1. An evaluation of the impact of total smoking cessation in a high secure forensic unit in Scotland
Dr Briju Prasad
Specialty Doctor - Forensic Psychiatry
UK National Smoking Cessation Conference
Victoria Park Plaza Hotel, London
28th June 2013

2. Content of this presentation
Introduction
Background to smoking and mental health
Aims of this study
Methodology
Results
Limitations and conclusions
Discussion

3. 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

4. What we know about smoking and 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)

5. 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

6. Why do people with mental health 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
Form of self medication –regulate dysfunctional mesolimbic dopamine system

7. Myths associated with smoking cessation
“irritable and angry”
“mental health will deteriorate”
“agitated and aggressive”
“will not be relaxed”
“self harm more”
“psychotic symptoms might get worse”
“use more medications”

8. 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

9. 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.
Questions included beliefs about the smoke-ban, effect on physical/mental health, history of their smoking habit, anxieties of smoke ban on the individual, future after stopping smoking, moral view on enforcing a ban etc…

10. 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

11. Methodology : Behavioural patterns
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

12. Methodology : Physical activity 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.

13. 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

14. Smoking database Patients Smokers Smoking Quits Quit Success Dec-10
Patients
Smokers
Smoking Quits
Quit Success
Dec-10
132 82 5 2
Jan-11 77 7
Feb-11
136 6 1
Mar-11
135 10
Apr-11
137 11
May-11 65 8 3
Jun-11
Jul-11
Aug-11
133 12
Sep-11 79
Oct-11
134 74
Nov-11
Dec-11

15. Results: Smoking habits

16. Results: Attitudes about smoking cessation (patients)

17. Results: Opinion on smoke ban
Slight increase in patients favouring total smoke ban
Significant increase in staff favouring total smoke ban

18. Results: How do you think the smoke ban 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.

19. Results: Mental and 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.

20. Results: Aggression and psychosis
Significant number of staff now believe that smoking ban has not caused an increase in aggression.

21. Results: Opinion on enforcing 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.
60% felt enforcing it in secure Hospital was wrong but 30% patients favoured total ban.
60% staff said they favoured a total ban but only 52% believed it was right to enforce it.

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

23. Results: Behaviour
Total smoke ban

24. Results: Aggression
Total smoke ban

25. Results: Physical activity

26. Results: Spending

27. Results: Medication (Clozapine) levels

28. 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.

29. 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

30. Email: briju.prasad@nhs.net
Thank you
Contact information:
#brijuprasad