Mental health and smoking cessation-a population survey in England

Self-reported depression and anxiety and healthcare professional interactions regarding smoking cessation and nicotine vaping: Findings from 2018 International Tobacco Control Four Country Smoking and Vaping (ITC 4CV) Survey

INTRODUCTION

People with mental health conditions are disproportionately affected by smoking-related diseases and death. The aim of this study was to assess whether health professional (HP) interactions regarding smoking cessation and nicotine vaping products (NVPs) differ by mental health condition.

METHODS

The cross-sectional 2018 International Tobacco Control Four Country (Australia, Canada, England, United States) Smoking and Vaping Survey data included 11040 adults currently smoking or recently quit. Adjusted weighted logistic regressions examined associations between mental health (self-reported current depression and/or anxiety) and visiting a HP in last 18 months; receiving advice to quit smoking; discussing NVPs with a HP; and receiving a recommendation to use NVPs.

RESULTS

Overall, 16.1% self-reported depression and anxiety, 7.6% depression only, and 6.6% anxiety only. Compared with respondents with no depression/anxiety, those with depression (84.7%, AOR=2.65; 95% CI: 2.17-3.27), anxiety (82.2%, AOR=2.08; 95% CI: 1.70-2.57), and depression and anxiety (87.6%, AOR=3.74; 95% CI: 3.19-4.40) were more likely to have visited a HP. Among those who had visited a HP, 47.9% received advice to quit smoking, which was more likely among respondents with depression (AOR=1.58; 95% CI: 1.34-1.86), and NVP discussions were more likely among those with depression and anxiety (AOR=1.63; 95% CI: 1.29-2.06). Of the 6.1% who discussed NVPs, 33.5% received a recommendation to use them, with no difference by mental health.

CONCLUSIONS

People with anxiety and/or depression who smoke were more likely to visit a HP than those without, but only those with depression were more likely to receive cessation advice, and only those with depression and anxiety were more likely to discuss NVPs. There are missed opportunities for HPs to deliver cessation advice. NVP discussions and receiving a positive recommendation to use them were rare overall.

Associations between smoking and vaping prevalence, product use characteristics, and mental health diagnoses in Great Britain: a population survey

BACKGROUND

Rates of diseases and death from tobacco smoking are substantially higher among those with a mental health condition (MHC). Vaping can help some people quit smoking, but little is known about vaping among people with MHCs or psychological distress. We assessed the prevalence and characteristics (heaviness, product type) of smoking and/or vaping among those with and without a history of single or multiple MHC diagnoses and with no, moderate or serious psychological distress.

METHODS

Data from 27,437 adults in Great Britain surveyed between 2020 and 2022. Multinomial regressions analysed associations between smoking, vaping and dual use prevalence, smoking/vaping characteristics and (a) history of a single or multiple MHC and (b) moderate or serious psychological distress, adjusted for age, gender, and socioeconomic status.

RESULTS

Compared with people who had never smoked, those who currently smoked were more likely to report a history of a single (12.5% vs 15.0%, AOR=1.62, 95% CI=1.46-1.81, p<.001) or multiple MHCs (12.8% vs 29.3%, AOR=2.51, 95% CI=2.28-2.75, p<.001). Compared with non-vapers, current vapers were more likely to report a history of a single (13.5% vs 15.5%, AOR=1.28, 95% CI=1.11-1.48, p<.001) or multiple MHCs (15.5% vs 33.4%, AOR=1.66, 95% CI=1.47-1.87, p<.001). Dual users were more likely to report a history of multiple MHCs (36.8%), but not a single MHC than exclusive smokers (27.2%) and exclusive vapers (30.4%) (all p<.05). Similar associations were reported for those with moderate or serious psychological distress. Smoking roll-your-own cigarettes and smoking more heavily, were associated with a history of single or multiple MHCs. There were no associations between vaping characteristics and a history of MHCs. Frequency of vaping, device type and nicotine concentration differed by psychological distress.

CONCLUSIONS

Smoking, vaping and dual use were substantially higher among those with a history of MHC, especially multiple MHC, and experiencing past month distress than those not having a history of MHC or experiencing past month distress respectively. Analysis used descriptive epidemiology and causation cannot be determined.

Tobacco Screening Practices and Perceived Barriers to Offering Tobacco Cessation Services among Texas Health Care Centers Providing Behavioral Health Treatment

Tobacco use, and thus tobacco-related morbidity, is elevated amongst patients with behavioral health treatment needs. Consequently, it is important that centers providing health care to this group mandate providers' use of tobacco screenings to inform the need for tobacco use disorder intervention. This study examined the prevalence of mandated tobacco screenings in 80 centers providing health care to Texans with behavioral health needs, examined key factors that could enhance screening conduct, and delineated providers' perceived barriers to tobacco use intervention provision. The results indicated that 80% of surveyed centers mandated tobacco use screenings; those that did were significantly more likely than those that did not to have a hard stop for tobacco use status in health records and were marginally more likely to make training on tobacco screening available to providers. The most widespread barriers to tobacco use disorder care provision were relative perceived importance of competing diagnoses, lack of community resources to refer patients, perceived lack of time, lack of provider knowledge or confidence, and belief that patients do not comply with cessation treatment. Overall, the results suggest that there are opportunities for centers providing care to Texans with behavioral health needs to bolster their tobacco screening and intervention capacity to better address tobacco-related health disparities in this group. Health care centers can support their providers to intervene in tobacco use by mandating screenings, streamlining clinical workflows with hard stops in patient records, and educating providers about the importance of treating tobacco with brief evidence-based intervention strategies while providing accurate information about patients' interest in quitting and providers' potential impacts on a successful quit attempt.

Effectiveness of Mental Health Warnings on Tobacco Packaging in People With and Without Common Mental Health Conditions: An Online Randomised Experiment

Background

Health warning labels on tobacco packaging are a cost-effective means of health risk communication. However, while an extensive range of physical health risks are well-portrayed via current tobacco health warnings in the UK, there are none that currently portray the negative impact of smoking on mental health.

Aims

(i) develop novel mental health warning labels for tobacco packaging and (ii) test perceptions of these warnings in smokers and non-smokers, with and without mental health problems.

Methods

Six mental health warning labels were developed with a consultancy focus group. These warning labels were tested in an online randomised experiment, where respondents (N = 687) rated six Mental Health Warning Labels (MHWLs) and six Physical Health Warning Labels (PHWLs) on measures of perceived effectiveness, believability, arousal, valence, acceptability, reactance and novelty of information.

Results

MHWLs were perceived as low to moderately effective (mean = 4.02, SD = 2.40), but less effective than PHWLs (mean = 5.78, SD = 2.55, p < 0.001, η p 2 = 0.63). MHWLs were perceived as less believable, arousing, unpleasant, and acceptable than PHWLs. MHWLs evoked more reactance and were rated as more novel. Perceptions of MHWLs did not differ in people with and without mental health problems except for reactance and acceptability, but consistent with the PHWL literature, perceptions of MHWLs differed between non-smokers and smokers.

Conclusion

MHWLs could be an effective means to communicate novel information about the effects of smoking on mental health. MHWLs are perceived as less effective, believable, arousing, unpleasant, and acceptable than PHWLs, but MHWLs evoke more reactance and are rated as more novel.

Harm perceptions of nicotine-containing products and associated sources of information in UK adults with and without mental ill health: A cross-sectional survey

BACKGROUND AND AIMS

People with mental ill health are more likely to smoke and experience smoking-related harm than those without. Switching from combustible tobacco to lower-risk nicotine-containing products may be of benefit; however, misperceptions of harm may prevent their use. We aimed to assess, among adults with and without mental ill health, (1) perceptions of harm from nicotine and relative harm and addictiveness of different nicotine-containing products and (2) sources of information associated with harm perceptions.

DESIGN

Cross-sectional study.

SETTING AND PARTICIPANTS

On-line survey of adults (n = 3400) who smoke cigarettes and/or use e-cigarettes, or have recently stopped, in the United Kingdom.

MEASUREMENTS

Outcomes: harm perceptions of nicotine; relative perceived harm and addictiveness of different nicotine-containing products; sources of information for harm perceptions of nicotine, cigarette smoking and e-cigarettes. Demographics: sex, age, education, ethnic group and region. Other measures: self-reported smoking, vaping and mental health status.

ANALYSES

frequencies and logistic regressions adjusting for demographic/other measures.

FINDINGS

Among those with serious mental distress (versus no/low mental distress): 9.6% [13.9%, adjusted odds ratio (aOR) = 0.69, 95% confidence interval (CI) = 0.50-0.97] correctly identified that none/a very small amount of the health risks of smoking cigarettes come from nicotine; 41.7% (53.5%, aOR = 0.67, 95% CI = 0.54-0.84) perceived e-cigarettes and 53.2% (70.3%, aOR = 0.62, 95% CI = 0.50-0.77) perceived nicotine replacement therapy to be less harmful than cigarettes; and 42.1% (51.3%, aOR = 0.77, 95% CI = 0.62-0.95) perceived e-cigarettes as being less likely than cigarettes to cause cancer, 35.4% (45.5%, aOR = 0.71, 95% CI = 0.57-0.88) heart attacks and 34.9% (42.3%, aOR = 0.80, 95% CI = 0.64-0.99) lung problems. The most popular sources of information for cigarette smoking, e-cigarettes and nicotine were scientific experts' opinions and media reports, with little variation by mental distress.

CONCLUSIONS

Among adults with a history of tobacco and/or e-cigarette use, those with serious mental distress appear to have less accurate harm perceptions of nicotine and nicotine-containing products than those with no/low distress, despite reporting similar sources of information.

A systematic review of mental health professionals, patients and carers' perceived barriers and enablers to supporting smoking cessation in mental health settings

Introduction

Evidence-based smoking cessation and temporary abstinence interventions to address smoking in mental health settings are available, but the impact of these interventions is limited.

Aims and Methods

We aimed to identify and synthesize the perceived barriers and enablers to supporting smoking cessation in mental health settings. Six databases were searched for articles reporting the investigation of perceived barriers and enablers to supporting smoking cessation in mental health settings. Data were extracted and coded using a mixed inductive/deductive method to the theoretical domains framework, key barriers and enablers were identified through the combining of coding frequency, elaboration, and expressed importance.

Results

Of 31 included articles, 56 barriers/enablers were reported from the perspectives of mental healthcare professionals (MHPs), 48 from patient perspectives, 21 from mixed perspectives, and 0 from relatives/carers. Barriers to supporting smoking cessation or temporary abstinence in mental health settings mainly fell within the domains: environmental context and resources (eg, MHPs lack of time); knowledge (eg, interactions around smoking that did occur were ill informed); social influences (eg, smoking norms within social network); and intentions (eg, MHPs lack positive intentions to deliver support). Enablers mainly fell within the domains: environmental context and resources (eg, use of appropriate support materials) and social influences (eg, pro-quitting social norms).

Conclusions

The importance of overcoming competing demands on staff time and resources, the inclusion of tailored, personalized support, the exploitation of patients wider social support networks, and enhancing knowledge and awareness around the benefits smoking cessation is highlighted.

Implications

Identified barriers and enablers represent targets for future interventions to improve the support of smoking cessation in mental health settings. Future research needs to examine the perceptions of the carers and family/friends of patients in relation to the smoking behavior change support delivered to patients.

An evaluation of junior doctors' experience in smoking cessation training in a rural mental health setting

INTRODUCTION

Smoking prevalence remains high amongst people with mental illness, however, they are less likely to be screened for tobacco dependence and offered treatment to quit. Smoking cessation and education training are insufficient in medical schools, despite a positive relationship between training and practice once qualified. However, the question as to whether there is adequate skill and expertise to address smoking in people with mental illness within Australian mental health settings is unclear. Furthermore, people living in rural and remote areas smoke at higher rates, quit at lower rates than those in urban areas, and experience limitations in their ability to access smoking cessation supports. The Smokers' Clinic is an initiative established in a rural Australian mental health service offering a smoking cessation service to patients and staff employed by the service.

AIM

This study aims to assess the change in the knowledge and confidence of resident medical officers in their understanding of nicotine dependence, smoking cessation strategies and prescribing nicotine replacement therapy in a community mental health setting. It was hypothesized that providing education and supervised clinical experience would improve knowledge, increasing confidence and motivation in managing smoking cessation in mental health patients. The research was undertaken using data collected through a questionnaire obtained from surveying resident medical officers administering the Smokers' Clinic following a 10-week rural community mental health rotation.

MATERIALS AND METHODS

Twenty resident medical officers completed the 10-week rotation, with 14 completing the questionnaire. Knowledge of tobacco smoking, nicotine dependence and smoking cessation interventions improved with the experience of the Smokers' Clinic during the clinical rotation. Resident medical officers were motivated to spend additional time engaged in self-directed learning and all reported continued use of acquired experience and information in their clinical work after the rotation.

CONCLUSION

This study indicates the utility of a novel approach in delivering education, training, building clinical expertise, and facilitating sustained clinical capacity amongst junior medical staff for smoking cessation in a rural community mental health setting. It offers an efficient approach for mental health services to deliver smoking cessation services to reduce the morbidity and mortality burden associated with tobacco smoking.

Mental Health Symptoms and Associations with Tobacco Smoking, Dependence, Motivation, and Attempts to Quit: Findings from a Population Survey in Germany (DEBRA Study)

INTRODUCTION

This study aimed to estimate prevalence rates of mental health symptoms (anxiety, depression, and overall psychological distress) by tobacco smoking status, and associations between such symptoms and the level of dependence, motivation, and attempts to quit smoking in the German population.

METHODS

Cross-sectional analysis of data from six waves of a nationally representative household survey collected in 2018/19 (N = 11,937 respondents aged ≥18). Mental health symptoms were assessed with the Patient Health Questionnaire-4. Associations with smoking status, dependence, motivation to quit, and ≥1 past-year quit attempt (yes/no) were analysed with adjusted regression models among the total group, and among subgroups of current (n = 3,248) and past-year smokers (quit ≤12 months ago, n = 3,357).

RESULTS

Weighted prevalence rates of mental health symptoms among current, former, and never smokers were: 4.1%, 2.4%, 2.5% (anxiety), 5.4%, 4.7%, 4.0% (depression), and 3.1%, 2.5%, 2.4% (psychological distress). Current versus never smokers were more likely to report symptoms of anxiety and depression. Smokers with higher versus lower levels of dependence were more likely to report higher levels of all three mental health symptoms. Higher versus lower levels of overall psychological distress were associated with a higher motivation to quit smoking and, among past-year smokers, with higher odds of reporting a past-year quit attempt.

CONCLUSIONS

We found various relevant associations between mental health symptoms and smoking behaviour. Healthcare professionals need to be informed about these associations and trained to effectively support this vulnerable group in translating their motivation into abstinence.

The Potential Impact of Widespread Cessation Treatment for Smokers With Depression

INTRODUCTION

Experts recommend integrating smoking-cessation treatments within U.S. mental health settings, but the population health benefits of doing so have not been estimated. This study simulates the impact of widespread cessation treatment for patients with depression under best-case treatment and maximum potential cessation scenarios.

METHODS

Cessation interventions were simulated for U.S. adult smokers seeing a health professional for depression from 2020 to 2100. Interventions included (1) Any Treatment (behavioral counseling, pharmacological, combination) and (2) Pharmacological Treatment (including counseling), combined with increased mental health service utilization each. These were compared with a maximum potential cessation scenario where all patients with major depression quit smoking. Analyses were conducted in 2016-2020.

RESULTS

Widespread uptake of Any Treatment among patients with depression would avert 32,000 deaths and result in 138,000 life-years gained by 2100; Any Treatment combined with 100% mental health service utilization would result in 53,000 and 231,000, respectively. Pharmacological Treatment would avert 125,000 deaths, with 540,000 life-years gained. Pharmacological Treatment combined with 100% mental health service utilization would result in 203,000 deaths averted and 887,000 life-years gained. Health gains under best-case treatment scenarios represent modest fractions of those projected under maximum potential cessation scenarios at current mental health service utilization levels (835,000 deaths averted, 3.73 million life-years gained) and at 100% utilization (1.11 million deaths averted, 5.07 million life years gained).

CONCLUSIONS

Providing smoking-cessation treatment to patients with depression and increasing mental health service utilization would reduce the toll of tobacco on this population. These gains would be considerably larger if cessation treatments were more effective.

Re-examining the Association Between E-Cigarette Use and Myocardial Infarction: A Cautionary Tale

INTRODUCTION

Cross-sectional analyses have suggested that e-cigarette use, independent of combustible cigarette use, elevates the risk of myocardial infarction. Previous researchers confused their own models' assumptions that these risks were independent with the idea that their analyses validated the presence of independent risks. This study avoids this pitfall.

METHODS

Cross-sectional analyses of the 2014-2019 National Health Interview Surveys (N=175,546) were conducted in 2020.

RESULTS

Logistic regressions found that e-cigarette use was associated with having had a myocardial infarction, but this association significantly varied on the basis of one's smoking history. With a host of demographic and clinical variables controlled, e-cigarette use was associated with lifetime myocardial infarction occurrence only among current smokers. A counterfactual analysis first removed all (current or former) e-cigarette‒using respondents who had suffered a myocardial infarction without a history of smoking. The independent-effects model used in previous research misleadingly indicated that daily vaping increases never smokers' odds of having had a myocardial infarction by 1.55 (95% CI=1.11, 2.15), even though no such myocardial infarction sufferers remained in the analyzed data. The association between myocardial infarction and vaping daily has shown a significant annual decline (AOR=0.81, 95% CI=0.67, 0.98).

CONCLUSIONS

There is no reliable evidence that e-cigarette use is associated with ever having had a myocardial infarction among never smokers. Contrary to concerns that the harms associated with e-cigarettes are only now emerging after more years of possible product use, the only evidence of time-dependent variation in the association between e-cigarette use and myocardial infarction ran counter to this possibility. The scientific community must insist that researchers engage in accurate public communication of peer-reviewed findings.

Mental health, smoking, harm reduction and quit attempts - a population survey in England

BACKGROUND

Tobacco control strategies have engendered overall declines in smoking; however, a large gap remains between people with and without mental health problems, causing substantial health inequalities. Population-level information on barriers and opportunities for improvements is scarce. We aimed to assess mental health status of cigarette smokers and recent ex-smokers ('past-year smokers') in England, and smoking and harm reduction behaviour and quit attempts by mental health status.

METHODS

Data were collected from 5637 current and 434 recent ex-smokers in 2016/17 in household surveys of representative samples of adults. We calculated weighted prevalence of different indicators of mental health problem: a) ever diagnosis, b) none, moderate, serious past-month distress, c) past-year treatment. We compared weighted smoking status, cigarette type, dependence, motivation to stop smoking, cutting down, use of nicotine replacement therapy or e-cigarettes, short-term abstinence, and quit attempts according to mental health status.

RESULTS

Among past-year smokers: 35.9% ever had a diagnosis; 24.3% had experienced moderate, an additional 9.7% serious, past-month distress; 21.9% had had past-year treatment. Those with an indication of a mental health problem were more highly dependent and more likely to smoke roll-your-own cigarettes but also more likely to be motivated to stop smoking, to cut down, use nicotine replacement therapy or e-cigarettes and to have attempted to quit in the past year.

CONCLUSIONS

About a third of cigarette smokers in England have mental health problems. Interventions should address their increased dependence and leverage higher prevalence of harm reduction behaviours, motivation to stop and attempts to stop smoking.