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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. 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

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  1. 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

  2. What is this and where is it? Patsi Davies 21/10/10

  3. Introduction *Mental health residential facilities Tentacles – smoking normalisation Challenges – 2020 Vision Observations Implications

  4. “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

  5. 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

  6. Tobacco Control Initiatives Legislation NZ Health Strategy Advocacy Policies National targets Putea ($) Education/campaigns Cessation support & programmes Hospitals/communities

  7. 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

  8. 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

  9. 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

  10. 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

  11. 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…

  12. 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

  13. 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

  14. ‘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:

  15. 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)

  16. 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)

  17. 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

  18. Smoking relieves stress... Alertness/Relaxation Agitation/Cravings/Anxiety

  19. 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

  20. 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)

  21. 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

  22. 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”

  23. 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

  24. 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

  25. 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

  26. 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

  27. 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

  28. 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”

  29. 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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