This article is brazenly one-sided because it is about an addictive killing substance sold legally. The author is unapologetically anti-smoking because tobacco is the only killing substance sold legally for consumer use. Smoking (of tobacco) is normally seen as a physical health problem. This article will show it is a serious mental health problem as well. No evidence has been found to support tobacco smoking as beneficial to mental health for longer than 5 minutes.
Unlike journals which are limited by space and word count, a web-publication is unlimited. This article is very long and in-depth, serving as a growing respository of accumulated evidence and expert opinions from authoritative sources. Reading including study time is approximated at 20 hours. The author spent ~120 hours of personal time reading and collating evidence up to 23/11/2024. The author does not expect everyone to spend 20 hours studying the contents of this article.
The author maintains a rigid belief based on hard evidence, that nicotine dependence is a killing mental disorder – one that compels people to fund their own death through substantial tobacco taxation. This addiction is particularly devastating for those with other mental disorders, who are more vulnerable to its effects and more likely to suffer significantly reduced life expectancy. The legal sale of tobacco products enables and perpetuates this lethal cycle, turning patients into unwitting participants in their own premature death. Any policy that facilitates the use of tobacco is an institutional endorsement of premature death – turning healthcare services into unwitting accomplices in maintaining a lethal addiction.
Some readers may wish to listen to our conclusions first in audio or video below.
The GMC guidance states doctors must make the care of patients their first concern. Given the evidence that smoking, is uniquely lethal, a killing mental disorder (nicotine addiction), interferes with treatment, reduces life expectancy
NHS Advice is that “Stopping smoking can be as effective as antidepressants. People with mental health problems are likely to feel much calmer and more positive, and have a better quality of life, after giving up smoking. Evidence suggests the beneficial effect of stopping smoking on symptoms of anxiety and depression can equal that of taking antidepressants.“
Tobacco: preventing uptake, promoting quitting and treating dependence – NICE guideline [NG209] (108 pages) Last updated: 16 January 2023 – consolidated eight previous guidance documents. NG209 emphasises the need to provide ‘support and services’ to help patients stop smoking. At 1.22 there is mention of the need to priortise people with ‘mental health conditions’. NICE rejected several research papers because they were reviews, in their body of evidence (87 pages).
Key references for all of this article: The ASH report 2019, The vicious cycle of tobacco use and mental illness – a double burden [WHO, Nov 2021], The Bristol University Study (2022), Smoking Cessation and Changes in Anxiety and Depression in Adults With and Without Psychiatric Disorders (JAMA, May 2023).
This is a call for integrated treatment approaches that address both tobacco dependence and mental health conditions simultaneously, as this can lead to better overall health outcomes..
Acknowledgement: The author is thankful to CE for motivation to write this article.
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Table of Contents
- Mental and physical
- Attitudes of mental health staff
- Double whammy
- More evidence-based sources
- Triple Whammy
- Smoking cessation is high priority
- Paying to die faster
- Personal choice
- Capacity to damage physical and mental health
- The Section 17 gateway
- Conclusions
Mental and physical
Physical
- Most people know or ought to know that ‘Smoking Kills’ because packets of tobacco are all labelled as such in the UK.
- Kills one person in the UK every 5 minutes [Cancer Research UK].
- Is responsible for an estimated 55,000 cancer deaths in the UK each year – more than a quarter (28%) of all cancer deaths [Cancer Research UK].
- Is the leading preventable cause of illness and premature death, killing around 74,600 people in England in 2019. US data indicates that for every death caused by smoking, at least 30 smokers are living with a serious smoking-related illness. In England in 2019 to 2020, there were an estimated 506,100 smoking-related admissions to hospital, equating to almost 1,400 each day. One in four patients in a hospital bed is a smoker. Smokers also see their GP 35% more than non-smokers [Gov.uk]
- Is the number one preventable cause of death, disability and ill health and is responsible for 80,000 deaths a year in the UK, and 1-in-4 of all cancer related deaths. No other consumer product kills up to two-thirds of its users [ASH.org.uk]
- Life expectancy was shortened by more than 10 years among the current smokers, as compared with those who had never smoked. Adults who had quit smoking at 25 to 34, 35 to 44, or 45 to 54 years of age gained about 10, 9, and 6 years of life, respectively, as compared with those who continued to smoke [21st-Century Hazards of Smoking and Benefits of Cessation in the United States | New England Journal of Medicine [January 2013]
- Smoking is the single largest cause of a 10-20 year lower life expectancy for people with mental disorders (RCP & RCPsych 2013.) That means if they were supposed to get 80 years, they’ll get roughly 60 to 70 years. [Life expectancy is a statistical concept. This does not mean that ‘every smoker’ will lose 10 or more years of life. Some may lose far more or much less.]
Mental
Persons with a current mental illness smoked 44% of all cigarettes in the United States. [Lasser, K. E. (2009). Update in Smoking and Mental Illness: A Primary Care Perspective. Journal of Dual Diagnosis, 5(2), 191–196. https://doi.org/10.1080/15504260902869121].
The WHO article titled “The vicious cycle of tobacco use and mental illness – a double burden“ [Nov 2021] highlights the complex and bidirectional relationship between tobacco use and mental health. It emphasises that:
- Tobacco use is more prevalent among individuals with mental health conditions compared to the general population.
- Nicotine dependence can exacerbate mental health symptoms, creating a cycle where individuals continue to smoke to alleviate these symptoms, which in turn reinforces the dependence.
- Mental health conditions such as depression, anxiety, and schizophrenia are associated with higher rates of smoking.
- Smoking cessation can lead to improvements in mental health, including reduced depression, anxiety, and stress, and enhanced quality of life.
- Healthcare providers often overlook the importance of smoking cessation in people with mental health conditions, despite the clear benefits.
The frequent separation of smoking and mental health discussions in public discourse masks a critical and complex interplay between these two issues. This intricate relationship carries significant consequences for individuals and public health, demanding focused attention and understanding.
But what is worse is that between 70 to 75% of the cost of a 20 pack of cigarettes is taxes that go back to the government. [Click this to see our conservative calculations]. At Paying to die faster (below), I show that a person suffering with schizophrenia could be paying around £874/year to ‘your government’ to lose a year of life expectancy. But ask the question: Why should anybody pay your government £874 per loss of a life year for the pleasure of a highly addictive killing substance? Does that make sense? For some the issue is capacitious ‘individual choice’.
A growing body of evidence reveals a disproportionately high prevalence of smoking among individuals with mental health conditions, raising concerns about the potential for ‘self-medication’ and the influence of social and environmental factors. Disturbingly, smoking exacerbates the symptoms of various mental health conditions, including anxiety, depression, and psychosis, creating a detrimental cycle of dependence and diminished well-being.
Furthermore, statistics expose a stark reality: smoking acts as the primary contributor to the drastically reduced life expectancy observed in individuals battling mental illness. This alarming trend underscores the urgent need to address the underlying causes of this interconnectedness and advocate for comprehensive support systems.
It might surprise many people, but nicotine dependence is classified as a mental disorder 6C4A in ICD-11 (International Classification of Diseases, 11th Revision). The fact that substance and non-substance dependence are not detainable mental disorders for the purposes of the Mental Health Act 1983, is immaterial. The fact is – like it or not – that every person with a nicotine dependence has a mental disorder under 6C4A. How ethical is it for health care workers to be facilitating the perpetuation of a particular dependence which is ‘killing’? Alcohol for public consumption is not labelled as ‘killing’. If mental health workers would not turn a blind eye to alcohol dependent patients, they should not to those with tobacco dependence.
Attitudes of mental health staff
A paper of significant improtance highlights a source of resistance to change: Staff attitudes to completely smoke-free policies and smoking cessation practices in a mental health setting (A Ratier-Cruz, J G Smith, M Firn, M Rinaldi Journal of Public Health, Volume 42, Issue 2, June 2020, Pages 403–411, https://doi.org/10.1093/pubmed/fdaa033). The findings from this 2020 study are quite concerning, particularly given how long the evidence has been available about the harm to mental health associated with smoking.
Key Statistics
- 59.6% of staff disagreed with smoke-free policy on wards
- 57.4% disagreed with smoke-free policy throughout mental health settings
- Clinicians showed significantly lower organisational policy support than non-clinicians
Particularly Concerning Aspects
Professional Divide:
- Clinicians were less supportive than non-clinical staff
- Only psychiatrists showed strong support compared to nurses and allied health professionals
- This suggests those with the most direct patient contact were least supportive
Cultural Entrenchment
- Study was conducted before mandatory implementation in 2018
- Shows deep-rooted resistance to evidence-based policy
- Reflects continuing institutional acceptance of harmful behaviour
Staff Smoking Impact:
- Current smokers showed significantly less positive attitudes
- This affected both organisational policy support and staff practice views
- Suggests personal smoking status influences professional judgment
Training Effect:
- Those with smoking cessation training showed more positive attitudes
- However, the study suggests training may simply reinforce existing positive attitudes rather than changing negative ones
- This indicates a potential selection bias in who seeks training
The findings are particularly troubling because they show resistance to change even as the evidence base for smoking harm in mental health populations has grown stronger, as documented in both this study and the 2008 paper cited earlier.
Double whammy
While smoking is undeniably harmful to everyone who regularly inhales tobacco smoke, there is a rapidly growing body of evidence that suggests that the physical risks might be even worse for individuals with mental health conditions. This is supported by research findings in the last 10 years, summarised as follows:
1. Increased Vulnerability:
- Biological factors: Some reputable studies suggest that people with mental illness may have a heightened biological vulnerability to the harmful effects of smoking. This could be due to differences in how their bodies metabolise nicotine or respond to the toxins in cigarette smoke.
- Medication interactions: Certain psychiatric medications can interact with nicotine, potentially increasing the risk of side effects or reducing the effectiveness of the medication. This can lead to higher doses being prescribed, which in turn might increase the risk of further health complications.
2. Higher Smoking Rates and Intensity:
- Prevalence: People with mental health conditions tend to smoke at much higher rates than the general population. This increased exposure to cigarette smoke naturally elevates their risk of smoking-related diseases.
- Heavier smoking: Individuals with mental illness often smoke more heavily and are more nicotine dependent, further compounding the physical damage.
3. Reduced Access to Healthcare and Support:
- Barriers to care: People with mental health conditions may face challenges in accessing healthcare, including preventive care and smoking cessation programs. This can lead to delayed diagnoses and treatment of smoking-related diseases.
- Stigma and discrimination: Stigma surrounding mental illness can also prevent individuals from seeking help for their smoking addiction, further exacerbating the problem.
4. Lifestyle Factors and Comorbidities:
- Unhealthy habits: Individuals with mental health conditions may be more likely to engage in other unhealthy behaviours, such as poor diet and lack of exercise, which can compound the negative effects of smoking.
- Co-occurring conditions: Mental illness often co-occurs with other physical health conditions, such as obesity or cardiovascular disease, which can increase vulnerability to the harmful effects of smoking.
None of the above information is new – though it may appear to be ‘new’ to those who did not know.
The paper by Campion et al: Advances in Psychiatric Treatment , Volume 14 , Issue 3 , May 2008 , pp. 217 – 228 DOI: https://doi.org/10.1192/apt.bp.108.005710 is important study for those who did not know. A summary with excerpts follows but the accumulation of research post-2008 has clarified grey ares, and hardened even more.
Note that the following were at 2008 – 10 years later the areas of doubt have be clarified. Between 2018 and 2024 there is even greater clarity.
Mortality Rates:
- 20% shorter life expectancy in schizophrenia
- 50% of people with serious mental illness who smoke regularly will die prematurely
- One in two regular smokers dies 15 years prematurely
- One in four dies 23 years prematurely
- Two-thirds of people with schizophrenia die of coronary heart disease
- 10 times higher risk of death from respiratory disease in schizophrenia
Prevalence of Smoking:
- 70% of psychiatric inpatients smoke
- 50% of inpatients smoke heavily
- 64% of those with probable psychosis are smokers
- 29% of those without psychosis are smokers
- 22% of UK adults were smokers (2006)
- Two-thirds of smokers wanted to give up
Disease Risk from Passive Smoking:
- 25% increased risk of lung cancer and ischaemic heart disease
- 50-60% increase in risk of coronary heart disease from heavy passive smoking
Mental Health Association:
- Double probability of any mental health problem in smokers versus non-smokers (22.4% vs 12.2%)
- About half of people with schizophrenia misuse illicit substances and alcohol
Cessation Statistics:
- 90% of lung cancer mortality risk can be avoided if quitting before middle age
- 2-3% per year permanent remission rate in UK
- 15% of smokers stopped completely following workplace bans
Smoking and Depression:
- People with depressive/anxiety disorders are twice as likely to smoke
- Evidence suggests smoking increases risk of depression
- Ex-smokers report less depression than current smokers
- Clear relationship between smoking prevalence and number of depressive/anxiety symptoms
- Higher suicide rates and thoughts among smokers
Smoking and Anxiety:
- Cigarette smoking increases risk of anxiety disorders in late adolescence/early adulthood
- Daily smoking associated with increased risk of first panic attack
- Perceived stress levels reduce on stopping smoking and increase on return to smoking
- Anxiety decreases after first week of abstinence
- Evidence suggests smoking is chronically anxiogenic (anxiety-causing) rather than anxiolytic (anxiety-reducing)
Smoking and Schizophrenia: Contradictory findings in two areas:
- As Precipitator or Protector:
- Some studies show 90% started smoking before illness onset (potential risk factor)
- Other studies show early smoking associated with lower rate of subsequent schizophrenia (potential protective factor)
- Self-medication Hypothesis:
- Contradictory evidence regarding effects on positive and negative symptoms
- Smoking decreases blood serum levels of antipsychotics
- Smokers often prescribed higher doses of antipsychotics
- No randomized clinical trials support self-medication hypothesis
The neurotransmitter effects of smoking:
Initial Mechanism:
- Nicotine crosses blood-brain barrier within seconds of inhalation
- Binds to nicotinic cholinergic receptors
Neurotransmitters – Nicotine causes release of:
- Noradrenaline
- Serotonin
- Dopamine
- Acetylcholine
- GABA
- Glutamate
Key Receptor Effects:
- Causes up-regulation of nicotinic receptors
- Notable as this contrasts with typical down-regulation seen with most neurotransmitter receptors when exposed to agonists
MAO-B Effects:
- Smoking inhibits monoamine oxidase B (MAO-B)
- MAO-B normally catabolizes dopamine, serotonin, and noradrenaline
- Smokers have lower brain MAO-B levels
- Levels return to normal after quitting
- MAO-B inhibition increases dopamine, making smoking rewarding
Specific Mental Health Links:
Depression:
- Neurochemical abnormalities in locus cerulus similar to antidepressant effects
- MAO inhibitor effects might provide antidepressant action
Schizophrenia:
- Nicotine especially reinforcing due to stimulation of:
- Subcortical reward system
- Prefrontal cortex (both hypofunctional in schizophrenia)
- Dopamine release in mesolimbic reward centers may overcome anhedonia in both schizophrenia and depression
- Noradrenergic effects may increase attentiveness and improve repetitive task performance
Specific Mental Health Links
Depression:
- Neurochemical abnormalities in locus cerulus similar to antidepressant effects
- MAO inhibitor effects might provide antidepressant action
Schizophrenia:
- Nicotine especially reinforcing due to stimulation of:
- Subcortical reward system
- Prefrontal cortex (both hypofunctional in schizophrenia)
- Dopamine release in mesolimbic reward centers may overcome anhedonia in both schizophrenia and depression
- Noradrenergic effects may increase attentiveness and improve repetitive task performance
More evidence-based sources
Summary of evidence
- Public Health England: Reports significantly higher smoking prevalence and associated health risks among people with mental health conditions. Health Matters: Smoking and mental health
- National Institute on Drug Abuse (NIDA): Highlights the complex relationship between smoking, mental illness, and physical health outcomes. Do people with mental illness and substance use disorders use tobacco more often?
- ASH (Action on Smoking and Health): Provides research and data on smoking prevalence and health risks among people with mental health conditions. Smoking and Mental Health
Bristol University 2022
From the Executive Summary: “There is a large body of longitudinal research that finds strong evidence for a prospective association between smoking and mental health, in particular for depression, anxiety and schizophrenia. However observational studies can be biased by residual confounding and reverse causation, and we cannot rule out prodromal symptoms of mental illness leading individuals to start smoking. These studies can be complemented by the method of Mendelian randomisation which has different assumptions and sources of bias (see Box 1). Therefore, consistent evidence across these methods can allow us to draw stronger causal conclusions. Evidence from observational and Mendelian randomisation studies suggest an effect of smoking on both depression and schizophrenia (see section 2.1 and 2.2).”
Other Mental Illnesses: Not enough meta-analyses were found to draw conclusions about other mental illnesses.
Depression & Anxiety:
- Two meta-analyses found that smokers had a 60-70% increased odds of developing depression compared to non-smokers.
- One systematic review found inconsistent results, with only a third of the studies suggesting a link between smoking and depression/anxiety.
- Some studies also suggest a reverse effect, with depression and anxiety increasing the likelihood of smoking.
Schizophrenia & Psychosis:
- Two meta-analyses showed a two-fold increased risk of schizophrenia in smokers compared to non-smokers.
- A systematic review found that heavy smokers had a 1.5 to 6-fold increased risk of schizophrenia spectrum disorders.
Mendelian Randomisation (MR) Studies:
Depression & Anxiety:
- Recent MR studies using genetic instruments for smoking initiation and lifetime smoking found a 54% increased risk of depression in smokers.
- Some evidence also suggests a reverse effect, with genetic risk for depression linked to increased smoking.
Schizophrenia & Psychosis:
- MR studies using the CHRNA5-A3-B4 gene cluster found an association between smoking heaviness and schizophrenia risk, with one study showing a 60% increased risk in a psychiatric sample.
- MR studies using genetic instruments for smoking initiation found a 53% to 94% increased risk of schizophrenia in smokers.
Other Mental Illnesses:
One MR study found an OR (odds ratio) of 3.72 for ADHD in adulthood among those with smoking initiation genes, but this might be due to factors like maternal smoking.
MR studies found evidence for a causal effect of smoking initiation on bipolar disorder risk, with one study showing an OR of 2.46 (meaning more than double the risk).
Other Genetically Informative Studies:
Another co-twin study found that the association between smoking and schizophrenia is only partially explained by shared genes.
A co-twin control study concluded that the association between smoking and depression is likely due to shared genetic factors.
FERGUSSON DM, GOODWIN RD, HORWOOD LJ. Major depression and cigarette smoking: results of a 21-year longitudinal study. Psychological Medicine. 2003;33(8):1357-1367. doi:10.1017/S0033291703008596 found 21 years ago (from 2024) that, “[..] much of the association between smoking and depression reflects common confounding factors that are associated with both outcomes. Nonetheless, even after control for these factors there is evidence of a possible causal linkage between smoking and depression. The direction of causality between smoking and depression remains unknown.”
Triple Whammy
People with severe mental conditions are more prone to smoking and less likely to quit. An important study found 15 Brain Circuits That Link Schizophrenia to High Risk of Cigarette Smoking (Schizophrenia Bulletin 2012 Dec 12;39(6):1373–1381. doi: 10.1093/schbul/sbs149)
From a fascinating study by Kelly & McCreadie in Scotland (Am J Psychiatry 1999 Nov;156(11):1751-7. doi: 10.1176/ajp.156.11.1751) the following findings were startling:
- The rate of smoking in the general population sample, 28%, is similar to that found in other countries in the developed world.
- 90% of the patients started smoking before the first episode of illness – thus making it unlikely that institutionalisation was a causative factor.
- The principal difference between patients and the general population sample was that the level of addiction among patients was much higher: 68% of the smoking patients smoked 25 or more cigarettes per day, compared with 11% of general population smokers.
- More smokers were receiving intramuscular antipsychotic medication and fewer were receiving oral and atypical antipsychotics.
- Patients who smoked were younger than non-smokers, and more of them were male. They had had more hospitalisations, and more were in contact with psychiatric services. More were receiving intramuscular antipsychotic medication.
- Smokers had poorer childhood social adjustment. Among the female patients, there was a positive correlation between age at starting smoking and age at onset of schizophrenia.
- many fewer schizophrenic patients than subjects in the general population are able to quit, especially among male patients (10% versus 53%).
Smoking cessation is high priority
Smoking cessation must be high priority for individuals with schizophrenia, bipolar disorders, depression, and anxiety for several reasons:
- Evidence suggests that smoking may worsen the symptoms of these mental health conditions or even increase the risk of developing them.
- People with these conditions tend to smoke at higher rates and with greater intensity, increasing their risk for smoking-related physical harm.
- Quitting smoking may improve the effectiveness of treatments for these mental health conditions and enhance overall quality of life.
- Smoking cessation significantly reduces the risk of developing serious physical health conditions such as cancer, cardiovascular diseases, and respiratory diseases, which are already a greater threat for individuals with severe mental illness.
- Quitting smoking can help bridge the life expectancy gap faced by individuals with severe mental illness, who often have a shorter lifespan due to a combination of factors, including smoking.
Who stops smoking?
Key points from the SCIMITAR+ (Smoking cessation for people with severe mental illness (SCIMITAR+): a pragmatic randomised controlled trial, Gilbody, Simon et al.The Lancet Psychiatry, Volume 6, Issue 5, 379 – 390)
In the SCIMITAR+ trial, “quitting” was defined as biologically verified abstinence from smoking (paraphrased) at the six-month and twelve-month follow-up points. This typically involved providing a saliva sample that was tested for the presence of cotinine, a metabolite of nicotine, to confirm that the participant had not smoked during the specified period.
- Study Objective: The SCIMITAR+ trial aimed to evaluate the effectiveness of a bespoke smoking cessation intervention for people with severe mental illness (SMI) compared to usual care.
- Participants: The trial included 526 participants who were randomly allocated to either the bespoke intervention or usual smoking cessation services.
- Intervention: The bespoke intervention was tailored specifically for people with SMI and included a combination of behavioural support and pharmacotherapy.
Intervention: The bespoke intervention included tailored behavioural support and pharmacotherapy specifically designed for people with SMI.
Results:
| Follow-Up Period | Bespoke Intervention Group | Usual Care Group | Difference (Bespoke – Usual Care) | Statistical Significance |
|---|---|---|---|---|
| Six Months | 32 out of 226 participants (14%) | 14 out of 217 participants (6%) | 8% (7.7% risk difference) | Statistically significant (p=0.010) |
| Twelve Months | 34 out of 223 participants (15%) | 22 out of 219 participants (10%) | 5% (5.2% risk difference) | Not statistically significant (p=0.10) |
- Significance: The study demonstrated that tailored smoking cessation interventions can significantly improve quit rates among people with SMI, addressing a major health inequality.
- Policy Implications: The findings support the need for mental health services to implement specialised smoking cessation programs to better support patients with SMI.
Conclusion: The authors said, “The main outcome of interest was whether smoking cessation could be achieved using a biochemical measure, and the SCIMITAR+ trial used long-term quitting as measured at 12 months after randomisation as its primary endpoint. The difference in the proportion of participants who quit was not significant at 1 year. This finding is in line with research in the general population that shows that long-term cessation of smoking is difficult to achieve and remains a challenge in treatment for nicotine dependence in any population.” Citing other authors the study said, “In the face of substantial health inequalities for people with severe mental illness, smoking is the most important modifiable risk factor for poor health and reduced life expectancy.11,45 In this study, we have shown that people with severe mental illnesses more readily engage with a bespoke intervention than usual care, and that the intervention results in an increased proportion of patients who quit at 6 months. Health systems should provide smoking cessation interventions that are responsive to the needs of people who use mental health services. Further research is needed to establish how long-term quitting can be supported.
Comment: While the SCIMITAR+ trial provides valuable insights, adapting these insights to the practical constraints of NHS Trusts requires creativity, collaboration, adequate sustained funding, and a commitment to improving patient outcomes. At 12 months there was no statistical significance.
Medications more rapidly metabolised by CYP1A2 induction
| Antipsychotics | Antidepressants |
|---|---|
| Clozapine | Fluvoxamine |
| Olanzapine | Mirtazapine |
| Haloperidol | Imipramine |
| Chlorpromazine | Clomipramine |
| Trifluoperazine | Amitriptyline |
| Asenapine | Duloxetine |
| Loxapine | Trazodone |
| Thiothixene | Venlafaxine |
In the UK TDM (therapeutic drug monitoring) of serum levels of medications is rare except for clozapine. This means that psychiatrists will have no scientific data to estimate what serum levels work for individual patients and how smoking may affect therapeutic levels.
Paying to die faster
How could a person who smokes be paying to die faster?
But at today’s date in 2024, assuming the £15 price per packet includes VAT.
The calculations below are based on an assumption of £15 price per packet including VAT. A further assumption was made for ease of calculaton – that price remains at £15 which it won’t in the future. [The trajectory of price from 1987 suggests that price of a packet of cigarettes has ‘always’ increased. This means that estimates on the conservative side. Capitalisations of words in some headings are based on MLA Convention]
Specific Duty: Assuming a standard pack contains 20 cigarettes, we can calculate the specific duty per pack.
Specific Duty per cigarette = £244.78 / 1000 = £0.24478
Specific Duty per pack = £0.24478 x 20 = £4.8956
Total Tobacco Duty: add the ad valorem duty and the specific duty to find the total tobacco duty:
Total Tobacco Duty = £2.06 + £4.8956 = £6.9556
Calculation of Total Tax: To calculate the total tax on a pack of cigarettes, add the tobacco duty and the VAT amount (which is already included in the £15 price):
VAT amount = £15 - £12.50 = £2.50
Total Tax = £6.9556 (Tobacco Duty) + £2.50 (VAT) = £9.4556
Percentage of Total Cost as Tax: To determine the percentage of the total cost attributed to taxes, divide the total tax by the total cost and multiply by 100:
Tax Percentage = (£9.4556 / £15) x 100 = 63.04%Cost of continued long term smoking
Based on the previously calculated total tax of £9.4556 per pack of cigarettes, if a person smokes 2 packs per week, the weekly tax contribution would be: £9.4556/pack * 2 packs/week = £18.9112/week
Annually, this equates to: £18.9112/week * 52 weeks/year = £983.3824/year
Over 20 years, the total tax contribution *would be: £983.3824/year * 20 years = £19,667.648
[*Assuming price remains the same – but it would probably go higher with inflation.]
Cost per Year of Lost Life Expectancy:
- Total money paid to government: £19,667.648
- Assumed loss of Life Expectancy: 10 years.
- Cost per Year of Lost Life Expectancy: £19,667.648 / 10 years = £1968 per year
Personal choice
The issue cuts to the very heart of addiction and free will. While it might appear that someone is making a conscious choice to smoke whilst knowing the serious harmful effects, the powerful neurobiological effects of nicotine addiction can significantly compromise their ability to make fully informed and unconstrained decisions in their own best interests.
Nicotine addiction can impact decision-making in the following ways:
- Altered brain chemistry: Nicotine affects the brain’s reward system, creating a sense of pleasure and reinforcing the smoking behaviour. This can lead to compulsive smoking despite an individual’s desire to quit or awareness of the harmful consequences.
- Withdrawal symptoms: When a person tries to quit smoking, they may experience withdrawal symptoms such as anxiety, irritability, and difficulty concentrating. These symptoms can be powerful motivators to continue smoking, even when the person wants to stop.
- Impaired decision-making: Nicotine addiction can affect cognitive integrity, including decision-making abilities about addiction. This can make it harder for individuals to weigh the risks and benefits of smoking and to make choices that are in their best interests.
Therefore, while personal choice is involved in the initiation of smoking, the progression to addiction can significantly undermine an individual’s ability to make genuine choices about their smoking behaviour. In other words, nicotine addiction is a costly death-trap.
But – the law as it stands states that if one is of capacity for a decision to consume an addictive killing substance that poses serious risks to their physical and mental health, and is making a free-willing choice, then it is fine to make the decision even if it is an irrational decision. This seems to mean:
- that if one is internally affected by some 15 brain circuits primed for vulnerability to smoking, the law would be disinterested.
- if a mentally unwell person is willing to pay circa £874 to £2000/yr to the government per loss of one year of life-expectancy and damage their mental and physical health, the law would be disinterested.
Supporters of the above will be expected to believe that the law is always right, and that medical ethics is to be thrown away. It is essential to remember that the law is a tool for achieving a just and equitable society. When the law falls short of this goal, it is our responsibility to advocate for its improvement, or to make reasonable lawful policy changes.
Capacity to damage physical and mental health
The following key facts are suggested for what people with mental health disorders ought to know as part of a capacity assessment.
Mental health facts
| Key Fact | Description |
|---|---|
| Impact on Symptoms | Smoking can exacerbate symptoms of mental health conditions, such as anxiety, depression, and stress. Nicotine may provide temporary relief, but withdrawal worsens symptoms. |
| Medication Interaction | Smoking can reduce the effectiveness of psychiatric medications, requiring higher doses and potentially leading to more side effects. |
| Financial Costs | Smoking is expensive. For instance, a heavy smoker spending £15 per day will spend approximately £5,460 annually on cigarettes. Of that approximately £3,451/year goes to the government in taxes. |
| Life Expectancy | Smoking significantly reduces life expectancy, particularly in individuals with mental health conditions, by 10-20 years. |
| Relapse Rates | Smokers with mental health conditions have higher relapse rates and more frequent episodes of their conditions. |
| Addiction | Nicotine is highly addictive, creating a dependence that interferes with the ability to make autonomous decisions. |
| Quality of Life | Smoking impacts overall quality of life, affecting physical health, social relationships, and daily functioning. |
Physical health facts
| Key Fact | Description |
|---|---|
| Cancer Risk | Smoking is the leading cause of lung cancer (responsible for ~85% of cases) and increases the risk of multiple other cancers (mouth, throat, pancreas, etc.). |
| Cardiovascular Disease | Smoking significantly increases the risk of heart disease, stroke, and peripheral vascular disease, with smokers being 2-4 times more likely to develop heart disease. |
| Respiratory Issues | Causes chronic obstructive pulmonary disease (COPD) including emphysema and chronic bronchitis, leading to reduced lung function and breathing difficulties. |
| Reproductive Health | Increases risk of infertility in both men and women and causes complications during pregnancy (preterm birth, low birth weight, stillbirth). |
| Immune System | Weakens the immune system, making the body more susceptible to infections and slowing down the healing process. |
| Bone Health | Linked to osteoporosis and increased risk of fractures by reducing bone density and impairing the body’s ability to absorb calcium. |
The Section 17 gateway
A separate publication on S17 and risk of harm will soon be available.
Section 17(3) leave is a relaxation of detention for the specific purposes of treatment as defined in S145. That means that leave must serve recovery and rehabilitation purposes. Quite a proportion of detained patients will have been admitted for the most serious mental conditions (and deterioration) such as schizophrenia, bipolar disorders, depression and complicating personality disorders. That is a reasonable assumption because of bed shortages in the NHS for the last 30-odd years. Beds are precious and normally reserved for the most serious unwell patients who cannot be managed in the community by Crisis and Home Treatment Teams.
What has been happening for the last three decades at least, is as follows:
- Responsible clinicians have been bartering leave for greater compliance good behaviour. [Evidence for this is almost never recorded conspicuously].
- Nursing staff would be happier about unescorted leave because there would be less patients to attend to on the wards.
- There has only been ‘soft focus’ on patients who smoke when on leave.
- There has been ignorance of the fact that smoking is nicotine dependence (which is a mental disorder).
[Caution: the above wording does not mean that ‘every’ Responsible Clinician and nurse in the country is so inclined or doing that. It means that I have seen quite a lot of it.]
The familiar argument is that ‘if a patient has capacity to decide about taking a toxic substance of addiction that is labelled as killing‘, then it is a non-issue in relation to a decision by the Responsible Clinician to grant leave. The argument is without a strong foundation because:
- It aims to insert Mental Capacity Legislative principles. If capacity was the defining issue, then patients of capacity to endanger their mental and physical health, should be allowed to smoke tobacco on any type of S17(3) leave when no other person is put at risk by their smoking. By extension of this the argument, patients should be allowed to engage in any sort of other risky activity once they are of equal capacity: mountain climbing, sex-work, gambling, go-cart racing, recreational use of cannabis, and driving vehicles when advised not to.
- Whilst substance and non-substance use disorders (as per ICD-11) are not within the reach of the MHA 1983, those conditions if allowed to perpetuate could prolong recovery.
- Nothing in law prohibits the Responsible Clinician from taking action to protect a patient’s mental health where there is a small but material risk [Montgomery 2015], or tail risk.
- Nothing in law stipulates nor implies that risk to mental health must be acute or foreseeable in the short term.
- It ignores the probability that an addiction disorder which is a mental disorder, is perpetuated and ultimately ‘killing’ (as stated on all packets of tobacco sold in the UK).
- Avoidance of the issue, neglects patients’ Right to Life (under HRA 1998), whilst protecting rights to liberty, movement, freedom of association etc.
Doctors have other medical duties (aka ethics) to ‘do no harm’ arising from the Medical Act 1983 coursing down through the GMC’s standards. Smoking harms disproportionally in comparison to any popular claims about benefits – without a doubt. But that has traditionally been seen only in the context of physical harm. The new research points strongly to mental harm, even if not acute harm – especially for patients with Serious Mental Conditions. There is a large body of longitudinal research that finds strong evidence for a prospective association between smoking and mental health, this focuses on depression, anxiety and schizophrenia [p14 The Bristol University Study (2022)].
Conclusions
The right to life is a fundamental human right. Yet institutional policies that facilitate tobacco use in mental health settings effectively compromise this right – particularly for those already vulnerable due to mental illness. When healthcare services enable a killing addiction through permissive smoking policies, they become passive participants in shortening patients’ lives. This is not just an issue of clinical practice or institutional policy – it is a human rights concern. When mental health workers tacit accept tobacco this becomes a source of systemic failure to protect the most basic human right: the right to life itself. Any argument about personal choice must be weighed against our duty to prevent premature death, especially in those under our care.
Recent research in the last 10 years has shown strong associations between mental disorder and smoking. Causal links are forming that there may be a biological foundation for vulnerability of people with mental disorders to risk of smoking.
While research continues to explore the intricate relationship between smoking and mental health, the existing evidence strongly suggests a link, particularly for conditions like schizophrenia and depression. Waiting for definitive proof of unidirectional causality – an academic exercise – might mean missing opportunities to address the potential harm of smoking on mental well-being. The unfolding evidence is compelling enough to warrant action.
- Pre-emptive action: Even without absolute certainty about causation, the potential benefits of quitting smoking for mental health are significant. Encouraging individuals with mental health conditions to quit smoking is likely to lead to improved symptoms and overall quality of life.
- Harm reduction: Given the known detrimental effects of smoking on physical health, promoting smoking cessation among those with mental illness is a harm reduction strategy. They already face a higher risk of premature death, and smoking exacerbates this risk.
- Dual diagnosis focus: Emphasising the link between smoking and mental health can help address the issue of dual diagnosis, where individuals struggle with both a mental health condition and a substance use disorder. Integrated treatment approaches are essential for effective recovery.
While further research is always valuable, it is important to act on the available evidence. By promoting smoking cessation and supporting individuals with mental health conditions in their quit attempts, we can potentially improve their mental and physical well-being significantly.
Individuals with serious mental disorders who engage in long-term tobacco use face a convergence of detrimental consequences, a “triple whammy” effect. Firstly, smoking run the realistic probability of worsen existing mental health conditions and potentially increase the risk of developing new ones. Secondly, smoking significantly elevates the risk of life-threatening physical health conditions such as cancer, cardiovascular diseases, and respiratory diseases. Lastly, the financial burden associated with smoking, particularly for those on limited incomes or state benefits, can lead to neglect of essential needs and further exacerbate their overall situation. The strongest evidence points to a causal link between smoking and schizophrenia, with MR studies showing a more than two-fold increased risk.
The persistence of permissive attitudes toward smoking amongst some mental health workers represents a remarkable form of institutional denial, if not apathy. Despite overwhelming evidence that smoking significantly worsens mental health outcomes, reduces medication efficacy, and dramatically shortens lives, many healthcare professionals continue to remain passive about this lethal behaviour. This is not mere institutional inertia – it is a collective ethical failure. That such attitudes persist in the face of high quality evidence suggests something more troubling: a deep-seated cultural complicity that prioritises perceived short-term pragmatism over our fundamental duty to protect life.
Psychiatrists who adopt a permissive stance toward smoking during Section 17 leave are failing in their fundamental duty of care. This failure is particularly egregious as it transforms a therapeutic intervention – leave from detention – into a mechanism for maintaining a lethal addiction. These clinicians are effectively using their statutory powers to facilitate a diagnosed mental disorder that kills half its long-term sufferers. The argument that we cannot prevent smoking during leave misses the point entirely – our duty is not just to avoid enabling harm, but to actively prevent it. When we grant leave knowing it will be used partly for smoking, we become complicit in maintaining both the addiction and its lethal consequences. That some clinicians view this as acceptable practice, despite their GMC obligation to make patient health their first concern, represents a troubling departure from basic medical ethics. This is not about enforcement – it is about maintaining clear, consistent clinical standards that prioritise life over expediency.
The sheer weight of evidence demonstrating smoking’s lethal impact on people with mental illness seems powerless against entrenched institutionalised attitudes. This represents more than mere resistance to change – it is a collective moral failure that costs lives daily. That such attitudes persist – nebulously out of sight – despite irrefutable proof of harm suggests something deeply troubling about our profession: we seem to have somehow normalised our complicity in maintaining a lethal behaviour that we would never tolerate in any other context. This seems to be more than professional inertia – it is an ethical blindness that makes us collectively complicit in a devastating triad: maintaining a killing addiction, prolonging mental illness, and contributing to repeated episodes of psychiatric illness – each element preventable, yet each enabled by our collective failure to act.
The capacity argument creates a troubling paradox in healthcare. While we must respect that capacitous individuals can make unwise decisions, this legal principle is being used to justify institutional inaction against a killing addiction. The law, in attempting to protect individual autonomy, has in effect created a framework where healthcare professionals are compelled to allow harm. We find ourselves in the absurd position of being legally compelled to go softly on a diagnosed mental disorder (nicotine dependence) while treating other mental disorders – simply because patients’ may have capacity to choose to shorten their life and court dangerous medical conditions. This reveals a fundamental flaw in how capacity law interfaces with healthcare professionals’ duty to prevent harm. The result is a system where we must watch patients with capacity literally pay money to the government to kill themselves, while our professional duty to protect life is rendered impotent by rigid legal interpretations of autonomy. However, in a free and democratic society that values Human Rights, the autonomy to irrationally consume killing substances must be respected.
Perhaps the most bitter irony in this tragic situation is that the greatest beneficiary of healthcare’s ethical paralysis is the government itself. While healthcare professionals wrestle with capacity arguments and passively enable a killing addiction, the Treasury profits handsomely – extracting around 70% in taxes from every packet of cigarettes bought by our mentally ill patients. This creates a perverse economic incentive where the state benefits financially from the very addiction that kills its most vulnerable citizens. Our patients are effectively paying premium rates, through punitive taxation, for the privilege of maintaining an addiction that will likely kill them faster. The government simultaneously funds smoking cessation services while reaping billions in tobacco taxation – a contradiction that would be laughable if it weren’t so lethal. Mental health services have become unwitting accomplices in this macabre economic circle, where our most vulnerable patients fund the Treasury through their own destruction.
We are therefore not just morally bankrupt – we are ethically disabled by a system we are forced to adhere to. In respect of S17 leave, our capacity to act according to fundamental medical ethics has been paralysed by self-imposed constraints: permissive policies that enable harm, capacity laws that force us to facilitate destruction, and attitudes stand to contribute towards normalising the maintenance of a killing addiction. This ethical disability is a product of our own apathy, constructed from layers of justification for inaction, upheld by misaligned respect for ‘autonomy’, and perpetuated by a State that profits from lethal cycles leading to an earlier death. We have disabled our own moral compass so thoroughly that we can no longer recognise the profound contradiction of healthcare professionals becoming agents in maintaining an addiction that kills those under our care. This is more than moral bankruptcy – it is a wholesale paralysis of ethical practice, where we have lost not just our moral assets but our very ability to act on our fundamental duty to protect life.
