When the government introduced legislation in July 2007 to make nearly all public places and workplaces in England smoke-free, in-patient units for people with mental health problems were given an extra year to prepare themselves.
“Smoking is a massive part of their culture,” says Jane Wright, the smoking cessation manager at Warwickshire Primary Care Trust. “Nurses smoked with patients on the wards – it was seen as a good way to build relations.”
It was so much part of the culture that as the deadline approached this year many staff were worried about the consequences. Some said it would lead to violence and aggression among patients. Others were unsure of their ability to enforce it among patients who were unwell.
There is no shortage of reasons for helping people with mental health issues stop smoking, and reducing what is a major health inequality. They are twice as likely to smoke as the general population and are four times as likely to have respiratory diseases. Smoking rates approach 80% among those with disorders such as schizophrenia. Mental health service users also find it more difficult to quit. And as smoking exacerbates stress, anxiety and sleep disorders it is likely to be detrimental to mental health.
With funding from the Care Services Improvement Partnership, two demonstration projects are helping to smooth the path of the legislation’s introduction. Wright manages one partnership between Coventry and Warwickshire Stop Smoking Services and Coventry and Warwickshire Partnership NHS Trust.
“We needed to do something innovative – we needed to put in more effort,” says Becky Nash (pictured, far right), an acute ward manager at St Michael’s Hospital, Warwick, where smoking rates are 75%. “In the old days we gave people a nicotine patch and let them get on with it. Now the approach is to give people the information and the choice.”
St Michael’s has a “systematic approach”, says Wright, where a member of staff from each in-patient ward receives specific training. On admission each client is asked about their smoking status and whether they’d like support in giving up.
They work with clients on a one-to-one or group basis. An information pack spells out the facts and figures of smoking, what it does to the body, the financial savings of not smoking, and how people can find the motivation to give up. If they’re not ready to quit there are outside areas where they can smoke and they can use nicotine replacement devices during the night when these are inaccessible. A major difficulty for people trying to stop smoking is the boredom factor, says Nash. But staff can direct people towards other activities including arts and crafts, walking or swimming.
“They experience greater social isolation, and need help to guide them through the change,” says Nash. “It can be a very stressful time when they arrive in hospital and then discover they cannot smoke.”
Wright is pleased with their approach, and the evidence that smoking rates have reduced. “Everyone said how hard it was going to be to introduce the legislation,” she says. “But the restriction hasn’t impeded our relations with patients and in some areas, contrary to people’s fears, the violence and aggression have diminished.
“If we had tried doing this a couple of years ago it wouldn’t have worked – it would have been like pulling teeth,” she adds. “But there has been less resistance than people thought. The door was ready to be opened. Smoking had been high on the agenda for a long time, the legislation provided a focus, and the approach we are taking has gone down well.”
The second demonstration project is delivered through a partnership between South Staffordshire and Shropshire Healthcare NHS Foundation Trust and Help2Quit, the NHS stop smoking service for Shropshire and Telford & Wrekin. Clients are referred by local community mental health teams and GPs.
During the 16-week programme clients are introduced to activities such as yoga and aerobics as an alternative focus. The programme’s weekly 90-minute sessions also take clients through issues such as the effects of smoking, planning to give up and preventing relapse.
Take-up is low – only nine people are attending – but Helen Morton, a psychiatric nurse delivering the course, is pleased with participation. “They were not aware of the effects of smoking and where to go for help,” she says. “People are cutting down, and at least three have quit. It is about making small steps, and knowing they have that safety net if they need it.”
Among those attending is 55-year-old Alan,* a diagnosed schizophrenic who used to smoke 40 cigarettes a day. He gave up for a month and, after a brief relapse, is no longer smoking. “Not smoking has made me fitter and more able to do things I enjoy, like weightlifting. Anything that makes me happy helps.”
● Name has been changed
● Work in partnership and across services.
● Projects should be led by service users and specialist staff.
● Allow people to make incremental improvements, rather than giving up all smoking at once.