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Abstract Background Tobacco dependence among people with mental health problems is an issue that deserves attention both from a clinical and from a public health perspective. Research suggests that Stop Smoking Services often fail to ask clients about underlying mental health problems and thus fail to put in place the treatment adaptations and liaison procedures often required to meet the needs of clients with a mental health condition who want to stop smoking. This study assesses the recording of mental health problems in a large NHS stop smoking service in England and examines the effect of implementing a short screening procedure on recording mental health conditions. Methods Treatment records from the Stop Smoking Service covering a period of 13 months were audited. The prevalence of reported mental health problems in the six month period before the implementation of the mental health screening procedure was compared with that of the six month period following implementation. The screening procedure was only implemented in the support services directly provided by the Stop Smoking Service. Comparisons were also made with third-party sections of the service where no such screening procedure was introduced. Results The prevalence of reported mental health problems among a total of n = 4999 clients rose from less than 1% before implementation of the screening procedure to nearly 12% in the period following implementation, with the change being statistically significant. No significant rise was observed over the same period in the sections of the service where no screening procedure was implemented. Conclusions The absence of standard procedures to record mental health problems among service users in many stop smoking services is currently likely to prevent the detection of co morbidity. Implementing a simple screening procedure appears suitable to increase the routine recording of mental health problems in a stop smoking service, which is an essential step to ensure services can be tailored and delivered appropriately to the client group.

Abstract Background People with mental health problems exhibit smoking rates up to three times that of the general population. Metabolic interactions between hydrocarbon agents in tobacco smoke and some antipsychotic drugs account for a change in medication metabolism on stopping smoking, and potentially for increased blood levels. Nicotine withdrawal can mimic or exacerbate symptoms of mental illness. Therefore, appropriate screening for mental health problems and liaison with local mental health care providers should be a priority for NHS Stop Smoking Services. The present study aimed to examine this issue through surveys with NHS Stop Smoking Service staff in London. Methods Semi-structured telephone interviews were conducted with one senior staff member from 27 of the 29 NHS Stop Smoking Services in London. Results It was found that only a minority of services routinely check the mental health status or mental health service use of their clients. In addition, most services do not routinely implement special checks or actions when mental health problems are revealed. It was notable that respondents reported a lack of strategic drivers supporting work with mental health patients (such as targets relating to successful quits) as well as a low level of partnership working with local mental health care providers. Conclusions NHS Stop Smoking Services may not be operating appropriate procedures for supporting people with mental health problems. There is a need for local protocols to be implemented that include routine screening for mental health issues and liaison with mental health care providers.

Abstract Background According to the provisions of the Health Act 2006, NHS acute Trusts had to become smoke-free by July 2007. Mental health Trusts were granted a further year before all indoor smoking areas have to be removed. This study was carried out to determine the extent of smoke-free policy implementation in English NHS acute and mental health Trusts, and to explore challenges and impacts related to policy implementation. Methods Questionnaire-based survey of all English NHS acute and mental health hospital settings, supplemented by semi-structured telephone interviews with 22 respondents and direct observation at a sample of 15 Trusts (22 different sites). Human Resources Directors of all 245 English NHS Trusts providing acute and/or mental health inpatient care were identified as potential study participants. Main outcome measures comprised the proportions of Trusts reporting smoke-free policy implementation; whether these relate to buildings only or to whole premises including grounds; most frequently reported exemptions; reported and observed frequencies of policy breaches. Results Smoke-free policies were reported to be implemented in all mental health and 98% of acute settings studied. They applied to whole premises including grounds in 84% of acute, and 64% of mental health settings. However, exemptions were granted by 50% of acute and 78% of mental health settings, typically for bereaved relatives or psychiatric patients, in sheltered outdoor areas and smoking rooms. Reported challenges included policy enforcement and related risks of abuse, and litter on premises and adjacent public grounds. Nearly two thirds of acute and over a third of mental health trusts reported that policy infringements occurred on a daily basis. Indeed, patients and visitors were observed smoking at 94% of acute sites visited and staff smoking at 35% of them. Conclusion NHS hospitals should play an exemplary role in making a smoke-free environment the norm. Although smoke-free policies have been implemented in nearly all English NHS hospitals, exemptions are frequently granted and policy breaches appear to be commonplace.

Background: According to the provisions of the Health Act 2006, NHS acute Trusts had to become smoke-free by July 2007. Mental health Trusts were granted a further year before all indoor smoking areas have to be removed. This study was carried out to determine the extent of smoke-free policy implementation in English NHS acute and mental health Trusts, and to explore challenges and impacts related to policy implementation.Methods: Questionnaire-based survey of all English NHS acute and mental health hospital settings, supplemented by semi-structured telephone interviews with 22 respondents and direct observation at a sample of 15 Trusts (22 different sites). Human Resources Directors of all 245 English NHS Trusts providing acute and/or mental health inpatient care were identified as potential study participants. Main outcome measures comprised the proportions of Trusts reporting smoke-free policy implementation; whether these relate to buildings only or to whole premises including grounds; most frequently reported exemptions; reported and observed frequencies of policy breaches.Results: Smoke-free policies were reported to be implemented in all mental health and 98% of acute settings studied. They applied to whole premises including grounds in 84% of acute, and 64% of mental health settings. However, exemptions were granted by 50% of acute and 78% of mental health settings, typically for bereaved relatives or psychiatric patients, in sheltered outdoor areas and smoking rooms. Reported challenges included policy enforcement and related risks of abuse, and litter on premises and adjacent public grounds. Nearly two thirds of acute and over a third of mental health trusts reported that policy infringements occurred on a daily basis. Indeed, patients and visitors were observed smoking at 94% of acute sites visited and staff smoking at 35% of them.Conclusion: NHS hospitals should play an exemplary role in making a smoke-free environment the norm. Although smoke-free policies have been implemented in nearly all English NHS hospitals, exemptions are frequently granted and policy breaches appear to be commonplace. [ABSTRACT FROM AUTHOR]

Introduction: Digital technology is increasingly used to support interventions targeting smoking cessation in people with severe mental illness (SMI). However, little is known about their implementation and effectiveness in this population. We aimed to determine their effectiveness, stakeholder experiences, factors influencing implementation, and quality of reporting of digital interventions for smoking cessation in adults living with SMI., Method: Five online bibliographic databases were searched for articles published between 31 December 2000 and 31 January 2023. Studies involving adults accessing treatment for alcohol and substance use disorders, neurocognitive disorders and terminal illnesses were excluded. Risk of bias was assessed using the Mixed Methods Appraisal Tool (MMAT). A Mantel-Haenszel random-effects meta-analysis of randomized controlled trials (RCTs) was conducted. Participant experience and intervention implementation were explored using a narrative synthesis. Quality of reporting of interventions was assessed using the Template for Intervention Description and Replication (TIDieR) checklist., Results: Thirty-one studies enrolling 3,794 participants were included. Meta-analysis of biochemically verified abstinence at longest follow-up (month-1 to month-6) did not find an overall effect in favour of intervention [risk ratio (RR) = 0.66, 95% confidence interval (CI) = -0.005 - 1.37]. Interventions tailored to people with SMI were perceived as acceptable. Implementation strategies concentrated on overcoming practical challenges at the participant/user level., Conclusion: No evidence of the effectiveness of digital interventions to support smoking cessation in people with SMI was found. The importance of tailoring interventions to the needs of people with SMI is highlighted. Robust reporting of implementation is required to enhance future efforts to support smoking cessation in adults with SMI., Implications: The findings of this review add to the emerging evidence on digital interventions to support smoking cessation among people with SMI. We highlight the importance of tailoring interventions to the population, particularly considering the role of mental illness and the side effects of psychotropic medication in the accessibility and usability of digital interventions., (© The Author(s) 2024. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco.)

Background: Animal-assisted interventions (AAIs) are increasingly common in UK health settings. The Covid-19 pandemic has impacted on their delivery, with many organizations offering AAIs virtually during lockdown periods. This small-scale survey aims to explore the impact of Covid-19 on the delivery of AAIs, and associated challenges and opportunities., Methods: A cross-sectional, retrospective questionnaire survey was conducted with UK AAI providers. The anonymized survey was distributed via academic and third sector networks and social media. Descriptive statistics and free-text responses are presented., Results: Thirty-six AAI providers completed the survey. Of these, 83.3% continued to deliver AAIs during the pandemic. Twenty-eight delivered AAIs remotely and highlighted associated challenges, such as clients being unable to touch the animal, and clients having restricted access to the required technology. Over half reported their animal missed face-to-face interaction. However, they also reported advantages to remote delivery, such as for those who are allergic or fearful of animals. The most commonly reported challenges of in situ delivery included difficulty maintaining distance from the client and the use of face masks, which were perceived to hinder communication., Conclusion: The transition to remote delivery has highlighted challenges and opportunities. Further research could explore these in greater depth and compare the impact of different delivery modes., (© The Author(s) 2022. Published by Oxford University Press.)

Background: Animal-assisted interventions and robotic animal interventions are becoming increasingly popular to support the care of people with dementia and may have the potential to improve a range of psychosocial outcomes. This review aims to identify, describe, and compare animal-assisted and robotic animal interventions delivered to people with dementia, their characteristics, effectiveness, and the proposed mechanisms underlying any potential impact., Methods: A systematic literature search was conducted in MEDLINE, AMED, EMBASE, PsycINFO, OVID Nursing, PubMed, CINAHL and Web of Science. Random-effects meta-analyses of randomised controlled trials (RCTs) were conducted to summarise studies that evaluated common outcomes (agitation, depression, quality of life). A narrative approach was used to synthesise other findings., Results: Fifty-one studies were included: 18 RCTs; 12 non-randomised trials, 13 cohort studies, 7 qualitative studies and one mixed-methods study. Meta-analyses were conducted for a small number of RCTs, with effectiveness of animal-assisted interventions demonstrated for agitation. Narrative findings suggested animal-assisted and robotic animal interventions may be promising in improving depression, agitation, and quality of life. Three potential mechanisms of action were identified for both animal-assisted and robotic animal interventions, namely enhancing social connections, providing engaging and meaningful activities, and the affect-generating aspect of the human-animal bond. A fourth mechanism was identified for animal-assisted interventions only: promoting physical activity. Robotic animals appear to have a place in complex human-animal relationships, but a greater understanding of robotic animal interventions is required to harness the benefits that may be derived from their use., Conclusion: Delivering these interventions appear promising in improving psychosocial outcomes for people with dementia. As most included studies had methodological limitations, these findings are preliminary, but contribute to the body of evidence providing an understanding in terms of intervention characteristics and mechanisms of action. When developing intervention guidance, attention should be given to potential mechanisms and fundamental characteristics such as session content, delivery format and facilitator role.

Introduction: Evidence suggests that smokers can successfully quit, remain abstinent or reduce smoking during a smoke-free mental health inpatient stay, provided behavioral/pharmacological support are offered. However, few evidence-based strategies to prevent the return to prehospital smoking behaviors post-discharge exist., Aims and Methods: We report the development of an intervention designed to support smoking-related behavior change following discharge from a smoke-free mental health stay. We followed the Behavior Change Wheel (BCW) intervention development process. The target behavior was supporting patients to change their smoking behaviors following discharge from a smoke-free mental health stay. Using systematic reviews, we identified the barriers and enablers, classified according to the Theoretical Domains Framework (TDF). Potential intervention functions to address key influences were identified by consulting the BCW and Behavior Change Technique (BCT) taxonomy. Another systematic review identified effectiveness of BCTs in this context. Stakeholder consultations were conducted to prioritize and refine intervention content., Results: Barriers and enablers to supporting smoking cessation were identified within the domains of environmental context and resources (lack of staff time); knowledge (ill-informed interactions about smoking); social influences, and intentions (lack of intention to deliver support). Potential strategies to address these influences included goal setting, problem-solving, feedback, social support, and information on health consequences. A strategy for operationalizing these techniques into intervention components was agreed upon: Pre-discharge evaluation sessions, a personalized resource folder, tailored behavioral and text message support post-discharge, and a peer interaction group, delivered by a trained mental health worker., Conclusions: The intervention includes targeted resources to support smoking-related behavior change in patients following discharge from a smoke-free mental health setting., Implications: Using the BCW and TDF supported a theoretically and empirically informed process to define and develop a tailored intervention that acknowledges barriers and enablers to supporting smoking cessation in mental health settings. The result is a novel complex theory- and evidence-based intervention that will be formally tested in a randomized controlled feasibility study., (© The Author(s) 2022. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco.)

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., Aims and Methods: We aimed to identify and synthesize the perceived barriers and enablers to supporting smoking cessation in mental health settings. 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, key barriers and enablers were identified through the combining of coding frequency, elaboration, and expressed importance., Results: Of 31 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 (eg, MHPs lack of time); knowledge (eg, interactions around smoking that did occur were ill informed); social influences (eg, smoking norms within social network); and intentions (eg, MHPs lack positive intentions to deliver support). Enablers mainly fell within the domains: environmental context and resources (eg, use of appropriate support materials) and social influences (eg, pro-quitting social norms)., Conclusions: The importance of overcoming competing demands on staff time and resources, the inclusion of tailored, personalized support, the exploitation of patients wider social support networks, and enhancing knowledge and awareness around the benefits smoking cessation is highlighted., Implications: Identified barriers and enablers represent targets for future interventions to improve the support of smoking cessation in mental health settings. Future research needs to examine the perceptions of the carers and family/friends of patients in relation to the smoking behavior change support delivered to patients., (© The Author(s) 2022. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco.)

Background: Multiple sclerosis (MS) is associated with lower quality of life, reduced social participation, and decreased self-efficacy. The COVID-19 pandemic has had documented effects on the health and wellbeing of people with and without MS. Previous research has demonstrated the positive impact pets can have for people living with long-term conditions. Objectives: To explore the rates of pet ownership and pet attachment in people living with MS and pet ownership associations with quality of life, satisfaction with social roles, and self-efficacy scores; and to explore the effects of the COVID-19 outbreak on people's perceived relationships with their pets. Materials and Methods: A postal questionnaire was distributed to members of a local MS Register and a control group of people without MS. The questionnaire assessed quality of life, satisfaction with social roles, self-efficacy, the perceived roles of pets, and pet-related concerns experienced during the COVID-19 pandemic. Results: No apparent difference in attachment to pets was found between the patient and control groups. Pet ownership and level of attachment were not associated with differences in quality of life or self-efficacy scores in people living with MS. Using multiple regression analysis, pet ownership was associated with a decrease in satisfaction with participation in social roles, but with the estimated effect being small compared to having a diagnosis of MS or being unemployed. Most participants reported that pets had positive roles during the pandemic, and the most reported pet-related concern was access to veterinary treatment. Conclusion: Pet owners both with and without MS reported subjective benefits to their wellbeing from pet ownership during COVID-19, although analysis suggested that pet ownership was associated with a reduction in satisfaction with social roles. The study had several limitations and suggestions are made for future work.

Research has reported the benefits of companion animals for people with severe mental illness (SMI). However, this evidence base is fragmented and unclear. The COVID-19 pandemic presents an opportunity to explore the role of companion animals in the context of social distancing and isolation measures for people with SMI. Therefore, we aimed to investigate the links between mental and physical health and animal ownership in people with SMI and to explore animal owners' perceptions related to human-animal interactions during the pandemic restrictions. A survey was conducted with a previously assembled cohort of individuals with SMI in the UK. The survey included previously validated and new bespoke items measuring demographics, and outcomes related to mental and physical health, and human-animal interactions. The survey also included a question inviting free-text responses, allowing participants to describe any experiences of their human-animal relationships during the pandemic. Of 315 participants who consented to participate, 249 (79%) completed the survey. Of these, 115 (46.2%) had at least one companion animal. Regression analyses indicated that animal ownership was not significantly associated with well-being and loneliness. However, animal ownership was associated with a self-reported decline in mental health ( b = 0.640, 95% CI [0.102-1.231], p = 0.025), but no self-reported change in physical health. Thematic analysis identified two main themes relating to the positive and negative impact of animal ownership during pandemic restrictions. Animal ownership appeared to be linked to self-reported mental health decline in people with SMI during the second wave of the pandemic in the UK. However, the thematic analysis also highlighted the perceived benefit of animal ownership during this time. Further targeted investigation of the role of human-animal relationships and the perceived human-animal bond for human health is warranted.

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, I 2  = 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., (© 2021 The Authors. Addiction published by John Wiley & Sons Ltd on behalf of Society for the Study of Addiction.)

Introduction: The prevalence of smoking among people living with HIV (PLWH) in Uganda is high., Aims and Methods: We assessed the smoking patterns, behaviors, and associated factors among PLWH in Uganda through a cross-sectional survey. Descriptive statistics were used to describe smoking patterns and behaviors. Logistic regression was used to identify factors associated with current smoking status., Results: We recruited 777 participants between October and November 2019: 387 (49.8%) current smokers and 390 (50.2%) nonsmokers. 60.9% were males, and the mean age was 40.5 (SD 10.7) years. In multivariate logistic regression, the following increased the odds of being a current smoker: being male (odds ratio [OR] 6.60 [95% confidence interval, CI = 4.34-10.04]), having at least two smokers among five closest friends (OR 3.97 [95% CI = 2.08-7.59]), living in smoking-permitted households (OR 5.83 [95% CI = 3.32-10.23]), alcohol use (OR 3.96 [95% CI = 2.34-6.71]), a higher perceived stress score (OR 2.23 [95% CI = 1.50-3.34]), and higher health-related quality of life (OR 5.25 [95% CI = 1.18-23.35]). Among smokers, the mean Fagerström Test for Nicotine Dependence score was 3.0 (SD 1.9), and 52.5% were making plans to quit. Self-efficacy to resist smoking and knowledge of the impact of smoking on PLWH's health were low., Conclusions: Being male, having at least two smokers among five closest friends, living in smoking-permitted households, alcohol use, higher perceived stress scores, and higher health-related quality of life were associated with being a current smoker. Smokers had low to moderate nicotine dependence, high willingness to quit, and low self-efficacy., Implications: Future behavioral smoking cessation interventions for PLWH should address co-consumption with alcohol and comorbid mental health conditions that are common among PLWH such as stress. In addition, they should take into account the lack of knowledge among this population of the impact of smoking on their health, and low self-efficacy. Given the relatively low levels of nicotine dependency and high levels of willingness to quit in our sample, smoking cessation interventions, if offered, are likely to support this population in achieving long-term smoking abstinence., (© The Author(s) 2020. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco.)

Background: Companion animals may be a positive presence for their owners during the COVID-19 pandemic. However, the welfare of a companion animal is strongly influenced by the behaviour of their owners, as well as their physical and social environment. We aimed to investigate the reported changes in companion animal welfare and behaviour and to examine the association between these changes and companion animal owners' mental health., Methods: A cross-sectional online survey of UK residents over 18 years of age was conducted between April and June 2020 (n = 5926). The questionnaire included validated, bespoke items measuring outcomes related to mental health, human-animal bonds and reported changes in animal welfare and behaviour. The final item of the survey invited open-ended free-text responses, allowing participants to describe experiences associated with human-animal relationships during the first UK lockdown phase., Results: Animal owners made up 89.8% of the sample (n = 5323), of whom 67.3% reported changes in their animal's welfare and behaviour during the first lockdown phase (n = 3583). These reported changes were reduced to a positive (0-7) and negative (0-5) welfare scale, following principal component analysis (PCA) of 17 items. Participants reported more positive changes for cats, whereas more negative changes were reported for dogs. Thematic analysis identified three main themes relating to the positive and negative impact on companion animals of the COVID-19 pandemic. Generalised linear models indicated that companion animal owners with poorer mental health scores pre-lockdown reported fewer negative changes in animal welfare and behaviour. However, companion animal owners with poorer mental health scores since lockdown reported more changes, both positive and negative, in animal welfare and behaviour., Conclusion: Our findings extend previous insights into perceived welfare and behaviour changes on a very limited range of species to a wider range of companion animals. Owner mental health status has a clear, albeit small, effect on companion animal welfare and behaviour.

Introduction: In line with national guidance, mental health Trusts in England are implementing complete smoke-free policies. We investigated inpatients' changes in smoking behavior, tobacco dependence, vaping, and motivation to stop smoking between pre-admission and post-discharge., Methods: We surveyed acute adult mental health inpatients from 14 wards in three mental health Trusts in England in 2019. Structured face-to-face and telephone interviews with patients who smoked on or during admission were conducted during the admission period and at one week and one month after discharge. Data on smoking status; daily cigarette consumption; Heaviness of Smoking Index (HSI); Strength of Urges to Smoke (SUTS); Motivation to Stop Smoking (MTSS) and vaping were collected and analyzed using regression and probit models., Results: Inpatient smoking prevalence was 51.9%, and a total of 152 of all 555 eligible smokers (27%) were recruited. Attrition was high: 49.3% at the first and 50.7% at the second follow-up interview. Changes in self-reported smoking status, motivation to quit, and vaping did not change significantly over the study period. Cigarette consumption (p < 0.001) and Heaviness of Smoking Index (p < 0.001) modestly reduced. The frequency and strength of urges to smoke (p = 0.011 and 0.012, respectively) decreased modestly after discharge but were scored as high by 57% and 60% of participants during admission respectively. Just over half (56%) reported being offered smoking cessation support on admission., Conclusions: This study identified very modest changes in smoking-related outcomes during and after admission and indicates major challenges to smoke-free policy implementation, including limited support for patients who smoke., Implications: Despite mental health Trusts in England had developed and implemented smoke-free policies to meet national guidelines, adherence to these policies and provision of effective smoking cessation and temporary abstinence support for inpatients admitted to acute adult mental health wards appear to be limited. Patients who smoke on admission are likely to continue to do so during admission and after discharge, and only a very modest change in smoking behaviors appears to take place. Important opportunities to promote smoking cessation in this population are missed. Barriers to effective support need to be identified and addressed., (© The Author(s) 2020. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Smoking rates are higher for people who use mental health services, which contributes substantially to health inequalities. Smoking can lead to worse COVID-19 outcomes, yet it remains unclear whether smoking has changed for people who use mental health services. We examined smoking patterns in a large clinical cohort of people with severe mental illness, before and during the pandemic. We found high levels of nicotine dependence and heavier patterns of smoking. Although some people had reported quitting, it is likely that smoking inequalities have become further entrenched. Mental health services should seek to mitigate this modifiable risk and source of poor health.

The coronavirus disease 2019 (COVID-19) pandemic presents an opportunity to explore the role of animals as sources of emotional and physical support during a period when most of the population is experiencing social and environmental challenges. We investigated how companion animal owners perceived the influence of human-animal interaction on their physical and mental health during the first COVID-19 lockdown phase in the U.K., and what concerns they had regarding their animals at this time. We also explored the impact of participants' interaction with non-companion animals during this phase. A cross-sectional online survey of U.K. residents aged over 18 was conducted between April and June 2020. The final item of the survey invited open-ended free-text responses, allowing participants to describe any experiences and/or perceptions of their human-animal relationships during the COVID-19 lockdown phase. A qualitative thematic analysis of responses was undertaken. Four main themes related to the following aspects of human-animal interactions during the COVID-19 lockdown phase were identified: the positive impact of animal ownership during the COVID-19 lockdown (e.g., amelioration of wellbeing and mental health), concerns relating to animal ownership during the COVID-19 lockdown (e.g., concerns over animals carrying the COVID-19 virus), grief and loss of an animal during the COVID-19 lockdown and the impact of engaging with non-companion animals during the COVID-19 lockdown. The findings complement and extend previous insights into the impact of human-animal interaction with both companion and non-companion animals. They also highlight the challenges of caring for an animal during the lockdown phase and indicate the need to consider the development of further targeted support strategies, such as "day care" for the companion animals of key workers in this context.

Background: The Covid-19 pandemic raises questions about the role that relationships and interactions between humans and animals play in the context of widespread social distancing and isolation measures. We aimed to investigate links between mental health and loneliness, companion animal ownership, the human-animal bond, and human-animal interactions; and to explore animal owners' perceptions related to the role of their animals during lockdown., Methods: A cross-sectional online survey of UK residents over 18 years of age was conducted between April and June 2020. The questionnaire included validated and bespoke items measuring demographics; exposures and outcomes related to mental health, wellbeing and loneliness; the human-animal bond and human-animal interactions., Results: Of 5,926 participants, 5,323 (89.8%) had at least one companion animal. Most perceived their animals to be a source of considerable support, but concerns were reported related to various practical aspects of providing care during lockdown. Strength of the human-animal bond did not differ significantly between species. Poorer mental health pre-lockdown was associated with a stronger reported human-animal bond (b = -.014, 95% CI [-.023 - -.005], p = .002). Animal ownership compared with non-ownership was associated with smaller decreases in mental health (b = .267, 95% CI [.079 - .455], p = .005) and smaller increases in loneliness (b = -.302, 95% CI [-.461 - -.144], p = .001) since lockdown., Conclusion: The human-animal bond is a construct that may be linked to mental health vulnerability in animal owners. Strength of the human-animal bond in terms of emotional closeness or intimacy dimensions appears to be independent of animal species. Animal ownership seemed to mitigate some of the detrimental psychological effects of Covid-19 lockdown. Further targeted investigation of the role of human-animal relationships and interactions for human health, including testing of the social buffering hypothesis and the development of instruments suited for use across animal species, is required., Competing Interests: The authors have declared that no competing interests exist.

Objectives: High levels of particulate pollution due to secondhand smoke (SHS) have previously been recorded in English prisons. As part of an evaluation to ascertain whether a new comprehensive smoke-free policy introduced in the first four prisons in England was successfully implemented, this study compares indoor air quality on prison wing landing locations three months before and three months after going smoke-free., Design: An indoor air quality monitoring study, comparing SHS levels before and after a comprehensive smoke-free prison policy., Setting: The first four prisons in England to implement a comprehensive smoke-free policy., Primary and Secondary Measures: We compared concentrations of airborne particulate matter <2.5 microns in diameter (PM₂.₅), as a marker for SHS, on wing landing locations three months before and three months after the smoke-free policy was implemented. Static battery operated aerosol monitors were used to sample concentrations of PM₂.₅ on wing landings., Results: After discarding data from monitors that had been tampered with we were able to analyse paired data across four prisons from 74 locations, across 29 wing landing locations, for an average sampling time of five hours and eight minutes. When comparing samples taken three months before with the paired samples taken three months after policy implementation (paired for prison, day of the week, time of day, wing location and position of monitor), there was a 66% reduction in mean PM₂.₅ concentrations across the four prisons sampled, from 39 to 13 µg/m³ (difference 26 µg/m³, 95% CI 25 to 26 µg/m³)., Conclusion: Prison smoke-free policies achieve significant improvements in indoor air quality. A national smoke-free policy would therefore be an effective means of protecting prisoners and staff from harm due to SHS exposure in the prison environment., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY. Published by BMJ.)

Background: Second-hand smoke (SHS) causes numerous health problems in children such as asthma, respiratory tract infections and sudden infant death syndrome. The home is the main source of exposure to SHS for children, particularly for young children. We estimated the cost-effectiveness of a complex intervention designed to reduce SHS exposure of children whose primary caregiver feels unable or unwilling to quit smoking., Methods: A cost-effectiveness analysis was carried out alongside an open-label, parallel, randomised controlled trial in deprived communities in Nottingham, England. A complex intervention combining behavioural support, nicotine replacement therapy and personalised feedback on home air quality was compared with usual care. A total number of 205 households were recruited, where the main caregivers were aged 18 and over, with a child aged under five years living in their household reporting smoking inside their home. Analyses for this study were undertaken from the National Health Service/Personal Social Services perspective. All costs were estimated in UK pounds (£) at 2013/14 prices. The primary outcome was the incremental cost-effectiveness of change in air quality in the home, measured as average 16-24 h levels of particulate matter of < 2.5 μm diameter (PM 2.5 ), between baseline and 12 weeks. Secondary outcomes included incremental cost per quitter, quit attempts and cigarette consumption in the home. A non-parametric bootstrap re-sampling technique was employed to explore uncertainty around the calculated incremental cost-effectiveness ratios., Results: The complex intervention achieved reduced PM 2.5 by 21.6 μg/m 3 (95% CI: 5.4 to 37.9), with an incremental cost of £283 (95% CI: £254-£313), relative to usual care. The incremental cost-effectiveness ratio was £131 (bootstrapped 95% CI: £72-£467) per additional 10μg/m 3 reduction in PM 2.5 , or £71 (bootstrapped 95% CI: -£57-£309) per additional quitter., Conclusions: This trial targeted a socio-economically disadvantaged population that has been neglected within the literature. The complex intervention was more costly but more effective in reducing PM2.5 compared with the usual care. It offers huge potential to reduce children's' tobacco-related harm by reducing exposure to SHS in the home. The intervention is considered cost-effective if the decision maker is willing to pay £131 per additional 10μg/m 3 of PM 2.5 reduction., Trial Registration: The Smoke Free Homes trial was registered with isrctn.com on 29 January 2013 with the identifier ISRCTN81701383 .

Background: Recent guidelines from the UK recommend that men and women should drink no more than 14 units of alcohol per week. This recommendation takes into account the link between alcohol and several cancers; however, there is a dearth of high quality evidence from the UK to support this., Methods: Alcohol consumption using a detailed diary was obtained from 8670 adults representative of the UK population in 1984/5, with follow-up data from cancer registries until 2009. Hazard ratios (HRs) adjusted for several variables including cigarette smoking were calculated for cancers of the breast, lung, colorectum and prostate separately using Cox regression., Results: Units per week on a typical basis, fitted as a linear term, was associated with breast cancer in women (HR = 1.27 per 10 units/week; 95% CI 1.03-1.58) and lung cancer in men (HR = 1.16; 95% CI 1.06-1.27). Increased risks of lung (HR = 2.23; 95% CI 1.18-4.24) and colorectal (HR = 2.28; 95% CI 1.13-4.57) cancer were seen in men at 15-28 units/week along with higher levels of consumption. Some findings differed by alcohol type., Conclusions: Overall, alcohol consumption of 15-28 units/week may be harmful in men with respect to common cancers. A linear association between alcohol consumption and risk of breast cancer was observed in women.

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.

Objectives: Exposing children to secondhand tobacco smoke (SHS) causes significant harm and occurs predominantly through smoking by caregivers in the family home. We report a trial of a complex intervention designed to reduce secondhand smoke exposure of children whose primary caregiver feels unable or unwilling to quit smoking., Design: An open-label, parallel, randomised controlled trial., Setting: Deprived communities in Nottingham City and County, England PARTICIPANTS: Caregivers resident in Nottingham City and County in England who were at least 18 years old, the main caregiver of a child aged under 5 years living in their household, and reported that they were smoking tobacco inside their home., Interventions: We compared a complex intervention combining personalised feedback on home air quality, behavioural support and nicotine replacement therapy for temporary abstinence with usual care., Main Outcomes: The primary outcome was change in air quality in the home, measured as average 16-24  hours levels of particulate matter of  < 2.5  µm diameter (PM 2.5 ), between baseline and 12 weeks. Secondary outcomes included changes in maximum PM 2.5 , proportion of time PM 2.5 exceeded WHO recommended levels of maximum exposure of 25  µg/mg 3 , child salivary cotinine, caregivers' cigarette consumption, nicotine dependence, determination to stop smoking, quit attempts and quitting altogether during the intervention., Results: Arithmetic mean PM 2.5 decreased significantly more (by 35.2 %; 95%  CI 12.7% to 51.9 %) in intervention than in usual care households, as did the proportion of time PM 2.5 exceeded 25  µg/mg 3 , child salivary cotinine concentrations, caregivers' cigarette consumption in the home, nicotine dependence, determination to quit and likelihood of having made a quit attempt., Conclusions: By reducing exposure to SHS in the homes of children who live with smokers unable or unwilling to quit, this intervention offers huge potential to reduce children's' tobacco-related harm., Trial Registration Number: ISRCTN81701383.This trial was funded by the UK National Institute for Health Research (NIHR): RP-PG-0608-10020., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Background: The prevalence of tobacco smoking in Germany is high (~27%). Monitoring of national patterns of smoking behaviour and data on the "real-world" effectiveness of cessation methods are needed to inform policies and develop campaigns aimed at reducing tobacco-related harm. In England, the Smoking Toolkit Study (STS) has been tracking such indicators since 2006, resulting in the adaptation of tobacco control policies. However, findings cannot be directly transferred into the German health policy context. The German Study on Tobacco Use (DEBRA: "Deutsche Befragung zum Rauchverhalten") aims to provide such nationally representative data., Methods/design: In June 2016, the study started collecting data from computer-assisted, face-to-face household interviews in people aged 14 years and older. Over a period of 3 years, a total of ~36,000 respondents will complete the survey with a new sample of ~2000 respondents every 2 months (=18 waves). This sample will report data on demographics and the use of tobacco and electronic (e-)cigarettes. Per wave, about 500-600 people are expected to be current or recent ex-smokers (<12 months since quitting). This sample will answer detailed questions about smoking behaviour, quit attempts, exposure to health professionals' advice on quitting, and use of cessation aids. Six-month follow-up data will be collected by telephone., Discussion: The DEBRA study will be an important source of data for tobacco control policies, health strategies, and future research. The methodology is closely aligned to the STS, which will allow comparisons with data from England, a country with one of the lowest smoking prevalence rates in Europe (18%)., Trial Registration: This study has been registered at the German Clinical Trials Register ( DRKS00011322 ) on 25th November 2016.

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.

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.

Background: To measure levels of indoor pollution in relation to smoking in four English prisons., Methods: TSI SidePak AM510 Personal Aerosol Monitors were used to measure concentrations of particulate matter less than 2.5 μm in diameter (PM2.5) for periods of up to 9 h in selected smoking and non-smoking areas, and personal exposure monitoring of prison staff during a work shift, in four prisons., Results: PM2.5 data were collected for average periods of 6.5 h from 48 locations on 25 wing landings where smoking was permitted in cells, on 5 non-smoking wings, 13 prisoner cells, and personal monitoring of 22 staff members. Arithmetic mean PM2.5 concentrations were significantly higher on smoking than non-smoking wing landings (43.9 μg/m(3) and 5.9 μg/m(3) respectively, p < 0.001) and in smoking than non-smoking cells (226.2 μg/m(3) and 17.0 μg/m(3) respectively, p < 0.001). Staff members wore monitors for an average of 4.18 h, during which they were exposed to arithmetic mean PM2.5 concentration of 23.5 μg/m(3)., Conclusions: The concentration of PM2.5 pollution in smoking areas of prisons are extremely high. Smoking in prisons therefore represents a significant health hazard to prisoners and staff members.

Background: The benefits of smoking cessation among older people are well documented. Despite this, evidence suggests that older smokers are rarely engaged in smoking cessation efforts, and that existing tobacco dependence treatments require further tailoring to the specific needs of older smokers. This study assesses the knowledge, attitudes, and clinical practice of primary care clinicians in relation to addressing tobacco dependence among older people., Methods: A cross-sectional survey of 427 NHS primary care clinicians in a large English city was conducted using modified version of a previously validated questionnaire., Results: One hundred and seventy one clinicians (40 % response rate) completed the survey. While the majority (90.0 %) of respondents reported enquiring regularly about older patients' smoking status, just over half (59.1 %) reported providing older patients with smoking cessation support. A lack of awareness in relation to the prevalence and impact of smoking in later life were apparent: e.g. only 47 % of respondents were aware of that approximately 10 life years are lost due to smoking related disease, and only 59 % knew that smoking can reduce the effectiveness of medication prescribed for conditions common in later life. Self-reported attendance at smoking-related training was significantly associated with proactive clinical practice., Conclusions: There is a need to improve clinicians' knowledge, in relation to smoking and smoking cessation in older patients and to build clinician confidence in seizing teachable moments.

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 cigarettes (e-cigarettes), have recently been the focus of much attention and debate. This article attempts to highlight their relevance and potential importance for mental health settings, with a focus on in-patient units. To do so, the complexities involved in smoking among people with mental disorder, the debate surrounding e-cigarettes, and their potential to be utilised as a smoking cessation or temporary abstinence aid in the context of smoke-free policies and new National Institute for Health and Care Excellence guidance for smoking cessation in mental health settings, will be discussed and synthesised below.

Background: High smoking prevalence has been observed among those misusing other substances. This study aimed to establish smoking behaviours and attitudes towards nicotine dependence treatment among clients and staff in substance abuse treatment settings., Methods: Cross-sectional questionnaire survey of staff and clients in a convenience sample of seven community and residential addiction services in, or with links to, Europe's largest provider of mental health care, the South London and Maudsley NHS Foundation Trust. Survey items assessed smoking behaviour, motivation to quit, receipt of and attitudes towards nicotine dependence treatment., Results: Eighty five percent (n = 163) and 97% (n = 145) response rates of clients and staff were achieved. A high smoking prevalence was observed in clients (88%) and staff (45%); of current smokers, nearly all clients were daily smokers, while 42% of staff were occasional smokers. Despite 79% of clients who smoked expressing a desire to quit and 46% interested in receiving advice, only 15% had been offered support to stop smoking during their current treatment episode with 56% reported never having been offered support. Staff rated smoking treatment significantly less important than treatment of other substances (p < 0.001), and only 29% of staff thought it should be addressed early in a client's primary addiction treatment, compared with 48% of clients., Conclusions: A large unmet clinical need is evident with a widespread failure to deliver smoking cessation interventions to an extraordinarily high prevalence population of smokers in addiction services. This is despite the majority of smokers reporting motivation to quit. Staff smoking and attitudes may be a contributory factor in these findings.

Background: In England, point-of-sale (PoS) displays in larger shops were prohibited in April 2012, with an exemption for smaller retailers until 2015. The aim of this study was to examine the association between tobacco displays and brand communication at the PoS and adolescent smoking behaviour, and to assess the potential benefits likely to accrue from this legislation., Methods: Self-completion questionnaire survey in students aged 11-15 years in March 2011., Results: The odds of ever-smoking doubled for those visiting shops almost daily relative to less than once a week (OR 2.23, 95% CI 1.40 to 3.55), and susceptibility increased by around 60% (OR 1.62, 95% CI 1.25 to 2.10). Noticing tobacco on display every time during store visits increased the odds of susceptibility more than threefold compared with never noticing tobacco (OR 3.15, 95% CI 1.52 to 6.54). For each additional tobacco brand recognised at the PoS, the adjusted odds of being an ever-smoker increased by 5% (OR 1.05, 95% CI 1.03 to 1.06) and of susceptibility by 4% (OR 1.04, 95% CI 1.02 to 1.05). The association between frequency of visiting stores and susceptibility was predominantly due to exposure in small shops., Conclusions: Exposure to and awareness of PoS displays and brands in displays were associated with smoking susceptibility. The association between PoS display exposure and smoking susceptibility was predominantly due to exposure in small shops. These findings suggest that a one-off, comprehensive tobacco display ban is the recommended approach for countries considering a display ban.

Background: The prevalence of tobacco smoking among homeless people can reach more than 90%, with related morbidity and mortality being high. However, research in this area is scarce. This study aims to explore smoking and quitting related behaviours, experiences and knowledge in homeless smokers in the context of other substance abuse., Methods: Face-to-face interviews were conducted with homeless smokers accessing a harm reduction service in Nottingham, UK. Data on smoking history, nicotine dependence, motivation and confidence to quit were collected using structured instruments; a semi-structured interview guide was used to elicit responses to predefined subject areas, and to encourage the emergence of unprecedented themes. Data were analysed using framework analysis and descriptive statistics., Results: Participants were generally highly dependent smokers who did not display good knowledge/awareness of smoking related harms and reported to engage in high risk smoking behaviours. The majority reported notable motivation and confidence to quit in the future, despite or indeed for the benefit of addressing other dependencies. Of the many who had tried to quit in the past, all had done so on their own initiative, and several described a lack of support or active discouragement by practitioners to address smoking., Conclusion: High levels of tobacco dependence and engagement in unique smoking related risk behaviours and social interplays appear to add to the vulnerability of homeless smokers. Given reported motivation, confidence, previous attempts and lack of support to quit, opportunities to address smoking in one of the most disadvantaged groups are currently missed.

Background: Although research suggests that the majority of smokers want to quit smoking, the uptake of Stop Smoking Services, designed to assist smokers with quitting, remains low. Little is known about continuing smokers who do not access these services, and opportunities to influence their motivation and encourage quit attempts through the uptake of services. Using PRIME theory, this study explored differences between continuing smokers who had varying levels of motivation to quit, in terms of their plans to quit, evaluative beliefs about smoking, cigarette dependence, and attitudes towards tobacco control policies and services., Methods: Twenty-two current smokers, recruited from the community, were classified by motivation level to quit using a self-report questionnaire (two groups: high/low). Four focus groups (n=13) and individual interviews (n=9) were conducted with both groups using an interview guide incorporating aspects of PRIME theory. Discussion areas included motives for smoking, attitudes towards smoking and quitting, perceptions of dependence, motives for quitting, barriers to quitting, and attitudes towards existing and impending tobacco control policies and services. Verbatim transcripts were analysed using thematic framework analysis., Results: All participants expressed low motivation to quit during discussions, despite some initially self-classifying as having high explicit levels of motivation to quit. Both groups reported similar attitudes towards smoking and quitting, including a perceived psychological addiction to smoking, positive evaluations about smoking which inhibited plans to quit, and similar suggested methods to increase motivation (simply wanting to, save money, improve health). Most felt that they 'ought' to quit as opposed to 'wanted' to. Little influence was ascribed towards tobacco control policies such as plain packaging and hidden sales displays, and participants felt that price increases of tobacco products needed to be considerable in order to influence motivation. Highly motivated smokers expressed more willingness to visit Stop Smoking Services, although none had done so., Conclusion: Continuing smokers' attitudes towards smoking and quitting suggests that research and policy need to focus on increasing smokers' implicit motivation to quit smoking, even for those who classified themselves as having high motivation to quit. Targeted information and further education about Stop Smoking Services is required to increase uptake.

Aims: Although smoking prevalence among people with severe mental illness is high, it remains largely unaddressed. This pragmatic pilot project aimed to develop and implement a tailored tobacco dependence service in mental health settings and to assess its impact, as well as barriers and facilitators to implementation., Design: An integrative service model, spanning acute, rehabilitation and community services, including the design of tailored instruments and referral pathways, delivered by two mental health professionals., Setting and Participants: Four adult acute and two rehabilitation wards (129 beds), and the community recovery team (2038 cases) of the United Kingdom's largest Mental Health Trust., Measurements: Audit of smoking information in patient notes; service uptake; quit attempts; smoking cessation and reduction; qualitative data on implementation barriers/facilitators., Findings: A total of 110 patients attended at least one support session: 53 inpatients (23% of inpatient smokers) and 57 community (of unknown number of community smokers, as recording of smoking status is not mandatory). Thirty-four of these (31%) made a quit attempt; 17 (15%) stopped smoking and 29 (26%) reduced cigarette consumption by up to 50% at the final contact. Barriers to service implementation related to: (i) trust policy, systems and procedures, (ii) staff knowledge and attitudes and (iii) illness-related factors., Conclusions: Despite the strong anti-smoking climate in the United Kingdom, including a law requiring smoke-free policies in mental health settings, establishing a smoking cessation treatment service for people with mental illness proved difficult, due to complex systemic barriers. However, there is clearly a demand, by patients, for such a service., (© 2012 The Authors, Addiction © 2012 Society for the Study of Addiction.)

Background: Since the implementation of the 2002 Tobacco Advertising and Promotion Act, point-of-sale (PoS) tobacco displays are one of few remaining means of communication between the tobacco industry and customers in the UK. This study aimed to explore the characteristics of tobacco displays in a UK city, and particularly to assess the tobacco prices and promotional offers, types and pack sizes on display., Methods: Digital pictures of PoS displays were taken in 117 small retail shops in Nottingham in mid 2010. Data were analysed using Windows Photo Gallery software and SPSS version 16., Results: Just over half (52%) of cigarette packs on display were packs of 20, and 43% packs of 10. Cigarette prices differed substantially between brands, ranging from £4.19 to £6.85 for 20-packs, and from £2.12 to £3.59 for 10-packs. Forty four percent of cigarette packs and 40% of RYO (Roll-Your-Own) tobacco pouches, almost exclusively lower priced brands, were displayed with a pricemark, implying a promotional price offer. Eighty percent of 20-pack cigarette brand or brand variants on sale were priced below the EU-defined Most Popular Price Category (MPPC) for the UK in 2010; 45% were priced below the Weighted Average Price (WAP), which replaced the MPPC in 2011., Conclusion: PoS displays communicate value by displaying a high proportion of lower cost brands, and smaller and hence lower-cost packs, and by displaying price discounts on packs. The MPPC substantially overestimated the prices at which most 20-cigarette packs were available. Removal of PoS displays will prevent this means of price marketing but our study also suggests that minimum pricing of 20-pack cigarettes, prohibition of sale of cigarettes in packs less than 20, and plain packaging to prevent pricemarking are necessary if price is to be used effectively as a tobacco control measure.

Background: Tobacco dependence among people with mental health problems is an issue that deserves attention both from a clinical and from a public health perspective. Research suggests that Stop Smoking Services often fail to ask clients about underlying mental health problems and thus fail to put in place the treatment adaptations and liaison procedures often required to meet the needs of clients with a mental health condition who want to stop smoking. This study assesses the recording of mental health problems in a large NHS stop smoking service in England and examines the effect of implementing a short screening procedure on recording mental health conditions., Methods: Treatment records from the Stop Smoking Service covering a period of 13 months were audited. The prevalence of reported mental health problems in the six month period before the implementation of the mental health screening procedure was compared with that of the six month period following implementation. The screening procedure was only implemented in the support services directly provided by the Stop Smoking Service. Comparisons were also made with third-party sections of the service where no such screening procedure was introduced., Results: The prevalence of reported mental health problems among a total of n = 4999 clients rose from less than 1% before implementation of the screening procedure to nearly 12% in the period following implementation, with the change being statistically significant. No significant rise was observed over the same period in the sections of the service where no screening procedure was implemented., Conclusions: The absence of standard procedures to record mental health problems among service users in many stop smoking services is currently likely to prevent the detection of co morbidity. Implementing a simple screening procedure appears suitable to increase the routine recording of mental health problems in a stop smoking service, which is an essential step to ensure services can be tailored and delivered appropriately to the client group.

Background: People with mental health problems exhibit smoking rates up to three times that of the general population. Metabolic interactions between hydrocarbon agents in tobacco smoke and some antipsychotic drugs account for a change in medication metabolism on stopping smoking, and potentially for increased blood levels. Nicotine withdrawal can mimic or exacerbate symptoms of mental illness. Therefore, appropriate screening for mental health problems and liaison with local mental health care providers should be a priority for NHS Stop Smoking Services. The present study aimed to examine this issue through surveys with NHS Stop Smoking Service staff in London., Methods: Semi-structured telephone interviews were conducted with one senior staff member from 27 of the 29 NHS Stop Smoking Services in London., Results: It was found that only a minority of services routinely check the mental health status or mental health service use of their clients. In addition, most services do not routinely implement special checks or actions when mental health problems are revealed. It was notable that respondents reported a lack of strategic drivers supporting work with mental health patients (such as targets relating to successful quits) as well as a low level of partnership working with local mental health care providers., Conclusions: NHS Stop Smoking Services may not be operating appropriate procedures for supporting people with mental health problems. There is a need for local protocols to be implemented that include routine screening for mental health issues and liaison with mental health care providers.

Background: In 2008, mental health units in England went smoke-free by law. This study explores inpatients' experience with a smoke-free policy, their smoking behaviour, dependence, withdrawal and related issues., Material: Semi-structured interviews in a criterion sample of 15 inpatient smokers., Discussion: Patients generally approved of the smoke-free policy, provided they could smoke outside. Most participants had changed their smoking behaviour following admission. Most had little knowledge of nicotine dependence, reported a lack of structured support for smoking cessation, and a general interest in this being made available. Nicotine dependence was reportedly lower in the ward than in the home setting., Conclusions: More structured support is needed to ensure that opportunities for health promotion in a vulnerable population are not being missed.

Background: Mental health inpatient units in England have to be smoke-free by law. Preliminary studies have indicated that staff may not have the necessary knowledge and resources to support the implementation of a smoke-free policy., Objective: The objective of this study was to investigate staff knowledge and attitudes relating to smoking prevalence, dependence, treatment and the relationship between smoking and mental illness., Design: This study used a questionnaire survey for all the clinical staff of 25 inpatient mental health units of a UK National Health Service mental health Trust., Results: Four hundred fifty-nine (68%) staff returned the questionnaire. Less than half (42%) of the participants agreed that dealing with patients' smoking was their responsibility as a mental health professional, and only half (50%) asserted that they could make time to treat smoking in their working routine. All professional groups demonstrated a lack of knowledge about tobacco dependence, treatment and its relation with mental illness, with healthcare assistants being least knowledgeable overall. Nevertheless, 41% of doctors were unaware that smoking can decrease blood levels of antipsychotic medications, and 36% were unaware that stopping smoking could reduce the dose needed. Staff overestimated the prevalence of smoking in the general population, and over a third (36.4%) believed that nicotine was carcinogenic. Staff smoking prevalence was 26% (10% of doctors, 22% of other qualified staff and 37% of nonqualified staff), and smokers were more likely to have reservations about the importance of the smoke-free policy and the treatment of nicotine dependence among patients. Reported participation in training was associated with greater knowledge related to some items of the questionnaire., Conclusions: Support for inpatient smokers by staff is likely to be severely compromised by low levels of knowledge and awareness of tobacco dependence. Further training and support for all staff groups are urgently required.

Background: Mental health units in England had to become smoke-free by law from July 2008. Concerns regarding the implementation and enforcement of smoke-free policies in these settings have been raised., Aims: To study difficulties and challenges associated with smoke-free policy implementation in English National Health Service (NHS) mental health settings., Method: Questionnaire survey of all 72 English NHS trusts providing mental health in-patient services and facilities, supplemented by semi-structured telephone interviews at a systematic sample of 7 trusts and site visits at a convenience sample of 5 trusts., Results: Questionnaires were returned by 79% of the trusts, all of whom had implemented smoke-free policies. Most respondents (91%) believed that mental health settings faced particular challenges, arising from the high smoking prevalence among patients (81%), related safety risks (70%), adverse effects on the clinician-patient relationship (36%), and potential interactions with antipsychotic medication (34%). Interviews indicated that sustained policy enforcement was perceived as difficult, but that despite challenges and concerns, the impact of the policy was regarded as beneficial, with some evidence of positive behavioural changes occurring in people., Conclusions: Many mental health trusts across England have implemented comprehensive smoke-free policies but the majority state that they are facing specific difficulties. Challenges and concerns need to be explored in depth and addressed to ensure that smoke-free policies implemented under the terms of the Health Act in July 2008 are not undermined.

Objective: The objective of this work was to explore the practical implications of, and the problems arising from, the implementation of a comprehensive smoke-free policy in acute adult inpatient mental health wards., Method: This is a qualitative study that uses semistructured interviews with a stratified purposive sample of 16 medical and nonmedical staff of two wards in an acute mental health trust in England that had implemented a smoke-free policy in buildings and grounds in March 2007., Results: The smoke-free policy was viewed ambivalently and was substantially compromised by widespread use of exceptions such as permitting patients to smoke in an outdoor patio and covert indoor smoking. Smoking breaks were described to be a fixation for patients and sometimes disruptive to therapeutic activities. Nicotine dependence and withdrawal were not assessed or supported systematically. Awareness of interactions between smoking and certain antipsychotic medications was anecdotal and did not impact on clinical practice., Conclusions: The implementation of smoke-free policies in these acute mental health wards suffered from the provision of regular institutionalized smoking breaks, a lack of sustained investment in staff training and a lack of comprehensive cessation or abstinence support for patients. These issues need to be addressed; otherwise, the implementation of smoke-free policies in mental health settings may result in unintended adverse effects.