Mary Yates is a nurse consultant for health promotion wellbeing at South London and Maudsley NHS foundation trust with responsibility for implementing their smoke-free policy. Around 12 years ago, when working as a learning disability and mental health nurse, Mary noticed that the people she was caring for were dying 20 years earlier than everyone else in the community and that typically they were all smokers. The SSA caught up with Mary to talk about her work and about recent changes in vaping policy.
SSA: Why is smoking cessation so important for people with mental health conditions?
Mary Yates: “About one-third of the tobacco in this country is consumed by people with mental health problems. So, for those of us who are working in this area, we need to be skilled in supporting people to cut down and quit because it’s a very prevalent issue.
Not only do we have very high rate of smoking among people with mental health problems, but they have also usually been smoking for a very long time and are often severely dependent. They’re also smoking many cigarettes a day; so usually more than 20 cigarettes a day. But it’s not unusual for me to work with somebody smoking 60 cigarettes a day.
Around 60% of people who have psychosis or severe mental health problems will smoke. Among people who use illicit substances or who are in prison mental healthcare services the rate of smoking goes up to about 88% or even 90%; so, we can’t ignore this issue. We know that this is the single biggest reason why these people develop completely preventable illnesses and die very young.”
It’s not unusual for patients to have two NRT patches, one on each arm, together with their e-cigarettes
What kind of techniques do you use to help people quit smoking and how do they differ when you work with people with mental health problems?
“We use exactly the same interventions because we know they work. For people trying to stop smoking it doesn’t matter whether they have mental health problems, substance misuse problems, a learning disability, autism, dementia or a brain injury. The principles of supporting smokers to quit are the same across the population.
We do, however, tweak the interventions depending on the cognitive ability of a patient or ability to concentrate at the time that we meet them. So, of course we are always adapting and changing. We have a lot of people in our services for whom English is not their first language, so we need to use interpreters or other ways of communicating. We’re always adapting and being creative about what we do, but the principles, the products that we offer to people, the range of nicotine replacement therapy (NRT), the offer of e-cigarette starter packs, they’re all on the table and they’re all provided in the same way.
We sometimes need to give people much more NRT and often we provide our very heavy smokers with e-cigarette starter packs together with NRT. It’s not unusual for patients to have two NRT patches, one on each arm, together with their e-cigarettes.
We’re much more generous I think with our support, and we often see people for longer as well. So, I would typically have shorter meetings with patients if their concentration is limited. I would often see them more frequently, so would extend the duration of the treatment programme. But essentially the ingredients, the steps in the programme are the same, but we probably work through them at a slower pace.”
You’re always looking at high-risk moments …if they usually smoke at a bus stop you might suggest going to a different bus stop. Or if they always have a cigarette with coffee in the morning, trying tea instead.
Alongside NRT, do you use behavioural techniques?
“Again, the behavioural support techniques would be the same as those used with the general population. But it’s always about getting to know the person that you are working with and finding out what might work for them.
We introduce people to new ideas and give them new options for dealing with stress or boredom. These are sometimes the reasons why people with mental health problems smoke so much, especially when they’re in hospital.
Of course, we also look at high-risk moments when people smoke and try to help them plan to manage those periods or to change those patterns or routines. It can be various things; if they usually smoke at a bus stop, I might suggest going to a different bus stop. Or if they always have a cigarette with coffee in the morning, trying tea instead and seeing what happens. Just to try and shift that pattern slightly.
We have also started groups where people knit together on the ward. They’re then doing things with their hands, but are also being creative, changing their routines and finding other interesting things to do.”
What impact can smoking cessation have on metal health medication?
“When people smoke, the tar in the tobacco smoke speeds up the metabolism of some commonly used mental health medications. For example, clozapine or olanzapine, which are two of the most widely used anti-psychotic medications.
If someone stops smoking, the tar no longer speeds up the metabolism of those medications. The medicine then stays in the body for longer. The dose can potentially be reduced. With clozapine, for example, the dose can potentially be reduced by half. So, it’s a big motivator for patients when we have conversations with them about the possibility of cutting down or quitting.”
..having gone through that initial period of a dip in mood…they describe feeling really energised, feeling positive, having a greater sense of control over their life.
Would someone then experience fewer side effects from their medication?
“Yes, everyone who stops smoking feels a big boost to their mental health, so although it can be initially a feeling of low mood. Some people say they feel like their best friend has gone, because whenever they had any issues, whenever anything happened in life, if they were worried, stressed, anxious, or happy they had a cigarette. And once that’s gone, people can feel a bit lost without it. So yeah, I think having gone through that initial period of a dip in mood, once people come out of the other side, after about a month or 6 weeks, they describe feeling really energised, feeling positive, having a greater sense of control over their life and feeling that they can tackle other things in their life as well.”
It’s just recently been announced that e-cigarettes will be available on prescription, will that have an impact on your work?
“I hope so! I’m a big fan of e-cigarettes and I’ve been supporting people to use e-cigarettes since 2012 here in South London and Maudsley (SLaM). Since March 2020, we’ve been giving free starter packs to all our adult smokers and refills for the duration of their hospital stay. I would love to be able to extend that even further to all the smokers in community metal health services. So that’s my next plan, and if the rules around e-cigarettes change, then we will definitely be able to do that.
One-third of all the people admitted to acute hospitals every day up and down the country are admitted because they have smoking-related illness, and the NHS is in crisis. If we could prevent young people from starting to smoke and invest more in treating tobacco dependence as an urgent clinical condition, not as a lifestyle choice, then I really am firmly of the belief that we could save the NHS. We could turn off that pressure of people coming through the door every single day with all of these completely preventable illnesses.
So yes, I am excited about the proposed changes to e-cigarettes, and more and more I would encourage people to use them. Of course, I would only encourage smokers to use them, and only adult smokers, but I am very hopeful that when these changes happen, we will continue to see the rate of smoking decline, and that we will accelerate the rate of quitting in the mental health population in particular, which is what I’m really passionate about.”
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