Hazel Cheeseman, Director of Policy Hazel.cheeseman@ash.uk

1. The Stolen YearsThe case for action to reduce smoking prevalence among those with a mental health condition Hazel Cheeseman, Director of Policy Hazel.cheeseman@ash.org.uk

2. Overview • Why this report, why now? • Report findings • Report recommendations • What next?

3. Why do we need this report? Adapted from: Szatkowski & McNeill. Diverging trends in smoking behaviours according to mental health status. Nicotine & Tobacco Research, 2015;3:356-60. http://ntr.oxfordjournals.org/content/17/3/356

4. Why do we need this report? • Work being undertaken by NICE, RCP, RCPsych, Rethink, PHE etc • Evidence of changing culture and attitudes in mental health around smoking, driven, in part, by an agenda of parity of esteem • BUT: the challenge remains significant: • People with a MH condition are just as likely to want to quit but face more barriers to quitting • Change is too slow, inequalities are widening and people are being left behind • Change requires action from many different stakeholders across the whole health and social care system.

5. The Stolen Years

6. The Stolen Years: mental health and smoking action report • Builds on existing work (NICE Guidance, RCP/RCPsych report) • Informed by the input of a wide range of experts (frontline staff, user groups, PHE academic network). • It was informed by 2 surveys (for staff and those with a MH condition) • Commissioned new research looking at the relationship between poverty and smoking in this population.

7. Report findings • Impact of smoking on people with a mental health condition is extensive: • Low life expectancy and higher incidence of illness • poorer mental health • High levels of medication • Lower incomes.

8. Report findings Higher rates of smoking were found among those with a mental health condition who are below the poverty line

9. Report findings The University of Nottingham research also looked at how many people in the UK might be draw into poverty if spending on smoking was taken into account • An additional 135,300 people with a common mental disorder are in poverty • An additional 55,300 people currently taking psychoactive medication • An additional 100,000 people with a long standing mental health disorder

10. Report findings What respondent report having done in the past if they have not had enough money to buy tobacco

11. Report findings • Staff attitudes are changing but there is evidence that too many see quitting smoking as incompatible with other therapeutic outcomes

12. Report findings Do you discuss smoking with your patients/ clients?

13. Report findings Do you discuss smoking with your patients/ clients?

14. Report findings Hospitalisation is a good opportunity to address smoking cessation

15. Report findings • People want to quit and often try and quit however, the culture and structure of services does not always support that choice.

16. Report findings Percentage of current smokers who have attempted to quit smoking

17. Report findings

18. Report findings • While the highest inequalities are among those with the most acute illnesses high smoking rates are found in nearly all groups with a MH condition. • Effective solutions need to reach all of those whether they are accessing inpatient care, community care, primary care or no mental health support at all.

19. Report findings

20. Report findings • Change is needed across the system and will be driven by: • Improved training of staff • Better communication and involvement of service users • Targeted support and services • Inclusion of a harm reduction approach alongside conventional quit models

21. Ambition Smoking among people with a mental health condition declines to be less than 5% by 2035, with an interim target of 35% by 2020.

22. Report ambitions • AMBITION 1: National and local leadership drives forward action that reduces smoking among those with a mental health condition. • AMBITION 2: People with a mental health condition are empowered to take action to reduce their smoking. • AMBITION 3: Staff working in all mental health settings see reducing smoking among service users as part of their core role. • AMBITION 4: Services for people with mental health conditions provide effective advice and support to quit smoking and access to appropriate specialist stop smoking models. • AMBITION 5: Local Authority funded stop smoking services (SSS) effectively support those with a mental health condition to quit smoking. • AMBITION 6: People with mental health conditions who access mainstream physical health services are routinely advised to quit smoking and sign-posted to effective support.

23. Report ambitions AMBITION 7: People with mental health conditions who are not yet ready or willing to quit are supported through harm reduction strategies. AMBITION 8: All inpatient and community mental health sites are smokefree by 2018, through full implementation of NICE PH48 guidance and embedding support for service users who smoke. AMBITION 9: Support to quit smoking for those with complex multiple needs and across different settings is appropriate and consistent. AMBITION 10: Data regarding smoking status and progress towards quitting are collected in a timely and appropriate way in all settings and appropriately shared. AMBITION 11: Populations at risk of developing mental health conditions are identified and appropriate interventions put in place to prevent uptake of smoking. AMBITION 12: Robust evidence into the most effective means to sustainably reduce smoking rates among those with a mental health condition is available.

24. Progress to date • Mental Health Taskforce Report • Improving the physical health of people with mental health problems: Actions for mental health nurses • Child and Adolescent Mental Health • Tobacco Control Plan for England development

25. What next? • Mental health and Smoking Partnership • Research with service users • Briefing on medication • ‘Make the case’ suite of tools

26. Hazel Cheeseman Hazel.Cheeseman@ash.org.uk

27. In-patient and Community Mental Health Service to Support Service User to Quit Smoking Rubyni Krishnan Specialist for Mental Health

28. The work undertaken in Ealing around In-Patient, Forensic Service & Community • Setting up In-patient Tobacco Management Service – Business Case • Physical health care agenda • Increasing awareness - Clinical meeting - Governance meeting - Physical Health meeting - Ward rounds/Handover meeting

29. Recording smoking status • Referral pathway for in-patients, forensic and community • Bespoke training – VBA, Level 1 & Level 2 • One to One clinic • Home Visit with Home Treatment Team • Psychoeducation lesson • Mapping Intervention

30. Forensic Mapping Intervention ITEP (International Treatment Effectiveness Project) by NTA • Map 1: a map for exploring the client’s views about their current situation (‘Me Today’) • Map 2: a map summarizing key elements from the initial comprehensive assessment process (‘Assessment Feedback’) • Map 3: a map for discussing the client’s pressing concerns (‘Things I Would Like to Change’) • Map 4: (homework) a map for identifying strengths/resources (‘Strengths’).

32. Psycho-education classes • Psychoeducation is a therapeutic focus in which patients learn practical and positive emotional and behavioral skills to management of emotions and self-awareness. • Therapy handouts, worksheets, individual and group therapy activities and visualizations • Use educational skill - It gives patients the tools needed to make changes in their lives, feel empowered, and learn tips to effectively manage an individualized personal development plan. Psychoeducation lesson ; 350 WLMHT patients trained (face-to-face)

33. The success:

34. The challenges and recommendation in commissioning and delivering services • Don’t give up – Business Case • Harm reduction approach • Working with CCG • Engaging with stakeholders

35. Areas of development • Community Setting – expanding the service • Integrating the wider health and well-being agenda • Working towards a recovery model

36. Thank you For information: Rubyni.krishnan@wlmht.nhs.uk

37. The value of peer support and how it can work effectively to support people with a mental health condition to quit smokingGillian Connor, Head of Policy & DevelopmentRethink Mental Illness

38. Room-to-Breathe Groundswell

39. Who is Groundswell? • We enable homeless and vulnerable people to take more control of their lives, have a greater influence on services and play a fuller role in the community. • Homeless health Peer Advocacy • TB Peer Support • In financial year 2014/15 we delivered 1400 one-to-one appointments – this year we will deliver near to 2000. • 450 Health Promotion sessions.

40. How do we know ‘breathing’ is an issue? • Peers - unique position to highlight homeless health inequalities. • 10% of clients have had treatment for a respiratory condition. • 59% - not identified as a health need at the point of first. • 18% of appointments with these clients “Working with clients with breathing problems is really common. We had one guy referred to us from [Day Centre] who was having difficulty breathing. I went to pick him up. Every 5 steps he stopped and lit a fag. I couldn’t get him on a bus… It turned out to be severe chronic asthma. He was coughing up loads of phlegm. He hadn’t been to a doctors for a long while. He was advised to stop smoking but he said he was 60, he had done it all his life and he enjoyed it.” – Groundswell Peer Advocate

41. Exploring Respiratory Health “Breathing difficulties have impact on all your body. You can’t move, and you can’t leave. And you cannot walk for a long time… you get tired. When you have breathing difficulties… you have zero energy. Because your body doesn’t get that oxygen if you want it. You can’t be a normal person and can’t look after yourself.” – Focus Group Participant • Designed a peer-led Project • Extensive Literature Review • 6 Co-researchers • Focus Groups • One-to-one survey • In total 322 people with experience of homelessness directly participated in this project.

42. The Respiratory health of participants • 26% use an inhaler (8% in general population) • 20% report to suffer with Asthma(8.4% general population). • 4.9% diagnosed with COPD(1.9% in the general population). • The longer a participant had spent homeless the higher the likelihood that they had a diagnosed condition. • 64% had chest infections when sleeping rough. • High rates of hospital admissions “Well I have difficulty with sleeping. In the night I will be wheezing in my chest. I was sweating and so on and so forth… initially they thought I was having asthma so they give me that [inhaler] so I said I use it, but later it stops, so they gave me some tablets… What I normally do is if there is any issues I just rush to the A&E. Then everything is done.” – Focus Group Participant

43. Homelessness & Respiratory Health • 85% current tobacco smokers. (18% across the UK) • 35% have smoked crack cocaine regularly in the past • Risky Smoking Behaviours – Smoking ‘Dogends’ and sharing Pipes. • Where you sleep impacts on health - 69% had difficulty breathing traffic fumes. • Concerns around living in hostels & temporary accommodation.

44. Extent of the problem • Quantities of tobacco smoked places participants at drastically increased risk of COPD, Chronic Bronchitis and Lung Cancer. 43% of participants have a pack year history of over 20. • Drug usage can make detection of illness difficult. 80% of participants find it difficult to know when they are ill. • Rough sleepers explain symptoms as due to their situation not as an indicator of underlying issue. 69% of participants reported that they expect to have a cough when they slept rough.

45. Smoking Cessation – Lessons learnt • Smoking Cessation is not working. Half of participants want to stop smoking. A similar figure to smokers among the general population. • Part of the ‘Lifestyle’ – Boredom a key factor • Smoking Cessation not available enough. 42% of participants reported that they have access to smoking cessation support in a homeless service that they use. • Licensed Medication underutilised. “I went to my doctor’s surgery and he put me on the non-smoking thing. It worked for about three orfour months. Patches and such yeah. But then again four months after – uh huh, these boys was …pressing me back smoking again. Then I stop on my own for another month. Back again.” - FocusGroup Participant

46. Smoking Cessation – lesson’s Learnt • Half Want to Quit! Homeless people are not beyond help! • GP would be the most help to stop smoking (36%). 86% visited a medical practitioner in the last 12 months, only half advised to quit smoking. • Support Workers Missing a trick – two thirds have not been advised by a support worker to stop smoking in the last 12 months • ‘Harm reduction’ – Smokers should be advised to cut down. • New Thinking is needed…

47. Tackling the Issue • Steps needed to improve the prevention, diagnosis and treatment of respiratory health conditions. • Specialist Homeless Stop Smoking Services and Tariffs for people with complex needs. • Stop Smoking Peer Support. • Training for medical professionals on the health needs of homeless people including approaches to quitting smoking.

48. Questions for the panel

49. Questions for you What are the key actions needed in your area to support those with mental health conditions to quit smoking? What would help facilitate this action?

50. The Stolen YearsThe case for action to reduce smoking prevalence among those with a mental health condition09 June 2016 Hazel Cheeseman, Director of Policy Hazel.cheeseman@ash.org.uk