Written evidence submitted by the Mental Health and Smoking Partnership (MHSP) (CMH0064)

Health and Social Care Committee Inquiry into Community Mental Health Services

Introduction

1. The Mental Health and Smoking Partnership is a coalition of organisations committed to improving the health and lives of people with mental health conditions by tackling the high rates of smoking in this population. The partnership is jointly chaired by Professor Ann McNeill, Professor of Tobacco Addiction at the National Addictions Centre, King’s College London, and Mark Rowland, Chief Executive of the Mental Health Foundation. It is coordinated by Action on Smoking and Health who receive funding from Cancer Research UK and British Heart Foundation.

Summary

2. The Partnership’s position is that effective support for tobacco dependence must be a core component of community mental health services. The NHS Long Term Plan included a commitment to implement Tobacco Dependency Treatment Services in community settings. Despite promising results from piloting these services, wider rollout was cancelled due to funding cuts, meaning that people with severe mental illness (SMI) do not have access to tailored, opt-out stop smoking support in the community. Given the substantial inequalities experienced by this population, it is vital that these programmes are part of the standard treatment pathway for all patients.

What does high-quality care look like for adults with severe mental illness and their families/carers?  

3. High quality care for people with SMI must consider physical health and address the wider health inequalities faced by people with serious and long term mental health conditions. Someone with SMI will live on average 15 to 20 years less than someone without, and will experience ill health 10 years earlier than those without[1]. It is estimated that smoking accounts for two-thirds of the reduced life expectancy in this group.[2] High-quality care for people with SMI must include support to quit or reduce their tobacco use. 

Background on smoking and mental health:

4. Nearly half (45%) of those with serious mental illness in England smoke, with this number increasing to just over half (51%) for those using inpatient services[3]. Smoking rates are likely to be similar for people accessing community mental health services. People with mental health conditions who smoke also tend to be heavier smokers. This traps people in a stress cycle where smoking increases the risk of poor mental health and poor mental health increases the chances of smoking and the number of cigarettes someone smokes.

5. There is also a growing body of evidence that smoking causes poor mental health, particularly increasing the chance of developing bi-polar, schizophrenia and depression with a weaker link between smoking and going on to develop ADHD and anorexia.[4] [5] [6] It is not clear how smoking causes poor mental health. However, smoking is highly addictive and damages every organ in the body so it is unsurprising that it also impacts the brain. Meanwhile, quitting has a positive impact on mental health, comparable to the impact of antidepressants for improving mood.[7]

6. Smoking also indirectly affects mental health through:
• Making people sicker and reducing their employment prospects.
• Reducing household incomes and increasing the likelihood of living in poverty. The average smoker spends up to £2,500 a year on tobacco.
• Trapping smokers in a cycle of addiction and withdrawal.

7. These factors combined make smokers less financially secure which can result in stress, anxiety and depression, contributing to the burden of poor mental health. Reducing smoking prevalence in this population would have a meaningful impact in tackling the socio-economic and health disparities experienced by this group.

8. The Tobacco and Vapes Bill will phase out the sale of tobacco to future generations by raising the age of sale progressively[8] . The Bill is welcome, but it will not impact the 6 million current smokers in the UK. More needs to be done to support people with mental health conditions to quit smoking to ensure they are not left further behind. ASH and the Partnership have called on the government to publish a roadmap to a smokefree country including a comprehensive strategy to eliminate the disparity in smoking rates between people with and without mental health conditions. Such a strategy should include the availability of stop smoking support in inpatient and community mental health services.

How could the service user journey be improved within community mental health services?

9. Tobacco dependence treatment services are currently being rolled out across inpatient mental health settings, in line with the NHS Long Term Plan. As of December 2024, the ASH survey of Mental Health Trusts found that the service was fully implemented in 70% of respondent Trusts and partially implemented in a further 25%[9].

10. The same support should now be implemented in community mental health settings, to ensure continuity of care for those moving from inpatient to community care and for those accessing community services. We recommend that the government and NHSE deliver on their original commitment to implement tobacco dependency treatment support in community mental health services.

11. Tobacco dependence treatment within community mental health services should include opt-out behavioural support and medicines which relieve symptoms of withdrawal such as Varenicline and Cytesine, Nicotine Replacement Treatments (NRTs) and provision of vapes. The ‘gold standard’ combination of prescription medication and behavioural support is only used by 1.1% of people who smoke, despite improving chances of quitting by around 80%[10]. Access to vapes is also of particular importance as significantly more people who smoke and have mental health conditions report using a vape during a quit attempt than those without (39% to 25%)[11].

12. People with mental health conditions have a similar or greater desire to quit[12], but are less likely to be offered the support to do so. Tobacco dependency support has been continuously underfunded in mental health settings compared to acute and maternity. Whilst acute settings had funding for tobacco dependency treatment sustained, and maternity had funding increased, mental health settings saw a 17% decrease in funding for 2023/24[13]. Funding for both inpatient and community mental health settings must committed to and protected to ensure that the most vulnerable and addicted patients do not lose out on support.

How could this be measured/monitored locally and nationally?

13. NHS England are monitoring the roll out of tobacco dependency treatment services in hospitals, including mental health settings. Services are required to submit metrics on service delivery and quit attempts/success. Data has also been collected in pilot trails rolling out these services in community mental health settings. These models of measuring and monitoring outcomes could be implemented across community mental health services. Community services may want to consider which metrics will best reflect progress for their patient population, given that those with mental health conditions may need more time, or cut-down-to-quit programmes to achieve smokefree status.

What are the examples of good or innovative practice in community mental health services?  

What needs to happen to scale up the adoption of these practices across the country? 

14. The National Collaborating Centre for Mental Health (NCCMH) carried out an evaluation of the early implementer sites piloting tobacco treatment in community services[14]. This findings from this evaluation will be central to ensuring these services can be scaled up and adopted across the country[15].

15. The evaluation found that there are issues with wider staff teams being ambivalent about the importance of supporting patients to make a quit attempt[16]. This reflects findings from ASH’s survey of inpatient mental health settings which found that staff escorted patients on smoking breaks at least once a day in 50% of Trusts, despite 85% of Trusts having comprehensive smokefree policies. Having policy in place was therefore not sufficient to change staff behaviour around smoking signalling a greater need for culture change.

16. All staff involved in patient care should understand the importance of treating tobacco dependency. This requires a clear commitment from senior leadership to implement tobacco treatment services and ensure that staff are given the necessary support and guidance. Government and NHS England can also play a vital role in driving this change by prioritising implementation of these services and providing the necessary funding and guidance.

How can community mental health services work with social care, the third sector and local government to better address service users’ health and wider social needs that are wider determinants of mental health outcomes?  

17. Community mental health services would benefit from maintaining strong links with their local authority stop smoking services (SSS’s). These services are well equipped to support community mental health services by delivering training, sharing materials and creating referral pathways. Local authorities already provide extensive stop smoking support to people with mental health conditions, with 88% of surveyed authorities reporting that people with mental health conditions are a target population for their service[17].

18. Alongside local authority SSS’s, community mental health services could benefit from developing relationships with regional tobacco control networks and programmes, such as those in North East, Yorkshire and the Humber, Greater Manchester, Cheshire and Merseyside and London. These programmes have been highly effective for coordinating activity across regional footprints, addressing inequalities and sharing best practice and resources. Connecting with these services would support implementation of stop smoking support for people with SMI in the community and ensure community mental health services are informed on the latest developments in tobacco control.

January 2025