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Smoking by people with mental illness and benefits of smoke-free mental health services

  • Jonathan Campion, Ken Checinski, Jo Nurse and Ann McNeill


Smoking is the largest single cause of preventable illness in the UK. Those with mental health problems smoke significantly more and are therefore at greater risk. The new Health Act (2006) will require mental health facilities in England to be completely smoke-free by 1st July 2008. This article reviews the current literature regarding how smoking affects both the physical and mental well-being of people with mental health problems. It also considers the effects of smoke-free policy in mental health settings.

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Smoking by people with mental illness and benefits of smoke-free mental health services

  • Jonathan Campion, Ken Checinski, Jo Nurse and Ann McNeill
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Smoking ban and Clozapine level !

Mohammed Ashir, SpR
23 July 2008

The smoking ban implemented this July will affect psychiatric in-patients of whom 74% are smokers (Meltzer, 1996). Plasma concentrations ofcertain psychotropics are known to be affected by smoking status. Smokersare usually prescribed higher doses compared to non-smokers and abrupt smoking cessation will lead to high plasma concentrations and potentially more side-effects.

Clozapine plasma concentrations can rise 1.5 times in 2–4 weeks following smoking cessation (de Leon, 2004) and in some instances 50-70% within 2-4 days. If baseline plasma concentrations are higher – particularly over 1mg\L - the plasma concentration may rise dramatically due to non linear kinetics. If patients smoking more than 7-12 cigarettes per day while taking clozapine decide to quit the dose may need to be reduced by 50 % ( Haslemo et al 2006).

Although patients may not quit during an admission their access to cigarettes may be limited depending on leave status or other practicalities e.g. availability of staff to escort them off the ward. The“PRN” prescription of Nicotine Replacement Therapy, although strictly speaking off license, may help cravings but NRT has NO effect on clozapineplasma concentration.

All patients should be informed that in-patient settings are now smoke-free and we need to clarify and record smoking status on admission. Clinicians will need to monitor clozapine plasma concentrations in smokersclosely during admissions and shortly after discharge. All UK assays are performed at the Toxicology Unit, Kings College Hospital, London and electronic access to results is possible after registration. ( Savings made by clozapine dose reductions will mitigate the additional costs incurred!

Dr Mohammed Ashir, Specialist Registrar in Psychiatry, Tomswood Rehabilitation Unit, Whipps Cross Hospital, E11 1NR,

Dr Louise Petterson, Consultant in Rehabilitation Psychiatry, Goodmays Hospital, London.
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Conflict of interest: None Declared

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