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Wasted Lives More of the same Yet you choose not to ask. Patsi Davies 20/101/10. Patsi Davies Auckland University of Technology 4/11/10. What is this and where is it?. Patsi Davies 21/10/10. Introduction *Mental health residential facilities

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Wasted lives more of the same yet you choose not to ask

Wasted Lives

More of the same

Yet you choose not to ask

Patsi Davies 20/101/10

Patsi Davies Auckland University of Technology 4/11/10


Wasted lives more of the same yet you choose not to ask

What is this and where is it?

Patsi Davies 21/10/10


Wasted lives more of the same yet you choose not to ask

Introduction

*Mental health residential facilities

Tentacles – smoking normalisation

Challenges – 2020 Vision

Observations

Implications


Wasted lives more of the same yet you choose not to ask

“That is the only

pleasure

they have in life”

(Funder)

“I am only interested

in from here to here”

(Team leader)

No evidence they

stay quit after discharge

so no basis

to have smokefree

facilities

(Board member)

“ Unbelievable”

(How did this get onto

the choice side of the

equation?)

Patsi Davies AUT 04/1/10


Wasted lives more of the same yet you choose not to ask

Vision: Tobacco-Free Aotearoa 2020

Theme

“Achieve Together”

Kotahitanga - oneness/unity

Journey

Involves - building community

Bonds of Unity

“Inclusion in the journey

against the harms of smoke”

Rationale

Harms of smoke “smoke not smoker”

2020


Wasted lives more of the same yet you choose not to ask

Tobacco Control Initiatives

Legislation

NZ Health Strategy

Advocacy

Policies

National targets

Putea ($)

Education/campaigns

Cessation support &

programmes

Hospitals/communities


Wasted lives more of the same yet you choose not to ask

Tobacco Control Initiatives

NZ Health and Disability Services Act 2000

Purpose: improve, protect, promote health

S3. Reduce health inequalities

Smokefree Environments Amendment Act 2003 s6

'All indoor workplaces smokefree with few exceptions'

(MoH, 2008)

Hospital care institutions

“...may permit smoking by patients of a workplace,

that is, or is part of...a hospital care institution...”

eg ventillation/patients only


Wasted lives more of the same yet you choose not to ask

New Zealand Tobacco Control

General Hospitals

  • Evidence of Harm (1950’s)

  • Research base – well established (2000)

  • Nicotine

  • Smoke

Mortality

Morbidity

Economic

Social

General Hospitals:

Mid 2000's

Smokefree

Policies


Wasted lives more of the same yet you choose not to ask

NZ Tobacco Control Initiatives

General Hospitals

Smokefree

But (mid 2000's)

Mental Health Facilities (inpatient)

Exemptions

Evidence

indefinite

sunset clause

HR - different treatment?

Rationale ?...policy silence…let’s see


Wasted lives more of the same yet you choose not to ask

Mental Health Service Users

Vision 2020

Theme

Kotahitanga - oneness/unity

Journey

Building community

Bonds of Unity

“Inclusion in the journey

against the harms of smoke”

Rationale

Harms of smoke

“smoke not smoker”

Economic

Political

Social

Exclusion

Historical

Experiences

Initiatives

Inclusion

Participation


Wasted lives more of the same yet you choose not to ask

Mental Health & Smoking

Normalisation

= Climate of tolerance for smoking

Place/space *

Uptake

2HSmoke

Quit - harder

RYO v TM

Nurses - 27%

Why has Mental Health been left behind…


Wasted lives more of the same yet you choose not to ask

The Place of Tobacco

Institutional

Practice

Spaces for

Smoking

Institutional

Economic

Arrangements

A

Commodity

Everyday product

Acceptable

Essential

Easy access

Budgeted item

Legitimate Need

State Role

Named by institution


Wasted lives more of the same yet you choose not to ask

Systemic

Exposure to

Tobacco

Use

Institutional

Practice

Multi

functional

Tool

Barter/Power

Smoking Uptake

Harder to Quit

Staff buy it

Roll/light

Exposure SHS

Stand over tactics

C4Sx

Build Rapport

Time

Control Device

Therapeutic Rel

“FLOT”

Tolerance of Harm

Routine training - x

Nic assessments - x

Consistent Policies - x

Silence - yes

Misinformation - yes


Wasted lives more of the same yet you choose not to ask

‘Even when the majority of patients

accessing psychiatric services are

nicotine dependent (50-90%)

and despite clear diagnostic description

and definition of nicotine dependence as a

mental disorder, it is not common for

nicotine dependence to feature

in either the diagnostic formulation

or the management plan of patients

in written psychiatric reports.’

(Sellman, 2005)

Perhaps it is not surprising that:


Wasted lives more of the same yet you choose not to ask

In Essence...

The mental health workforce has less positive attitudes

to smokefree policies, assessment and treatment even

though nicotine fulfills the core criteria for a mental disorder

in the DSMIV.

This, together with the exemption of mental health service

users from smoke policies, reflects the tentacles of

normalisation.

Davies (2009)


Wasted lives more of the same yet you choose not to ask

Evidence for Better Health Outcomes

General hospital – clinical care/support

Current mental illness

1:3 cigarettes

Elevated rates:

lung disease

chronic heart disease

(MHF, 2008)


Wasted lives more of the same yet you choose not to ask

Evidence for Better Health Outcomes

Depression

Schizophrenia

50-60% service users

>rates (daily/dep)

(Fergusson et al 2003)

>likely

smoke/earlier/harder

(Edwards et al 2006)

< 20% L/E

(Hennekens et al 2005) (Brown et al 2000)

>likely

smoke/heavily/dep

(Campion et al 2006)

> psych symptoms + >meds doses +

>hospitalisations

cessation - toxicity


Wasted lives more of the same yet you choose not to ask

Smoking relieves stress...

Alertness/Relaxation

Agitation/Cravings/Anxiety


Wasted lives more of the same yet you choose not to ask

Compounding

Health Inequalities

'

“Smoking is a major contributor

to inequalities in health” (MoH,2007)

Service Users – health inequalities

High levels

Maori

Effect

Smoking – high levels

Maori

Pacific Peoples

Lower SES

Effect

>Health inequalities

eg cancer survival & mortality

> health in equalities

eg cancer survival & mortality

45.8

89-93 = 1/3

20/61%/T2

36.2


Wasted lives more of the same yet you choose not to ask

Royal Australiasian College Physicians/Psychiatrists

Tobacco Policy

“Smoking is particularly high among the most vulnerable

and disadvantaged people of society: those with mental

illness, people living with disability, those from lower

socio-economic backgrounds, youth and indigenous

people”.

(2005, p23)


Wasted lives more of the same yet you choose not to ask

1. Smoking – human right = X

(HRA/NZBoRA/HDCA)

2. Policies – SU discrimination

(burden = responsibility)

3. Home – right to smoke = X

(MoH, 2008)

4. Policies - > violence

(Lawn & Pols, 2005) Ca/Aus/USA/UK

5. Policies – avoid care

(Lawn & Campion 2008) Aus

6. Will smoke after discharge

Unique approach

7. Only pleasure...

(Lawn & Campion, 2008)

Agenda/prompt

Exemption Arguments


Wasted lives more of the same yet you choose not to ask

Case law: Rampton (HC - UK) QB (2008)

High Security Hospital

Decision: not allowed to smoke

“...is very strong evidence that smoking causes diseases

and endangers the health of smokers themselves and other

people who live and work in the vicinity...powerful evidence

that in the interests of public health...strict limitations on

smoking and a complete ban in appropriate circumstances

are justified”


Wasted lives more of the same yet you choose not to ask

Case law: Rampton (HC - UK) QB (2008)

High Security Hospital

Decision: not allowed to smoke

“...a need to protect the 'rights and freedoms of others'

...is engaged in the present context...a duty to protect others

from smoke pollution with respect to patients, some of

whom may be vulnerable and to staff (Lopez)...substantial

benefits arise from the ban and the disbenefits are

insubstantial...evidence supports the defendant's case”

1096


Wasted lives more of the same yet you choose not to ask

Mental Health Service Users

Vision 2020

Theme

Kotahitanga - oneness/unity

Journey

Building community

Unity Bonds

“Inclusion in the journey

against the harms of smoke”

Rationale

Harms of smoke

“smoke not smoker”

Economic

Political

Social

Exclusion

Historical

Experiences

Initiatives

Inclusion

Participation


Wasted lives more of the same yet you choose not to ask

Observations

1. Evidence base exists

(GP + MH + HI + DC = WL)

2. Resistance to SF /Policies

3. Reframed – focus on smokers

not the smoke/harms

4. MHSU + smoking - special characteristics

5. Smoking – justified

6. Normalisation - alive


Wasted lives more of the same yet you choose not to ask

Policy Challenge

? Inclusion and exclusion

the only game in town?

? Keeping out those deemed different?

? Deemed superfluous to the vision?

? Exempt from policy framework that enables access to healthy pursuits

? Sites of the past - replaced by urban MHF

? Difference in treatment

2020/25


Wasted lives more of the same yet you choose not to ask

Policy Response

2020

Evidence - burden of harm

Spot the normalisation – insidious

Entitlement - equal treatment

'Reframe - from smoke to smoker to whole person who smokes'

Why?

‘Only pleasure in life‘ - telling

Life threatening MH Disorder

Quality of care systems – wake up


Wasted lives more of the same yet you choose not to ask

Evidence - burden of harm

Spot the normalisation – incidious

Entitlement - equal treatment

'Reframe - from smoke to smoker to whole person who smokes'

Policy Response

Policy Response

2020

Evidence

Normalisation

Entitlement

-burden of harm

- know it

- insidious

- spot it

- equal treatment (at least)

“Only pleasure in life” – telling

Life threatening MH Disorder

Life threatening – all users

Quality of care systems – wake up

Why?

‘Only pleasure in life‘ - telling

Life threatening MH Disorder

Quality of care systems – wake up

Reframe

“MHSU smoker to whole person who smokes”


Wasted lives more of the same yet you choose not to ask

Wasted Lives

More of the same

(exclusion/unworthy)

Yet you choose not to ask

(about the evidence)

Patsi Davies 20/101/10

Patsi Davies 21/10/10


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