People with severe mental illness (SMI) experience profound health inequalities, with increased rates of long-term physical health problems and behavioural risk factors, such as smoking.Reference Dregan, McNeill, Gaughran, Jones, Bazley and Cross1 There are concerns that the COVID-19 pandemic will disproportionately affect the health of people with SMI, increasing already existing health inequalities.Reference Druss2 Around 40% of people with SMI smoke,Reference Public Health England3 compared with a current smoking prevalence in England of around 14%.Reference NHS Digital4 High rates of smoking remain an important modifiable risk factor, and there is good evidence that effective interventions can encourage successful quitting.Reference Peckham, Brabyn, Cook, Tew and Gilbody5
The COVID-19 pandemic has affected health risk behaviours, and there has been an increase in quit attempts in the wider UK population, although the impact on smoking rates remains unclear.Reference Jackson, Garnett, Shahab, Oldham and Brown6 For example, in England, it has been reported that 300 000 people quit smokingReference Action on Smoking and Health7 during the first months of the pandemic. A national campaign urging people to ‘QuitForCOVID’ was rolled out, but it is uncertain whether people with SMI benefitted from this health promotion campaign. UK population surveys (e.g.Reference Jackson, Garnett, Shahab, Oldham and Brown6) have not been able to study this, and it remains possible that disparities in smoking and quitting have been further entrenched among people with SMI during the pandemic. Studies describing health risk behaviours among people with SMI provide an opportunity to explore changes during the COVID-19 pandemic. Here, we describe changes in smoking behaviour and quitting among people with SMI.
The Closing the Gap (CtG) study is a large (n = 10 176) clinical cohort, recruited between April 2016 and March 2020. Participants have documented diagnoses of schizophrenia or delusional/psychotic illness (ICD-10Reference World Health Organization8 codes F20.X and F22.X or DSM IV or Vequivalent) or bipolar disorder (ICD-10 code F31.X or DSM equivalent). The composition of the CtG cohort has previously been described,Reference Mishu, Peckham, Heron, Tew, Stubbs and Gilbody9 and the data at inception included descriptions of self-reported smoking behaviour and e-cigarette use.
We aimed to explore the effects of the COVID-19 pandemic in a subsection of this clinical cohort, and we identified participants for the Optimising Well-being in Self-Isolation (OWLS) study (https://sites.google.com/york.ac.uk/owls-study/home). We aimed to recruit 300 people to the OWLS study, as this number was feasible in the timescale. To ensure that the OWLS study subcohort was representative, we created a sampling framework based on gender, age, ethnicity and whether they were recruited via primary or secondary care. OWLS study participants were recruited from 17 mental health trusts (in six clinical research networks areas across urban and rural settings in England). People who met the eligibility criteria were contacted by telephone or letter, and invited to take part in the study.
We explored smoking behaviour and e-cigarette use during the COVID-19 pandemic. For those who reported smoking or using e-cigarettes, we asked whether this was more, less or about the same since the pandemic restrictions began. Those who reported smoking also completed the Heaviness of Smoking Index (HSI), derived from the Fagerstrom Test for Nicotine DependenceReference Heatherton, Kozlowski, Frecker, Rickert and Robinson10 (i.e. how many cigarettes per day they smoked and how long after waking they had their first cigarette), with categories of low, medium and high.
Changes in smoking status since completing the original CtG survey were established by participant linkage between self-reported smoking status before and after the pandemic restrictions began. We also compared smoking statistics within our SMI population with recent figures drawn from the UK-wide survey of smoking in the general population.Reference NHS Digital4
We assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008. All procedures involving human patients were approved by the North West – Liverpool Central Research Ethics Committee (reference 20/NW/0276). Written or verbal informed consent was obtained from all patients.
Between July and December 2020, 367 people with SMI were recruited to the OWLS study. The mean age was 50.5 (range 20–86) years, 51% were men and 77.4% were White British.
Smoking-related behaviour is given in Table 1. A total of 27.0% (95% CI 22.6–31.7%) of study participants reported that they smoked, compared with 14.1% of the general population,Reference NHS Digital4 and 12.8% (95% CI 9.7–16.5%) of study participants reported that they used an e-cigarette. Participants who smoked reported smoking a mean of 17.5 cigarettes per day (minimum of 2 and maximum of 60), compared with 9.1 of the general population.Reference NHS Digital4 With reference to the HSI, 54.5% of study participants reported smoking within 5 mins of waking, compared with 6.9% of the general population. In terms of the HSI, 50.5% of people were moderately addicted and 23.2% were highly addicted.
OWLS, Optimising Well-being in Self-Isolation study.
a. Per cents are out of those who smoked.
b. Per cents do not add up to 100% because of non-responders.
Of the people who reported smoking in the OWLS survey, 54.5% (95% CI 44.7–64.1%) said that they had been smoking more heavily since the pandemic restrictions began, and 12.1% (95% CI 6.8–19.6%) said that they had been smoking less.
A total of 355 participants provided smoking data both in the OWLS study and in a pre-COVID-19 data collection. Longitudinal linkage with pre-COVID-19 data showed that, by self-report, 9.0% (95% CI 6.4–12.3%) of people with SMI had stopped smoking. However, 5.9% (95% CI 3.8–8.7%) of people had started smoking. This change in smoking status could have taken place at any time between April 2016 to March 2020 (initial data collection) and July to December 2020 (follow-up time period).
Smoking remains one of the most important modifiable risk factors for reduced life expectancy among people with SMI.Reference Dregan, McNeill, Gaughran, Jones, Bazley and Cross1 To our knowledge, this is the first study to examine smoking status and smoking behaviour change for people with SMI during COVID-19, and other smoking population surveys have not been able to study this. Our study complements recent population surveys of mental health,Reference O'Connor, Wetherall, Cleare, McClelland, Melson and Niedzwiedz11 which have either not been able to capture the experiences of people with SMI, or have focused on mental health and not health risk behaviours. Compared with when cohort participants were first surveyed pre-COVID-19, the smoking rate has dropped, which is encouraging and suggests that there have been successful quit attempts; however, we cannot be certain whether this change in smoking behaviour is a result of COVID-19 and the pandemic restrictions. We also noted that smoking intensity increased for people who currently smoke, with more than half reporting smoking more. This suggests that although the pandemic may have prompted some people to change their smoking behaviour, for those who continued to smoke, aspects of the pandemic restrictions may have led to them smoking more.
As anticipated, when compared with the general population,Reference NHS Digital4 people were smoking on average about twice as many cigarettes per day as people without SMI, and people with SMI were nearly ten times more likely to report smoking within 5 mins of waking. This indicates that people with SMI who smoke are likely to have a higher level of nicotine dependence than those without an SMI, although we cannot link this to COVID-19. A limitation of the study is that data on nicotine dependence were not available pre-COVID-19. However, we propose to study temporal trends in smoking and nicotine dependence beyond the COVID-19 pandemic.
We conclude that important disparities between the wider population and people with SMI remain, and that smoking-related inequalities have potentially increased since the beginning of the COVID-19 pandemic. It is therefore important that effective quitting services are provided for, and responsive to, the needs of people who use mental health services.
The data that support the findings of this study are available on request from the corresponding author, E.P.
We thank the participants in the OWLS study and NHS mental health staff for their support with this study.
All authors contributed to the study protocol. S.C., P.H., P.S. and L.W. recruited participants to the study. E.P. and S.G. took the lead in drafting the manuscript. All authors were responsible for critical review of the manuscript for important intellectual content, and all authors read and reviewed the transcript.
This study is supported by the Medical Research Council (grant reference MR/V028529) and links with the Closing the Gap cohort, which was part-funded by the Wellcome Trust (reference 204829) through the Centre for Future Health at the University of York, UK Research and Innovation (reference ES/S004459/1), and the NIHR Yorkshire and Humberside Applied Research Collaboration. Any views expressed here are those of the project investigators and do not necessarily represent the views of the Medical Research Council, Wellcome Trust, UK Research and Innovation, National Institute for Health Research or the Department of Health and Social Care.
Declaration of interest