Changing the story on smoking and mental health

Jim O’Rorke looks back on years of working in addiction services, and makes a few personal suggestions as to changes that could support more action on smoking and mental health…

ASH Scotland’s IMPACT guidance resource

Prior to coming to work for ASH Scotland I was an Addictions worker, latterly working in the community after a 18-month spell working in Saughton jail (sorry, HMP Edinburgh as it is now known). I supported people with drug and/or alcohol misuse problems and my job was to help them construct a recovery plan to address their particular issues, apply psychosocial support and refer to NHS specialist services and other third sector services if required. 97% of my average caseload of 35 people smoked tobacco and whilst we nearly always acknowledged a desire by some to quit smoking by writing it into their Recovery Plan, the truth is that action on this was parked at some distant point in the future and actually never addressed.

Why was this important issue never addressed by taking some action? There are three main reasons in my opinion.

1. Service Users usually believed, (and Support Workers went along with it) that they would have to deal with their drug and/or alcohol problem first, “…one thing at a time…” and that stopping smoking would just cause anxiety and stress which would negatively impact on their efforts to get clean/sober.
2. Addiction services are never contractually obliged to deal with smoking tobacco; there are no stated outcomes in their Service Level Agreement for this and with funding being tight and achieving stated outcomes paramount in order to get the contract renewed, why would you divert resources to dealing with smoking?
3. Smoking tobacco is not considered an addiction in the same way as drug and alcohol.

If I take the last point first, my reasons for believing this is the way we deal with smoking tobacco as opposed to drugs and alcohol. Drugs and alcohol policy and legislation are embedded in all the mechanisms of public policy and planning in a way that tobacco is not. For example, the Edinburgh Partnership Community Plan 2015–2018 which describes the strategic priorities for the city in economy, jobs, health and wellbeing, young people and safer communities and should link to Scottish Government national outcomes, the word “alcohol” appears 35 times, “drug” 23 times and tobacco/smoking….well they are never mentioned at all. You’ll find mentions of drugs and alcohol mostly in the section about health and wellbeing but they also appear in sections on; improving early support, strategic themes for focused attention, improving outcomes for children and young people and creating safer communities.

It is quite right that government at all levels deal with the effects of drug and alcohol addiction, but why is nicotine addiction not given the same force of public planning and action? Here are some figures. In 2016 there were 867 drug-related deaths, there were 1,265 alcohol-related deaths but there were over 10,000 smoking-related deaths.

We know that smoking contributes enormously to inequalities in our society, not just in health but also financially and in life chances generally so why nicotine addiction is not afforded the same level of resources as alcohol and drugs? Whilst there is a strong and influential Peer Mentor and Recovery movement in the drug and alcohol arena, there is nothing like this the many more people who are addicted to nicotine.

Of course the Scottish Government does take this issue of the harm caused by smoking tobacco seriously. They recently included an action point on smoking in the latest 10-year mental health plan, they are in the process of forming a new Tobacco Strategy, the NHS funds smoking cessation services in the community, in Pharmacies, on-line and on the phone (Smokeline 0800 84 84 84) and they also fund the IMPACT Project.

I would like to see the following happening to raise the profile of the issue of the harm caused by smoking tobacco.

• Get major funders of services, particularly local authorities to include outcomes for numbers of people accessing smoking cessation and actually quitting smoking in contracts to service providers.
• Get service providers to ask questions about smoking in their application/assessment processes and continue this into their planning and review services.
• Get local authorities to start to include actions on smoking in their three year Partnership Community Plans and recognise that smoking does not just impact on health and wellbeing but into other areas of strategic concern also.

In terms of the first point, if you are already providing support to help someone overcome an addiction to substances, why not deal with all the substances? Would you advise someone with an addiction to eating to cut out the chips but carry on with the sweeties meanwhile, you know, “..one thing at a time…” Also we know that smoking cause’s anxiety, the only thing it relieves is withdrawal from nicotine (see page 4–5 of the IMPACT Guide)

For point two get all public services or publicly funded services to ask people about their smoking whenever they are applying for something or being assessed for a service. It would be voluntary, people would not be obliged to answer but if they did and confirmed that they smoke tobacco it opens the door for some brief advice, handing out some information and signposting to smoking cessation services. Even if a small percentage of the people who use these services then accessed smoking cessation support, it would greatly increase the numbers who successfully quit.