The hacking, choking sound coming from the tiny pack of cigarettes attached to a souvenir key chain that sits on the desk of Dr. Peter Selby, Head, Nicotine Dependence Clinic at the Centre for Addiction and Mental Health, graphically illustrates the need for smoking cessation programs.
“More people with mental illness and addiction die from smoking than from their other disorders,” says Selby who is also an Assistant Professor, Department of Family and Community Medicine and Psychiatry at the University of Toronto. While 23 per cent of the population smokes, 60 to 80 per cent of clients with a psychiatric illness or who have another concurrent addiction are smokers.
In the past, it has been challenging to help these clients to stop, Selby says. Clients with a mental illness have sometimes found that smoking helps them deal with the symptoms of their illness. For example, people with schizophrenia or attention deficit disorder may be able to concentrate better while smoking, while for people who are depressed smoking can serve as an antidepressant. Also, smoking can sometimes serve to help balance the side effects of some of the major medications. Specific treatments have also not been developed for people with mental illness and addiction who have often been excluded from the research on new products.
It is also more difficult to quit smoking than other substances. There is easier access to cigarettes than other drugs. The hand-to-mouth action that accompanies smoking is very reinforcing and tends to get associated with a large number of the person’s daily activities, developing into an over learned behaviour.
But the most significant barrier to helping people with mental illness and addiction to stop smoking has been the culture, according to Selby. “In the past, it has been acceptable for people with mental illness or addiction to smoke because people have said that this is their only pleasure so let them indulge. Also, there has been this myth that people can’t quit more than one addiction at a time.” Selby says historically some care providers, some of whom have been smokers themselves, have not discouraged clients from smoking. Selby thinks that it is unethical to allow people to continue using the drug that is more likely to cause serious health impairment and potentially, death while they are attempting to stop an addiction that is giving them a problem now.
In addition to providing outpatient counselling, Selby and his staff provide consultation and support for the other staff in the hospital to help the people who are inpatients at CAMH to stop smoking. Selby says that the important factors necessary for smoking cessation include an implementation plan that staff understand, agree with and commit to, elimination of ventilated smoking areas, a systematic way of screening patients for their smoking status and their desire to quit, training of staff to help them treat patients and access to medications and behavioural therapies. This is particularly important as many people with addiction and mental health problems also experience poverty. The medications and nicotine replacements available can be out of reach financially. These items are included in CAMH’s formulary.
The staff of the nicotine clinic works closely with the multidisciplinary teams, including nurses, occupational therapists and physicians to help their clients with mental illness and addiction stop smoking. Stress management therapists also help by teaching patients how to use other techniques than smoking to deal with stress.
Robert Conway, who has schizophrenia and other addiction related issues, is very pleased with his progress with smoking cessation. Conway, 48, started smoking over 30 years ago when he was 12 or 13. With the help of his therapist, Wayne Charles, at the CAMH program, weekly attendance at the program’s support group and other external support, he is soon coming up to his six months of being smoke free. “I feel healthy, don’t cough and have more money,” Conway says.
A number of psychiatric facilities in the United States and Canada have gone completely smoke free. While Selby looks forward to a day when this is true for CAMH, he acknowledges that there is an important process that needs to take place to ensure that this happens without creating other potential risks such as people forced into hiding their smoking. In the meantime, he gets satisfaction from the people his service has helped free from the hacking cough and other serious health effects resulting from this serious addiction.