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It's essential. Welcome. Welcome to this roundtable discussion where we're going to be looking for solutions, exploring solutions for this C Three Burdette project that we're doing winning parts and mine's so I'm Helen Donovan. I'm one of the nurse associates at C three and I'm really just here to listen and hopefully learn a few things. Um So first of all, who is C three, who are we at C three. So, collaborating for health, we are a global charity looking at preventing non communicable disease. And our aim and our vision is to have a world where nobody dies of chronic diseases that are preventable. So those diseases that are triggered by people smoking, people eating the wrong things, being overweight and by drinking too much alcohol. Um So winning hearts of hearts and minds. So this is a project a combined, see three Burdette project that we have been running. Um And that the aim of it is predominantly around preventing cardiovascular disease through smoking, but also about preventing people with mental health problems from smoking. Now, very conservative estimate is that 40% of people with mental health problems smoke. Um And that is in comparison to 14% in the rest of the population. And of course, with all of the overriding physical health problems that go this smoking, what we want to try and do is to come up with some solutions to try and prevent that. Now, as part of the project that we've been running, we have got and we will be developing more resources that will go on to the C three website and we'll make sure that everybody's got the link to that. Um And of course, this roundtable will be part of that. So we've got some webinars looking at what is cardiovascular disease, how does smoking impact on cardiovascular disease, brilliant resources on, on vaping and how that can help also them on behavior change. Um So that will form a suite of resources that we hope will be useful for nurses. But I'm really delighted and I go to Passover to very, very good colleague of my Cath Gamble, very experienced nurse leader in mental health nursing, who's going to introduce the rest of the panel and sort of chair this discussion. So really looking forward to hearing all of the discussion and the solutions. Thank you very much, Helen. I'm also greatly impressed to be surrounded by in credible experts in smoking sensation, one and tobacco harm. I think maybe we'll be useful just to go around and say what our backgrounds are. But I you will also notice that we are live here, but also that we're joined by Hannah more. And Hannah, do you want to just say a bit about, give it a, the audience bit of, about who you are and, and what draws you to, to this discussion panel. Yep. So I'm Hannah More. I work for equally Well UK which is parity, which is looking at parity of esteem between mental health and physical health and trying to cut the mortality rate. And smoking is one of our big, big projects and I'm the vice chair for that. So, smoking is true to my heart. And I will, I will admit I am a smoker. I'm a vapor, but I want to quit. I have quit before. But it's important to me because I think that people who have been in my situation who've been five years without smoking in a secure unit and then suddenly gone into supported housing where everyone smokes and then started smoking and even though I've been quit for five years, so I think there needs some or smoking sensation and things like that and, and smoking for nurses as well. So, yeah, that's why I'm about this project. Thank you. And Doctor Deputy Pharmacy. Hi, everyone. I'm Debbie Robson. I'm a mental health nurse. I've been a mental health nurse for over 30 years now and I'm also a senior lecturer in tobacco harm reduction at the Institute, Psychiatry Psychology and Neuroscience at King's College Hunted. Thank you, Mary. Hi, everyone. My name is Mary Yates. I'm a learning disability and mental health nurse and I'm here on the panel because I'm also really passionate about helping smokers quit. In the past, I've been uh providing leadership for the smoke free program at Southampton. The Lord's been a Chest foundation trust and now that I'm retired, I'm working nationally as a trainer doing tobacco harm reduction work across the rest of the UK. So that's been with your and over to Louise, Louise, Louise Ross, I launched the first Baby Friendly Stop Smoking Service when I managed the service in Leicester. Um and I now work for the National Center for Smoking cessation training and I'm business development manager rather smoke free app as well. Excellent. And I hope that the next uh three quarters of an hour is going to give us an opportunity to tap into all everybody's expertise. Both Hannah's from lived experience uh to yours in terms of developing a strategy to your evidence and research and to your training arm as well. So I don't know where perhaps wanted to start. But I think the richness of some of the data, uh it's something that Barry you have something to talk through about or what your understanding of. Anyway, it is highlight. Thank you. Well, I think it's a good place for us to start is to just get our heads around. The huge gap there is between the prevalence of smoking in the general adult population because if you look at it, you might think. Well, the UK are doing brilliantly, 14% of the population are now currently smoking. And so that looks really great, but it hides the fact that um, in our experience around about 60% of people in inpatient acute mental health services are currently smoking and in forensic services, the figure is closer to about 80 percent. So if we look at the data that, that you refer to Helen at the beginning, the GP data will tell us that it's about 40%. But actually, we think it's much higher than that and we see that the impact of that is not just on people's physical health, but also on their mental health. Um And, and so therefore, it's got to be a really big concern for us as mental health nurses and, and other mental health care professionals. And I do recall Hannah, that you talked about your last experience as an inpatient. Um And whether you wanted to, to share some examples with us. Yeah. So when I was an inpatient, the last time I um knew I, I went in a smoker and then I obviously I was sectioned, so I wasn't able to have leaves. I wasn't allowed to smoke. So they said I'll just buy vapes off Ebay. So I bought Vapes. So I'm now addicted to vapes and smoking, which is not good. Uh Patient's who came in as non smokers and non vapors and left as Vapers and smokers because they got leave because they basically would get leave to smoke and they wouldn't get leave if they didn't smoke. And that leaves us with a real challenge to consider what's actually available for people. And actually thinking heavens as mental health nurse, are we exacerbating that 11 person in a training session that I did recently said that he hadn't realized that by facilitated smoking and taking people out for smoking breaks, he was actually contributing to an unnecessarily early death for that person. And that, that was really quite shocking to, to hear it put in those terms. So I think, I think that they, that's quite an awful experience in 2023 that people are coming in to hospital. Um, like you say, as a nonsmoker and I believe in as a smoker or even leaving as a vapor, because I think we would all agree that coming in a smoker and leaving as a, you know, just vaping is probably a good, is a good outcome. But if you're, you know, if you're leaving as a, as a never smoker, never vapor, uh if you, if you're coming in as a never smoker, never vapor, but leaving as a smoker, a vapor. And that's not great. And so I just, I just wonder why in 2023 we're still in this situation because I think all of us who kind of worked on the world's decades ago we were facing these, we were facing these challenges years ago and it seemed we were, things were improving at around in 2014, 2015. And then nice guidelines for smoking. The secondary care came in and the government and trust what a huge amount of money and effort into trying to change in Pissants services. And it feels possibly since the pandemic, we've taken a huge backwards step and then we just, you know, here in, you know, stories like Hannah's, uh, which, which are not great. I think you're right, Debbie, we've been talking about it for so long. I was working on smoke free policies back in 2016 and we thought we more or less got there and, and yes, you're right. You know, I've heard many times that the, uh, the COVID, um, issues becoming a priority meant that some trusts actually undid, uh, they're, they're smoke free policies and went back to a lamic smoking. We've got to undo all that damage now. And, uh, you know, get people back on board with the idea that, that smoking kills, it kills more people with mental health. Yeah. Hannah, the population of smokers in the mental health unit that I was in was so high, like it was literally 99%. I think, I don't think it was, I actually don't think the one patient that didn't smoke and then had to Vape instead of smoking when they came in and I think because of the population is so high, people don't smoke and who don't Vape would go out to the garden to smoke, to Vape just to socialize with other people. Okay, I just think what I'm sorry about your experience, Hannah, I feel ashamed that we have failed really to recognize this really urgent clinical needs that patient's have. And it bothers me that we are still seeing smoking as a lifestyle choice rather than a really urgent clinical condition. What I see is mental health nurse is coming to work and really wanting to do a good job and being quite busy on the wards all the time, but probably busy doing the wrong things. I think in policy terms, we are not collecting good date on our smokers. We are not treating tobacco dependence as an urgent clinical conditions. So we're not routinely monitoring carbon monoxide levels, for example, which I really passionately believe that if we started to do that, I think it would help to change the hearts and minds of doctors and nurses because would be able to see here's a medical device, here's an intervention, here's way into this conversation because nurses are really not quite sure. How do we start the conversation about smoking? How can we, you know, force people to stop when it's their choice to do that? And then we have all this issue about restrictive practices and concerns from nurses that they don't want to be creating an environment where we have among those best approach to care where we tell people what they should be doing. So, you know, there are lots of challenges but I think there are ways that we can move forwards and, and one of the things that listening to you, Hannah, I feel is really important for us as mental health nurses, as well as carbon oxide testing is too be able to create an environment where health can flourish because your patient's are bored in hospital wards and it's very barren environment, very little activities other than going out to smoke. And so I think there's lots of a whole lot of different things that we need to be doing. And then of course, there's treatment options and making sure they're really available promptly and in a plentiful supply, most patient's that I see there are smokers, they're under trees is with nicotine replacement therapy. And because of that they fail, none of us want to have a negative failing experience. So, um I think there's lots of things we need to fix and, and as Louise said, you know, we seem to have gone a bit backwards really. Um I hope that, you know, this conversation can generate some enthusiasm to start see how we can start to move forward again. I don't think there's a, I don't know what you wanted to mention, but there's something for me about the culture that we are prepared. We are exacerbating. Uh, you know, I think the point that Hannah, when we discuss things that you were very much aware that, you know, there were nurses who smoked, coming back onto the units smelling of smoke, which exacerbates the need or wish to smoke again. There are, and, you know, this is my profession. So of course, I'm extremely proud of it. But I also think that we have to start having that really open conversation about the challenges that we are presenting to our patient's. They are much more challenged by, are smelling of smoke or reinforcing it by saying or, you know, deescalating situations by saying, um you know, would you like to come out to have a cigarette rather than perhaps you could get more agitated in on ward environment? I don't know what your experience has a bit of that, whether you wanted to have anything to, to those points around how we use as mental health nurses, almost so smoking as part of our tool care. I think, I think that's right. I think for, for decades, smoking has been part of the mental health nurses to okay. And increasingly you seeing veiling has been part of uh nurses to okay with, which is a really good alternative to smoking, providing you've got education and we know what you're doing uh around it. But I often think sometimes just even just even reminding nurses of just the basics of smoking because sometimes we forget how uniquely dangerous smoking is. And you know, we, and a lot of the time tobacco addiction isn't taught during this training or during training, psychiatrists or, or medics or other allied health professionals. And, and so sometimes, and, and so when I start the three of us do lots of training. And so one of the things I often start with as a way of winning hearts and minds of the people and training is to remind them and, and kind of visually just what's in a cigarette and how a cigarette is deliberately engineered to get nicotine in the brain as fast as possible. And tobacco companies are legally allowed to add an extra 600 extra ingredients to the dried of chop tobacco leaves. Um so that the tobacco tastes nice because tobacco is quite foul and you need to, you need to uh make it much more palatable. But also tobacco companies add ingredients so they can make nicotine even more addictive than it than it naturally is. But the harm from tobacco comes from when you set piloting cigarette because there's 600 extra ingredients to the trying to chop tobacco leaves then turn into a cocktail of about 4000 different chemicals. And we got lots of those chemicals that cause cancers, but they also cause cardiovascular disease and and respiratory diseases. And so what I often said to the nurses I teaches, you know, just, just think, just stop for a moment when you're happily, you're starting somebody out for a cigarette. Um, and just, just think about every puff on that cigarette that your patient is getting endorse of 4000 different chemicals and a lot of those chemicals will damage their health. We know definitely they will damage their health. And increasingly we know that smoking, actually, it, it increases your chances of having a mental illness in the first place. And it also gets in the way of your mental health recovery. So we know that people who experience it's creamier, uh people who experience depression, they have much more severe symptoms of those illnesses. And we know that a lot of the medications we prescribe on our walks. Patient's who smoke need much higher doses of those medicines because the tobacco smoke and it's not the nicotine, it's the tobacco smoke that uh speeds up the metabolism and medicines. And so those medicines are cleared out to the body, which more quickly if you're a smoker. So then you have a whole and as Mary said, you know, sometimes, you know, 80% of our patient's on inpatient units are smoking. So 80% of patient's again aware how your doses they're antipsychotic medication, then then they need if they weren't smoking. And so then you've got this, you've got this, this, this health behavior, you've got smoking and then you've got the medication that we give people that we know causes side effects, it causes cardiovascular problems. It causes weight problems and, and, and smoking, as having said, amongst the general population, it's a minority health behaving that. So in some ways, it's smoking has become stigmatized. And so for you as all that, you pile all them together on a group of people that are already stigmatized. You know, what are we doing as mental health nurses to contribute to that? But importantly, and more importantly, what are we doing to stop that and prevent that? And as Mary said, create environments where health, both mental health and physical health flourish because really, that's the business we shouldn't be, it should be. Yeah. And, and just to add to that Debbie because you know, you're absolutely right, there's a toll of physical health problems and the mental health problems. But of course, we're in the middle of the cost of living crisis and we add into the mix, the fact that smoking traps are patient's in poverty. And we know that about two third of all the tobacco smoked in this country now is by people with mental health problems. Um And people with serious mental health problems are spending about one third of their disposable income on their fags and prioritizing the facts before other really essential things in life. So for all those reasons, um yeah, it just seems incumbent on us that we really start to get our heads around this as a really serious issue. Um come together through training, through changing policies through changing systems and through partnerships, I think because we've got to understand also that patient's, we can't fit them into boxes. You know, Hannah, you're not going to stay in hospital forever. You know, you're there briefly and then you're moving and you're back home again or you're in a, as you said, you're moving on to a care home and another. So it's really important that we understand back the dependence treatment isn't something that happens in one place, but it goes with you on your journey throughout your experience, wherever it is that you're receiving care. Uh Sorry, how are you saying something coming back to the point about how many, how much toxins come out of a tobacco smoke, that's that the patient's breathing in. But the point is the nurse who's escorting that patient is also breathing in that smoke him or, or they are taking in the same toxins because they have to be a certain distance from the patient have to be an eyesight or an arm's reach and things like that. So they're breathing in the toxins as well. And yeah, yeah. Good point. Very good point. It's not good, is it? Uh and, and that inpatient experience is a really good time to address things like, you know, the the the financial side, isn't it? Because, you know, for, for many people, tobacco use is the only area of flex in their budget. You know, everything else might be committed to to rent and food and so on. But, you know, reducing spend, you know, eliminating spend on tobacco can make a huge difference to people's quality arrived afterwards. And the mask. Sorry. Yeah. Yeah. Absolutely. Massively. Singapore cigarettes now costs about 13 14 lbs and if you can drum that into patient's heads and nurses heads, that you're gonna be saving that much money from just quitting smoking. You can, you can spend hundreds of pounds that you haven't, that you wouldn't have had if you, you were smoking. Absolutely. It's a real quality of life issue, isn't it? How, uh, and, and the other thing that you mentioned Mary about the medications that can be reduced, dealing with that on, on the ward where people are inpatient, um, needs to be carried on and they get, um, get home otherwise that medication has got to be increased again. So, so again, the inpatient experience a really good place to start, you know, making sure that that message is, is understood and acted on when people are discharged. So I'm just thinking about that. The point you just made Debbie around, the sort of chemical, um, issues around is vaping is more harmful than how we, how are we working and introducing vaping to our patient's and what should we be doing to encouraging people to start seeing this is a different pathway. So, where I work, we spent a lot of time doing research on vaping and pulling together evidence reviews for the government. Um, and what we know, what we definitely know is that vaping is only causes a, a small fraction of the risk of smoking. So, if you smoke, switching to their pain is a really good choice to make and, uh, even better choice if you can completely switch to Fabian and ditch the cigarettes altogether. But there's panas said sometimes that's tricky and a lot of people, small kind of and, and a lot of people being together and that doesn't, that doesn't increase your risk of having kind of any kind of, uh, kind of physical health problems or even mental health problems, but not smoking or vaping together. It doesn't necessarily reduce your risk. So you kind of you maintaining you nicotine addiction and half of your, your, your intake is coming from a, uh, what I guess we can call the dirty source, which is your cigarettes. And then the other half is coming from a cleaner source, which is, which is your vaping in terms of Hannah mentioned something at the beginning that, um, somebody, uh, you know, a young person who came into hospital who never smoked, never vet leaves the hospital as a vapor because they've been introduced to it because, you know, out of boredom because they see, you know, people do it then that's also not a good outcome. It's better than leaving. It's better than common in as a nonsmoker and leaving as a smoker but again, that's, that would be something we need to address. But in terms of the exposure, all the toxicants that you get on the toxicants, your body absorbs from vaping, um uh that are related to cancers, cardiovascular disease, respiratory disease considerably consistently lower in the bodies of vapors than they are smokers. And even there's some studies, there's a lot of studies to suggest that, you know, some of the toxicants are actually similar levels in the bodies of vapors than people in. Don't Vape. It's just a few toxicants are a bit higher that we need to be concerned. Can I just ask? Because there's an interesting question in the chatter from Zoey asking you were talking about the metabolism of the medication with cigarettes as opposed to bates. And so is there any evidence as to whether vaping reduces that need for more medication? So, Zoe, that's an absolute excellent question and no one is actually looked at that before, but we're just about to start a study next week. And this house London a moment and NHS trust where we are collecting urine uh from people who just Vape people who just smoke, people who smoke and Vape and people who do neither. Uh And we're doing that in cause a pain clinics. So we'll be able to work out. Is there, is there a difference in the drug metabolism of people uh with mental, with serious mental health problems who take cause pain, who don't smoke. But what I would suggest, what, what I think is, uh what we'll likely find is vaping does affect the drug, drug metabolism but not as much as smoking. And, and the main, and then we talked a lot about toxicants, but the, the main toxicants that we were concerned about drug metabolism, uh is it, is, it, is, it is a toxicants called polycyclic aromatic hydrocarbons. And they're part of the tarin tobacco smoke. It's not anything to do with nicotine. It's to do with, with a particular part of the torrent tobacco smoke that the changes the metabolism of medicines. And in lots of studies that we've looked at it comparing vapors and small workers, you do still get some polycyclic aromatic hydrocarbons uh as a result of vaping but not to the same extent as you do with smoking. So it is possible that it's a very long winded answer and I'm terribly sorry, but it is likely but not as much as, as smoking is my very long answer. But we will. It's great. Yeah, we're on it. Ironic. Absolutely. Yeah, particularly with me, but you're going to say absolutely, just add whilst we are talking about vaping, we should always say that if you are not a smoker, then it is never recommended that you start to bathe and certainly it is never recommended that you start to fake if you're a young young person and just wanted to stress that, you know, it is against law to purchase vapes or E cigarettes for people under 18 in this country or, you know, to, to support young people's babe. I think what you beautifully highlighted is what we're doing is actually adding to the complexity of people's recovery if we're not encouraging people to stop. Definitely. And then what we're also doing is providing a really effective small conversation tool to people's tool kits by allowing baby in and, and creating an infrastructure where we allow safe faith. Can, can we answer Zoey's other questions? Another question. Another great question. Uh Yes. Although do chip in if I if I miss bit. So you ask if there are plans to make vaping available on prescription. Um The MHR A would be the organization to give a medicinal license to evade product and they would love to have a product put forward um to um to be medically license and the benefits would be that there would be less vat on the product. It could be prescribed two under eighteens who are already smoking and need an exit out of smoking. It could be wide more widely um prescribed in say mental health units and so on. But the process itself is very long winded and quite expensive. And at the moment, we haven't got any manufacturers putting forward their product for a medicinal license. And what I would say people is, you know, don't wait for a prescription because you could be waiting a lot for a long time. If you're smoking, uh, you know, get a, get a Vape as an alternative, just buy one because they are much cheaper than cigarettes. And there's a definite health benefit there in, in a complete switch. Anything else to anti that? Um, no, I think it's so another advantage of having a vaping device on the prescription. It, it might give confidence to, uh, the health workforce that this is an all care intervention. Um But as Louise said, you don't, you know, we've been waiting for years. MHR. MHR A have had a rita licensing an option, you know, pathway to licensing since 2016. And as we said, we still haven't seen someone. I'm under the impression that that there's one manufacturer that's going through the licensing process at the moment. So there's a potential we may have a license product in the next couple of years. Uh have still quite a weight. Is it is. Yeah, but also I think playing devil's advocate is a counterfactual to that because once you medical is something because vaping at the moment in this country, it's a consumer product. Once you medical is something and you turn something into a medicine, it becomes something different in the minds of people who are prescribed medicines. And we know in psychiatry adherence with prescribed medicines is quite poor. Um So if you, then if you then treat, if you just treat them as a medicine, it will turn some people off. But alternatively, it'll, it'll turn some people on two vehicles as well. So we just need to be mindful of that. It also means that the product can't be improved after it receives its medical license. So with consumer products, um uh every time there's a sort of like a technological tweak, the product actually becomes more effective, more satisfied for the user, you couldn't do that once it's got an additional license so it could become out of date and inefficient quite quickly. Whereas Vivian technology is probably one of the most fastest growing technologies and innovations we've got. But at the moment and Louis said they're getting better all the time, they're getting better at delivering nicotine all the time and they're getting more satisfying as technology in groups. And I know you've covered quite a bit of this in your session. Yes, there's a webinar that's recorded and there's on this, this platform. That's the word. Yes. So it might be worth for anybody that's interested in the vaping issues to have a look at the uh the recording session. Uh Pick that up. You go on. Hello, you just sorry to carry on and then we'll come back to you and Harry, I think also if vaping was prescribed on prescription, I think it would encourage more people to stop smoking because they instead of completely and then Vape because they wouldn't have to buy the vapes and they wouldn't still be out of pocket and the vapes if they could get them on prescription, if they're on benefits or people of people who are more like smoke. Yeah. What about I was just going to add, we might want to move on from Vegas because we could talk for hours about it. But it might be helpful for people to know that all of the, of Abe's available for purchase in the UK from reputable outlets are regulated by the MHR A. So if you're unsure of what products to get, you can type the name of the product into the MHR A website and then just check if it's, uh, if it's been approved by them, you can also report any adverse reactions that you have to Vegas using the yellow card scheme. So these are just a couple of things that might be of interest to people before we, we move on from talking about it. I think the point I wanted to move is slightly on to and I'd like to hear your ideas about how people recognize tobacco withdrawal because I think it's something that we really do need to consider because if somebody has been admitted, but we're going to offer some alternative, what is tobacco withdrawal? What does it look like? Great question. Um Well, I think it's often misunderstood and it's often not considered for what it is. So typically somebody in tobacco withdrawal or maybe feel lightheaded, they might have a headache, they might feel dizzy, they probably struggle with concentrating, they might be restless, pacing around, find it difficult to sleep. They may have a dip in their mood, feel a bit agitated. Um You know, we'll have a urges to smoke. Um in the long term, they may, you know, really, really struggle. Um What you noticed about this list, list of symptoms and I probably missed a couple is that these are, there's a big overlap between these things and common natural health problems and so on. Award. If you're a nurse on awards and you observe a patient's experiencing these thing things, then immediately you think this is patient who's relapsing, they've got their common mental health problems, which we respond typically as mental health nurses with some promethazine or some sleeping tablets or tranquilizing medication. When actually what patient really needs is some nicotine replacement therapy. The four full range of nicotine replacement therapy um is fantastic, but it's got to be given promptly to patient's and it's got to be given in plentiful supplies and best for patient's to have fingertip control over it because they're used to having their cigarettes in their pockets. Most people who are smoking in our services, they start smoking and their Children. And so they're used to regulating their own nicotine levels. So we can trust them to do that, but we very rarely do. And I think we very rarely give our patient's enough nicotine replacement therapy I don't know if that was your experience. Hannah. What, what was it like for you where you ever offered? NRT? Were you ever given that kind of level of support? So, in, in my secure unit, which was, I was, I came out of about eight years ago, I was just given one of those little inhalator things that basically looked like tampons, but they didn't help at all. And they just said this is what I said. Yeah. And they said, here you go, have one of the, and you would be given, um, if every now and then when you thought they'd run out, you'd asked for a new cartridge. But in, in my inpatient setting, when I was last admitted about a year ago, I, um, was just told all the vapes on ebay and deliver them to the ward and that, that wasn't helpful because it got me into vaping and now I'm addicted to both, but there are some good nicotine replacement therapies like Champix and things like that that could be offered. And I think if they, they were offered as an in, uh, in, in patient settings, they could really reduce the rate of people, the people smoking cam pics is a really good medication and patches could be good. Um, other thing, there's other things that could be good as well, but I, I wasn't given the option but there are options available that I know how. Yeah, I'm sorry, the inhalation didn't really help you is likely that you needed something together with the inhalator. And I think that's often the experience that actually people aren't given enough. You're absolutely right about the Champex. Maybe some people will know it's also called Forensically. Unfortunately, it's not currently available to us here in the UK because of the manufacturing uh difficulties. So we don't have it available to give to patient's at the moment, but it was a fantastic option. Um Hopefully we'll have it back again soon or we have something else. There is conversations about another medicine. That's why he is across Eastern Europe called uh cytosine, which I think MHR A are looking at as well at the moment. So do you know thanking you about it, Debbie or uh isolating? So, yeah, I've just records where we first met in relation to and I did a piece of work with the family, helping somebody to take champions because the value of uh involving our attitude and reliefs are only exacerbated by those around us. So of course, course, if we can change this culture in the same way that we supported and I did that case study with this family and we all work together to stop being so critical of the person when they weren't able to fit it and stop. And I think that's the essence what I would really like is just to, to wrap up and this is such an enormous subject. We cannot that ignore the fact that the point in our pre discussion about how we monitor how we monitor peoples at the tobacco was really powerful for me. Do you want to say a bit more about the idea that we monitor people's insulin? You know, we monitor these things and in mental health care settings, we don't have the same sort of monitors, but I just wanted to hear what you have to say a bit more before we come up with some key messages to take away. I think, I think that, you know, every smoker nose is not a good idea to be smoking and it's written on the packs, you know, smoking kills. It's in big bulbs letters and the images are quite horrific but yet smoke because I still continuing to smoke. And for me, one of the things in my own practice that really helped to change the minds of people and to motivate people to change because let's be honest, you know, quitting smoking, it's just one of the hardest things you can do and what you need is, you know, everyone wrapped around you, helping you and supporting you. And I think that really helps people is regular carbon monoxide monitoring because when people do start to make a small change to their smoking, then they can see that reflected in that score a bit. Like if you're measuring someone's blood sugar level and you know, that you can't just guess what people's BP is, you have to check it or you can't guess what their blood sugar levels is. Once you do that carbon monoxide check, you can have a completely different conversation with people. You can see, set them a realistic goal with them. So they can start to make some incremental and sustained changes to their smoking because let's face it. You know, it's been usually heavily dependent. Longstanding smokers don't find it hard to change. And I think, you know, Hannah's told us how hard it is and even switching to pretty good quality e cigarettes. Um uh it's still hard. So we need to, in addition to using E cigarettes and having behavioral support, we need this extra things as well like carbon monoxide monitoring to really put all the places together while patient's tell us is rid that feedback, visual feedback, seeing those levels come down is a time to celebrate. And it's, it's such a powerful thing to just to, to, to see somebody's confidence change in front of you with a dependence and then all of a sudden they feel empowered, you know, I can do this. Um And then that is a springboard for changing other parts in their lives. Sorry, Hannah. No, I just said that it's 16 when you see the levels coming down just like you get on the scales if you're on higher and you see your weight. Yeah, smoking her later and you're on whatever and then next week you puff into it lower down, you think? Yes, that's an achievement. Yeah. Yeah. Exactly. And I think that's the point that it's emerged from these conversations that I've had, we've been planning this discussion roundtable that it's really brought home to me, um, that, you know, often in mental health nursing, we don't have the same equivalent of a temperature chart that you can show to a patient. This is how you're improving. This is what? And actually, that's a wonderful opportunity. I know we're getting um nears the end of finishing. And as I said, this is a rich discussion, but I'm just wondering if there's some things that you want to add or some key messages that you really want us to go away and take away from this and do something about. I'd encourage anybody watching this to, to realize that, that, you know, there's a body of knowledge around this, but it's not ever so complicated. You know, the conversation with somebody who smokes can be quite simple and very empathetic as well. It doesn't have to be a finger wagging thing. And I'd encourage you all to have a look at the NCSCT website and you know, have a look at very brief advised module, the vaping module. Best practice in mental health settings. There's a lot of information there. It's free, it's all online. Um It's, it's very accessible and you know, evidence based. So have a look at what there is. And you know, you might be surprised at how easy it is to have that conversation with a patient that smokes, that avoid the conversation. I think I would say that remind people that smoking is not a lifestyle choice. It's, it's a chronic relaxing condition that usually starts in childhood. And as mental health nurses, psychiatrists, general health nurses, allied health professionals, we've got a really responsibility to address that and make it our core business. And I think, you know, mental health nurses, psychiatrists in particular, have they already have this skill set that's transferable. Um So you're not, you know, you're not having to learn a whole new set of skills, you already got them. And uh that can be adapted to support people who smoke to reduce their home from tobacco and it's such a rewarding thing to do. Absolutely. I mean, I would just finish by saying, I think definitely it's incumbent on us to not leave our patient's behind. It isn't right. It's shameful that people with seriously enduring mental health problems are suffering so much from this completely treatable condition that we need to step up and get our heads around. It's not okay for us to create a culture and a system where we support smoking rather than supporting people to not smoke. So the way that we organize ourselves, escorting patient's to smoke, storing tobacco for, for patient's failing to treat people adequately for their addiction, failing to do the carbon monoxide reading. It's really, there's no room for that anymore in a modern progressive mental health service. In too 2023 we've got the evidence. We've got the knowledge we need to come together and really our patient's deserve better. So, thank you for listening to us. Well, I don't want to hear from Hannah. Any top message that you want us to take away from this discussion. Basically that we're not just smokers were people as well. We're people with hobbies, with people with families where people with lives and don't look at us just a smoker. Look at us as a whole and, and don't basically just pass everything else off. Look at us as a whole person. Yes, a very good place to finish. And interestingly, I, I was just remembered, I, I've worked in this area where in South London at the moment and I worked in this area for, gosh, nearly 35 years and I bumped into a patient a few months ago who I hadn't seen for. And he was a considerable smoker and he was looked completely different, completely different. And I said, you look, you know, you so well, you look at the bright eyes and he said, yes, I finished, I stopped smoking about five years ago, his skin looked different. He looked different. And if there's nothing that can give you a bigger message is actually how your skin looks, how, how much it's sort of some sort of lift that has come about. And I think I'd like to thank all of you for Hannah and, and all of you for continuing this because it's so important. And I think the every single one of you and what I think you're demonstrating is actually what a fantastic uh role we can play as mental health nurses in this and your research, Debbie and your strategy and your training, all that that is coming before out, buying mental health nurses and there aren't enough of us really signed up to it. And so I want to thank you for your passions for share ing it this afternoon. And thank you again, Hannah for ever contributing to and doing all you do with the equally well. UK It's very, very important uh message can I just say? Thank you, I've learned a lot. I think Zoe has put in the chat. This has been fascinating, really appreciate your time, lots to take away. And I would, I mean, I think, you know, the professional responsibility, the monitoring, the fact that, you know, people will feel better and, you know, surely as healthcare professionals, that's our duty to try and do. Um and, and not using, you know, it is a diffusing tool. There are other tools to use and, and, and it shouldn't be there in that armory at all. So thank you all and thank you for contributing to this, you know, for the anybody dealing with people try to stop smoking on mental health units or elsewhere. Do have a look at the winning hearts and minds resources. We'll make sure that the website link is available. There's lots there. So I hope you find it useful. Thank you very much for listening.