The impact of a smoke-free psychiatric hospitalization on patient smoking outcomes: a systematic review

Interventions for smoking cessation in inpatient psychiatry settings

OBJECTIVES

This is a protocol for a Cochrane Review (intervention). The objectives are as follows: To assess the effects of smoking cessation interventions on tobacco smoking in adults receiving inpatient psychiatry treatment. To assess whether the effects of smoking cessation interventions differ according to psychiatric diagnosis or type of intervention or comparator condition.

Enhancing Provider Delivery of Tobacco Treatment Within the Inpatient Psychiatric Setting

People with mental illnesses (MI) smoke at higher rates than the general population. However, few mental health providers (MHPs) deliver tobacco treatment to patients with MI especially within inpatient psychiatric settings. According to evidence, fewer than half of MHPs in the US mental and behavioral health settings provide the recommended evidence-based tobacco treatment interventions to their clients with MI. This paper uses the theory of planned behavior to examine factors associated with provider intentions to deliver and their experiences in providing evidence-based tobacco treatment to clients with MI. Data were obtained from a cross-sectional survey of 219 providers in a state psychiatric hospital in Kentucky. Attitudes, subjective norms, and perceived behavioral control were associated with providers' intentions to deliver tobacco treatment when controlling for demographic and work-related variables. However, only profession, subjective norms, and attitudes were associated with reported provision of evidence-based tobacco treatment. Given the underuse of routine tobacco treatment for this vulnerable population, understanding factors influencing provider delivery of tobacco treatment is needed to guide strategies for reducing the disproportionate rates of tobacco use and related burden among people with MI.

Nurses’ Perspectives on Smoking Policies, Safety and Cessation Support in Psychiatric Wards: A Cross-Sectional Survey

A high prevalence of smoking and low rates of smoking cessation interventions can be observed in psychiatric wards. A questionnaire-based, cross-sectional study was performed in five hospitals among 107 psychiatric ward nurses. The aim was to investigate nurses’ views on patients’ smoking practices and their influence on the safety of both the patients and medical personnel. In addition, we asked about the availability of smoking cessation support. Most of the respondents noticed the negative impacts of smoking on patients and medical personnel. Nearly a third of our respondents (29.0%) recalled smoking-related accidents in their facilities. In 45.2% of these accidents, a patient set someone else on fire. Around one fifth of nurses had rather permissive attitudes towards tobacco use in hospital wards. Significant associations were identified between respondents’ smoking status and their opinions on amending smoking policies and on unsupervised smoking. Regarding professional help available to smoking patients, 88.8% of participants reported that interventions to address smoking were available in their wards. Psychiatric hospitalisation can be an opportunity to offer tobacco treatment to patients with mental health conditions. To make use of this opportunity, smoke-free policies need to be put in place and hospital personnel, particularly nurses, should be trained and equipped with the knowledge and skills needed to assist in the smoking care of psychiatric ward patients.

Exploring attitudes towards smoking behaviour and cessation among hospitalised smokers via a socio-ecological framework: A scoping review

OBJECTIVES

Cigarette smoking is a leading cause of preventable mortality and disability. Smoke-free policies in healthcare settings have been implemented as a public health measure. This scoping review aims to explore attitudes on smokers' cessation in smoke-free healthcare settings using a socio-ecological framework.

METHODS

Four databases were searched for terms: smoking cessation, patient attitudes, and smoke-free policy. Of 420 studies, 17 met full inclusion criteria.

RESULTS

The review identified four socio-ecological aspects of smoking cessation in smoke-free healthcare settings: Intrapersonal factors (health literacy, health conditions, and self-efficacy), interpersonal factors (social support, peer pressure, and social responsibility), healthcare factors (perceived mixed messages, healthcare setting, clinical, psychosocial and health promotion supports), and societal factors (restrictions on smoking in a public place and social acceptability of smoking). Smoke-free policies effectively encouraged cessation in some patients but were ineffective in those that felt a loss of autonomy. Provision of smoke breaks within smoke-free policies was considered a mixed message.

CONCLUSIONS

Holistic strategies are required to interconnect the four socio-ecological dimensions for successful smoking cessation.

Cigarette Smoking in an Acute Partial Hospital Program

ABSTRACT

This study explored demographic and clinical features, plus clinical outcomes, in a smoke-free acute partial hospital (PH) among current smokers, former smokers, and those who had never smoked (nonsmokers). Compared with nonsmokers, current smokers were younger and more likely to be unmarried and unpartnered, unemployed, or receiving disability benefits. They had more prior inpatient (IP) and PH episodes. They also had more problems with interpersonal relationships, mood lability, psychosis, and substance use. Compared with nonsmokers, current smokers were more likely to miss PH treatment days and drop out. They also had longer time to readmission to PH or IP. Former smokers resembled nonsmokers, except that former smokers also had a high rate of dropout. Changes in symptoms and functioning for patients who completed PH were the same among all groups. In an acute PH setting, smoking is a marker for psychiatric and psychosocial impairment plus treatment interruption.

Investigating Changes in Patients' Smoking Behavior, Tobacco Dependence, and Motivation to Stop Smoking Following a "Smoke-Free" Mental Health Inpatient Stay: Results From a Longitudinal Survey in England

INTRODUCTION

In line with national guidance, mental health Trusts in England are implementing complete smoke-free policies. We investigated inpatients' changes in smoking behavior, tobacco dependence, vaping, and motivation to stop smoking between pre-admission and post-discharge.

METHODS

We surveyed acute adult mental health inpatients from 14 wards in three mental health Trusts in England in 2019. Structured face-to-face and telephone interviews with patients who smoked on or during admission were conducted during the admission period and at one week and one month after discharge. Data on smoking status; daily cigarette consumption; Heaviness of Smoking Index (HSI); Strength of Urges to Smoke (SUTS); Motivation to Stop Smoking (MTSS) and vaping were collected and analyzed using regression and probit models.

RESULTS

Inpatient smoking prevalence was 51.9%, and a total of 152 of all 555 eligible smokers (27%) were recruited. Attrition was high: 49.3% at the first and 50.7% at the second follow-up interview. Changes in self-reported smoking status, motivation to quit, and vaping did not change significantly over the study period. Cigarette consumption (p < 0.001) and Heaviness of Smoking Index (p < 0.001) modestly reduced. The frequency and strength of urges to smoke (p = 0.011 and 0.012, respectively) decreased modestly after discharge but were scored as high by 57% and 60% of participants during admission respectively. Just over half (56%) reported being offered smoking cessation support on admission.

CONCLUSIONS

This study identified very modest changes in smoking-related outcomes during and after admission and indicates major challenges to smoke-free policy implementation, including limited support for patients who smoke.

IMPLICATIONS

Despite mental health Trusts in England had developed and implemented smoke-free policies to meet national guidelines, adherence to these policies and provision of effective smoking cessation and temporary abstinence support for inpatients admitted to acute adult mental health wards appear to be limited. Patients who smoke on admission are likely to continue to do so during admission and after discharge, and only a very modest change in smoking behaviors appears to take place. Important opportunities to promote smoking cessation in this population are missed. Barriers to effective support need to be identified and addressed.

The right to smoke and the right to smoke-free surroundings: international comparison of smoke-free psychiatric clinic implementation experiences

BACKGROUND

In Scandinavia, people with a severe mental disorder have a reduced life expectancy of 15-20 years compared with the general public. Smoking is a major contributor, and smoke-free policies are increasingly adopted in psychiatric clinics around the world. We compared potential facilitators and barriers among staff and management, for the implementation of smoke-free psychiatric clinics.

AIMS

To investigate the attitudes and experiences regarding smoke-free policies among managers and staff involved in the implementation processes of smoke-free psychiatric clinics at hospitals in Malmö (Sweden) and Barcelona (Spain).

METHOD

We used a qualitative methodology, with 15 semi-structured interviews. The interviews were conducted with each participant individually, and were subsequently transcribed. The data were analysed with systematic text condensation.

RESULTS

There were notable differences in how the smoke-free policies were carried out and experienced, and attitudes regarding the policy changes differed in the two settings. Key differences were the views on the right to smoke in compulsory care and to stay in smoke-free surroundings supported by smoking cessation intervention; the prioritisation of staff facilitation of smoking breaks; and views on smoking and smoke-free psychiatry. In contrast, participants agreed on the importance of staff education and management support. A smoking ban by law and belonging to a network of smoke-free hospitals were also relevant.

CONCLUSIONS

Staff education, and support from staff and management for the patients' right to stay in smoke-free surroundings, facilitated successful implementation of smoke-free policies in the psychiatric clinics, whereas supporting the right to smoke was a barrier.

Nicotine Replacement Therapy and Healthy Lifestyle Psychoeducation for Smoking Reduction in Acute Psychiatric Inpatients: A Cluster-Randomized Parallel Study

BACKGROUND

Effectiveness of nicotine replacement therapies in acute psychiatric inpatient settings remains under-researched. The aim of this study was to compare effectiveness and acceptability of 3 different forms of nicotine replacement therapy in achieving smoking reduction among acute psychiatric inpatients.

METHODS

This cluster-randomized, parallel study compared effectiveness and acceptability of nicotine inhalers, nicotine gum, and nicotine patches for smoking reduction in the acute psychiatric inpatient setting. The primary outcome was the exhaled breath carbon monoxide (CO) level change from baseline at weeks 4 and 8. Secondary outcomes included changes in nicotine withdrawal symptoms and psychiatric symptom severity.

RESULTS

Three hundred ten inpatients on the acute care wards were randomly assigned to nicotine inhalers (n = 184), gum (n = 71), and patches (n = 55). Only the nicotine inhaler group showed statistically significant reduction in CO level from baseline at both weeks 4 and 8 (P < 0.001 and P = 0.032, respectively). The nicotine inhaler and the patch group showed significant decrease in nicotine withdrawal symptoms from baseline at both weeks 4 and 8. Meanwhile, the nicotine inhaler and the gum group showed significant decrease in psychiatric symptom severity from baseline at both weeks 4 and 8. Post hoc comparisons revealed that the inhaler group had a greater decrease in psychiatric symptom severity compared with the patch group.

CONCLUSIONS

Nicotine inhalers may be an effective choice for smoking reduction in acute psychiatric inpatient settings given its significant effects on CO level, withdrawal symptoms, and psychiatric symptom severity, particularly during the first 4 weeks of treatment.

Smokefree mental health inpatient settings – a matter of debate?

Abstract. Background: The prevalence of tobacco smoking among people with severe mental illness (SMI) substantially exceeds smoking rates in the general population and has been identified as the largest contributor to health inequalities in this group. Historically deeply embedded in the culture of mental health treatment environments, smoking until very recently was the norm in inpatient settings and still prevails in many settings internationally. In England however, mental health Trusts are currently implementing recent national guidance, according to which mental health settings will become entirely smokefree, with no exemptions, providing comprehensive evidence-based support to patients for smoking cessation and smoking abstinence during the inpatient stay. Aim: The aim of this article is to summarise the rationale for and the debate surrounding smokefree mental health inpatient settings, and to review and discuss the evidence on challenges, opportunities and impact of smokefree policy implementation in these settings, with a focus on the English debate and experience to date.

Correlates of Tobacco Use and Consumption Among Hospitalized Psychiatric Patients

Using a cross-sectional analysis, we assessed correlates of tobacco use and tobacco consumption from inpatient records (N = 2,060) from a state psychiatric hospital. We used multivariate logistic regression analyses to examine correlates of tobacco use in the total sample and multivariate linear regression to examine correlates of tobacco consumption among tobacco users. Tobacco-use associated variables in the total sample were being male, being White, lower education, having a substance-use disorder/treatment, having an externalizing or psychotic disorder, being from a rural county, being younger, and shorter length of hospital stay. Among tobacco users (n = 1,153), correlates of amount of tobacco consumption were being male; being White; lower education; having an internalizing, externalizing, and psychotic disorder; using cigarettes; and living in a county without a smoke-free policy. Psychiatric patients should be screened for specific associative variables as part of tobacco-use assessments. Future research may expand on the current findings to develop strategies to enhance tobacco treatment among psychiatric patients.

Moving Beyond the Behavior-Change Framework for Smoking Cessation: Lessons for a Critical Ontology From the Case of Inpatient Psychiatric Units

BACKGROUND: Leading scholars have called on nursing schools to pay more attention to smoking cessation in the education of nursing students. AIM: This article argues that attention to this subject should include a rethinking of the behavior-change framework that forms the methodological basis of this field. METHOD: Drawing on classic and contemporary work in sociology, anthropology, and critical public health, this article explores the specific example of smoking in long-term inpatient units to illustrate the limitations of a behavior-based ontology and suggest an alternative conceptual vocabulary. RESULTS: An alternative approach posits smoking as a social practice. It sheds light on situational factors that incentivize smoking and might be contributing to patient resistance to cessation. CONCLUSIONS: A different conceptual framing of smoking can point to interventions beyond the level of individuals, focusing instead on the broader interface between people and situations, where decisions and desires meet institutional and organizational dynamics and structures of opportunity and access.

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.

“Resisting the Ban”

Purpose

The purpose of this paper is to present an evocative story “Resisting the Ban” which illustrates the ethical and pragmatic issues that nurses face when contending with smoking ban policies in inpatient psychiatric settings.

Design/methodology/approach

The creative story “Resisting the Ban” was developed based on an organisational auto-ethnographic approach. The story was crafted through employing creative writing techniques and through framing and critiquing memories via several theoretical frames.

Findings

The story illustrates how smoking ban policies have created pragmatic and ethical issues on wards. The work practices of nurses have changed as have their relationships with patients. The liberties of involuntary patients have also been infringed.

Research limitations/implications

This approach can illuminate links between acts of resistance and issues associated with public policies.

Practical implications

The effects of smoking bans need to be considered more carefully particularly in relation to their effects on workers and patients. The social meaning of the smoking bans needs closer investigation. Policy needs to be recrafted so that it better addresses the liberties of involuntary patients. Also ward nurses need to be able to carry out their roles in a manner which is consistent with their values.

Social implications

Public policies, such as smoking bans, can produce negative consequences maligning relationships, practices and cultures. Critical auto-ethnography provides a means of understanding issues that have resulted from problematic policies.

Originality/value

Scholarly work conducted on the relationship between everyday resistance in workplaces and public policies is rare. This study offers new “insider” insights into the negative effects of a smoking ban policy in psychiatric inpatient settings.

What Are the Perceptions, Experiences, and Behaviors of Health Care Providers After Implementation of a Comprehensive Smoke-Free Hospital Policy?

The aim of this study was to explore the perceptions, experiences, and behaviors of health care providers (HCPs) after the implementation of a comprehensive smoke-free policy. This qualitative descriptive study, using semi-structured interviews, was conducted with 28 HCPs working in a Canadian hospital. Four overarching themes emerged from the analysis including (a) greater support for tobacco reduction, (b) enhanced patient care and interactions, (c) improved staff morale, and (d) some barriers still exist. The main findings suggest a comprehensive smoke-free hospital environment can strengthen the tobacco-free workplace culture within a hospital setting among HCPs where support for tobacco reduction is amplified, patient care and interactions regarding tobacco dependence are improved, and staff morale is enhanced. While there are still some challenging barriers as well as opportunities for improvements, the implementation of a comprehensive smoke-free policy heightened the call-to-action among HCPs to take a more active role in tobacco reduction.

Maintaining abstinence from smoking after a period of enforced abstinence - systematic review, meta-analysis and analysis of behaviour change techniques with a focus on mental health

BACKGROUND

Smoking prevalence is doubled among people with mental health problems and reaches 80% in inpatient, substance misuse and prison settings, widening inequalities in morbidity and mortality. As more institutions become smoke-free but most smokers relapse immediately post-discharge, we aimed to review interventions to maintain abstinence post-discharge.

METHODS

MEDLINE, EMBASE, PsycINFO, CINAHL and Web of Science were searched from inception to May 2016 and randomised controlled trials (RCTs) and cohort studies conducted with adult smokers in prison, inpatient mental health or substance use treatment included. Risk of bias (study quality) was rated using the Effective Public Health Practice Project Tool. Behaviour change techniques (BCTs) were coded from published papers and manuals using a published taxonomy. Mantel-Haenszel random effects meta-analyses of RCTs used biochemically verified point-prevalence smoking abstinence at (a) longest and (b) 6-month follow-up.

RESULTS

Five RCTs (n = 416 intervention, n = 415 control) and five cohort studies (n = 471) included. Regarding study quality, four RCTs were rated strong, one moderate; one cohort study was rated strong, one moderate and three weak. Most common BCTs were pharmacotherapy (n = 8 nicotine replacement therapy, n = 1 clonidine), problem solving, social support, and elicitation of pros and cons (each n = 6); papers reported fewer techniques than manuals. Meta-analyses found effects in favour of intervention [(a) risk ratio (RR) = 2.06, 95% confidence interval (CI) 1.30-3.27; (b) RR = 1.86, 95% CI 1.04-3.31].

CONCLUSION

Medication and/or behavioural support can help maintain smoking abstinence beyond discharge from smoke-free institutions with high mental health comorbidity. However, the small evidence base tested few different interventions and reporting of behavioural interventions is often imprecise.

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.

Efficacy of a universal smoking cessation intervention initiated in inpatient psychiatry and continued post-discharge: A randomised controlled trial

OBJECTIVE

Interventions are required to redress the disproportionate tobacco-related health burden experienced by persons with a mental illness. This study aimed to assess the efficacy of a universal smoking cessation intervention initiated within an acute psychiatric inpatient setting and continued post-discharge in reducing smoking prevalence and increasing quitting behaviours.

METHOD

A randomised controlled trial was undertaken across four psychiatric inpatient facilities in Australia. Participants ( N = 754) were randomised to receive either usual care ( n = 375) or an intervention comprising a brief motivational interview and self-help material while in hospital, followed by a 4-month pharmacological and psychosocial intervention ( n = 379) upon discharge. Primary outcomes assessed at 6 and 12 months post-discharge were 7-day point prevalence and 1-month prolonged smoking abstinence. A number of secondary smoking-related outcomes were also assessed. Subgroup analyses were conducted based on psychiatric diagnosis, baseline readiness to quit and nicotine dependence.

RESULTS

Seven-day point prevalence abstinence was higher for intervention participants (15.8%) than controls (9.3%) at 6 months post-discharge (odds ratio = 1.07, p = 0.04), but not at 12 months (13.4% and 10.0%, respectively; odds ratio = 1.03, p = 0.25). Significant intervention effects were not found on measures of prolonged abstinence at either 6 or 12 months post-discharge. Differential intervention effects for the primary outcomes were not detected for any subgroups. At both 6 and 12 months post-discharge, intervention group participants were significantly more likely to smoke fewer cigarettes per day, have reduced cigarette consumption by ⩾50% and to have made at least one quit attempt, relative to controls.

CONCLUSIONS

Universal smoking cessation treatment initiated in inpatient psychiatry and continued post-discharge was efficacious in increasing 7-day point prevalence smoking cessation rates and related quitting behaviours at 6 months post-discharge, with sustained effects on quitting behaviour at 12 months. Further research is required to identify strategies for achieving longer term smoking cessation.

Factors Associated With Staff Engagement in Patients' Tobacco Treatment in a State Psychiatric Facility

BACKGROUND

Persons with mental illnesses (MI) who use tobacco are likely to experience poorer physical health and worsened psychiatric symptomology as compared to their non-tobacco-using counterparts. Therefore, engaging them in treatment is an important aspect of evidence-based care.

OBJECTIVE

To use the theory of planned behavior to examine factors associated with intentions to provide and the provision of evidence-based tobacco treatment.

DESIGN

This study is based on a cross-sectional analysis of survey data from 195 staff at a state psychiatric hospital.

RESULTS

When controlling for demographic variables, attitudes, subjective norms, and perceived behavioral control toward providing tobacco treatment were associated with intentions to provide tobacco treatment, but only subjective norms and perceived behavioral control were associated with reported provision of evidence-based tobacco treatment.

CONCLUSIONS

Understanding factors that influence provider delivery of tobacco treatment can better determine strategies to reduce the disproportionate tobacco use and related illnesses in behavioral health settings.

An Exploration of Smoking Among People Attending Residential Substance Abuse Treatment: Prevalence and Outcomes at Three Months Post-Discharge

OBJECTIVES

Smoking continues to be a major health concern for people with a history of alcohol or other substance use problems. The current research is aimed to (1) describe the prevalence of smoking in residential addictions treatment services and (2) compare characteristics of people who had or had not quit smoking.

METHODS

Participants were attending residential substance abuse treatment provided by the Australian Salvation Army. These programs are up to 10 months in length and offer a range of low-intensity smoking cessation supports. Measures of smoking, substance use, and clinical characteristics were collected from 2008 to 2015 at baseline and three months post-discharge from treatment (N = 702).

RESULTS

At baseline, 86% of people were smokers (n = 606). At follow-up, only 48 participants who were smokers at baseline (7%) had quit smoking. Participants who had quit smoking at follow-up also reported higher rates of abstinence from alcohol or other substances at follow-up (72%) than people who had not quit smoking (46%; OR = 2.95, 95% CI [1.52, 5.74]).

CONCLUSIONS

There is potential for smoking cessation to be better addressed as part of routine care in substance abuse treatment settings. Future research should evaluate the provision of more systematic smoking cessation interventions within these settings.

Smoking Cessation Care for People with a Mental Illness: Family Carer Expectations of Health and Community Services

Introduction: Smoking prevalence remains high among people with a mental illness, contributing to higher levels of morbidity and mortality. Health and community services are an opportune setting for the provision of smoking cessation care. Although family carers are acknowledged to play a critical role in supporting the care and assistance provided by such services to people with a mental illness, their expectations regarding the delivery of smoking cessation care have not been examined.

Aims: To explore family carer expectations of smoking cessation care provision by four types of health services, to clients with a mental illness, and factors associated with expectations.

Methods: A cross-sectional survey was conducted with carers of a person with a mental illness residing in New South Wales, Australia. Carers were surveyed regarding their expectations of smoking cessation care provision from four types of health services. Possible associations between carer expectation of smoking cessation care provision and socio-demographic and attitudinal variables were explored.

Results: Of 144 carers, the majority of carers considered that smoking cessation care should be provided by: mental health hospitals (71.4%), community mental health services (78.0%), general practice (82.7%), and non-government organisations (56.6%). The factor most consistently related to expectation of care was a belief that smoking cessation could positively impact mental health.

Conclusions: The majority of carers expected smoking cessation treatment to be provided by all services catering for people with a mental illness, reinforcing the appropriateness for such services to provide smoking cessation care for clients in an effective and systematic manner.

Preparing for Completely Smoke-Free Mental Health Settings: Findings on Patient Smoking, Resources Spent Facilitating Smoking Breaks, and the Role of Smoking in Reported Incidents from a Large Mental Health Trust in England

INTRODUCTION

Despite high smoking prevalence and excessive smoking-related morbidity and mortality among people with mental disorder compared to the general population, smoking treatment is often neglected in mental health settings. The UK National Institute of Health and Clinical Excellence (NICE) recently issued public health guidance stipulating completely smoke-free mental health settings. This project evaluated existing smoking-related practices in preparation for guidance implementation. The objectives were to: audit the recording of smoking-related information and treatment provision; explore current arrangements relating to the facilitation of patient smoking; measure staff time spent and identify costs of facilitating smoking; and explore the role of smoking in smoking-related incidents.

METHODS

A mixed-methods study was conducted across four acute adult mental health wards, accommodating 16 patients each, over six months. It included a case-note audit, on-site observations, and a qualitative content analysis of incident reports.

RESULTS

Smoking status was recorded for less than half of the 290 patients admitted (138, 48%). Of those, 98 (71%) were recorded as current smokers, of whom 72 (74%) had received brief smoking cessation advice. Staff spent 6028 h facilitating smoking, representing an annual cost of £ 131,040 across four wards. Incident reports demonstrated that smoking facilitation was often central to the cause of incidences, triggered frustration in patients, and strained staff resources.

CONCLUSION

The findings highlight the importance and potential of implementing completely smoke-free policies using comprehensive pathways.

Implementation of a smoke-free policy in an inpatient psychiatric facility: Patient-reported adherence, support, and receipt of nicotine-dependence treatment

The implementation of smoke-free policies in inpatient psychiatric facilities, including patient adherence, mental health nursing staff support, and provision of nicotine-dependence treatment to patients, has been reported to be poor. The extent to which the quality of smoke-free policy implementation is associated with patient views of a policy is unknown. We conducted a cross-sectional survey of 181 patients (53.6%, n = 97 smokers; and 46.4%, n = 84 non-smokers) in an Australian inpatient psychiatric facility with a total smoke-free policy. Smokers' adherence to the policy was poor (83.5% smoked). Only half (53.6%) perceived staff to be supportive of the policy. Most smokers used nicotine-replacement therapy (75.3%); although few received optimal nicotine-dependence treatment (19.6%). Overall, 45.9% of patients viewed the smoke-free policy in the unit as positive (29.9% smokers; 64.3% non-smokers). For smokers, adhering to the ban, perceiving staff to be supportive, and reporting that the nicotine-replacement therapy reduced cravings to smoke were associated with a more positive view towards the smoke-free policy. These findings support the importance of patient adherence, mental health nursing staff support, and adequate provision of nicotine-dependence treatment in strengthening smoke-free policy implementation in inpatient psychiatric settings.

Do people with mental illness receive adequate smoking cessation advice? A systematic review and meta-analysis

BACKGROUND

Prevalence rates of smoking in people with mental illness are high, and premature mortality attributed to tobacco related physical comorbidity is a major concern. We conducted a meta-analysis comparing rates of receipt of smoking cessation advice among people with and without mental illness.

METHOD

Major electronic databases were searched from inception till August 2014 for studies comparing rates of receipt of smoking cessation advice of people with and without a mental illness. Two independent authors completed methodological appraisal and extracted data. A random-effects meta-analysis was utilized.

RESULTS

Seven studies of satisfactory methodological quality (n mental illness=68,811, n control=652,847) were included. Overall there was no significant difference in smoking cessation advice rates between those with and without a mental illness [relative risk (RR)=1.02, 95% confidence interval (CI)=0.94-1.11, n=721,658, Q=1421, P<.001]. Subgroup analyses demonstrated people with severe mental illness (SMI) received comparable rates of smoking cessation advice to those without SMI (RR=1.09, 95% CI=0.98-1.2, n=559,122). This remained true for people with schizophrenia (RR=1.09, 95% CI=0.68-1.70) and bipolar disorder (RR=1.14, 95% CI=0.85-1.5). People with non-SMIs were slightly more likely to receive smoking cessation advice (RR=1.16, 95% CI=1.04-1.30, Q=1364, P<.001, n=580,206).

CONCLUSIONS

People with SMI receive similar smoking cessation advice rates to people without mental illness, while those with non-SMI are slightly more likely to receive smoking cessation advice. While progress has been made, offering smoking cessation advice should receive a higher priority in everyday clinical practice for patients with a mental health diagnosis.