Dr Debbie Robson, RMN, PHD

Senior Research Fellow

Widening access to e-cigarettes for people with

mental health &/or substance use problems

Overview

• Development of an e-cigarette policy in one NHS mental health organisation (South London, England)

• Overview of e-cigarette policies across NHS mental health organisations in England (ASH survey)

• Do e-cigarettes help people with a mental health and/or substance use problems stop smoking?

COI: Salary funded by NIHR, Maudsley Charity, Cancer Research UK @KingsNRG

Smokers – wider general population

15%

Smokers – mental health condition

50%

Smokers – substance use disorder

88%

We’ve left this group of smokers behind

Historically……..

Smoking was (is) seen as therapeutic and necessary by some patients, clinicians and families (despite lack of evidence)

Support to quit not provided (or offered in a way that is not appealing)

Often excluded from research studies – beginning to change

When they are included, struggle to achieve similar success rates to wider general population (according to gold standard criteria for smoking abstinence)

Development of an e-cigarette policy in a NHS mental health organization (England)

South London and Maudsley NHS Foundation Trust (SLaM)

• Provides mental health and substance use services

• Serves a local population of 1̴.3 million

• Provides • inpatient care to approx. 5,300 people &

• community care to approx. 45,000 people

• Part of King’s Health Partners Academic Sciences Centre

• Partial smokefree policy since 2007

• Comprehensive smokefree policy since October 2014

• Tobacco dependence treatment includes combination NRT, varenicline behavioural support from a team of 12 advisors

E-cigarette policy timeline (SLAM)

2012 -

Forensic Services sold disposable e-cigs in hospital shop

Oct ‘13- Sept ‘14

SLaM & King’s develop e-cig policy as part of smokefree policy and treatment protocol

Oct ‘14

SLaM go smokfree. e-cigs allowed across the whole organization

Feb ’17 -

Policies reviewed – widened type of e-cig devices allowed (following individual risk assessment)

Balancing mitigating risk with widening access

o First line treatment – NRT and/or varenicline

o Vaping has to be included in care plan

o Clients can vape in single use bedrooms, hospital grounds

o Not allowed in communal areas or therapeutic activities (e.g. group therapy)

o Prevent uptake in Child & Adolescent Mental Health Services

o Mitigate unintended consequences through individual risk assessment and safety procedures (e.g. safe charging)

Characteristics of vaping in a convenience sample of clients in SLaM (in 2018)

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

Device type Nicotine strength Flavours

N=185 60% male

90% ever-smokers 47% exclusive smokers

20.5% dual users

10% exclusive vapers

Robson et al (in preparation)

What’s happening nationally in NHS mental health organisations?

National Health Service (NHS England) position on the use of e-cigarettes in mental health settings

Care Quaity Commission Smokefree policies in mental health settings (2017)

‘It not appropriate to prohibit EC use in health services as part of smokefree policies’

House of Commons Science & Technology Committee (2018)

‘NHS England should set a policy of mental health facilities allowing e-cigarette use by patients unless Trusts can demonstrate evidence-based reasons for not doing so’

NHS England Long Term Plan (2019)

‘All people admitted to hospital who smoke will be offered NHS-funded tobacco treatment service….. for long-term users of specialist mental health & learning disability services, this includes the option for smokers to switch to e-cigarettes’

ASH survey of mental health NHS organisations in England (2019)

• 83% (45/54) Mental Health NHS Trusts responded to an online survey

• 82% (37/45) had a comprehensive smokefree policy (no smoking allowed in hospital grounds and buildings and tobacco dependence treatment)

• 100% offered smokers NRT

• 49% offered smokers varenicline

• 91% allowed the use of e-cigarettes

ASH (2019) Progress towards smokefree mental health services

Where can patients vape?

9%

2% 2%

44%

13%

76% 73%

0%

10%

20%

30%

40%

50%

60%

70%

80%

Not allowedanywhere

Off site only Sharedbedrooms

Single usebedrooms

Communalareas of ward

Ward courtyardor garden

Hosptal grounds

ASH (2019) Progress towards smokefree mental health services

How do patients access e-cigarettes?

9%

18% 20%

22%

27%

42%

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

Not allowed Vending machines Sold on wards Sold in hospital shops Bought off site/fromfriends

Provided free byhospital Trust

ASH (2019) Progress towards smokefree mental health services

Do e-cigarettes help people with a MHC and/or SUD quit smoking?

E-cigarettes for smoking cessation in smokers with a mental health condition

Caponnetto 2013 Italy

Pratt 2014 USA

O ’Brien 2014 New Zealand

Valentine 2018 USA

Hickling 2019 England

Caponnetto 2019 Italy

Diagnosis Schizophrenia Schizophrenia or bipolar

Px’d mental health meds

Dual diagnosis Psychosis Schizophrenia

Sample size 14 19 86 43 50 40

Vaping products 4 week supply Rechargeable,

prefilled, disposable

Nic -7.5mg/ml

4 week supply Prefilled tank

12 week supply Rechargeable,

prefilled, disposable

Nic-16mg/ml

4 week supply Refillable tank

Nic - 12-27mgs/ml

6 week supply Disposable

Nic- 45mg/ml

4 week supply Pod device

50mg/ml

Quit rate (longest follow up)

14% (1yr) 10% (1 month) 6% (6 months) 7% (1 month) 2% (6 months) 40% (3 months)

Ref: McNeill, Brose, Calder, Bauld & Robson (2020) EC evidence update – PHE commissioned report

At least half of participants in each sample reduced cigarette intake by ≥50%

All single group, before and after studies except O’Brien

E-cigarettes for smoking cessation in smokers with a substance use condition

Stein et al (2016) USA

Guillaumier et al (2018) Australia

Robson et al England

(results due in Spring 2020)

Condition Methadone treatment service

Residential drug & alcohol withdrawal service

Community drug & alcohol service

Sample size 12 100 124

Study design Single group before & after

RCT Service evaluation

Vaping device 2 week supply Disposable

Starter kit Tank

4- week supply of e-liquid

Choice of disposable, tank or pod devices 12 weeks supply of e-liquids/ nic salt pods Variety of flavours Also NRT Funded by CRUK

Stein et al (2016) Nic & Tobacco Research. Guillaumer et al (2018) Trials

Summary

• Smoking rates remain high in this group

• Need to increase quit attempts and translate these into successful quits

• E-cigarettes appear to be supporting the implementation of smokefree polices in NHS mental health organisations in England

• Emerging evidence that e-cigs can help his group quit or reduce cigarette intake (with the right e-cig product)

• Should not just settle on harm reduction (i.e. reduced smoking) – as this will just increase inequalities

• Whilst at the same time redefining what success looks like for this group of smokers – and understand what outcomes they value most http://smokefreeaction.org.uk/smoke

free-nhs/smoking-and-mental-health/

Resources for health professionals

Acknowledgements: Ann McNeill, Gilda Spaducci (King’s) Mary Yates SLaM). Mental Health Smoking Partnership (ASH)