Smoking and mental health - NCSCT

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Smoking and mental health harm reduction in the context of smoking cessation interventions, as will be promoted in forthcoming National Institute for Health and Clinical Excellence (NICE) guidance, 63 but harm reduction also offers potential at the population level by making alternative sources of nicotine, of which electronic cigarettes are an example, available to smokers as a retail alternative to tobacco for use independent of smoking cessation, medical services or any commitment to quit smoking. The UK Medicines and Healthcare products Regulatory Agency (MHRA) is currently considering regulatory approaches to enable harm reduction while ensuring that alternative nicotine products are safe, and is expected to announce its new policy in the spring 2013. 6.3 Population strategies and smoking prevention in mental health Although it is likely that all of the above strategies influence smoking behaviour in mental health populations, evidence on the impact of tobacco control interventions is generally based on population-based surveys, which are able to explore attitudes, knowledge and behaviours in a range of sociodemographic groups but do not typically identify people with mental disorders. Direct evidence on the effects of population strategies in people with mental disorders is therefore scarce, although the fact that smoking prevalence has changed so little over recent decades in people with mental disorders (see Chapter 2) indicates a relative lack of effect. Finding and developing more effective ways to measure and monitor the impact of tobacco control interventions in populations with mental disorders are therefore an important priority. The measure for which the most evidence exists is the introduction of smoke-free policies in mental health treatment settings. 6.3.1 Smoke-free policies in mental health treatment settings As outlined in section 6.2.1, smoking is now prohibited, with few and specific exemptions, in all enclosed and substantially enclosed work and public places in the UK. In advance of the introduction of the 2007 smoke-free legislation, a 2004 government White Paper, Choosing Health, strongly encouraged all NHS trusts to implement smoke-free policies by the end of 2006, thus setting an example for health promotion. Guidance was provided for the implementation of comprehensive policies which, as a ‘gold standard’, should include buildings and grounds. 64,65 However, during the development of the smoke-free legislation, a debate arose as to whether mental health trusts should be exempt from the law, 66–68 on the grounds of the high prevalence and levels of nicotine dependence among psychiatric patients, the complexities involved in the relationship between smoking and mental illness, and perceived practical difficulties anticipated in 116 © Royal College of Physicians 2013
Population strategies to prevent smoking in mental disorders 6 enforcing smoke-free treatment environments. It was also argued that imposing smoking bans on long-stay patients living on mental health trust premises, and those detained under the Mental Health Act, infringed human rights and rights of privacy. On the other hand, proponents of smoke-free policy argued that to exempt mental health settings from the law would worsen and, moreover, institutionalise existing health inequalities. The outcome of the debate in England was not to grant exemptions for mental health settings but to allow an additional year, to July 2008, in which to prepare to comply with the legislation. 69 Northern Ireland adopted the same approach, but, in Scotland and Wales, mental health settings were exempted from smokefree legislation. A survey of all 72 English NHS mental health trusts in 2007 revealed that by that time all respondents (79%) had in fact implemented indoor smoke-free policies, although with variation as to the extent of inclusion of outdoor areas. 70 Almost all respondents reported perceived challenges specific to implementation of smoke-free legislation in mental health trusts, particularly in relation to safety risks (such as fires caused by covert smoking) and policy enforcement. 70 However, a review of 26 international studies found that concerns raised before implementation, eg smoke-free policy might lead to an increase in aggression or number of seclusions, discharge against medical advice or use of as-needed medication, generally proved unfounded when the policy was introduced. 71 Another review, of 22 international studies, concluded that smoke-free policies had no longstanding untoward effect on patients in terms of behavioural indicators of unrest or compliance, 72 although there are reports of complications arising from abrupt forced abstinence among highly nicotinedependent patients 73 (see Chapter 5). It is now recognised that smoke-free policies in mental health settings, although in theory an opportunity to promote cessation at the point of hospitalisation, have to be complemented by comprehensive cessation or abstinence support for smokers if they are to be successful. 71,72 There is also evidence that complete and rigorously enforced smoke-free policies in psychiatric settings are easier to implement, and more effective, than approaches that are incomplete and leave room for interpretation, 71,74 eg facilitation of smoking breaks for patients, which require staff to escort smokers off and back on to the ward, are disruptive and can lead to an untoward fixation on regularly facilitated smoking breaks, which then come to take priority over other therapeutic activities. 75 There is also evidence that, after admission to treatment environments in which partial smoke-free policies are implemented, patients who smoke may alter their smoking behaviour. 76 A study of 135 inpatients in England found that 14% increased their consumption of cigarettes, 23% decreased consumption and two patients relapsed to smoking during admission. Boredom and stress, and using smoking as a means to socialise, were the main reasons given for increased smoking. 76 Similar results have been reported in other studies, showing that people who are © Royal College of Physicians 2013 117
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PDF not for circulation Smoking and
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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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Ethical and legal aspects 9 pose co
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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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Smoking and mental health - NCSCT

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