As a fitness instructor in a gym in Ireland I was often frustrated at the lack of progress many of my clients achieved, despite giving them the skills, knowledge and equipment they needed to achieve their goals. Now as a Public Health Registrar, I know that the barriers to their success were not simply a lack of motivation and time, but broader social determinants were at play. Without addressing these my ability to support my clients was limited.

Where we live, work, play, our genetics, our income, our education, our relationships will impact on our ability to be healthy.  When we are trying to tackle complex behaviours such as physical inactivity and tobacco dependency we need to look beyond the individual and recognise the wider influences on behaviour. This is not ignoring the influence individuals have on their health but appreciating the complexity of health and the external enablers and barriers.

Today is national No Smoking Day a very important day in the calendar, not least because smoking is one of the major contributors to health inequalities, especially in people with severe mental illness (SMI). Through the Core20Plus5 series of blogs we have discussed the 15-20 year life expectancy gap in people with SMI and the important role physical health checks play in supporting better physical health.

Through this blog I want to highlight the complexity of health by unpicking the issue of smoking in people with SMI. I want to demonstrate the value in taking a whole systems approach to tackling the issue and the need to distribute leadership across the system.

Deconstructing the issue….

Let’s start with the person. People with SMI are more likely to be more dependent and heavier smokers, making it very difficult to quit. Smoking rates are at least 3 times higher in people with SMI compared to the general population, and almost 7 times higher in people with psychosis.

Where we live and our communities can shape our physical and mental health. Some people with SMI will reside in mental health settings and unfortunately not all are fully implementing a comprehensive smokefree policy or offering patients treatment options in line with NICE best practice.  This creates organisational and cultural barriers to stopping smoking. There is also a well-established link between mental illness and social deprivation. For those that live at home they are more likely to experience unemployment and/or income insecurity, fuel poverty, housing or food insecurity. These factors can further exacerbate mental health and smoking rates.

Social norms are shaped by those around us. Some people with SMI live at home, sometimes with partners or carers who also smoke. Within mental health settings there may be a bias towards addressing mental health over physical health. A systematic review of mental health professionals’ attitudes towards smoking cessation indicated that some staff hold views that were negative towards tobacco dependency treatment/interventions and permissive attitudes towards smoking. There is also a belief that might be too difficult for people with SMI, in fact they are as likely to want to quit and with the right treatment can quit.

To effectively address tobacco dependency you must support the individual, fully implemented organisational policies that are fully supported by staff. This brings me to the role of leadership.

Redistribute the power…

Often within clinical settings there is a tendency for top-down style leadership models. Tobacco dependency is a complex issue and therefore leadership must be distributed across the system.

Using leadership and healthy policy to create healthy places. South London and Maudsley (SLaM) have worked intensely with all staff to educate them on the impact of smoking on the SMI population, ensure that identification and referral of smokers became routine processes, and medicines policies were adapted to allow all registered nurses to administer nicotine replacement therapy (NRT). Trust wide smokefree policies were fully implemented. The trust retained stop smoking advisors but by sharing some of the key roles, the responsibility of tackling tobacco dependency extended across the organisation through their policies.

Using distributed leadership to make every contact count. Nottinghamshire Healthcare NHS Trust recognised the opportunistic role outpatient receptionists could play in supporting patients into treatment. Reception staff were offered training in stop smoking advice, making passing conversations an opportunity to refer into treatment. Using these everyday contacts as opportunities creates strong and supportive cultural norms and increases access to treatment.

Building capacity through distributed leadership. Tees, Esk and Wear Valleys NHS (Mental Health) Trust delivered a number of interventions that specifically targeted staff to increase the capacity to deliver smoking cessation advise. All staff who smoked were encouraged to quit as part of an organisational wide push. All staff received training in very brief advice, ensuring patients received the right advice and timely access to support. In addition, a large number of staff were offered Level 2 stop smoking advisor training building capacity within the trust to treat more patients.

Empowering patients to be leaders. East London Foundation Trust (ELFT) are using peer support workers, these are people that have lived experience of mental health. Peer support workers act as role models and help disrupt social norms around smoking. This wrap around support, to tobacco dependency treatment, helps address the wider social (social isolation and boredom) and economic influences (supporting clients into employment support) on smoking.

The pandemic has encouraged me to reflect on the different leadership styles at play, from command and control, to heroic, to distributed leadership. The leadership style isn’t static, it has to adapt. One thing that is apparent is the value of a distributed leadership model, it recognises the wider assets and empowers more people within the system. Smoking in people with SMI is complex, and arguably requires a leadership approach that distributes power and resource across the health and care system creating the right factors for successful treatment outcomes.

Aideen Dunne

Aideen Dunne is a public health registrar in London and has worked across a diverse range of organisations at a local, regional and national level. Aideen is particularly passionate about the role of wider determinants, such as the physical environment, on health enhancing behaviours and has enjoyed focusing on delivering population health initiatives across complex systems.

Aideen is currently a National Medical Directors Clinical Fellow based in NHS England and Improvement’s Prevention Team. Within her current role Aideen is focusing on tobacco dependency in people with SMI and working with NHS EI Regions and Integrated Care Systems to deliver these services. The fellowship has afforded her excellent opportunities to gain experience within the NHS, and to work alongside some fantastic leaders.

Declaration of interests 

I have read and understood the BMJ Group policy on declaration of interests and declare the following interests: none.