Dont give up giving up

1

• Dont give up giving up
• But what if you have psychosis?
• Debbie Cleaveley
• Team Manager
• Kingston Richmond Rehabilitation Team

2
Aim of presentation

• Brief overview of historical views of smoking in
  mental health
• Action on Smoking Project
• Benefits and lessons learnt

3
About me

• Mental Health Nurse by profession
• Team manager for inpatient rehabilitation team
  with operational and clinical responsibilities
• Lead on team wide nursing and clinical care
• Former smoker!

4
Facts about smoking and SMI

• Smoking rates are higher amongst people with
  mental illness when compared with the general
  population
• Smoking rates are highest in users who have
  psychosis- up to 80 of users with a diagnosis of
  schizophrenia smoke

5
Facts about smoking and SMI

• Over 70 of users in inpatient care smoke, 52
  are heavy smokers
• Higher rate of smoking related illnesses/ death
  in users with psychosis
• 52 of users in inpatient care want to give up
  smoking

6
First thought

• As a health service provider, what have we done
  about smoking?

7
Historical context 1900

• Tobacco was used as tranquilliser and, like beer
  and extra tea, snuff, sugar and cakes, were also
  given as a reward for good behaviour in 1900
  asylums.
• Cited in Nolan (1993)

8
Historical Context 1950

• A charge nurse told me to always carry a tobacco
  tin in my pocket as you can get patients to do
  anything for a fag. Tobacco was a very powerful
  means of becoming accepted
• 1950s Student Nurse Cited in Nolan (1993)

9
Historical Context 1990s

• Poor things, what else have they got if they
  dont smoke?
• Behaviour management programmes included
  cigarettes as rewards
• Cigarettes are my friends
• Anecdotal quotes from staff and users from 1993

10
Current Picture

• Mental Health is the only NHS sector that allows
  smoking in buildings/ wards
• Negative/ pessimistic view of client group-
  cant give up/ wont give up
• Charitable model- cant help it/ what else have
  people got?

11
But what about.

• The staff tell me that I have to use the
  communal lounge to watch TV. The lounge is where
  everyone smokes and I dont like smoke, it makes
  my eyes sting what I am I supposed to do?
• Current user 2005

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So what did we do about it.
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About our team

• We are a 2 borough mental health inpatient
  rehabilitation service
• We have a full MDT
• We have 44 users in total on 3 sites
• We work with a variant population of adults of
  working age with severe and enduring mental
  illness

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About our users

• 89 of users have diagnosis of schizophrenia, 10
  affective psychosis, 1 OCD
• Youngest user 19, Oldest 73, average age 41
• 12 out of 44 users are detained under the MHA
• User representation and advocacy systems in place

15
About our services

• Rose Lodge- fast track rehab unit in local
  community
• South Bank House- slow stream/ continuing care
  unit in local community
• Riverside Lodge (pictured)- high support unit in
  grounds of a small hospital

16
About the project

• Action on Smoking is a year long project focusing
  upon smoking cessation and has two components
• Providing smoking cessation advice and support
• Providing Smoke free environments

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First Steps- Environments

• Local variations in smoking area provision
  ranging from purpose built to smoking in all
  communal areas
• Purpose built area very comfortable and
  encouraging to stay in
• Communal lounges all smoking
• Smoke exposure in non smoking areas

18
Progress on Environments

• Rose Lodge 100 smoke free internal environment
  achieved on 1st March 2005
• Riverside Lodge- partially smoke free, smoking
  restricted to purpose built room which is being
  gradually withdrawn by the end of the year.
  Purpose built area made more spartan
• South Bank House- partially smoke free, smoking
  restricted to one area, this will be withdrawn at
  the end of the year

19
First Steps- Smoking Cessation Advice

• Local variations in advice dependant on levels of
  disability
• PCT smoking cessation advisors visiting on site,
  users visiting local clinics
• Unit psychiatrists pharmacists advising on and
  prescribing Nicotine Replacement Treatments
• Train own staff in smoking cessation

20
Progress on smoking cessation

• 1 staff nurse trained
• Support from PCT advisors
• Local prescribing of NRT
• 8 users have actively attempted to give up
  smoking using NRT 1 gave up for over 6 months
• 20 users have expressed an interest in giving up
  smoking

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Observed Benefits

• Physical health
• Financial
• Social context/ accessing mainstream services
• Medication and symptom control
• Environmental

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Financial Benefits

• Current inpatient benefit 16pw
• Therapeutic earnings up to 40 on top of benefits
• Cigarettes retail at c.5.00 per pack of 20.
• Increased personal income widens horizons for
  social life, personal items, hobbies better
  quality of life

23
Social Benefits

• Reduced anxiety/ withdrawal symptoms when in non
  smoking areas/ places/public transport etc
• Increased social contact in and outside of
  building
• Increased interaction with staff
• Reduced rate of incidents in and around smoking
  area/ room

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Social Inclusion Benefits

• Normal and socially inclusive response to people
  with psychosis
• Access to mainstream services/ activities
  health and non service provision
• Counters charitable model
• Adult and age appropriate response

25
Environmental Benefits

• Smoke free rooms and communal areas
• Elimination of smoke contamination/ drift in non
  smoking areas e.g. kitchens
• Reduction in smoke damage to furniture and
  fittings
• Reduction in fire risks

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Medication Symptom Control Benefits

• Reduced dosages of atypical medication especially
  Clozapine observed in non smokers
• No link between non smoking and increased
  positive psychotic symptoms
• Increased self esteem
• Cutting down smoking can be helpful in initial
  stages

27
Learning Points

• Project with a variant and challenging user group
  has been successful to date
• Proactive approach and attitude- no nagging!
• Focus on all positive steps to engagement
• Antipsychotic medication levels, esp. Clozapine
  need careful monitoring
• Staff anxiety/ low expectation a factor

• Individual approach required
• Slower transition for more disabled users is
  successful
• Encouragement with smaller steps (e.g. reducing
  cigarette intake) can and does lead to bigger
  steps
• Not to underestimate users with significant
  disabilities

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Future Challenges

• Sustaining progress especially in the winter
  months
• Trust becoming 100 Smoke free including grounds

29
References/ Recommended Reading

• McNeil A (2001) Smoking and Mental Health a
  review of the literature. Smoke Free London.
• Cormac I, Martin D, Ferriter M (2004) Improving
  the physical health of long stay psychiatric
  inpatients. Advances In Psychiatric Treatment.
  Vol 10 pp107-115
• Nolan P (1993) A History of Mental Health
  Nursing. Chapman Hall, London