News and Updates from todays Smoking Cessation in Mental Health Conference.
Chairman Dr Jonathan Champion opens the conference. Jonathan is a co-author of a RCP/RCPsych report on smoking and mental disorder (2013) and was part of the NICE committee which produced guidance on smoking cessation in secondary care including mental health services (NICE, 2013). In 2014, he updated primary care guidance on smoking and mental disorder, contributed to 2016 PHE implementation guidance on smoke-free mental health services and in 2017 updated pharmacy guidance on smoking cessation for people with mental disorders.
Jonathan also did a further extended session on The importance of smoking cessation in improving the physical health of people with mental disorder: The evidence. He discussed the impact of smoking on mental health, physical health and mortality in mental health and how we can take a population approach to smoking cessation.
He went on to discuss the effectiveness of various intervention methods as well as discussing some of the prescribing consideration for people with mental disorders. Following smoking cessation some medication doses would need to be reduced to prevent toxicity. Reduced doses of medication after smoking cessation could save the NHS up to £40million a year. He also talked about minimising weight gain following smoking cessation.
The Chairs introductions was followed by a session "The Stolen Years: The case for action to reduce smoking prevalence among those with a mental health condition" from Vicky Salt Senior Policy and Campaigns Officer, Action on Smoking and Health where she looked at the case for action to reduce smoking prevalence among those with a mental health condition as well as report findings and recommendations. Research has found that 40.5% of people with mental illness are smokers.
Pre- Conference Abstract:
Mental health conditions affect almost a quarter of the population who die on average 10 – 20 years earlier than the general population. Smoking is the single largest cause of this gap in life expectancy.
Despite smoking rates among the general population falling consistently over the last 20 years, smoking rates among those with a mental health condition have remained stubbornly high at around 40%. This is more than double the national smoking rate (15.5%) and shows that effective interventions are urgently needed to address this growing health inequality.
In April 2016, ASH launched The Stolen Years: The mental health and smoking action report endorsed by 27 other health and mental health organisations.
The report found that smoking has a profound impact on the life and health of someone with a mental health condition including: lower life expectancy and higher incidence of illness, poorer mental health, higher levels of medication and lower income including higher incidence of poverty.
The report sets out a series of ambitions with the overall goal of reducing smoking among those with a mental health condition to less than 5% by 2035, with an interim target of 35% by 2020. The report’s recommendations look at all aspects of the health and social care system, focusing on integrated working across the system which will be key to reducing smoking rates.
ASH launched the Mental Health and Smoking Partnership in September 2016, bringing together Royal Colleges, third sector organisations and academia as a mechanism for taking forwards these recommendations.
The Partnership is working with both national and local government to highlight the importance of smoking cessation in relation to care and support for people with a mental health condition, and was influential in securing the commitments to reducing smoking among people with a mental health condition in the Government’s Tobacco Control Plan published in July 2017.
• Rethink Mental Illness/The Innovation Network: Making a difference: Smoking cessation in mental health settings
• Public Health England: Smoking cessation in secondary care: Mental health settings
• Department of Health: Towards a Smokefree Generation: A Tobacco Control Plan for England
Di Hurley, Head Occupational Therapist, Harrow Mental Health Service Central and North West London NHS Foundation Trust ran a session "Addressing the burning issues: Communicating smoke free restrictions to smokers with mental health problems". Which covered:
• implementing smoke free grounds on acute psychiatric Unit in Harrow
• difficult conversations – how they prepared ourselves and our patients to go smoke free: what helped and what hindered
• their experience with e-cigarettes
• their film – using service user’s perspectives to change hearts and minds.
Di Hurley (Dip COT, BSc Hons) is the Head Occupational Therapist for Harrow Mental Health Service in Central & North West London (CNWL) NHS Foundation Trust. For over thirty years she has specialised in the mental health field, with a particular interest in health promotion, including developing and researching interventions to support people with stress and mental health problems to quit smoking. Within her Trust, and Harrow Mental Health service where she is based, she has worked on the development of a supportive approach to the implementation of smoke free restrictions for staff and patients.
This presentation explores some of the challenges in creating a smoke free hospital environment, both for smokers with mental health problems, and for ward staff in communicating and supporting smoke-free implementation. Whilst recognising the unacceptable and disproportionate harm that smoking does to those with mental illness, it is essential to fully understand the barriers to quitting experienced by this group, in order to find the best way forward.
For psychiatric patients who are highly dependent smokers and in acute crisis, smoke free restrictions are very difficult to accept and adjust to for many reasons. For instance, all dependent smokers use their smoking habit as a way of regulating the whole gamut of emotional states. It follows that smokers with psychiatric issues will find managing their emotions without the freedom to smoke still harder. In addition, there is a growing awareness that those with severe psychiatric disorders such as schizophrenia experience impaired cognitive function and sensory gating when deprived of nicotine. All these factors add to the likelihood that they will experience extreme emotional distress, and increased psychiatric symptoms, leading to overt distress or aggression when abstinence is enforced.
Ward staff attempting to maintain the smoke free environment, both inside and outside the hospital building, may feel they are being forced to adopt an unhelpful stance of enforcement, which detracts from the ‘recovery’ focused environment and supportive relationship they are trying to create with their patients.
The way in which the smoke free message is communicated is all important and should be as supportive as possible with a clear understanding of the patient’s perspective. Sources of inspiration include the ‘Safewards’ approach, coupled with effective and liberal provision of nicotine replacement – particularly e-cigarettes. E-cigarettes have proved extremely helpful in making harm reduction goals achievable for smokers with mental health problems.
The presentation ends with a 7 minute film which exemplifies this approach and can be shown to smokers in order to assist staff in communicating smoke free restrictions in a positive way.
Heather Thomson, Smokefree Lead Local Partnerships, Nottinghamshire Healthcare NHS Foundation Trust session on Developing a smoke free organization - Create and enable working environments which encourage smokers to quit focussed on
• developing a smoke free organisation sharing our challenges and successes, with a particular focus on specialist services
• our policy with regard to e-cigarettes
• supporting and helping people to stop smoking, and managing the fear of being in a
no smoking organisation
Heather currently works for Nottinghamshire Healthcare NHSFT as Smokefree Lead, project managing the implementation of NICE Guidance PH48, Smoking; acute, maternity and mental health services. From a working life which began in general nursing in respiratory medicine, thoracic surgery and community, she moved to Leicestershire’s Stop Smoking Service fifteen years ago. During that time she led on several projects including a Local Area Agreement and developing services for pregnant women who smoke and young people.
Pre- Conference Abstract
Cultural change will never be an easy win. Smoking has been an ingrained element of mental health service for decades and the reasons for this are complex. NICE Guidance PH48 has provided an invaluable framework to assist NHS organisations to provide an environment which enables people to be Smokefree. This is in stark contrast to the historical picture for mental health setting; people being admitted as non-smokers and discharged as smokers; admitted smoking 10-20 per day and discharged smoking many more. “In some instances, healthcare staff will escort patients on and away from hospital grounds to smoke. This practice is outdated. It reduces the resources available to deliver clinical care.”
Guidance is just that though, successful implementation is something else and ensuring senior level support is vital. Many barriers exist, not least unpicking mistaken myths, beliefs and practices that have seen smoking used as part of the solution rather than the misery it can inflict not only on physical health but mental health alike with some researchers believing that “smoking could act as a trigger for mental ill-health.”
NCH NHSFT has been Smokefree since 2016 when the revised policy was launched, but there remains much work to do. Whether we can say we have achieved our goal depends on how we measure success. In my view, we have to start by winning the hearts and minds of our increasingly stretched work-force who have already very full plates to spin. Patients may still be seen smoking at times on our sites. This is not facilitated by our staff now, and each patient who smokes, is having very different conversations than ever before. I am confident that with continued investment so far, we have huge amounts of invaluable work happening each day to bring about the changes needed to reduce the needless harm associated with smoking over the coming years for our staff, our patient and their families.
Wendy Preston, Head of Nursing Practice, Royal College of Nursing session on The role of e-cigarettes will cover:
• evidence regarding electronic nicotine delivery devices
• recent research
• implications for smoking cessation practice
Since qualifying as RGN in 1992 Wendy has continued studies, achieving MSc in Respiratory Care with post graduate certificates in prescribing and higher education and practices clinically as an Advanced Nurse Practitioner and Honorary Respiratory Nurse Consultant.
Previous teams include Nursing Times ‘Team of the Year’ 2014 (acute medical unit/ ambulatory care) and Senior Lecturer at Coventry University. She is involved with policy and clinical practice leadership at a national and international level and co-edited a respiratory book published in 2016. Her work was acknowledged in 2014 by being recognised as an HSJ Rising Star. Wendy is the current Chair of ARNS and a board member of ERNA & ESNO.
Pre- Conference Abstract
Electronic nicotine delivery devices (ENDDs) are commonly known as e-cigarettes and thought to be growing in popularity and use in the United Kingdom by the general public. They are an electronic device that mimics real cigarettes. They deliver nicotine through vapour rather than smoke, and usually look like a cigarette with a light and steam produced to look like a real cigarette which required a chargeable battery. The nicotine content is variable and can be purchased in several strengths; marketing is generally for replacing nicotine consumption than quitting smoking. E-cigarettes and related devices may in the future once regulated become a useful tool in the smoking cessation field as part of a treatment plan that includes behavioral support.
They are generally recognised as a safer alternative to tobacco smoking however they still pose a harm and the extent of this harm is not yet fully understood or how to limit this risk.
This session will discuss the development of electronic cigarettes, current/ future research, current usage and where we are with regulation. Advice on what to say to your clients when they ask about e-cigarettes and how to encourage users into smoking cessation services to increase their chances of quitting tobacco.
Sources for additional information:
Britton, J & Bogdanovica, I. (2014) Electronic Cigarettes: A report commissioned by Public Health England. Available online at: www.gov.uk/phe
National Centre for Smoking Cessation Training (2014) E-Cigarette Briefing available online at: http://www.ncsct.co.uk/publication_ecigarette_briefing.php
Ratschen (2014) E-cigarettes in mental health settings – solving a conundrum?
Available online at: http://pb.rcpsych.org/content/38/5/226.long
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