Identification and treatment of tobacco dependence among young people in residential homes during the statutory annual health assessment: a retrospective case-note review

Background Rates of tobacco smoking are substantially higher among young people accommodated in residential homes than in the general youth population. Public health guidance from the National Institute for Health and Care Excellence (NICE) recommends that all smokers should be identified, advised to quit, and offered treatment for tobacco dependence during health-care consultations. Opportunities to address tobacco dependence are available for young people in residential care through the annual statutory health review assessment (HRA). However, little is known about the extent to which HRA is used to address tobacco dependence among this population. We aimed to assess smoking-related recording and clinical practice during the HRA. Methods A retrospective review of the statutory health assessment forms of all young people accommodated in residential homes by an English local authority in the East Midlands between June 1, 2013, and May 31, 2014, was conducted. Practice was assessed with standards developed from statutory and NICE guidance relating the recording of smoking-related information during annual health assessments. Descriptive statistics were used to summarise the characteristics of the young people and the level of smoking-related recording. Associations between categorical variables were analysed with χ2 tests, and one-way ANOVA was used to assess continuous data. Ethics approval was provided by the Families, Young People & Children Clinical Audit, Standards, Effectiveness and Research Group of Leicestershire Partnership NHS Foundation Trust, and data were accessed under Section 251 of the NHS Act. Findings 31 young people were included in the review, of whom 30 (97%) had completed a statutory HRA. Inquiries about smoking were made in 23 (77%) instances. 12 (52%) of those who had participated in the HRA and who were asked about smoking were identified as smokers. Nine (75%) of these smokers engaged in discussions about their smoking and were offered treatment for tobacco dependence: two (22%) accepted a referral for treatment. The reasons for declining support for smoking cessation were documented in two (17%) cases. Interpretation Opportunities to address tobacco dependence among young people in residential homes are being missed during the HRA. Further research should explore clinician practice and attitudes to addressing tobacco dependence during the HRA and the perceptions of these young people in relation to receiving smoking cessation advice and the treatment offered. Funding This study was funded by a UK Centre for Tobacco and Alcohol Studies PhD studentship

Tobacco use and looked-after children: developing a complex intervention to address smoking in residential care

Levels of tobacco smoking among looked-after children (LAC) substantially exceed those reported among the general youth population. Research highlights that smoking is common among LAC, further increasing the health and social inequality experienced by this vulnerable group. However, there is limited research evidence about smoking and the factors that influence tobacco use in residential units, and if opportunities exist to address tobacco use in residential care. The overall purpose of this thesis was to develop a theory- and evidence-based intervention to address tobacco use in residential units for LAC. This thesis adopted both quantitative and qualitative methods in a pragmatic mixed-methods design, and followed the developmental phase of the United Kingdom Medical Research Council framework for the development and evaluation of complex interventions. It comprised three stages. The first stage comprised a review of published articles describing interventions that aimed to address the lifestyle behaviours of residentially accommodated LAC. The purpose of the review was to assess the status of the literature, identify existing effective interventions, and to explore implementation issues in residential settings. Four articles describing two interventions targeting lifestyle behaviours among residentially accommodated LAC were identified. None of the articles specifically targeted tobacco use. However, descriptions of the implementation issues likely to be encountered were provided. To complement the existing evidence, two primary research studies were conducted. First, a quantitative retrospective case-note evaluation of statutory health assessment documentation (n=31) was carried out to assess prevalence and characteristics of residentially accommodated LAC, including those who smoke and to identify current smoking-related practice. According to statutory health assessment documentation enquiries about smoking were made in 23 (77%) instances. Twelve (52%) of those children who had participated in the health assessment and who received enquiries about smoking were identified as smokers. Smoking was found to be significantly more common among LAC over the age of 15 years [p=0.043, OR3.33, (95%CI 0.91-12.27)] and more frequently reported among LAC with mental health disorder (58%). Nine (75%) smokers were recorded as engaging in discussions about their smoking and as being offered treatment for tobacco dependence. Just two of the nine (22%) smokers accepted a referral for treatment. Second, a sequential, mixed-methods study comprising a cross-sectional survey of Residential Care Officers (RCOs) in the East Midlands (n=42) and semi-structured interviews with RCOs and residential unit managers (n=14) to explore and understand the use of tobacco in residential units, from the perspective of residential carers. Survey data were analysed descriptively and findings informed the development of a schedule of topics for discussion during the subsequent interviews. Qualitative data were analysed using a thematic framework approach. Forty-two RCOs (18% response rate) completed the survey, and 14 participants took part in the interviews. Despite reporting substantial awareness of smoke-free policies, a lack of adherence and enforcement became apparent, and levels of reported training in relation to smoking and smoking cessation were low (21%). Potential problems relating to wider tobacco-related harms, such as exploitative relationships; a reliance on tacit knowledge; and pessimistic attitudes towards LAC quitting smoking, were reported. Stage two synthesised the findings from the case-note evaluation and the mixed-methods study using an existing socioecological model, to identify 33 factors as influencing tobacco use in residential units for LAC, across seven interacting levels. A consultation with four local authority and community health stakeholders identified behaviours to target with an intervention and explored challenges and enablers to implementation. Strategies that address the wider harms of tobacco use by LAC, facilitate the implementation of completely smoke-free residential units, and those which encourage and support smoking cessation among LAC were prioritised by stakeholders, achieving mean scores of 4.5 (SD 0.57), 3.25 (SD 1.25), and 3.0 (SD 1.41) from a maximum of five points, respectively. Stakeholders identified 16 barriers and five facilitators to behavioural change and 13 implementation issues. Nine behaviours were identified as being amenable to change. In stage three, an exercise to develop potential intervention components involved mapping behavioural change targets and implementation issues to the Theoretical Domains Framework and the Diffusion of Innovation in Service Organisations model in order to identify and select behavioural change techniques and mode of intervention component delivery using the behavioural change technique taxonomy. Seven behavioural change techniques and ten modes of intervention delivery were selected from the behavioural change technique taxonomy to address target behaviours. The behavioural change techniques and modes of delivery were then modelled into an intervention comprising five components (stakeholder meeting, local leader engagement, a tobacco training programme, a smoke-free co-ordinator, and resources and tools). Finally, two social care professionals reviewed the intervention components and confirmed its relevance and utility to residential carers and their practice. In conclusion, the studies undertaken in this thesis have widened the understanding of tobacco use among LAC and has led to the development of a potential intervention to address this concern. While the intervention requires refinement and piloting before effectiveness can be determined, nonetheless, this thesis has addressed calls from successive governments, third-sector organisations, and health and social care professionals to examine and address the health needs of LAC. It is hoped that this research will lead to better awareness of the risks of smoking among LAC, and ultimately improve the health and social outcomes of LAC. Recommendations for further research are also made

Preparing for completely smoke-free mental health settings: findings on patient smoking, resources spent facilitating smoking breaks, and the role of smoking in reported incidents from a large mental health trust in England

Introduction: Despite high smoking prevalence and excessive smoking-related morbidity and mortality among people with mental disorder compared to the general population, smoking treatment is often neglected in mental health settings. The UK National Institute of Health and Clinical Excellence (NICE) recently issued public health guidance stipulating completely smoke-free mental health settings. This project evaluated existing smoking-related practices in preparation for guidance implementation. The objectives were to: audit the recording of smoking-related information and treatment provision; explore current arrangements relating to the facilitation of patient smoking; measure staff time spent and identify costs of facilitating smoking; and explore the role of smoking in smoking-related incidents. Methods: A mixed-methods study was conducted across four acute adult mental health wards, accommodating 16 patients each, over six months. It included a case-note audit, on-site observations, and a qualitative content analysis of incident reports. Results: Smoking status was recorded for less than half of the 290 patients admitted (138, 48%). Of those, 98 (71%) were recorded as current smokers, of whom 72 (74%) had received brief smoking cessation advice. Staff spent 6028 h facilitating smoking, representing an annual cost of £131,040 across four wards. Incident reports demonstrated that smoking facilitation was often central to the cause of incidences, triggered frustration in patients, and strained staff resources. Conclusion: The findings highlight the importance and potential of implementing completely smoke-free policies using comprehensive pathways

Smoking and looked-after children: a mixed-methods study of policy, practice, and perceptions relating to tobacco use in residential units

Despite the implementation of smoke-free policies by local authorities and a statutory requirement to promote the health and well-being of looked-after children and young people in England, rates of tobacco use by this population are substantially higher than in the general youth population. A mixed-methods study, comprising a survey of residential care officers in 15 local authority-operated residential units and semi-structured, face-to-face interviews with residential carers in three local authority-operated residential units, was conducted in the East Midlands. Survey data were descriptively analysed; and interview data were transcribed and analysed using thematic framework analysis. Forty-two care officers (18% response rate) completed the survey, and 14 participated in the interviews. Despite reporting substantial awareness of smoke-free policies, a lack of adherence and enforcement became apparent, and levels of reported training in relation to smoking and smoking cessation were low (21%). Potential problems relating to wider tobacco-related harms, such as exploitative relationships; a reliance on tacit knowledge; and pessimistic attitudes towards LAC quitting smoking, were indicated. The findings highlight the need for the development of comprehensive strategies to promote adherence to and enforcement of local smoke-free policy within residential units for looked-after children and young people, and to ensure appropriate support pathways are in place for this population

Application of normalisation process theory in understanding implementation processes in primary care settings in the UK: a systematic review

Abstract: Background: Normalisation Process Theory (NPT) provides a framework to understand how interventions are implemented, embedded, and integrated in healthcare settings. Previous reviews of published literature have examined the application of NPT across international healthcare and reports its benefits. However, given the distinctive clinical function, organisational arrangements and the increasing management of people with a wide variety of conditions in primary care settings in the United Kingdom, it is important to understand how and why authors utilise and reflect on NPT in such settings to inform and evaluate implementation processes. Methods: A systematic review of peer-reviewed literature using NPT in primary care settings in the United Kingdom (UK) was conducted. Eight electronic databases were searched using replicable methods to identify articles published between January 2012 and April 2018. Data were analysed using a framework approach. Results: Thirty-one articles met the inclusion criteria. Researchers utilised NPT to explore the implementation of interventions, targeting a wide range of health services and conditions, within primary care settings in the UK. NPT was mostly applied qualitatively; however, a small number of researchers have moved towards mixed and quantitative methods. Some variation was observed in the use of NPT constructs and sub-constructs, and whether and how researchers undertook modification to make them more relevant to the implementation process and multiple stakeholder perspectives. Conclusion: NPT provides a flexible framework for the development and evaluation of complex healthcare interventions in UK primary care settings. This review updates the literature on NPT use and indicates that its application is well suited to these environments, particularly in supporting patients with long-term conditions and co-morbidities. We recommend future research explores the receipt of interventions by multiple stakeholders and suggest that authors reflect on justifications for using NPT in their reporting

A systematic review of mental health professionals, patients and carers’ perceived barriers and enablers to supporting smoking cessation in mental health settings

Introduction: Evidence-based smoking cessation and temporary abstinence interventions to address smoking in mental health settings are available, but the impact of these interventions is limited. Therefore, this review aimed to identify and synthesise the perceived barriers and enablers to supporting smoking cessation in mental health settings. Method: Six databases were searched for articles reporting the investigation of perceived barriers and enablers to supporting smoking cessation in mental health settings. Data were extracted and coded using a mixed inductive/deductive method to the Theoretical Domains Framework (TDF), Key barriers and enablers were identified through the combining of coding frequency, elaboration, and expressed importance. Results: Of thirty-one included articles, 56 barriers/enablers were reported from the perspectives of mental healthcare professionals (MHPs), 48 from patient perspectives, 21 from mixed perspectives, and 0 from relatives/carers. Barriers to supporting smoking cessation or temporary abstinence in mental health settings mainly fell within the domains: environmental context and resources (e.g. MHPs lack of time); knowledge (e.g. interactions around smoking that did occur were ill-informed); social influences (e.g. smoking norms within social network), and intentions (e.g. MHPs lack positive intentions to deliver support). Enablers mainly fell within the domains: environmental context and resources (e.g. use of appropriate support materials) and social influences (e.g. pro-quitting social norms). Conclusion: The importance of overcoming competing demands on staff time and resources, the inclusion of tailored, personalised support, the exploitation of patients wider social support networks, and enhancing knowledge and awareness around the benefits smoking cessation is highlighted

Supporting smoking cessation and preventing relapse following a stay in a smokefree setting : a meta-analysis and investigation of effective behaviour change techniques

Background and Aims: Admission to a smoke-free setting presents a unique opportunity to encourage smokers to quit. However, risk of relapse post-discharge is high, and little is known about effective strategies to support smoking cessation following discharge. We aimed to identify interventions that maintain abstinence following a smoke-free stay and determine their effectiveness, as well as the probable effectiveness of behaviour change techniques (BCTs) used in these interventions. Methods: Systematic review and meta-analyses of studies of adult smokers aged ≥ 18 years who were temporarily or fully abstinent from smoking to comply with institutional smoke-free policies. Institutions included prison, inpatient mental health, substance misuse or acute hospital settings. A Mantel–Haenszel random-effects meta-analysis of randomized controlled trials (RCTs) was conducted using biochemically verified abstinence (7-day point prevalence or continuous abstinence). BCTs were defined as ‘promising’ in terms of probable effectiveness (if BCT was present in two or more long-term effective interventions) and feasibility (if BCT was also delivered in ≥ 25% of all interventions). Results: Thirty-seven studies (intervention n = 9041, control n = 6195) were included: 23 RCTs (intervention n = 6593, control n = 5801); three non-randomized trials (intervention n = 845, control n = 394) and 11 cohort studies (n = 1603). Meta-analysis of biochemically verified abstinence at longest follow-up (4 weeks–18 months) found an overall effect in favour of intervention [risk ratio (RR) = 1.27, 95% confidence interval (CI) = 1.08–1.49, I2 = 42%]. Nine BCTs (including ‘pharmacological support’, ‘goal-setting (behaviour)’ and ‘social support’) were characterized as ‘promising’ in terms of probable effectiveness and feasibility. Conclusions: A systematic review and meta-analyses indicate that behavioural and pharmacological support is effective in maintaining smoking abstinence following a stay in a smoke-free institution. Several behaviour change techniques may help to maintain smoking abstinence up to 18 months post-discharge

The impact of an intervention to increase uptake to structured self-management education for people with type 2 diabetes mellitus in primary care (the embedding package), compared to usual care, on glycaemic control: study protocol for a mixed methods study incorporating a wait-list cluster randomised controlled trial

Abstract: Background: Approximately 425 million people globally have diabetes, with ~ 90% of these having Type 2 Diabetes Mellitus (T2DM). This is a condition that leads to a poor quality of life and increased risk of serious health complications. Structured self-management education (SSME) has been shown to be effective in improving glycaemic control and patient related outcome measures and to be cost-effective. However, despite the demonstrated benefits, attendance at SSME remains low. An intervention has been developed to embed SSME called the ‘Embedding Package’. The intervention aims to address barriers and enhance enablers to uptake of SSME at patient, healthcare professional and organisational levels. It comprises a marketing strategy, user friendly and effective referral pathways, new roles to champion SSME and a toolkit of resources. Methods: A mixed methods study incorporating a wait-list cluster randomised trial and ethnographic study, including 66 UK general practices, will be conducted with two intervention start times (at 0 and 9 months), each followed by an active delivery phase. At 18 months, the intervention will cease to be actively delivered and a 12 month observational follow-up phase will begin. The intervention, the Embedding Package, aims to increase SSME uptake and subsequent improvements in health outcomes, through a clear marketing strategy, user friendly and effective referral pathways, a local clinical champion and an ‘Embedder’ and a toolkit of resources for patients, healthcare professionals and other key stakeholders. The primary aim is, through increasing uptake to and attendance at SSME, to reduce HbA1c in people with T2DM compared with usual care. Secondary objectives include: assessing whether there is an increase in referral to and uptake of SSME and improvements in biomedical and psychosocial outcomes; an assessment of the sustainability of the Embedding Package; contextualising the process of implementation, sustainability of change and the ‘fit’ of the Embedding Package; and an assessment of the cost-effectiveness of the Embedding Package. Discussion: This study will assess the effectiveness, cost-effectiveness and sustainability of the Embedding Package, an intervention which aims to improve biomedical and psychosocial outcomes of people with T2DM, through increased referral to and uptake of SSME. Trial registration: International Standard Randomised Controlled Trials Number ISRCTN23474120. Assigned 05/04/2018. The study was prospectively registered. On submission of this manuscript practice recruitment is complete, participant recruitment is ongoing and expected to be completed by the end of 2019

A cross-sectional survey of mental health clinicians’ knowledge, attitudes, and practice relating to tobacco dependence among young people with mental disorders

BACKGROUND: Mental health services in England are smoke-free by law and expected to provide comprehensive support to patients who smoke. Although clinicians’ knowledge in this area is reported to be limited, research exploring the issue in Child and Adolescent Mental Health Services (CAMHS) is lacking. This study aimed to investigate the knowledge, attitudes, and practice of clinicians working within specialist and highly specialist Child and Adolescent Mental Health Services (CAMHS) relating to tobacco dependence, its treatment and its relation to mental disorder. METHODS: A cross-sectional survey of clinicians working across all CAMHS teams of a large UK National Health Service mental health Trust. RESULTS: Sixty clinicians (50% response rate) completed the survey. Less than half (48.3%) believed that addressing smoking was part of their responsibility, and half (50%) asserted confidence in supporting patients in a cessation attempt. Misconceptions relating to smoking were present across all staff groups: e.g. only 40% of respondents were aware of potential interactions between smoking and antipsychotic medications, although psychiatrists were more knowledgeable than non-medical clinicians (91.6% vs 27.1%; OR 3.4, p < .001). Self-reported attendance at smoking-related training was significantly associated with more proactive clinical practice. CONCLUSIONS: There is a need to improve clinicians’ knowledge, capacity and confidence in effectively identifying, motivating, supporting and treating young smokers in the context of treatment for mental disorders. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (doi:10.1186/s12913-014-0618-x) contains supplementary material, which is available to authorized users

Implementing complete smokefree policies in mental health inpatient settings Results from a before and after mixed-methods evaluation : results from a before and after mixed-methods evaluation

Abstract Background Tobacco smoking is extremely prevalent in people with severe mental illness (SMI) and has been recognised as the main contributor to widening health inequalities in this population. Historically, smoking has been deeply entrenched in the culture of mental health settings in the UK, and until recently, smokefree policies tended to be only partially implemented. However, recent national guidance and the government’s tobacco control plan now call for the implementation of complete smokefree policies. Many mental health Trusts across the UK are currently in the process of implementing the new guidance, but little is known about the impact of and experience with policy implementation. Methods This paper reports findings from a mixed-methods evaluation of policy implementation across 12 wards in a large mental health Trust in England. Quantitative data were collected and compared before and after implementation of NICE guidance PH48 and referred to 1) identification and treatment of tobacco dependence, 2) smoking-related incident reporting, and 3) prescribing of psychotropic medication. A qualitative exploration of the experience of inpatients was also carried out. Descriptive statistical analyses were performed, and the feasibility of collecting relevant and complete data for each quantitative component was assessed. Qualitative data were analysed using thematic framework analysis. Results Following implementation of the complete smokefree policy, increases in the numbers of patients offered smoking cessation advice (72% compared to 38%) were identified. While incident reports demonstrated a decrease in challenging behaviour during the post-PH48 period (6% compared to 23%), incidents relating to the concealment of smoking materials increased (10% compared to 2%). Patients reported encouraging changes in smoking behaviour and motivation to maintain change after discharge. However, implementation issues challenging full policy implementation, including covert facilitation of smoking by staff, were reported, and difficulties in collecting relevant and complete data for comprehensive evaluation purposes identified. Conclusions Overall, the implementation of complete smokefree policies in mental health settings may currently be undermined by partial support. Strategies to enhance support and the establishment of suitable data collection pathways to monitor progress are required