Smoking in Mental Health: A Thorny Public Health Issue New Zealand Workshop Series Aug 18th 21st 200

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Smoking in Mental Health A Thorny Public Health
Issue New Zealand Workshop SeriesAug 18th
21st 2009

• Based on Community and Politics Symposium on
  Smoking in Mental Illness, Presented at RANZCP
  Congress Melbourne 2008
• Tobacco Control and Mental Health Populations
  Controversies for Research and Practice, South
  Australian Mental Health Research Day, 2008
• Dr Sharon Lawn
• Email sharon.lawn_at_flinders.edu.au

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Why is research on Smoking and Mental Health
Populations Important?

• A much neglected addiction
• The most insidious cause of physical health
  problems poverty, vicious cycles
• Extremely value laden
• Huge unresolved ethical dilemmas for mental
  health professionals others

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What we know

• Smoking contributes substantially to physical
  health comorbidity in people with mental illness
  (2-3 times for all the major health conditions).
• 31.8 of Australians with mental illness are
  smokers / 17.7 non mentally ill are smokers
  (ABS).
• High of people with Schizophrenia are smokers
• People with mental illness comprise 38.3 of all
  adult smokers, gt 42 of all cigarettes consumed.

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Current Clinical Issues

• 70 of inpatients have co-morbid nicotine
  dependence
• Smoke 40 per day average (Lawn 2001)
• Increases when patients relapse
• Most detained patients are highly nicotine
  dependent
• Withdrawal exacerbates psychosis
• Cigarette seeking, demanding behaviour, begging,
  intimidation and violence
• Failure to diagnose and treat withdrawal

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A Number of Paradoxes Exist

• Un-intended consequences of public health policy
• Clinicians use a harmful substance in the
  management of MH patients
• Otherwise good clinicians fail to diagnose
  treat
• Violence to family, staff and other patients is
  tolerated
• Passive smoking is tolerated
• OHS is ignored
• Medical co-morbidity is not addressed
• Consumers perspectives become distorted and
  demoralised further
• Families and workers are co opted into the
  distortion
• Hospitals as a smoke-free environments - not
  enforced

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A Problem of Need

• (Mark - Schizophrenia)
• The first time when I had no money and I couldnt
  get credit at the deli, I used to go around the
  streets looking for butts...looking for butts...I
  dont know where or who they came from but Id
  unroll them and join them all up again into one.
  (pause) It was just a smoke wasnt it? Ive been
  that bad. When you cant have a smoke you just go
  around knocking on peoples door asking for
  smokes and some I didnt even know the people,
  and theyd say, Who are you and what do you
  want? Some just used to swear at me and push the
  door in my face, bang the door. It was just a
  smoke (pause). I would have done anything for one
  at the time.
• (Jean Depression)
• Sometimes when I have a smoke it means I don't
  have to think it gives me time out. If I had
  more time to think, I'd probably get depressed
  about my situation, just knowing they're there is
  enough to keep me calm, but when I run out of
  them I panic

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A Problem with Values

• (Grace - psychiatric nurse/ex-smoker)
• In the locked ward I don't think there's much in
  the way of one-to-one therapeutic activity that
  happens. It's a kind of, "Let's wait for the
  medication to work". There's just nothing to do.
  The only normal thing to do at the time is to
  smoke.
• (Jane - social worker/smoker).
• My ability to empathise and almost openly model
  smoking behaviour at different points in my
  career when I didn't have different tools.And
  part of working with really difficult clients is
  trying to find an entry point where you can
  develop rapport with them. And what was more easy
  than sitting around with them and having a smoke.
• (John consultant psychiatrist/ex -smoker)
• In my heart of hearts, with patients with
  schizophrenia, I feel that they haven't got much
  left for them, so good luck to them. If they want
  to smoke, let them.

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Current Systemic Issues

• The use of cigarettes in the management and
  control of patients
• Deskilling of clinical staff
• Most psychotic patients/detained patients have no
  funds, hence they withdraw abruptly
• NRT is often not available, is inadequately
  provided or too little, too late
• Rationing one cigarette per hour is punishment,
  not treatment, reinforces addiction
• We have little objective data to guide us

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Current Systemic Issues

• Passive smoking
• Other patients
• Nurses and other MH staff
• Partners, families, children
• getting drug (cigarette) supplies
• Harms to patients, others
• Poverty
• Enzyme induction and fluctuating effects of
  medication
• OHS issues
• Many MH Nurses smoke
• doctors others less

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Current Public Health Approaches

• Current campaigns increasing prices have little
  impact on quitting by MH patients
• Elasticity for disadvantaged populations
• Just making them poorer
• 37 of their income to treasury per week
• Quit advisors quit resources lack an
  understanding of withdrawal symptoms interacting
  with mental illness symptoms.
• Few targeted quit programs for MH clients

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Why is this not addressed at this time?
Smoking - a tool in a much larger set of
interactions and relationships
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Smoking Mental Illness Myths

• They choose to smoke
• They cant quit
• They need to smoke
• Smoking between staff and patients facilitates a
  therapeutic relationship
• Attempting to quit makes symptoms worse
• If they quit they will put on more weight.

• not free choice, not a level playing field
• yes they can and do with appropriate support and
  hope/belief
• a vicious cycle of need based on addiction,
  reinforcement and our ignorance
• therapeutic for whom? An excuse not to use other
  skills
• no evidence for this, UK study - smoking sustains
  depression, reduces opportunities to gain more
  adaptive coping skills development, increased
  hopelessness
• Surely this is already enough of a problem?

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Smoking Mental Illness Myths

• One of their few pleasures and sources of
  control!
• The mentally ill are disempowered in so many
  other ways
• MH workers
• As a society
• Eg. UK campaign (Stubbing out our rights) NSW
  Campaign (Right to Choose)
• is this a good enough reason to allow smoking?
  Policy needs to enhance their choices on many
  fronts.
• This is about many aspects of mental health care
• stop using it as the excuse to avoid questioning
  our overall practice/treatment.

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So What can be Done?
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A Rational Clinical Response

• A complex pathway of interactions that requires
• skilled mental health support effective
  collaboration with families, Quit Workers, GPs
  and others.
• high quality self-management knowledge, skills
  support
• Anticipate chart high dose nicotine withdrawal
  (probably gt 45 ngm/ml)
• Anticipate craving, drug seeking, cognitive and
  behavioural consequences
• Treat vigorously
• One patch 16-20 ngm/ml more patches needed?
• NSW protocol including supplements (gum, inhaler)
• Encourage people to continue to stay quit
• Collect data

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Quitting by the Organisation Group

• Similar approach to that of the individual
  attempting to quit
• It needs multiple strategies
• It is hard
• Often more than one attempt is needed
• Attempting gives opportunities for learning
• A slip isnt a complete lapse (AVE)
• Do we just give in when it gets too hard what
  message does this give consumers, staff the
  community?

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Consequencialism Vs Rule-based Ethics

• Consequencialism the morality of actions should
  be judged by their consequences
• Rule-based ethics (Deontological theory) certain
  courses of action will always hold true eg
  autonomy must always be respected, paternalism is
  to be avoided
• Be honest with ourselves
• Smoking as a tool in a much larger set of
  interactions and relationships
• Shifting arguments when it suits us

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Policy Options

• Clarifying exemptions/legal statements to avoid
  confusion
• Does debating the ethical issues arrive at any
  productive conclusions? Moral debates on this
  issue will always have 2 sides - unresolvable
• How are policy makers to navigate through the
  chaos created?

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A Rational Systemic Response

• A clear policy of a smoke free hospital that is
  supported by hospital administration, ED, ICU and
  MHU
• Well trained staff to implement the policy
• Availability of NRT, protocols and withdrawal
  charts
• Alternative strategies to deal with the barren
  desert of boredom in units, SRFs etc.
• Regular, supported Quit programs for all

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Policy solutions

• Move beyond trying to resolve the debate
  ethically
• Support greater Individual Group staff clinical
  skills development
• Support interdisciplinary learning and practice.
  Multi-D teams often dont work. Rivalries,
  splits, circling the wagon responses perpetuate
  inaction. Get over it!
• Develop more leadership skills and support
  leaders who can lead
• Support research to dispel the myths
• Start treating it seriously like the clinical
  addiction that it is, broad coordinated strategy
  needed across service systems

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Exempting Psychiatric Units from Smoke Free
Policies

• Be careful what we wish for
• Both negative and positive consequences in the
  short long term
• Already unintended consequences
• Deskilling of staff
• Poor health of people with mental illness
• Increasing proportion of remaining smokers have
  mental illness
• Public perceptions of people with mental illness

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Can Psychiatric Units Become Smoke Free ?

• Discuss, plan, examine the evidence
• Clinical pathways, protocols
• Consensus clear policy
• Clear implementation strategy
• Train clinical staff properly (mentored skills
  development)
• Bring patients, representative groups on side
• Liaise/policy/quit programs in the community
• Baseline evaluation
• Feedback, monitor, review

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Outcomes

• Havent met one individual who didnt value the
  achievement after quitting
• Havent found one unit that said it would return
  once achieved smoke-free
• Pleasantly surprised by less aggression, not more
  as expected.
• Consumers positive thankful that someone has
  finally set limits and supports, taken it
  seriously.
• Just like the individual quit attempt, watch that
  3 month high risk relapse point.

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Some Issues for Clinical Staff Administrators

• Duty of care
• Premature mortality a response is needed
• Avoidable verbal/physical assault on staff
  other patients is overlooked
• Nicotine withdrawal causes the exacerbation of
  psychosis
• Non-smoking policy is in place but ignored
• NRT is available, often not used effectively
• Skill training protocols are available
• Inpatient units outpatient care- a barren
  desert of boredom is an issue of neglect
• Are costs budgets more important than people?

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Research Opportunities and Challenges

• Researcher as Worker / Insider reporting
• Handling taboo issues
• Whistle blowing and Change
• Understanding all sides / complexity
• Respecting the difficulty
• Communicating ideas / results
• Causing more harm

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What research in this area has really shown

• How we fundamentally treat people in our systems
  of care and the community, the values we hold,
  the decisions we make and the impact and
  consequences of those decisions on service users,
  workers, service systems and beyond.
• Quickly identified cigarettes as the tool for
  exchange and interactions within a token economy
  that has been heavily reliant on smoking to
  mediate symptoms and exchanges between the
  various players.

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• References
• Lawn, S. Campion, J. (2008) Smoke-free
  Initiatives in Psychiatric Inpatient Units A
  national Survey of Australian Sites. Flinders
  University, Adelaide.
• Lawn, S. (2008) Tobacco Control Policies, Social
  Inequality and Mental Health Populations Time
  for a comprehensive treatment response.
  Australian and New Zealand Journal of Psychiatry,
  42 353-356.
• Campion, J., Lawn, S., Brownlie, A., Hunter, E.,
  Gynther, B. and Pols, R. (2008) Implementing
  smoke-free policies in mental health inpatient
  units learning from unsuccessful experience.
  Australasian Psychiatry, 16 92-97, 2008.
• Lawn, S. (2007) Chapter One in J.E. Landow (Ed)
  Smoking Cessation Theory, Interventions and
  Prevention A Day in the Life of. The Culture
  of Cigarette Smoking for Psychiatric Populations
  Nova Science Publications, New York.
• Lawn, S. (2007) Should psychiatric facilities be
  smoke free? Are we even asking the right
  questions? Australasian Psychiatry. 153, 246.
• Lawn, S. and Condon, J. (2006) Psychiatric
  Nurses Ethical Stance on Cigarette Smoking by
  Patients Determinants and Dilemmas in their Role
  in Supporting Cessation. International Journal of
  Mental Health Nursing, 15, 111-118.
• Lawn, S. J. and Pols, R. G. (2005) Smoking Bans
  in Psychiatric Inpatient Settings? A Review of
  the Research, Australian and New Zealand Journal
  of Psychiatry, 39, 874-893.

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• Lawn, S. J. (2005) Cigarette Smoking in
  Psychiatric Settings Occupational Health,
  Safety, Welfare and Legal Concerns, Australian
  and New Zealand Journal of Psychiatry, 39,
  894-899.
• Lawn, S.J. (2004). Systemic Barriers to Quitting
  Smoking Among Institutionalised Public Mental
  Health Service Populations A Comparison of Two
  Australian Sites. International Journal of Social
  Psychiatry. 50, 204-215.
• Lawn, S.J. Pols, R.G. (2003). Nicotine
  Withdrawal Pathway to Aggression and Assault in
  the Locked Psychiatric Ward. Australasian
  Psychiatry, 112, 199-203.
• Lawn, S.J. (2003). Is it Time to Consider the
  Sociology of Nicotine Addiction? Smoking and
  Social Disadvantage. In Touch, 20 1, 8.
• Lawn, S.J., Pols, R.G. Barber, J.G. (2002).
  Smoking and Quitting A Qualitative Study with
  Community-Living Psychiatric Clients. Social
  Science and Medicine. 54, 93- 104.
• Lawn, S.J. (2001) Australians with mental illness
  who smoke. British Journal of Psychiatry, 1
  7885.
• Lawn, S.J. (2001) Systemic Barriers to Quitting
  Smoking Among Institutionalised Public Mental
  Health Service Populations. Unpublished PhD
  Thesis, Flinders University of South Australia,
  Adelaide, South Australia.