Smoking and Mental Health: What is best practice?

1. Smoking and Mental Health: What is best practice? Dr Rosanne Palmer ASH Wales Towards a Tobacco Free Wales Tuag at GymruDdiDybaco

2. “This persistent high prevalence of smoking reflects a major failure of public health and clinical services to address the needs of a highly disadvantaged sector of society.” Royal College of Physicians, Royal College of Psychiatrists. Smoking and mental health. London: RCP, 2013: p201 Towards a Tobacco Free Wales Tuag at GymruDdiDybaco

3. Why is this important? Smoking around twice as common among people with mental disorders – higher rates amongst those with more severe disease However, smoking prevalence has changed little over the past 20 years Yet smokers with mental disorders just as likely to want to quit Though more likely to be heavily addicted and expect it to be hard to quit Most people with mental disorders cared for in the community Towards a Tobacco Free Wales Tuag at GymruDdiDybaco

4. Cessation Interventions (1) Combining behavioural support with cessation pharmacotherapy likely to be effective in people with mental disorders NRT may require high doses, for longer, with more behavioural support Bupropion and varenicline both effective (with caveats), but require appropriate supervision and monitoring – to date, reluctance to use Be aware of confusing symptoms of nicotine withdrawal with those of underlying mental disorder Towards a Tobacco Free Wales Tuag at GymruDdiDybaco

5. Cessation Interventions (2) Cessation affects metabolism of some drugs used to treat mental disorder Should encourage harm reduction where unwilling/feel unable to make quit attempt Smoking status should be recorded by all services and provide effective cessation/harm reduction interventions “as a central, systematic” component of care delivery Towards a Tobacco Free Wales Tuag at GymruDdiDybaco

6. Cessation Interventions (3) Need for coordination across primary and secondary care settings Population-level policies appears to be less effective So need to capitalise on opportunities presented by contact with services Special circumstances: need to embed smokefree policies and cultures in institutions providing care – and, unlike in England, our MH inpatient facilities are exempt from smokefree premises legislation Towards a Tobacco Free Wales Tuag at GymruDdiDybaco

7. Core recommendation “Smokers with mental disorders using primacy and secondary care services, at all levels, should be identified and provided routinely and immediately with specialist smoking cessation behavioural support, and pharmacotherapy to relieve nicotine withdrawal, promote cessation and reduce harm.” Royal College of Physicians, Royal College of Psychiatrists. Smoking and mental health. London: RCP, 2013: p201 Towards a Tobacco Free Wales Tuag at GymruDdiDybaco

8. Obstacles Acceptance of smoking – overcoming a smoking culture Smoking as self-medication Smoking as an area of personal control Lack of priority Lack of training/awareness among staff Concern over impact of quitting/an unsuccessful quit attempt Towards a Tobacco Free Wales Tuag at GymruDdiDybaco

9. Discussion Points How can the obstacles raised on the previous slide be overcome? Are there any other difficulties you can foresee with implementing these recommendations? Do we need to close the exemption in the smokefree premises legislation? What are the next steps for Wales? Do we need to change our policy? Do we need more training? Where do we go from here? Towards a Tobacco Free Wales Tuag at GymruDdiDybaco

10. Useful Links http://www.ncsct.co.uk/usr/pub/Smoking%20and%20mental%20health.pdf http://www.londondevelopmentcentre.org/cms/site/docs/Stop%20Smoking%20Cessation/Microsoft%20PowerPoint%20-%20Dr%20Lisa%20McNally.pdf Towards a Tobacco Free Wales Tuag at GymruDdiDybaco