Written evidence from the UK Centre for Tobacco Control Studies (LTC 32)

This submission is made on behalf of the UK Centre for Tobacco Control Studies, a UKCRC Public Health Research Centre of Excellence established in 2008 and comprising a network of leading tobacco control researchers from ten UK universities. A full list of the researchers involved in the Centre, and background information on the objectives and activity of the Centre, is available at www.ukctcs.org.

Tobacco smoking is highly addictive and the largest avoidable cause of ill-health, chronic disease and premature death in the UK. The adverse effects of smoking contribute to the causation and/or exacerbation of all of the chronic conditions listed by the Select Committee in this call for evidence, with the possible exception of epilepsy. Preventing smoking is crucial to the primary and secondary prevention of these chronic conditions.

As particular examples, smoking causes over 80% of Chronic Obstructive Pulmonary Disease (COPD) and lung cancer in the UK,[1] and smoking cessation is the only intervention that has a significant impact on disease progression in COPD. Around 20% of deaths from ischaemic heart disease, and 60% of those from aortic aneurysm, are attributable to smoking,[2] and smoking prevention contributed more to the decline in mortality from heart disease in the UK over recent decades than almost all other interventions combined.[3] Smoking among people with mental health problems accounts for the majority of reduced life expectancy of this group,[4] and has been particularly neglected; in contrast to the progressive downward trend in smoking prevalence, to around 20%, in the general population, the prevalence of smoking among people with mental health problems has remained static at around 40% for the past two decades.

Any strategy to improve and prevent morbidity and mortality from long term conditions should therefore have smoking prevention and harm reduction at its core. It is of particular importance to promote all population-level preventive strategies, including the use of price, media campaigns, smoke-free policies, preventing direct and indirect advertising and promotion (for example through smoking in films marketed to children and young people) and pursuing harm reduction strategies by making alternative sources of nicotine available to the general population. At individual level, it is also essential to build smoking cessation and harm reduction into the delivery of routine care for all chronic and long-term conditions. This is especially important for those with mental health problems, for whom smoking remains culturally accepted and even facilitated by healthcare professionals, who should instead be providing treatments and support to help smokers to quit.

A recent joint report by the Royal College of Physicians and Royal College of Psychiatrists, led by UKCTCS members but with contributions from over 30 experts, drew attention to the major impact that smoking has in reducing quantity and quality of life among people with mental health problems. Key conclusions include:

• Smoking is around twice as common among people with mental disorders, and more so in those with more severe disease
• Up to 3 million smokers in the UK, 30% of all smokers, have evidence of mental disorder and up to 1 million with longstanding disease
• One third of all cigarettes smoked in England are smoked by people with a mental disorder
• In contrast to the marked decline in smoking prevalence in the general population, smoking among those with mental disorder has changed little, if at all, over the past 20 years
• Smokers with mental disorders are just as likely to want to quit than those without, but are more likely to be heavily addicted to smoking, to anticipate difficulty quitting smoking, and are historically much less likely to succeed in any quit attempt

• Smoking cessation interventions that combine behavioural support with cessation pharmacotherapy that are effective in the general population are also likely to be effective in people with mental disorders
• Smoking cessation does not exacerbate symptoms of mental disorders, and improves symptoms in the longer term
• Smokers who do not want to quit smoking, or else feel unable to make a quit attempt, should be encouraged to cut down on smoking, and to use NRT or other nicotine-containing devices (in line with NICE tobacco harm reduction guidance) to support smoking abstinence in secondary care or other smoke-free settings, and promote the likelihood of future quit attempts.

• Smoking is however a widely accepted component of the culture of many mental health settings, making cessation more difficult for smokers
• Smoke-free policies are a vital means of changing this culture

• Provision of effective smoking cessation and harm reduction support for smokers is crucial in maintaining smoke-free policy

• The NHS spends approximately £720 million per annum in primary and secondary care treating smoking-related disease in people with mental disorders.
• These costs arise from an annual estimated 2.6 million avoidable hospital admissions, 3.1 million GP consultations, and 18.8 million prescriptions.
• The majority of these service costs arise from people diagnosed with anxiety and/or depression.
• Smoking increases psychotropic drug costs in the UK by up to £40 million per annum.
• Achieving cessation in 25%, 50% and 100% of people with mental disorder would respectively result in a gain of 5.5 million, 11 million and 22 million undiscounted life years in the UK. At 3.5% discounting, the corresponding figures are 1.4, 2.7 and 5.4 million life years gained.
• Harm reduction through lifelong substitution with medicinal nicotine is highly cost-effective when compared to continuing smoking, at around £8,000 per QALY gained for lifetime nicotine patch use and £3,600 per QALY for inhalators.
• Addressing the high prevalence of smoking in people with mental disorder offers the potential to realise substantial cost savings to the NHS, as well as benefits in quantity and quality of life.

Recent draft guidance published by the National Institute for Clinical Excellence on smoking cessation in secondary care settings,[5] and on tobacco harm reduction,[6] provide the practical guidance necessary to ensure that smoking cessation interventions become properly integrated into NHS care delivery. We recommend that the Committee considers this guidance, and ways to ensure implementation, and particularly in relation to mental health settings, in its review of services for chronic and long-term conditions. Preventing smoking probably has more to offer in terms of preventing and ameliorating long-term conditions than any other measure.

The UKCTCS is an ESRC funded Investment. The views and statements expressed are those of the authors and do not necessarily reflect the views of the ESRC.

May 2013