Guidelines for Tobacco Management in

Mental Health Settings

Miriam GunningCo-ordinator Irish Tobacco free

Hospital Initiative (TFHI)19th March 2009

I want to quit

Background to the Irish situation

2004 Tobacco legislation & exempted premises

Duty of care to staff V rights of clients

Variation in settings – no exemption if part of general hospital facility

Little guidance for exempted premises

Lack of resources

Concerns in relation to litigation

Residential Long term

Care centres

Acute MH units in general Hospital facility

Day care facilitiesFor MH clients(day hospitals)Community residential

care units for MH clients(hostels)

Facilities for MH clients only

(inc. acute care facilities)

Legislation in Ireland

Mental Health Services are exempt from the workplace smoking ban because they can be considered a patient’s home

Acute Mental Health units attached to a general hospital are not exempt

Smoking is permitted for patients only – not for staff

Mental health units can choose to implement the indoor smoking ban and are encouraged to do so

Process used in Ireland

Jan – Mar 2006 - Research best practice, agree membership of expert group & draft discussion document

April 2006 – 1st Expert group meeting & 1st draft of guidelines, email consultation process

May 2006 – National Workshop, wide consultation process, updated document & email consultation process

Sept 2006 – 2nd Expert group meeting, updated document & email consultation process

Nov 2006 – Agree final document content & layout

ENSH Project Aim & objectives

To develop “Consensus Management Guidelines” for smoke free psychiatric / mental health services

To identify and analyse existing European guidelines for smoke free psychiatric / mental health services

To identify management models of good practice in psychiatric / mental health hospitals from within participating European Partners

To make recommendations on a common set of management guidelines for European psychiatric / mental health services

Countries that participated

NORTHERN EUROPEDENMARKIRELAND(Scotland)

(Translated guidelines from Sweden & Denmark)

SOUTHERN EUROPESPAIN

WESTERN EUROPEGERMANYBELGIUMFRANCE

EASTERN EUROPEROMANIA

Project plan

December 2006 - June 2007Engage psychiatric/mental health services

Develop survey toolSurvey participating psychiatric / mental health services

Review literature to assess the range, gaps and effectiveness of European smoke-free legislation and management guidelines in relation to psychiatric and mental health services

Review and return feedback from surveyTranslate identified materialsParticipate at expert workshop to discuss findings and agree draft European Recommendations Review feedback on draft recommendations Agree final draft

Smoking rates by mental health disorders (HDA 2004)

Smoking rates

Mc Neill 2001 - different psychiatric disorders

40% of people diagnosed with neurotic disorders (e.g. depression, anxiety disorder, phobia, obsessive compulsive disorder) are smokersThe more neurotic symptoms a person has the higher the smoking levelSmoking prevalence is highest in those with diagnosed psychotic disorders. 88% of Schizophrenia patients smoke with over 50% being heavy smokers (>20 cigarettes/day)Over 70% of patients living in psychiatric hospitals and institutions smoke

Smoking Legislation - UK

Long-stay care institutes where patients are resident for more than 6 months are allowed to have designated smoking places

The average length of stay on a psychiatric ward is 58 days (Jochelson, 2006) implying most psychiatric units do not qualify for such an exemption

Psychiatric units have been given a one-year extension until July 2008 to provide secure outdoor smoking areas (Draft Statutory Instrument 2007 No.)

Smoking Legislation - France

Total smoking ban introduced in February 2007 includes psychiatric hospitals and units

Patients and staff are only allowed to smoke outside

The only exception will be for long stay units where smoking will be permitted in patients’ rooms as these are considered their private space

Literature findings

Keizer and Eytan, 2005 Many patients who enter as non-smokers leave as smokers

Jochelson and Majrowski (2006)Banning indoor smoking throws up the debate of the right of the individual to smoke versus the right of other patients and staff not to work in a smoky atmosphere

King’s Fund report (2006)

The right of staff to work in a safe work environment.

The right of patients to choose their lifestyle.

The right of patients to smoke against the right of non-smoking patients

King’s Fund report (2006)Against

Lack of indoor smoking in residential units may be perceived as a breach of a patient’s rightsStaff have preconceived ideas of impracticality, and expect an increase in abusive behaviour.Severe withdrawl and relapse is more common amidst the mentally ill (Glassman et al, 1990)A new episode of major depression may appear up to six months after cessation in those suffering from depression (Covey et al, 1997; Glasman et al, 2001)During tobacco cessation patients can relapse to other drugs

FindingsHealth promotion should be considered part of mental health servicesTotal indoor bans compared with partial bans are less likely to result in aggressive behaviour (Jochelson and Majrowski, 2006)Indoor smoking bans do not prevent patients from smokingPatient resistence has not been experienced where no-smoking policies have been implementedPatients conform when policies are clarified It is difficult to motivate patients to quit when smoking is allowed indoors

Findings contd.

Staff accept the no-smoking policies when they are enforcedCigarette consumption is reduced when it is more difficult to smokePatients become calmer and sleep betterWhen staff don’t smoke it creates a ripple effectA smoking ban is an opportunity to ask about tobacco use and give a short counselling sessionThere is no proof that smoking cessation increases the effects of schizophreniaSerious smoking-related diseases and mortality are more common in schizophrenics due to their high smoking prevalence and heavy smoking rates (Brown et al, 2000)

Effectiveness of smoking bans in psychiatric units

Willemsen et al, 2004 (Holland)87% of individuals in psychiatric units exposed to ETS when no ban on smoking

Even where a general smoking ban existed, where smoking was meant to be confined to designated areas, non-compliance resulted in a high exposure to ETS

Only when a complete ban was implemented was compliance high and employees sufficiently protected from ETS

Jochelson 2006reported 60% of psychiatric nursing staff disapproving of the ban beliving staff should smoke with patients in order to break down barriers, a view supported by 78% of patients

US (el-Guebaly, 2002) & Canadian Research(Willemsen, 2004)

supports smoke-free policies in psychiatric units with careful planning and consistency by all staff

Patten et al, 1995Fewer than expected adverse effects anticipated by staff were produced on implementing a smoke-free policy

Role of psychiatric nursing staff in aiding smoking cessation

Psychiatric nurses ideal to aid their patients in quitting smoking

Nurses, especially those who smoke themselves, appear reluctant to advise their patients to quit (Pelkonen and Kankkunen, 2001)

This reluctance stems from nurses’ respect for their patients’rights to make their own decisions

Nurses are often with patients who have been sectioned and smoking aids interaction between them and such patients

Lawn and Condon (2006) found that nurses have to be properly trained to be more effective in supporting patients’quit attempts

Smoking cessation support for psychiatric patients

All patients should be advised to quit (Swedish Psychologists Against Tobacco, 2005)

West el al 2000 (England) suggested the following evidence based guidelines

brief interventions for smoking cessation should be given to all patients identified as smokersMore intensive smoking cessation support should also be available during a patient’s period of hospitalisationSupport should be provided through specialist trained staff or if not through primary healthcare staff with smoking cessation counselling skills

Pharmacological aids for psychiatric patientsThe psychiatric illness with which a patient suffers must be taken into consideration prior to describing bupropion as it can be contra indicated

Two or more strategies tend to be better than using only one method of intervention, which applies to the population as a whole

On being discharged from a psychiatric unit, smoking cessation support should be continued (Jochelson, 2006), and patients whose medication is linked to their smoking/non-smoking need additional monitoring and advice

Training for health professionals

Staff need to be trained in intervention methods to maximise the benefits they can offer to smokers

A variety of training practices are in operation across Europe, within hospitals and community health services

The European Network of Smoke Free Hospitals (ENSH) assessed the current available smoking cessation services within European hospitals in 15 countries (McLoughin,2006a,b)

The report considered it necessary to tailor smoking cessation training for specific groups such as mental health

Summary - psychiatric services

can work effectively by being smoke-free without adverse patient effect

National smoking legislation could be expanded to include psychiatric institutes with special considerations taken into account

Psychiatric services should be supported to go smoke-free indoors

Need to raise awareness about the problems of smoking in the mental health services and bring about cultural change

Psychiatric services need a well-thought out tobacco policy

It is difficult to get patients to quit as long as it is permitted indoors

Summary - psychiatric patients

Designated secure outdoor smoking facilities should be provided for patientsAdequate smoking cessation support needs to be provided for patients when they are resident in psychiatric units and should continued when they leave the unitSmoking cessation support needs to be adapted to the specific clinical needs of a patientCigarettes should not be used as rewardsPatients should be asked about their tobacco use and offered brief smoking cessation interventionNRT should be supplied to patients

Summary - psychiatric staff

Staff have a strategic role to play in supporting smoking cessation in patientsStaff need to be trained in smoking cessation counsellingPsychiatric staff need support to help them quit smokingStaff should have separate smoking facilities to patientsStaff should avoid smoking in front of patients and visitors

It’s cynical to treat the psychiatric disorder and leave the patient to die from smoking!

Thank you for listening!

Conclusion