Transcript to the presentation - UK National Smoking Cessation

Collaboration for
Leadership in Applied
Health Research and
Care South London
(CLAHRC South London)
Debbie Robson, RMN, PhD
Mental Health Nurse &
Snr Post Doc Researcher in Tobacco Addiction
Institute of Psychiatry, Psychology & Neuroscience, KCL
Change this
Professor Michael Russell
1932- 2009
How We Traditionally Treat Tobacco Dependence In
Mental Health Settings
Maudsley Hospital
Bethlem Hospital
Lambeth Hospital
Lewisham Hospital
Serves a diverse local population of 1.2m
London boroughs of Southwark, Lambeth, Lewisham & Croydon
4 hospital sites: 49 wards: 1000 beds –
treats approx 5,300 inpatients a year
200+ community services (45,000 + patients a year) +
specialist/national services
Employs approx 4,800 staff
Time & opportunity cost of facilitating
smoking in mental health settings
Pre smoke free survey
25 mental health
wards
Time dedicated to
smoking
2.23hours
(per day/ward)
(Robson et al, 2016 NTR)
Potential annual
(opportunity) cost per ward
£18,250* - £86,870**
* Band 2 worker, ** band 5 nurse
We have protected the
perceived right to
smoke during a
admission to a
psychiatric hospital
We have protected the rite
of passage for a person to
enter the bewildering world
of a psychiatric ward as a
non smoker and leave as a
20 a day smoker
Health professionals attitudes towards
smokers with mental illness
Staff attitudes about smoke-free policy
Violence
Fires
Detained
patients
Listening exercises in SLAM (74 staff)
WIDENING GAP BETWEEN THOSE WITH AND WITHOUT
MENTAL ILLNESS WHO SMOKE
4
Substance use
Psychosis3
Depression &
Anxiety2
General population 1
62%
88%
40%
69 years
18.5%
81 years
1.PHE Health Profiles, 2015 2. McNeill et al, 2013
3. Wu C-Y et al. (2013). PLoS ONE 8(9): e74262. 4. Cookson C, et al (2014) BMC
Health Services Research 2014, 14:304 , 5. Chang et al PLoS One 2011;6(5)
 Smoking contributes to poor mental health1 (more severe symptoms of
psychosis, higher rates of depression, longer time in hospital)
 Increased risk of suicide2
 Lower plasma levels of clozapine and olanzapine (up to 50%) - higher
doses of medication3
 Poverty4 (clients spent approx a third of their income on cigarettes)
 Exploitation & stigma5 (begging for cigarettes, picking up butts)
 Growing evidence that daily tobacco use is associated with
increased risk of psychosis and an earlier age at onset of
psychotic illness6
ASH’s ambitions
Smoking among people with
mental health conditions
declines to 35% by 2020 and
<5% by 2035
•
•
•
•
•
National and local leadership
Empowered service users
Effective commissioning
Core role of staff
System wide and integrated treatment
and support to quit smoking/or
reduce harm
HEALTH SERVICE
Lack of alternatives to smoking & empty time
Lack of treatment choices
Knowledge, attitudes & behaviour of staff
SOCIAL WORLD
Smoking initiation. ■Family influence Peer
relationships. Choice & control
INTERNAL WORLD
Vulnerability to stress & nicotine
addiction
Beliefs about cigarettes
Ambivalence in smoking &
quitting
Meta synthesis of
12 qualitative
studies397 smokers with
severe mental
illness
Robson (2013)
HEALTH SERVICE BARRIERS
Lack of alternatives to smoking & empty time ■ Lack of treatment choices
■ Knowledge, attitudes & behaviour of staff
Getting the balance right between treating smokers and
enforcement of smoke free policy
Closing the gap
Support & guidance
for policy
implementation
Treatment
Enhance the
infrastructure to
support
implementation
Improved
intelligence
pathways
Research &
evaluation
Education & Training
Pathways
Support from
government,
commissioners, CQC
Underpinned and driven by co-production with service users,
carers & clinicians
Studies included in review: 17 RCTs
n= 356 in the efficacy analysis, n= 423 in the tolerability
analysis
Bupropion odd ratio (OR) 4.15 (95% CrI = 1.45-14.04)
Varenicline OR 5.91 (95% CrI = 1.96-17.85)
116
countries
Neuropsychiatric ides effects e.g.
anxiety, depression, aggression,
delusions, hallucinations, psychosis,
suicidal behaviour
Funded by the manufacturers of bupropion & varenicline
Nonpsychiatric
cohort
Psychiatric
cohort
n=4028
n=4116
Depression or bipolar disorder = 2160
Anxiety = 488
Psychosis = 292
Personality disorder = 22
Efficacy: Quit rates at 9-24 weeks
Bupropion
30
30
25
25
KEY MESSAGE
20
15
10
5
0
25.5%
20
15
10
5
0
15
10
Psychiatric (n=1032)
18%
13.7%
Non psychiatric (n=1001)
Psychiatric (n=1033)
whether
youpatch
have a psychiatric history or not, varenicline
Nicotine
Placebo appears
30
to be the most effective single medication
of all the first line
25
treatments; whereas bupropion and nicotine
patch are more effective
20
than placebo.
15
% Quit
% Quit
25
20
5
Overall the abstinence rates in the psychiatric
cohort were lower than
the non psychiatric cohort, but…… 0
Non psychiatric (n=1005)
30
18%
% Quit
% Quit
Varenicline
10
Shows
for the first time that13%
the efficacy of the medications
in terms of ORs is similar for
18.5%
5
10.5%
8.3%
smokers with or without psychiatric disorders. 0
Non psychiatric (n=1013)
Psychiatric (n=1025)
Non psychiatric (n=1009)
Psychiatric (n=1026)
Safety: Neuropsychiatric effects
Bupropion
20
18
16
14
12
10
8
6
4
2
0
% neuropsych effects
% neuropsychiatric side effects
Varenicline
20
18
16
14
12
10
8
6
4
2
0
KEY MESSAGE
No
1.3%
6.5%
significant increase in rates of moderate-to-severe
neuropsychiatric adverse events with either varenicline or bupropion
relative to nicotine
patch or placebo in those
with or
Non psychiatric (n=990)
Psychiatric (n=1026)
Non psychiatric (n=989)
Psychiatric (n=1017)
without psychiatric disorders.
Placebo
Give all people who smoke18 the BEST treatment
20
2.5%
Non psychiatric (n=1006)
5.2%
Psychiatric (n=1016)
% neuropsych effects
% neuropsych effects
Nicotine patch
20
18
16
14
12
10
8
6
4
2
0
6.72%
2.2%
16
14
12
10
8
6
4
2
0
2.4%
4.9%
Non psychiatric (n=999))
Psychiatric (n=1015)
15 sessions, combination NRT + MI + CBT.
Delivered in a venue of pts choice. Quit date flexible
Evaluated in 30 people with schizophrenia
Number of smokers
Preparing to
cut down
35
30
25
20
15
10
5
0
Cutting
down with
oral NRT
Stopping
Patch + oral
Staying
smokefree
47%
33%
baseline
Robson (2013) KCL
1 week
4 weeks
Post quit date
27%
6 months
The ebb & flow of motivation to stop smoking:
Clare, 52. Smoker for 30 years. Schizophrenia
Preparing to cut down
Cutting down
Stopping
Staying stopped
Phase 1
Phase 2
Phase 3
Phase 4
It’s not like I have been
thinking about stopping or
anything, it’s its when Sarah
(Psychologist) asked me if I
wanted see you, I thought,
“I think it would probably be
easier to cut out ones in the
evening… but you see that’s
very pleasurable in the evening…
listening to music, drinking,
having a cigarette……In fact
now I’m starting to think about
this, I’m thinking I don’t want to
do it at all”
“I’m amazed I’ve stopped,
my sister can’t believe it, I
don’t even want one, I’ll
reach for the inhalator now
instead of having a
cigarette”
“First thing I think about when
I wake up is I’m going to have
a cigarette today…I fight it all
day long”
I’d just take a leap of
faith
MOST HARMFUL
NICOTINE DELIVERY SYSTEM
LEAST HARMFUL
NICOTINE DELIVERY SYSTEM
Develop policies that make it as easy as possible to reduce tobacco related harm
SLAM E cigarette policy
• Staff should offer licensed stop smoking meds first
• E cig use should be documented in care plan
• Can be used in single use bedrooms and grounds
• Cannot be used in ward gardens or therapeutic conversations
Prompt access to treatment for temporary abstinence
+
NRT Patch + oral NRT + behavioural support
3 options for accessing NRT
Doctor/non medical prescriber
Homely remedy policy
(nurse can administer for limited NRT
products up to 24 hours)
South London & Maudsley Smokefree Policy
Patient Group Direction for
NRT
nurses, who have received level 2
training + pass a competency test
Education & Training
Make sure that
the mental
health
workforce is
trained to the
standards set
by the NCSCT
SLaM Training Pathway
ELearning. Basic knowledge
( 2 hours)
Tobacco addiction in mental health
settings
Use of NRT, bupropion, varenicline
Providing Very Brief Advice
How to refer for specialist support
1300 staff trained to date
Knowledge increases from
54.4% to 87.6%, p <0.001
LEVEL 2: Advanced clinical skills (3 days)
Assessing tobacco dependence
Facilitating choice of stop smoking
medication
Managing temporary abstinence
Provision of specialist stop smoking
support
Use of E Cigarettes
Therapeutic management of stress &
boredom
150 staff trained to date
Knowledge , attitudes & confidence
all significantly improves
Evaluation of smoke-free policy: responding
to staff fears:
Has the smoke-free policy increased fire incidents?
49 wards
12 months before
smoke-free policy
12 months after
smoke-free policy
31% (13/42) of fire
incidents were cigarette
smoking related
23% (12/51) of fire
incidents were cigarette
smoking related
Has the smoke-free policy lead to an increase of
legally detained patients on the wards?
The average number of people detained per month in a sample of 18,271 in-patients.
30 months before
smoke-free policy
Mean = 190.7 per month
12 months after
smoke-free policy
Mean per month = 190.5
p=0.97
Has the smoke-free policy lead to an increase of violence in
inpatient services?
Reported physical assaults (towards staff & pts) n=3017
Related to Smoking
Unrelated to Smoking
160
103 assaults per month
102 assaults per month
5.8 assaults per month
4.2 assaults per month
120
100
80
60
40
20
0
Apr-12
May-12
Jun-12
Jul-12
Aug-12
Sep-12
Oct-12
Nov-12
Dec-12
Jan-13
Feb-13
Mar-13
Apr-13
May-13
Jun-13
Jul-13
Aug-13
Sep-13
Oct-13
Nov-13
Dec-13
Jan-14
Feb-14
Mar-14
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
Mar-15
Apr-15
May-15
Jun-15
Jul-15
Aug-15
Sep-15
number of physical assaults
140
 Reducing the widening smoking and mortality gap requires
dramatic action
 Take into account service users, carers and mental health
clinicians experiences when designing tobacco dependence
interventions
 Give ALL smokers access to the best treatment & a choice of
treatment
Leave no one behind
Collaboration for
Leadership in Applied
Health Research and
Care South London
(CLAHRC South London)
[email protected]
Acknowledgements: Ann McNeill & Mary Yates