Smoking & mental illness

Why make the change?

Cutting down and quitting is worth it for lots of reasons. From the moment you reduce your smoking, your health and your finances improve.

Better health

As soon as you quit smoking:

• after 12 hours – your body starts to relax and feel warmer (as blood pressure, pulse, and skin temperature return to normal)
• after one day – your body is healthier (containing more oxygen and less carbon monoxide)
• after two days – you may smell and taste things better.

Over the longer term, you will breathe more easily (as your lungs start to recover). Your chance of dying from heart disease has been cut by half. You have more energy, you get fewer colds and your blood flow improves. Your family and friends benefit from cleaner air.

More money to spare

If you no longer spent money on cigarettes:

• every day of being smokefree – saves you enough money to treat yourself to a nice lunch, buy some magazines, or hire a dvd
• every week of being smokefree – saves you enough to buy a cd, have dinner out, or put aside for rent or phone bills
• every year of being smokefree – saves you enough for a holiday, a new sound system, private health insurance, or even save for a car.

And there are more reasons too

You will look and smell better (no more stained fingers and teeth), people will congratulate you, and you are likely to feel more proud and sure of yourself.

It will be easier to go to places that are smokefree like the movies or to visit friends in hospital.

I asked one of the staff at the rehab program I visit to support me. She asks how I’m going when we catch up, and has given help as I’ve needed it.

Why do people affected by a mental illness smoke?

There are a number of reasons why so many people with a mental illness seem to smoke.

People say that they smoke because they feel addicted, enjoy smoking and it helps them to cope with stress and anxiety. Another common reason being that it’s ‘something to do’ to reduce boredom. People with mental illness say they smoke for these reasons too.

Smoking has been tolerated and even encouraged in mental health services in the past, and this has reduced opportunities for people with mental illness to quit smoking. However, many hospitals are now changing to completely smokefree environments, and this is now also having an effect on mental health services.

Some research suggests that nicotine relieves some of the symptoms of mental illness. Nicotine also affects the body’s absorption of medication. This is why medication needs to be reviewed when you reduce or quit smoking.

Some people say that one of the hardest things about quitting is dealing with feelings that they have always handled, or possibly suppressed, by smoking – feelings like anger, sadness, or grief. Dealing with these feelings can be stressful, and this stress can lead to fears that you may become unwell. This is where a doctor, psychologist or other mental health worker can help.

Why do smokers with a mental illness want to quit?

Many people living with a mental illness seriously want to quit smoking tobacco.

As well as the very serious health effects of smoking, people with a mental illness want to quit because it costs a lot of money. Smoking also makes it harder to overcome isolation and mix with others, because public places such as cinemas, restaurants and shopping centres have banned smoking and are now smokefree.

Smoking also has an impact on your appearance: the characteristic smell of smoke, yellow fingers and teeth, wrinkles and grey skin.

Health reasons, social reasons, worries about money, or a desire to take control of your life, these are all good reasons to change.

The process of quitting

It is important to realise that quitting smoking is a process rather than a one-off event.

For most people there is much thinking and preparing that happens before they actually quit. Some people do quit more spontaneously, sometimes in response to something that has happened in their lives. Whether you quit on the spot or, more likely, over a period of time, it will be natural to be faced with problems or fears that tempt you to smoke again.

Stages of the process

The important first stage is taking on board that smoking is having an impact on your health, and starting to think about quitting one day. You may then decide you are going to quit and start preparing. Cutting down by five cigarettes a day is a great start, then ten, and so on.

The next stage is acting on your plan to quit, followed by maintaining a smokefree lifestyle. With good preparation and support some people quit on their first attempt. However because of nicotine’s strong addiction, many people smoke again. Some try many times before they stop smoking, but each time they try, they will have learned something that will help them next time.

At the moment, having managed to stop completely for three months earlier this year, I’ve relapsed again – so I’m trying harder now to stop those last few cigarettes a day.

How many reasons can you think of for quitting?

Think about how much you spend on cigarettes over 12 months, that’s how much you’ll have available to do other things once you’ve quit.

Write down reasons that are important to you for quitting – including things you could buy with the money you save, but also important things like your health and activities that would be easier if you didn’t smoke.

After I’d given up smoking for nearly a year, I’d put enough aside to buy a brilliant new mountain bike. No one can believe I saved all that money simply by not smoking.

Your journey to a smokefree life

Giving up smoking is often not a single act, but a journey – one that begins with the first step.

The first step

An important first step in preparing to quit is to become aware of the habits that tempt you to smoke. Things that tempt you to smoke are called triggers.

Learn to identify triggers and deal with them without smoking. Common triggers include:

• being with other smokers
• socialising and alcohol
• drinking coffee
• feeling bored
• feeling stressed.

Write it down

Take your first step by writing down the things that especially trigger you to smoke.

After you’ve written down things that trigger you to smoke, think about all the alternatives to having a cigarette.

Write these next to the triggers, and try the alternatives until you find ones that works for you.

For example, try the 4Ds (from Quit Victoria):

1. delay and the urge will pass
2. deep breathe
3. do something else to distract yourself
4. drink water slowly to keep your hands and mouth occupied.

Or try:

• chewing some nicotine gum or use another nicotine replacement product.
• if coffee is a trigger, drink tea, orange juice or water.
• if you’re bored, phone someone or go for a walk.
• put an elastic band around your cigarette packet, so it is harder to open. This will stop you smoking automatically, and give you time to think about doing something else instead.

Talk to other people with mental illness who have quit and ask them how they did it.

As an alternative to smoking, try picking the most relaxing cd you have and keep it as your ‘chill out music’. When you felt stressed, put this on and lie down with your eyes shut for ten minutes.

Getting over the obstacles

After deciding why you want to quit and taking the first step, it’s likely you’ll need to deal with other things that get in the way too.

As well as old habits, there are common obstacles people have to deal with when trying to give up smoking. The most common of these is withdrawal symptoms.

Withdrawal symptoms

Smoking cigarettes is highly addictive because they contain nicotine, which is very addictive. When you stop smoking you are likely to experience withdrawal symptoms and these can be uncomfortable.

The common withdrawal symptoms are:

• coughing
• restlessness
• feeling irritable, anxious or angry,
• difficulty sleeping and feeling very tired,
• difficulty concentrating
• depressed mood.

It is important to remember these feelings are normal, and that many people experience them when they are quitting. They are signs that your body is repairing itself, and will usually get easier to manage after a few days and then disappear within a few weeks.

Many people say the hardest part about this chemical addiction is dealing with the feelings you can experience when you stop smoking. Anger, sadness, stress and discomfort are common withdrawal symptoms. They may also be associated with making a big change in your life, and having to adjust to this.

Remember these feelings are a common experience when people quit and are likely to pass with time.

Take good care of yourself and if you are concerned, talk to your supporter, health worker or doctor.

Strategies to make withdrawal symptoms easier to handle

Make nicotine withdrawal symptoms easier to handle by:

• using the 4Ds
• checking out any concerns with your doctor or a supporter
• talking about nicotine replacement therapy (NRT) to your doctor or pharmacist (ideally before you quit)
• thinking positively – ’These feelings will pass – I am one step closer to being smokefree’.

Recognise other obstacles if they emerge

Overcoming obstacles is important. Take the time to recognise those that affect you, and write them down with ideas on how you’re going to deal with them.

Some strategies to overcome obstacles could include:

• if you get stressed or emotional – try talking to someone, exercising, listening to peaceful music, or deep breathing
• if you get bored – try dealing with this by chatting with a friend on the phone or online, playing a game, or taking up an interest
• deal with cravings – by using nicotine replacement, the 4Ds or other material from Quit
• if you are worried about gaining weight – try to eat well and get some exercise every day
• don’t judge yourself on past efforts to give up – you learn more about quitting with every attempt. 

Once you are satisfied you’ve identified the obstacles and have started to deal with them, think about taking the next step and setting goals that are right for you.

It’s not unusual to feel a bit ratty for a few days after quitting. Make sure you tell people you’re giving up, so they know what’s going on and will hopefully be more understanding.

Dealing with stress

Overcoming stress is a big step in quitting. There’s no doubt that everyone who gives up smoking feels stressed at first. Coping successfully with this is a part of quitting.

Your body needs to adjust to life without its dose of nicotine and the many other chemicals in each cigarette. You also need to learn how to live without the habit of smoking – what to do with your hands, how to take a break from whatever you are doing.

Any change feels strange for a while, including changing your smoking habits. Remember that this feeling will pass.

Some people worry that the stress of quitting will trigger a relapse of their mental illness. This is unlikely to happen but it is important to deal with this concern. Make sure you talk to your doctor and have a supporter if possible.

Be ready for stress

Be ready for stress by learning healthy ways of coping. Try these ideas for dealing with stress:

• try to be active – walk, swim, ride a bike
• work on good sleeping habits
• talk things over with your smokefree supporter, friends or family.
• practise a deep breathing exercise:
  • Close your eyes
  • Slowly take a deep breath through your nose
  • Hold your breath while counting to five
  • Breathe out slowly through your mouth
  • Relax and feel your shoulders drop.
• enrol in a stress management course (ask at your local health centre, or neighbourhood house).

Going for a walk is a great way of unwinding when you’re feeling stressed. It’s simple. It’s free. When I get back from a walk, I’ve often forgotten what it was that had stressed me out.

Dealing with boredom

Boredom may tempt you to smoke if not dealt with, try these ways of avoiding it:

• if you find it hard to get out of bed, ask someone to ring to help you wake up and get active
• play a game – solitaire, cards, or an electronic game
• do some art or listen to music – drawing, painting, playing an instrument, listening to music or the radio
• join a course or group at your local neighbourhood house or other community centre, as a way of meeting new people.

Write down your favourite tips and put them somewhere visible, such as beside your bed, where you keep your keys, or near the TV.

Involve your supporter in these activities, and think positively about all the benefits of being more active.

Feeling good about yourself

Some people use cigarettes as a way of distracting themselves from their feelings – like putting a smokescreen between anger or sadness and themselves.

People can do this if their confidence has been knocked around by mental illness. Quitting smoking can release these feelings and challenge people to face them.

Spend time focusing on what is good about you. It will help you to take charge of your smoking, too. Even simple things like using positive words make change easier.

Try it – you’ll be surprised at what a difference this makes. Learning to think and talk positively:

• ‘Quitting isn’t easy, but I’m getting there’
• ‘I’m feeling a bit stuck – I’ll call my supporter for ideas’
• ‘I’m feeling angry, I’ll write this feeling down and talk about it with someone.’

If you continue to feel sad, angry or lacking in confidence, it is a good idea to check this out with your supporter or doctor. A psychologist or counsellor could also help at this time – ask your doctor about this.

Dealing with how you feel

Try writing down any doubts you have – then add a positive statement about each that helps you deal with it.

Taking charge of your smoking is about making small steps towards your goal. Remember all the many positive things you’ve done already: decided to change your smoking habits – read this guide – talked about it with your doctor and maybe enlisted a supporter – started to think about ways of dealing with stress and boredom – you’ve come a long way along the road already.

Dealing with weight gain

Putting on weight can be a real hassle if you’re on medication that has this side-effect (including antipsychotic, mood stabilizer and antidepressant medication – see ‘Side-effects’ in Medication and other treatments). Some people also eat more and put on weight when they quit smoking.

If you’re worried about putting on weight, try not to replace cigarettes with chocolates or other salty or sugary snacks. If you’re tempted to eat more when you quit, make an effort to eat low-fat healthy snacks like fruit instead, and drink lots of water.

Don’t forget that getting some exercise every day will help keep the weight off too. The secret is to do it regularly, every day if possible – walking or even cycling or swimming. Try to use the stairs rather then a lift or escalator when you go out shopping or to the movies.

Being more active will increase your chances of quitting successfully too. Talk to your supporter if you need some help to get started.

For further information, please see ‘Healthy living’.

Everyone gets the munchies when they give up! To avoid putting on weight, switch from biscuits to fruit . . . It’s tasty, cheap, and fills you up too.

Setting your goals

A goal is something set by you, not someone else. Everyone has their own way to take charge of their smoking. You need to set goals that are right for you.

You might find it helpful to make an agreement, a ‘contract’ with your supporter. This will help you to set realistic goals and stick to them.

Setting goals will help you in the long-term, whether you achieve them immediately or not. When you do achieve them, you will have a good reason to celebrate. If you don’t achieve the goals, then use this positively – as a way of finding out what obstacles are still stopping you, then make more achievable goals.

Don’t make things too tough for yourself. Be realistic and give yourself time to allow for those days when you don’t feel so good.

Make a contract with yourself

Fill in this contract. Set a goal you want to achieve. Learn from your experiences and celebrate when you’ve done well.

Starting to cut down

Cutting down can give you confidence to quit. There are lots of practical strategies for cutting down that people who’ve quit say have worked for them.

Cutting down the number of cigarettes you smoke each day can be helpful if you are not sure whether you can quit. It can also kick-start a quit attempt. Here are a few hints to cutting down successfully:

• as well as using the 4Ds, make a plan to tackle times when you crave for a cigarette. Through trial and error you’ll discover the strategies that work for you
• ask your doctor about special types of NRT (Nicotine Replacement Therapy) that you can take when you are cutting down the number of cigarettes you smoke
• talk to a supporter about ways of tackling cravings.

Set a day to quit

When you’re ready to stop smoking, make sure you set a quit date that is not too far away. This will build your confidence and make the process easier. Many people feel ready to quit once they are down to about five cigarettes a day.

Find the strategies that work for you, and stick with them.
Don’t forget to let your doctor know you are cutting down or quitting. It’s easier if your medication is monitored and your doctor is supporting you.

I left a single cigarette in a drawer at home. If I felt like a smoke while I was out, I’d say to myself – I’ll put it off ‘til I get back. Then when I got home, I could say Oh no you don’t . . .

Staying in control

Sticking with your strategies makes all the difference. As well as being able to cut down and stop smoking, it’s important to stay in control using the strategies that work for you, so that you stay smokefree for good.

It can take a while to overcome triggers every time, and some people can slip up when they get into their own trigger situations. (A slip-up is when someone has a cigarette after giving up.) Watch out for these situations, so you can respond to them with the strategies that work for you.

Watch out for

Feeling sad, angry, stressed, or bad about yourself are a part of everyone’s life, but it might be a long time since you have handled them without a cigarette. You may know them as early warning signs related to your mental illness, but they can also be signs of nicotine withdrawal.

These feelings are quite common after quitting or a slip-up, so it’s a good idea to have strategies ready to deal with them. Look after yourself and try to relax.

If you are concerned about these feelings, talk them over with your doctor or a counsellor.

Dealing with conflict

Arguments with family or friends, hassles with the system, feeling irritable – there’s a lot you can do to avoid smoking when these things make you feel stressed.

Here are some suggestions:

• leaving the situation (get away before it’s out of hand).
• changing tactics (instead of trying to make a point, just don’t bother to argue with the other person).
• practising being assertive (don’t feel guilty at having different opinions or wishes to other people).

Many support programs and community centres offer support on good communication or anger management, for example:

• Lifeline offers 24 hour phone support on 13 11 14.
• Mensline gives assistance to both men and women regarding relationships on 1300 789 978.

Dealing with triggers

Drinking alcohol in company can make it tempting to have a cigarette. Try these hints for smokefree socialising:

• plan ahead (have a supply of snacks or use nicotine replacement like gum or patches)
• avoid alcohol for a while until you feel more confident that you can resist smoking
• just say ‘no’ (practise saying ‘No thanks, I don’t smoke’ with a smile in front of a mirror)
• ask friends to help, by agreeing not to offer you cigarettes for example
• avoidance (if there are too many temptations, don’t go – take time out or leave early)
• ring Quitline on 13 7848 to get some ideas.

It can be difficult to say no if someone asks if you want a smoke. Tell your friends not to offer you cigarettes. They won’t mind – it’s saving them money too.

Medication to help you quit

Here are a few medication options to help you quit.

Nicotine Replacement Therapy (NRT)

NRT is medication that contains nicotine for the purpose of quitting smoking. There are currently five types of NRT available in varying strengths: patches, inhaler, chewing gum, lozenges and microtabs (tablets that dissolve under the tongue).

It is very important for anyone affected by mental illness to talk to their doctor before using NRT, because of side-effects and possible interactions with other medications.

NRT can help you reduce smoking before you quit. It is also possible to combine different forms of NRT, with guidance from your pharmacist. Like any medication, it needs to be used according to instructions and only for the length of time recommended.

NRT takes some of the stress out of quitting by reducing withdrawal symptoms and encouraging contact with a supportive health professional. Research shows that it can double the chances of quitting successfully.

A week’s worth of NRT costs about the same as three packets of cigarettes. However, the cost of NRT should only be short-term (about three months), while the cost of continuing to smoke is ongoing, financially as well as in terms of your health.

Discuss your progress regularly with your doctor or pharmacist. This helps to iron out any problems you may have with using NRT, and help you on your quitting journey.

Some people believe that NRT alone will help them quit, but for NRT to be most effective counselling is also required. This may be from Quitline, your doctor or a mental health professional.

Other medication

Buproprion (Zyban) is another medication that can assist with quitting. Varenicline (Champix) also helps relieve physical withdrawal symptoms and craving. Your doctor can advise you about whether either of these is suitable for you, as a cautious approach is recommended for people affected by mental illness.

Tips for anyone supporting a smoker to quit

It is up to the smoker to decide whether they want to change their smoking habits. You cannot make someone quit. But there are ways in which you can provide support to help them reach their goals.

It will help if you:

• learn about the process of quitting
• are supportive and encouraging
• avoid being critical or negative
• avoid telling them what they ‘should’ do – instead offer strategies and information.

Your patience, support, willingness to listen, and helpful attitude can make a difference. Good communication is especially important.

Supporters say that the hardest part of helping someone who is trying to quit is staying positive. It’s not always easy, especially with the added challenges that mental illness brings. It is important to also look after your own health during the process.

Establish an agreement

Ask the person who is quitting how they would like you to help. Your role may be different if you are the smoker’s key worker than if you are their friend or partner.

You also need to talk about your ideas and hopes for supporting the person to become smokefree. You can then come to an agreement about the type of support offered. Use the ‘contract’ to keep a record of this if you both think it would be helpful.

Tackling obstacles

It is helpful to discuss potential obstacles at this stage, rather than waiting for them to arise. These obstacles for the person quitting can include:

• feeling pressured by your expectations
• feeling bad about themselves if they don’t attain their goals
• that the supporter does not know what to do or say
• that the supporter worries too much about the person quitting becoming stressed and unwell.

Work out how you will handle each situation. What does the quitter want from you in difficult times? Is it to back off, or to keep on encouraging? Or just to acknowledge that they are struggling? It may be that you need a break from supporting, or reassurance and support for yourself at some point in the process.

You can call Quitline for advice about your role as supporter on 13 7848.

Ways of supporting

Some people think of themselves as a ‘spark plug’ who fires up the person to quit. Some become a ‘coach’, helping to teach and work with the smoker every step of the way. Others are the ‘cheer squad’, interested in barracking from the sidelines. Some act as ‘boosters’ once the person has made a change, giving support and applause which keeps up their confidence.

Finally, it may be best to be a ‘bystander’ who supports the person, but knows that too much involvement may actually be unhelpful.

Important things to remember

Some people are concerned about their smoking but do not have the confidence to consider quitting. Let them know that mental illness is no barrier to quitting with the right information and support.

Some other ways in which you can be supportive:

• encourage the person to talk to their doctor before they cut down or quit, and to have regular appointments. Learn to distinguish between nicotine withdrawal symptoms and symptoms of mental illness
• listen to how the smoker would like to quit – gradually or all at once? Reducing smoking is also a good outcome on the journey to becoming a non-smoker
• don’t get into a position where you argue with the person. Positive, open communication is the key to being an effective supporter
• suggest strategies or provide information, rather than give direct advice
• encourage the smoker to draw on other support in the community, such as Quitline or a community-based mental health service.

Paddy made himself a badge that said ‘Don’t ask me for a smoke’. When he wore this to the drop-in centre people stopped asking him for cigarettes and this has helped him to quit smoking.

Becoming ‘someone-who-used-to-smoke’

Things you’ve achieved already include:

• realising the benefits of cutting down and quitting
• working out how much money you’ll save
• becoming aware of your smoking habits
• learning about the obstacles to change
• developing practical strategies to cut down and quit
• setting goals that are right for you
• preparing yourself to stay in control when tempted.

Look back at how far you’ve come, and take time to feel pleased with your progress. Remember – its normal to make a number of attempts to quit smoking before you quit for good.

It’s important to keep in touch with your doctor, especially if you start to experience an increase in any symptoms relating to mental illness while cutting down or quitting.

After I’d given up, I started to go swimming a few times a week and that makes me feel healthier and more calm. I’ve got a whole different set of habits now – ones that are good fun, and are good for me too . . .

For more information

When you need to know more:

• contact the SANE Help Centre on 1800 18 SANE (7263) or This email address is being protected from spambots. You need JavaScript enabled to view it.
• Quitline – 13 7848 (13 QUIT) and website: www.quitnow.gov.au for information and resources available to help you give up smoking.
• contact your doctor – If you have any concerns about your mental or physical health, whether related to quitting or in general, make sure you talk about them with your doctor.

See also How to help in a crisis for guidance when you or someone else experiences a mental health crisis.