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Table 1 Risks and consequences associated with mortality for tobacco, alcohol and drug use in SMDs

From: Gaps and challenges: WHO treatment recommendations for tobacco cessation and management of substance use disorders in people with severe mental illness

Tobacco Alcohol Drugs
Systemic factors
Lack of data- so that scale of problem in some countries is unclear- allowing the issue to be ignored [47, 48]
Lack of/ or limited funding for healthcare service provision [49]
Mental health provision or tackling service provision for dual diagnoses populations is a low priority for government [49]
Low levels of service provision for people with SMDs to be able to access interventions [48]
Lack of training/ capacity building- impacting on ability to deliver interventions, particularly in lower resourced settings [49]
Vertical approaches to healthcare delivery which lead to ‘silos’ in service provision (mental health and physical health provision not well integrated, or health and social care poorly integrated) [49, 50]
   Criminal justice (instead of public health) to address people with substance use disorders
Beliefs/ Awareness
Healthcare provider belief that smoking cessation may exacerbate mental state or concerns about pharmacotherapy interactions- leading to lower levels of cessation advice and intervention being offered [51]. Beliefs that alcohol and/or drugs are helpful as self-treatment for depression and other mental health conditions
Healthcare provider belief of futility- that patients will not benefit- leading to lower levels of intervention offered
Healthcare provider- Lack of awareness or knowledge relating to evidence-based interventions and application of these
  Lack of awareness (on part of healthcare provider or service user) of treatment need for substance use disorders [48]
‘Culture’ of smoking in services for people with SMDs which may increase the risk of smoking initiation [52]  
Inequalities
In the general population, a social class gradient is observed for tobacco use. May be reflected in people with SMDs who are also more likely to ‘drift’ into lower socioeconomic position Complex bidirectional associations with unemployment, lower socioeconomic position and other indicators of poverty and exclusion (e.g. homelessness) associated with usage and with poorer physical health and excess mortality
Social exclusion
  Higher risk of social exclusion and ‘extreme inequalities’ for dual diagnosis populations- directly impacting on reduced or delayed access to mental/ physical healthcare [50], also reflected in exclusion from research [39].
Mental state impact
  Impact on mental state- comorbid substance use impacts on severity and remission, increasing the risk of onset, recurrence and reducing chances of recovery. Impact on adherence to treatments.
Physical health impact
Respiratory disorders, e.g. COPD leading to pneumonia Alcohol withdrawal, delirium tremens Overdose (opioids and other drugs)
Cancers e.g. Lung, other Acute alcohol/ drug intoxication
Exacerbation of mental state, death through indirect pathways
Increased susceptibility to infection e.g. TB Alcoholic hepatitis, pancreatitis, ulcer (gastric, duodenal)  
  Increased risk-taking behaviours as a result of intoxication with impact on physical health (e.g. infectious diseases, increased risk of STDs)
  Increased risk of accidents- leading to trauma/ head injury (subdural haemorrhage) Injecting drug use- Infections including HIV, hepatitis (A, B, C)
Modifiable risk factor for dementia in later life [53] Neurological sequelae and impact on cognition- Wernicke Korsakof’s syndrome, alcohol-related brain damage  
  Malnutrition
  Increased risk of range of infections- chest infection, TB, HIV, hepatitis- through multifactorial causes
  Self-harm/ suicidal behaviours secondary to intoxication/ withdrawal