DOCUMENT CONTROL:

Version: 5.1

Ratified by: Covid-19 Gold Command

Date ratified: 7 April 2020

Name of originator/author: Deputy Director of Nursing and Quality

Name of responsible committee / individual:

Executive Director of Nursing and Allied Health Professionals

Unique Reference Number: 32

Date issued: 1 May 2020

Review date: February 2021

Target Audience All Trust Staff

Description of Changes: Due to the Covid-19 Pandemic Gold Command agreed a review extension from August 2020 to February 2021

Patient and Visitor Harm

Reduction / Smoke Free Policy

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CONTENTS

SECTION PAGE

1. INTRODUCTION 3

2. PURPOSE 6

3. SCOPE 7

4. RESPONSIBILITIES, ACCOUNTABILITIES AND DUTIES 7

5. PROCEDURE / IMPLEMENTATION 9

6. TRAINING IMPLICATIONS 20

7. MONITORING ARRANGEMENTS 20

8. EQUALITY IMPACT ASSESSMENT 21

8.1 PRIVACY, DIGNITY AND RESPECT 21

8.2 MENTAL CAPACITY ACT 21

9. LINKS TO OTHER PROCEDURAL DOCUMENTS 22

10. REFERENCES 22

11. APPENDICES 23

App. 1 SMOKING RISK ASSESSMENT FOR INPATIENT SERVICES

24

App. 2 INFORMATION FOR PATIENTS 25

App. 3 QUICK REFERENCE FLOWCHART 26

App. 4 NICE Guidance PH48, November 2013. Key Points 27

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1. INTRODUCTION

Evidence of the damage caused to health by smoking tobacco is overwhelming and irrefutable. Smoking is a major cause of disease killing one out of every two smokers. Tobacco use is a significant problem that affects us all. It affects our health, our wealth and our safety. Tobacco use is the biggest cause of premature death in the UK. One in two long-term smokers will die prematurely as a result of smoking - half of these in middle age. The most recent estimates show that around 114,000 people in the UK are killed by smoking every year, accounting for one-fifth of all UK deaths. Those with mental health problems smoke significantly more and are therefore at greater risk (NHS Scotland, 2011). Smoking is the largest cause of preventable death in England. In 2013, smoking was responsible for over 78,000 deaths, 17% of all deaths in adults aged 35 and over that year. Around one in four people in England experience a mental health condition in any one year, most commonly being anxiety and depression. Although mental health conditions vary widely, there is long-standing evidence that smoking prevalence is substantially higher among most mental health conditions, and increases with the severity of the condition. Smoking rates are around 60% in those with probable psychosis, and up to 70% for people in psychiatric units. It has been clear for many years that people with mental health conditions die on average 10-20 years earlier than those without. It is now clear that increased suicide rates are not responsible for this discrepancy but in fact it is due to socioeconomic, healthcare, and clinical risk factors, with smoking the single largest contributor to reduced life expectancy (Katy Harker and Hazel Cheeseman, 2016). People with mental health conditions will receive care and support in a range of settings, for example from their GP, community-based services, home treatment teams, inpatient services. Change is needed in all settings to support people who smoke and have a mental health condition. The higher rates of smoking in this population and the challenges they face in quitting smoking calls for a more targeted response (Katy Harker and Hazel Cheeseman, 2016). The most common diseases caused by smoking include coronary heart disease, lung cancer, chronic bronchitis, emphysema, pneumonia and chronic obstructive pulmonary disease (COPD). It can also cause illnesses including mouth, nose, throat, oesophagus and larynx cancer, strokes, decreased fertility, gangrene leading to amputations, and premature ageing. Toxic chemicals in cigarette smoke suppress the immune system, and also deplete the body of vitamins. A smoker can have up to 30 per cent less vitamin C in their system than a non-smoker. Studies have shown a link between smoking during pregnancy and an increased risk of adult attention deficit hyperactivity disorder in the child when it is in adulthood.

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Having a mental health problem increases the risk of physical ill health. Depression increases the risk of mortality by 50% and doubles the risk of coronary heart disease in adults. People with mental health problems such as schizophrenia or bipolar disorder die on average 10–20 years sooner than the general population. They have higher rates of respiratory, cardiovascular and infectious disease and of obesity, abnormal lipid levels and diabetes. They are also less likely to benefit from mainstream screening and public health programmes. Increased smoking is responsible for most of the excess mortality of people with severe mental health problems. Adults with mental health problems, including those who misuse alcohol or drugs, smoke 42% of all the tobacco used in England. Many wish to stop smoking, and can do so with appropriate support (No health without mental health: a cross-government mental health outcomes strategy for people of all ages, DOH (2011). Passive smoking or second hand smoking – breathing other people’s tobacco smoke – and side stream smoke has now been shown to cause lung cancer and heart disease in non-smokers, as well as many other illnesses and minor conditions. As of the 1st July 2007 smoking was banned in virtually all enclosed public spaces, workplaces, public vehicles and employer owned vehicles used for work purposes. The law applies to almost all substances that can be smoked, including cigars and herbal cigarettes. NICE Guidance PH48 (2013) states “Secondary care providers have a duty of care to protect the health of, and promote healthy behaviour among, people who use, or work in, their services. This duty of care includes providing them with effective support to stop smoking or to abstain from smoking while using or working in secondary care services.” In the words of Professor Sue Bailey OBE, President of the Royal College of Psychiatrists; “There is a common but mistaken belief among some mental health professionals that it’s alright for patients in their care to smoke. This is wrong. Patients with mental health problems are far more likely to smoke than the general population, they suffer disproportionately higher rates of physical illnesses, and they die earlier. It’s a disgrace that this section of our NHS patient population is left to suffer the consequences of smoking”, Press and media (2013) In line with the guidance PH48 issued by NICE (2013), the Rotherham Doncaster and North Humber NHS Foundation Trust (Trust) will operate a policy that positively promotes a smoke free environment and thereby health and wellbeing for all. The Trust will provide support and treatment to smokers who wish to quit and support smokers who do not want to quit to temporarily abstaining from smoking whilst in Trust premises and vehicles used for the purposes of patient transport.

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Legal position Section 2(2) of the Health and Safety at Work Act 1974 places a duty on employers to: ‘…provide and maintain a safe working environment which is, so far as is reasonably practical, safe, without risks to health and adequate as regards facilities and arrangements for welfare at work.’

The Health Act (2006) chapter 28, part 1, section 4 and sub section 1 states that ‘the appropriate national authority may make regulations designating as smokefree any place or description of place that is not smoke-free under section 2. The Trust derives its power from the NHS as an appropriate national authority and thereby makes this Smoke free policy; prohibiting smoking in Trust premises i.e. buildings, grounds and Trust vehicles. This policy reflects the following legislation and guidance:

Health Act 2006 which is found at: http://www.legislation.gov.uk/ukpga/2006/28/pdfs/ukpga_20060028_en.pdf

The Smoke free (Premises and Enforcement) Regulations (2006) that requires virtually all enclosed public places and workplaces in England to be Smokefree. The legislation in full is detailed at: http://www.smokefreeengland.co.uk/thefacts/the-regulations.html

Guidance from DH ‘Reducing Exposure to Second-hand Smoke’, 29 October 2009

Royal College of Nursing Guidance’ Protecting Community Staff from Exposure to Second-hand Smoke’, 2006

ASH research report: The health effects of exposure to second hand smoke Planned review published March 2014, http://ash.org.uk/download/ash-research-report-secondhand-smoke/

The Care Quality Commission, Brief guide for inspection teams: Smoke free polices in mental health inpatient services. www.cqc.org.uk

Electronic cigarettes: A briefing for stop smoking services. Issued 2016 by the National center for smoking cessation and training. www.ncsct.co.uk

Pharmacy Guidance on Smoking and Mental Disorder. 2017 update. www.rpharms.com

Public Health England guidance. Use of e-cigarettes in public places and work places: Advice from evidence based policy making. Published 2016. www.gov.uk

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Smoking Cessation and Mental Health: A briefing for frontline staff. Issued 2014 by the National center for smoking cessation and training. www.ncsct.co.uk

2. PURPOSE

The purpose of this policy is to raise clinical staff awareness, and set out the responsibilities of Trust staff to ensure compliance relating to the legislation on smokefree environments. This will:

Enable all staff, patients and visitors to the Trust premises to benefit from a sensible approach to a smoke-free environment

Protect patients, visitors, staff and others from potential health risks associated with second hand smoke inhalation whilst on Trust premises.

Protect staff from exposure to smoke when making home visits, see Appendix 1

Provide opportunities and support to patients and visitors who wish to give up smoking

Support inpatient smokers to help them cope and comply with increased restrictions or to stop smoking by providing free nicotine replacement and behavioural support

Give authority to staff as part of implementing this policy to carry out random, routine or dedicated searches aimed at maintaining a smokefree environment. This means that all patients with unescorted access (including informal patients) will on return to the ward may be subject to a rub down search at nurse in charge discretion. Please refer to the Policy and Procedure for the Searching of a Person (Patients and Visitors) or their Property

Identify and minimise fire risks within Trust premises. In addition this policy seeks to:

Comply with Health Act 2006

Comply with the Smoke Free regulations which commenced on 1st July 2007

Comply with Health & Safety at Work Act 1974

Provide a safe and healthy working environment and protect the current and future health of staff, patients and visitors

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Observe the right of everyone to breathe in air free from tobacco smoke

Raise awareness of the hazards associated with exposure to tobacco smoke

Take account of the needs of those patients who choose to smoke and to support those who wish to stop

3. SCOPE

This policy applies to all staff, patients who are in an episode of treatment, visitors, and other persons, whilst they are on Trust premises.

3.1 Exclusions.

This policy does not cover patients who are undergoing an assessment for possible access to our services through one of the Gate Keeping teams.

3.2 Definitions: Trust – Wherever stated, this means Rotherham Doncaster and South Humber NHS Foundation Trust Patient – means service user, patient and or client Cigarette – means cigarette, cigar, roll-ups, etc. that contains nicotine based products.

4. RESPONSIBILITIES, ACCOUNTABILITIES AND DUTIES 4.1 The Chief Executive and Board of Directors are responsible for ensuring that

the Trust has policies and procedures in place to support best practice, the management of associated risks and compliance with all legislation which is applicable to the Trust. The Chief Executive has overall responsibility for the health, safety and welfare arrangements of the Trust and compliance with legislation. The Director who is accountable with responsibility to ensure implementation of this policy is the Chief Operating Officer.

There is a legal Duty of Care placed on the Trust to put in place reasonable arrangements for the improvement of the health of patients and staff and the Trust acknowledges that breathing other people’s smoke is both a public health hazard and welfare issue, proven to cause ill health. This policy recognises that second-hand smoke may adversely affect the health of all staff and patients. This policy relates to where a person is smoking and the effect this may have on patients, visitors, Trust staff, contractors and other members of the wider health community who may be on Trust premises. In providing a smoke-free environment the Trust will actively support patients to stop smoking.

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4.2.1 Care Group Directors, Modern Matrons and Service Managers The Health Act 2006 chapter 28, part 1, section 8 and sub section 1 states that ‘It is the duty of any person who controls or is concerned in the management of smokefree premises to cause a person smoking there to stop smoking’ and therefore Directors, Care Group Directors and Managers are responsible for:

Raising clinical staff awareness of this policy and maintain effective communication of the policy to all staff

Ensuring that ward/treatment team information leaflets, and appointment letters for patients and carers clearly state that the Trust promotes a smokefree environment and what support can be provided to anyone using the services who smokes.

Maintaining a safe, healthy working environment through implementation and compliance with this policy

Address, note and take relevant action regarding concerns raised by staff that individual requirements or circumstances are not being met in relation to this policy

Ensure that necessary risk assessments are completed when staff report that they are being subjected to passive smoking which includes staff who visit patients in their own home or community based residence

Take appropriate action where patients or visitors do not comply with this policy.

Ensure that patients are aware of and have access to advice and support to either manage their personal smoking habits or to stop smoking

4.3 It is the responsibility of all Trust staff to:

Comply with and implement the requirements of this policy. It is of vital importance that all staff see the beneficial aspects of this policy in order to be able to comply with its implementation.

Report promptly to their manager any circumstances which have resulted in them being subjected to passive smoking in the course of their duties, which includes visiting patients in their own home or community based residence. Staff should request from patients who are smokers that they have their last cigarettes an hour prior to scheduled visits and appointments. Such an agreement will be recorded as part of the treatment plan. See appendix 1

Desist from turning a blind eye when a patient is found smoking on Trust premises.

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Take steps to prevent ignition sources (such as lighters and matches) and smoking paraphernalia being brought into the Trust premises.

Report any incidents of non-compliance in relation to any aspect of this policy to their line manager and via the Trust IR1 Incident Reporting System

Be aware that non-compliance with any particular element of this policy may amount to active lack of care or negligence, a breach of duty of care and therefore constitute a wilful or intentional failure to obey a lawful and reasonable request and may result in disciplinary action, in accordance with the Trust’s Policy for the Management of Disciplinary Matters.

5. PROCEDURE/ IMPLEMENTATION

NICE (2013) recommends strong leadership and management to ensure that Trust premises remain smokefree to help to promote non-smoking as the norm for people using the Trust services.

The smoking of tobacco products is not permitted within any part of the Trust premises. The exception is St. John’s Hospice as it is exempt from smoke free Legislation under Regulation 5 of the Smoke free (Exemptions and Vehicles) Regulations 2007. Within St. John’s Hospice, the management team should have an internal arrangement in place that will prevent staff from being exposed to second hand smoke.

Ward staff should not keep on the ward or themselves while on duty any ignition sources or smoking paraphernalia for use by handing them over to patients for the purpose of enabling them to smoke.

Patients and visitors on Trust premises will be made aware of the smoke

free policy through signs, posters, and leaflets as well as conversations with staff. Patients and visitors will be provided with a list of the contraband items in the hospital which includes tobacco, cigarettes, lighters, matches, re-chargeable e-cigarettes and chargers. The list of banned items will be published on a noticeable location beside the entrance to a ward and patients and visitors attention drawn to it on entering premises. Any visitor who is found to be supplying a patient in hospital with contraband items will be reminded about the relevant policy and asked to support the patient’s treatment plan. Persistent offenders may be banned from visits in the future. The rationale for the smoke free policy will be explained and carers will be offered support to learn more about the harmful effects of tobacco dependence. If appropriate they will be directed towards their local stop smoking service.

It is recommended that where staff choose to approach a patient, or visitor to inform them of the Trust policy, this approach is made only once and adheres to the principles taught in the Trust’s conflict resolution and reducing restrictive interventions training courses. The information provided should be limited and along the lines of; ‘Can I make you aware that this is a smokefree

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Trust within both the hospital and grounds.’ Breaches can be reported to the appropriate manager with a brief explanation of the circumstances and outcome. A zero tolerance approach will be applied to any individual who becomes abusive when reminded of the smoke free policy. Should the person become aggressive then the member of staff is to walk away from the situation and seek support from their line-manager.

5.1 COMMUNITY SERVICIES.

Staff working within community services play an important role in advising patients on the management of their tobacco dependency and as a minimum need to take the following steps.

5.1.1 Assess the patient’s smoking status.

As part of the initial assessment into a treatment service, patients are to be asked:

If they are a smoker.

How many cigarettes they smoke on average each day.

If they have ever tried to quit smoking in the past.

If yes, what methods did they use, how long did they quit for, what prompted them to start smoking again.

If they have never tried to quit before ask what has stopped them in the past.

All patients who smoke are to be provided with the contact details for their local quit smoking support service.

A record of the above is to be made in the patient’s clinical record.

Throughout their episode of treatment the patient’s smoking status should be reviewed at regular intervals, and for patients subject to a Care Programme Approach (CPA) this review should be done as part of their CPA reviews. Community staff are to carry a small supply of health promotional material in relation to local smoking cessation services, and inform patients of the fact that the inpatient services are smokefree.

Where the patient is likely to have contact with inpatient services they are to be reminded of the fact that all local hospitals are smokefree, and where possible, encouraged to prepare an advance statement detailing how they would like to be supported to abstain during an inpatient episode.

5.1.2 Visiting patients who smoke in their own homes

All staff visiting or treating a patient in the patient’s home should make a request that a smokefree environment is provided for the duration of the visit. Where first appointments are provided in writing this request should be made

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in the text of the appointment and an information leaflet should be sent with the letter (see Appendix 2). When making appointments by telephone a verbal request is to be made for the patient not to smoke whilst any member of Trust staff is working within the patient’s home environment.

5.1.3 Action to be taken in the event of a patient receiving care in the

patient’s home struggling to comply with the request that they not smoke immediately prior to or during the planned visit.

If any patient receiving treatment from our Trust in their own home struggle to comply with the requirements of this policy consideration needs to be given as to whether or not arrangements need to be put in place such as:

Will they agree that in the hour leading up to their appointment they will smoke in an alternative room to the one being used to for the home visit.

Use of nicotine patches prior to and during the consultation/treatment episode.

The need for the patient to attend an alternative venue such as a clinic for their appointments rather than being seen in their own home.

Detail of any alternative arrangements will be included in the patients care plan.

For any patients in the community who persistently fail to comply with this policy a review will be undertaken by the clinical team to agree appropriate next steps taking account of the patient’s treatment programme and risk assessment.

5.2 ADMISSION TO INPATIENT SERVICES.

With the exception of the Hospice, all of the Trust inpatient wards are smoke free. This includes the mental health wards and according to NICE (2013), the episodic nature of mental health conditions can impact on a person’s ability or willingness to stop smoking. However, in a smokefree secondary care environment, mental health patients will be subject to enforced abstinence – even during an acute phase of illness – and will need help to abstain. Therefore, on admission patients are to be informed of the Trust’s Smokefree Policy, and, as part of the initial assessment the admitting/ assessing clinician will establish the following:

If the patient is a smoker.

How many cigarettes they smoke on average each day.

If they have ever tried to quit smoking in the past.

If yes, what methods did they use, how long did they quit for, what prompted them to start smoking again.

If they have never tried to quit before ask what has stopped them in the past.

All patients who smoke are to be offered a referral to a local quit smoking support service.

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The above discussion is to be recorded in the patient clinical records. In all cases of planned inpatient admission, information regarding the Trust status as a smoke free organization and banned items list will be given in advance to the patient and their identified next of kin/ carers or visitors. At admission patients are to be asked if they have any cigarettes, tobacco products, rechargeable e-cigarettes, chargers and ignition sources on them. If yes these are to be removed from the patient and securely stored until the patient is either able to make arrangements for their relatives to remove these items from the ward or is discharged from the ward .In the event of a patient refusing to hand over any of these items that they have with them, staff are to refer to the Trust policy for the Searching of a Person (Patients and Visitors) or their Property Policy and Procedure. The use of approved disposable E-cigarettes or Nicotine Replacement Therapy should be offered as part of the admission process. Staff should provide brief advice to patients on a regular basis. Please note that e-cigarettes cannot be used by pregnant women or anyone under the age of 18. The AAA approach is to be adopted when discussing smoking with a patient: ASK and record smoking status ADVISE the patient of personal health benefits in quitting ACT on the patient’s response, including referral to NHS support. (Brief Interventions and Referral for Smoking Cessation in Primary Care and Other Settings’ February 2009). Where patients decline this opportunity they must be advised to remain abstinent from smoking tobacco products whilst on Trust premises. For all smokers a care plan is to be put in place which details how they will be supported to remain abstinent during their episode of inpatient care.

5.2.1 Risk Management on an inpatient ward.

All patients who are identified as smokers should have a smoking risk assessment completed (see appendix 1) and a risk management care plan put in place to manage any known risks. Risks that need to be considered include:

Covert smoking, particularly in bed.

Banned items such as ignition sources and cigarettes being brought onto the ward by visitors, or following a period of leave.

Increased risk of the patient absconding.

The risk that a patient who is using disposable e-cigarettes may ingest the lithium battery as a way of self-harming.

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5.2.2 Medication management.

It is known that smoking increases the metabolism of different medications, including some antidepressants (tricyclics and mirtazapine), antipsychotics (clozapine, olanzapine and haloperidol), some benzodiazepines and opiates. This can result in significantly lower plasma levels and therefore, larger doses of the medication are required to achieve a similar therapeutic effect as in a non-smoker. Therefore when a person stops smoking the metabolism of some medication can be reduced resulting in higher, sometimes toxic plasma levels developing over a few days. This means that should a patient chose to stop smoking close monitoring will be required and doses of the medications listed above will need to be reduced within days if a patient choses to stop smoking and by up to 50% within a month of cessation. For patients who are prescribed Clozapine it is recommended that plasma levels of clozapine should be measured before smoking cessation commences to enable more accurate and timely monitoring and adjustment of medications. The current recommended reduction levels for medication are as follows:

Doses of clozapine and olanzapine should be reduced by 25% during the first week of cessation and then further plasma levels taken on a weekly basis until levels have stabilised.

Doses of fluphenazine and some benzodiazepines should be reduced by up to 25% in the first week of cessation.

Tricyclic antidepressants may need to be reduced by 10-25% in the first week

Further dose reductions may be required with continued cessation (Campion et al, 2017). When considering medication doses and reduction regimes for patients who wish to quit smoking the prescribing clinician should seek advice from a member of the pharmacy team.

5.2.3 Patients subject to assessment under section 136.

A person who has been brought to one of the Trust’s Section 136 suites is there for an assessment of their mental health and not formally admitted to the inpatient services it is recognised that if they are a regular smoker and unable to have a cigarette whilst awaiting assessment it can lead to an increase in their agitation and consequently negatively impact on their assessment. In view of this staff should offer the patient the option of an approved disposable e-cigarette, or the following 24 hour Nicotine Replacement Therapy:

21mg/24 hours if patient smokes more than 10 cigarettes per day. 14mg/24 hours if patient smokes less than 10 cigarettes per day.

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The use of this is to be recorded on the form PRN Nicotine replacement therapy NRT record of use.

5.2.4 Seclusion.

A secluded patient will not be able to smoke cigarettes, cigars, e-cigarettes or roll-ups etc. for the duration of his/ her seclusion and will have to be offered nicotine replacement therapy for the duration of his/ her seclusion.

5.2.5 Visitors.

This policy applies to all visitors to Trust premises. Staff will give advance information in their carer’s information packs to next of kin/ visitors regarding the Trust’s Smokefree status and list of banned items. In cases where this is not possible, every effort will be made to inform the next of kin/ visitor on arrival and or on first contact about this situation and request them to co-operate with the Trust by not smoking whilst on Trust premises. Any smoking paraphernalia they have in their possession is to be stored in one of the available lockers for the duration of their visit.

5.2.6 Prohibitions in relation to staff.

This Policy prohibits cigarettes, cigars, pipes, roll-ups, rechargeable e-cigarettes, ignition sources and any form of smoking paraphernalia from being kept on the ward by staff or on themselves for the purposes of facilitating smoking for themselves, patients or visitors.

5.2.7 Environmental management.

At the start of each shift a member of staff will be designated to undertake the routine observation of patients and these routine observations will include checking the general ward environment for evidence of none compliance with this policy. Where it has been identified by the ward team that any particular patient/s is a high risk of non-compliance consideration needs to be given to the need to vary the frequency and times of these routine checks.

5.2.8 Access to health promotion information on the harmful effects of smoking and smoking cessation support.

All wards will have this information clearly displayed and available on their information/ leaflet racks.

5.2.9 Smoking cessation support to inpatients.

The Trust recognises that patients who smoke may need support to comply with this policy. Therefore those patients identified as smokers will be offered either the use of disposable e-cigarettes or nicotine replacement therapy.

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Use of disposable e-cigarettes.

Due to the nationally reported fire risk rechargeable e-cigarettes will not be permitted for use on the inpatient wards. Disposable e-cigarettes are available and only these will be permitted on the inpatient wards. The Trust has chosen to issue the E Burn e-cigarette free of charge to inpatient as this is :

A brand of disposable electronic cigarette distributed in the UK with a

single on-line distributor.

A consumable and therefore not considered a medicine, so access and

storage are not governed by the requirements of the Medicines Act.

Designed with security features that are applicable to secure settings

and is currently used in around 50 Mental Health Trusts and prisons.

Each e-cigarette equates to 35 nicotine based cigarettes.

If due to personal preference an inpatient wishes to use an alternative brand

of disposable e-cigarette to the E Burn they will be responsible for

purchasing these themselves.

The smoking of disposable e-cigarettes inside any Trust buildings will not be permitted. Patients are to only smoke them in the designated outdoor areas. Stock Control of the disposable e-cigarettes. Each ward will order the E Burn e-cigarettes via purchasing. When the stock arrives onto the ward the number of e-cigarettes is to be entered into the stock book. When an e-cigarette is given to a patient the following details are to be entered into the stock book:

Date

Patient name.

Name and signature of the staff member giving the e- cigarette to the patients.

Name and signature of the staff member witnessing the patient being provided with the e-cigarette.

Number of e-cigarettes that remain in the ward stock. As each patient will have been asked at the point of admission how many cigarettes they smoked per day on average staff will know if anyone is over using the e-cigarettes

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Provision of e-cigarettes to patient who are having a period of leave from the ward. Any patient engaged in a quit programme with the smoking cessation services who is due to have a period of overnight leave from the ward will be provided with enough e-cigarettes to last for the duration of the leave. Patients who have declined access to the smoking cessation services are to make their own arrangements whilst on leave.

Prescribing of Nicotine Replacement Therapy.

The mainstay of inpatient NRT (nicotine replacement therapy) provision is the regular use of NRT patches to provide a baseline nicotine level with the addition of either PRN (as required) nicotine lozenges or inhalator to manage additional craving. Patients should be assessed to follow either a smoking cessation pathway or a nicotine replacement pathway through the course of their admission. To facilitate this nicotine replacement therapy will be available on all inpatient wards to be provided from the earliest appropriate time following admission. Access will be through assessments by qualified staff and may be administered against prescription or in line with the Trust Guidelines for nicotine management therapy on inpatient and attached units, which staff are to refer to for full guidance. While there is a wide variety of NRT available, due to the practicalities of ward storage and the need for accessibility it has been agreed within the Trust that the range will be limited to NRT patches (24 hour), lozenges (2 strengths) and spray, Therapy will be provided as a single product or a combination as appropriate to the patient smoking level and preference.

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Flowchart for Ward use of Nicotine Replacement.

PATIENT ASSESSMENT

Smoking

NRT PROVISION ON THE WARD. ( Patches to be securely stored in the treatment room ,or nurses’ station)

PATIENT DISCHARGED. Patients on problematic medication MUST be advised of consequences of re-starting smoking and where appropriate

additional monitoring arranged and information provided.

Cessation attempt COMPLETED :

No discharge NRT supplied. Patient advised of local

smoking cessation service.

Cessation attempt INCOMPLETE or patient wishing to attempt cessation on discharge: 2 weeks NRT to be provided and patient

referred to local Smoking cessation service.

Attempted NRT maintenance only (patient intends to re-start smoking once

home). No discharge NRT supplied and patient

advised of local smoking cessation service.

Initial assessment of need- Supply of NRT patch and PRN.

Daily assessment of need- supply of NRT patch and PRN.

Level 2 smoking cessation assessment for patient to either cessation pathway or NRT maintenance pathway. Consideration given to problematic medications – extra monitoring requirements to be

care planned.

SMOKING CESSATION PATHWAY NRT MAINTENACE PATHWAY

10- 12 week cessation program care-planned as per guidance.

Level 2 smoking champion support through programme to total cessation.

Assessment for regular and/ or PRN NRT supplements.

Level 2 smoking cessation assessment for patient to either continue NRT maintenance pathway or cessation pathway.

Regular Daily NRT patch to be prescribed on drug card and administered.

PRN – Lozenge prescribed

Assessment for self-administration.

Self – administration appropriate.

Access to own labelled pack. Level of access determined by patient and ward circumstances. Use recorded on the form PRN Nicotine replacement therapy NRT record of use.

Self – administration NOT appropriate.

Use of ward stock on patient request and recorded on the form PRN Nicotine replacement therapy NRT record of use.

Section 136 suite.

Initial assessment of need.

Offer following dose.

21mg/24 hours if patient smokes more than 10 cigarettes per day.

14mg/24 hours if patient smokes less than 10 cigarettes per day.

Use recorded on the form PRN Nicotine replacement therapy NRT record of use.

Initial response by nursing staff for up to 72hrs NRT use. Usage recorded on form Nicotine Replacement Therapy Assessment and Administration

Form.

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5.2. 11 Action to be taken if an inpatient refuses to comply with this policy In cases where a patient is found smoking nicotine based products and refuses or becomes violent when requested to stop or hand over the cigarette or the smoking paraphernalia there is no expectation that the staff member should in anyway put themselves at risk. The action taken will be dependent on a number of factors which although not exhaustive includes:

The level of perceived risk to the staff member or others if they try to force the issue with the patient.

Where the patient is smoking.

The legal status of the patient.

De-escalation is always the preferred option but if the situation requires immediate action staff are to follow the Trust ‘Policy and Proactive Care for Reducing Restrictive Interventions’. In all cases where a patient persistently breaches the smoke free policy an MDT review should be held to agree what action needs to be taken to manage the situation. The agreed actions will then form part of the patients agreed plan of care, and where the patient has been identified as posing a fire risk due to covert smoking the Trust ‘Policy for the Care of In-patients Who are Identified as Posing a Significant Risk to Themselves or Others’ should be implemented.

5.2.12 Staff escorted leave.

As part of their recovery programme some patients have periods of leave from Trust premises which are supported by staff. Whilst escorted leave forms an integral part of the patients recovery programme the smoking of tobacco products is not permitted whilst on escorted leave.

5.2.13 Discharge

As part of discharge planning it should be ascertained if the if patient wishes to maintain their abstinence following discharge. If yes:

Include in discharge care plan.

Notify relevant community staff.

Refer / sign post to local smoking cessation service ( if not already in contact with them) .

5.3 Smoking cessation training /awareness for staff.

All frontline staff in both community and inpatient services will complete the on-line training, brief advice in smoking cessation, which is accredited by the National Centre for Smoking Cessation Training. Staff can access this at: http://elearning.ncsct.co.uk/vba-stage_1

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5.4 Reporting of non-compliance with this policy.

All breaches of this policy are to be reported on the Trust Safeguard incident reporting system. Such reporting will enable the Trust to monitor any trends that are arising and take steps to proactively manage these and reduce the likelihood of future reoccurrence. Repeated non-adherence is to be reported to the relevant Modern Matron/ Service Manager. Any complaint relating to this policy from or on behalf of patients should be dealt with by the ward/ team manager or Matron/ Service Manager. If the issues remain unresolved the concern should be raised with PALS (Patient Advice and Liaison Service) or through the Trust’s formal complaints procedure.

5.5. Referral to smoking cessation services.

In addition to the support provided by the clinical teams, patients can also be referred to their local smoking cessation services for support to stop smoking. These services can also be accessed through a self-referral, and information on how to do this will be included in the patient information packs. The NHS Go Smoke Free Helpline number can also be given to patients, carers and staff which is 0300 123 1044. The helpline can offer advice and support on stopping smoking along with a website at www.givingupsmoking.co.uk. Alternatively, the Local Stop Smoking Services listed below can provide support and advice:

Yorkshire Smoke free if you live or work in Doncaster or Rotherham Tel: 0800 612 0011.

SmokeFreelife North Lincolnshire If you live or work in North Lincolnshire Tel: 01724 642014.

5.6 Sale of tobacco products on Trust premises.

No sales of tobacco products will be allowed on Trust premises including the provision of vending machines. It is a criminal offence for anyone to sell, transport or possess illegal tobacco products. Penalties for such offences may include imprisonment and/ or fines including fines of up to £5000 for any manager allowing their premises to be used for such activities. The selling/ storing and dealing in any way of illegal cigarettes and tobacco on Trust premises will not be tolerated. Where staff have reasonable suspicion that there is cigarette and or associated paraphernalia in a clinical area, they will take steps including search to identify and remove it from the premises. The Trust will fully co-operate with law enforcement agencies, such as HM Revenue and Customs, in their investigations. Any such illegal activity by a

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member of staff will be considered as gross misconduct and will result in appropriate disciplinary action.

5.7 Promoting the Policy

All Trust staff will promote a smoke free environment and healthy living. The Trusts expectation is to promote and develop a culture across all its premises that smoking is unacceptable and that everyone respects this.

5.8 CQC view of smoke free polices.

There has been concern amongst clinicians that implementation of a smoke free policy could be viewed by the CQC as a blanket restriction. However it is made clear in their brief guide to inspectors on smoke free polices in mental health inpatient services that such a policy does not constitute a blanket restriction as long as there is evidence of the following.

That staff have been trained in tobacco dependency, and brief smoking cessation support.

That written and verbal information is provided to patients and visitors which includes the Trust policy, what support is available and how to access it. .

That patients have access to and are provided with nicotine replacement therapy or supported in the use of e–cigarettes.

That appropriate medication reviews take place to take account of the need to adjust medication doses as a patient’s smoking status changes.

6. TRAINING IMPLICATIONS

Staff will be made aware of the contents of this policy through:

Line Manager

Trust Weekly Bulletin

Team Brief

Performance Review

Trust Intranet

Trust Induction

All clinical areas should have suitably trained staff to support patients to stop smoking. A Physical Health and Wellbeing Practice Development Programme is available to clinical staff which includes information on smoking and signposting to local stop smoking services.

7. MONITORING ARRANGEMENTS

Area for Monitoring

Methodology Who by Reported to Frequency

Policy Implementation

Via IR1’s as they arise

All Managers

Care Group Quality

As and when incidents of

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Area for Monitoring

Methodology Who by Reported to Frequency

meetings. non-compliance are reported.

Smoking related fire incidents

Exception report

Safety Team

Health, Safety and Security Forum

Bi Monthly

Smoking Related (but non-fire) Incidents

Exception report

All Managers.

Care Group Quality meetings.

Bi Monthly

8. EQUALITY IMPACT ASSESSMENT

The completed Equality Impact Assessment for this Policy has been published on this Policy’s webpage on the Trust (Policy) website.

8.1 Privacy, Dignity and Respect

The NHS Constitution states that all patients should feel that their privacy and dignity are respected while they are in hospital. High Quality Care for All (2008), Lord Darzi’s review of the NHS, identifies the need to organise care around the individual, ‘not just clinically but in terms of dignity and respect’. As a consequence the Trust is required to articulate its intent to deliver care with privacy and dignity that treats all Service User / Patients with respect. Therefore, all procedural documents will be considered, if relevant, to reflect the requirement to treat everyone with privacy, dignity and respect, (when appropriate this should also include how same sex accommodation is provided).

Indicate how this will be met

There are no additional requirements in relation to privacy, dignity and respect

8.2 Mental Capacity Act

Central to any aspect of care delivered to adults and young people aged 16 years or over will be the consideration of the individuals capacity to participate in the decision making process. Consequently, no intervention should be carried out without either the individuals informed consent, or the powers included in a legal framework, or by order of the Court

Therefore, the Trust is required to make sure that all staff working with individuals who use our service are familiar with the provisions within the Mental Capacity Act. For this reason all procedural documents will be considered, if relevant to reflect the provisions of the Mental Capacity Act 2005 to ensure that the interests of an individual whose capacity is in question can continue to make as many decisions for themselves as possible.

Indicate How This Will Be Achieved.

All individuals involved in the implementation of this policy should do so in accordance with the Guiding Principles of the Mental Capacity Act 2005. (Section 1)

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9. LINKS TO OTHER TRUST PROCEDURAL DOCUMENTS

Physical Health Policy

Supportive Observation of Inpatients who are identified as Posing a Significant Risk to Themselves or Others Policy

Prevention and Management of Violence and Aggression (PMVA) Policy (Reducing Restrictive Interventions, Positive and Proactive Care)

Policy and Procedure for the Searching of a Person (Patients and Visitors) or their Property

10. REFERENCES

Brief Interventions and Referral for Smoking Cessation in Primary Care and Other Settings’ February 2009.

Campion, Jonathan et al (2017). Pharmacy guidance on smoking and mental disorder – 2017 update. Royal College of Psychiatrist, National Pharmacy Association and Royal Pharmaceutical Society.

Department of Health Guidance HSG (92)41

Health Act (2006) Smoke-Free Premises, Places and Vehicles

Health Development Agency (2005) Guidance for Smoke-Free Primary Care Trusts

Health and Safety at work Act 1974

Katy Harker and Hazel Cheeseman, (2016), The Stolen Years: Mental Health and Smoking Action Report, Action on Smoking and Health (ASH)

NHS Stop Smoking Service and Monitoring guidance 2010/11

Nice Guidance PH48

NICE (2013), Smoking: acute, maternity and mental health services, Public health guideline Published: 27 November 2013, https://www.nice.org.uk/guidance/ph48

No health without mental health: a cross-government mental health outcomes strategy for people of all ages, DH, 2 February 2011

Press and media (2013), Press release archive: NICE says hospitals have a duty of care to help all patients who smoke to quit, 27 November 2013

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https://www.nice.org.uk/news/press-and-media/nice-says-hospitals-have-a-duty-of-care-to-help-all-patients-who-smoke-to-quit

Smoke Free legislation 2007

The Equality Act 2010 11. APPENDICES

1. Smoking Risk Assessment for Inpatient Services. 2. Information for Service User/ Patients. 3. Patient Assessment Flow Chart 4. NICE Guidance PH48, November 2013. Key Points.

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APPENDIX 1

Smoking Risk Assessment for Inpatient Services Mental Health and Learning Disabilities

Question Response Risk Identified

YES NO NA

Type of tobacco smoked. E.g. pipe, roll ups.

Average quantity smoked in a 24 hour period.

Length of time Service User/ Patient has been smoking.

Where does the Service User/ Patient usually smoke

Is there a time of day when they smoke more than at others.

For the following questions a yes indicates an area of risk for which a management plan will need to be put in place.

Do they ever smoke in bed?

Have they ever accidentally started a fire as a result of their smoking?

If they have had previous inpatient stays is there any record of them having smoked in non-designated areas, or accidently starting a fire.

Does the Service User / Patient have any identified or suspected memory /capacity problems?

If any risks have been identified please refer to the flow chart and include the recommended action in care plan.

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APPENDIX 2

INFORMATION FOR PATIENTS

Take Care of the Health Worker who takes Care of You

Important Information for People Receiving Home Visits Please consider the needs of our staff and provide them with a smoke free environment. Second hand smoke or passive smoking as it is sometimes called has been found by the Government Scientific Committee on Tobacco Health to be harmful to people’s health. It can cause heart disease, stroke and lung cancer in adults. Being exposed to second hand smoke even for a short time can cause eye irritation, headache, cough, sore throat, dizziness and nausea. Employers have a common law Duty of Care to take reasonable care to protect the health, safety and welfare of employees. The Trust is required by the Health and Safety at Work Act 1974 to ensure employees and others are not put at risk. We therefore ask you and/or you’re relative to provide a smoke free environment on the day when Trust staff are due to visit you in your home. How to protect staff from exposure to second hand smoke:

Avoid smoking inside your house for at least 1 hour before the healthcare worker is due to arrive

Open windows and doors to ventilate the room/ area where the visit will take place

Try to keep one room smoke free at all times to be used for when the healthcare worker visits

During the visit:

Do not smoke or let anyone else in the house smoke

Whilst the healthcare worker is in the house please ask anyone else in the house who smokes to go outside to smoke

Trust Smoking Policy We ask staff to assess whether any environment they enter is safe for them to work in. If a smoke free environment cannot be provided staff will undertake a risk assessment and if necessary you will be offered alternative treatment options. The Trust will support staff to leave any environment they consider to be unsafe. Our undertaking to you: You will be advised of the day our staff will visit you. If the staff member is delayed you will be contacted as soon as possible.

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APPPENDIX 3

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APPENDIX 4

NICE Guidance PH48, November 2013. Key Points.

Recommendations

This guideline includes recommendations on:

identifying people who smoke and offering help to stop, including intensive support

in acute and mental health services, and maternity services

providing information and advice for carers, family, other household members and

hospital visitors

advising on and providing stop smoking pharmacotherapies, and making these

available in hospital

adjusting drug dosages for people who have stopped smoking

putting referral systems in place for people who smoke

developing smokefree policies and commissioning smokefree secondary care

services

supporting staff to stop smoking and providing stop smoking training for frontline

staff

Who is it for?

Health and social care professionals, including clinical leads in secondary care

services and managers of clinical services

Commissioners, leaders of the local health and care system and Trust boards

Estate managers and other managers

People using secondary care services and their families and carers