Date Published: March 1, 2019
Publisher: Elsevier Science
Author(s): Sol Richardson, Ann McNeill, Leonie S. Brose.
Smoking is a major contributor to the disparity in life expectancy between those with and without a mental health condition. Previous work has found associations between individual conditions such as depression and current smoking, cigarette consumption and dependence, but did not compare a range of specific mental disorders. Using data from the nationally-representative Adult Psychiatric Morbidity Survey, we characterised trends in smoking prevalence in the general population in Great Britain and among those with and without mental health conditions for the period 1993–2014. We tested associations across different common mental health conditions (including depression, phobia, generalised anxiety and mixed anxiety and depression), in addition to personality conditions, and heaviness of smoking, desire to quit, perceived difficulty of remaining abstinent and successful cessation within the previous 12 months. Smoking prevalence among those without any mental health condition decreased from 29.3% in 1993 to 19.6% in 2014. Prevalence was higher among those with a condition but fell from 44.6% to 34.1%. Having a mental health condition was associated with current smoking, heavy smoking, difficulty remaining abstinent, desire to quit and perceived difficulty remaining abstinent. The same was found for all conditions individually but the strength and significance of the associations varied. Having any common mental health condition was associated with lower odds of smoking cessation—but not after adjustment for heavy smoking. We found no significant associations between individual conditions and cessation outcomes, however. In summary, smoking prevalence among people with common mental health conditions remained around 50% higher than among those without despite their higher desire to quit. Adequately addressing higher dependence could support cessation and contribute to narrowing health disparities.
There exist significant inequalities in health and life expectancy between individuals with mental health conditions and the general population (Chang et al., 2011; Chesney, Goodwin, & Fazel, 2014; Thornicroft, 2013) which have been estimated at up to 12.0 years for women and 15.9 years for men (Lawrence, Hancock, & Kisley, 2013). The difference in smoking prevalence between these groups is a major contributor to these persistent inequalities which can account for up to two thirds of the disparity in life expectancy (Tam, Warner, & Meza, 2016).
Data were obtained from the Adult Psychiatric Morbidity Survey (APMS), a representative survey of psychiatric morbidity among adults in private households in Great Britain administered by the Office for National Statistics (ONS) on behalf of the Department of Health, the Scottish Executive and the National Assembly for Wales (Meltzer, Gill, Petticrew, & Hinds, 1995). Four waves are currently available (1993, 2000, 2007 and 2014) and sample sizes per wave range from 7403 to 10,108. Smokers were defined as respondents who replied “yes” to the question “do you smoke cigarettes at all nowadays?” Ex-smokers were defined as those who had reported ever trying a cigarette and were not currently smoking as per the pre-2016 ONS definition1 (ONS, 2017). The 2000 wave of APMS included variables pertaining to respondents’ smoking behaviour including quantity smoked and cessation.
Smoking prevalence in the general population in Great Britain decreased from 31.8% in 1993 to 22.3% in 2014, and from 29.3% to 19.6% for those without a MHC, as evidenced by the non-overlapping 95% CIs. Prevalence remained over 50% higher among those with a MHC, but fell from 44.6% to 34.1% in the same period. The proportion of never-smokers in the general population exceeded that of current smokers by 2007 and ex-smokers by 2014. The proportion of smokers who had a MHC increased over the period studied from 22.3% (95% CI: 20.9–23.9) in 1993 to 24.3% (95% CI: 22.5–26.1) in 2000, 24.5% (95% CI: 22.2–26.8) in 2007, and 28.8% (95% CI: 25.9–31.7) in 2014 (See Graph 1, Graph 2, Graph 3). Although the proportion of ex-smokers in the general population remained constant or even declined over the study period, the proportion of ex-smokers as a proportion of ever-smokers increased over time (increasing from 41.7% to 49.4% among those with a MHC and from 57.1% to 66.2% among those without a MHC from 1993 to 2014).Graph 1Overall British population.Proportions of smokers (solid line), ex-smokers (dashed line) and never-smokers (dotted line) in the British population aged 16–64 years overall and according to presence of mental health conditions (1993–2014).Graph 1Graph 2Individuals with a CIS-R common mental health condition.Proportions of smokers (solid line), ex-smokers (dashed line) and never-smokers (dotted line) in the British population aged 16–64 years overall and according to presence of mental health conditions (1993–2014).Graph 2Graph 3Individuals without a CIS-R common mental health condition.Proportions of smokers (solid line), ex-smokers (dashed line) and never-smokers (dotted line) in the British population aged 16–64 years overall and according to presence of mental health conditions (1993–2014).Graph 3
We found a consistent and significant decline in smoking prevalence from 1993 to 2014 regardless of presence of MHCs. Promisingly, smoking prevalence decreased by around ten percentage points among those both with and without MHCs. Smoking prevalence among those with a MHC remained notably higher, however, with little indication of convergence. Estimates of smoking prevalence among people with mental health conditions using APMS 2014 data were comparable with those from other sources (Royal College of Physicians, Royal College of Psychiatrists, 2013). For example, Health Survey for England data estimated a smoking prevalence of 37.4% (95% CI: 31.9–43.1) among people reporting a longstanding mental health condition in 2010. People with MHCs in Great Britain had higher odds of smoking, heavy smoking, dependence, having desire to quit and perceiving abstinence as difficult while having lower odds of successful cessation (but not after adjusting for heavy smoking). Certain personality conditions were associated with higher odds of smoking, cigarette dependence and perceived difficultly remaining abstinent, but also greater desire to quit.
SR designed the study, conducted the statistical analysis and drafted the manuscript. AM and LB revised the manuscript for intellectual content. All authors substantively contributed to and approved the final manuscript.
This study was funded by a Cancer Research UK (CRUK)/BUPA Foundation Cancer Prevention Fellowship (C52999/A19748). The authors are members of the UK Centre for Tobacco and Alcohol Studies, a UK Clinical Research Collaboration Public Health Research: Centre of Excellence. Funding from the Medical Research Council, British Heart Foundation, Cancer Research UK, Economic and Social Research Council and the National Institute for Health Research under the auspices of the UK Clinical Research Collaboration is gratefully acknowledged (MR/K023195/1).