Objective: Togather information on smoking rates and interest in smoking cessation among consumers at a Psychiatric Disability Rehabilitation and Support Service (PDRSS).
Method: Aquestionnaire was offered to all consumers at Neami Victoria by support staff in March 2007. Two hundred and eighty people (81%) completed the survey. Relationships between categorical variables were analysed using Fischer's exact test (p=0.05).
Results: Sixty-two per cent of consumers were smokers. Twelve per cent had previously quit smoking. PDRS consumers smoked 50% more than the general population and high rates (17%) of illegal tobacco smoking were identified. Fifty-nine per cent of smokers wanted to quit while 74% wanted to reduce.
Conclusions: While smoking rates were almost four times higher than the general population, interest in quitting and cutting down was also high.
Implications: Opportunities exist for public health advocates to collaborate with PDRSSs to increase knowledge related to smoking harms, and to reduce smoking in this group.
Australia is recognised internationally for its ‘public health success story’ in tobacco control.1 According to the OECD, cigarette smoking rates in the Australian population halved over the past 20 years (from 35% in 1983 to 17.7% in 2004).2 However, smoking rates remain four times higher among people with mental illness than the general population with little change over the past 10 years.3–6 Attempts to quantify the cost of smoking among people with mental illness in Australia have led to estimates of more than $30 billion per year.7
Smoking and its consequences exacerbate mental health problems and increase support needs. Smoking lowers energy and fitness levels that restrict mobility and may worsen psychological problems.8,9 This increased support affects the Psychiatric Disability Rehabilitation and Support Service (PDRSS) sector. The PDRSS sector is well-placed to address smoking cessation, yet little is known about interest in quitting within this context.
PDRSSs support individuals aged between 16 and 64 years of age who experience “serious mental illness and associated significant psychiatric disability”.10 Principal consumer diagnoses include schizophrenia, bipolar disorder, major depressive disorder and personality disorders.
The PDRSS sector functions as a bridge between clinical services and the broader community. It assists in the prevention of relapse and re-admission to hospital and promotes social inclusion and participation.11
This bridging function between clinical and community services means PDRSSs are ideally placed to facilitate smoking cessation.
Neami is a national PDRSS servicing four Australian states. Neami Victoria has identified that smoking is an important issue for consumers, due to financial and health impacts. Furthermore, secondary smoke inhalation can impact on staff health. Previous research at Neami found that smoking rates were high (61%), but that 62% of smokers wanted to reduce and 35% wanted to quit smoking.3
To survey consumers of Neami Victoria (a leading PDRSS provider) about smoking rates, including amount and type of tobacco product smoked; and interest in cutting down or quitting smoking.
Neami Victoria had 346 consumers registered at the survey time. Participants were drawn from this group. Characteristics of this group include 45% female, 60% have a diagnosis of schizophrenia and 24% have a co-occurring alcohol and other drug problem.12 Service users' main source of income was the Disability Support Pension (73%).
A simple one page questionnaire was developed to identify demographic and psychiatric characteristics, determine smoking status, including number and type of cigarettes smoked, and desire to quit or reduce smoking. Respondents were asked if they smoke and if not, had they ever smoked. They were then asked what type of tobacco products they smoked (readymades, roll-your-owns or ‘chop-chop’) and how many per day. Interest in quitting was measured by asking participants to state whether they wanted to quit, a) in the next 30 days, b) in the next six months, or c) other – give details. The same question format was used to assess interest in reducing smoking. Finally, respondents were asked to indicate gender, age and psychiatric diagnosis. Previous research has indicated that simple questions regarding desire to quit function as effective measures of actual desire to quit.13 A copy of the questionnaire is available from the author.
Ethics approval was gained from the University of Melbourne Human Research Ethics Committee. This approval was deemed sufficient for the purposes of Neami's management committee. Data collection occurred in March 2007.
Support staff administered questionnaires because they have regular contact with consumers. Staff were then available to answer any questions or assist with the completion of the survey if required. In the rare case that consumers were not in face-to-face contact with support staff, the questionnaire was administered through a phone interview.
A return rate of 81% was obtained, (n=280). Reasons for non-completion of the survey included hospitalisation for mental illness, away or temporarily out of contact with the service, or just entering/exiting the service.
The data were analysed using SPSS (Version 15). Relationships between categorical variables were analysed using Fischer's exact test (p=0.05). An independent samples t-test was used to compare quitters and smokers in terms of mean age.
Sample characteristics did not differ significantly from the broader Neami population of service users indicating a representative sample across demographic and diagnostic profiles.
Sixty-two per cent of the sample (n=174) were smokers. Twelve per cent of the sample (n=33) were non-smokers who had previously been smokers, indicating that they had successfully quit smoking. A further 26% of Neami consumers had never smoked (n=73).
Smokers were most likely to have a diagnosis of schizophrenia (60%), with bipolar disorder the next most common diagnosis (7%) then depression (6%). Because the number of smokers with a diagnosis other than schizophrenia was so small, no further analyses were conducted on smoking and diagnosis.
The mean age of quitters was 44.7 years (SD=12.3) and smokers was 40.9 years (SD=11.3), however this difference was not statistically significant (t=1.655, p=0.105). More males were current smokers than females (60% vs 40%) and quitters were less likely to be male (47% vs 53%). Fischer's exact test did not show a statistically significant association between smoking status and gender (p=0.443).
Most smokers smoked readymade cigarettes (66.7%), with a further 34.5% smoking roll-your-owns, and 16.7% smoking illegal tobacco. These figures total more than 100%, indicating that some people smoke more than one tobacco product. The mean number of cigarettes smoked was 21.9 per day (SD 13.4, range 79.5).
When the smokers were asked if they would like to quit smoking, 5 9% indicated that they did want to quit smoking and 74% wanted to reduce. Because of the high proportion of people in both categories, analysis of the overlap was conducted.
Cross-tabulation of the overlap between the two groups indicated that only 3% wanted to quit only, with a further 18.5% wanting to reduce only. The largest group of 56% wanted to both quit and reduce, while 22.5% wanted to do neither (see Figure 1).
For those who wanted to quit, 27% wanted to cease use in the next 30 days, 31.5% within the next six months and 41% chose some other time. One third of respondents who chose other, gave clarifying responses. These responses were either linked to a significant date beyond the six-month category, such as a particular birthday; indicated a lack of readiness for action – such as “when my shrink says I'm ready”“when I feel confident”, or “when I can cope with withdrawal”; or were don't know responses.
This study found that the smoking rate among people attending a Victorian PDRSS was almost four times higher than the general population rate (62% vs 16%).14 Furthermore, the smoking cessation rate was much lower than general population samples (12%vs27%).14
Ready-made cigarettes were the most commonly smoked product, however use of other tobacco products was also high. Prevalence of roll-your-own (34.5% vs 22%)15 and ‘chop-chop’ (17% vs 6%)16 cigarettes was higher than general population samples. Finally, smoking consumption rates were almost 50% higher than those found in the general population (22 per day vs 15 per day).14
More than half the smokers expressed interest in quitting, with just over a quarter of that group wanting to take action in the next month and a further third wanting to take action in the next six-months. Those interested in quitting also responded almost unanimously to wanting to reduce.
The high levels of smoking identified in this PDRSS service user sample supports previous prevalence studies and confirms that smoking rates have remained high among people with mental illness in Australia. The knowledge that most smokers wanted to quit and reduce is useful information for designing interventions. If emphasis is placed on abstinence without acknowledging the preferred method of cutting down, then interventions may not meet the perceived needs of consumers. Evaluations should also include cutting down as an indicator of program success.
Illegal tobacco would appear to reduce the smoking cost burden for many consumers. As most of this group receive welfare benefits, this cost burden is acutely felt and translates into increased need for support from PDRSS workers. Interestingly, the overall consumption rate in this study is lower than the average of 40 per day reported previously17 and may indicate a change in smoking behaviour. This study also indicated that interest in quitting among consumers maybe increasing. Further Australian research with mentally ill populations is required to clarify these changes in consumption and interest in quitting.
This study highlights the need for PDRSSs to conduct research and take the lead on smoking cessation and reduction. As smokefree policies are implemented in hospitals and community spaces, PDRSS agencies can play an important role in assisting consumers who want to reduce or quit smoking.
This study was limited to one large psychiatric disability support agency in metropolitan Melbourne and these findings need to be replicated in larger samples, rural settings and other Australian states. Further research across a broader range of PDRSSs in other settings is required to increase understanding of smoking and attitudes to quitting. In addition, while the simple questionnaire devised for this research was quick and easy to use, it could not capture the subtleties of attitudes to behaviour change such as confidence in capacity to quit or reduce usage. This would provide important information about consumer self-efficacy around changing smoking status.
Thanks to Glen Tobias, Sue Finch, Nich Rogers and Marcel Saxone for their support and advice in the preparation of this work.