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Introduction
The smoking ban
Aim of the ban
The effects of smoking on health
Relationship between smoking and mental health
Financial impact
Impact on medication
Why people with mental health problems smoke
Impact of the smoking ban
The health benefits of giving up smoking
Help with giving up smoking
Smoking cessation services
Specialist mental health support
Telephone counselling
Nicotine replacement therapy
Alternative pharmaceuticals
Alternative treatments

Mental health workers
The mental health worker's perspective
What mental health workers can do
NICE guidelines

Useful organisations

About this factsheet

This factsheet is intended for professionals and students who want to know more about the relationship between smoking and mental health and to support people they work with in giving up smoking, should they wish to do so. A lot of the information in this factsheet is also useful for people experiencing mental distress and their family, friends and carers.

Introduction

The smoking ban

During 2007 a smoking ban will come into force in England (from July) and Wales (from April).

In Wales, smoking is now banned in all enclosed public spaces and workplaces, including healthcare organisations, educational establishments, restaurants, cinemas, leisure centres, shopping centres, work vehicles and public transport (including taxis). Exempt are workplaces that are also a person's home: this includes adult residential care homes, adult hospices and residential mental health treatment settings. Here smoking will be allowed in a designated room – this could be either a bedroom or a room used only for smoking. [1]

In England, smoking will also be banned in enclosed public places, workplaces and public and work vehicles. There will be some exemptions including care homes, hospices and prisons. There is also a temporary exemption in adult mental health units until 1 July 2008 only. [2]

For more details on legislation visit www.smokingbanwales.co.uk  and www.smokefreeengland.co.uk

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The aim of the ban

The aim of the ban is to protect non-smokers from second-hand smoke, also called passive smoke. This is the smoke that a non-smoker is exposed to when in the same room as a smoker.

Second-hand smoke contains the same 4,000 chemicals that a smoker inhales. Many of these are toxic and over 50 of these substances can cause cancer, including:

• tar, which causes cancer and lung damage
• carbon monoxide, which is a toxic gas found in car exhaust fumes
• benzene, which is found in petrol fumes and causes leukaemia
• ethanol, which is found in anti-freeze
• formaldehyde, which is an embalming fluid
• hydrogen cyanide, which is classed as an industrial pollutant
• arsenic, which is effectively rat poison
• polycyclic aromatic hydrocarbon, which is found in diesel exhaust. [3] 

Second-hand smoke is a major indoor pollutant and can seriously damage the health of non-smokers. Immediate effects of being exposed to second-hand smoke can include irritation of the eyes, nose and throat; headache; dizziness and sickness; and breathing difficulties. [4] Long-term exposure to second-hand smoke can lead to an increase of lung cancer by 24 per cent and an increase of heart disease by 25 per cent in adult non-smokers. [5]

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The effects of smoking on health

Tobacco use is the biggest cause of premature death in the UK. [6] One in two long-term smokers will die prematurely as a result of smoking – half of these in middle age. The most recent estimates show that around 114,000 people in the UK are killed by smoking every year, accounting for one-fifth of all UK deaths. [7]

The most common diseases caused by smoking include coronary heart disease, lung cancer, chronic bronchitis, emphysema, pneumonia and chronic obstructive pulmonary disease (COPD). It can also cause illnesses including mouth, nose, throat, oesophagus and larynx cancer, strokes, decreased fertility, gangrene and subsequent amputations, and premature ageing.

Toxic chemicals in cigarette smoke suppress the immune system, and also deplete the body of vitamins. A smoker can have up to 30 per cent less vitamin C in their system than a non-smoker. [8]

Studies have shown a link between smoking during pregnancy and an increased risk of adult attention deficit hyperactivity disorder in the child when it is in adulthood.[9]

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The relationship between smoking and mental health

While general smoking rates are falling, this is not the case amongst the psychiatric populations, who suffer poor health as a consequence. [10]

Smoking rates for people from this group tend to be, on average, twice as high as those for the general public. [11] Smokers with a mental health problem also tend to smoke more heavily and be more dependent than smokers without mental health problems. For example, 51 per cent of individuals with a schizophrenia diagnosis and 50 per cent of those with a bipolar affective disorder smoked over 20 cigarettes a day compared to only eight per cent of the general population. [12] A USA survey estimated that in one particular month, 45 per cent of all the cigarettes smoked were consumed by individuals with a psychiatric or substance misuse disorder. [13]

Smoking related fatal diseases are also more prominent among individuals experiencing mental health problems than amongst the general public. [14] A study in Finland found that having a mental health disorder predicted a higher risk of cardiovascular disease, coronary heart disease and respiratory disease.' [15] It also found that individuals with schizophrenia were almost ten times more at risk of dying of a respiratory disease than other participants. These people 'are also often the least capable of coping with the effects of devastating medical illnesses caused by smoking.' [16]

It was found that smoking, in contradiction to popular belief, exacerbates stress, state anxiety [17] and sleep disorders. [18] All of these are detrimental to most mental health conditions. Anxiety levels fall significantly after successfully giving up smoking for one week. [19]

A research review [20] found that smokers reported above-average stress prior to smoking, rather than below-average stress after smoking. Smokers smoke mainly to avoid the stress that nicotine depletion causes.

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Financial impact

Smokers with a mental health problem can spend a large percentage of their, often low, income on tobacco and cigarettes. In a USA study it was estimated that a smoker with schizophrenia spends just over one-third of their weekly income on cigarettes. [21] This money is therefore not available to be spent on food, heating, socialising or other things such as leisure activities which could help to improve quality of life. As a consequence, physical and mental health might suffer.

Interestingly, one of the reasons for smoking, stated by McNeill, [22] is that it is a coping mechanism to deal with the stress of financial hardship. This is obviously a perception from the smoker, just as stress reduction is only a perceived benefit.

Impact on medication [23]

Smokers on antipsychotic medication are often prescribed higher doses than non-smokers on the same medication. This maybe because smoking increases the speed at which the medication gets metabolised. Smoking induces higher levels of the enzyme CYP1A2, which is responsible for the activation of metabolising drugs. When giving up, less CYP1A2 is produced; this in turn slows down the metabolisation of the drug.

Drugs (including antipsychotics) affected by a giving up smoking are:

• Clozapine
• Diazepam
• Fluvoxamine (partly)
• Haloperidol (partly)
• Mirtazapine (partly)
• Olanzapine (partly)
• Paracetamol
• Perphenazine
• Propranolol
• Tamoxifen
• Theophylline
• Tricyclics – tertiary (eg amitriptyline, clomipramine, desipramine, imipramine)
• Verapamil
• Warfarin-R (major)
• Zotepine

Smokers that are prescribed any drug metabolised by the enzyme CYP1A2 can build up toxic levels of that drug in their blood whilst giving up smoking.

The build-up will happen over a few days as the metabolism slows down. This should be monitored – it could be that a reduction of the drug is needed. [24]

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Why people with mental health problems smoke

One study asked smokers from the general public about their reasons for smoking. In their responses, enjoyment, boredom relief and stress relief scored highest. When people with schizophrenia were asked the same question, habit, relaxation, making social contact, pleasure and addiction were the most frequent answers. [25] Why people with mental health issues smoke more than the general public is not yet fully understood. [26] A number of factors are involved and research is ongoing.

It may be that nicotine through smoking is used as a form of self-medication. It is thought that nicotine helps to alleviate some of the positive (or 'active') psychiatric symptoms (such as voices, delusions and confusion) and the negative psychiatric symptoms (such as withdrawal, inertia and lack of motivation) and that it improves cognition. [27] Smoking might also help to alleviate some of the side effects of antipsychotic medication, such as Parkinsonism and sedation. [28]

Smoking might be used as a mechanism to cope with the stress of having a mental health problem; to cope with being isolated and bored; to create a feeling of being in control; or to deal with financial difficulties. [29] McNeill mentions the clear link between smoking rates and deprivation as well as a relationship between mental health disorders and deprivation. The more deprived groups of our society tend to smoke more and be more nicotine dependent. Individuals with chronic mental health problems might end up in the poorest category of society because of unemployment as a result of their illness. [30]

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Impact of the ban

Socially the ban might lead to isolation of individuals who are heavy smokers; they may find it difficult to go out because they are no longer allowed to smoke in the places where they go to socialise, such as cafés or drop-in centres. Some may feel stigmatised as smokers because of increased emphasis on the negative effects of smoking in the media, and because in order to smoke they will have to go outside and be seen by the world as smokers. It could also lead to increased isolation if people are more inclined to stay home where they can smoke out of view.

For some people with mental health problems, simply attending an appointment with a health professional can be a source of anxiety. Not being able to smoke in the building while waiting to be seen could result in additional stress, which might be reflected in increased numbers of missed appointments.

On a positive note, it might give people an opportunity to give up or at least to examine their smoking – one of the most difficult things people giving up report is not smoking in social situations, especially in pubs and cafés.

The smoking ban will also have a big impact on professionals. It has been found that interventions and policies around smoking are less popular among mental health staff than other healthcare professionals. [31] A small-scale UK study found that female mental health nurses smoked twice as much as non-mental health nurses. [32] The ban will mean that this group of people cannot smoke while working anymore. It will also mean a change in culture: anecdotal evidence indicates that some mental health staff use smoking as 'a way of social interaction and to facilitate communication'. [33] A new way of working and relating will have to be found by these staff.

On the other hand it may also make their job healthier, and for those staff who smoke it might be seen as an opportunity to try to give up smoking. Perhaps giving up smoking together with clients will give fresh opportunities for building therapeutic relationships.

The voluntary sector will have to go smoke-free as well. This will put some initial strain on staff implementing the policy and working with service users around it. But it is also an opportunity; for example, Mind Aberystwyth, a therapeutic service in Wales, has been smoke-free from the day they opened in 2005. In that same year they developed a smoking cessation service. This service has recorded good results and members are happy that the premises are smoke-free. Even the smokers comment positively on how it reduces their smoking because they have to go outside to light up. It also offers staff an opportunity to talk about smoking behaviour with members, examining possibilities of giving up. (Also see 'Specialist mental health support')

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The health benefits of giving up smoking

Giving up smoking will help avoid most of the risks of developing cancer, even in middle age. Giving up smoking before middle age can prevent 90 per cent of the health risks associated with smoking. [34] These benefits apply to giving up cigarettes, cigars, pipe and chewing tobacco. (Also see 'The effects of smoking on health')

When giving up, your body will go through several changes:

Time stopped	Benefits
20 minutes	Blood pressure and pulse rate return to normal. Circulation improves, especially to hand and feet.
8 hours	Blood oxygen levels increase to normal, and your chances of having a heart attack start to fall.
24 hours	Carbon monoxide leaves the body. The lungs start to clear out mucus and debris
48 hours	Your body is now nicotine-free. Your sense of taste and smell begin to improve.
72 hours	Breathing is easier, and your energy levels increase
2-12 weeks	Circulation improves throughout the body. Walking and exercising is getting easier.
3-9 months	Breathing problems, coughing, shortness of breath and wheezing improve. Lung efficiency increases by 5-10 per cent.
5 years	Risk of having a heart attack falls to about half that of a smoker.
10 years	Risk of lung cancer falls to around half that of a smoker. Risk of a heart attack falls to about the same as someone who has never smoked.

Source: Department of Health, 2005, Giving up for life

Most smokers giving up will experience some temporary withdrawal symptoms. These are a result of the body ridding itself of toxins.

Withdrawal symptoms can include:

• irritability
• feeling emotional
• cravings
• headaches
• flatulence
• sleep disturbance
• constipation
• feeling of loss/deprivation/ grief
• light headedness
• poorer concentration
• hunger
• aches and pains
• pins and needles
• mouth ulcers
• warmer skin due to improved circulation
• coughs.

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Help with giving up smoking

About half of smokers with mental health problems in Britain are interested in giving up smoking, but this group has reported feeling excluded from mainstream stop smoking programmes or they feel that health promotion campaigns are not directed towards them. [35] Trials in the USA have found that specialist smoking cessation programmes enable people with schizophrenia to stop smoking. [36] The trials combined nicotine replacement therapy or bupropion with psychological interventions such as cognitive behavioural therapy and motivational interviewing.

Smoking cessation services

The UK has national smoking cessation services operated by the NHS. This service works with pharmacological treatment and intensive specialist cessation support, either one-to-one or in a group, for those who need it.

The services also give training and support to health professionals in how to give brief opportunistic advice to patients to help them stop smoking. NICE (the National Institute for Health and Clinical Excellence) guidelines say all professional health workers should refer people who smoke to an intensive support service. [37] Up to 40 per cent of smokers who are advised to give up will make an attempt to quit smoking. [38] (See 'What mental health workers can do'.)

Specialist mental health support

Some specialised mental health smoking cessation services do exist. But at present these are not mapped and not reviewed. Some examples are given here:

Mind Aberystwyth smoking cessation service
Mind Aberystwyth operates an evidence based smoking cessation service for people experiencing the effect of mental distress, including family, friends and carers. The service has recorded good results: for many, trying to give up is a positive experience which empowers and builds self-confidence and self-esteem, providing motivation to making further positive changes in their lives, such as addressing their social needs. Mind Aberystwyth works with a holistic model using nicotine replacement therapy, motivational interviewing, stress management, exercise and dietary guidance.

Wandsworth PCT
Smoking is not allowed in the buildings and on any of the grounds of the PCT.

The PCT coordinates the provision of 'stop smoking' support to patients and staff within the SW London and St George's Mental Health NHS Trust. To date, more than 200 staff have been trained to deliver smoking cessation interventions, and more than 50 have trained as NHS Stop Smoking Advisors – this includes mental health workers. Their model works with nicotine replacement therapy and psychosocial support. One-to-one and group sessions are available. To access their service, phone 020 8682 6131.

West Surrey Stop Smoking Service
This service offers tailored smoking cessation for people with mental health problems, mainly one-to-one. To access the service, phone 0845 602 3608.

Telephone counselling

A review of telephone counselling found that it helped smokers with giving up. One or two brief calls were not that likely to leave any measurable benefit; three or more calls were more beneficial than standard self-help materials, brief advice or treatment with pharmaceuticals alone; call-back services were found to enhance the usefulness of telephone counselling. [39]

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Nicotine replacement therapy (NRT)

Using nicotine replacement therapy in an attempt to give up smoking has been found to double a person's chances of succeeding compared with no treatment. [40] NRT works by helping to manage withdrawal symptoms, by providing 'clean' nicotine, ie. nicotine without all the chemicals found in cigarettes that are detrimental to health.

NRT relieves cravings and withdrawal symptoms by releasing controlled amounts of nicotine into your body. A course of NRT slowly weans you off nicotine. It reduces relapse and provides a coping behaviour.

NRT products vary in speed of nicotine absorption, ease of use, frequency of use, type of sensory effects, amount of behavioural replacement and the potential to adjust the dose as needed. Most smoking cessation services will recommend a combination of different types of NRT because it has been proven to be more effective than one alone.

The side effects of NRT can vary, with individuals reacting differently to different products. It is important to read and follow the instructions on the packaging.

NRT is available in shops, supermarkets and over the counter in pharmacies. It is available on prescription and will be free when the smoking bans are implemented.

The six different types of NRT are listed below.

Patches
Patches work by providing a constant supply of nicotine. They come in 16- hour and 24-hour patches. Nicotine levels rise slowly with patches and plateau after about eight hours. The placement of the patch needs to be changed daily to avoid skin irritation. Side effects can include slight itching and redness, which usually disappear within two days.

Nicotine gum
This is nicotine on demand. The nicotine is absorbed in the lining of the mouth and so it is more effective to chew then rest the gum in the cheek for a while before chewing again and repeating the cycle. Any nicotine that goes to the stomach is wasted and may cause stomach upset, although this is unlikely if used in accordance with the directions on the packet. The gum is available in two strengths and comes in a variety of flavours. Use should not exceed more than 15 pieces a day. It can take up to 15 minutes for the nicotine to be absorbed by your system.

Microtabs
A microtab is a small tablet which is dissolved under the tongue – this can take up to 20 minutes. Nicotine levels in the body peak after 20 to 30 minutes. The tablets come in one strength and should not be sucked, chewed or swallowed since nicotine that ends up in the stomach has no benefit and may cause stomach irritation. Side effects can include a peppery feeling in the mouth, hiccups and stomach ache (if the tablet is swallowed).

Lozenges
Lozenges come in different strengths and are like sweets. However, they shouldn't be sucked, chewed or swallowed, for the same reasons as the microtab (see above). The lozenge should be moved from side to side with intervals until it dissolves, which will take up to 30 minutes. The nicotine peaks after 20-30 minutes. Side effects can be the same as with microtabs.

Inhalator
This is a plastic device shaped like a cigarette, which holds cartridges containing nicotine. You suck on the mouth-piece to release the nicotine vapour to be absorbed in your mouth and throat. This device is especially good for people who miss the hand-to-mouth action of smoking. Nicotine levels peak after 20-30 minutes. Side effects can include coughing and throat irritation.

Spray
More suitable for heavy smokers, this is the strongest form of NRT available. It is the fastest acting product – nicotine levels peak in 5-10 minutes – and comes in just one strength. The spray is squirted in each nostril – this technique may require some practice. Side effects can include nasal and throat irritation, a runny nose and stinging.

Alternative pharmaceuticals

A couple of alternatives to NRT are bupropion (Zyban) and varenicline (Champix) – the latter is very new. Both are non-nicotine pharmaceuticals and only available on prescription.

Bupropion (Zyban)
Zyban, which comes in tablet form, reduces cravings and withdrawal symptoms. It does not contain nicotine; instead it works on neural pathways in the brain. This form of treatment is only available on prescription. The side effects include dry mouth, insomnia, headaches, dizziness, depression and sweating. There are a number of contra-indications for taking this drug which include a history of bipolar affective disorder, people with a history of seizures and people with a history or diagnosis of an eating disorder. [41] There are also some drug interactions possible between Zyban and antidepressants and antipsychotics.

Varenicline (Champix) [42]
This is a very new drug. It comes in tablet form and is taken orally. It is unusual as it both stimulates and blocks specific nicotine receptors in the brain. It is only available on prescription. The main adverse side effect is nausea, and no other serious side effects have been found. [43]

The National Institute for Health and Clinical Excellence is in the process of producing guidance for this drug which should come out in late 2007. (Visit www.nice.org.uk)

Varenicline has not been tested yet with people with psychiatric illness. ASH's interim guidance notes [44] suggest that people with a psychiatric illness should only be prescribed Champix under close surveillance.

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Alternative treatments

There is considerable anecdotal evidence about the benefit that people have found in the use of alternative treatments to help in giving up smoking. There is however little scientific evidence to support these claims. This does not mean that they are necessarily invalid: problems with research methods mean that no firm conclusions can be drawn. Brief descriptions of the more popular and widely used methods are included below.

Hypnotherapy
This form of therapy uses hypnosis which is an altered state of awareness or trance. Different types of hypnotherapy are used to try and help people quit smoking. Some methods try to weaken people's desire to smoke, strengthen their will to quit, or help them concentrate on a quit programme. A review of trials has not found enough good evidence to show whether or not hypnotherapy can help people trying to quit smoking. [45]

Acupuncture
Acupuncture is a form of traditional Chinese medicine. It uses needles to stimulate points on the body. Acupuncture is offered with the aim of reducing nicotine withdrawal symptoms. Related therapies include acupressure, laser therapy and electro stimulation.

So far there is no consistent evidence that acupuncture, acupressure, laser therapy or electro stimulation are effective in giving up smoking, but acupuncture may be better than nothing: there is not enough evidence to dismiss acupuncture as having no greater effect than placebos. [46]

Aversive therapy
This is a treatment that pairs undesirable behaviour to negative sensations. In the case of smoking cessation it would take the form of rapid smoking, taking puffs every few seconds, to make smoking unpleasant.

A research review shows that evidence is not conclusive because most studies have research method problems. However, it was found that more research would be worthwhile. [47]

Self-help
Written and audio self-help materials have not been found very helpful for giving up. There is potentially some benefit if self-help materials are the only form of intervention, however it does not compare to advice or behavioural therapy. [48]

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Mental health workers

The mental health worker's perspective

Mental health professionals may miss opportunities to offer smoking cessation counselling to clients. [49] A UK survey asking about smoking habits and attitudes found that 60 per cent of mental health workers believed that staff should be allowed to smoke with patients; 54 per cent believed that it plays a valuable role in creating therapeutic relationships. [50] Mental health workers are inclined to be sceptical about the level of motivation and confidence that people with schizophrenia have in giving up. [51] There is a perception amongst mental health workers that giving up smoking increases psychotic symptoms and increases the risk of violent behaviour. [52] However, a literature review has shown that smoking bans in mental health settings show 'no major longstanding untoward effects in terms of behavioural indicators of unrest or compliance.' [53] Another study shows no significant increase or decrease of the symptoms of psychiatric disorders of patients during hospitalisation in hospitals with a smoking ban. [54]

What mental health workers can do

For information on how to support smokers who want to give up and on how to stimulate smokers to give up, contact the nearest smoking cessation service. Part of their remit is to give support, training and advice to primary care professionals.

NICE guidelines

People who smoke should be asked how interested they are in quitting. All smokers should be advised to quit, unless there are exceptional circumstances. Individuals who are not ready to give up should be asked to consider the possibility and should be encouraged to seek help in the future. Advice to give up smoking should be sensitive to the individual's preferences, needs and circumstances. All health professionals should refer people who smoke to an intensive support service (for example, NHS Stop Smoking Services). [55] (For more information, visit www.nice.org.uk)

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Useful organisations

NHS smoking cessation services

Both England and Wales have national NHS smoking cessation services which are free. They can give you support and advice and refer you to your nearest smoking cessation clinic.

Smokefree
web: www.gosmokefree.co.uk
NHS website with information and resources to help you quit.

(England)

NHS Smoking Helpline
freephone: 0800 169 0169 (Open 7am – 11pm)

NHS Pregnancy Smoking Helpline
free phone:0800 169 9 169 (Open 12 midday – 9pm)

NHS Asian Tobacco Helplines (Open Tuesday 1pm – 9pm)
Call-back service offered:
Urdu 0800 169 0 881
Punjabi 0800 169 0 882
Hindi 0800 169 0 883
Gujarati 0800 169 0 884
Bengali 0800 169 0 885

(Wales)

All Wales Smoking Cessation service
freephone: 0800 085 2219

Other help with giving up smoking

ASH (action on smoking and health)
tel: 020 7739 5902
web: www.ash.org.uk 
A campaigning public health charity working to eliminate the harm caused by tobacco. The website is packed with interesting information and tips for quitting.

No smoking day
tel: 0800 169 0 169
web: www.nosmokingday.org.uk
Provides information, campaign materials and top tips for quitting.

QUIT
smoking helpline: 0800 00 22 00
web: www.quit.org.uk
Charity providing help and support for people who want to stop smoking.

SmokeFree London
web: www.smokefreelondon.org

Training for mental health workers

GASP
tel: 0117 955 0101
web: www.gasp.org.uk
A tobacco control consultancy offering training and workshops; presentations, campaign and event organisation and various resources. Materials available include colourful posters, leaflets and manuals.

Tobacco Control Resource Centre
web: www.tobacco-control.org
The TCRC works in partnership with national medical associations across Europe, supporting them in their efforts to educate their members, help patients and inform public policy with respect to tobacco. One of their projects is the Tobacco Factfile presenting key facts and data about tobacco – visit www.tobaccofactfile.org

Other useful sources of information

Asthma UK
web: www.asthma.org.uk
The National Asthma Campaign calls for smoke-free air at home, at college, at work, on public transport and in pubs.

British Heart Foundation
web: www.bhf.org.uk 
Britain's largest heart charity. The site has a quick guide to healthy hearts and offers statistics on smoking and heart disease.

The British Lung Foundation
web: www.lunguk.org 
The only UK charity to fund research into the prevention, diagnosis, treatment and cure for all lung diseases.

British Thoracic Society
web: www.brit-thoracic.org.uk 
Official body of respiratory specialists. Produces a range of publications on lung diseases for both patients and health professionals.

Cancer Research UK
web: www.cancerresearchuk.org 
The largest cancer charity in Europe.

This factsheet was written by Joyce Borgs and Alan Briscoe, Mind Aberystwyth, January 2007.

Footnotes

[1] 2 April 2007 What you need to know about the new smoke-free law, a guide for employers, managers and those in control of premises and vehicles www.smokingbanwales.co.uk Welsh Assembly Government. (Proposed Legislation on Smoke-Free Workplaces)
[2] Smoke Free England, Everything you need to know to prepare for the new smokefree law on 1st July 2007. www.smokefreeengland.co.uk/files/everything_u_need_new_sf_law.pdf
[3] www.smokefreeengland.co.uk/whysmokefree/health-benefits.html
[4] www.smokingbanwales.co.uk/english/index.php?nID=33[5] www.smokefreeengland.co.uk/whysmokefree/health-benefits.html
[6] www.ctsu.ox.ac.uk/pressreleases/2000-08-02/uk-lung-cancer-deaths-halved-by-smoking-cessation-us-deaths-are-following-but-worldwide-tobacco-deaths-increase
[7] Factsheet No 2, 'Smoking statistics; illness and death', action on smoking and health 2002, www.ash.org.uk 
[8] 2005, Dr Trisha Macnair www.bbc.co.uk/health/ask_the_doctor/skininfections.shtml
[9] McNeill, A. 2001, Smoking and mental health - a review of the literature, SmokeFree London Programme
[10] McCloughen, 2003, 'Association between schizophrenia and cigarette smoking: a review of the literature and implications for mental health nursing practice' International Journal of Mental Health Vol. 12, pp119-129
[11] McNeill, A. 2004, Smoking and patients with mental health problems, Health Department Agency
[12] McNeill, A. 2004, Smoking and patients with mental health problems, Health Department Agency
[13] McNeill, A. 2001, Smoking and mental health – a review of the literature, SmokeFree London Programme
[14] McNally L. 'Stop smoking advisors resource pack', Wandsworth PCT
[15] McNeill, A. 2004, Smoking and patients with mental health problems, Health Department Agency
[16] Boyd J.W. and Lasser K. 2001, 'Tobacco madness: Commentary', Psychiatric Times 17
[17] 'State-anxiety has been defined as a transitory emotional response involving unpleasant feelings of tension and apprehensive thoughts. Trait-anxiety, on the other hand, has been defined as a personality trait referring to individual differences in the likelihood that a person would experience state anxiety in a stressful situation.' Encephale, 1999 Jan-Feb;25(1):44-9 www.ncbi.nlm.nih.gov (pub med)
[18] McNally L. 'Stop smoking advisors resource pack', Wandsworth PCT
[19] West R. and Hajek P., 1997, 'What happens to anxiety levels on giving up smoking?' American Journal of Psychiatry; 1997; 154; 1589-92
[20] Parrot, A. 1995, 'Stress modulation over the day in cigarette smokers' Addiction Vol. 90; pp233-244
[21] Brown, C. 2004, Tobacco and mental health: a literature review, ASH Scotland
[22] McNeill, A. 2001, Smoking and mental health – a review of the literature, SmokeFree London Programme
[23] McNeill, A. 2004, Smoking and patients with mental health problems, Health Department Agency
[24] McNeill, A. 2004, Smoking and patients with mental health problems, Health Department Agency
[25] Robbinson and Gray, 2005, 'Can we help people with schizophrenia stop smoking'. Mental Health Practice Vol 9, no 4, p14-17.
[26] McNeill, A. 2004, Smoking and patients with mental health problems, Health Department Agency
[27] McNeill, A. 2001, Smoking and mental health – a review of the literature, SmokeFree London Programme
[28] Ziedonis et al. 2003, 'Serious mental illness and tobacco addiction: a model programme to address this common but neglected issue.' American Journal of Medical Science 326, 4, 223-230.
[29] McNeill, A. 2001, Smoking and mental health – a review of the literature, SmokeFree London Programme
[30] McNeill, A. 2001, Smoking and mental health – a review of the literature, SmokeFree London Programme
[31] McNally L.,Oyefeso A, Annan J, Smoke Free Policy and Interventions in Mental Health Settings: A Toolkit, www.smokefreelondon.com 
[32] McNeill, A. 2001, Smoking and mental health – a review of the literature, SmokeFree London Programme
[33] Brown, C. 2004, Tobacco and mental health: a literature review, ASH Scotland
[34] Department of Health, 2005, Giving up for life (NHS leaflet, available from GP surgeries and smoking cessation advisors in England)
[35] Brown, C. 2004, Tobacco and mental health: a literature review, ASH Scotland
[36] Addington et al, 1998, 'Smoking cessation treatment for patients with schizophrenia' American Journal of Psychiatry. 155, 974-976.
[37] NICE, 2006, Brief interventions and referral for smoking cessation in primary care and other settings , NICE
[38] McNeill, A. 2001, Smoking and mental health – a review of the literature, SmokeFree London Programme
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