Smoking and mental health - NCSCT

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Smoking and mental health Fourth, active promotion of a smoke-free lifestyle should also be an integral part of any health service, including those for mental disorders. Finally, nicotine substitution as a harm reduction strategy and/or to enable compliance with smoke-free environments in secondary care settings should be a default support for smokers unwilling or otherwise unable to engage in cessation activities but obliged by admission to a smoke-free setting to abstain from smoking. However, there is little available information on the extent to which stop smoking support is (or is not) delivered within specialist mental health settings in England. Although all NHS mental health trusts in England have now implemented smoke-free policies, most of which are likely to include a statement on the importance of addressing smoking and providing appropriate support or referrals to NHS SSS, in the absence of minimum standards, reporting requirements or monitoring in this area makes it difficult to evaluate the effectiveness of these policies. Overall, there is evidence that resources allocated to enforcing smoke-free policies, including those that would ensure the provision of adequate behavioural and pharmacological support (such as staff training and provision of NRT), are often lacking and that complex barriers to the implementation of effective tobacco dependence treatment in mental healthcare settings exist. 21,22,91 Perhaps most fundamentally, studies have highlighted how the ‘culture’ within mental healthcare settings tends to facilitate smoking 19 (see Chapter 6, section 6.2 for details). A possible vehicle for implementation of more systematic delivery of stop smoking support in mental health settings is the Commissioning for Quality and Innovation (CQUIN) payment framework, 83 which was introduced in 2009 as a national framework for locally agreed priorities; it was intended for use by commissioners to reward excellence by linking a proportion of providers’ income to the achievement of local quality improvement goals. The focus of the framework on innovation and directly measurable indicators that are aligned with national priorities would seem to suggest stop smoking support programmes within mental health settings as an ideal application for CQUIN schemes. However, as the schemes are negotiated locally, there is no currently agreed standard for this. 5.5.3 Child and adolescent mental health services As most smoking starts before adulthood, prevention of uptake among adolescent non-smokers and intervention to promote cessation in young people who smoke are especially important. A recent meta-analysis has demonstrated that smoking prevalence among young people at the time of presentation for treatment of first-episode psychosis is around 60%, and six times higher than in age- and gender-matched controls, 92 demonstrating that more attention needs to be paid to the reasons for starting tobacco use before diagnosis, as well as 98 © Royal College of Physicians 2013
Smoking cessation interventions for individuals with mental disorders 5 exploring better ways to help smokers quit. However, there is no evidence available on provision and/or effect of tobacco dependence treatment in child and adolescent mental health service (CAMHS) settings in the UK. The lack of research in this area is counterintuitive to its obvious importance and clearly highlights the need for future initiatives. 5.5.4 NHS stop smoking services In 1998 in the UK, the White Paper Smoking Kills announced new government funding to set up what have become known as NHS SSS. 93 Originally focused in areas of socioeconomic deprivation, the aim was to apply cessation services as a mechanism to reduce health inequality. Within a few years, however, almost every primary care trust area had established a dedicated NHS SSS, and in 2009–10 the services helped over three-quarters of a million smokers to make a quit attempt. 94 NHS SSS treatment usually comprises several weekly behavioural support sessions supplemented by NRT, or varenicline or bupropion pharmacotherapy (see section 5.1). The behavioural support is led by a trained stop smoking practitioner and delivered either individually or in a group-based format. Increasingly, a range of health professionals collaborates with the specialist SSS in the delivery of support (including those in both primary and secondary care). 94 As outlined in section 5.1, there is no reason why the treatment programmes delivered by NHS SSS should not be appropriate for most people living with a mental disorder, particularly if adapted to meet the special demands and high levels of dependence prevalent in this group. However, a recent survey suggests that only a minority of NHS SSS routinely assess the mental health status or mental health service use of their clients, and that most services do not routinely implement special checks or actions even if mental health problems are revealed. 95 As SSS audit work has shown that at least one in nine clients of NHS SSS has a current and diagnosed mental health condition, 96 the need for widespread adoption of appropriate protocols within these services is evident. Towards this aim, the most recent national guidance aimed at NHS SSS 97 includes full guidance on treating people with mental disorders. Furthermore, the National Centre for Smoking Cessation and Treatment has recently developed a specialist module to train smoking cessation advisers on the specific links between smoking and mental illness. NHS SSS have been shown to be highly cost-effective, the average cost per life gained being as low as £684. 98 However, it has been argued that the system within which such services operate may prevent them from fulfilling their full potential to reduce health inequalities, 99 in particular because services have traditionally been driven by large quantitative ‘4-week’ quit targets. The demands of these targets have to date tended to inhibit provision of services for people, including those with mental health problems, who are disadvantaged and may © Royal College of Physicians 2013 99
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Contents Members of the Tobacco Adv
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Contents 4.4.3 Attention deficit hy
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Contents 6.4.3 Staff knowledge 122
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Contents 10.5 Tobacco policy and me
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Contributors Anthony Aclet - Specia
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Contributors Jill Williams - Associ
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1 Mental disorders 1.1 What is a me
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Mental disorders 1 1.3 Common menta
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Mental disorders 1 1.4.4 Somatisati
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Mental disorders 1 In addition to s
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Mental disorders 1 not diagnosed un
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Mental disorders 1 Similar to many
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Mental disorders 1 12 Chang CK, Hay
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Mental disorders 1 52 Young S, Toon
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Smoking among people with mental di
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The economic cost of smoking in peo
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Ethical and legal aspects 9 pose co
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Ethical and legal aspects 9 less an
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Ethical and legal aspects 9 patient
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10 Summary and conclusions 10.1 Smo
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Summary and conclusions 10 10.4 Smo
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Summary and conclusions 10 although
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11 Key conclusions and recommendati
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Key conclusions and recommendations
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