Investigating smoking and nicotine dependence among people with severe mental illness during the COVID-19 pandemic: analysis of linked data from a UK Closing the Gap cohort.

Smoking rates are higher for people who use mental health services, which contributes substantially to health inequalities. Smoking can lead to worse COVID-19 outcomes, yet it remains unclear whether smoking has changed for people who use mental health services. We examined smoking patterns in a large clinical cohort of people with severe mental illness, before and during the pandemic. We found high levels of nicotine dependence and heavier patterns of smoking. Although some people had reported quitting, it is likely that smoking inequalities have become further entrenched. Mental health services should seek to mitigate this modifiable risk and source of poor health.

Cost-effectiveness of a complex intervention to reduce children's exposure to second-hand smoke in the home.

BACKGROUND: Second-hand smoke (SHS) causes numerous health problems in children such as asthma, respiratory tract infections and sudden infant death syndrome. The home is the main source of exposure to SHS for children, particularly for young children. We estimated the cost-effectiveness of a complex intervention designed to reduce SHS exposure of children whose primary caregiver feels unable or unwilling to quit smoking. METHODS: A cost-effectiveness analysis was carried out alongside an open-label, parallel, randomised controlled trial in deprived communities in Nottingham, England. A complex intervention combining behavioural support, nicotine replacement therapy and personalised feedback on home air quality was compared with usual care. A total number of 205 households were recruited, where the main caregivers were aged 18 and over, with a child aged under five years living in their household reporting smoking inside their home. Analyses for this study were undertaken from the National Health Service/Personal Social Services perspective. All costs were estimated in UK pounds (£) at 2013/14 prices. The primary outcome was the incremental cost-effectiveness of change in air quality in the home, measured as average 16-24 h levels of particulate matter of < 2.5 µm diameter (PM2.5), between baseline and 12 weeks. Secondary outcomes included incremental cost per quitter, quit attempts and cigarette consumption in the home. A non-parametric bootstrap re-sampling technique was employed to explore uncertainty around the calculated incremental cost-effectiveness ratios. RESULTS: The complex intervention achieved reduced PM2.5 by 21.6 µg/m3 (95% CI: 5.4 to 37.9), with an incremental cost of £283 (95% CI: £254-£313), relative to usual care. The incremental cost-effectiveness ratio was £131 (bootstrapped 95% CI: £72-£467) per additional 10µg/m3 reduction in PM2.5, or £71 (bootstrapped 95% CI: -£57-£309) per additional quitter. CONCLUSIONS: This trial targeted a socio-economically disadvantaged population that has been neglected within the literature. The complex intervention was more costly but more effective in reducing PM2.5 compared with the usual care. It offers huge potential to reduce children's' tobacco-related harm by reducing exposure to SHS in the home. The intervention is considered cost-effective if the decision maker is willing to pay £131 per additional 10µg/m3 of PM2.5 reduction. TRIAL REGISTRATION: The Smoke Free Homes trial was registered with isrctn.com on 29 January 2013 with the identifier ISRCTN81701383 .

Complete smokefree policies in mental health inpatient settings: results from a mixed-methods evaluation before and after implementing national guidance.

BACKGROUND: Tobacco smoking is extremely prevalent in people with severe mental illness (SMI) and has been recognised as the main contributor to widening health inequalities in this population. Historically, smoking has been deeply entrenched in the culture of mental health settings in the UK, and until recently, smokefree policies tended to be only partially implemented. However, recent national guidance and the government's tobacco control plan now call for the implementation of complete smokefree policies. Many mental health Trusts across the UK are currently in the process of implementing the new guidance, but little is known about the impact of and experience with policy implementation. METHODS: This paper reports findings from a mixed-methods evaluation of policy implementation across 12 wards in a large mental health Trust in England. Quantitative data were collected and compared before and after implementation of NICE guidance PH48 and referred to 1) identification and treatment of tobacco dependence, 2) smoking-related incident reporting, and 3) prescribing of psychotropic medication. A qualitative exploration of the experience of inpatients was also carried out. Descriptive statistical analyses were performed, and the feasibility of collecting relevant and complete data for each quantitative component was assessed. Qualitative data were analysed using thematic framework analysis. RESULTS: Following implementation of the complete smokefree policy, increases in the numbers of patients offered smoking cessation advice (72% compared to 38%) were identified. While incident reports demonstrated a decrease in challenging behaviour during the post-PH48 period (6% compared to 23%), incidents relating to the concealment of smoking materials increased (10% compared to 2%). Patients reported encouraging changes in smoking behaviour and motivation to maintain change after discharge. However, implementation issues challenging full policy implementation, including covert facilitation of smoking by staff, were reported, and difficulties in collecting relevant and complete data for comprehensive evaluation purposes identified. CONCLUSIONS: Overall, the implementation of complete smokefree policies in mental health settings may currently be undermined by partial support. Strategies to enhance support and the establishment of suitable data collection pathways to monitor progress are required.

Preparing for Completely Smoke-Free Mental Health Settings: Findings on Patient Smoking, Resources Spent Facilitating Smoking Breaks, and the Role of Smoking in Reported Incidents from a Large Mental Health Trust in England.

INTRODUCTION: Despite high smoking prevalence and excessive smoking-related morbidity and mortality among people with mental disorder compared to the general population, smoking treatment is often neglected in mental health settings. The UK National Institute of Health and Clinical Excellence (NICE) recently issued public health guidance stipulating completely smoke-free mental health settings. This project evaluated existing smoking-related practices in preparation for guidance implementation. The objectives were to: audit the recording of smoking-related information and treatment provision; explore current arrangements relating to the facilitation of patient smoking; measure staff time spent and identify costs of facilitating smoking; and explore the role of smoking in smoking-related incidents. METHODS: A mixed-methods study was conducted across four acute adult mental health wards, accommodating 16 patients each, over six months. It included a case-note audit, on-site observations, and a qualitative content analysis of incident reports. RESULTS: Smoking status was recorded for less than half of the 290 patients admitted (138, 48%). Of those, 98 (71%) were recorded as current smokers, of whom 72 (74%) had received brief smoking cessation advice. Staff spent 6028 h facilitating smoking, representing an annual cost of £ 131,040 across four wards. Incident reports demonstrated that smoking facilitation was often central to the cause of incidences, triggered frustration in patients, and strained staff resources. CONCLUSION: The findings highlight the importance and potential of implementing completely smoke-free policies using comprehensive pathways.

The forgotten smoker: a qualitative study of attitudes towards smoking, quitting, and tobacco control policies among continuing smokers.

BACKGROUND: Although research suggests that the majority of smokers want to quit smoking, the uptake of Stop Smoking Services, designed to assist smokers with quitting, remains low. Little is known about continuing smokers who do not access these services, and opportunities to influence their motivation and encourage quit attempts through the uptake of services. Using PRIME theory, this study explored differences between continuing smokers who had varying levels of motivation to quit, in terms of their plans to quit, evaluative beliefs about smoking, cigarette dependence, and attitudes towards tobacco control policies and services. METHODS: Twenty-two current smokers, recruited from the community, were classified by motivation level to quit using a self-report questionnaire (two groups: high/low). Four focus groups (n=13) and individual interviews (n=9) were conducted with both groups using an interview guide incorporating aspects of PRIME theory. Discussion areas included motives for smoking, attitudes towards smoking and quitting, perceptions of dependence, motives for quitting, barriers to quitting, and attitudes towards existing and impending tobacco control policies and services. Verbatim transcripts were analysed using thematic framework analysis. RESULTS: All participants expressed low motivation to quit during discussions, despite some initially self-classifying as having high explicit levels of motivation to quit. Both groups reported similar attitudes towards smoking and quitting, including a perceived psychological addiction to smoking, positive evaluations about smoking which inhibited plans to quit, and similar suggested methods to increase motivation (simply wanting to, save money, improve health). Most felt that they 'ought' to quit as opposed to 'wanted' to. Little influence was ascribed towards tobacco control policies such as plain packaging and hidden sales displays, and participants felt that price increases of tobacco products needed to be considerable in order to influence motivation. Highly motivated smokers expressed more willingness to visit Stop Smoking Services, although none had done so. CONCLUSION: Continuing smokers' attitudes towards smoking and quitting suggests that research and policy need to focus on increasing smokers' implicit motivation to quit smoking, even for those who classified themselves as having high motivation to quit. Targeted information and further education about Stop Smoking Services is required to increase uptake.

Tailored tobacco dependence support for mental health patients: a model for inpatient and community services.

AIMS: Although smoking prevalence among people with severe mental illness is high, it remains largely unaddressed. This pragmatic pilot project aimed to develop and implement a tailored tobacco dependence service in mental health settings and to assess its impact, as well as barriers and facilitators to implementation. DESIGN: An integrative service model, spanning acute, rehabilitation and community services, including the design of tailored instruments and referral pathways, delivered by two mental health professionals. SETTING AND PARTICIPANTS: Four adult acute and two rehabilitation wards (129 beds), and the community recovery team (2038 cases) of the United Kingdom's largest Mental Health Trust. MEASUREMENTS: Audit of smoking information in patient notes; service uptake; quit attempts; smoking cessation and reduction; qualitative data on implementation barriers/facilitators. FINDINGS: A total of 110 patients attended at least one support session: 53 inpatients (23% of inpatient smokers) and 57 community (of unknown number of community smokers, as recording of smoking status is not mandatory). Thirty-four of these (31%) made a quit attempt; 17 (15%) stopped smoking and 29 (26%) reduced cigarette consumption by up to 50% at the final contact. Barriers to service implementation related to: (i) trust policy, systems and procedures, (ii) staff knowledge and attitudes and (iii) illness-related factors. CONCLUSIONS: Despite the strong anti-smoking climate in the United Kingdom, including a law requiring smoke-free policies in mental health settings, establishing a smoking cessation treatment service for people with mental illness proved difficult, due to complex systemic barriers. However, there is clearly a demand, by patients, for such a service.

Retail price and point of sale display of tobacco in the UK: a descriptive study of small retailers.

BACKGROUND: Since the implementation of the 2002 Tobacco Advertising and Promotion Act, point-of-sale (PoS) tobacco displays are one of few remaining means of communication between the tobacco industry and customers in the UK. This study aimed to explore the characteristics of tobacco displays in a UK city, and particularly to assess the tobacco prices and promotional offers, types and pack sizes on display. METHODS: Digital pictures of PoS displays were taken in 117 small retail shops in Nottingham in mid 2010. Data were analysed using Windows Photo Gallery software and SPSS version 16. RESULTS: Just over half (52%) of cigarette packs on display were packs of 20, and 43% packs of 10. Cigarette prices differed substantially between brands, ranging from £4.19 to £6.85 for 20-packs, and from £2.12 to £3.59 for 10-packs. Forty four percent of cigarette packs and 40% of RYO (Roll-Your-Own) tobacco pouches, almost exclusively lower priced brands, were displayed with a pricemark, implying a promotional price offer. Eighty percent of 20-pack cigarette brand or brand variants on sale were priced below the EU-defined Most Popular Price Category (MPPC) for the UK in 2010; 45% were priced below the Weighted Average Price (WAP), which replaced the MPPC in 2011. CONCLUSION: PoS displays communicate value by displaying a high proportion of lower cost brands, and smaller and hence lower-cost packs, and by displaying price discounts on packs. The MPPC substantially overestimated the prices at which most 20-cigarette packs were available. Removal of PoS displays will prevent this means of price marketing but our study also suggests that minimum pricing of 20-pack cigarettes, prohibition of sale of cigarettes in packs less than 20, and plain packaging to prevent pricemarking are necessary if price is to be used effectively as a tobacco control measure.

The prevalence of mental health problems among users of NHS stop smoking services: effects of implementing a routine screening procedure.

BACKGROUND: Tobacco dependence among people with mental health problems is an issue that deserves attention both from a clinical and from a public health perspective. Research suggests that Stop Smoking Services often fail to ask clients about underlying mental health problems and thus fail to put in place the treatment adaptations and liaison procedures often required to meet the needs of clients with a mental health condition who want to stop smoking. This study assesses the recording of mental health problems in a large NHS stop smoking service in England and examines the effect of implementing a short screening procedure on recording mental health conditions. METHODS: Treatment records from the Stop Smoking Service covering a period of 13 months were audited. The prevalence of reported mental health problems in the six month period before the implementation of the mental health screening procedure was compared with that of the six month period following implementation. The screening procedure was only implemented in the support services directly provided by the Stop Smoking Service. Comparisons were also made with third-party sections of the service where no such screening procedure was introduced. RESULTS: The prevalence of reported mental health problems among a total of n = 4999 clients rose from less than 1% before implementation of the screening procedure to nearly 12% in the period following implementation, with the change being statistically significant. No significant rise was observed over the same period in the sections of the service where no screening procedure was implemented. CONCLUSIONS: The absence of standard procedures to record mental health problems among service users in many stop smoking services is currently likely to prevent the detection of co morbidity. Implementing a simple screening procedure appears suitable to increase the routine recording of mental health problems in a stop smoking service, which is an essential step to ensure services can be tailored and delivered appropriately to the client group.

Implementation of smoke-free policies in mental health in-patient settings in England.

BACKGROUND: Mental health units in England had to become smoke-free by law from July 2008. Concerns regarding the implementation and enforcement of smoke-free policies in these settings have been raised. AIMS: To study difficulties and challenges associated with smoke-free policy implementation in English National Health Service (NHS) mental health settings. METHOD: Questionnaire survey of all 72 English NHS trusts providing mental health in-patient services and facilities, supplemented by semi-structured telephone interviews at a systematic sample of 7 trusts and site visits at a convenience sample of 5 trusts. RESULTS: Questionnaires were returned by 79% of the trusts, all of whom had implemented smoke-free policies. Most respondents (91%) believed that mental health settings faced particular challenges, arising from the high smoking prevalence among patients (81%), related safety risks (70%), adverse effects on the clinician-patient relationship (36%), and potential interactions with antipsychotic medication (34%). Interviews indicated that sustained policy enforcement was perceived as difficult, but that despite challenges and concerns, the impact of the policy was regarded as beneficial, with some evidence of positive behavioural changes occurring in people. CONCLUSIONS: Many mental health trusts across England have implemented comprehensive smoke-free policies but the majority state that they are facing specific difficulties. Challenges and concerns need to be explored in depth and addressed to ensure that smoke-free policies implemented under the terms of the Health Act in July 2008 are not undermined.

Smoke-free policy in acute mental health wards: avoiding the pitfalls.

OBJECTIVE: The objective of this work was to explore the practical implications of, and the problems arising from, the implementation of a comprehensive smoke-free policy in acute adult inpatient mental health wards. METHOD: This is a qualitative study that uses semistructured interviews with a stratified purposive sample of 16 medical and nonmedical staff of two wards in an acute mental health trust in England that had implemented a smoke-free policy in buildings and grounds in March 2007. RESULTS: The smoke-free policy was viewed ambivalently and was substantially compromised by widespread use of exceptions such as permitting patients to smoke in an outdoor patio and covert indoor smoking. Smoking breaks were described to be a fixation for patients and sometimes disruptive to therapeutic activities. Nicotine dependence and withdrawal were not assessed or supported systematically. Awareness of interactions between smoking and certain antipsychotic medications was anecdotal and did not impact on clinical practice. CONCLUSIONS: The implementation of smoke-free policies in these acute mental health wards suffered from the provision of regular institutionalized smoking breaks, a lack of sustained investment in staff training and a lack of comprehensive cessation or abstinence support for patients. These issues need to be addressed; otherwise, the implementation of smoke-free policies in mental health settings may result in unintended adverse effects.