Fewer assaults as trust goes smoke free

A mental health trust that found one quarter of patients first started smoking when they were admitted to hospital, has saved more than £1.5 million of nursing time and seen the number of assaults drop since it went smoke free.

The South London and Maudsley NHS Foundation Trust (SLAM) analysed 31,719 patient records and found mental disorders were associated with ‘substantially’ lower life expectancy – up to 14.6 years for men and 17.5 years for women.

The trust’s health promotion and wellbeing nurse consultant Mary Yates says everybody knows the single most important cause of cancer, lung and heart disease and premature mortality is smoking.

And whereas smoking rates among the general population have fallen, the same cannot be said for people with enduring mental illness.

Parallel with 1950s

‘The prevalence of smoking is the same now as it was in the 1950s for those with mental health problems.’

Ms Yates says a conversation with a patient made her realise the organisation was making it hard for patients to kick a dangerous habit.

‘I feel ashamed about this – we were advertising on all wards telling patients when to smoke – one patient said he would go and have a cigarette even if he didn’t feel like it.’

A trust audit revealed:

• 58% of smoking patients were interested in quitting and most had tried, but nicotine replacement therapy (NRT) was not being used.
• 5% of all the violence in the trust was related to smoking
• 23% of patients had first started smoking after they had been admitted to hospital.

A survey of 18 adult wards showed that in each ward 2.47 hours a day of staff time was lost on supervising smoking breaks; one SLAM ward took 19 breaks a day.

Cost of supervision

The estimated cost to the nurses on band 5 supervising these breaks amounted to a staggering £1,609,650 over the course of a year.

Ms Yates said the decision to go entirely smoke free was about recognising tobacco dependence as an 'urgent clinical condition’.

‘People like me were facilitating and supporting people to smoke.

‘Before they die, smokers have debilitating chronic illnesses, such as chronic obstructive pulmonary disease or heart disease – lives are blighted and then they have stolen years.

‘It’s a huge problem and we cannot afford to not do something proactive about it.’

SLAM developed a strategy, piloting in forensic medium secure services, before the trust went smoke free in late 2014 using National Institute for Health and Care Excellence guidelines as a blueprint.

‘We wanted to make sure we did not just shove our patients outside the front gate,’ says Ms Yates, explaining it had been important to change people’s attitudes and the organisation’s culture.

‘We wanted to move away from this scenario where people were smoking as many cigarettes as they could in 15-minute opportunities in the garden, or going cold turkey in more restrictive environments.'

‘Neither scenario is right – it is very distressing to be in withdrawal.’

Today, everyone who comes into a SLAM hospital stops smoking, whether temporarily or permanently, and patients are offered ‘generous’ levels of NRT within 30 minutes of arrival. There is also a tobacco dependence advisor on each SLAM site.

Feeling the benefits

Smoke-free benefits to the trust have included financial savings, a significant reduction in the number of smoking related assaults, a better working environment and 519 referrals for support.

By quitting smoking, many patients have also reduced their dosage of antipsychotic medicine Clozapine by 50%, because smoking interferes with the effects of the medication.

‘In one of our rehabilitation services, the prevalence of smoking has dropped from 60% to 20%,’ said Ms Yates. ‘It’s an opportunity, not an obligation to stop smoking permanently.’

Case study one

Sally* is a 49 year old woman with schizoaffective disorder. She was admitted to the ward as the service was preparing to introduce the smoke free policy. Her routine was smoking 20 cigarettes per day and she has smoked since she left primary school, having started to help feel part of a group.

Sally was initially resistant to being in a smoke free environment – she was not interested in learning about the benefits of quitting and did not believe that it was possible to achieve. However, She responded well to using a carbon monoxide monitor to measure her carbon monoxide levels, and later joined a healthy living programme where she learned about the harmful effects of smoking – most of which she did not know.

As part of the ward plan she began to gradually cut down her daily cigarette consumption so that by the time the quit day arrived she was smoking just four cigarettes per day. She achieved this goal with the help of nicotine replacement therapy (NRT) patches as well as an NRT inhalator.

Sally coped well with quitting. She says the main things that helped her to get to this stage have been the education about the harmful effects of smoking.

Case study two

Simon* is a health care assistant in his 40s who has smoked for most of his adult life. He enjoyed the social aspect of smoking especially when he was off duty. However, he had concerns about the impact of smoking on his health and took the opportunity to quit as the trust's smoke free policy ensured free help and support was easily accessible to staff.

Simon benefitted from having help. He was able to formulate a coping plan that helped him manage the risky situations he found himself in.

Simon also benefitted from support and encouragement from his colleagues, the patient group and weekly meetings with his smoking cessation advisor. He used nicotine replacement products to manage the cravings and has been smoke free for more than a year.

*Names have been changed