Transcript An evaluation of the impact of total smoking cessation in a high

SoFMH
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Forensic
Mental
Health
An evaluation of the impact of
total smoking cessation in a high
secure forensic unit in Scotland
Dr Briju Prasad
Specialty Doctor - Forensic Psychiatry
UK National Smoking Cessation Conference
Victoria Park Plaza Hotel, London
28th June 2013
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Content of this presentation
Introduction
Background to smoking and mental health
Aims of this study
Methodology
Results
Limitations and conclusions
Discussion
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Introduction
• Smoking banned in public places in Scotland since 2006
• Residential mental health units exempt from the ban
• More research in smoking and mental health
• March 2010 Scottish Government guidance –
• Mental health service providers to move towards banning smoking
altogether.
• Some mental health units have become smoke free
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What we know about smoking
and mental health…
• Smoking rates - significantly higher
• Highest levels (60-70%) of smoking is among psychiatric inpatients
(20-22 % in general population)
• Mental health staff are less positive about smoking cessation in
mental health patients
• Life expectancy - 20% less than general population
• Increased rates of cardiac and respiratory diseases (10 times >
general population.
• More heavily addicted (>25 cigarettes per day)
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What we know…
• Increased levels of nicotine dependency
• Quit rates are lower
• Up to 1/3rd of their state benefits is spent on cigarettes
• Strong association between mental illness and smoking
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• Smoking does not cause mental illness
• 40-50% of people with depression/ anxiety disorders smoke
• 60-80% of people with Schizophrenia smoke
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Why do people with mental
health issues smoke more?
• Relief of stress
• Self medication
• Increased vulnerability to smoking
• Misleading messages about smoking
• Institutional and cultural factors:
– Inpatient psychiatric units
– staff/patients beliefs
– reward/punish practices.
Deprivation
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Myths associated with
smoking cessation
“mental health
will deteriorate”
“self
harm
more”
“will not be
relaxed”
“use more
medications
”
“irritable and
angry”
“agitated
and
aggressive”
“psychotic
symptoms might
get worse”
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Aims
• To study the beliefs of patients’ and staff before
and after smoking cessation
• Compare the effect on weight and physical
activity
• Study the change in rates of aggression,
psychosis, self harm rates and medications
• Patterns of spending before and after smoking
cessation
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Methodology: Patients’
and staff attitudes
• Survey questionnaire had up to 30 questions - 90% patients (n=122)
and 61% (n=236) staff
• Respondents:
– All patients
– Staff (Nursing, Psychology, Pharmacy, Social Work,
Occupational Therapies, activity staff, Dietetics and Medical)
• Five months before and five months after smoking cessation
• Questions
• Anonymous
• Data compared between patients and staff, smokers and nonsmokers and pre and post smoking cessation.
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Methodology : Weight
• Weight: Naturalistic data of body weight (in kg) was
retrospectively collated from dietetic hospital records
• Pre smoking cessation: December 2010, June 2011 and
December 2011(baseline)
• Post smoking cessation: March, June and December
2012
• Comparisons between smokers and non-smokers, pre
and post smoking cessation were analysed
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Methodology : Behavioural
patterns
• Assault, aggression and self-harm rates
• Data recorded from hospital Datix security system
• Time scales: One year before and one year after total
smoking cessation
• Patterns compared between smokers and non-smokers
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Methodology : Physical
activity and spending
• Gym sessions and access to grounds - studied for 12
months before and 12 months after smoking cessation
• Data collected retrospectively from hospital recording
systems
• Spending on confectionery and soft drinks patterns were
studies 12 months before and 12 months after smoking
cessation
• Data collected retrospectively from Hospital shop.
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Methodology : Medication
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Clozapine – Antipsychotic medication
Plasma levels
Adverse effects – seizures
Dosage
Effect on mental state
Naturalistic data recorded retrospectively a year
before and a year after smoking cessation
• Data analysed using SPSS statistical software
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Smoking database
160
140
120
100
Patients
80
Smokers
60
Smoking Quits
40
Quit Success
20
0
Patients
Dec-10
Jan-11
Feb-11
Mar-11
Apr-11
May-11
Jun-11
Jul-11
Aug-11
Sep-11
Oct-11
Nov-11
Dec-11
Smokers
132
132
136
135
137
135
136
132
133
133
134
133
132
Smoking Quits
82
77
77
77
77
65
65
65
65
79
74
74
0
Quit Success
5
2
7
2
6
1
10
5
11
5
8
3
6
6
10
3
12
7
6
3
8
3
7
3
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74
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Results: Smoking habits
How many cigarettes do you smoke per
day
How long have you been a smoker?
None
16% 18%
1 - 10
1 - 5 years
11 - 20
18%
5%
20%
21 - 30
28%
More than 30
6 - 10 years
11%
28%
11 - 20 years
How much loose tobacco do you
smoke per week? None
13% 4%
up to 1 packet
30%
26%
21 - 30 years
More than 30
years
1 - 2 packets
26%
28%
3 - 4 packets
29%
More than 4
packets
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Results: Attitudes about
smoking cessation (patients)
Is it difficult to stay off cigarettes when
you see others smoking around you?
Have you tried to give up smoking?
Yes
Yes
21%
No
No
Once or
79%
More
How easy will it be for you to give up
smoking if the hospital goes totally
smoke free?
Do you want to give up smoking?
Yes
40%
60%
Very easy
12% 8%
16%
Easy
Difficult
No
43%
21%
Very difficult
Not sure
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Results: Opinion on
smoke ban
100%
Are you in favour of smoke ban?
90%
Total smoke
ban
80%
Partial smoke
ban
70%
60%
No smoke ban
50%
40%
30%
Not recorded
20%
10%
0%
Pre Smoke Ban
(patient)
Post Smoke Ban
(patient)
Pre Smoke Ban (staff)
Post Smoke Ban
(staff)
•Slight increase in patients favouring total smoke ban
•Significant increase in staff favouring total smoke ban
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Results: How do you think the smoke
ban will / has affected you?
Much better
Better
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
The same
Worse
• Patients reported feeling
better after smoke ban.
Much worse
Not recorded
Pre Smoke
Post Smoke
Ban (patient) Ban (patient)
Pre Smoke
Ban (staff)
• Fewer patients felt their
situation was worse
following the cessation.
Post Smoke
Ban (staff)
Much better
100%
Better
80%
The same
Worse
60%
Much worse
40%
20%
• Smokers were divided in
their opinion, but nonsmokers felt much better
after the smoke ban.
0%
Smoker
Non Smoker
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Results: Mental
and physical health
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100%
How do you think having to stop smoking
will/has affected your mental health?
80%
Much better
Better
The same
60%
Worse
40%
Much worse
20%
0%
Pre Smoke Ban (patient)
100%
Post Smoke Ban (patient)
How do you think stopping smoking will/has
affected your/patient physical health?
80%
60%
40%
Much better
Better
The same
Worse
Much worse
Not recorded
• Increase in the number
of patients reporting
that their mental health
did not deteriorate, post
ban
• 84% patients either felt
better or the same in
terms of physical
health.
20%
0%
Pre Smoke Ban
(patient)
Post Smoke Ban
(patient)
Post Smoke Ban
(staff)
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100%
Results: Aggression
and psychosis
Do you think patients will be/are more
aggressive if/now they cannot smoke
anywhere in the hospital?
Yes
90%
80%
Do you think smoking improves mental
health in psychotic patients?
No
70%
3%
Maybe
60%
50%
Not
recorded
40%
17%
No
29%
Maybe
30%
51%
20%
Yes
Not
recorded
10%
0%
Pre Smoke Ban (staff)
Post Smoke Ban (staff)
• Significant number of staff now believe that smoking ban
has not caused an increase in aggression.
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Results: Opinion on
enforcing smoke ban
Do you think enforcing a smoke free
environment in a secure hospital is right?
100%
90%
Are you now happy you
stopped smoking?
Yes
80%
No
70%
Not
recorded
60%
Yes
14%
47%
39%
No
Not
sure
50%
• Many smokers were unhappy
about smoke ban but they were
happy that they had an opportunity
to quit.
40%
30%
20%
10%
0%
Pre Smoke Ban Post Smoke Pre Smoke Ban Post Smoke
(patient)
Ban (patient)
(staff)
Ban (staff)
•Patients’ opinion about enforcing
smoke ban remained same before
and after.
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Results: Weight
100.00
98.77
Total Smoke Ban
98.00
96.51
95.85
96.00
97.65
Partial Smoke Ban
94.00
92.00
90.18
89.49
90.00
88.00
87.89
86.82
87.72
87.68
89.05
Smokers
Non-Smokers
87.37
86.00
84.00
82.00
80.00
Dec-10
Jun-11
Dec-11
Mar-12
Jun-12
Dec-12
• Weight gain noted in the first three months post cessation.
This continued for up to an year, post cessation.
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Results: Behaviour
110
Total smoke ban
100
90
80
Health and Safety
70
60
Direct Patient
Care
Security
50
40
30
20
10
0
5 Dec 2010 - 4 Jun 5 Jun 2011 - 4 Nov 5 Nov 2011 - 4
2011
2011
Dec 2011
5 Dec 2011- 4 Jan
2012
5 Jan 2012- 31
May 2012
1 Jun 2012- 30
Nov 2012
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Results: Aggression
45.00
Total smoke ban
40.00
35.00
Assault
30.00
Behaviour
25.00
Sexual
20.00
Verbal aggression/abuse
Self harming behaviour
15.00
Security Breach
10.00
Clinical Security
5.00
Prohibited Item
0.00
5 Dec 10 - 4
Jun 11
5 Jun 11 - 4
Nov 11
5 Nov 11 - 4
Dec 11
5 Dec 11- 4
Jan 12
5 Jan12- 31 1 Jun 12- 30
May 12
Nov 12
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Results: Physical activity
Gym Sessions (hours)
680
700
650
681
666
661
638
623
595
600
581
559
500
517
450
400
514
509
474
456
438
555
545
550
524
533
507
Gym Ses s i ons
479
463
454
350
326
D
ec
-1
Ja 0
nFe 11
b
M -11
ar
A 11
pr
M -11
ay
-1
Ju 1
n1
Ju 1
l-1
A 1
ug
Se 11
pO 11
ct
N -11
ov
D 11
ec
Ja 11
nFe 12
b
M -12
ar
-1
A 2
pr
M -12
ay
-1
Ju 2
n1
Ju 2
l-1
A 2
ug
Se 12
pO 12
ct
N 12
ov
-1
2
300
Pa ti ents
a ttendi ng
gym
Physical Activity
before and after
smoking cessation
74
71
Pa ti ents
wi th
grounds
a cces s
Pre s moki ng ces s a ti on
(Dec 2010-Nov 2011
79
80
Pos t s moki ng ces s a ti on
(Dec 2011-Nov 2012)
134
Tota l
pa ti ents
134
0
50
100
150
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Results: Spending
£400.00
Total Smoke Ban
Spending Patterns
£350.00
X Axis: Time
Y Axis: Average
spending per day
£300.00
£250.00
Confectionery
£200.00
Soft Drinks
Groceries
£150.00
Toiletries
£100.00
£50.00
Dec-12
Nov-12
Oct-12
Sep-12
Aug-12
Jul-12
Jun-12
May-12
Apr-12
Mar-12
Feb-12
Jan-12
Dec-11
Nov-11
Oct-11
Sep-11
Aug-11
Jul-11
Jun-11
May-11
Apr-11
Mar-11
Feb-11
Jan-11
Dec-10
£0.00
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Results: Medication
(Clozapine) levels
Mean Plasma Clozapine Levels for smokers
1.1
n=19
1
n=2
0.9
n=20
0.8
n=16
0.7
0.6
0.97mg
n=2
n=19
0.5
0.4
0.57mg/l
0.3
0.2
0.1
0
2010
2011
(baseline)
+ 1 month
+ 3 month
+ 6 month + 12 month
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Results summary
• Weight: Increased in the first 12 months (Average 3-4 Kgs)
• Spending: Spending on confectionery and soft drinks increased.
• Behaviour: Rates of aggressive behaviour reduced.
• Physical activity: Remained the same.
• Attitudes of patients and staff favouring a total smoke free
environment increased.
• Increase in the number of patients who believed their mental health
remained same after smoking cessation
• 84% of the patients felt better about their physical health after
smoking cessation.
• 50% of patients would like to smoke again after discharge.
• Medication: Clozapine plasma level increased, requiring dose
reduction.
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Conclusions
• Psychotic symptoms, ‘as required medication’ usage and
aggressive incidents did not rise, dispelling myths that restricting
smoking would destabilise mental state
• The study revealed patient and staff beliefs about smoking and
smoke restriction
• It also highlighted practical considerations relating to patient and
staff anxieties about facing smoking restrictions.
• The positive results achieved relating to patients’ mental and
physical health, should provide encouragement to other psychiatric
units considering smoking restrictions
• Enforcing total smoking cessation in open psychiatric inpatient
wards will be more challenging
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Thank you
Contact information:
Email: [email protected]
#brijuprasad
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