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Why is research on Smoking and Mental Health Populations Important?. A much neglected addictionThe most insidious cause of physical health problems
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1. 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
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Tobacco Control and Mental Health Populations: Controversies for Research and Practice, South Australian Mental Health Research Day, 2008
Dr Sharon Lawn
Email: sharon.lawn@flinders.edu.au
2. 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
3. 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, > 42% of all cigarettes consumed.
4. 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
5. 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
OH&S 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
So where does this all leave us?
Hospitals as a smoke-free environments - not enforced
So where does this all leave us?
Hospitals as a smoke-free environments - not enforced
6. A Problem of Need (Mark - Schizophrenia)
The first time when I had no money and I couldn’t get credit at the deli, I used to go around the streets looking for butts...looking for butts...I don’t know where or who they came from but I’d unroll them and join them all up again into one. (pause) It was just a smoke wasn’t it? I’ve been that bad. When you can’t have a smoke you just go around knocking on people’s door asking for smokes and some I didn’t even know the people, and they’d 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
7. 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.
8. 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
9. 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
OH&S issues
Many MH Nurses smoke
doctors & others less
10. 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 40 cigarettes per day smoker (BJP paper)
Accessing black market tobacco40 cigarettes per day smoker (BJP paper)
Accessing black market tobacco
11. Why is this not addressed at this time? Smoking - a tool in a much larger set of interactions and relationships
12. Smoking & Mental Illness Myths “They choose to smoke”
They can’t 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?
13. 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.
14. So What can be Done?
15. 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 > 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
16. 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 isn’t a complete lapse (AVE)
Do we just give in when it gets too hard & what message does this give consumers, staff & the community?
17. 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 Let’s be honest with ourselvesLet’s be honest with ourselves
18. 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?
19. 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
20. 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 don’t 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
21. 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
22. 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
23. Outcomes Haven’t met one individual who didn’t value the achievement after quitting
Haven’t 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.
24. 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?
25. 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 When you are researching an area with such an undercurrent of unspoken rules and behaviours, it is certainly interesting.
However, it demands the researcher to be highly conscious of their role and their impact. There is no such thing as an objective researcher under such circumstances.
Taking the lid off the can of worms creates a number of challenges that must be managed.When you are researching an area with such an undercurrent of unspoken rules and behaviours, it is certainly interesting.
However, it demands the researcher to be highly conscious of their role and their impact. There is no such thing as an objective researcher under such circumstances.
Taking the lid off the can of worms creates a number of challenges that must be managed.
26. 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. Ie. how the system coped.
Ie. how the system coped.
27. 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. 15:3, 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.
28. 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, 11:2, 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 78:85.
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.