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Mental health and smoking for GPs
1. www.hertsdirect.org
Smoking and Mental Health
For GP Mental Health Leads
Jim McManus
Director of Public Health
Liz Fisher
Head of Provider Services, Tobacco Control Lead
Emily Clarke
Assistant Manager
Hertfordshire Stop Smoking Service
2. www.hertsdirect.org
Why Tobacco Control remains important
• Single most important cause of premature
morbidity and mortality
• Kills 80,000 people prematurely in England alone
and 1,500 people in Herts die every year
• Accounts for 50% of health inequalities between
better and worst off
• Disproportionately affects
most deprived groups
• 135,300 smokers in Herts
• Cost the NHS £55 million in 2013-2014
3. www.hertsdirect.org
Smoking not social status is the greatest
cause of health inequalities
References:
1. Gruer L et al. BMJ 2009;338;bmj.b480 (Relative mortality assessed at 2nd 14 year follow-up between male smokers & non-smokers of highest & lowest social class)
Smokers from the highest social class have a lower life expectancy than
non-smokers in the lowest social class
0.00
0.50
1.00
1.50
2.00
2.50
3.00
3.50
I+II IV+V
Social Class
Relativemortality
Male non-smokers Male smokers
Highest Lowest
The life
expectancy
between rich and
poor smokers is
similar
Richer smokers
have a lower life
expectancy than
poorer non-
smokers
8. www.hertsdirect.org
Smoking and Mental Health
• Greatest impact on
health inequalities
• High prevalence – no
change over 20 years
• 70% in some groups
• 16-25 years of life lost
• 42% of all tobacco
smoked
• Misconceptions about
wanting to quit and
impact on mental
health
9. www.hertsdirect.org
Smoking and Mental Health
• Improved mental health
reduces lifestyle risk
behaviours
• Mental ill health: increased
risk - range of unhealthy
lifestyle behaviours
• Smoking responsible for
most of the excess mortality
in people with severe mental
health conditions
• Young people - emotional
disorders
10. www.hertsdirect.org
RCGPs: guidance smoking and mental
disorders
• Smoking is the largest avoidable cause of premature
death and health inequality in those with mental
disorders who die 10-20 years earlier than the general
population.
• Adults with mental disorders disproportionately
experience tobacco related harm.
• With appropriate support, people with mental disorder
are able to stop smoking.
• Smoking cessation improves mental and physical health
even in the short term and reduces risk of premature
death.
• Impact of smoking cessation on mood and anxiety
disorders is at least as large as antidepressant
treatment.
12. www.hertsdirect.org
What is difficult about smoking and
mental health:
• Mental health care staff see smoking as less of a priority
than general NHS staff
• There remains a culture of acceptability within mental
health providers
• There are no national reporting systems on stopping
smoking and mental health
Myths:
• Stopping smoking has adverse effects on mental health
• Mental health service users have other priorities
• Mental health service users don’t want to stop smoking
• Mental health service users can’t stop smoking
14. www.hertsdirect.org
Tobacco – an NHS priority
• NICE PH48
• NICE PH45
No change in smoking prevalence
in people with a mental health
disorder for 20 years
15. www.hertsdirect.org
What’s happening locally?
• Regional smoking and mental health seminar
• CLeaR review on tobacco control
• NHS systems leaders’ commitment to tobacco
control
• Herts smoking and mental health action group
• Implementing NICE PH48
• Implementing NICE PH45 – harm reduction
• Mental health and smoking master classes
• Developing more specialist stop smoking services
– behavioural sciences
16. www.hertsdirect.org
Harm Reduction Guidance
• Implementing NICE PH 45
• Stopping smoking main recommendation
• Effectiveness and cost effectiveness of harm
reduction
• For smokers not ready/unable to quit in one
step
• Behavioural support
• Nicotine containing products – right doses
• Role of e –cigarettes for harm reduction
17. www.hertsdirect.org
Mental Health and Primary care
• The scale of the problem – 1:4 adults have a
mental health problem in any one year
• QOF points
• Identification of all smokers
• MECC – build confidence in ability to quit with
specialist support
• Referring to specialist services
• Heavier smokers – need higher doses and
longer term NRT
• Role of varenicline
18. www.hertsdirect.org
Medicines that need dose adjusting
• Stopping smoking requires the immediate
reduction of doses of some antidepressants,
antipsychotics and benzodiazepines by up to
25% within the first week and up to 50% within 4
weeks.
20. www.hertsdirect.org
Commissioning for smoking and
mental health
• HPfT CQUIN 13/14
Herts.P.f.T (Mental Health)
Department Total Referrals
A.O.T. 25
Community Mental Health Team (CMHT) 318
Early Intervention in Psychosis 4
Enhanced Primary Mental Health Service 2
RAID 2
Hertfordshire Commuinty Eating Disorder Service 2
TOTAL 353
21. www.hertsdirect.org
Proposed Quality Schedule metrics
15/16
• All service users to have smoking status
recorded
• Brief intervention advice to be given to all
smokers
• All smokers to be referred to Hertfordshire Stop
Smoking Service (HSSS) unless they ‘opt out’
• All staff to be asked to complete an online
survey (in Q1) on attitudes to smoking and
electronic cigarettes (to be provided by
Hertfordshire Stop Smoking Service).
22. www.hertsdirect.org
Quality Schedule metrics15/16 cont.
• All staff to be encouraged to quit smoking and
offered a referral to HSSS
• To promote campaigns such as Stoptober and
National No Smoking Day with service users
and staff
• Adopt Hertfordshire Tobacco Harm Reduction
Guidance
• HPfT to become Smokefree by the end of 2016,
with the Lister site becoming Smokefree pilot
site by 1 October 2015 (plans to achieve this at
the Lister are already in progress)
23. www.hertsdirect.org
Public Health
• TC Alliance – representation from mental
health stakeholders
• NHS Health Checks
• Mental Health Health Checks
• Vol orgs (MIND, Viewpoint, Living Room)
• Drug and alcohol services
24. www.hertsdirect.org
Offender health
• Smoking prevalence similar to mental health
clients
• 770 prisoners – but expanding
• Health of probation caseload
• Prison and specialist SSSs
• Smokefree prison/Smokefree cells
• Access to NRT for harm reduction
• Staff SSSs
• Probation action plan being developed
26. www.hertsdirect.org
Next Steps
• Ensure revisions to HWb Board tobacco control
priorities include mental health
• Agree QS metrics with HPfT15/16
• Improve quality of stop smoking services for
metal health service users
• Implement harm reduction guidance
• Increase knowledge and skills of frontline staff
and volunteers who work with mental health
service users
28. www.hertsdirect.org
Further reading
Primary Care Guidance on Smoking and Mental Disorders:
http://www.rcgp.org.uk/clinical-and-research/clinical-resources/mental-health.aspx
RCP report:
https://www.rcplondon.ac.uk/sites/default/files/smoking_and_mental_health_-_key_re
NICE PH 48: https://www.nice.org.uk/guidance/ph48
NICE PH 45: https://www.nice.org.uk/guidance/ph45
BI training for GPs :
http://learning.bmj.com/learning/module-intro/advice-smoking.html?
moduleId=10032720&locale=en_GB
Notes de l'éditeur
What we want to cover
Why tobacco remains important
National and Local Tobacco Control Priorities
Review of progress towards meeting TC ambitions
Review of smoking cessation targets/performance
Highlight the importance of priority groups
Discuss and debate the issues and consider what our Tobacco Control ambitions
Consider how smoking cessation services should be prioritised
170,000 smokers in 2011
the mortality rate of people with mental illness (Domain 5); in Domain 1 of the NHS Outcomes Framework a related indicator is ‘under 75 mortality rate in people with serious mental illness’;