Simon Gilbody Professor of Psychological Medicine & Health Services Research University of York

1. Enabling people with severe mental ill health (SMI) to quit smoking: insights from the SCIMITAR trial Simon Gilbody Professor of Psychological Medicine & Health Services Research University of York June 2015 On behalf of the SCIMITAR collaborative

2. Today's talk • Smoking and severe mental ill health – poor health, poverty and early death • Cultural & social determinants of smoking in SMI • What works? – systematic reviews • The SCIMITAR pilot trial – first look at the results • Making mental health services more conducive to quitting rather than smoking

3. Today's talk • Smoking and severe mental ill health – poor health, poverty and early death • Cultural & social determinants of smoking in SMI • What works? – systematic reviews • The SCIMITAR pilot trial – first look at the results • Making mental health services more conducive to quitting rather than smoking • @SimonGilbody

4. What proportion of people with severe mental ill health smoke?

5. What proportion of people with SMI smoke?

6. Cultural influences • People with SMI ‘enter the service as non-smokers and come out … as smokers because of the culture’(House of Commons Health Select Committee 2005)

7. The smoking culture in mental health services • Elevated smoking rates amongst MH staff • Staff accept smoking as routine and offer cigarettes • Staff smoke with users of services; ‘fresh air breaks’ • Means of pacifying distressed people in inpatient settings • Lack of stimulation and relief of boredom in inpatient units • Access to cigs is a source of conflict and control between staff and users (between users of services) • The ‘cigarette economy of institutions’ • Non-smokers initiated in smoking upon admission Lawn 2004; Hempel et al 2000

8. Consequences of smoking for those with SMI • Poor physical health • Early death 20 – 25 years • Tobacco poverty • Increasing health inequalities • Stigma

9. Smoking and mortality in SMI • Tobacco related conditions comprise 53% of deaths of people with schizophrenia • 48% of people with bipolar

10. Smoking is the single most important modifiable risk factor in SMI

11. Some common myths which maintain high levels of smoking mythbusting

12. Myth #1 Smoking relieves stress, and people with SMI have more reason to be stressed

13. Myth #2 ‘its their last pleasure, its not ethical to encourage people to quit’

14. Myth #3 Smoking relieves the side effects of medication

15. Myth #4 Quitting smoking will cause relapse, deterioration in mental health, admission to hospital…….it is never a good time to quit

16. Myth #5 People who use mental health services just aren’t interested in quitting No point asking, since nothing works Therapeutic nihilism

17. Are people with SMI interested in cutting down or quitting?

18. Do people with SMI want to quit?

19. What works for people with SMI?

21. Biochemically verified quit rates at 6 months

22. Quitting rates at 6 months The same things work in SMI as for everyone else

23. Problem People with SMI want to quit, but don’t access conventional NHS Smoking Cessation Services

24. Problem People with SMI want to quit, but are not encouraged to do so by people working in mental health services

25. Developing a user-centred model of care for people with SMI who smoke Active area of research and development interest of York Mental Health and Addictions Research Group (MHARG)

26. SCIMITAR Smoking Cessation in Mental Ill health Trial

28. Bespoke Smoking Cessation – the SCIMITAR model CPN with L2 smoking cessation training GP or Practice Nurse Behavioural support Mental Health Team

29. Different from NHS STP in the following ways • Delivered by a mental health professional • NRT was the mainstay of treatment • Nicotine pre-loading & ‘cut down to quit’ • Failed quit attempts allowed • More intensive and 1:1 • Special attention to psychotropic medication management • Planning for quit attempt. What to do in place of smoking

31. SCIMITAR pilot trial Funded by NIHR HTA 2010-2014 Now complete Results now in the public domain – Lancet paper and HTA report Fully powered trial planned 2015 Collaborators? See me

32. Purpose of the pilot….. • Develop and test the intervention • Learn about recruitment, randomisation and retention • Established the parameters for the full trial • Preliminary estimates of effect

33. Who took part? • 98 People with SMI • Long history of smoking – 27 years • Heavy smokers – 25/day (range 5-60) • Overweight BMI - 29

34. Important outcomes • Exhaled Carbon Monoxide @ 12 months • Mental state • Nicotine dependence/motivation to quit • Utilisation of smoking cessation products & services

35. CO-verified quit at 12 months • 23% control group • 36% intervention group • adjusted odds of quitting 2·9, 95% CI 0·8 to 10·5

37. Opening the black box Understanding more about smoking, mental health services and what works for people with SMI

38. What did they receive? • 80% uptake of the intervention • 1:1 and telephone support lasting four hours • Cost £221 (£174 - £269) • Pharmacotherapy £106 (£65 - £147) • Mostly NRT

39. Depth interviews with participants • Prior experience of smoking cessation • Acceptability of the intervention and satisfaction with the bespoke smoking cessation service • Patients’ engagement with the intervention • Implementation in routine care

40. Theme 1 Generic stop smoking services didn’t currently meet the needs of people with SMI lack of support from NHS health professionals for smoking cessation for patients with SMI.

41. Experience of standard NHS SSS “one of my patients [with bipolar illness] been to normal standard NHS services, and he’d been to a group, and … she’d given them all a prescription request sheet for Champix,. And he went to see his GP and his GP said, ‘I’m not giving you Champix, you’ve got bi-polar. ’ So he came back next week, and he was the only one in the room that hadn’t been given the’’MHSCP 1

42. ‘the last thing you want to think about is giving up’ “I’ve actually had a doctor [psychiatrist] ……and I talked about giving up, he said, oh no, you don’t want to be giving up at the moment. So it was kind of like a medical permission to carry on smoking… He said ‘The last thing you want to think about is giving up’ Y1085

43. Theme 2 The benefits of a smoking advisor with a background in mental health The benefits of a bespoke intervention for patients with SMI.

44. Someone who understands mental health issues • ‘“You work flexibly, they get someone that’s got some understanding of their mental health issues, someone who can work with, you know, have the time to work with the other network of people that are involved with them as well” MHSCP 3

45. ‘she understood the mental health side’ • ‘It wasn’t just a stop smoking clinic for Tom, Dick and Harry, she understood the mental health side, which is obviously a big concern… Because I wouldn’t go to a normal - because I’m frightened…Well [the MHSCP] knows what I’ve got. Whereas if you go to a normal stop smoking thing and they know you’ve got mental health problems then it’s stigma isn’t it?’

46. Theme 3 Reported challenges and barriers

47. Not something all CPNs can do • ‘“You could put this work into the mainstream, you know, into CPNs [Community Psychiatric Nurses] work, but I don’t know that everybody would do it, that’s the thing….you need to be quite focused….you need to give it time and attention” MHSCP 3

48. Difficulties accessing the meds • ‘If the GP wouldn’t prescribe... then you’re chasing it up and then when the client goes it’s not there and they get annoyed that they’ve wasted a visit to the doctors. Some GP surgeries refused to do it on my recommendation and had to see the client. So then the client had to make an appointment with the GP which just didn’t happen’

49. Chaotic lifestyle & going the extra mile • ‘“She would lose the prescription, the house was, you know, quite chaotic, she’d lose her NRT, then she’d think she’d run out of them and she’d get muddled with them, so I had to do quite a bit of work around that really, I mean, if I went in her house now, I know exactly where she keeps everything and where she loses everything! I don’t know if that was my role, but it helps!” MHSCP 3

50. Purpose of the pilot….. • Road test the intervention • Learn about recruitment, randomisation and retention • Established the parameters for the full trial • Preliminary estimates of effect 