Good News and…..the Same News

The Scottish Health Survey was published by the Scottish Government last week. It aims to provide reliable information on the health, and factors related to health, of people living in Scotland that cannot be obtained from other sources. It looks at different health conditions, estimates health risk factors, compares geographical regions and subgroups of the population and monitors trends and progress toward health targets. The good news is that the summary document is a modest 12 pages long! I recommend you have a read,

We here at ASH Scotland, of course, went straight to the figures for smoking prevalence rates which reported 18% of adults smoked in 2017, down from 21% in 2016 and 28% in 2003. Cue (non-alcoholic) celebrations! (There’s a whole chapter on alcohol in the survey). This figure is now lower that in Wales (19%) and Northern Ireland (20%) but more than in England (15.5%). The figure of 18%, if looked at by gender, is made up of 20% of the adult male population and 16% of the adult female population. So one fifth of the entire male adult population of Scotland still smokes tobacco, so still quite a way to go, but steady progress none-the-less.

This particular survey does not give the smoking prevalence rate amongst people with mental health problems. The last figure we have is that it was about 40% of all those who experienced mental health problems.
So whilst figures for the general population show a steady reduction, figures for people with mental health problems remain stubbornly high. Why is this? Probably because people use smoking tobacco as a coping mechanism. Nicotine stimulates the release of Dopamine in the brain. Dopamine is neurotransmitter (a messenger between brain cells) and its release gives individuals a feeling reward that helps reinforce certain behaviours. The reward effect soon wears off and the behaviour reinforcement part soon kicks in, and another cigarette is lit. The smoking prevalence rate for severe mental health problems is around 70% and in my experience (as a drug and alcohol worker) the rate was near 90% for people with addiction problems. Again, these figures show very little change over time.

So with these high prevalence rates would it surprise you to know that people with severe and enduring mental health problems are just as motivated to stop smoking as the rest of the population? Generally, around 70% of all people who smoke would like to stop smoking. So what’s going wrong? Here’s my own personal take on this.
• Nicotine is as addictive as Cocaine and Heroin so once hooked, it is hard to give it up.
• The Dopamine stimulated by Nicotine gives a very temporary relief to worries and feelings of stress, so people experience it as helping them cope.
• Ironically people addicted to Nicotine soon start to experience withdrawal symptoms, just like with any other drug or alcohol; anxiety, stress, trembling. And like any other drug or alcohol a hit of the substance you’re addicted to helps cope with withdrawal.
• In the west we tend to medicate people with mental health problems to control the effects of a person’s condition and help them cope better. Ironically tobacco smoke renders many mental health medications less effective.

I guess the theme here is that many people with mental health problems choose smoking to help them cope and in the absence of anything else, many people will stick with what they know.

ASH Scotland’s IMPACT Project has trained over 200 Support Workers and volunteers, who work with people with mental health problems, about the adverse effect of smoking tobacco on mental health and mental health medications. The mission of the project is to get information about smoking and mental health to the 40% of people with mental health problems who still smoke. The project has moved into a new phase of training new trainers around Scotland so look out for IMPACT training in your area in 2019.

Working with People with Mental Health Problems

When I was offered a job working with people with mental health problems for the first time I was very concerned at my lack of knowledge about mental health. I had been lucky enough to enjoy good mental health and, to my knowledge, had never known anybody with mental health problems, or at least, that’s what I thought at the time. I had been in full-time employment for 15 years by the time I got this job, so I certainly would have had colleagues who had/were experiencing mental health problems and of course customers and Service Users from previous places I worked, but I just didn’t know that that was the case. People didn’t talk about mental illness as there was a real stigma around this.
The small amount of knowledge I did have had come from TV and the newspapers. I had heard/read about people who were “psychotic” and this was always in the context of something they had done which was really bad. Of course newspapers would refer to “Psychos” even if the person didn’t have a mental health problem, but their act was so terrible they must be mad. Madness! One definition of this word is to have a serious mental illness, although you would never hear a GP or Psychiatrist give a diagnosis of “madness”. Madness also means “foolish, wild or chaotic behaviour.” So, if you are foolish, wild or chaotic, you must be mad, and if you’re mad you must be mentally ill.
The people I was to work with had, I was told, “severe and enduring mental health problems.” So I was worried. Would they be psychotic or wild or chaotic? Would I be at risk from them? Also I know nothing about mental health! I started reading books (this was before the internet folks) and very quickly got more confused. Manic Depression, psychotic symptoms, hearing voices, delusions, hallucinations. Ah, Schizophrenia, I’d heard of that. This is when you have a split personality, right (WRONG!).
I started my job. It was a brand new service and I was a Vocational Guidance Counsellor for people with severe and enduring mental health problems looking to get into, or back into work. People started to arrive at the service and, shock horror, they were really normal! Most were on medication which managed their condition well and that’s why they were now thinking about work. No foolish, wild or chaotic behaviour. I confided in one Service User that I was worried about my lack of knowledge about mental health. He smiled and told me that he knew enough about it for both of us and if he needed any more information about his condition, he would seek that from a Psychiatrist or Nurse, not from me! Feeling a bit useless I asked him what use I was going to be to him then. He asked if I knew anything about helping people back into work. “Oh yes! I know loads about that”, I replied. “Great!” he replied, “you’re just the person I need to help me then.”
The moral of this story is that I didn’t need to know a great deal about mental illness to help somebody get a job. An understanding of what mental health problems were, how they were treated and how they might affect a person was all I needed to know. And it’s the same with smoking and mental health. An understanding of how smoking tobacco affects mental health and some mental health medications so that you can inform people about this is all you need (click here for information on IMPACT training)

Mental illness is an illness just like any other. If I had been going to support people with diabetes to get work, I would not for a second have thought that I need to be some sort of expert in that condition, just enough knowledge to understand people’s needs in relation to getting a job. Also I would not have been worried for my own safety. Even if someone with diabetes did commit some terrible crime, it’s very unlikely that the media would link that condition to the crime, as is usually the case with mental illness.
I worked in the mental health field for many years and never needed to be an amateur psychiatrist. A person with a mental health problem is the expert in their condition and they’ll tell you everything you need to know to help you do your job. Just ask.

Smoking and Mental Health….Who Knew?

IMPACT – Let’s talk about smoking
The IMPACT Project is an initiative to get information about the adverse effect of smoking on mental health and the help available to help people stop smoking, to Support Workers in the Third Sector who support people with mental health problems.
So what is the point of this? I’ve worked in Third Sector services, primarily mental health and latterly in addictions (alcohol and drugs). I was ignorant of the facts about smoking and mental health and so never had that conversation with those I supported. The IMAPCT Guidance contains information that I know if I could have shared with some people in the past, it would have motivated them to access stop-smoking services.
I look back with some amazement now but as an addictions worker I could have told you a lot about withdrawal effects from alcohol and drugs but the words “withdrawal” and “cigarette” never joined together in my mind. The fact that a heavy smoker could be suffering the effects of withdrawal (anxiety, distracted, stressed) from nicotine 20-30 times a day never occurred to me. People were telling me they felt anxious, distracted and stressed, but this was assumed to be due to their anxiety disorder or symptom of another condition which they had disclosed at assessment. And, of course, when the person went out for a fag they felt better. “Smoking helps my anxiety!” was the cry.
I now know that nicotine once inhaled into the body stimulates the release of Dopamine in the brain which produces pleasant feelings of calm and reward. I knew that cocaine does the same and was well aware of the withdrawal symptoms from cocaine once the Dopamine levels reduced but never attributed the same to withdrawal from nicotine. The symptoms are largely stress and anxiety. So, far from alleviating stress and anxiety smoking was causing or exacerbating it. If I had been able to explain this relationship to people I feel sure that some would have looked at ways to quit smoking.
I’ve visited around 50 Third Sector organizations and talked to hundreds of workers about the IMPACT Guidance and without fail the topic in the Guidance that generates the most interest is the effect of smoking upon some mental health medication. Tobacco smoke stimulates an enzyme in blood plasma which metabolizes medication more quickly than in a non-smoker. Heavy smokers in particular will have to take significantly higher doses of medication to get the same effect as a non-smoker. I certainly did not know about this when I was a Support Worker. Some anti-psychotic medications have unpleasant side effects. I know a lot of people who would gladly have considered stopping smoking if their dose could have been reduced. It’s estimated that this costs the NHS in the UK £40 million per year.
ASH Scotland has distributed nearly 200 IMPACT Guidance packs to Third Sector organizations in Scotland and has also delivered the free IMPACT Guidance training to 80 people so far with another 7 sessions planned in the coming months. Have a look at the IMPACT website for more information.



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 dugs and alcohol. Drugs and alcohol policy and legislation is 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 is nicotine addiction not afforded the same level of resources as alcohol and drugs? Whilst there are strong and influential Peer Mentor and Recovery movements 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 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, “ thing at a time…” Also we know that smoking causes anxiety, the only thing it relieves is withdrawal from nicotine (see page 4-5 of the IMPACT Guidance)

For point two get all public services and 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.