmaceutical and behavioral interventions effective within the general population is also helpful for people with severe mental illness who smoke (Banham & Gilbody, 2010;Morrison & Naegle, 2010;Schreoder & Morris, 2010).…”

Inequity in smoking cessation clinical trials testing pharmacotherapies: exclusion of smokers with mental health disorders

“…Although this review did not specifically explore conditional/explicit exclusion based on MHD diagnosis, the findings align with those of a 2011 meta-analysis of 54 RCTs assessing the effectiveness of pharmacotherapies for smoking cessation that found similarly high rates of exclusion across studies for MHD groups: 40.7% current depression, 35.2% current psychosis, 33.3% current bipolar disorder and 31.5% current panic disorder 34. While such exclusions could be driven by the researchers and by the regulatory and/or ethics committee approving the trials, the lack of explicit evidence from research to guide effective treatment in this group due to under-representation in RCTs indicates inequity in health outcome research and delivery 35. The pragmatic application of RCT findings is compromised and often contributes very little to clinical practice when the population for whom the intervention is most applicable are excluded from study participation 15 36.…”

Reply to Chapman: Misrepresentation in Stapleton's Commentary

“…By arguing for the abandonment of clinical treatments for smokers, Chapman would deny the disproportionately large group of smokers with a mental illness the sort of caring help that respects and considers their comorbidities. Smoking and mental illness was the subject of my original commentary [2], and I will not reiterate the evidence on the high smoking prevalence rates and tobacco dependence levels among people with mental illness which tell of their past neglect in smoking cessation efforts. However, the UK National Health Service (NHS) now treats about 500 000 smokers annually, suggesting that in the region of 250 000 with a history of mental illness and 125 000 with a current mental illness are cared for [6,7].…”

“…Professor Chapman's suggestion that I misrepresented his views on the clinical treatment of tobacco addiction, particularly in the case of people with mental illness, may surprise those familiar with his long‐standing stance against providing such help [1–5]. Perhaps I chose the wrong paper to cite [3], rather than the more specific papers in which he argues forcefully for ‘the abandonment of smoking cessation clinics’[4,5], i.e.…”