Achieving Tobacco and Smoke-free in Psychiatric Institutes. European Experiences. Christa Rustler, Berlin Germany

Transcription

1 Achieving Tobacco and Smoke-free in Psychiatric Institutes European Experiences Christa Rustler, Berlin Germany

2 Tobacco problems in psychiatric services Why? Tobacco smoke is the most dangerous avoidable indoor pollutant. Tobacco smoke is carcinogenic, mutagenic and teratogenic There is no tolerable exposition of tobacco smoke. Interior spaces, where people smoke, are a constant source of exposure to the pollutants contained in tobacco smoke (dkfz 2006) The fundamental right to physical integrity and thus protection against passive smoking has priority over other personality rights. (GG art. 2) Tobacco consumption of psychiatric patients increases during the hospital stay. (Keizer 2005)

3 Tobacco problems in psychiatric services Tobacco kills (especially mentally ill persons) People with schizophrenia have 20 % shorter life spans. (Brown et.al., 2000) Persons with mental illness smoke more cigarettes than other smokers Many mentally ill persons even start to smoke in a psychiatric facility, where smoking often is used as a reward or incentive for the patients to comply with the staff. (Parks, 1999 zit. NASMHPD, 2006) Mentally ill smokers have more severe symptoms than mentally ill nonsmoker and a higher risk for alcohol and drug abuse. (Pisinger 2007)

4 Psychiatric diseases and smoking prevalences Depression: 40-50% Panic disorders: 20-30% Schizophrenia: 68-94% Alcoholism: >80% Drug dependence: >95% (Batra 2000)

5 Smoking prevalence psychiatric services ,8 72,7 87,6 offene Stationen geschlossene Stat. Sucht Staff prevalence Smokers: 34,5% Ex-Smokers: 27,7% Never-Smokers: 37,8% (Batra 2002)

6 Legislation and exemptions in Europe - examples Exemptions for psychiatric units in most European countries Smoking rooms available in long stay units (patients homes) Designed rooms with ventilation Patients are allowed to smoke outdoors All kinds of regulations for staff Strict regulations for indoor ban: UK and France, recommendations for Ireland Restricted areas outside Experience with complete tobacco free forensic hospital in Germany

7 Four myths about smoking in psychiatry In psychiatry we encounter four myths about smoking: 1. The patients do not wish to quit smoking 2. Patients experience a deterioration of their disorder if they quit smoking 3. The patients are unable to quit smoking 4. A smoking ban is difficult/impossible to implement in psychiatric units. (Pisinger 2007)

8 Conclusions in literature I Much resistance from patients and staff prior to implementation but attitudes become positive shortly after a ban has been introduced No increase in aggression and violence in the majority of the studies. Improvement of mental and physical health of patients. More social contacts between smokers and nonsmokers. Tobacco is no longer used as a reward or incentive for long stay or mental health service users A tobacco-free environment encourages tobacco cessation, increases the motivation to quit and reduces the risk of relapse. (ENSH, Pisinger 2007)

9 Conclusions in literature II Smoking needs intervention and treatment, especially because of the high risk in this population. (Irish HPH 2006) The risk of possible worsening of mental health is balanced by the prevention of very serious tobacco-related diseases such as COPD, cardiovascular disease and cancer. (Pisinger 2007) Health promotion should be part of the treatment of psychiatric patients. (Brown, 2000)

10 Motivation and ability to quit Many are concerned about their health and want to stop smoking % of patients in psychiatric units want to quit smoking. (Meltzer 1996) 82% of all patients with severe mental disorders want to reduce or stop smoking. (Pisinger 2007) 37% of all people with mental disorders can stop smoking (vs 43% of all people without mental disorders) (Lasser 2000) Abstinence rates of schizophrenic, depressive, addicted patients after 6 months: 12-46% (Batra 2007)

11 Best Practice Guidelines for Tobacco Management in the Mental Health Setting (2008) Consensus Management Guidelines for smoke free psychiatric / mental health services Based on European guidelines for tobacco free psychiatric services Based on management models of good practice in psychiatric / mental health hospitals from within participating European Partners Recommendations on a common set of management guidelines for European psychiatric / mental health services

12 Overall strategies and recommendations The full support by management and medical staff is essential. Make a good plan and involve all relevant stakeholders in the implementation even patients Staff needs training -this also supports the cultural change to deal with smoking in the hospital. The severe tobacco addiction of psychiatric patients needs intensive medical and psychotherapeutic support. Nicotine replacement therapy must be available. Staff need time to discuss and understand the attitudes and ethical values that are affected by the changes.

13 ENSH Standards for Tobacco Free Health Care Services 1. Engagement: Engage decision-makers. Appoint a working group and reject tobacco industry sponsorship. 2. Communication: Develop a strategy and an implementation plan. Inform all personnel, patients/residents and the community. 3. Education & Training: Set up a training plan to instruct all staff on how best to approach tobacco consumer. 4. Tobacco cessation: Organise cessation support facilities for patients/residents in the organisation and ensure continuity of support after discharge. 5. Tobacco control: Develop the organizations campus to be tobacco free. If smoking areas remain, they should be clearly indicated. 6. Environment: Display clear tobacco free signage. Ban all incentives to consume tobacco. 7. Healthy Workplace: Develop human resource management policies and support systems to protect and promote the health of all that work in the organisation. 8. Health Promotion: Promote tobacco control activities in the community setting. 9. Compliance Monitoring: Renew and broaden information to maintain commitment to the policy. Ensure followup and quality assurance. 10. Policy Implementation: First convince, then constrain considering legislation if needed. Have patience!

14 ENSH Standards and recommendations 1. Commitment Main objective is health and safety Provide a tobacco-free building and restrict outdoor smoking areas - if they seen to be necessary Management is responsible for risk management procedure Appoint a working group for implementation and monitoring Implementation is in the annual agreement of objectives 2. Communication Make staff and patient aware of the high risk through active and passive smoking paradigm change As role models, all staff must promote the appropriate behavior to service users.

15 ENSH Standards and recommendations 3. Education & Training Information and training in policy implementation and monitoring for all staff Specialist training programme designed specifically for those working in mental health. Risk Assessment training on dealing with emergency situations Workshops and training on implementation for departments to discuss and exchange experiences 4. Tobacco cessation Smoking / tobacco use is treated as a care issue of all patients in mental health settings Tobacco cessation is included in regular treatment setting adjust medical treatment Nicotine replacement therapy /medical treatment of tobacco addiction must be available Incentives for attending treatment

16 ENSH Standards and recommendations 5. Tobacco Free Environment Develop risk-management strategies Provide access to the outdoor areas hidden area used for restricted exemptions Interior rooms only for exceptional situations (acute situations, violence) Minimize secondhand smoke exposure, even in exceptional situations Complete tobacco free environment as long-term goal Experiences show it s possible intensive treatment necessary 6. Environment Never use tobacco as a reward, incentive or a penalty! Develop strategies to combat boredom. Give information and orientation through signage

17 ENSH Standards and recommendations 7. Healthy Workplace Smoking / tobacco cessation support should be made available to staff in an effort reduce consumption Staff exposure to ETS to be minimized to the greatest extent possible Staff smoking habits and prevalence is monitored on a regular basis. Motivation and incentives for smoking cessation among personnel Smoking is not allowed during working hours 8. Health Promotion Promotes, contribute to and support tobacco free activity outside of the organization. Share evolving best practices locally, nationally and internationally on tobacco control in challenging settings Include family members in your information and outpatient program

18 ENSH Standards and recommendations 9. Compliance Monitoring A stated commitment to monitor and review the tobacco control policy including regular environmental inspections to assess levels of smoke pollution 10. Sustainable Policy Implementation Recognition that moving to totally smoke-free is the long-term goal (developed in ENSH/HPH Ireland 2007).

19 Achieving Tobacco and Smoke-free in Psychiatric Institutes: It s cynical to treat the psychiatric disorder and leave the patient to die from smoking It s almost impossible to quit without adequate support It s almost impossible to get adequate support (Boethius 2006). for goodness sake we are health professionals and it s an addiction that kills! Prof. Bryan Stoten, UK NHS

20 Christa Rustler, Special thanks to: Ann O Riordan, David Chalom, Sibylle Fleitmann, Miriam Gunning, Manja Nehrkorn, Julia Sahling, Porf. Bertrand Dautzenberg, Cristina Martinez, Esteve Fernandez