Clinical management of tobacco dependence in inpatient psychiatry: provider practices and patient utilization

A Pilot Randomized Clinical Trial of Brief Interventions to Encourage Quit Attempts in Smokers From Socioeconomic Disadvantage

INTRODUCTION

Cigarette smoking disproportionately affects communities of low socioeconomic status where greater smoking prevalence and poorer cessation rates have been observed. Utilizing brief evidence-based interventions to increase cessation attempts may be an effective and easily disseminable means by which to mitigate undue burden in this population.

AIMS AND METHODS

The current intervention randomized daily smokers (N = 57) recruited from a local community soup kitchen to receive either Brief (eg, 30 m) Motivational Interviewing, Nicotine Replacement Therapy (NRT) sampling, or a Referral-Only intervention. Approximately half of participants (50.9%) reported not completing high school and many reported either just (41.4%) or not (40.4%) meeting basic expenses. Follow-up was completed approximately 1-month postintervention.

RESULTS

Nonsignificant group differences indicated that participants randomized to the NRT sampling condition were more likely to make a quit attempt (moderate effect size). Approximately 40% of the sample reported making a serious quit attempt at follow-up. Significant differences in cigarettes per day at follow-up, controlling for baseline, were observed, with participants in the Motivational Interviewing condition, only, reporting significant reductions. Participants randomized to the NRT condition were significantly more likely to report using NRT patch and lozenge at follow-up (large effect). There were no differences between groups with respect to seeking behavioral support. Finally, we found that subjective financial strain moderated the effect of condition on change in cigarette consumption where NRT sampling was more effective for participants reporting less financial strain.

CONCLUSIONS

Findings provide initial evidence for personalizing brief interventions to promote quit attempts in low-income smokers.

IMPLICATIONS

While most clinical research on tobacco use and dependence focuses on successful sustained abstinence, the current study is novel because it examined three brief interventions designed to increase the number of quit attempts made by a nontreatment-seeking group suffering from health disparities (ie, smokers from socioeconomic disadvantage). These data suggest that nontreatment-seeking smokers from socioeconomic disadvantage can be influenced by Brief MIs and these interventions should be used to motivate smokers from socioeconomic disadvantage to make a quit attempt. Future studies should examine combined MIs including pharmacological and behavioral interventions.

Targeted Intervention to Reduce Smoking among People with Severe Mental Illness: Implementation of a Smoking Cessation Intervention in an Inpatient Mental Health Setting

Background and Objectives: Smoking and smoking-related harms are highly prevalent among people with severe mental illness. Targeted smoking cessation programs are much needed in this population. This pilot study aimed to assess the effectiveness of implementing smoking cessation system change interventions within an acute inpatient mental health unit. Materials and Methods: Design: Pre-post intervention study. System change interventions for smoking cessation were delivered over a three-month period (05 March 2018-04 June 2018) on an acute inpatient mental health unit. Participants (n = 214) were all individuals receiving care as inpatients during the three-month intervention. Outcomes assessed pre- and post-intervention were: (i) recording of patient smoking status in medical notes, (ii) number of inpatients offered smoking cessation medication, and iii) number of violent incidents reported. Results: Recording of smoking status significantly increased from 1.9% to 11.4% (X² = 14.80; p ≤ 0.001). The proportion of inpatients offered smoking cessation treatment significantly increased from 11.0% to 26.8% (X² = 16.01; p ≤ 0.001). The number of violent incidents decreased by half, which was not statistically significant. Conclusion: Evidence-based smoking cessation interventions can be successfully implemented on an inpatient mental health unit. Modest gains were made in routine screening for smoking and in smoking cessation treatment prescription. Future studies should prioritize effective participatory collaboration with staff to optimize effectiveness of interventions and should include additional strategies such as brief intervention training and smoking cessation treatments such as varenicline and buproprion in addition to nicotine replacement therapy (NRT).

Systematic review and meta-analysis of the provision of preventive care for modifiable chronic disease risk behaviours by mental health services

People with mental illness experience increased chronic disease burden, contributed to by a greater prevalence of modifiable chronic disease risk behaviours. Policies recommend mental health services provide preventive care for such risk behaviours. Provision of such care has not previously been synthesised. This review assessed the provision of preventive care for modifiable chronic disease risk behaviours by mental health services. Four databases were searched from 2006 to 2017. Eligible studies were observational quantitative study designs conducted in mental health services, where preventive care was provided to clients for tobacco smoking, harmful alcohol consumption, inadequate nutrition, or inadequate physical activity. Two reviewers independently screened studies, conducted data extraction and critical appraisal. Results were pooled as proportions of clients receiving or clinicians providing preventive care using random effects meta-analyses, by risk behaviour and preventive care element (ask/assess, advise, assist, arrange). Subgroup analyses were conducted by mental health service type (inpatient, outpatient, other/multiple). Narrative synthesis was used where meta-analysis was not possible. Thirty-eight studies were included with 26 amenable to meta-analyses. Analyses revealed that rates of assessment were highest for smoking (78%, 95% confidence interval [CI]:59%-96%) and lowest for nutrition (17%, 95% CI:1%-35%); with variable rates of care provision for all behaviours, care elements, and across service types, with substantial heterogeneity across analyses. Findings indicated suboptimal and variable provision of preventive care for modifiable chronic disease risk behaviours in mental health services, but should be considered with caution due to the very low quality of cumulative evidence. PROSPERO registration: CRD42016049889.

Changes in voluntary admission and restraint use after a comprehensive tobacco-free policy in inpatient psychiatric health facilities

Background: Cardiovascular and respiratory diseases, predominantly due to tobacco use, are the leading causes of death among individuals with serious and persistent mental illness. However, many psychiatric health facilities do not routinely treat tobacco use disorder. The purpose of the current study was to examine the impact of implementing a tobacco-free policy in inpatient psychiatric health facilities in a large, urban setting on behavioral problems, treatment access, and tobacco treatment. Methods: Data on seclusion and restraint incidents, voluntary commitment at admission for each hospitalization episode, and nicotine replacement therapy (NRT) prescriptions were collected through secondary analysis of Medicaid administrative records from baseline in January 2015 (n = 8983) to follow-up in December 2016 (n = 9685) at 14 inpatient psychiatric health facilities. Results: There were no significant changes from baseline to follow-up in odds of seclusion and restraint incidents or voluntary admission status. There was a significant increase in the odds of NRT prescriptions at both 30 and 180 days post discharge (odds ratio [OR] range = 1.58-2.09, P < .01). Conclusions: In a large, urban setting among Medicaid enrollees, implementation of a tobacco-free policy in inpatient psychiatric health facilities had no negative impact on behavioral problems or treatment access and improved access to NRT, although overall NRT use remained low. This study challenges perceptions among some providers that addressing tobacco use disorder will negatively impact treatment outcomes in individuals with serious mental illness. These findings support tobacco-free policies in psychiatric health facilities and the role of psychiatric health providers in treating tobacco use in this population, which is at high risk for tobacco-related mortality.

Improving patient education about tobacco withdrawal and nicotine gum use by registered nurses in inpatient psychiatry: A feasibility study

WHAT IS KNOWN ON THE SUBJECT?: Many psychiatric inpatients use tobacco, but most psychiatric hospital units prohibit tobacco use. Psychiatric nurses do not receive adequate education about how to teach patients to best manage tobacco withdrawal symptoms. WHAT DOES THIS PAPER ADD TO EXISTING KNOWLEDGE?: Psychiatric nurses who receive a brief educational intervention about tobacco withdrawal symptoms and best practices for using nicotine gum may be more prepared to teach patients about these topics. In turn, patients may use nicotine gum more often during their hospitalization, leading to improved outcomes for them as well as for staff. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: A simple educational intervention aimed at psychiatric nurses can result in positive outcomes for psychiatric inpatients who use tobacco. Patients who have a positive experience with stopping tobacco use while hospitalized may be more likely to commit to lifelong tobacco cessation afterwards. The results of this feasibility study demonstrate that additional research that builds on the work presented here is warranted.

ABSTRACT

Introduction Tobacco use is prohibited in most psychiatric facilities in the United States, yet many psychiatric inpatients are tobacco users. Psychiatric nurses have reported inadequate education about best practices for managing tobacco dependence. Aim To explore the feasibility of an educational intervention for psychiatric nurses designed to improve their ability to educate patients about best practices for managing tobacco dependence, as well as effective use of nicotine gum. Method Fourteen nurses on a psychiatric inpatient unit at a community hospital were educated about the targeted topics. Chart reviews of nonequivalent pre-intervention and post-intervention patient groups were conducted to explore the outcomes of the intervention. Results Patients received more teaching, and used nicotine gum more often, following the intervention. However, no statistically significant differences between the pre-intervention and post-intervention patient groups were found. Discussion Educating nurses about best practices for managing tobacco withdrawal symptoms may have positive outcomes. Existing research suggests that such interventions may be most effective when support and structure are provided to ensure long-term practice changes. Implications for practice This feasibility study demonstrates that a brief nurse education intervention has the potential to improve the experience of tobacco withdrawal for psychiatric inpatients. Future research that expands upon the current project is warranted.

A retrospective analysis of the association between providing nicotine replacement therapy at admission and motivation to quit and nicotine withdrawal symptoms during an inpatient psychiatric hospitalization

BACKGROUND

Psychiatric patients have high tobacco use prevalence, dependence, and withdrawal severity. A tobacco-free psychiatric hospitalization necessitates the management of nicotine withdrawal (NW) for tobacco using patients. NW management often requires the provision of approved nicotine replacement therapy (NRT) to patients, which may also motivate tobacco users towards cessation. However, few studies have examined the associations between providing NRT, motivation to quit, and NW among psychiatric patients.

OBJECTIVE(S)

To examine the associations between providing NRT at admission and motivation to quit smoking and severity of NW symptoms.

DESIGN

A retrospective review of the medical records of 255 tobacco using patients on whom NW was assessed during their hospital stay. The time when NRT was provided (i.e., at admission vs. not provided vs. on the unit), motivation to quit smoking, and 8-item Minnesota Nicotine Withdrawal Scale were assessed.

RESULTS

The primary NW symptom was 'craving' (65.1%); reporting of 'anxiety' varied by psychiatric diagnosis. Providing NRT at admission was not associated with motivation to quit. Patients receiving NRT on the unit (i.e., delayed receipt) had significantly higher NW than those who received NRT at admission. In multivariate analyses, receiving NRT on the unit was significantly associated with greater NW severity (β = .19, p = .002).

CONCLUSIONS

Among psychiatric patients, providing NRT at admission is associated with greater severity of NW. The provision of NRT for NW management may be considered as standard practice during tobacco-free psychiatric stays. Future studies may consider the effect of other tobacco treatment medications (such as varenicline, bupropion) on managing NW.

Patient receipt of smoking cessation care in four Australian acute psychiatric facilities

This study aimed to report the receipt of smoking care, and associated clinical and smoking characteristics among smokers admitted to four public psychiatric inpatient facilities in New South Wales, Australia. Between October 2012 and July 2014, adult smokers (N = 236) were surveyed during admission to and 1 month following discharge from the facilities. Measures of smoking care receipt were reported descriptively, and logistic regression analyses were used to explore characteristics associated with care receipt. The majority of participants were offered (78%) and used (78%) nicotine replacement therapy (NRT), with 66% of NRT-users reporting the amount provided was sufficient to reduce cravings. A minority of participants (16%) received information or advice to quit smoking, and 60% reported smoking throughout their admission. Patients not contemplating quitting and those with non-psychotic disorders were more likely to receive an offer of NRT. The findings suggest the provision of smoking care in Australian acute psychiatric units is sub-optimal overall, with an indication that care may be provided selectively to certain patients, rather than systematically to all. Development and dissemination of interventions to increase smoking care provision in inpatient psychiatry are needed.

A cross-sectional analysis of factors associated with the intention to engage in tobacco treatment among inpatients in a state psychiatric hospital

WHAT IS KNOWN ON THE SUBJECT?: People admitted to psychiatric facilities have high rates of tobacco use and hospitalizations present an opportunity for patients to have conversations about tobacco use treatment. Clinicians may believe that people with mental illnesses are not interested in quitting or that they do not understand the importance of treatment. Positive attitudes towards tobacco treatment, viewing that participating in treatment is normal care, and feeling that one is quite able to participate in such treatment predicts intentions to participate in treatment, which, in turn, predicts actual participation. WHAT DOES THIS PAPER ADD TO EXISTING KNOWLEDGE?: Psychiatric patients who use tobacco use report poor prior involvement with tobacco treatment. Positive attitudes towards, encouraging opinions of other people about, and having a sense of control over taking part in tobacco treatment increases plans to engage in treatment. Having a sense of control in taking part in tobacco treatment is strongly associated with prior experiences with evidence-based treatment. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Because psychiatric hospitalizations are an opportunity for addressing tobacco use and treatment, clinicians should be prepared to support willing patients, especially those with prior substance use histories. Support should include providing them with information regarding tobacco treatment options during their hospital stay and ways that they can continue to receive care after discharge. Clinicians should be promoters of pro-tobacco treatment attitudes and supporting patients' sense of control over participating in treatment during hospitalization.

ABSTRACT

Introduction Hospitalized tobacco users with mental illnesses (MI) may face several barriers to stopping smoking. However, motivational factors that affect the intention to engage in tobacco treatment have been shown to predict actual engagement. Aim To use the Theory of Planned Behavior to assess intentions to and prior experiences of engaging in evidence-based tobacco treatment among hospitalized individuals with MI. Method A cross-sectional survey was conducted among 115 patients in a state psychiatric hospital. Multivariate analyses were used to examine associations with the intentions and prior experiences of engaging in tobacco treatment. Results After controlling for demographic and smoking history, attitudes, subjective norms and perceived behavioural control towards engaging in tobacco treatment were significantly associated with intentions towards treatment engagement. Only higher scores on perceived behavioural control and lower education levels were associated with reported prior experiences of tobacco treatment. Discussion The low prior treatment engagement scores, but relatively higher intention to engage scores among participants suggests the need for deliberate support for evidence-based tobacco treatment during psychiatric hospitalizations. Implications for practice Clinician training in tobacco treatment can promote self-efficacy to engage patients while supporting patients' control so that tobacco treatment is an expected component of psychiatric care.

An audit of the management of nicotine withdrawal in an Australian inpatient unit: are we there yet?

OBJECTIVES

This paper reports outcomes of a clinical audit of smoke-free policy implementation within an Australian inpatient psychiatric setting. It aimed to evaluate assessment of smoking status and subsequent management of nicotine withdrawal, and investigate any patient factors influencing these processes.

METHODS

A total of 67 medical case notes were retrospectively analysed for inpatients admitted to psychiatric units of a general hospital in South Australia, from July to September 2015. Patient demographic variables and information from the hospital's Smoking Assessment and Management Form (SAMF) were recorded. Data analysis involved descriptive statistics and Chi-square tests of association between dependent variables (how the SAMF was completed) and independent variables (sex, voluntary status, diagnosis).

RESULTS

The SAMF was implemented for most patients (76.1%), with 64.71% completed within 24 hours of admission; though, many were incomplete. Nicotine dependence was not properly assessed for 42.3% of smokers; 69.23% were prescribed nicotine replacement therapy (NRT), despite most scoring moderate to high nicotine dependence. No statistically significant relationships were found between patient factors and form completion.

CONCLUSIONS

SAMF completion was timely for most patients; however, sections important for determining support actions remained largely incomplete, suggesting patients' nicotine withdrawal is not being adequately addressed. More work is needed to improve inpatient staff's assessment to ensure optimal care.

Effect of implementation of a smoke-free policy on physical violence in a psychiatric inpatient setting: an interrupted time series analysis

BACKGROUND

Smoke-free policies are important to protect health and reduce health inequalities. A major barrier to policy implementation in psychiatric hospitals is staff concern that physical violence will increase. We aimed to assess the effect of implementing a comprehensive smoke-free policy on rates of physical assaults in a large UK mental health organisation.

METHODS

We did an interrupted time series analysis of incident reports of physical assault 30 months before and 12 months after the implementation of the policy in the inpatient wards of South London and Maudsley National Health Service Foundation Trust, London, UK. We used a quasi-Poisson generalised additive mixed model to model the monthly incidence of physical assaults as a function of several explanatory variables.

FINDINGS

4550 physical assaults took place between April 1, 2012, and Sept 30, 2015; 225 (4·9%) of which were smoking-related. After adjustment for temporal and seasonal trends and key confounders (sex, age, schizophrenia or related disorders, or having been sectioned under the Mental Health Act), there was a 39% reduction in the number of physical assaults per month after the policy introduction compared with beforehand (incidence rate ratio 0·61, 95% CI 0·53-0·70; p<0·0001).

INTERPRETATION

Introduction of a comprehensive smoke-free policy appeared to reduce the incidence of physical assaults. Adequately resourced smoke-free policies could be part of broader violence reduction strategies in psychiatric settings.

FUNDING

National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care South London (King's College Hospital NHS Foundation Trust).

Does menthol cigarette use moderate the effect of nicotine metabolism on short-term smoking cessation?

The nicotine metabolite ratio (NMR) has been shown to predict response to the transdermal nicotine patch, such that faster nicotine metabolism is associated with a lower abstinence rate. Menthol cigarette use, versus nonmenthol cigarette use, slows nicotine metabolism and therefore may attenuate the effect of NMR on smoking abstinence. In this study, we evaluated whether cigarette type (menthol vs. nonmenthol) modified the association between NMR and short-term abstinence. This was a secondary analysis examining treatment in the first 8 weeks of 21 mg/day nicotine patch therapy in a completed clinical trial (n = 474). Menthol cigarette use was based on self-report. NMR was defined dichotomously (0 = fast, 1 = slow) to distinguish between fast (≥0.47) versus slow NMR. Using logistic regression analysis, we tested whether cigarette type moderated the association between NMR and bioverified 7-day point prevalence abstinence at Week 8. Covariates include nicotine dependence, age, race, and gender. Three hundred two participants reported smoking menthol cigarettes, of which 234 (77%) were classified as slow NMR. Among the 172 nonmenthol smokers, 136 were classified as slow NMR (79%). Contrary to our expectations, the NMR ×Cigarette Type interaction effect on abstinence was not significant (odds ratio [OR] = 0.91, p = .86). Excluding the interaction variable, fast NMR was associated with decreased likelihood of abstinence (OR = 0.55, p = .03), but menthol cigarette use was not (OR = 1.15, p = .56). Further exploration of risk factors among menthol cigarette smokers, especially among racially diverse and light smokers, could clarify the association between menthol cigarette use and poorer smoking outcomes. (PsycINFO Database Record

Correlates of nicotine withdrawal severity in smokers during a smoke-free psychiatric hospitalization

Psychiatric hospitals are increasingly adopting smoke-free policies. Tobacco use is common among persons with mental illness, and nicotine withdrawal (NW), which includes symptoms of depression, anxiety, anger/irritability, and sleep disturbance, may confound psychiatric assessment and treatment in the inpatient setting. This study aimed to characterize NW and correlates of NW severity in a sample of smokers hospitalized for treatment of mental illness in California. Participants (N=754) were enrolled between 2009 and 2013, and averaged 17 (SD=10) cigarettes/day prior to hospitalization. Though most (70%) received nicotine replacement therapy (NRT) during hospitalization, a majority (65%) reported experiencing moderate to severe NW. In a general linear regression model, NW symptoms were more severe for women, African American patients, and polysubstance abusers. Though invariant by psychiatric diagnostic category, greater NW was associated with more severe overall psychopathology and greater cigarette dependence. The full model explained 46% of the total variation in NW symptom severity (F [19, 470]=23.03 p<0.001). A minority of participants (13%) refused NRT during hospitalization. Those who refused NRT reported milder cigarette dependence and stated no prior use of NRT. Among smokers hospitalized for mental illness, NW severity appears multidetermined, related to cigarette dependence, demographic variables, psychiatric symptom severity, and other substance use. Assessment and treatment of NW in the psychiatric hospital is clinically warranted and with extra attention to groups that may be more vulnerable or naïve to cessation pharmacotherapy.

Smokers with serious mental illness and requests for nicotine replacement therapy post-hospitalisation

BACKGROUND AND AIMS

Smoke-free psychiatric hospitalisation provides opportunity for initiating tobacco cessation treatment. The current study reports on psychiatric patients' interest in continuing nicotine replacement therapy (NRT) posthospitalisation and examines patient predictors of NRT requests, quit attempts and abstinence at 1-week follow-up.

METHODS

Daily smokers were recruited and interviewed on locked psychiatric units at three smoke-free San Francisco Bay Area hospitals. Intent to quit smoking was not required to participate and 73% of eligible smokers enrolled. Analyses focused on 816 participants (49% female) randomised to interventions providing counselling tailored to readiness to quit with availability of NRT posthospitalisation. Logistic regressions tested demographic, smoking and psychiatric factors predictive of NRT requests, quit attempts and abstinence 1-week postdischarge.

RESULTS

Participants averaged 17 (SD=10) cigarettes/day for an average of 19 (SD=14) years. Most (88%) requested study-provided NRT (74% right at discharge). Participants preparing to quit and those with more severe psychiatric symptoms were more likely to request NRT at discharge (p<0.01). Those with more severe psychiatric symptoms also were more likely to request NRT refill, as were older participants (p<0.05). Participants who requested NRT at discharge were more likely to make a 24 h quit attempt and self-report abstinence at the 1-week follow-up (54% quit attempt, 14% abstinent) than participants who did not (25% quit attempt, 4% abstinent) (p<0.05).

CONCLUSIONS

The great demand for NRT and the association between NRT use with quit attempts and abstinence at 1-week posthospitalisation supports adoption of tobacco treatment in acute psychiatric settings.

TRIAL REGISTRATION NUMBER

# NCT00968513.