wasted lives more of the same yet you choose not to ask patsi davies 20/101/10 patsi davies auckland...
TRANSCRIPT
Wasted Lives
More of the sameYet you choose not to ask
Patsi Davies 20/101/10
Patsi Davies Auckland University of Technology 4/11/10
Patsi Davies 21/10/10
What is this and where is it?
Introduction
*Mental health residential facilities
Tentacles – smoking normalisation
Challenges – 2020 Vision
Observations
Implications
Patsi Davies AUT 04/1/10
“ Unbelievable”
(How did this get ontothe choice side of the
equation?)
No evidence theystay quit after discharge
so no basisto have smokefree
facilities
(Board member)
“That is the only
pleasure
they have in life”
(Funder)
“I am only interested
in from here to here”
(Team leader)
Vision: Tobacco-Free Aotearoa 2020
Theme
“Achieve Together”
Kotahitanga - oneness/unity
Journey
Involves - building community
Bonds of Unity
“Inclusion in the journeyagainst the harms of smoke”
Rationale
Harms of smoke “smoke not smoker”
2020
Tobacco Control Initiatives
Legislation
NZ Health Strategy
Advocacy
Policies
National targets
Putea ($)
Education/campaigns
Cessation support & programmes
Hospitals/communities
Tobacco Control Initiatives
Smokefree Environments Amendment Act 2003 s6
'All indoor workplaces smokefree with few exceptions'(MoH, 2008)
Hospital care institutions“...may permit smoking by patients of a workplace,that is, or is part of...a hospital care institution...”
eg ventillation/patients only
NZ Health and Disability Services Act 2000
Purpose: improve, protect, promote health
S3. Reduce health inequalities
New Zealand Tobacco ControlGeneral Hospitals
Evidence of Harm (1950’s)
Research base – well established (2000)
Nicotine
Smoke
Mortality
Morbidity
Economic
Social
General Hospitals:
Mid 2000's
Smokefree
Policies
NZ Tobacco Control Initiatives
General Hospitals
Smokefree
But (mid 2000's)
Mental Health Facilities (inpatient)
Exemptions
indefinite
sunset clause
HR - different treatment?
Rationale ?...policy silence…let’s see
Evidence
Mental Health Service Users
Historical
Experiences
Initiatives
Exclusion
Social
Economic Political
Participation Inclusion
Vision 2020
Theme
Kotahitanga - oneness/unity
Journey
Building community
Bonds of Unity
“Inclusion in the journeyagainst the harms of smoke”
Rationale
Harms of smoke “smoke not smoker”
Mental Health & Smoking
Normalisation
Place/space *
Uptake
2HSmoke
Quit - harder
RYO v TM
Nurses - 27%
= Climate of tolerance for smoking
Why has Mental Health been left behind…
The Place of Tobacco
InstitutionalPractice
Institutional Economic
ArrangementsA
Commodity
Spaces for Smoking
Budgeted item
Legitimate Need
State Role
Everyday product
Acceptable
Essential
Easy access
Named by institution
InstitutionalPractice
SystemicExposure to
TobaccoUse
Barter/Power
Multi functional
Tool
Smoking Uptake
Harder to Quit
Staff buy it
Roll/light
Exposure SHS
Stand over tactics
C4Sx
Build Rapport
Time
Control Device
Therapeutic Rel
“FLOT”
Tolerance of Harm
Routine training - xNic assessments - x
Consistent Policies - xSilence - yes
Misinformation - yes
‘Even when the majority of patients accessing psychiatric services are
nicotine dependent (50-90%) and despite clear diagnostic description
and definition of nicotine dependence as a mental disorder, it is not common for
nicotine dependence to feature in either the diagnostic formulation
or the management plan of patients in written psychiatric reports.’
(Sellman, 2005)
Perhaps it is not surprising that:
In Essence...
The mental health workforce has less positive attitudes
to smokefree policies, assessment and treatment even
though nicotine fulfills the core criteria for a mental disorder
in the DSMIV.
This, together with the exemption of mental health service
users from smoke policies, reflects the tentacles of
normalisation.
Davies (2009)
Evidence for Better Health Outcomes
General hospital – clinical care/support
Current mental illness
1:3 cigarettes
Elevated rates:
lung disease
chronic heart disease
(MHF, 2008)
Evidence for Better Health Outcomes
Depression
Schizophrenia
50-60% service users
>rates (daily/dep)(Fergusson et al 2003)
>likely smoke/earlier/harder(Edwards et al 2006)
< 20% L/E(Hennekens et al 2005) (Brown et al 2000)
>likelysmoke/heavily/dep(Campion et al 2006)
> psych symptoms + >meds doses +>hospitalisationscessation - toxicity
Smoking relieves stress...
Agitation/Cravings/Anxiety
Alertness/Relaxation
'
High levels
Maori
Effect
> health in equalitieseg cancer survival & mortality
20/61%/T245.8 36.2
Health Inequalities
“Smoking is a major contributorto inequalities in health” (MoH,2007)
Service Users – health inequalities
Smoking – high levels
Maori
Pacific Peoples
Lower SES
Effect
>Health inequalities
eg cancer survival & mortality
89-93 = 1/3
Compounding
Royal Australiasian College Physicians/Psychiatrists
Tobacco Policy
“Smoking is particularly high among the most vulnerable
and disadvantaged people of society: those with mental
illness, people living with disability, those from lower
socio-economic backgrounds, youth and indigenous
people”.
(2005, p23)
1. Smoking – human right = X(HRA/NZBoRA/HDCA)
2. Policies – SU discrimination(burden = responsibility)
3. Home – right to smoke = X(MoH, 2008)
4. Policies - > violence(Lawn & Pols, 2005) Ca/Aus/USA/UK
5. Policies – avoid care(Lawn & Campion 2008) Aus
6. Will smoke after discharge Unique approach
7. Only pleasure...(Lawn & Campion, 2008) Agenda/prompt
Exemption Arguments
Case law: Rampton (HC - UK) QB (2008)
High Security Hospital
Decision: not allowed to smoke
“...is very strong evidence that smoking causes diseases
and endangers the health of smokers themselves and other
people who live and work in the vicinity...powerful evidence
that in the interests of public health...strict limitations on
smoking and a complete ban in appropriate circumstances
are justified”
Case law: Rampton (HC - UK) QB (2008)
High Security Hospital
Decision: not allowed to smoke
“...a need to protect the 'rights and freedoms of others'
...is engaged in the present context...a duty to protect others
from smoke pollution with respect to patients, some of
whom may be vulnerable and to staff (Lopez)...substantial
benefits arise from the ban and the disbenefits are
insubstantial...evidence supports the defendant's case”
1096
Mental Health Service Users
Historical
Experiences
Initiatives
Exclusion
Social
Economic Political
Participation Inclusion
Vision 2020
Theme
Kotahitanga - oneness/unity
Journey
Building community
Unity Bonds
“Inclusion in the journeyagainst the harms of smoke”
Rationale
Harms of smoke “smoke not smoker”
Observations
1. Evidence base exists(GP + MH + HI + DC = WL)
2. Resistance to SF /Policies
3. Reframed – focus on smokers not the smoke/harms
4. MHSU + smoking - special characteristics
5. Smoking – justified
6. Normalisation - alive
Policy Challenge
? Inclusion and exclusionthe only game in town?
? Keeping out those deemed different?
? Deemed superfluous to the vision?
? Exempt from policy framework that enables access to healthy pursuits
? Sites of the past - replaced by urban MHF
? Difference in treatment
2020/25
2020Policy Response
Evidence - burden of harm
Spot the normalisation – insidious
Entitlement - equal treatment
'Reframe - from smoke to smoker to whole person who smokes'
Why?
‘Only pleasure in life‘ - telling
Life threatening MH Disorder
Quality of care systems – wake up
2020Policy ResponseEvidence - burden of harm
Spot the normalisation – incidious
Entitlement - equal treatment
'Reframe - from smoke to smoker to whole person who smokes'
Why?
‘Only pleasure in life‘ - telling
Life threatening MH Disorder
Quality of care systems – wake up
Policy Response
Evidence
Normalisation
Entitlement
-burden of harm
- know it
- insidious
- spot it
- equal treatment (at least)
Reframe
“MHSU smoker to whole person who smokes”
“Only pleasure in life” – telling
Life threatening MH Disorder
Life threatening – all users
Quality of care systems – wake up
Wasted Lives
More of the same(exclusion/unworthy)
Yet you choose not to ask(about the evidence)
Patsi Davies 20/101/10
Patsi Davies 21/10/10