An evaluation of the impact of total smoking cessation in a high secure forensic unit in Scotland

www.forensicnetwork.scot.nhs.uk

SoFMHSchool of Forensic Mental Health

An evaluation of the impact of total smoking cessation in a high secure forensic unit in Scotland

Dr Briju PrasadSpecialty Doctor - Forensic Psychiatry

UK National Smoking Cessation ConferenceVictoria Park Plaza Hotel, London

28th June 2013



Content of this presentation

• Introduction• Background to smoking and mental health• Aims of this study• Methodology• Results• Limitations and conclusions• Discussion



Introduction

• Smoking banned in public places in Scotland since 2006

• Residential mental health units exempt from the ban

• More research in smoking and mental health

• March 2010 Scottish Government guidance –

• Mental health service providers to move towards banning smoking altogether.

• Some mental health units have become smoke free



What we know about smokingand mental health…

• Smoking rates - significantly higher

• Highest levels (60-70%) of smoking is among psychiatric inpatients (20-22 % in general population)

• Mental health staff are less positive about smoking cessation in mental health patients

• Life expectancy - 20% less than general population

• Increased rates of cardiac and respiratory diseases (10 times > general population.

• More heavily addicted (>25 cigarettes per day)



What we know…

• Increased levels of nicotine dependency

• Quit rates are lower

• Up to 1/3rd of their state benefits is spent on cigarettes

• Strong association between mental illness and smoking• • Smoking does not cause mental illness

• 40-50% of people with depression/ anxiety disorders smoke

• 60-80% of people with Schizophrenia smoke



Why do people with mentalhealth issues smoke more?

• Relief of stress

• Self medication

• Increased vulnerability to smoking

• Misleading messages about smoking

• Institutional and cultural factors:– Inpatient psychiatric units– staff/patients beliefs– reward/punish practices.

Deprivation



Myths associated withsmoking cessation

“agitated and aggressive”“self harm

more”

“use more medications”

“will not be relaxed”

“psychotic symptoms might get worse”

“irritable and angry”

“mental health will deteriorate”



Aims

• To study the beliefs of patients’ and staff before and after smoking cessation

• Compare the effect on weight and physical activity

• Study the change in rates of aggression, psychosis, self harm rates and medications

• Patterns of spending before and after smoking cessation



Methodology: Patients’and staff attitudes

• Survey questionnaire had up to 30 questions - 90% patients (n=122) and 61% (n=236) staff

• Respondents:– All patients– Staff (Nursing, Psychology, Pharmacy, Social Work,

Occupational Therapies, activity staff, Dietetics and Medical)

• Five months before and five months after smoking cessation

• Questions

• Anonymous

• Data compared between patients and staff, smokers and non-smokers and pre and post smoking cessation.



Methodology : Weight

• Weight: Naturalistic data of body weight (in kg) was retrospectively collated from dietetic hospital records

• Pre smoking cessation: December 2010, June 2011 and December 2011(baseline)

• Post smoking cessation: March, June and December 2012

• Comparisons between smokers and non-smokers, pre and post smoking cessation were analysed



Methodology : Behaviouralpatterns

• Assault, aggression and self-harm rates

• Data recorded from hospital Datix security system

• Time scales: One year before and one year after total smoking cessation

• Patterns compared between smokers and non-smokers



Methodology : Physicalactivity and spending

• Gym sessions and access to grounds - studied for 12 months before and 12 months after smoking cessation

• Data collected retrospectively from hospital recording systems

• Spending on confectionery and soft drinks patterns were studies 12 months before and 12 months after smoking cessation

• Data collected retrospectively from Hospital shop.



Methodology : Medication

• Clozapine – Antipsychotic medication• Plasma levels• Adverse effects – seizures• Dosage• Effect on mental state• Naturalistic data recorded retrospectively a year

before and a year after smoking cessation• Data analysed using SPSS statistical software



Smoking database

Patients Smokers Smoking Quits Quit SuccessDec-10 132 82 5 2Jan-11 132 77 7 2Feb-11 136 77 6 1Mar-11 135 77 10 5Apr-11 137 77 11 5

May-11 135 65 8 3Jun-11 136 65 6 6Jul-11 132 65 10 3

Aug-11 133 65 12 7Sep-11 133 79 6 3Oct-11 134 74 8 3Nov-11 133 74 7 3Dec-11 132 0 74 74



Results: Smoking habits



Results: Attitudes aboutsmoking cessation (patients)



Results: Opinion onsmoke ban

•Slight increase in patients favouring total smoke ban

•Significant increase in staff favouring total smoke ban



Results: How do you think the smokeban will / has affected you?

• Patients reported feeling better after smoke ban.

• Fewer patients felt their situation was worse following the cessation.

• Smokers were divided in their opinion, but non-smokers felt much better after the smoke ban.



Results: Mentaland physical health

• Increase in the number of patients reporting that their mental health did not deteriorate, post ban

• 84% patients either felt better or the same in terms of physical health.



Results: Aggressionand psychosis

• Significant number of staff now believe that smoking ban has not caused an increase in aggression.



Results: Opinion onenforcing smoke ban

• Many smokers were unhappy about smoke ban but they were happy that they had an opportunity to quit.

•Patients’ opinion about enforcing smoke ban remained same before and after.



Results: Weight

87.89

90.18

95.8596.51

97.6598.77

86.8287.72 87.68 87.37

89.49 89.05

80.00

82.00

84.00

86.00

88.00

90.00

92.00

94.00

96.00

98.00

100.00

Dec-10 Jun-11 Dec-11 Mar-12 Jun-12 Dec-12

Smokers

Non-Smokers

Partial Smoke Ban

Total Smoke Ban

• Weight gain noted in the first three months post cessation. This continued for up to an year, post cessation.



Results: Behaviour

0

10

20

30

40

50

60

70

80

90

100

110

5 Dec 2010 - 4 Jun 2011

5 Jun 2011 - 4 Nov 2011

5 Nov 2011 - 4 Dec 2011

5 Dec 2011- 4 Jan 2012

5 Jan 2012- 31 May 2012

1 Jun 2012- 30 Nov 2012

Health and Safety

Direct Patient CareSecurity

Total smoke ban



Results: Aggression

0.00

5.00

10.00

15.00

20.00

25.00

30.00

35.00

40.00

45.00

5 Dec 10 - 4Jun 11

5 Jun 11 - 4Nov 11

5 Nov 11 - 4Dec 11

5 Dec 11- 4Jan 12

5 Jan12- 31May 12

1 Jun 12- 30Nov 12

Assault

Behaviour

Sexual

Verbal aggression/abuse

Self harming behaviour

Security Breach

Clinical Security

Prohibited Item

Total smoke ban



Results: Physical activity Gym Sessions (hours)

438

623

680666

517

595

681

581

638

456474

509

454

559

514

545

524

661

507533

555

326

463479

300

350

400

450

500

550

600

650

700

Gym Sessions

134

80

71

134

79

74

0 50 100 150

Totalpatients

Patientswith

groundsaccess

Patientsattending

gym

Pre smoking cessation(Dec 2010-Nov 2011

Post smoking cessation(Dec 2011-Nov 2012)

Physical Activitybefore and after smoking cessation



Results: Spending

£0.00

£50.00

£100.00

£150.00

£200.00

£250.00

£300.00

£350.00

£400.00

Dec

-10

Jan

-11

Feb

-11

Mar

-11

Apr

-11

May

-11

Jun

-11

Jul-

11A

ug-1

1S

ep-1

1O

ct-1

1N

ov-1

1D

ec-1

1Ja

n-1

2Fe

b-1

2M

ar-1

2A

pr-1

2M

ay-1

2Ju

n-1

2Ju

l-12

Aug

-12

Sep

-12

Oct

-12

Nov

-12

Dec

-12

Confectionery

Soft Drinks

Groceries

Toiletries

X Axis: TimeY Axis: Averagespending per day

Total Smoke BanSpending Patterns



Results: Medication(Clozapine) levels

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

1.1

2010 2011 (baseline)

+ 1 month + 3 month + 6 month + 12 month

Mean Plasma Clozapine Levels for smokers

n=19

n=2

n=2

n=19

n=20

n=16

0.57mg/l

0.97mg



Results summary

• Weight: Increased in the first 12 months (Average 3-4 Kgs)

• Spending: Spending on confectionery and soft drinks increased.

• Behaviour: Rates of aggressive behaviour reduced.

• Physical activity: Remained the same.

• Attitudes of patients and staff favouring a total smoke free environment increased.

• Increase in the number of patients who believed their mental health remained same after smoking cessation

• 84% of the patients felt better about their physical health after smoking cessation.

• 50% of patients would like to smoke again after discharge.

• Medication: Clozapine plasma level increased, requiring dose reduction.



Conclusions

• Psychotic symptoms, ‘as required medication’ usage and aggressive incidents did not rise, dispelling myths that restricting smoking would destabilise mental state

• The study revealed patient and staff beliefs about smoking and smoke restriction

• It also highlighted practical considerations relating to patient and staff anxieties about facing smoking restrictions.

• The positive results achieved relating to patients’ mental and physical health, should provide encouragement to other psychiatric units considering smoking restrictions

• Enforcing total smoking cessation in open psychiatric inpatient wards will be more challenging



Thank you

Contact information:

Email: [email protected]

#brijuprasad

An evaluation of the impact of total smoking cessation in a high secure forensic unit in Scotland

Documents

Transcript of An evaluation of the impact of total smoking cessation in a high secure forensic unit in Scotland