A two-year follow-up on the effects of a smoking ban in an inpatient psychiatric service

Staff perspectives on smoking cessation treatment in German psychiatric hospitals

Aim

Although people with mental illness show a greater severity of nicotine dependence and have a significantly reduced life expectancy because of it, psychiatric staff rarely offer their patients smoking cessation support and are reluctant to encourage patients to quit. In order to improve smoking cessation treatment for psychiatric patients, such staff resistance must be better understood.

Subjects and methods

A total of 448 members of staff in eight psychiatric units in Berlin were surveyed in relation to their attitudes towards smoking cessation.

Results

Although most participants recognize the importance of smoking cessation in psychiatric patients, they state that they do not adhere to international guidelines which recommend regularly asking patients about their smoking habits and offering cessation support. Staff have little knowledge about how to facilitate smoking cessation treatment and about the influences of smoking on the metabolism of drugs. They also harbor misconceptions about how smoking affects their patients’ mental well-being. Many express concern that a quit attempt might thwart psychiatric treatment and lead to aggressive behavior—assumptions unsupported by scientific evidence. The overwhelming majority does not believe it to be realistic that patients can manage to give up smoking during treatment.

Conclusions

Staff training should be directed to heighten awareness of the international guidelines and treatment options for smoking cessation and impart knowledge on how smoking impacts both the physical and mental health of psychiatric patients.

Smoking-related violence in a mental health setting following the implementation of a comprehensive smoke-free policy: A content analysis of incident reports

Smoke-free policies in mental health settings are important to protect health but are often impeded by staff concerns that physical violence may increase. We aimed to address the literature gap about the frequency, nature, and management of physical violence in relation to smoking. We compared the antecedents and containment of smoking-related incidents of physical violence over a two-year period, (12 months when an indoor-only smoke-free policy was in place, followed by 12 months after a new comprehensive smoke-free policy was introduced) using incident reports completed by staff in a large mental health organization in London, UK. Sixty-one smoking-related incidents occurred during the indoor-only smoke-free policy period; 32 smoking-related incidents occurred during the comprehensive smoke-free policy. We identified four antecedent categories for physical violence: i) patient request to smoke denied by staff; ii) during a supervised smoking break; iii) staff response to a patient breach of the smoke-free policy iv) asking for, trading or stealing smoking materials. The antecedent pattern changed across the two policy periods, with fewer incidents of denying a patient's request to smoke and a greater number of incidents involving staff responding to breaches occurring after the introduction of the comprehensive smoke-free policy. The prohibition of smoking breaks removed this source of violence. Timeout and PRN medication were the most common containment interventions. Understanding the context of smoking-related violence may inform clinical guidelines about its prevention and management.

Violence in mental health settings: A systematic review

The introduction of smoke-free policies is increasingly common in mental health settings, to improve health. However, a barrier to implementing smoke-free polices is staff concern that violence will increase. We conducted a systematic review comparing the rates of violence before and after the introduction of smoke-free policies in mental health settings. Two authors searched major electronic databases. We included studies reporting the prevalence of violence (verbal and/or physical or combined) before and after the introduction of a smoke-free policy in a mental health, forensic, or addiction setting. We included 11 studies in the review. A narrative synthesis was used to describe the key results of each study. Six studies measured physical violence specifically; four reported a decrease or no change and two reported a short-term increase. Five of these six studies also measured verbal violence; two found an increase, with one of the studies reporting that this increase was temporary. Three reported a decrease in verbal violence. A further five studies evaluated the rate of combined verbal and physical violence; four reported a decrease or no change and the other an increase. We conclude that the introduction of smoke-free policies generally does not lead to an increase in violence. There is a need for more robust studies to support this finding. However, the conclusions from this review may be a step in reducing staff concerns.

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).

Strategies to deal with comorbid physical illness in psychosis

Individuals with serious mental illnesses such as psychosis still experience higher mortality rates than the general population, decades after data have linked the gap to increased rates of physical illness, delayed diagnosis, low treatment rates and worse outcomes from treatment received. The nature of the relationship between psychosis and comorbid physical illness is complex. Multiple strategies directed at different levels of disease process, health care systems and stakeholder culture are likely required to make sustained progress in reducing the mortality gap. Evidence for strategies that effectively reduce the burden of physical co-morbidity and lead to improved health outcomes are still in their infancy but growing at a reassuringly fast rate. This editorial considers the existing evidence base and makes suggestions for the development and future direction of this urgent research agenda and how this knowledge can be implemented in clinical practice.

[Tobacco smoking and psychiatric intensive care unit: Impact of the strict smoking ban on the risk of violence]

BACKGROUND

Tobacco smoking is the main cause of death among mentally ill persons. Since February 2007, smoking has been strictly forbidden in French covered and closed psychiatric wards. The fear of an increased violence risk induced by tobacco withdrawal is one of the most frequent arguments invoked against this tobacco ban. According to the literature, it seems that the implementation of this ban does not imply such a risk. All these studies compared inpatients' violence risk before and after the tobacco ban in a same psychiatric ward.

AIM

We aimed to analyse the strict tobacco withdrawal consequences on the violence risk in a retrospective study including patients hospitalised in a psychiatric intensive care unit of the university hospital of Caen during the same period.

METHODS

We compared clinical and demographic data and the violence risk between the smoker group (strict tobacco withdrawal with proposed tobacco substitution) and the non-smoker group (control group). In order to evaluate the violence risk, we used three indicators: a standardised scale (the Bröset Violence Checklist) and two assessments specific to the psychiatric intensive care setting ("the preventing risk protocol" and the "seclusion time"). The clinical and demographic data were compared using the Khi2 test, Fisher test and Mann-Whitney test, and the three violence risk indicators were compared with the Mann-Whitney test. Firstly, comparisons were conducted in the total population, and secondly (in order to eliminate a bias of tobacco substitution) in the subgroup directly hospitalised in the psychiatric intensive care setting. Finally, we analysed in the smoker group the statistical correlation between tobacco smoking intensity and violence risk intensity using a regression test.

RESULTS

A population of 72 patients (50 male) was included; 45 were smokers (62.5%) and 27 non-smokers. No statistically significant differences were found in clinical and demographic data between smoker and non-smoker groups in the whole population, as well as in the subgroup directly hospitalised in the psychiatric intensive care setting. Whatever the violence risk indicators, no statistically significant difference was found between the smoker group and the non-smoker group in the total population, as well as the subgroup directly hospitalised in the psychiatric intensive care setting. Moreover, no correlation was found between the tobacco smoking intensity and the violence risk intensity in the smoker group.

CONCLUSION

Strict tobacco withdrawal does not appear to constitute a violence risk factor in psychiatric intensive care unit inpatients. However, further studies are needed to confirm these results. They should be prospective and they should take into account larger samples including patients hospitalised in non-intensive care psychiatric wards.

[Prohibición de fumar y sus implicaciones potenciales en cuidados de salud mental. Revisión de la evidencia]

Different publications have described a close relation between tobacco consumption and major psychiatric disorders. A great number of countries have enacted smoking bans in public or working places since the early 2000s; nonetheless, concerns remain over the exemption in some psychiatric settings regarding smoking bans. Admission of smokers to smoke-free units may lead to behavior deterioration, but some recent evidence refutes this argument.

METHODS

Literature review.

RESULTS

One of the earliest smoking bans was a 1.575 Mexican ecclesiastical council ban aimed at smoking prevention in churches. Several recent studies have documented health and economic benefits related to smoking bans. Over 83 countries now have introduced different sorts of regulations. There was no increase in aggression, seclusion or discharge against medical advice, neither increased use of PRN (as needed) medication following the ban. As part of the ban imposition, Nicotine Replacement Therapy- NRT was used by patients. Consistency, coordination and full staff support for the ban were seen as key success factors. Many patients continued smoking after discharge.

CONCLUSIONS

Evidence shows that smoking has no place in psychiatric hospitals or facilities. The introduction of smoking bans in psychiatric settings is possible, but these bans must be conceived only as part of a much larger strategy, necessary to diminish smoking high rates among mental health populations.

Nonmedication smoking reduction program for inpatients with chronic schizophrenia: a randomized control design study

People with schizophrenia are more likely to smoke, and to smoke more frequently, than those without schizophrenia. Furthermore, inpatients smoke even more frequently compared with those living in the community. In light of this, we implemented and assessed a smoking reduction intervention using a wide array of behavioral group techniques and methods in chronic hospitalized schizophrenic clients. Using a controlled design, we randomly assigned chronic schizophrenic clients to either a five-session smoking reduction intervention (n = 35) or a waiting list (WL; n = 18). We assessed self-reported smoking behavior, clinical status (Positive and Negative Syndrome Scale, Hamilton Rating Scale for Depression; Clinical Global Impression Scale for Psychosis), subjective quality of life (Quality of Life Enjoyment and Satisfaction Questionnaire-abbreviated version), and weight before and 3 months after the intervention. The intervention successfully reduced the number of cigarettes smoked compared with nonintervention. No clinical worsening or weight gain was observed. Behavioral group-oriented smoking reduction interventions can significantly reduce smoking behavior in hospitalized chronic clients with schizophrenia.

A tobacco reconceptualization in psychiatry: toward the development of tobacco-free psychiatric facilities

Tobacco dependence is the leading cause of death in persons with psychiatric and substance use disorders. This has lead to interest in the development of pharmacological and behavioral treatments for tobacco dependence in this subset of smokers. However, there has been little attention paid to the development of tobacco-free environments in psychiatric institutions despite the creation of smoke-free psychiatric hospitals mandated by the Joint Commission for Accreditation of Health Organizations (JCAHO) in 1992. This review article addresses the reasons why tobacco should be excluded from psychiatric and addictions treatment settings, and strategies that can be employed to initiate and maintain tobacco-free psychiatric settings. Finally, questions for further research in this field are delineated. This Tobacco Reconceptualization in Psychiatry is long overdue, given the clear and compelling benefits of tobacco-free environments in psychiatric institutions.

Total smoking bans in psychiatric inpatient services: a survey of perceived benefits, barriers and support among staff

BACKGROUND

The introduction of total smoking bans represents an important step in addressing the smoking and physical health of people with mental illness. Despite evidence indicating the importance of staff support in the successful implementation of smoking bans, limited research has examined levels of staff support prior to the implementation of a ban in psychiatric settings, or factors that are associated with such support. This study aimed to examine the views of psychiatric inpatient hospital staff regarding the perceived benefits of and barriers to implementation of a successful total smoking ban in mental health services. Secondly, to examine the level of support among clinical and non-clinical staff for a total smoking ban. Thirdly, to examine the association between the benefits and barriers perceived by clinicians and their support for a total smoking ban in their unit.

METHODS

Cross-sectional survey of both clinical and non-clinical staff in a large inpatient psychiatric hospital immediately prior to the implementation of a total smoking ban.

RESULTS

Of the 300 staff, 183 (61%) responded. Seventy-three (41%) of total respondents were clinical staff, and 110 (92%) were non-clinical staff. More than two-thirds of staff agreed that a smoking ban would improve their work environment and conditions, help staff to stop smoking and improve patients' physical health. The most prevalent clinician perceived barriers to a successful total smoking ban related to fear of patient aggression (89%) and patient non-compliance (72%). Two thirds (67%) of all staff indicated support for a total smoking ban in mental health facilities generally, and a majority (54%) of clinical staff expressed support for a ban within their unit. Clinical staff who believed a smoking ban would help patients to stop smoking were more likely to support a smoking ban in their unit.

CONCLUSIONS

There is a clear need to more effectively communicate to staff the evidence that consistently applied smoking bans do not increase patient aggression. There is also a need to communicate the benefits of smoking bans in aiding the delivery of smoking cessation care, and the benefits of both smoking bans and such care in aiding patients to stop smoking.

Legislative smoking bans for reducing secondhand smoke exposure, smoking prevalence and tobacco consumption

BACKGROUND

Smoking bans have been implemented in a variety of settings, as well as being part of policy in many jurisdictions to protect the public and employees from the harmful effects of secondhand smoke (SHS). They also offer the potential to influence social norms and smoking behaviour of those populations they affect.

OBJECTIVES

To assess the extent to which legislation-based smoking bans or restrictions reduce exposure to SHS, help people who smoke to reduce tobacco consumption or lower smoking prevalence and affect the health of those in areas which have a ban or restriction in place.

SEARCH STRATEGY

We searched the Cochrane Tobacco Addiction Group Specialised Register, MEDLINE, EMBASE, PsycINFO, CINAHL, Conference Paper Index, and reference lists and bibliographies of included studies. We also checked websites of various organisations. Date of most recent search; July 1st 2009.

SELECTION CRITERIA

We considered studies that reported legislative smoking bans and restrictions affecting populations. The minimum standard was having a ban explicitly in the study and a minimum of six months follow-up for measures of smoking behaviour. We included randomized controlled trials, quasi-experimental studies (i.e. non-randomized controlled studies), controlled before and after studies, interrupted-time series as defined by the Cochrane Effective Practice and Organization of Care Group, and uncontrolled pre- and post-ban data.

DATA COLLECTION AND ANALYSIS

Characteristics and content of the interventions, participants, outcomes and methods of the included studies were extracted by one author and checked by a second. Because of heterogeneity in the design and content of the studies, we did not attempt a meta-analysis. We evaluated the studies using qualitative narrative synthesis.

MAIN RESULTS

There were 50 studies included in this review. Thirty-one studies reported exposure to secondhand smoke (SHS) with 19 studies measuring it using biomarkers. There was consistent evidence that smoking bans reduced exposure to SHS in workplaces, restaurants, pubs and in public places. There was a greater reduction in exposure to SHS in hospitality workers compared to the general population. We failed to detect any difference in self-reported exposure to SHS in cars. There was no change in either the prevalence or duration of reported exposure to SHS in the home as a result of implementing legislative bans. Twenty-three studies reported measures of active smoking, often as a co-variable rather than an end-point in itself, with no consistent evidence of a reduction in smoking prevalence attributable to the ban. Total tobacco consumption was reduced in studies where prevalence declined. Twenty-five studies reported health indicators as an outcome. Self-reported respiratory and sensory symptoms were measured in 12 studies, with lung function measured in five of them. There was consistent evidence of a reduction in hospital admissions for cardiac events as well as an improvement in some health indicators after the ban.

AUTHORS' CONCLUSIONS

Introduction of a legislative smoking ban does lead to a reduction in exposure to passive smoking. Hospitality workers experienced a greater reduction in exposure to SHS after implementing the ban compared to the general population. There is limited evidence about the impact on active smoking but the trend is downwards. There is some evidence of an improvement in health outcomes. The strongest evidence is the reduction seen in admissions for acute coronary syndrome. There is an increase in support for and compliance with smoking bans after the legislation.

Acceptability and impact of a partial smoking ban followed by a total smoking ban in a psychiatric hospital

OBJECTIVE

To assess the impact of a partial smoking ban followed by a total smoking ban in a psychiatric hospital in Switzerland.

METHODS

In 2003, smoking was allowed everywhere in psychiatric units. In 2004, smoking was prohibited everywhere except in smoking rooms. In 2006, smoking rooms were removed and smoking was totally prohibited indoors. Patients and staff were surveyed in 2003 (n=106), 2004 (n=108), 2005 (n=119) and 2006 (n=134).

RESULTS

Exposure to environmental tobacco smoke (ETS) decreased after the partial ban and further decreased after the total ban. Among patients, after the total ban, more smokers attempted to quit smoking (18%) relative to before the total ban (2%, odds ratio=10.1, p=0.01). More smokers said that hospital staff gave them nicotine replacement products after the total ban (52%), compared with before (13%, odds ratio=7.6, p<0.001). Many participants (55%) commented that the total ban was too strict, and most (64%) preferred the partial ban.

CONCLUSIONS

The partial ban decreased exposure to ETS and the total ban further improved the situation and increased the proportion of smokers who attempted to quit smoking and received nicotine medications. The total ban was loosely enforced and was overall acceptable, but most participants preferred a partial ban.

Tobacco smoking within psychiatric inpatient settings: biopsychosocial perspective

Tobacco smoking remains a neglected issue within general psychiatry despite high rates of associated morbidity and mortality. While there has been a coordinated community campaign to reduce tobacco smoking within the general population, mental health facilities have been reluctant to adopt such regulatory controls, and rarely target smoking prevention or treatment. This paper summarizes and discusses evidence relating to the clinical impact of tobacco smoking within inpatient psychiatric settings. A selective review of psychiatric and psychological research on smoking within inpatient settings was conducted, with a particular focus on the influence of smoking on the physical and mental health, pharmacotherapy, and social interactions of patients during their inpatient stay. Patients frequently alter their smoking habits during inpatient treatment, which can affect both their presentation and pharmacotherapeutic management. Smoking also appears to play a central role in social interactions on the ward, with staff frequently using cigarettes to reinforce certain behaviours. Despite current guidelines, mental health professionals rarely address nicotine use among their patients. Nevertheless, programmes that assist patients to quit during an inpatient stay have been shown to be both efficacious and cost-effective. Strategies that address staff concerns and assist in the implementation of effective smoking bans on psychiatric units are also available. Cessation should be a key component of inpatient treatment planning because this setting provides a safe and timely opportunity to help patients quit. A flowchart of interventions that could be incorporated within standard inpatient settings is proposed.

Acceptability and impact of a partial smoking ban in a psychiatric hospital

OBJECTIVE

The acceptability and impact of partial smoking bans in psychiatric hospitals are not well documented. We assessed the impact of a partial smoking ban in a psychiatric hospital in Switzerland.

METHODS

Before the intervention, smoking was not allowed in bedrooms and dining rooms, but this ban was not enforced. The intervention consisted of banning smoking everywhere, except in dedicated smoking rooms. Patients and staff were surveyed before (October 2003, 49 patients and 57 staff) and 2 months after the smoking ban (April 2004, 54 patients and 54 staff). Analyses included both patients and staff.

RESULTS

Compared with baseline, after the intervention twice as many non-smokers reported that they were "never" exposed to environmental tobacco smoke (ETS) in bedrooms (before=25.0%, after=54.5%, p=0.046), dining rooms (35.5 vs. 65.5%, p=0.037), corridors (10.4 vs. 30.9%, p=0.001) and meeting rooms (36.8 vs. 75.0%, p=0.012). The smoking ban was loosely enforced; although the ban reduced ETS, substantial exposure to ETS remained after it was introduced. Most participants (87%) rejected the idea of a total smoking ban.

CONCLUSION

The partial smoking ban was well accepted and was associated with less exposure to ETS. However, even a partial ban proved difficult to enforce in this hospital.

Smoking bans in psychiatric inpatient settings? A review of the research

OBJECTIVE

This paper reviews the findings from 26 international studies that report on the effectiveness of smoking bans in inpatient psychiatric settings. The main aim is to identify which processes contribute to successful implementation of smoking bans and which processes create problems for implementation in these settings.

METHOD

After performing an electronic search of the literature, the studies were compared for methods used, subjects involved, type of setting, type of ban, measures and processes used and overall results. Total bans were distinguished from partial bans. All known studies of smoking bans in psychiatric inpatient units from 1988 to the present were included.

RESULTS

Staff generally anticipated more smoking-related problems than actually occurred. There was no increase in aggression, use of seclusion, discharge against medical advice or increased use of as-needed medication following the ban. Consistency, coordination and full administrative support for the ban were seen as essential to success, with problems occurring where this was not the case. Nicotine replacement therapy was widely used by patients as part of coping with bans. However, many patients continued to smoke post-admission indicating that bans were not necessarily effective in assisting people to quit in the longer term.

CONCLUSIONS

The introduction of smoking bans in psychiatric inpatient settings is possible but would need to be a clearly and carefully planned process involving all parties affected by the bans. Imposing bans in inpatient settings is seen as only part of a much larger strategy needed to overcome the high rates of smoking among mental health populations.

Cigarette smoking in psychiatric settings: occupational health, safety, welfare and legal concerns

OBJECTIVE

In the current climate of growing concern for the harmful effects of cigarette smoking and passive smoking, the high prevalence of this activity within psychiatric settings can no longer be ignored. This paper reviews the findings of research in a public stand-alone psychiatric facility in South Australia where significant legal and occupational health, safety and welfare (OHSW) concerns were apparent for both patients and staff as a consequence of the strong culture of smoking in that setting. The aim of this paper is to raise awareness of this significant health and legal issue and to inform policy and practice change.

METHOD

This paper reviews legal issues associated with smoking in psychiatric settings and presents relevant findings from previous studies in which in-depth interviews and observations in community and inpatient psychiatric settings were conducted.

RESULTS

Significant legal and OHSW concerns were apparent for both patients and staff in all settings. The potential for future litigation was high.

CONCLUSIONS

There are a number of legal and OHSW implications of continued smoking by staff and patients within mental health settings. Several administrative, clinical and cultural practices need to change within this system of care in order to improve overall patient wellbeing and to avoid the potential for litigation by patients and staff.

Exposure to environmental tobacco smoke (ETS) and determinants of support for complete smoking bans in psychiatric settings

OBJECTIVE

To measure environmental tobacco smoke (ETS) exposure in psychiatric settings and to assess determinants of support for complete smoking bans.

DESIGN

Cross sectional study

SETTING

Dutch psychiatric hospitals, outpatient care institutions, and sheltered home facilities.

SUBJECTS

A random sample of 540 treatment staff, 306 attendants/nurses, and 93 patients.

MAIN OUTCOME MEASURES

Self reported ETS exposure, current smoking policy, compliance with smoking policy, beliefs about smoking bans.

RESULTS

87% of respondents were exposed to tobacco smoke in psychiatric institutions; 29% said that on an average day they were exposed to "a lot of smoke". Although ETS originates mainly from smoking patients, both non-compliance from patients and employees with existing bans resulted in non-smokers being exposed to ETS. Due to non-compliance, ETS exposure was quite high when there is a general smoking ban (designated areas option). Only with a complete ban was compliance good and employees sufficiently protected from ETS exposure. Psychiatrists, psychologists, physicians, attendants, and nurses were most concerned about resistance from patients, partly because of the fear of infringing on patients' freedom to smoke.

CONCLUSIONS

Complete smoking bans are the only way to fully protect those working in psychiatry from ETS exposure, mainly because general smoking bans are not sufficiently complied with. Communication strategies to improve compliance with complete bans are crucial to protect those working in psychiatry from ETS. Compliance could be improved by addressing the belief that the ban will effectively result in less ETS exposure and the issue of patients' freedom to smoke versus employees' right to work in a smoke-free environment.

Systemic barriers to quitting smoking among institutionalised public mental health service populations: a comparison of two Australian sites

BACKGROUND

This article reports the findings from a comparative study investigating smoking behaviours among institutionalised psychiatric populations from a sociological perspective.

METHOD

The study involved participant observation of two separate Australian sites between 1999 and 2002, the second site serving to generalise the findings from the first site.

DISCUSSION AND CONCLUSIONS

Systemic barriers to quitting were identified, emanating from the mental health system in general. Cigarettes were identified as the currency by which economic, social and political exchange took place between participants who described an enculturation process that involved complex processes of reinforcement to smoke. Once entered into, escape from the smoking culture of the settings appeared to be extremely difficult for clients and staff.

Effects of nicotine on cognitive deficits in schizophrenia

Several lines of evidence suggest a pathophysiological role for nicotinic receptors in schizophrenia. Activation by nicotine alters physiological dysfunctions, such as eye movement and sensory gating abnormalities, but effects on neuropsychological performance are just beginning to be investigated. Nicotine-induced desensitization and the well-known tachyphylaxis of nicotinic receptors may confound such efforts. In all, 20 schizophrenics, 10 smokers, and 10 nonsmokers were assessed following the administration of nicotine gum and placebo gum. The Repeatable Battery for the Assessment of Neuropsychological Status was administered. Nicotine affected only the Attention Index; there were no effects on learning and memory, language, or visuospatial/constructional abilities. Attentional function was increased in nonsmokers, but decreased in nicotine-abstinent smokers after nicotine administration. The effects of nicotine in schizophrenia do not extend to all areas of cognition. Effects on attention may be severely limited by tachyphylaxis, such that decremented performance occurs in smokers, while modest effects may be achieved in nonsmokers.

Clinical experience with the management of schizophrenia in the general hospital

On the basis of experience with 74 psychiatric consultations involving patients with schizophrenia admitted to a general hospital medical or surgical ward over a 17-month period (3% of the psychiatric consultations during that period), the authors identified 10 types of problems leading to requests for consultation. The authors used these categories to organize recommendations for management of patients with schizophrenia in the general medical hospital. In addition to conducting conventional consultations, the consultation psychiatrist in such cases often has a role in educating hospital staff about schizophrenia and in serving as a physician for the mentally ill.

Effect of a total smoking ban in a maximum security psychiatric hospital

An archival study was performed in a maximum security forensic hospital to evaluate the effects of a total ban on smoking and all tobacco products. One hundred and forty patients were characterized as nonsmokers or light, moderate or heavy smokers. Patient records for the four weeks prior to the ban were compared with their records for the four weeks subsequent to the ban. Numbers of sick calls, total disruptive behaviors and verbal aggression declined markedly and significantly following the ban in those patients previously classified as moderate or heavy smokers. Weight increased significantly, but almost equally regardless of previous smoking status. Patients, and eventually staff, tolerated the smoking ban without significant negative effects. Patients relied very little on treatment modalities to alleviate nicotine withdrawal. Pre-ban apprehension by staff and patients dissipated with time after the smoking ban started.

Nicotine replacement methods on a psychiatric unit

Patients with psychiatric illness smoke more heavily than others in the community. They have more difficulty quitting and have more withdrawal symptoms than others.

OBJECTIVE

The purpose of the present study was to examine the utilization of nicotine replacement methods in a population of psychiatric patients.

METHOD

In a naturalistic retrospective review, we examined the records of 55 patients who were hospitalized on a smoke-free psychiatric unit. We abstracted the frequency of utilization of nicotine replacement. The rate of utilization was considered a ratio of the number of days utilized to the number of days prescribed.

RESULTS

There were 38 patients (69%) who used the transdermal patch, 26 patients (47%) used the inhaler, 4 patients (7%) used nicotine gum, and 2 patients (4%) used the nasal spray. The rate of utilization of the nicotine inhaler (63%) exceeded that of the transdermal nicotine patch (30%) (t = 4.6, p < .0001).

CONCLUSION

The hospitalization of smokers with mental illness in smoke-free psychiatric units often leads to further behavioral deterioration. The patients in the present study demonstrated a definite preference for the nicotine inhaler over the transdermal patch. Possible clinical and pathophysiological implications of this finding are discussed.

Caffeine and nicotine use in an addicted population

This study was undertaken to examine differences in caffeine and nicotine use between the psychiatric population and the addicted population in a private psychiatric inpatient facility. Eighty-six patients on an adult addictive disease inpatient unit and 80 patients on an adult psychiatry unit in a private psychiatric hospital were interviewed with regard to their use of nicotine and caffeine. In addition, demographic information and primary diagnoses were obtained from the psychiatric admission assessment in the medical record as listed by the admitting psychiatrist. Although there was little difference in psychiatric patients vs. chemically dependent patients with regard to the percentage of caffeine users, the chemically dependent individuals drank more coffee, soft drinks, and tea. A much greater percentage of the chemically dependent individuals also smoked cigarettes, although not in a greater amount than the psychiatric patients who smoked. Because group assignment was not random, ordinary least squares (OLS) regression analyses were conducted to determine the independent associations of age, sex, education, and treatment population in predicting levels of caffeine and tobacco use. Even after controlling for demographic differences between the two samples, chemically dependent patients still reported higher levels of daily caffeine and tobacco use than patients on the general psychiatric unit.