Much of the lower life expectancy in people with mental health problems is down to smoking, yet this issue is still often overlooked during their treatment, a report has found.

The report, Smoking and mental health, by the Royal College of Physicians (RCP) and Royal College of Psychiatrists (RCPsych) says that smoking in people with mental health conditions is neglected by the NHS. While the prevalence of smoking in the UK has fallen substantially over the past two decades, among people with mental disorders it has barely changed.

Three Royal College presidents – Sir Richard Thompson (RCP), Sue Bailey (RCPsych) and Lindsey Davies (Faculty of Public Health) say in their foreword to the report that this is an indictment of UK public health policy and clinical service provision, and an area where change is long overdue.

Although 20% of the general population smokes, the figure among people with mental health disorders is 40%, and is even higher in those with more severe mental health problems. Those with mental disorders also smoke more cigarettes, are more addicted to nicotine, and find it harder to quit than those without.

The report says it is likely that the high prevalence of smoking accounts for much of the substantially lower life expectancy – more than 10 years – of people with mental disorders. Smoking also reduces quality of life, exacerbates poverty, increases drug requirements to control symptoms and adds to social stigma in this group.

While smokers with mental health problems are just as likely to want to quit as those without, they are more likely to be heavily addicted, to believe it will be difficult to quit, and are much less likely to succeed in any quit attempt. Many are discouraged by mistaking the symptoms of nicotine withdrawal for those of underlying mental disorder. However, stopping smoking improves mental health in the longer term.

The report also found that people treated in specialist mental health settings are the most disadvantaged when it comes to the provision of cessation services. While heavy smokers often reduce consumption due to the smoke-free setting, studies have shown that there is a ‘culture’ of smoking in many service settings, and some light or moderate smokers will actually smoke more due to boredom, stress or as a means of socialising in service settings. Healthcare staff are often complicit in maintaining this culture, for example by prioritising supervision of smoking breaks rather than promoting a smoke-free policy.

Key recommendations of the report include:

• Smoke-free policy is crucial to promoting smoking cessation in mental health settings and therefore
• All healthcare settings used by people with mental disorders should be completely smoke free
• Smokers with mental disorders using primary and secondary care services should be identified and provided routinely and immediately with specialist smoking cessation behavioural support, and pharmacotherapy to relieve nicotine withdrawal, promote cessation and reduce harm
• Commissioners should require mental health service settings to be smoke free, and to provide support for cessation, temporary abstinence and harm reduction
• All professionals working with or caring for people with mental disorders should be trained in awareness of smoking as an issue, to deliver cessation advice, to provide or arrange further support for those who want help to quit. Such training should be mandatory
• Research funding agencies should consider encouraging and investing in research to address this major cause of ill-health, and health inequalities, in British society.

Professor John Britton, chair of RCP’s Tobacco Advisory Group, said: “As the prevalence of smoking in the UK falls, smoking is increasingly becoming the domain of the most disadvantaged in our society, and particularly those with mental disorders. That smoking prevalence has remained so high in this group, especially among those with severe disease, is a damning indictment of medical practice and public health policy. It is time for a radical change in our approach to smoking in mental health care provision, to make non-smoking the norm, and significantly enhance life expectancy and quality among millions of people.”

Louise Howard, Professor of women’s mental health at the Institute of Psychiatry, King’s College London, said: “Support for people with mental health problems to stop smoking needs to be prioritised urgently to improve not only the health of this vulnerable group but also the next generation, as smoking is the leading preventable cause of fetal and infant morbidity and mortality - pregnant women with mental health problems are motivated to stop smoking but are more likely to be smoking through pregnancy than other women.”

Paul Jenkins, chief executive of mental health charity Rethink Mental Illness, agreed that more support is needed. “It is scandalous that so many people with mental illness are given no support to stop smoking,” he said. “In fact, some of our members have been told not to bother trying because they’ll find it too stressful.

“People with schizophrenia and bipolar disorder die on average 15-20 years younger than the general population, and smoking plays a massive part in that.

“Last year The Schizophrenia Commission called on the NHS to make sure that people with mental illness are given support to stop smoking as standard. We urge the NHS to act now so that we can start to reduce the number of people with mental illness who are dying unnecessarily.”