Russ Moody MBA (Social Marketing & Behaviour Change) Health & Wellbeing Programme Lead

1. Does Social Marketing Benefit the Implementation of Smoke-free Policy in a Mental Health Setting?A Qualitative Case Study Russ Moody MBA (Social Marketing & Behaviour Change) Health & Wellbeing Programme Lead PHE South West

2. Introduction • A qualitative case study of Langdon Hospital in Dawlish • Using a ‘Social Marketing lens’ • Provides consideration for improvement of policy, guidance and practice • This is about how to improve the implementation of ‘policy’ in an ‘organisation’ Policy & Guidance An Effective, Comprehensive Smoke-free Policy Added Extra

4. Recommendations NICE guidance recommends that secondary care settings, including mental health trusts, should “…develop a policy for smoke-free grounds in collaboration with staff and people who use secondary care services, or their representatives.” (NICE, 2013, p. 16). PHE guidance recommends that “All medium and low secure units should progress towards providing care in completely smoke-free buildings and grounds.” (PHE, 2015b, p. 5). “Mental health inpatient services should be smoke free by 2018” (The Mental Health Taskforce, 2016, p. 14) We now have the NHS CQUIN on alcohol and tobacco (NHS Operational Planning and Contracting Guidance 2017-2019)

5. Aim of the study • Does the utilisation of social marketing approaches enhance the implementation of smoke-free policy in local mental health settings? • Objectives • Examine, the experience of a MHS implementing SFP • Is SM being used to manage barriers and facilitators? • Does it help? • Could findings inform policy implementation considerations?

6. Key Questions Research Question 1 Is there evidence of SM practice being used to manage barriers and facilitators to implementing smoke-free policy? Research Question 2 Does the application of SM principles benefit the adoption and outcomes of SFP in MHS?

7. Literature Review • A number of common themes emerge across the literature • Identified barriers included: • Smoking staff less likely to support SFP • Smoking patients are less likely to support SFP • Lack of staff consultation • Poor commitment from management • Perceived lack of ability to enforce SFP by MHS staff • Poor guidance and training for staff • A belief by staff that SFP will have adverse effects on patients • A belief by staff that SFP will lead to abusive patients • A belief by staff that SFP may damage carer/patient relationships • While facilitating factors included: • Established smokefree norms previous to SFP implementation • Strong leadership • Clear planning processes • Provision of good smoking cessation support

8. Literature Review • Other themes: • Resistance to SFP in MHS by staff and patients • Negative outlook on SFP leads to poor adherence • Arguments about ‘Rights’ and exemption for MHS • Exemptions frequently granted and breaches common place • SFP does have a positive effect on smoking prevalence • Fears are not realised, SFP ultimately garners support from staff and patients and that it is possible to do without serious negative consequences • “…the adverse effects associated with smoke-free policy in mental health settings can be ascribed to the way in which the policy has been implemented, rather than the policy itself.” • Lawn, S., & Campion, J. (2013). Achieving smoke-free mental health services: Lessons from the past decade of implementation research. International Journal of Environmental Research and Public Health, 10(9), 4224-4244. • BTW – searched for SM and SFP in MHS specifically = nil

9. Andreasen’s (2002) SM Benchmarks

10. Langdon Hospital The hospital is a 111 acre site and provides forensic mental health services for men with mental health needs who have had contact with the legal system. The service offers medium secure, low secure or open accommodation across five inpatient units. Inpatient Units in the observed hospital

11. Results A number of key themes emerged from the data summarised in the following tables which also endeavour to rate the level (very limited/limited/some/strong/very strong) of SM practice discovered against each benchmark. Themes highlighted in red were adjudged to be inconsistent in supporting the relevant benchmark.

12. Behaviour Change

13. Behaviour Change • Policy goal was crystal clear • Originally whole site to go smoke-free at once • ‘Smoke-free’ core group set up • Some ‘false starts’ but becoming smoke-free became more concrete as agenda gained momentum • SFP became the accepted norm

14. “…we wanted to take the whole site smoke-free at the same time…” (P1) “…the patients were moved from the old building into this new building and that was the cut-off date, you can’t smoke in this building…” (P5) “We had a couple of false starts almost with going smoke-free where we set, set the date a couple of times and we just thought actually no, we’re just not ready so we’d put it off. It did get to a point when we just said, ‘we’ve just got to do this’, set a date and then there was a real push.” (P7) “…this is just part of what normal is gonna look like here so we adapted the policies that we had to reflect the fact that we were smoke-free.” (P1)

15. Audience Research

16. Audience Research Participants were unanimous in emphasising the importance of having ‘open conversations’ to address the anxieties of patients and staff. These occurred in a variety of contexts and forums but essential to comprehending consumer characteristics, needs, feelings, thoughts and understanding was the network of interconnected meeting forums with dynamic meeting frequency Participants gave extensive accounts of activities related to facilitating ‘open discussion’ and repeatedly emphasised patient/staff participation and creating informal spaces to ask questions, voice concerns and collaboratively design solutions. Many of the participants stated that this was a fundamental practice for realising success.

17. “So we started talking to everybody about going smoke-free probably about a year before we actually started going smoke-free , so we talked about it in all our team meetings, we talked about it in supervision with the staff, we talked about it in patient forums, one of our patients came to the smoke-free meetings with me which was fantastic. So it was out there, there was no confusion about it, it was out there and because it was out there, all the questions and concerns and worries that people had were sort of dealt with before we actually started the process of going smoke-free.” (P7) “I did quite a few follow-up visits just walking around, actually, specifically talking about smoke-free and how it’s gone.” (P1)

18. “…they feel in control, they feel like they’ve got a choice and they feel they are being listened to, and they get invited to the governance board meeting once a month to say their piece as well.” (P5) “The patients were really involved in ‘how are we going to do this, how are we going to make this ward smoke-free, what we going to do, what are the boundaries around it’, so we had success there.” (P1)

19. This approach had the additional benefit of presenting multiple perspectives thus breaking down barriers and assumptions without the need for executive intercessions. “…interestingly we actually had people on our, from our service users who actually said ‘why shouldn’t we go towards smoking cessation?’ which was actually really positive, because actually it informed staff as well…” (P6) Evidence did emerge suggesting that not all the forums were successful with low attendance in some instances. Also some participants recounted a ‘top down’ approach early on in the history of the core group. There is also limited evidence of coordinated activities to formally test aspects of the SFP with relevant audiences.

20. Segmentation

21. “We didn’t group [patients/staff] up or define them but when we, particularly, looking at our patients it was a very individualised approach…” (P7) “…we identified who were the relevant stakeholders, so of course the smoking cessation team, there’s obviously of course the staff but I think most importantly there’re the patients…” (P6)

22. Exchange

23. Exchange All participants provided multiple, specific examples of coordinated activities and events designed to motivate people to engage with the SFP as well as offer something beneficial in return for removing smoking. “…it’s no good forcing somebody to do something if you’ve got nothing to replace it with…” (P5)

24. Activities “My role was to ensure that patients had structured physical activity on offer from the day one of implementation. So to try and help distract from, the side effects of not smoking and to keep them busy.” (P2) “We all sort of worked together and went through the day so from 8 o’clock, 9 o’clock, 10 o’clock we tried to make sure something was on offer for patients throughout the whole day…to have a structured programme.” (P3)

25. Exchange Examples of planned activities and events offered in anticipation of SFP implementation

26. Intangible Factors/Environment “…with the patients we did a lot of education around it and what the benefits of it will be, both in terms of physical health, mental health, finances…” (P7) “…they recognise quite quickly that they can run further and play football better and we monitor their physical, we are quite physical health orientated here so we will, you know, remind them when we see them running around better ‘oh actually don’t you feel a lot better now that is probably related to you not smoking’…” (P2)

27. NRT (systematic and fully funded) “…the pharmacy met all the patients to actually discuss with them all the benefits of what they can offer to help and said that they could have NRT…” (P2)

28. Promotion of Clozapine Reduction “…we’re gonna support you, we’re here for you and the benefits, if you give up smoking your clozapine levels will come down so you don’t have to take as many pills…” (P5) “We’ve seen a massive reduction in our, some of our drugs because, clozapine in particular… our use of it has halved since we went smoke-free… it’s got a real positive psychological impact that they’re not taking as much as they would have been…” (P1)

29. E-Cigarettes “…[patients] had an option to question and be involved and we wanted to work with them and that’s why we introduced e-cigarettes because a few of the patients on one of the wards said ‘why can’t we use e-cigarettes?’ And we thought, we didn’t think we could use them but we’ll look into it and when we looked into it, we thought ‘well yes actually we can meet them half way and probably manage this on some of the wards’, and that’s what we did.” (P2)

30. E-Cigarettes • “…but one of the things they did ask us to do was consider e-cigarettes. At the time we had a complete ban on them, and we said ‘no not going to go down the e-cigarettes, we don’t know enough about them,… we went away and said ‘yeah, okay we’ll go and have a look at it’… and we decided actually we could safely introduce them… that actually took a lot of the anger out of those guys when we had those.” • (P1)

31. Decision Making Power “We would talk about which smoking break would be good for you, would help you, for us to take out? So the patients led it, which I’m so proud of, I think was brilliant, but the patients led that, the patients decided which smoking breaks we were going to take out…” (P7)

32. Marketing Mix promotion/product/price/place [policy/people]

33. Marketing Mix • Promotion Lots! (count down clock) • Product Addressing needs of patients and staff • Price Addressed in exchange & competition • Place Environmental Factors • Policy Very good policy alignment • People Comprehensive Training • Possibly we focus too much on ‘promotion’?

34. Promotion “…certainly communication between when we started to meet and when, you know, when they went smoke-free, for me anyway, was one of the crucial aspects of it actually working well, the unit goes smoke free in nine months’ time needed to be communicated clearly to staff and to patients. So they were discussing sort of how that would be done, would it be done via sort of remote, you know, communication, emails, letters, etc. Or could they deliver some sort of face to face via team meeting, I suppose they just wanted to keep people informed of, the kind of rate of change and of why this change was happening, and again they were very good at that.” (P3)

35. Competition

36. Competition • Each participant provided several accounts of substantial activities that endeavoured to address factors that could be working in competition or opposition to the desired outcome of a comprehensive SFP (Staff/Patients/Carers/Family/Visitors) • Fears • Anxieties • Resistance • “…the impression was that the staff were probably more anxious than the service users, so for me it was really important to hear before we did that training ‘what are your fears, what are your concerns’, so a lot of the advice and help I’d given along the way has been trying to alleviate the staff’s fears around what it’s going to be like for them working with service users…” • (P4)

37. Competition • E-cigarette introduction • Moderation access to Tobacco • Phased approach to implementation • Prioritising the MSU (new unit, secure, easier, lead by example) • Environmental Factors (smoke-free in design) • Nicotine Withdrawal • Preparation for a legal challenge

38. “So in anticipation of a potential legal challenge we ensure the fact that actually the minutes of our meeting were very clear and addressing the very kind of issues that had already been brought up historically, and those that we thought that could be brought up potentially in the future,… we’ll inform the trust solicitors that this is what we are doing, we’ve got the trust’s backing.” (P6)

39. Evaluation • Participants were able to describe a raft of evaluation measures and internally validate the success of the SFP for this MHS • Recorded health measures (HR/BP/Peak Flow/Lung capacity) • Medication prescriptions and costs (e.g. Clozapine) • Meeting minutes • Structured reporting of smoking/tobacco related incidents • Structured reporting of violence/aggression related incidents • Anecdotal reports and behavioural observations of staff and patients • Recorded training attendance

40. “So we’ve got on our trust incident reporting system, there’s a flag for ‘is this a smoke-free incident or smoking incident’. So I then get copies of those so we can monitor it quite clearly and we’ve not had many. Yeah, so we had more smoking incidents before we went smoke-free… there is nobody smoking, there is no option to smoke so it’s kind of a, it’s a zero, always. (P1)

41. Other Factors • Several of the participants offered additional factors that they saw as being relevant and important in the adoption and development of a SFP in a MHS. Such factors were problematic in aligning with Andreasen’s (2002) SM benchmarks. They included: • Having the right ‘type’ of leaders/managers coordinate the programme • Senior level buy-in and commitment • External factors were driving the change (not internal management) • NHS Trust taking ‘ownership’ of SFP agenda and commitment to it • The intrinsic motivation of the organisation • Enforced policy not a voluntary behaviour change

42. Discussion Research Question 1 Is there evidence of SM practice being used to manage barriers and facilitators to implementing smoke-free policy? There is evidence of what can be considered SM activity

43. Discussion Research Question 2 Does the application of SM principles benefit the adoption and outcomes of SFP in MHS? This study proposes that the application of SM did benefit the adoption and outcomes of the implemented Smoke-free policy SM is observed particularly in elements relating to ‘Audience Research’, ‘Exchange’ and ‘Competition’.

44. Discussion This case study was able to demonstrate successful SFPimplementation with high compliance The hospital experienced all of the expected and typical barriers highlighted in the literature Practice was aligned with guidance recommendations and was able to overcome these barriers This study suggests that management went further than recognised initiatives when examined via a SM lens

45. Discussion Andreasen’s SM benchmarks is an effective way of identifying SM practice and could be a useful tool for SFP implementation plans Participants did not label the beneficial activity as SM Behavioural objective – ‘SF site’ or ‘policy compliance’? PHE (2016, p. 22) states “The terms of the consultation should make it clear that it is not the outcome (becoming smoke-free) that is under consultation, rather it is the ‘how to get there’ for which opinion is being sought.”

46. Discussion There were several other factors that participants felt strongly augmented the SFP that do not fall within the scope of Andreasen’s benchmarks. This study is not suggesting that SM is a panacea for SFP in MHS but there is evidence that validates SM as being of benefit and where things did not go so well the principles were not applied

47. Limitations • Generalisability (one case but likely to be seen in others) • Cross-sectional as such cannot demonstrate causation • Limited sample size (validity and confidence) • Reporting Bias • SM was declared as research foci • Interviewer was recognised to be from PHE • Judgements made on themes and validation of SM benefit

48. Conclusions • SM did occur (not labelled as such) in this case • A SM approach appeared to be of benefit in this case • Andreasen’s benchmarks is a useful framework • National Guidance aligned with ‘Marketing Mix’ • ‘Audience research’ should go beyond standard health sector consultation using more sophisticated formative research methods that SM has to offer • This case study’s success could be because they went beyond the established modus operandi and guidance • In particular ‘Exchange’ and ‘Competition’ activities • ‘Segmentation’ was not used to effect • SM is not a panacea for SFP implementation in MHSs

49. Recommendations • This study raises some interesting and pragmatic recommendations for managers and professionals who are tasked with implementing SFP in a MHS to consider beyond established guidance: • 1. Utilise a SM approach when designing plans to implement SFP in a MHS • 2. Use Andreasen’s (2002) SM benchmarks as a framework to develop SFP • 3. Define clear behavioural objectives in terms of policy compliance

50. 4. Conduct formative research with stakeholders and pre-test elements of the SFP. • 5. Exploit conventional SM segmentation techniques to identify priority stakeholders and tailor policy compliance interventions to meet their needs • 6. Invest in programmes to offer service users and staff something beneficial in exchange for a complete ban on smoking • 7. Apply a balanced marketing mix that goes beyond promotion and training • 8. Anticipate factors that may act in opposition to effective SFP adoption and compliance and design contingency actions to address them