Should we encourage smokers with severe mental illness to switch to electronic cigarettes?

Australian & New Zealand Journal of Psychiatry, 51(7) Although smoking rates in Australia have declined significantly in recent years, the very high smoking prevalence in patients with severe mental illness (SMI) has remained unchanged (Cooper et al., 2012). In all, 70% of patients with schizophrenia and 61% of patients with bipolar disorder smoke, compared to 16% of those without mental illness (Cooper et al., 2012). People with SMI have substantially poorer physical health and a reduced life expectancy by 15– 20 years compared to the general population. Smoking is the leading cause of this health gap. Smokers with SMI are just as motivated to quit as other smokers and most make repeated attempts to do so (Cooper et al., 2012). However, quit rates are low in this population due to a range of factors, including heavier smoking, more severe nicotine dependence, the beneficial effects of nicotine, comorbid substance use and environmental and social factors that reinforce smoking (Sharma et al., 2016). Additional approaches are urgently needed to reduce the devastating consequences to physical and mental health in those who are unable or unwilling to quit with conventional treatments. One novel option is switching to long term use of electronic cigarettes (e-cigarettes) (Sharma et al., 2016). Smokers with SMI who are unable to quit smoking could benefit from long-term substitution of combustible tobacco with ‘clean’ nicotine product such as e-cigarettes (tobacco harm reduction). E-cigarettes deliver the nicotine to which smokers are addicted without the products of combustion that cause almost all the adverse health effects of smoking (Royal College of Physicians [RCP], 2016). E-cigarette vapour contains low levels of toxins, but the Royal College of Physicians estimates the long-term risk from e-cigarette use (vaping) as likely to be no more than 5% of smoking tobacco (RCP, 2016). Similar harm reduction strategies are widely used for other harmful behaviours, such as the opiate substitution therapy and clean needle exchange to reduce risks from intravenous opiate use. E-cigarettes also have the added appeal of simulating the behavioural, sensory and social aspects of the smoking ritual. Many studies have shown that nicotine-containing e-cigarettes alleviate cravings and nicotine withdrawal symptoms and large population studies from Europe and the United Kingdom suggest that e-cigarettes are helping many smokers to quit combustible tobacco. The limited studies so far suggest that e-cigarettes can also help people with SMIs to stop or substantially reduce their smoking without serious adverse effects, even in those not ready to quit (Sharma et al., 2016). Further trials are underway to test the effectiveness of e-cigarettes in smokers with SMI. Switching completely to e-cigarettes is likely to lead to significant physical and mental health benefits, but there is also evidence that even partial substitution (dual use) may produce some health improvements. Those who reduce smoking while using e-cigarettes are more likely to quit smoking altogether in the longterm, as is the case with long-term use of nicotine replacement therapy. E-cigarettes appear to be an appealing option for smokers with SMI. Research suggests that smokers with SMI are more likely to have tried e-cigarettes and are more likely to be current users than other smokers (Cummins et al., 2014). Adherence to treatment is more likely if the products used are acceptable to patients. According to the Smoking Toolkit study (United Kingdom), e-cigarettes are now the most popular aid to quitting in the United Kingdom. The continued use of nicotine in e-cigarettes may also benefit specific illness-related deficits in SMI by augmenting the release of dopamine and several other neurotransmitters. Nicotine modestly improves Should we encourage smokers with severe mental illness to switch to electronic cigarettes?