Transcript Very Brief Advice on Smoking

Demystifying screening and brief advice
in clinical settings for alcohol and tobacco
North East Parity of Esteem conference Sunderland, 15th October 2014
Martyn Willmore – Fresh
Dr Dorothy Newbury-Birch, Institute of Health &
Society, Newcastle University
The nation`s health
Life expectancy of people
living with mental illness
Summary
o Majority of people living with a mental health condition
will die from one of the five big killers
o We know that people from the most deprived
communities are more likely to have mental illness and
likely to die younger
o “Better health, fairer health”?? We have made least
progress in outcomes for those with mental illness
Smoking
Supporting smokers to stop
o For people living with mental illness who smoke,
stopping smoking will have the greatest positive
impact on their physical health
o Very Brief Advice on smoking is a life-saving
intervention, and takes 30 seconds….
o Mental health staff (both inpatient and community) are
ideally placed to identify those that smoke, and offer
advice on stopping
What are the perceptions?
o Those with mental health issues don’t want to stop
/cannot stop
o Smoking is one of very few pleasures in life
o Tobacco/nicotine helps to relieve stress
o Cessation will negatively impact on mental health
Very Brief Advice on Smoking
VBA for smoking follows 3 simple steps:
ASK
(and record smoking status)
Is the patient a smoker, ex-smoker, or non-smoker
ADVISE
(on the best way of quitting)
Best way of stopping is with a combination of support and product
ACT
(on the patient`s response)
Give information, refer to service, prescribe
ASK and record
o Vital that MH staff use every
contact as a health improvement
opportunity
o Staff already have the skills to
engage patients in conversations
in behaviour change. Easily
applied to smoking
o Raising the issue re-enforces that
stopping smoking is integral to
overall health of patient
Do you smoke?
Have you
recently stopped
smoking?
ADVICE
o Once smoking status confirmed,
follow up with advice/offer of
support to quit
o Most effective way of quitting is
a combination of stop smoking
product, and behavioural support
o You are up to four times more
likely to quit with SSS support
than trying to quit unaided
Did you know that
stopping smoking is the
best thing you can do for
your health?
Support and medication
really improves your
chances of quitting
Would you like for me to
arrange for a stop smoker
advisor to chat with you?
ACT
o Act upon the patient`s response:
o If interested in quitting, make a referral to local SSS
o Encourage/Build up their self-confidence
o If inpatient, but not looking to quit, ensure access to
NRT or medication to help with nicotine management
o Be proactive about possible impact on dosage of
associated medications
o Record actions taken
o Majority of smokers say they want to stop, but lack
confidence or impetus to access proper support
Key role of mental health staff
o Trained SSS advisors will offer clients a 12-week
programme of support and medication
o But MH staff can support patients too by encouraging
correct use of medications, and helping to re-enforce
positive messages
o Motivation to quit can be easily undermined by staff:
o Offering cigarettes/purchasing them on behalf
o Smoking in front of them
o Conveying negative messages about chances to quit
Managing nicotine withdrawal
o Nicotine has a very short half-life, and so smokers will begin
to suffer withdrawal within 1-2 hours
o Withdrawal symptoms could include irritability and low
mood, and are easily misinterpreted as signs of worsening
mental health. Important to understand alternative options
o There are currently three main types of licensed product to
help with cravings from tobacco withdrawal:
• Nicotine Replacement Therapy
• Varenicline (Champix)
• Buproprion (Zyban)
Effect of cessation on metabolism
o Tobacco (specifically tar) speeds up the metabolism of some
antipsychotic medications, anti-depressants and
benzodiazepines
o Therefore some smokers need higher doses of these drugs
than non-smokers
o Blood levels of medication can be impacted by many things,
but stopping smoking likely to increase it within 7 days
o Doses of medicines may need to be reduced by 25%-50%
once someone stops smoking
Summary
o Tobacco dependence is a chronic relapsing condition –
may take a number of attempts to quit successfully
o MH staff have a vital role in supporting patients
o Normalising VBA is pivotal in prompting quit attempts
o Online VBA training available. Staff can also acquire
skills from local SSS to become advisors if they wish
o Smoking remains our biggest preventable cause of
premature mortality
VBA Smoking Resources
Online NCSCT Training module
http://elearning.ncsct.co.uk/vba-launch
Short film on VBA
http://elearning.ncsct.co.uk/vba-stage_1
Alcohol
Is IBA effective?
The IBA evidence base
• Over 30 years of research examining
impact of IBA in primary care and (more
recently) other settings.
• 24 systematic reviews covering at least 56
high quality studies in primary care alone
(O’Donnell et al 2014).
• Consistent message  IBA is effective at
reducing the quantity, frequency and
intensity of drinking when delivered in
primary healthcare.
• Evidence more equivocal in other settings
(A&E, workplace, criminal justice).
Impact on alcohol consumption
 For every eight people who receive simple alcohol advice, one
will reduce their drinking to within lower-risk levels (Moyer et
al., 2002).
 Kaner et al (2007) showed that IBA reduced the quantity of
alcohol drunk by an average 38 g per week.
 Varies by age  Jonas et al (2012) suggested effects may be
lesser in older adults aged 65 and over (23g) and for young
adults / college students aged 18-30 (23g).
Wider health impacts
Other positive outcomes include:
– Reduction in alcohol-related problems;
– Reduced health-care utilization;
– Improved mortality outcomes.
 A reduction from 50 units/week to 42 units/week will reduce
the relative risk of alcohol-related conditions by some 14%,
the attributable fractions by some 12%, and the absolute risk
of lifetime alcohol-related death by some 20% (Anderson
2008).
Cost-effectiveness of IBA
• Estimated quality-adjusted life-year (QALY) gain
associated with IBA ranges from 4-19 per 1000 (Anderson
2009)
• IBA based on new patient registrations and delivered by a
practice nurse provides modest cost savings to the health
care system of £120m over 30 years and health gains over
the same period amount to 32,000 QALYs, at £6900 per
QALY gained (Purshouse et al 2009).
• Doctor-delivered IBA would be more expensive but result
in incremental health gains equivalent to 92,000 QALYs,
at £1175 per QALY gained (Purshouse et al 2009).
1.
2.
To identify the most efficient and acceptable screening
strategy and tool to detect hazardous and harmful
drinking
To evaluate the effectiveness and cost effectiveness of
different intensities of BI
SIPS: impact on AUDIT scores
Fig 1: Changes in % AUDIT + overall and by intervention at 6 and 12 months
SIPS: Key findings
High overall recruitment and follow-up rates in PHC
High BI delivery immediately after screening
BI delivery drops if subsequent visit is needed
Risk drinking fell between baseline & follow-up
No significant differences between the 3 conditions
Gender and AUDIT score at outset predict outcome
(Kaner et al 2013)
IBA in practice……
http://www.alcohollearningcentre.org.uk/Topics/Browse/BriefAdvice/SIPS/BriefAdv
iceTrainingandTools/?parent=4449&child=5186
http://www.alcohollearningcentre.org.uk/Topics/Latest/Resource/?cid=5184