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


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 over-cautious 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 [3–6]. Other studies have shown consistently higher scorers on questionnaire measures of nicotine dependence [3,7–9]. 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 life-style to buy tobacco [12]. Whether rooted in genetic/neurobiological, therapeutic, psychological or cultural associations between tobacco and mental illness, such statistics—known for years—indicate a massive inequality in health due to smoking.

There are some who argue that the sort of effective help to stop smoking described in this issue of Addiction and in other reviews [13,14] should be denied people with mental illness, and all smokers. They argue that viewing tobacco dependence as a disorder and helping smokers individually in the way caring societies normally help those with health-related disorders is unnecessary and counter-productive [15]. For them, the solution is a higher intensity of established population-level control measures—tobacco taxation, smoking restrictions and educational and fear-arousing anti-smoking media campaigns. In the United Kingdom, a carrot-and-stick approach has been preferred to stick, stick. Alongside population-level measures to educate and encourage a cessation culture, evidence-based help sympathetic to individual comorbidities is offered through national stop smoking services [16]. As might be expected, given the high smoking prevalence rates and nicotine dependence levels among people with mental illness, a high proportion of those seeking help from these services have current or past mental illness. In one recent specialist clinic study, where varenicline was also seen to be equally as effective in those with and without mental illness, 27% reported a current mental illness, and 55% reported a history of mental illness [17]. In a study of 80 000 general population smokers seeking help to stop in primary care, 63% had a history of mental illness (25% psychosis, 50% depression, 38% other disorders) [18].

It is obviously long overdue that the health-care community took action and introduced policies to offer better help to stop smoking for people with mental illness. Where treatment services exist, they need to be redirected to where the need is greatest, and there appears no greater need than among people with mental illness. The Banham paper in this issue supports the view that established evidence-based treatments work, and should offer a new impetus to all psychiatric and smoking cessation clinicians.

Declaration of interests

John Stapleton was formerly an adviser to the manufacturers of smoking cessation medications, for which he has received remunerations and hospitality.