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

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 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)

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 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

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”

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. 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…

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 : 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

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.

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 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

Results: Smoking habits

Results: Attitudes about smoking cessation (patients)

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

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.

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.

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

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.

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

Results: Behaviour Total smoke ban

Results: Aggression Total smoke ban

Results: Physical activity

Results: Spending

Results: Medication (Clozapine) levels

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

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