Smoking is the world-leading cause of death and is associated with increased risk of COVID-19 severity (Reddy et al., 2021), infertility (Bundhun et al., 2019), pregnancy loss (Ng et al., 2021), multiple cancers (Tellini et al., 2021), and tooth loss (Souto et al., 2019), to name a few.

Thirty percent of smokers in the UK have a mental health condition, and more than 40% of adults with serious mental health conditions smoke (Souto et al., 2019). People with mental health conditions are 19% less likely to stop smoking than people without these conditions (Hitsman et al., 2013). People with mental health conditions have recognised the advantages of quitting smoking; however, they have expressed reluctance to do so based on concerns about potentially heightened anxiety levels and the perceived significance of smoking as a coping mechanism (Kerr et al., 2013). Their views contradict evidence from controlled trials that stopping smoking can reduce anxiety, depression and stress levels and, consequentially, the number/ dosage needed to treat poor mental health (Taylor et al., 2014, McFall et al., 2010).

Currently, the support for people with mental health conditions who wish to quit smoking is predominately non-integrated (NHS, 2022). This means that despite the associations between smoking and poor mental health, people often have to seek separate services for their mental health and smoking cessation. Integrating evidence-based stopping smoking treatments into mental health support might prevent 78,000 deaths in the next 80 years (Tam et al., 2021). A recent literature review found that most research in the past five years has focused on cognitive behavioural therapy (CBT) and mindfulness-based interventions and has shown initial efficacy for smoking cessation and mental health (Vinci, 2020).

In the UK, people with depression and/or anxiety can access psychological support via NHS Talking Therapies for Anxiety and Depression (formerly called Improving Access to Psychological Therapies, IAPTs) (NHS, n.d.). These services can provide guided self-help, cognitive behavioural therapy, and non-categorised counselling delivered using self-help workbooks, online courses, one-to-one in-person, or groups. A qualitative study found support from both practitioners and patients to integrate smoking cessation support in NHS Talking Therapies for Anxiety and Depression (Taylor et al., 2021).

The co-authors of this study interviewed people participating in a trial evaluating the integration of smoking cessation support in NHS Talking Therapies for Anxiety and Depression (Sawyer et al, 2023). The aim was to understand participants’ experiences and perceived acceptability of the integrated support.

Methods

This qualitative study was embedded in the ESCAPE (intEgrating Smoking Cessation treatment As part of usual Psychological care for dEpression and anxiety) randomised controlled trial. The control group received ‘usual care’ (NHS psychotherapies for anxiety and depression). The intervention group received usual care plus smoking cessation support.

With consent, participants from both trial arms were convenience sampled (Gentles et al., 2015). The sample included people who had quit and not-quit smoking during the trial. Recruitment stopped at information power; when there was sufficient information to answer the research question (Malterud et al., 2016).

Interviews were conducted between October 2018 and February 2021. Interview questions were semi-structured and focused on the perceived acceptability of integrating smoking cessation treatment into NHS talking therapies for anxiety and depression. The interview guide was reiterated with each interview.

Interview data were analysed thematically (Braun and Clarke, 2012) using deductive and inductive reasoning. Deductive reasoning was based on the capability, opportunity, and motivation model of behaviour (COM-B) (Michie et al., 2011). The themes were agreed upon by all authors and reviewed by two people with lived experience of smoking and poor mental health.

Results

The researchers interviewed 36 people and created four themes:

1. Psychological capability

Most participants described believing that an integrated approach had mutual benefits for mental health recovery and stopping smoking. They described how the treatment helped them understand that smoking was a component of their anxiety and provided temporary relief, ultimately worsening their anxiety. One participant described how stand-alone, non-integrated therapy may not have helped them quit smoking:

I think it was a really good thing to have because now I think about it, quitting and having the support with CBT is probably something that goes quite well together, hand in hand. Had I not quit smoking, I don’t know whether the CBT would have had as much impact as it did or vice versa, so I think they worked really well together.

2. Motivation

Many participants described their motivation to participate in the integrated treatment as their curiosity, openness to change, and questions about whether the treatment would successfully tackle mental health and smoking cessation simultaneously. However, a minority of participants also described feeling that it might not be beneficial to address both smoking and mental health. For example, one participant shared their belief that focusing on improving their mental health was more crucial than quitting smoking.

Others described that their motivation came from previous failed quit attempts. These participants said they hoped the integrated approach would be a new and supported way of helping that may help them quit:

I thought it was also an opportunity. I was kind of curious to see as well if the premise of quitting smoking, less anxiety helps your mental health, I wanted to see for myself. And I would work at it as well if it was something tangible that I could see as well.

3. Physical opportunity

Participants explained how the integrated approach provided regular, structured opportunities for open discussions about the challenges of quitting smoking:

What I did like about it [integrated smoking cessation support] is the fact that we, we had the ability to talk about it every month… I knew that there was going to be a certain period of time where we would sit and go through any issues that there were and anything along those lines and I knew that there was support there if I needed it.

However, others described feeling that the time between appointments was too long or that there was limited time to address the complexities related to stopping smoking. Some also described feeling that the integrated treatment was scripted and not as natural as other stopping smoking support.

4. Social opportunity

Many participants said having a good relationship with their Psychological Wellbeing Practitioner (PWP) was important for successfully integrating the smoking cessation treatment. They said that PWPs were important for providing a supportive, non-judgemental space for guiding and encouraging them to continue with the treatment and stop smoking.

Conclusions

Integrating smoking cessation treatment in NHS talking therapies for anxiety and depression was generally accepted. In the authors’ words:

Participants were open to change when first presenting to talking therapy and motivated by curiosity to see whether quitting smoking would help their mental health.

Strengths and limitations

This study was conducted in conjunction with the ESCAPE randomised controlled trial. Using both methods allowed the researchers to test the effectiveness of the intervention and to develop an in-depth understanding of the facilitators and barriers to implementing the intervention in the real world (O’Cathain et al., 2013). A thorough description of the methods was provided, meaning the results can be trusted and replicated. There was an almost equal number of males to females.

On limitations, there was a risk of recall and social desirability biases (Bergen and Labonté, 2020). Although the authors claim to have performed a reflexive thematic analysis, themes seem to belong to descriptive or content analysis and do not go beyond description to an interpretative level. Going beyond description is essential to reflexive thematic analysis for allowing researchers to interpret the underlying social processes that may inform people’s experiences. In general, I think it was a mistake to use reflexive thematic analysis. The authors’ research question to understand the perceived acceptability of integrated smoking cessation treatment does not necessarily lend itself to an analysis looking at underlying social processes. Descriptive thematic analysis or content analysis may have worked better.

Implications for practice

The integration of smoking cessation treatment in NHS Talking Therapies would help people with mental health conditions who smoke receive evidence-based support for both at the same time and location. However, more funding and staffing of these talking therapies would be necessary if the intervention was implemented. There are already long-wait times of twenty-three weeks (162 days) for an initial consultation for NHS Talking Therapies (NHS, n.d.). Making another population eligible for these services would potentially overwhelm these services and increase wait times. With the evidence in mind, it would be useful for clinicians to gather information on smoking and substance use during the initial mental health assessment and inform their practice.

Statement of interests

I am acquaintances with Katherine Sawyer. I work in the same department as Paul Aveyard. I have lived experience of bipolar but have not used NHS talking therapies for anxiety and depression, nor do I smoke.

Links

Primary paper

Sawyer, K., Fredman Stein, K., Jacobsen, P., Freeman, T.P., Blackwell, A.K., Metcalfe, C., Kessler, D., Munafò, M.R., Aveyard, P. and Taylor, G.M. (2023). Acceptability of integrating smoking cessation treatment into routine care for people with mental illness: A qualitative study. Health Expectations, 26(1), pp.108-118. Doi: https://doi.org/10.1111/hex.13580

Other references

Bergen, N. & Labonté, R. (2020). “Everything is perfect, and we have no problems”: detecting and limiting social desirability bias in qualitative research. Qualitative health research, 30, 783-792. DOI: https://doi.org/10.1177/1049732319889354

Braun, V. & Clarke, V. (2012). Thematic analysis. apa handbook of research methods in psychology, vol 2: research designs: quantitative, qualitative, neuropsychological, and biological. Washington, DC, US: American Psychological Association.

Bundhun, P. K., Janoo, G., Bhurtu, A., Teeluck, A. R., Soogund, M. Z. S., Pursun, M. & Huang, F. (2019). Tobacco smoking and semen quality in infertile males: a systematic review and meta-analysis. BMC Public health, 19, 36. DOI: https://doi.org/10.1186/s12889-018-6319-3

Gentles, S. J., Charles, C., Ploeg, J. & Mckibbon, K. A. (2015). Sampling in qualitative research: insights from an overview of the methods literature. The qualitative report, 20, 1772-1789.

Hitsman, B., Papandonatos, G. D., Mcchargue, D. E., Demott, A., Herrera, M. J., Spring, B., Borrelli, B. & Niaura, R. (2013). Past major depression and smoking cessation outcome: a systematic review and meta‐analysis update. Addiction, 108,294-306. Doi: https://doi.org/10.1111/add.12009

Kerr, S., Woods, C., Knussen, C., Watson, H. & Hunter, R. (2013). Breaking the habit: a qualitative exploration of barriers and facilitators to smoking cessation in people with enduring mental health problems. BMC Public health, 13, 1-12. Doi: https://doi.org/10.1186/1471-2458-13-221

Malterud, K., Siersma, V. D. & Guassora, A. D. (2016). Sample size in qualitative interview studies: guided by information power. Qualitative health research, 26, 1753-1760. Doi: https://doi.org/10.1177/1049732315617

Mcfall, M., Saxon, A. J., Malte, C. A., Chow, B., Bailey, S., Baker, D. G., Beckham, J. C., Boardman, K. D., Carmody, T. P. & Joseph, A. M. (2010). Integrating tobacco cessation into mental health care for posttraumatic stress disorder: a randomized controlled trial. JAMA, 304, 2485-2493. Doi: https://doi.org/ 10.1001/jama.2010.1769

Michie, S., Van Stralen, M. M. & West, R. (2011). The behaviour change wheel: a new method for characterising and designing behaviour change interventions. Implementation science, 6, 1-12. Doi: https://doi.org/10.1186/1748-5908-6-42

Ng, K. Y. B., Cherian, G., Kermack, A. J., Bailey, S., Macklon, N., Sunkara, S. K. & Cheong, Y. (2021). Systematic review and meta-analysis of female lifestyle factors and risk of recurrent pregnancy loss. Scientific reports, 11, 7081. Doi: https://doi.org/10.1038/s41598-021-86445-2

NHS (n.d.). Integrating mental health therapy into primary care [Online]. Available: https://www.england.nhs.uk/mental-health/adults/nhs-talking-therapies/integrating-mental-health-therapy-into-primary-care/ [Accessed: 9^th Jul 23].

NHS (2022). NHS Stop smoking services help you quit [Online]. Available: https://www.nhs.uk/live-well/quit-smoking/nhs-stop-smoking-services-help-you-quit/ [Accessed 9^th Jul 23].

NHS. NHS Talking therapies, for anxiety and depression [Online]. Available: https://www.england.nhs.uk/mental-health/adults/nhs-talking-therapies/ [Accessed 9th Jul 23].

O’Cathain, A., Thomas, K., Drabble, S., Rudolph, A. & Hewison, J. (2013). What can qualitative research do for randomised controlled trials? a systematic mapping review. BMJ Open, 3, e002889. Doi: https://doi.org/10.1136/bmjopen-2013-002889

Reddy, R. K., Charles, W. N., Sklavounos, A., Dutt, A., Seed, P. T. & Khajuria, A. (2021). The effect of smoking on covid‐19 severity: a systematic review and meta‐analysis. Journal of medical virology, 93, 1045-1056. Doi: https://doi.org/10.1002/jmv.26389

Souto, M. L. S., Rovai, E. S., Villar, C. C., Braga, M. M. & Pannuti, C. M. (2019). Effect of smoking cessation on tooth loss: a systematic review with meta-analysis. BMC Oral health, 19, 1-16. Doi: https://doi.org/10.1186/s12903-019-0930-2

Tam, J., Warner, K. E., Zivin, K., Taylor, G. M. & Meza, R. (2021). The potential impact of widespread cessation treatment for smokers with depression. American journal of preventive medicine, 61, 674-682. Doi: https://doi.org/10.1016/j.amepre.2021.04.024

Taylor, G., Mcneill, A., Girling, A., Farley, A., Kindson-Hawley, N. & Aveyard, P. (2014). Change in mental health after smoking cessation: systematic review and meta-analysis. BMJ, 348. Doi: https://doi.org/10.1136/bmj.g1151

Taylor, G. M., Sawyer, K., Kessler, D., Munafò, M. R., Aveyard, P. & Shaw, A. (2021). Views about integrating smoking cessation treatment within psychological services for patients with common mental illness: a multi‐perspective qualitative study. Health expectations, 24, 411-420. Doi: https://doi.org/10.1111/hex.13182

Tellini, R., Mari, A., Muto, G., Cacciamani, G. E., Ferro, M., Stangl-Kremser, J., Campi, R., Soria, F., Rink, M. & Xylinas, E. (2021). Impact of smoking habit on perioperative morbidity in patients treated with radical cystectomy for urothelial bladder cancer: a systematic review and meta-analysis. European urology oncology, 4, 580-593. Doi: https://doi.org/10.1016/j.euo.2020.10.006

Vinci, C. (2020). Cognitive behavioral and mindfulness-based interventions for smoking cessation: a review of the recent literature. Current oncology reports, 22, 58. Doi: https://doi.org/10.1007/s11912-020-00915-w

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