Start Champix earlier in quit attempt and it might work, says Pfizer study!

Pfizer's new study claiming that starting earlier on Champix would improve its effectiveness couldn't come at a better time. This drug has maimed countless lives, and is the subject of a black box warning. Peter Hajek of the UK Centre for Tobacco Control Studies (no competing interests of course) and colleagues 'compare the effect to making food look unappealing. "The level of hunger pangs may be the same, but it is easier to resist a food that has become less tempting," they note.'

This is a poor comparison. Messing with someone's brain doesn't resemble disfiguring somebody's dinner. 

The people at the UK Centre for Tobacco Control Studies know how ineffective many quit attempts are.  Another member, Tim Coleman expressed this view in November:

Currently stop smoking services are evaluated on the percentage of 4-week quitters, but around three-quarters relapse after this date. 

His solution was to attempt to get funding for people to take smoking cessation drugs (NRT) in the longer term as a kind of damage limitation exercise. A similar assessment comes from the Tobacco Control blog, discussing Turkey's new anti-smoking facilities:

It’s worth remembering that, if the Turkish experience mirrors international evidence, every hotline call represents several other smokers who have decided to quit on their own. Even in countries with excellent, and often free, quit resources, more than 80% of smokers quit cold turkey (pun intended!) on their own.

An editorial discussing this study comments: 

One in five Americans smokes [...] and only between 4 and 7 percent of those who try to stop succeed. 

 These people know what a poor success rate smoking cessation drugs have. Yet huge amounts of money are spent promoting them, even on solutions like Champix which occasionally spell disaster for those taking it and their families.  

ASH Scotland is on a crusade to persuade the managers of Scottish mental health facilities to remove smoking rooms. Their next event will 'explore the new implementation guidelines' published by the Scottish government. No doubt they will be urged to ensure that smoking cessation meds are always available to patients who are forced into a no-smoking regime at a catastrophic time in their lives. Stopping people from smoking trumps every other consideration.

Scottish Government guidelines for smoke-free mental health services

Here at last are the guidelines directed to health trusts, designed to show them how to implement a completely non-smoking regime in institutions and facilities dedicated to psychiatric care.

A recent post on this blog shows that, far from being demanded by respondents to the 2009 Scottish Government consultation on smoke-free services, both the guidelines themselves and the achievement of a smoke-free mental health service have been opposed by most of the patients' groups that responded.

Andy Kerr, Scottish Minister for Health at the time the smoking ban legislation was passed in 2005, said the following in committee:

The approach was largely humanitarian and involved common sense, in my view. Residential homes are where people live and have their home. We felt that, as long as there was a smoking policy in such places, people would have the right to smoke where it was deemed to be their home, just as others in the community have that right. That applies to adult care homes, but not to children's homes.

Adult hospices are on the list of exempt premises for obvious humanitarian reasons. Psychiatric hospitals and units are included on the list because clinicians and others told us that that would be appropriate, if individuals' overall mental health and well-being were to be looked after. There were obvious humanitarian and other reasons for that exemption [...]

As we have asked before, what has changed?

Has anything actually changed? The small print, as far back as December 2005 (pp. 13–14 in a document signed by the same Health Minister, Andy Kerr), said:

However, the Scottish Executive recognises that the physical health profile of those with mental illness in Scotland is poor and smoking rates are traditionally high. It is committed to reducing the health inequalities experienced by this group of patients and will work with service providers to implement a programme of targeted cessation, which may allow the exemption for designated rooms to be reviewed in due course.

Ever since announcing the exemptions, the Scottish Government has been working to get rid of them:

It is clear from this that the Scottish Government's wish is for mental health services to go smoke-free. We now know that the consultation responses did not show public support for comprehensively smoke-free mental health services. Not that a rejection rate of around four-fifths of patient group participants is anything for the government to worry about.

And here is the resulting government press release:

"This is a further step towards our vision of a smoke-free Scotland. Patients and staff in mental health services should have the same opportunities to enjoy the benefits of a smoke-free environment as the rest of the NHS in Scotland.

"Allowing smoking in residential mental health services, when it is completely banned in all other NHS settings, simply perpetuates inequalities.

"Removing smoking rooms in mental health settings will undoubtedly be challenging but there is evidence that smoke-free policies can be effectively introduced and this guidance will help health boards to achieve that.

We're still waiting for a comment from Andy Kerr (and have been since December 2010).

Royal Edinburgh Hospital now a no-go area for smokers

In fulfilment of the ambitions of smoking ban advocates everywhere, the Royal Edinburgh Hospital (Edinburgh's psychiatric hospital) banned smoking everywhere on the site at the beginning of 2011, with the exception of two smoking shelters. This involved closing the smoking rooms that marked psychiatric hospitals as exempt premises when the smoking ban was introduced.

The outrage expressed in the article can be understood against the Scottish Government's determination to challenge the exempt status of psychiatric units in respect of the ban, in spite of all the consultation results (read here, and here). Eighty-one per cent of patient groups voted against the ban, and only one-third of respondents voted in favour of the exemption accorded to psychiatric units being removed. This must be weighed against the conviction of health board directors that smoking doesn't relieve stress for patients in psychiatric hospitals.

Apart from the danger of people lighting up covertly, and the inconvenience to staff of having such limited smoking facilities on the hospital premises, there is also the issue (reflected in this report) of a blanket smoking ban resulting in more involuntary admissions and/or people avoiding psychiatric treatment.

Freedom to Choose (Scotland)'s effort to challenge the Scottish Government on this issue was brushed firmly under the carpet. Throughout, the government's intention has been to avoid parliamentary scrutiny of the results of its consultation on smoke-free mental health services and its findings.

ASH Scotland calls for new anti-smoking laws

Or does it? I have to say I am a little confused.

A writer in The Scotsman says ASH Scotland wants further legislation.

Sheila Duffy says it doesn't.

ASH Scotland's paper on the issue is pretty non-committal.

ASH Scotland's recent CRUK-funded paper Beyond Smoke-free backs up Sheila's position to an extent. It talks about interventions, consultations, social marketing projects. It does not refer to further legislation, but does  wish to remove current exemptions from smoking bans in the short term. In the long term, says the paper:

There is public support for more comprehensive tobacco control policies and a strong ethical justification for additional measures aimed at reducing exposure to second-hand smoke. In order to make advances and substantially reduce exposure to second-hand smoke in Scotland, new approaches are required to tackle this complex issue.

But just what does public support mean? 'Support' for removing the mental health exemption is claimed to be found in this paper (which has 'demonstrated support for this move') The paper includes strong criticisms of the consultation paper on removing the mental health exemption and also says (page 12):

Just over one-third (35%) of those who responded to this question recommended that the existing exemption which permits smoking in designated rooms be removed by amending the existing legislation.  [...]

The vast majority (81%) of patient representative groups advocated the retention of the status quo, as did 6 out of 10 of respondents who identified themselves as current service users

It also says: 'Around one in ten (12%) of respondents advocated producing detailed guidance material without amending the legislation.' This was the option the government has taken, and the guidance will appear early next year.

From ASH Scotland's contacts with smoking cessation practitioners at local level in Scotland, we know that services are awaiting government leadership on this issue. The Scottish Government plans to produce guidance to support psychiatric units to close their smoking rooms – we await publication with interest.

Thus ASH Scotland says there is 'support' for a policy that 81 per cent of patient respondents have opposed and only one-third of all respondents supported.

Based on their assessment of the facts, I conclude that The Scotsman's version of events is correct and that Sheila Duffy does want legislation that will ban smoking in cars and even in the home.

Financial Times writer deplores bad use of science in Scottish heart attack studies

I know. Sorry. Again. But the Scottish Government stood by this absurd claim in repeated correspondence last year, when we criticised its use in the mental health consultation document – the document that was supposed to consult the Scottish people about whether to remove the smoking ban from psychiatric hospitals Unequivocally it said (without supplying even a reference list) that among the benefits of the smoking ban had been 'a 17 per cent reduction in heart attack admissions'. (The current state of proceedings on the smoking ban exemptions are recorded here.)

This is what John Kay has written in the Financial Times. The article is generally accessible online but you need to register (free of charge). His title is unflattering ('Even a filthy habit deserves a fair hearing'), but his analysis is commendable. Writing about unconvincing claims made to justify policy, he refers to the English and Scottish heart attack claims, and 'the more extravagant claim that the similar ban in Scotland had an effect of 17 per cent. The evidence for the former proposal [2.4 per cent] is weak, and the latter claim is implausible'. He points out the long term declines in heart attack admissions, and observes that the slightly higher than average drop in heart attack admissions in 2007 was reversed the following year. He describes the researchers' methods as 'torturing data' to produce results that 'either fit the researchers' preconceptions, or the sponsor's policy objectives, or both'.

His conclusion is very welcome at a time when the logic of social marketing holds sway (namely, that the end justifies the means): 'these observations [that smoking is unpleasant and possibly harmful to bystanders] do not justify blurring the distinction between genuine scientific analysis and propaganda disguised as science. Policy should follow evidence, not evidence policy.'

More mainstream media observations like this are essential. Considering the Scottish and English claims on heart attacks together, in the same article, shows the absurdity of the 17 per cent claim.

No doubt the Scottish Government still stands by the claim and defends the wording of the mental health consultation.