Friday, 15 November 2013

A smoking ban for mental health workers at the workplace

To force a breakthrough in the smoking culture in psychiatry it should be prohibited for mental health staff to smoke in the work place. There I said it! (and yes I agree it should be like that everywhere in health care but in this blog I will focus on psychiatry).
Last time I said I would like to see a smoking ban for all mental health staff within hospital grounds and during home visits was when I arranged a meeting for mental health workers about psychiatry, health and sports. Many smokers weren’t pleased and that’s an understatement. Some were very annoyed and kind of hostile as if this was denying them a civil right. Many many health workers that smoke with patients say its good for bonding but its just an excuse to maintain the smoking culture.
It’s a challenge for patients to quit smoking in psychiatry where a lot of people smoke. They get discouraged. Mental health workers may often tell the patient that it’s too hard to quit with mental illness, that it stresses them out too much. And of course it’s quite an effort for them but I have seen enough to prove that it is not impossible. Sometimes I wonder if staff who smoke feel threatened by the brave attempts of patients who want to quit when they can’t manage to quit themselves.
Addiction to nicotine is the most common form of substance abuse in people with schizophrenia, who are more than three times more likely to be addicted to nicotine than the general population. The relationship between smoking and schizophrenia is complex. People with schizophrenia perceive certain benefits from smoking but at the same time it’s threatening their health and wellbeing in a serious way and can make antipsychotic drugs less effective. Heavy smokers often need higher doses of medication.
People with schizophrenia have a shorter life expectancy (up to 15-20 years shorter) than the average population and the main cause is smoking.

Over the years I have seen many people with mental illness die young because of smoking related diseases like heart failure, different forms of cancer, strokes, COPD. People in psychiatry can get help with quitting drinking, quitting street drugs, quitting benzo’s, quitting gambling… but there’s usually no specialised help for quitting or reducing smoking for people with mental health problems. Smoking doesn’t seem to have priority in the smoking culture of this specific field of health care with mental health staff having the highest percentage of smokers of all healthcare staff.
But with worrying statistics on physical health problems among people with mental illness we need clear measures. And mental health workers who are addicted to smoking should get over themselves and only practise their addiction outside the hospital gates and out of sight of patients, including in outpatients and in community settings. After all our goal is to improve and encourage health from a holistic point of view. Staff who smoke give the wrong message. Smoking should be banned and it should be the responsibility of managers in mental health care to enforce those bans.
I have been giving a “decrease-smoking-course” for people with mental illness for a few years now. The course is free. Most of the attendees have schizophrenia. There is always one chair for a mental health worker who wants to quit. They can attend the course during work hours. Thanks to the course we have a smoke free team now.
First it was called a “quit-smoking course” but we got very few subscribers. Quitting seemed a step too far for many. So we changed it to “decrease-smoking-course” which consisted of 10 sessions including a smoke break of 5 minutes. Soon we had a waiting list.
The first session was about smoking habits and keeping a smoking diary to get insight in smoking habits and coping. Many people started to smoke when they were admitted to a mental hospital for the first time. One of the patients started smoking when she was admitted with psychosis at age 27. She told us:
“Everyone, patients and nurses, seemed to smoke so I thought it might be helping and some nurses even promoted smoking by giving me a cigarette even though I didn’t smoke. And they took out the patients who smoked more often than the ones who didn’t smoke. So some started smoking to be with the others.”
Now at age 45 her GP told her she had to quit smoking because she had COPD. She joined the course and eventually managed to quit.
Most people who attend the course don’t quit but decrease a lot. That’s important improvement too. People who go from 60 to 10 cigarettes are not unusual. We involve psychiatrists, family, GP’s and mental health workers as supporters to make their resolution a success.
We notify and work closely with all people involved in their treatment and give information on how to offer support. The psychiatrist monitors blood levels especially when patients are taking Clozapine and sees the patient more frequently to adjust medication doses when needed. Smoking cessation can lead to higher plasma concentrations and potentially more side-effects. With Clozapine their levels can raise in a dangerous way.
Quitting smoking with this group should be monitored closely whether there is any exacerbation of symptoms or medication side effects, so possibly the dose of neuroleptic medication needs to be adjusted. Since quitting smoking is a challenge we make sure that the patients get extra support. Nicotine replacement methods may benefit their effort to quit.
Every mental health trust should offer specialised quit or reduce smoking support for patients and mental health workers.
I’m not promoting a smoking ban for patients. I’m very much against that. In the hardest times we shouldn’t force patients to quit. But I strongly believe that a healthier and more encouraging environment will help people to find the motivation to reduce or quit smoking and improve their wellbeing.
And that’s our job as mental health workers.