Smoking in Mental Health: A Thorny Public Health Issue New Zealand Workshop Series Aug 18th 21st 2009

1. Smoking in Mental Health: A Thorny Public Health Issue New Zealand Workshop SeriesAug 18th � 21st 2009 Based on �Community and Politics� Symposium on Smoking in Mental Illness, Presented at RANZCP Congress Melbourne 2008 & Tobacco Control and Mental Health Populations: Controversies for Research and Practice, South Australian Mental Health Research Day, 2008 Dr Sharon Lawn Email: sharon.lawn@flinders.edu.au

2. Why is research on Smoking and Mental Health Populations Important? A much neglected addiction The most insidious cause of physical health problems & poverty, vicious cycles Extremely value laden Huge unresolved ethical dilemmas for mental health professionals & others

3. What we know Smoking contributes substantially to physical health comorbidity in people with mental illness (2-3 times for all the major health conditions). 31.8% of Australians with mental illness are smokers / 17.7% non mentally ill are smokers (ABS). High % of people with Schizophrenia are smokers People with mental illness comprise 38.3% of all adult smokers, > 42% of all cigarettes consumed.

4. Current Clinical Issues 70% of inpatients have co-morbid nicotine dependence Smoke 40+ per day average (Lawn 2001) Increases when patients relapse Most detained patients are highly nicotine dependent Withdrawal exacerbates psychosis Cigarette seeking, demanding behaviour, begging, intimidation and violence Failure to diagnose and treat withdrawal

5. A Number of Paradoxes Exist Un-intended consequences of public health policy Clinicians use a harmful substance in the management of MH patients Otherwise good clinicians fail to diagnose & treat Violence to family, staff and other patients is tolerated Passive smoking is tolerated OH&S is ignored Medical co-morbidity is not addressed Consumers� perspectives become distorted and demoralised further Families and workers are co opted into the distortion Hospitals as a smoke-free environments - not enforced So where does this all leave us? Hospitals as a smoke-free environments - not enforced So where does this all leave us? Hospitals as a smoke-free environments - not enforced

6. A Problem of Need (Mark - Schizophrenia) The first time when I had no money and I couldn�t get credit at the deli, I used to go around the streets looking for butts...looking for butts...I don�t know where or who they came from but I�d unroll them and join them all up again into one. (pause) It was just a smoke wasn�t it? I�ve been that bad. When you can�t have a smoke you just go around knocking on people�s door asking for smokes and some I didn�t even know the people, and they�d say, �Who are you and what do you want?� Some just used to swear at me and push the door in my face, bang the door. It was just a smoke (pause). I would have done anything for one at the time. (Jean � Depression) Sometimes when I have a smoke it means I don't have to think; it gives me time out. If I had more time to think, I'd probably get depressed about my situation, just knowing they're there is enough to keep me calm, but when I run out of them I panic

7. A Problem with Values (Grace - psychiatric nurse/ex-smoker) In the locked ward I don't think there's much in the way of one-to-one therapeutic activity that happens. It's a kind of, "Let's wait for the medication to work". There's just nothing to do. The only normal thing to do at the time is to smoke. (Jane - social worker/smoker). My ability to empathise and almost openly model smoking behaviour at different points in my career when I didn't have different tools�.And part of working with really difficult clients is trying to find an entry point where you can develop rapport with them. And what was more easy than sitting around with them and having a smoke. (John � consultant psychiatrist/ex -smoker) In my heart of hearts, with patients with schizophrenia, I feel that they haven't got much left for them, so good luck to them. If they want to smoke, let them.

8. Current Systemic Issues The use of cigarettes in the management and control of patients: Deskilling of clinical staff Most psychotic patients/detained patients have no funds, hence they withdraw abruptly NRT is often not available, is inadequately provided or �too little, too late� Rationing one cigarette per hour is punishment, not treatment, & reinforces addiction We have little objective data to guide us

9. Current Systemic Issues Passive smoking Other patients Nurses and other MH staff Partners, families, children �getting drug (cigarette) supplies� Harms to patients, others Poverty Enzyme induction and fluctuating effects of medication OH&S issues Many MH Nurses smoke doctors & others less

10. Current Public Health Approaches Current campaigns & increasing prices have little impact on quitting by MH patients Elasticity for disadvantaged populations Just making them poorer 37%+ of their income to treasury per week Quit advisors & quit resources lack an understanding of withdrawal symptoms interacting with mental illness symptoms. Few targeted quit programs for MH clients 40 cigarettes per day smoker (BJP paper) Accessing black market tobacco40 cigarettes per day smoker (BJP paper) Accessing black market tobacco

11. Why is this not addressed at this time? Smoking - a tool in a much larger set of interactions and relationships

12. Smoking & Mental Illness Myths �They choose to smoke� They can�t quit� �They need to smoke� �Smoking between staff and patients facilitates a therapeutic relationship� Attempting to quit makes symptoms worse If they quit they will put on more weight. not free choice, not a level playing field yes they can and do with appropriate support and hope/belief a vicious cycle of need based on addiction, reinforcement and our ignorance therapeutic for whom? An excuse not to use other skills no evidence for this, UK study - smoking sustains depression, reduces opportunities to gain more adaptive coping skills development, increased hopelessness Surely this is already enough of a problem?

13. Smoking & Mental Illness Myths One of their few pleasures and sources of control! The mentally ill are disempowered in so many other ways MH workers As a society Eg. UK campaign (Stubbing out our rights) NSW Campaign (Right to Choose) � is this a good enough reason to allow smoking? Policy needs to enhance their choices on many fronts. This is about many aspects of mental health care stop using it as the excuse to avoid questioning our overall practice/treatment.

14. So What can be Done?

15. A Rational Clinical Response A complex pathway of interactions that requires skilled mental health support & effective collaboration with families, Quit Workers, GPs and others. high quality self-management knowledge, skills & support Anticipate & chart high dose nicotine withdrawal (probably > 45 ngm/ml) Anticipate craving, drug seeking, cognitive and behavioural consequences Treat vigorously One patch 16-20 ngm/ml; more patches needed? NSW protocol including supplements (gum, inhaler) Encourage people to continue to stay quit Collect data

16. Quitting by the Organisation & Group Similar approach to that of the individual attempting to quit It needs multiple strategies It is hard Often more than one attempt is needed Attempting gives opportunities for learning A slip isn�t a complete lapse (AVE) Do we just give in when it gets too hard & what message does this give consumers, staff & the community?

17. Consequencialism Vs Rule-based Ethics Consequencialism: the morality of actions should be judged by their consequences Rule-based ethics (Deontological theory): certain courses of action will always hold true eg autonomy must always be respected, paternalism is to be avoided Be honest with ourselves Smoking as a tool in a much larger set of interactions and relationships Shifting arguments when it suits us Let�s be honest with ourselvesLet�s be honest with ourselves

18. Policy Options Clarifying exemptions/legal statements to avoid confusion Does debating the ethical issues arrive at any productive conclusions? Moral debates on this issue will always have 2 sides - unresolvable How are policy makers to navigate through the chaos created?

19. A Rational Systemic Response A clear policy of a smoke free hospital that is supported by hospital administration, ED, ICU and MHU Well trained staff to implement the policy Availability of NRT, protocols and withdrawal charts Alternative strategies to deal with the �barren desert of boredom� in units, SRFs etc. Regular, supported Quit programs for all

20. Policy solutions Move beyond trying to resolve the debate ethically Support greater Individual & Group staff clinical skills development Support interdisciplinary learning and practice. Multi-D teams often don�t work. Rivalries, splits, circling the wagon responses perpetuate inaction. Get over it! Develop more leadership skills and support leaders who can lead Support research to dispel the myths Start treating it seriously like the clinical addiction that it is, broad coordinated strategy needed across service systems

21. Exempting Psychiatric Units from Smoke Free Policies Be careful what we wish for Both negative and positive consequences in the short & long term Already unintended consequences Deskilling of staff Poor health of people with mental illness Increasing proportion of remaining smokers have mental illness Public perceptions of people with mental illness

22. Can Psychiatric Units Become Smoke Free ? Discuss, plan, examine the evidence Clinical pathways, protocols Consensus; clear policy Clear implementation strategy Train clinical staff properly (mentored skills development) Bring patients, representative groups on side Liaise/policy/quit programs in the community Baseline & evaluation Feedback, monitor, review

23. Outcomes Haven�t met one individual who didn�t value the achievement after quitting Haven�t found one unit that said it would return once achieved smoke-free Pleasantly surprised by less aggression, not more as expected. Consumers positive & thankful that someone has finally set limits and supports, taken it seriously. Just like the individual quit attempt, watch that 3 month high risk relapse point.

24. Some Issues for Clinical Staff & Administrators Duty of care Premature mortality; a response is needed Avoidable verbal/physical assault on staff & other patients is overlooked Nicotine withdrawal causes the exacerbation of psychosis Non-smoking policy is in place but ignored NRT is available, often not used effectively Skill training & protocols are available Inpatient units & outpatient care- �a barren desert of boredom� is an issue of neglect Are costs & budgets more important than people?

25. Research Opportunities and Challenges Researcher as Worker / Insider reporting Handling taboo issues Whistle blowing and Change Understanding all sides / complexity Respecting the difficulty Communicating ideas / results Causing more harm When you are researching an area with such an undercurrent of unspoken rules and behaviours, it is certainly interesting. However, it demands the researcher to be highly conscious of their role and their impact. There is no such thing as an objective researcher under such circumstances. Taking the lid off the can of worms creates a number of challenges that must be managed.When you are researching an area with such an undercurrent of unspoken rules and behaviours, it is certainly interesting. However, it demands the researcher to be highly conscious of their role and their impact. There is no such thing as an objective researcher under such circumstances. Taking the lid off the can of worms creates a number of challenges that must be managed.

26. What research in this area has really shown: How we fundamentally treat people in our systems of care and the community, the values we hold, the decisions we make and the impact and consequences of those decisions on service users, workers, service systems and beyond. Quickly identified cigarettes as the tool for exchange and interactions within a token economy that has been heavily reliant on smoking to mediate symptoms and exchanges between the various players. Ie. how the system coped. Ie. how the system coped.

27. References: Lawn, S. & Campion, J. (2008) Smoke-free Initiatives in Psychiatric Inpatient Units: A national Survey of Australian Sites. Flinders University, Adelaide. Lawn, S. (2008) Tobacco Control Policies, Social Inequality and Mental Health Populations: Time for a comprehensive treatment response. Australian and New Zealand Journal of Psychiatry, 42: 353-356. Campion, J., Lawn, S., Brownlie, A., Hunter, E., Gynther, B. and Pols, R. (2008) Implementing smoke-free policies in mental health inpatient units: learning from unsuccessful experience. Australasian Psychiatry, 16 92-97, 2008. Lawn, S. (2007) Chapter One in J.E. Landow (Ed) Smoking Cessation: Theory, Interventions and Prevention �A Day in the Life of�.: The Culture of Cigarette Smoking for Psychiatric Populations� Nova Science Publications, New York. Lawn, S. (2007) Should psychiatric facilities be smoke free? Are we even asking the right questions? Australasian Psychiatry. 15:3, 246. Lawn, S. and Condon, J. (2006) Psychiatric Nurses� Ethical Stance on Cigarette Smoking by Patients: Determinants and Dilemmas in their Role in Supporting Cessation. International Journal of Mental Health Nursing, 15, 111-118. Lawn, S. J. and Pols, R. G. (2005) Smoking Bans in Psychiatric Inpatient Settings? A Review of the Research, Australian and New Zealand Journal of Psychiatry, 39, 874-893.

28. Lawn, S. J. (2005) Cigarette Smoking in Psychiatric Settings: Occupational Health, Safety, Welfare and Legal Concerns, Australian and New Zealand Journal of Psychiatry, 39, 894-899. Lawn, S.J. (2004). Systemic Barriers to Quitting Smoking Among Institutionalised Public Mental Health Service Populations: A Comparison of Two Australian Sites. International Journal of Social Psychiatry. 50, 204-215. Lawn, S.J. & Pols, R.G. (2003). Nicotine Withdrawal: Pathway to Aggression and Assault in the Locked Psychiatric Ward. Australasian Psychiatry, 11:2, 199-203. Lawn, S.J. (2003). Is it Time to Consider the Sociology of Nicotine Addiction? Smoking and Social Disadvantage. In Touch, 20: 1, 8. Lawn, S.J., Pols, R.G. & Barber, J.G. (2002). Smoking and Quitting: A Qualitative Study with Community-Living Psychiatric Clients. Social Science and Medicine. 54, 93- 104. Lawn, S.J. (2001) Australians with mental illness who smoke. British Journal of Psychiatry, 1 78:85. Lawn, S.J. (2001) Systemic Barriers to Quitting Smoking Among Institutionalised Public Mental Health Service Populations. Unpublished PhD Thesis, Flinders University of South Australia, Adelaide, South Australia.