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									          “The Tip Of The Iceberg”

               A Review of Smoking Cessation

              Leeds NHS Stop Smoking Service

         Mental Health and Learning Disabilities

Helen Hartley
Lead Specialist Smoking Cessation Advisor
Leeds NHS Stop Smoking Service
July 2009

Introduction………………………………………………………………….……...Page 3
Background…………………………………….....………………………...……...Page 4
Smoking and Mental Health...........................................................................Page4
Key Areas of Activity……………………………………………………..……….Page 6
Is This Work Beneficial?.................................................................................Page 7
Working with Clients-The Whole Process………………..............................Page 8
Consent To Smoking Cessation Interventions………………………….…....Page 9
Mental Capacity to Make Decisions About Care and Treatment…………..Page 9
Assessment and Planning………………………………………………….……Page 10
Planning the Cessation Attempt………………………………………….……Page 12
Documentation……………………………………………………………….…....Page 13
Supporting the Client……………………………………………………….….…Page 14
Visits / Appointments: when, where, and how often………………….….…Page 14
NRT, Buproprion and Varenicline……………………………………….….….Page 15
Cutting Down To Quit…………………………………………………………....Page 17
Medications Affected By Complete Cessation of Smoking………….…...Page 18
Pilot Group-Newsam Centre………………………………………………...…..Page 19
Cost Implications…………………………………………………………….…...Page 20
Mental Health Professionals………………………………………………...…..Page 20
What Have We Learnt?.................................................................................Page 21
Conclusion…………………………….............................................................Page 22
References……………………………………………………………………..….Page 23
Acknowledges………………………………………………………………….…Page 23
Appendix 1………………………………………………………………………...Page 24
Appendix 2…………………………………………………………………………Page 25


Leeds NHS Stop Smoking Service has offered smoking cessation interventions for people
with diagnosis of mental health issues and/or learning disability since June 2007,
approximately 2 years.

This document is intended to review these past experiences and to form a working
document for staff to use when working with people who have a mental illness and/or
learning difficulty.

It is well documented that people with mental health problems face some of the greatest
health inequalities, and are at greater risk of chronic physical ill-health and premature
death than the general population (M.H.F. 2007).

People with mental illness and/or learning disability are far more likely to smoke than the
general population and appear to experience greater difficulty attempting to stop. This is
possibly due to an impaired capacity to do tasks such as planning, remaining focused and
motivated, retaining adequate support and possessing adequate coping strategies that
lead to the required outcome i.e. quitting. Time management and organising extra
activities can also be difficult. The place of residence is often, in terms of social context,
rather boring or restricted and smoking is a popular activity as a means of passing time.
Smoking can also be a means to open lines of communication between peers or staff and
a mechanism for emotional management or to control the side effects of medications.

It is well documented that the cost of each cessation attempt for people with mental
illness/learning difficulties is much higher than that of the general population. This is due
to the increased length of nicotine replacement therapy (NRT), dual usage of NRT, and
possible changes in treatment within the cessation programme and the amount of
professional working hours put into each episode. However, it must be noted that when
people with mental illness and/or learning difficulties make an attempt at stopping smoking
this often triggers them to look at improving other areas of their lives, such as social
network, diet or fitness and in some cases an improvement of their mental health is

Evidence has shown that historically people with mental illness or learning difficulties have
been neglected as far as their physical health is concerned, hence poor mortality rates, but
recent guidelines and health improvement interventions will hopefully shift that balance.

Research has also highlighted the often inadequate availability or suitability of smoking
cessation strategies within mental health units pointing to the need for services to develop
effective cessation programmes (1)

It is important to be able to respond appropriately to requests for support and also to be
proactive in reaching smokers with mental illness and learning difficulties. A report by
Laun et al (2002) documents that smokers with mental health problems feel excluded from
mainstream smoking cessation programmes.

The Mental Health Foundation in their 2007 report, Taking A Deep Breath, suggests that
although adult tobacco use has shown a decline in the last decade amongst the general

population, tobacco use amongst people with mental health problems has shown no

Many smokers with mental health problems report a wish to stop smoking but struggle
when they try to do so. They need effective tailored support and we have a lot of hard
work to do. This is just the tip of the iceberg.


On 1 July 2008 all mental health and learning disability units, including residential were
required to be smoke free, with no exceptions.

Leeds Partnership Foundation NHS Trust (Leeds PFT) (previously Leeds Mental Health
Trust) had previously adopted the complete smoke free legislation on 1 January 2007.
Leeds PFT took the decision to continue to allow smoking within the grounds and
subsequently provided shelters for service users and staff. It is important to highlight at
this stage in the document that very little smoking cessation work had been done by the
trust prior to the launch of their “smoke free” signs.

For approximately the last 2 years, Leeds NHS Stop Smoking Service has provided
smoking cessation interventions for clients with mental illness and/or learning disability.
The key areas of activity will be addressed later in this document. The work has mainly
been done within the acute sector (residential/hospital units) due to capacity but the vision
is to take the work forward into the wider community. Working with primary care mental
health teams is challenging, potentially costly and complex, but making positive changes,
however small, to someone‟s life is rewarding for both client and advisor and justifiable in
light of the available evidence.


What is mental health and what is mental illness?

“Mental Health” properly describes a sense of well being; the capacity to live in a
resourceful and fulfilling manner, having the resilience to deal with the challenges and
obstacles which life presents.(2) The definition used by the World Health Organisation is
“Mental health is a state of well being in which the individual realises his or her own
abilities, can cope with the normal stresses of life, can work productively and fruitfully and
is able to make a contribution to his or her community”.

Definitions for mental illness vary widely across publications. Mental health „problems or
illness‟ are terms that can be used to describe temporary reactions to a painful event,
stress or external pressures, lack of sleep or physical illness. Mental health „problems‟ or

„illness‟ can be terminology to describe long-term psychiatric conditions that may have
significant effects on an individuals functioning.

Below is a brief summary of some symptoms of mental health problems, all of which
should only be diagnosed by a clinician.

Anxiety: Agitation, significant changes in appetite, headaches, digestive difficulties or panic
attacks, including post-traumatic stress disorder or flashbacks of a traumatic event.
Depression: Low mood, lack of motivation, sense of emptiness, change in appetite,
disturbed sleep patterns, withdrawal, neglect, self loathing, and thoughts of self harm.
Mania: Elated mood, rapid speech, little sleep, relentless high energy, reckless behaviour,
delusions or hallucinations. Mania with depression may also be a feature of bi-polar
disorder. (manic depression).
Bi polar: Previously called manic depression, is a condition that affects your mood, which
can swing from one extreme to another. Each extreme episode can last for several weeks
or longer. The high and low phases of the illness can be so extreme that they interfere with
daily life.
Psychosis: Disordered or paranoid thoughts, delusions, disorganised or strange speech,
hearing voices, agitated or bizarre behaviour, extreme emotional states.
Schizophrenia: Most common psychotic disorder. In addition to the symptoms of psychosis
listed above this disorder may be characterised by negative symptoms such as social
withdrawal, poor personal hygiene and poor motivation.
(Ahead4health, University of Leicester 2006)

When working as a smoking cessation advisor with this client group, there are some key
points to remember:-

    Smoking prevalence is significantly higher among people with mental health
     problems than among the general population.

    Studies have shown smoking rates to be as high as 80% among schizophrenics.

    People with psychotic disorders who live in institutions are particularly vulnerable
     and over 70% of this group are heavy smokers.

In the UK, one study put smoking amongst people with depression at around 56%. (3)
People with depression often report an increase in the severity of withdrawal symptoms
during cessation attempts. Evidence suggests that this is partly due to the role of
neurotransmitters such as dopamine, and the role it plays in both smoking and depression.
In people suffering from depression the amounts of dopamine is often depleted or
inadequate. Nicotine stimulates dopamine release in the brain, but this artificial supply of
dopamine from smoking eventually depletes the brain of its own resources. Dopamine, as
a chemical messenger is similar to adrenaline. Dopamine affects the brain processes that
control movement, emotional response and the ability to experience pleasure or pain.

Evidence also suggests that smoking rates amongst schizophrenics are high due to
sufferers using nicotine for self-medication.

Nicotine increases alertness by stimulating the dopaminergic pathways to the prefrontal
cortex. This enhances concentration, information processing and learning which is of

benefit to people with schizophrenia in whom cognitive dysfunction may be part of their
illness or a side effect of medication. (4)

Nicotine is unusual in that it can stimulate and relax. An Australian report (5) suggests that
nicotine reduces anxieties, tension and unpleasant emotions, such as anger.
Schizophrenia sufferers may have particular difficulties dealing with stressful situations
and negative feelings and as a consequence nicotine relieves this.

Decreased dopamine activity in the prefrontal cortex can result in negative symptoms for
schizophrenics. These symptoms include lack of motivation (in itself a challenge for
cessation of smoking), lack of energy and affective blunting. Smoking and the subsequent
intake of nicotine may alleviate these symptoms; this is related to as “self medicating”.

It is well documented that daily cigarette consumption is considerably higher among
smokers with mental health problems who consequently may also inhale more deeply from
their cigarettes (5). It is also documented that mental health institutions at times actively
encourage smoking as a reward system or as a communication tool and are reluctant to
encourage their clients to challenge their smoking habits and make steps towards
stopping. Boredom can be a major problem in institutions and smoking can provide a
framework for the day.

It is clear from all the evidence available, which is in certain areas limited, that smokers
with mental health and/or learning disabilities suffer inequalities from smoking cessation
services. This can be from treatments and supports not routinely been offered or due to
health professionals not offering encouragement, brief interventions or referrals to a
specialist service.

The proportion of smokers with schizophrenia who say that they would like to quit is
between 40 and 50% and those with depressive disorders even higher, although quit rates
in the two populations are significantly lower than those in the general population. (6) It is
therefore vitally important that effective and sustainable smoking cessation strategies are
in place for people with mental health and/or learning disabilities.

This document will try to capture all the work done by Leeds NHS SSS with this client
group and to reflect on experiences.


In the 2 years covered by this report we have intervened specifically with clients who have
a medically diagnosed mental illness and/or learning disability. Work has included: -

     Promotion of the Leeds NHS Stop Smoking Service, through awareness raising,
      visual displays, letters and e-mails etc.

     Promotion of the service has been at hospital sites, community based in and at
      patient units, or where requested.

    Piloting and continuing to run a weekly stop smoking ward round at a specific
     hospital unit. This will be discussed further later in the document.

    Receiving funding through CSIP (care services in partnership) to enable us to
     develop resources specifically designed to use with this client group.

    Offering One to One individual support and home visits.

    Accepting referrals from any source (professionals, carers or client themselves)
     and working in partnership with other key professionals involved in the care

    Working in partnership with the Leeds PFT and the Nutritional and Physical Well
     Being Group.

    Identifying a key champion within the Leeds PFT; consultant Mr D Newby.

    When clients with a mental illness and/or learning disability have presented at a
     group or drop in, we have offered advice and support to advisors.

    Promotion of our work at conferences.

    Receipt of an award for our work on a forensic in-patient mental health unit.


   The Mental Health Foundation report “Taking a Deep Breath” states that the
    proportion of smokers with schizophrenia that wish to stop smoking is around 50%
    and for clients with depressive disorders this is significantly higher. Therefore, it is
    important that intervention and cessation strategies are effective and easily
    accessible for this client group.

   Clients with mental illness and/or a learning disability reportedly have higher rates
    of morbidity associated with smoking than the general population. (7)

   Clients with mental illness and/or learning disability have an equal right to

   Financially prioritising smoking can lead to social isolation and acceleration of
    mental illness. In the UK people with schizophrenia who smoke contribute an
    estimated £139 million each year to the treasury. (8)

   For clients who have managed to stop smoking or reduce their consumption of
    cigarettes, this can have a positive effect on their physical and mental health,
    increasing confidence and self esteem.

    Accessing a smoking cessation intervention can be a catalyst to access other
     services that could have the potential to improve their lifestyle.

    Stopping smoking completely can have a positive effect on some psychiatric
     medication, in that dosage may need to be reduced.


Typically at Leeds NHS Stop Smoking Service, clients are seen for an average period of 7
weeks (approximately 1 hour per week), with the use of NRT or other medication up to 12

It is not unusual to be supporting a client with mental illness and/or learning disabilities for
a much longer period than this. The clients need for support and monitoring is far greater
than the general population and this should be taken into account when constructing a
plan of care with the client.
 More time is required to
      Inform clients of the cessation interventions available to them
      To help clients to plan and involve others
      Time is required to keep other professionals and carers informed
      Assist in building up motivation and maintaining confidence
      Deal with problems or relapses in mental health should they occur.
      Time and effort is also needed to understand and monitor the clients other

Below is a flow chart that should help understand the pathway of care to follow.

                                 REFERRAL PATHWAY
            Familiarisation with advisor, orientation and information giving

   Seeking clients consent and assessment of mental capacity→ Involvement of key
                                                            workers and/or carers

     Full assessment of smoking history and readiness to quit.→ Gaining of relevant
                                                               information re clients
                                              Mental health and/or learning disability
                         Assess risks of smoking cessation
                               e.g. psychotic relapse
Individualised planning. Discussion about coping strategies and psychiatric
    Maintenance of quit attempt or monitoring of cutting down → Review of NRT and
                                                           monitoring of psychiatric
                                                       Medication and mental health
                                                           Liaison with key workers

Rewards and
Congratulations      ← Period of review, measurement of success
                                and encouragement.
                            Discharge from the service

      For this example Champix and Zyban have been excluded as these
       medications are not available within the Leeds PFT.


Adults within the general population are assumed to have the capacity to consent to
treatment, unless they have demonstrated otherwise. When using NRT or other
treatments to assist someone stopping smoking, constitutes a treatment, so it is essential
that the client give their consent. It is important to say at this point that smoking cessation
interventions are only offered after an initial request from the client themselves. If a
referral is taken from another health professional or carer then contact is always made with
the potential client before embarking on any course of treatment. If there is any doubt
about a client‟s capacity to consent, then an appropriately qualified key worker must be
liased with to assess the situation before you progress any further.

Consent with regard to the Mental Health Act 1983 will probably not be an issue, as this
only addresses treatment of the condition which led to admission under the Act.


Having mental capacity means that a person is able to make their own decisions. The
Mental Capacity Act says that a person is unable to make a particular decision if they
cannot do one or more of the following four things:
    Understand information given to them
    Retain that information long enough to be able to make the decision

       Weigh up the information available to make the decision
       Communicate their decision – this could be by talking, using sign language or even
        simple muscle movement such as blinking an eye or squeezing a hand.
We all have problems making decisions from time to time, but the Mental Capacity Act is
about more than that. It is specifically designed to cover situations where some one is
unable to make a decision because of the way their mind or brain works is affected, for
instance by illness or disability or the effects of drugs or alcohol.
It is very important to remember that lack of capacity may not be a permanent condition.
Assessments of capacity should be time and decision specific.
(What is Mental Capacity? A Guide for People In Health Care.2006)

When involving other professionals e.g. Community Psychiatric Nurse‟s or carers it is
important to obtain informed and written consent from the client as this involves the
sharing of information that is relevant to their cessation attempt. When working with
clients with mental illness and/or learning disability, the seeking of consent and reviewing
of mental capacity should be an on going process and not a singular event. Accurate
documentation and record keeping are essential with this client group.


The following plan is by no means definitive, but is a comprehensive review of the work we
have done over the past 2 years. Where appropriate I have included recommendations
learnt by personal experience and reflective research based practice.

Other questions may come to mind during the assessment. The assessment attempts to
offer a holistic care package for the client with the aim of a successful quit attempt.
Assessment and planning is consistent for both in and outpatient. It may seem
unnecessary to ask about social contacts or leisure time to an in patient at a mental health
unit, but the time spent there can be short. The movement of patients between in patient
facilities and out patient facilities reinforces the need for continued assessments and
planning reviews.

Assessment of the client and their plan to stop smoking needs to address biological,
psychological and sociological aspects of cessation if success is to be achieved. The
following are not in any particular order but meant as a guide.

A client can present as quite chaotic, so then the assessment becomes chaotic and lists
are meaningless. The paper work is identical to that used with the general population,
though more in depth questioning and history taking will be done, so accurate
documentation is essential.


    What does the client smoke? E.g. roll up‟s

    How many does the client smoke or how much tobacco do they use?

    What is the pattern of smoking throughout a „typical day‟?

    How soon after waking do they have their first smoke?

    When do they most enjoy smoking?

    Does any particular activity, thought or feeling make them smoke? (More or less).

    How does the client feel about smoking?

    Does the client smoke any product other than tobacco?

    Have they tried to stop before?

    Did it affect their mental health in any way?

    How long did they remain stopped?

    What NRT products did they use?

    What other medication are they taking?

    Are they ready to stop smoking?


    Are there any other professionals involved in the client‟s care or treatment?

    Do they have capacity and opportunity to help the client with stopping smoking?

    Does the client give consent for them to be informed and involved?

    Is anyone else involved with the client as part of his/her care? E.g. friend, parent

    How does the client spend their time?

    Can the client ask for support from family or friends?

    Is there an obstacle within the social and professional network to impede the clients
     quit attempt? E.g. does a friend or relative encourage or facilitate smoking?

    Do any professional or social contacts need smoking cessation advice to enable
     them to adequately support the client?

The accurate gathering of information and subsequent assessment can present many
challenges. The client may find it difficult to communicate or to answer certain questions,
or may be aggressive and unreceptive.

Assessments can be potentially time consuming and may not be achieved in the first
contact. Subsequent visits may be needed to achieve an accurate assessment of the
client and their cessation needs. Time, patience, flexibility and understanding are
essential. Assessment is continuous with this client group. As mental health fluctuates,
needs change and the advisor must respond to this. Following assessment a decision will
be made with the client to support a cessation intervention.

Attempting to support the client when the chances of success are low carries the risk of
diminishing the clients self esteem through perceived failure, and creating and confirming
negative beliefs about the possibility of giving up smoking or possible change in general.
Such outcomes may impact negatively on the client‟s mental health. (9)


Once an agreement has been made with the client to go ahead with the quit attempt then
a plan needs to be formulated.

As a result of our work with this client group, and in agreement with the Leeds PFT, the
opportunity to set a date to stop smoking completely is offered as first line. If the client
feels unable to achieve this goal or the advisor in their assessment concludes a quit date
will be unachievable then the client is offered the option of cutting down the amount
smoked over an agreed period of time. The issue of “cutting down to quit” will be
addressed later in this report and is fully supported by Leeds PFT.

The process of planning allows the advisor to engage the client in their cessation attempt
and to enable them to come up with ideas, strategies and solutions. It is important to give
the client a feeling of control and empowerment and not to become a dictator of care. The
building of a solid relationship with the client is key to the success of any cessation
attempt. A discussion will always be had about the use and management of NRT,
Champix or Zyban. Within the Leeds PFT, treatment is restricted to the use of NRT alone;
however there is support for the use of multiple NRT treatments. Champix and Zyban are
prescribed in the community if the clients GP is in agreement. The use of these two drugs
is cautioned in clients with mental ill health, but is dependant on severity and type of
mental illness. These treatments will be addressed later in the report.

Some questions an advisor may be asking as part of the planning phase:-

     Does the client need support from anyone else?

     What other skills or resources has the client got or available to use to help them?
      E.g. in patient gym.

     How often do the advisor and client need to meet? (This is very individualised and
      addressed later).

     Is it appropriate to set goals and/or tasks e.g. not buying tobacco, recording
      savings, keeping a diary, setting new „house‟ rules, generating ideas to keep

     What purpose does smoking serve for the client in the context of their mental
      illness and/or learning disability? E.g. does the client use smoking to relieve side
      effects from antipsychotic medication? If so then how will this be managed during
      the cessation attempt?

     How does the client spend their time and can levels of interaction and activity be
      increased to relieve any boredom?

     If smoking is used to deflect from negative thoughts or feelings, how can this be
      managed? Could feelings and thoughts become dangerous e.g. self-harm or
      suicide thoughts – if so what are the coping and support mechanisms.

     What other medication is the client taking? Does the client need to be reviewed by
      the ward doctor or GP prior to a cessation attempt? Some medications used in the
      treatment of mental illness are metabolised at different rates, once smoking ceases
      completely. This will be discussed later in the report.

     Is the client well informed and have they enough information and relevant contact


Consistent, accurate documentation is essential and all plans and decisions made by
either the client or the advisor must be recorded, including those with other professionals,
carers or friends. It is well documented that accurate recording of information can assist
the advisor when dealing with often chaotic and unpredictable clients. A report by Keane
(2006) (9) states that clients with mental illness and/or learning difficulties are very poor at
documenting their plans, subsequently that task has to be taken over by the

Sometimes a client can present with a desire to stop smoking immediately, and say their
only requirement is quick availability of NRT. This problem can be compounded when
supported by ward staff and/or carer. It can be difficult to resist the need to go through an
assessment process to define a plan and to set goals. It can often be the clients reaction
to a peers attempt to stop smoking that their desire to act without planning is often part of
their psychopathology. There is the potential for the client to get angry and agitated if not
supported, and experience has shown never to discourage their attempts. If this initial
reactive attempt doesn‟t succeed at least the client has been given information and has
been introduced to the service. Experience has proven to me that these clients at some
future time will contact or use the service again, confirming the evidence for brief


Clients with mental health issues and/or learning difficulties usually have an extensive
network of support, either from professionals or relatives/friends and it is important to
involve this network where appropriate.

The level of support for clients is individualistic, dependant upon what skills the clients
possesses and how “well” they are, to what the advisor and the client wants to achieve at
the end of the partnership.

Engaging the clients support network and at times the client themselves can be a
challenge and takes patience and often great amounts of time. Clients with mental illness
and/or learning disability often have difficulty maintaining focus on given tasks, such as
smoking cessation and so involving the clients support network can help. By being
repeatedly reminded and encouraged by this support network will help the client keep to
their plan and work towards set goals or tasks set by the smoking advisor.


As the level of support is so individualistic, there is no definite answer, and often it is about
making decisions and judgements on a regular basis and not having set times or grand
rules. As these clients often lead chaotic and unpredictable lifestyles, where mood can
often change quickly, contact has to be flexible. However, it is important to have pre-
arranged times and meeting points arranged to help with the focus and cessation attempt.

Where the visit takes place ideally should be a venue agreed between the client and the
adviser, where both parties feel safe and relaxed. Venues regularly used by the Leeds
Service, include wards, health centres, hospital cafes or the clients own home.

Home visits can be time consuming but are often the only option available with this client
For some clients with mental illness and/or learning disabilities, the home environment is
the optimum place to work.

Some basic rules an advisor may follow when doing a home visit are:-

     Initially contacting the client to arrange an agreed date for the visit and time. It is
      helpful to also state the names of the advisors doing the home visit and how long
      you intend been there. We have found that stating how long we intend the visit to
      last, will help keep the meeting focused and allow the advisor to keep the
      conversation appropriate and meaningful.

     Remind the client and/or carer that the home should be smoke free for 1 hour prior
      to the visit.

     It is ideal to have 2 advisors attend the initial home visit.

     Some general safety rules include:

            Always sit nearest the exit.

            Request that the exit is left unlocked. If the client insists that the exit is
             locked, then ensure that that key is left in the lock.

            Always work in a well-lit environment.

            If at any point in time you become uncomfortable, make an excuse to leave,
             e.g. you left something in the car and leave. Always return to inform the
             client what your intentions are, by going to the door e.g. I‟ve just had a call
             and I need to leave now but I will be in touch with you very soon.

            Ensure you have a personal alarm or mobile assessable.

            Arrange an agreed date and time to meet again.

The initial home visit may not achieve a great deal in terms of the cessation attempt or
planning process, but may be more about building up trust and assessing what the client
needs in the future. This relationship between client and advisor can often be a long one
and ground rules need to be agreed and adhered to.


Three types of pharmacological interventions associated with smoking cessation; NRT,
Bupropion (also called Zyban) and Varenicline (also called Champix).

There are very few studies that explore the efficiency of these interventions in people with
mental health problems and learning difficulties, although those that have show
encouraging results. A study done by Covey et al (1997) (10) states that NRT is safe and
effective with inpatient psychiatric populations, although higher strength patches will
almost always require supplementation.

NRT has a proven benefit for smokers wishing to quit but El-Guebaly et al (2002) (11)
suggests this appears to be more effective when combined with psychosocial
interventions, such as counselling or cognitive behavioural therapy (CBT).

CBT also improves quit rates amongst smokers with schizophrenia, El-Guebalby et al
(2002), improving negative symptoms and greater stability of psychotic and depressive

symptoms during the quit attempt. In Leeds advisers are not given formal training on CBT
or counselling.

The main pharmacological intervention used in Leeds is NRT. Within the Leeds PFT only
NRT is available with bupropion and varenicline not used due to lack of conclusive
supporting evidence of efficiency and the potential for bupropion to interact with anti
depressants and anti psychotics.

This may change in the future within the community setting, although the main choice of
treatment is NRT, bupropion and varenicline are occasionally requested as treatment of
choice. The availability of these medications is then dependant on the clients GP. If used,
then the GP and smoking advisor work closely together, along with the client to monitor
and evaluate progress and well-being.

All clients with mental illness and/or learning disabilities are given the right to treatment of
choice. It is essential that the client be given a full, descriptive but understandable account
of each treatment, to allow them to reach their decision.

Clients who are mentally ill and/or learning disabled are often strongly influenced by what
they have heard from peers or carers or by irrational ideas arising from their

It is extremely beneficial with this client group, during the planning phase, to allow a period
of time when NRT can be “trialled”. Minimal amounts of NRT can be given to the client to
give them the opportunity to see if the product is acceptable and useable for them, before
embarking on a quit attempt or reduction programme.

If a client is unable to manage other medications, then they are unlikely to be able to
manage and monitor their NRT. Liaison with other key professionals or carers is essential
to ensure the client receives correct dosages.

On occasions when working with this client group, specifically those who have severe and
enduring mental health problems or are on a substance abuse recovery programme,
suspicions have been raised about the request to see an advisor and the subsequent
prescription of NRT. Signs to be aware of can be: -

     At initial visit, very limited engagement with advisor.

     No interest in planning, information and discussion.

     Demanding NRT.

     Continuous use of prescribed NRT with no evidence of reduction in smoking, often
      using maximum amounts prescribed and requesting more.

     Using NRT as a tradable commodity.

     Means to gain attention and medication, therefore satisfying a pathological need.

It is often very difficult to distinguish between a genuine need to stop smoking and improve
physical health or any of the above. In my experience this comes through education, or
experience but sometimes “a feeling”.

All forms of NRT are available to clients with mental health/learning difficulties. Attached
in Appendix I, is the Leeds PFT protocol for NRT, which is accessible on all inpatient
wards, all pharmacies and on the internet.

Given that this client group tend to be heavier smokers, it is important to draw on evidence
supporting the use of more than one NRT treatment. Dual usage is widely used in Leeds
for smokers demonstrating a high level of dependence on nicotine. This is supported by
NICE guidelines (February 2008) or where one product has proved inadequate in the past.


Given the high rates of smoking and the low rates of stopping in the client group, a harm
reduction approach may well be more appropriate, in parallel with specialist support.
McNeil (2001)(12) states there is good evidence that smoking related morbidity and
mortality are related to the dose or amount of smoking, so that if some cigarettes could be
replaced with less harmful forms of nicotine delivery, there might be an overall benefit to
the smokers health.

The obvious potential downside to this approach is that in the long term, it discourages a
complete quit attempt. However, there is evidence by McNeil to suggest the opposite.

A study by Hartman (1991) found that inpatient psychiatric clients smoked significantly
fewer cigarettes whilst receiving the nicotine patches than those receiving the placebo.

A further exploratory study by Dalack (1999) discovered that when given a nicotine patch
over a 32-hour period, a group of heavy smokers with diagnosed schizophrenia who were
not actively cutting down tolerated the patch well with no adverse effects. Nicotine levels
increased during the period without any evidence of nicotine toxicity. At Leeds Smoking
Services we are extremely lucky to work closely with the Leeds PFT, continually reviewing
and evaluating smoking cessation work, with the client the main focal point.

Evidence, as mentioned above, is taken into consideration when recognising that clients
with mental health/learning disabilities are not always able to set a quit date for a variety of
reasons, and that another option should be available. People with mental health/learning
disabilities have for a long time been victims of the health inequality gap, and this gap
needs to be reduced. Working with this client group is not clear-cut and these clients don‟t
always fit into neat little boxes of smoking or quit. To bridge that health inequality gap they
need options, flexibility and support.

NICE address this issue of people wanting to stop but not immediately, stating that clients
wishing to use N.A.R. Stop (NARS) strategy should only do so as part of a conducted
research study.

Work was done with LSS and the pharmacy department within the Leeds PFT, as we
needed this option to be available to our user group.

In November 2008, the Leeds PFT NHS Trust and Therapeutic Committee concluded that
they approved of the NARS or cutting down to quit method and as long as it was only used
second line to the abrupt quit method and closely monitored and supported by Leeds SSS
Specialist Advisers. All forms of oral NRT are available to use in this programme. This is
a great achievement and of so much benefit for our client group. (see appendix 2)

However, supporting the client through this process is essential. It must be monitored and
documented that the client is showing commitment to the programme and evidence of
cutting down the amount smoked per day, whilst continuing to use the NRT correctly. This
process can take months to conclude in a quit achieved, but can in extreme cases be

Clients with mental health/learning disabilities with severe and enduring mental health
problems are currently been seen by Leeds SSS, and they have been on the “cutting down
to quit” method for lengthy periods. The nature and severity of their illness prevents them
from achieving complete abstinence but the reduction programme has allowed them to
reduce the amount smoked significantly with huge health benefits, mentally and physically.
This does however have cost implications in terms of the prescribing of NRT; but can this
be measured against the positives gained by the client and their long-term future??


Stopping smoking completely can affect the way some medications are absorbed,
particularly some antipsychotic medications. Attached in appendix II is the list compiled by
M Dixon, pharmacist from Leeds PFT. It is important to inform the client that their
medication may need reducing which is a positive. This list is used with all clients, who
are asked to check the list, or, if unable to do so, the list is given to the client‟s doctor or

Before the client commences their quit attempt or reduction programme, it is important to;

    Identify and document if the client is taking any of the medications.

    Liase closely with the key professionals.

    Check that a recent blood test has been taken, recording dosage levels. If not then
     request prior to cessation attempt. DO NOT commence cessation attempt until you
     have a baseline level, especially with chlozipine and document this.

    Give Interactions and Medications sheet to prescribing doctor, documenting this.

    Document all support and ask client to report how they are feeling and to seek
     advice if required. Explain to the client why you are taking these precautions and
     the positives.


Due to the intensive and lengthy relationship we have with this particular client group, each
contact can be of varying length. This means that as an advisor timetabling accurately a
day‟s work can be difficult.

From experience, it is also difficult not to get drawn into lengthy discussions unrelated to
smoking. Many aspects of the client‟s life, such as accommodation, diet and social
networks are related to smoking and it is a continual learning process to be able to drive
the conversation in the required direction.

As Keene (2006) states in his review of cessation work, smoking is a bio-phych-social
activity and the boundaries of the problem and intervention are far wider than first appear.

It can be also difficult to know when to withdraw support from the client; this is often due to
fear that withdrawing support will negatively affect the client. However, praise and
encouragement of rewards to celebrate achieving goals can be the start of reducing the
support. Improvement of the client and/or carers is essential. The NHS demands that
only with a 4-week measurable quit attempt can we celebrate achievement.                    An
achievement in this client group is to a degree whatever the client sees as an
achievement, e.g. improved fitness, financial gain or improved self-esteem or awareness.

Any attempt at a lifestyle change by this client group is a celebration, but unrecognisable
and measurable by the Leeds Smoking Service and the wider NHS. This is an aspect of
the work with clients with mental health/learning disabilities that desperately needs
addressing, in order to be able to record the hard work done by the client and the
cessation advisor and to be able to evaluate for future work.
A pilot is underway at Leeds to evaluate the positive gains of clients during their cessation

When withdrawing support completely from a client, either due to a relapse, successful
quit attempt or the client has simply changed their minds, it is important to leave them with
contact details of advisers and relevant written documentation for future reference.


In January 2008, Leeds was asked to be a pilot site for targeted smoking cessation
interventions, and the key area of work was to be a forensic in-patient unit. This was in
response to our passion to take cessation measures forward in this area and as a result of
work already done within the identified unit.

A body called Care Services In Partnership was behind the pilot and funding was given to
aid the project.
Prior to the start of the pilot, a audit was done delivered on the two wards to establish how
many service users smoked, how many were asked smoking status on admission and how
may were offered support, advice or nicotine replacement therapy.

This audit was repeated at the end of the pilot, which was an 8 week period and the results
compared. The pilot resulted in an increase in the support offered by all staff, and the
uptake of nicotine replacement therapy.
An outcome of the pilot was that offering a drop in on a forensic locked ward was not
totally satisfactory, so the group was extended to the day hospital in the same unit, at the
request of service users and staff. This increased accesses.
Service users were involved in the pilot and their opinions were sought regarding the drop
in and the resources used.
As a result of service user input, it was agreed that the generic smoking services planner
was unsuitable for this client group. A small working party was established and a new
smoking cessation work book was developed specifically for this client group. The work
book was funded by the pilot and is now widely used for this client group. Also produced
were more basic posters and referral pads. It was decided to have the same colours as the
work book, to be easily identified.

At the end of the pilot the work was evaluated and it was agreed to continue offering
smoking cessation advice and support, but as a ward round. This was in response to
requests from other wards within the unit to have cessation input. A drop in would now not
be practical and to reach more service users and staff, a weekly ward round commenced.
This still continues, with huge success.


The cost of offering smoking cessation support to people with mental health and/or
learning disabilities, although difficult to evaluate can be significantly higher than for the
general population. This is in general down to extended periods of NRT and support.
However, work in this field has a huge role to play in bridging the health inequalities gap
and cannot be judged on cost alone. Judgements should be made from better mental
health, diet, physical health, financial well-being or social well-being and many more.

This field of work does not accurately record in terms of data collection and formal
definitions, and subsequently does not capture the wider social and health gains.


It is important to record that Leeds SSS also offers support to the staff, both in community,
Leeds PFT and the private mental health sector. Our work is not limited to service users
only. We see everyone from consultants to domestic staff.

A small-scale study in the UK, found that psychiatric nurses had a smoking prevalence
rate twice that among other groups of nurses (Gubbay 1992) (13). Reason enough to keep
working in this area.

It is also well documented that staff can be used as role models and encouragement to the
service users, so prompting them to address their smoking.


Working with clients with mental health and or learning disabilities has taught the service in
Leeds many things;

    You need time, patience, flexibility, understanding and a willingness to learn and
     reflect from experiences.

    Supporting clients requires different skills and strategies than those used in the
     general population.

    Clients with mental health/learning disabilities require resources tailored to their
     needs to aid in their cessation attempt.

    Do not assume anything. This client group may not have the life skills often
     available to the general population or the ability to use them.

    Always involve the wider social and professional network and liase regularly.

    Plan and prepare well, but make sure it is client led, depending on their mental
     health at any particular time.

    Remember, mental ill health fluctuates, you need to respond accordingly.

    Ensure the cessation programme doesn‟t have unintended pathological or
     psychological consequences.

    Accurate and consistent documentation.

    Build relationships, but empower the client to build skills and awareness of self
     throughout the process.

    Be flexible with support i.e. time, venue.

    Use praise and measure achievements no matter how small. They aren‟t small to
     the client.

    There is almost never an absolute right intervention; work can be experimental,
     what works one day …. may not work the next.

    Joint working, communication and the need for information sharing are paramount.


It is well documented that people with mental health problems face some of the greatest
health inequalities and are at greater risk of chronic physical ill-health and premature death
than the general population.

At Leeds Stop Smoking Service we feel it is paramount to address health inequalities and
improve accesses to the service for hard to reach communities.

This is just the tip of the iceberg as far as working with this client group goes, and the
service has many plans for the future.
This is a client group that needs our input. Work in this field has a huge role to play in
bridging the health inequality gap and cannot be judged on cost alone.


   (1) Taking A Deep Breath. The Mental Health Implications Of Anti Smoking Legislation.
       Mental Health Foundation. 2007
   (2) Ahead 4health. Association of Services In Higher Education. What Is Mental
       Health? 2006
   (3) Taking A Deep Breath. The Mental Health Implications Of Anti Smoking Legislation.
       Mental Health Foundation. 2007
   (4) Levin E.D, Wilson W, Rose J.E., McEvoy.J. Nicotine , Haloperidol, Interactions and
       Cognitive Performance In Schizophrenia. Neuropsychopharmacology.
   (5) Strasser.K. Smoking Reduction and Cessation for People with Schizophrenia.
       Royal College of Psychiatrists 2001
   (6) Jochelson KMB. Clearing The Air: Debating smoke free Policies in Psychiatric
       Units. 2006. London Kings Fund.
   (7) Taking A Deep Breath. The Mental Health Implications Of Anti Smoking Legislation.
       Mental Health Foundation. 2007
   (8) McNeil. A. Smoking and Mental Health: a review of the literature.2001
   (9) Keene.P. “ Wasting Time” Bournemouth PCT. August 2006
   (10)       Covey LS. Major Depression following smoking cessation. The American
       Journal of Psychiatry. 1997: 263-265
   (11)       El-Guebaly N .Smoking Cessation approaches for persons with mental
       illness or addictive disorders. Psychiatric serv. 2002. 1166-1170
   (12)       McNeil A. Regulation Of NRT. A Critique of current practice. Addiction.
   (13)       Gubbay J. Smoking In The Workplace. Centre For Health Policy Research.
       University Of East Anglia. 1992


Special thanks to everyone involved in the pilot and the Newsam Centre, especially
Michael Dixon.
Thank you to all my colleagues for your support and to Claire Gilman for help with the
huge task of typing this document.

                          Smoking and Interactions with Medication

Many medicines are broken down by the liver using enzymes belonging to the Cytochrome
P450 group. If a substance induces or inhibits one of these enzymes then it can affect the
dose of a drug that needs to be given to a patient.

 There are over 3000 chemicals in cigarette smoke but it is not known which ones are
significant with regards to drug interactions. Cigarette smoke is a potent inducer of the
cytochrome P450 1A2 isoenzyme. Various medications are metabolized using this enzyme
and therefore may be affected if a patient starts or stops smoking. Listed below are
medications that could be affected by a patient stopping smoking.

             Drug              Effect of stopping                        Dosing advice
                               smoking on drug
Haloperidol                Plasma levels may rise by           Haloperidol dose may need to be
                           23%                                 decreased
Clozapine                  Plasma levels may                   Decrease dose (contact
                           increase by 72%.                    pharmacy for further advice)
Olanzapine                 Increase half-life by 21%           May need to decrease dose
Fluvoxamine                Increase plasma levels              May need to decrease dose
Propranolol                Increased plasma levels             May need to decrease dose
Duloxetine                 Plasma levels may                   May need to decrease dose
                           increase by 50%
Fluphenazine               Plasma levels may                   Monitor symptoms/side-effects
Beta-blockers              May need a lower dose               Review dose
Flecainide                 Increased plasma level              May need to decrease dose
Insulin                    May need less insulin               Review dose of insulin and
                           when stop smoking                   monitor blood glucose
Theophylline/aminophylline Increased plasma levels             Decrease dose by 25 – 33%
                                                               within 1 week of stopping
                                                               smoking. Monitor patient as
                                                               further alterations in dosage may
                                                               be required
Cimetidine                        Nicotine increases           May need to decrease cimetidine
                                  cimetidine levels            dose or use alternative H2
                                                               antagonist e.g. ranitidine

1. Bazire,S. Psychotropic Drug Directory 2005
2. The South London and Maudsley NHS Trust Oxleas NHS Trust 2005-06 Prescribing Guidelines. 8 Ed.
3. (accessed 8/9/05)
4. Stockley, I. Stockley‟s Drug Interactions. 6 Ed.

Michael Dixon. Clinical Pharmacist 27.01.06


Drugs & Therapeutic Committee Decisions - November 2008
Important decisions from D&TC are circulated around the Trust in a summarised form as soon as possible
after the meeting in order to inform clinicians in a timely fashion. If you require further information on
any of these points please consult pharmacy or a relevant clinician. If a colleague does not receive this
can you let me know their name so I can add them to the distribution list. Please disseminate this around
your clinical areas.

"Cut down to Quit using NRT"
NICE guidance recommends using varenicline, bupropion or nicotine replacement therapy (stopping
smoking abruptly then using nicotine replacement therapy) as first line options to help people stop
smoking. Varenicline and bupropion are contra-indicated/cautioned in most mental health patients and
therefore nicotine replacement therapy (NRT) is the only viable option in most cases. Therefore, the
committee reviewed the evidence for nicotine replacement therapy using the "cut down to quit" method.
A lot of the products have a license for this indication but are not recommended by NICE. The committee
have approved the use of nicotine replacement therapy using the "cut down to quit" method as long as it
is used 2nd line after NRT has been tried with the abrupt quit method and that it is recommended and
closely monitored by the Leeds Stop Smoking Service.


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