mh intensive

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Smoking Cessation - Mental Health Level One
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The Impact of Smoking
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Smoking Mental Health
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Raising the Issue A Brief Intervention
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After Referral Quit Smoking Support
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The Impact of Smoking
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Whats In A Cigarette?
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Impact on the smoker

• 120,000 UK deaths per year

• Principal fatal diseases caused by smoking are
  cancer, COPD and CVD

• Deaths caused by smoking are often painful and
  premature

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LUNG CANCER
Smokers are 4 times more likely than non smokers
to die from lung cancer. US Department of Health
and Human Services (2004)
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GANGRENE
Smokers have a 16 times greater risk of
developing  peripheral vascular disease (Cole et
al 1993) .
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ORAL CANCER
Smoking causes 75 of oral cancer deaths US
Department of Health and Human Services (2004)
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Annual Deaths from Smoking Compared with Selected
Other Causes
Sources (AIDS) HIV/AIDS Surveillance Report,
1998 (Alcohol) McGinnis MJ, Foege WH. Review
Actual Causes of Death in the United States.JAMA
19932702207-12 (Motor vehicle) National
Highway Transportation Safety Administration,
1998 (Homicide, Suicide) NCHS, vital statistics,
1997 (Drug Induced) NCHS, vital statistics,
1996 (Smoking) SAMMEC, 1995
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Other effects of smoking
Smoking costs a fortune! A smoker of 20 a day
will spend around 150 a month, and around 1800
a year.
Smokers have more facial wrinkles and a greyish
pallor - smoking activates the genes responsible
for enzymes that breaks down collagen in the
skin. (Young et al, 2001)
For female smokers, the chances of conceiving
falls by 10 40 per cent per cycle. Smoking
increases the risk of impotence by around 50 for
men in their 30s and 40s. (ASH / BMA, 1999)
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Impact on Others

Breathing other people's smoke is called passive,
involuntary or second-hand smoking. Children are
particularly at risk.
The excess risk of lung cancer in life-long
non-smokers who live with a smoker is 24 per cent
(Hackshaw et al.1997) with an increased risk of
heart disease of around 30. (Glantz Parmley ,
1995)
Ventilation systems and designated smoking areas
provide little to no protection from the harmful
effects of tobacco smoke (Cains et al, 2004
Repace, 2003)
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Benefits of Stopping Smoking
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Smoking Mental Health
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Mental Health Smoking

• Psychiatric patients are twice as likely to smoke
  as the general population (El-Guebaly Hodgins,
  1992).

People with mental health disorders who live in
institutions exhibit rates of smoking in excess
of 70 (Meltzer et al., 1996)
One survey estimated that 45 of all cigarettes
smoked by individuals with a psychiatric disorder
(Lasser et al. 2000)
Reasons why?
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Why do psychiatric patients smoke so much?
Self Medication
Social Deprivation
Boredom
Culture of Mental Healthcare
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Culture of Psychiatric Care
Many have argued that smoking is facilitated
within psychiatric care (Lawn Pols, 2005,
McNally et al, 2006).
It has been observed that mental health staff may
often use cigarettes in order to appease or
engage patients.
Smoking acts as the mechanism for many of the
rules of interaction, and procedures and actions
taken in the settings. Lawn Pols, 2005
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Impact of Smoking among Mental Health Patients
Smoking-related fatal diseases are more prominent
among mental health patients than in the general
population (Brown et al. 2000)
Concerning mental health - smoking predicts
subsequent onset of depression (Wu et al, 1999).
and anxiety disorders (Johnson et al., 2000). .
Smoking exaccerbates stress (Parrot, 1989) state
anxiety (West and Hajek, 1997) and sleep
disorders (Htoo, 2004) all of which will be
detrimental to most mental health conditions.
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Raising the Issue A Brief Intervention
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Brief Intervention
BIs are the basis of service promotion.
They must be done routinely!
A person-centred approach to BI is crucial
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Brief Intervention The 4 As

• Ask smoking status
• Advise- all smokers to stop
• Assist- the smoker to stop
• Arrange- follow-up

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Ask

• Smoking Status
• How many do you smoke? How long have you
  smoked?
• Ever tried to quit? (What happened?)

• Readiness to quit
• Importance of quitting? (rate on 0 to 10)?
• Confident you can quit? (rate on 0 to 10)?

NB Record status and level of motivation in the
patients notes.
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• Advise
• When I asked you how important it is for you to
  quit smoking why did you not say zero?

Serious health risks!
Affects fitness
Costs a fortune!
It smells bad!
It hurts those around me
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• Allow the patient to tell you why they should
  quit
• Reinforce what they say with your own knowledge.
• Counter any misconceptions (eg Ive cut down)

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• Assist
• When I asked you how confident you are, why did
  you not say zero?

Ive done it before
Im determined
My family will encourage me
Im in control!
Im usually a strong person!
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• Allow the patient to tell you why they have
  confidence!
• Reinforce what they say with your own knowledge.
• Tell them about
• NRT
• Further support available

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Arrange

• Conclude intervention in a positive way.
• - Referral? (Who to?)
• - Another session?
• - Just information?

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After Referral Quit Smoking Support
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The Positive Effects of Intervention
Post-treatment and 12-month quit rates for
psychiatric patients appear to be only marginally
lower than those for non-psychiatric samples
(el-Guebaly et al., 2002).
Therapeutic approaches have included CBT,
Motivational Interviewing and health
education-based programmes.
There is still insufficient evidence to be able
to confidently identify any one approach as
superior.
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Effects of Intervention on Medication
The effect of smoking cessation will often
down-regulate the metabolism of certain
anti-psychotic (and other) drugs. Hence, blood
levels of drug may increase.
Clozapine, Diazepam, Haloperidol Mirtazapine,
Olanzapine Perphenazine, Propranolol Tamoxifen,
Verapamil, Zotepine, Amitriptyline,
Clomipramine, Desipramine, Imipramine
This shouldnt be a problem if appropriate
liaison is taking place between a patients
smoking cessation advisor and the clinician
prescribing their medication.
In fact, this may be viewed as a benefit as many
drugs used in metal health settings can raise the
risk of physical morbidity.
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Effects of Intervention on Psychological Condition
Among patients with a history of depression,
stopping smoking can increase the risk of a new
depressive episode (Glassman et al. 2001).
Is this a reason not not to offer quit support?
- Does the risk of depressive relapse outweigh
the costs of smoking?
- Is smoking effective in maintaining mental
health?
- Will MH patients stop trying to quit if we
cease quit support programmes?
Vulnerability to depression indicates a need in
intervention for
a) adequate assessment and mood management work
before quitting
b) close monitoring and support after quitting
c) liaison between mental health and smoking
cessation services throughout.
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What is a NHS Stop Smoking Advisor?
A health professional trained in smoking
cessation to level two.
Main areas of work are...
- support patients through quit (psychological
and pharmacological)
- supporting colleagues in the delivery of level
one brief interventions
- promoting smoking cessation within the team and
organisation
Extra training (level 3) can be undertaken to
enable advisor to conduct group-work.
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Level II Course Outline  
Section 1 Review of Level I
Section 2 An Overview of One-to-One Cessation
Treatment  
Section 3 Taking Referrals Wrong Place at
the Wrong Time?  
Section 4 NRT A Walking Stick, Not a
Wheelchair!
Section 5 Before the Quit Date Be Prepared
Section 6 After the Quit Date We Live and
Learn!
Section 7 Ending Treatment
Section 8 Service Promotion
Section 9 Advice for the Advisor