Cigarette smoking, nicotine dependence, and motivation for smoking cessation in psychiatric inpatients

Multidisciplinary barriers to addressing tobacco cessation during an inpatient psychiatric hospitalization

Tobacco use and resultant health complications disproportionately impact individuals with psychiatric disorders. Inpatient psychiatric hospitalizations provide an opportunity to initiate tobacco treatment. In this study, electronic medical record review identified demographic and clinical information, smoking status, and tobacco cessation treatment offered for adults hospitalized on two acute, non-smoking psychiatric units in Massachusetts from January 2016 to March 2018. We additionally conducted semi-structured interviews with 15 inpatient nursing, psychiatry, psychology and social work providers regarding their tobacco cessation treatment practices and perceived facilitators and barriers to addressing tobacco use on psychiatric inpatient units. Chart review identified 1099 of 3140 (35%) people admitted reporting daily tobacco smoking. On discharge, 5 (0.005%) of inpatient smokers received a prescription for varenicline, 43 (0.04%) for dual-nicotine replacement therapy, 211 (19.2%) for nicotine patch, and 5 (0.005%) for bupropion. Barriers to inpatient smoking cessation treatment initiation identified in qualitative interviews included: 1) smoking cessation as low priority, 2) smoking cessation as the responsibility of outpatient providers, 3) lack of education about tobacco treatment, and 4) treatment discussions framed as preventing withdrawal. Given the potential to impact a large percentage of psychiatric tobacco users, future interventions should investigate provision of tobacco cessation counseling and pharmacotherapy in inpatient settings, with interventions that take into account the barriers and opportunities presented in this study.

Validation of the MUSIC Model of Motivation Inventory for use with cognitive training for schizophrenia spectrum disorders: A multinational study

AIM

Low motivation is a core symptom of schizophrenia which significantly impacts successful engagement in and benefit from psychosocial treatments. Therefore, it is important for clinicians to design psychosocial treatments to effectively motivate and engage patients during the treatment. The MUSIC® Model of Academic Motivation Inventory (MMI) is an 18-item instrument with five scales that assess students' motivation during academic tasks. The objective of the current study was to validate the MMI for use with schizophrenia-spectrum patients undergoing cognitive training.

METHODS

Participants included 181 people with schizophrenia spectrum disorders enrolled in cognitive training in four countries. A confirmatory factor analysis (CFA) assessed construct validity. Quality of fit was determined using the Comparative Fit Index (CFI), the Standardized Root Mean Square Residual (SRMR), and the Root Mean Square Error of Approximation (RMSEA). Pearson's correlation coefficients assessed construct validity and Cronbach's alphas assessed reliability. Furthermore, we examined factor loadings for each inventory item and assessed predictive validity by analyzing MMI scales with attendance outcomes.

RESULTS

Consistent with the original MMI validation studies used in academic settings, we found CFI values indicated a good fit, as did the SRMR and RMSEA values. The scales were correlated yet distinct. Cronbach's alpha values ranged from good to excellent and factor loadings showed that all items loaded very well onto their intended factors. The MMI had a positive relationship to treatment intensity.

CONCLUSION

The MMI is a valid and reliable tool to use with individuals with schizophrenia spectrum disorders undergoing a cognitive training intervention.

Prospective study of provided smoking cessation care in an inpatient psychiatric setting

OBJECTIVE

People with mental health difficulties (MHD) are more likely to smoke and to have smoking-related diseases, yet little research has investigated the provision of smoking cessation care in psychiatric inpatient settings. This study aimed to evaluate current levels of cessation care provided, and 3-month quit-rates, in one such setting in Ireland.

METHODS

From January to October 2016, inpatients across all 8 adult wards of St Patrick's University Hospital were recruited to participate in a baseline face-to-face survey (N = 246), assessing demographic information, smoking history and quit attempts, motivation to quit, nicotine dependence, attitudes towards cessation advice and actual care received. For baseline current smokers (n = 84) who consented, casenotes were also audited for documentation of smoking status and cessation care (n = 77/84) while quit rates were assessed at three months (n = 72/84), including a carbon monoxide test for those who reported quitting.

RESULTS

Current smoking prevalence was 34% (n = 84/246). At baseline 75% of smokers wanted to quit and 48% reported they would like cessation advice while in hospital. Few reported receiving cessation advice from any healthcare professional in the past year (13%), while just 6% had smoking cessation care clearly documented in their casenotes. The 3-month quit-rate was 17%, with a 100% pass rate for those completing an objective CO validation test.

CONCLUSION

Despite a high current smoking prevalence among psychiatric inpatients, and similar motivation and quit rates to other populations, current cessation care rates are low. Smoking cessation care needs to be prioritised in psychiatric settings.

Facility-level, state, and financial factors associated with changes in the provision of smoking cessation services in US substance abuse treatment facilities: Results from the National Survey of Substance Abuse Treatment Services 2006 to 2012

Cigarette smoking is common among patients in substance abuse treatment. Tobacco control programs have advocated for integrated tobacco dependence treatment into behavioral healthcare, including within substance abuse treatment facilities (SATFs) to reduce the public health burden of tobacco use. This study used data from seven waves (2006 to 2012) of the National Survey of Substance Abuse Treatment Services (n=94,145) to examine state and annual changes in the provision of smoking cessation services within US SATFs and whether changes over time could be explained by facility-level (private vs public ownership, receipt of earmarks, facility admissions, acceptance of government insurance) and state-level factors (cigarette tax per pack, smoke free policies, and percent of CDC recommended tobacco prevention spending). Results showed that the prevalence of SATFs offering smoking cessation services increased over time, from 13% to 65%. The amount of tax per cigarette pack, accepting government insurance, government (vs private) ownership, facility admissions, and CDC recommended tobacco prevention spending (per state) were the strongest correlates of the provision of smoking cessation programs in SATFs. Facilities that received earmarks were less likely to provide cessation services. Adult smoking prevalence and state-level smoke free policies were not significant correlates of the provision of smoking cessation services over time. Policies aimed at increasing the distribution of tax revenues to cessation services in SATFs may offset tobacco-related burden among those with substance abuse problems.

Cigarette smoking, nicotine dependence, and motivation to quit smoking in South African male psychiatric inpatients

BACKGROUND

Smoking is the leading cause of preventable death worldwide and the prevalence is particularly high among psychiatric patients but recent international studies demonstrated that psychiatric patients are able and motivated to quit. The aim of this study was to evaluate cigarette smoking, nicotine dependence, and motivation for smoking cessation in male psychiatric inpatients in a sample of South African acute-care male psychiatric inpatients.

METHODS

All inpatients admitted during a 2-month period (April to May 2016) to the Stikland Hospital Acute Male Admissions Unit in Cape Town, Western Cape, were included. Subjects completed a survey including a set of tests: Global Adult Tobacco Survey (GATS), the Fagerström Test for Nicotine Dependence (FTND), and the Decisional Balance for Cigarette Smoking (DBCS) (6-item version). Demographic data were obtained from patients' clinical charts.

RESULTS

Among the 160 new inpatients, 72.5% (n = 116) completed the survey. Of the 116 participants, 91.4% (n = 106) were current smokers of whom 82% (n = 87) smoked daily and 55.6% (n = 59) were identified as having high nicotine dependence (FTND ≥ 6). Although a large majority (71.7%; n = 76) of current smokers expressed positive perceptions regarding smoking, a notable proportion (59.4%; n = 63) still attempted to quit the habit in the preceding 12 months and daily smokers were less likely to quit. However, only a minor proportion of all current (43.4%; n = 46) and specifically daily (40.2%; n = 35) smokers were advised on smoking cessation by a health worker.

CONCLUSION

This study confirms that, similar to populations elsewhere, rates of cigarette smoking among psychiatric inpatients in South Africa is exceedingly high. While patients are motivated to quit smoking, few were provided with the necessary advice. Our findings provide further support for the integration of smoking cessation support in mental health care.

Effectiveness of the Tobacco Tactics Program in the Trinity Health System

INTRODUCTION

This study determined the effectiveness of the Tobacco Tactics intervention.

DESIGN/SETTING/PARTICIPANTS

This was a pragmatic, quasi-experimental study conducted from 2010 to 2013 and analyzed from 2014 to 2015 in five Michigan community hospitals; three received the Tobacco Tactics intervention, and two received usual care. Smokers (N=1,528) were identified during hospitalization, and sent surveys and cotinine tests after 6 months. Changes in pre- to post-intervention quit rates in the intervention sites were compared with usual care control sites.

INTERVENTION

The toolkit for nurses included: (1) 1 continuing education unit contact hour for training; (2) a PowerPoint presentation on behavioral and pharmaceutical interventions; (3) a pocket card entitled "Helping Smokers Quit: A Guide for Clinicians"; (4) behavioral and pharmaceutical protocols; and (5) a computerized template for documentation. The toolkit for patients included: (1) a brochure; (2) a cessation DVD; (3) the Tobacco Tactics manual; (4) a 1-800-QUIT-NOW card; (5) nurse behavioral counseling and pharmaceuticals; (6) physician reminders to offer brief advice to quit coupled with medication sign-off; and (7) follow-up phone calls by trained hospital volunteers.

MAIN OUTCOME MEASURES

The effectiveness of the intervention was measured by 6-month 30-day point prevalence; self-reported quit rates with NicAlert(®) urinary biochemical verification (48-hour detection period); and the use of electronic medical record data among non-responders.

RESULTS

There were significant improvements in pre- to post-intervention self-reported quit rates (5.7% vs 16.5%, p<0.001) and cotinine-verified quit rates (4.3% vs 8.0%, p<0.05) in the intervention sites compared with no change in the control sites. Propensity-adjusted multivariable analyses showed a significant improvement in self-reported 6-month quit rates from the pre- to post-intervention time periods in the intervention sites compared to the control sites (p=0.044) and a non-statistically significant improvement in the cotinine-verified 6-month quit rate.

CONCLUSIONS

The Tobacco Tactics intervention, which meets the Joint Commission standards for inpatient smoking, has the potential to significantly decrease smoking among inpatient smokers.

TRIAL REGISTRATION

This study is registered at www.clinicaltrial.gov NCT01309217.

Smoking-Cessation Interventions for Urban Hospital Patients: A Randomized Comparative Effectiveness Trial

INTRODUCTION

Hospitalization is a unique opportunity for smoking cessation, but prior interventions have measured efficacy with narrowly defined populations. The objective of this study was to enroll smokers admitted to two "safety net" hospitals and compare the effectiveness of two post-discharge cessation interventions.

DESIGN

A randomized comparative effectiveness trial was conducted.

SETTING/PARTICIPANTS

At two New York City public hospitals, every hospitalized patient identified as a smoker (based on admission records) was approached. Inclusion criteria were: smoked cigarettes in the past 30 days; spoke English, Spanish, or Mandarin; had a U.S. phone number; not discharged to an institution where follow-up or smoking was limited; and not pregnant/breastfeeding. Of 18,797 patients identified as current smokers between July 2011 and April 2014, a total of 3,047 (16%) were discharged before being approached, 3,273 (17%) were not current smokers, 4,026 (21%) had no U.S. phone number, 2,831 (15%) were ineligible for other reasons, and 3,983 (21%) refused participation. In total, 1,618 (9%) participants enrolled in the study. During follow-up, 69% of participants were reached at 2 months and 68% at 6 months.

INTERVENTION

At discharge, participants were randomized to multisession telephone counseling from study staff (n=804) or referral to the state quitline for proactive outreach and counseling (n=814).

MAIN OUTCOME MEASURES

Self-reported abstinence at 6 months was measured. Analyses were conducted in late 2015.

RESULTS

One quarter of participants were homeless or in unstable housing, 60% had a history of substance abuse, 43% reported current hazardous drinking, and half had a psychiatric diagnosis other than substance abuse. At follow-up, the rate of abstinence (30-day point prevalence) was higher in the intensive counseling arm than the quitline arm at 2 months (29.0% vs 20.7%; relative risk=1.40; 95% CI=1.13, 1.73) and 6 months (37.4% vs 31.5%; relative risk=1.19; 95% CI=1.01, 1.40).

CONCLUSIONS

Intensive counseling was more effective than referral to the state quitline. Long-term abstinence was excellent in both groups. Many patients were not eligible for enrollment despite minimal exclusion criteria.

TRIAL REGISTRATION

This study is registered at www.clinicaltrials.gov NCT01363245.

Impact of self-reported lifetime depression or anxiety on effectiveness of mass distribution of nicotine patches

BACKGROUND

Large-scale public health initiatives providing free nicotine replacement therapy have been shown to increase smoking cessation rates; however, their effectiveness among the highly prevalent population of smokers with depression and anxiety disorders has not been explored. The aim of this study was to investigate the influence of lifetime history of depression or anxiety on smoking cessation success following the free distribution of nicotine patches.

METHOD

In the context of a randomised controlled trial, a secondary analysis was conducted on 1000 adult regular smokers randomised to be mailed a 5-week supply of nicotine patches or to a no intervention control group. Participants were divided into subgroups based on the presence of self-reported lifetime diagnosis of depression and anxiety.

RESULTS

Irrespective of self-reported lifetime history of depression or anxiety, odds of self-reported cessation at 6 months were significantly greater among groups receiving nicotine patches compared to no intervention control (no history of depression or anxiety: OR 2.20; 95% CI 1.05 to 4.63; history of depression or anxiety present: OR 3.90; 95% CI 1.28 to 11.88). Among nicotine patch recipients only, quit outcomes did not differ between those with and without self-reported lifetime depression or anxiety in models unadjusted and adjusted for differences in demographic and smoking characteristics.

CONCLUSIONS

The mass distribution of free nicotine patches (without behavioural support) is effective among smokers with or without lifetime history of depression or anxiety alike, providing further support for the adoption of similar initiatives as a means of promoting tobacco cessation on a population level.

TRIAL REGISTRATION NUMBER

NCT01429129, Post-results.

Real-world effectiveness of varenicline versus nicotine replacement therapy in patients with and without psychiatric disorders

OBJECTIVE

To compare the effectiveness and safety of varenicline with nicotine replacement therapy (NRT) among smokers with or without psychiatric disorders attending a storefront smoking cessation clinic in an urban addiction and mental health academic health science center.

METHODS

A retrospective chart review was conducted to compare treatment outcomes, demographics, and clinical characteristics for adult smokers prescribed varenicline (n = 98) or NRT (n = 98) between 2007 and 2010. Subjects were matched 1:1 on age, sex, and year of initial assessment.

RESULTS

End-of-treatment quit rates were almost twice as high among those prescribed varenicline (33.7%) versus NRT (18.4%) (RR = 1.83, 95% CI = 1.11-3.03, P = 0.02). After adjusting for several baseline and treatment characteristics, varenicline was still significantly more effective than NRT (ARR = 1.71, 95% CI = 1.05-2.79, P = 0.03). History of psychiatric disorder (excluding substance use disorders) and treatment duration were also independent predictors of end-of-treatment quit rates. Nausea was more commonly reported among those using varenicline (13.3% vs 3.1%, P = 0.009). No single neuropsychiatric adverse effect significantly differed between groups; however, overall reporting of any neuropsychiatric effect was somewhat higher in the varenicline group (31.6% vs 20.4%, P = 0.07). There was one incident of suicidal ideation in each medication group.

CONCLUSIONS

Varenicline seems to be more effective than NRT and as safe in real-world settings among patients with and without a history of psychiatric disorder.

Perfil Sócio-demográfico e Clínico de uma Amostra de Fumantes Portugueses: Implicações do Sexo para a Intervenção na Cessação Tabágica

RESUMO As medidas de cessação tabágica mostram resultados positivos na diminuição da morbidade e mortalidade associadas ao consumo do tabaco. Esses programas possuem maior eficácia quando se adequam às especificidades dos tabagistas. Este estudo teve como objetivo analisar as diferenças de sexo em uma amostra de 100 fumantes portugueses, através da administração de um questionário sócio-demográfico e clínico. Observaram-se diferenças de sexo no número de cigarros consumidos por dia, no momento do dia e no contexto social de maior consumo, no residir com fumantes, na pressão social para deixar de fumar e no sono. As implicações clínicas dos resultados foram discutidas no sentido de otimizar a prestação dos serviços de saúde em contexto de cessação tabágica.

Effectiveness of the tobacco tactics program for psychiatric inpatient veterans: an implementation study

BACKGROUND

The objective of this study was to evaluate the effectiveness of the inpatient, nurse-administered Tobacco Tactics program for patients admitted for psychiatric conditions in two Veterans Affairs (VA) hospitals compared to a control hospital.

METHODS

This is a subgroup analysis of data from the inpatient tobacco tactics effectiveness trial, which was a longitudinal, pre- post-nonrandomized comparison design with 6-month follow-up in the three large Veterans Integrated Service Networks (VISN) 11 hospitals.

RESULTS

Six-month self-reported quit rates for patients admitted for psychiatric conditions increased from 3.5% pre-intervention to 10.2% post-intervention compared to a decrease in self-reported quit rates in the control hospital (12% pre-intervention to 1.6% post-intervention). There was significant improvement in self-reported quit rates for the pre- versus post-intervention time periods in the Detroit and Ann Arbor intervention sites compared to the Indianapolis control site (P=0.01) and cotinine results were in the same direction.

CONCLUSION

The implementation of the Tobacco Tactics intervention has the potential to significantly decrease smoking and smoking-related morbidity and mortality among smokers admitted to VA hospitals for psychiatric disorders.

Smoking reduction in psychiatric inpatients is feasible: results from a 12-month prospective study

BACKGROUND

Despite the fact that smoking is a crucial morbidity factor among psychiatric patients, little progress has been made in order to reduce smoking during psychiatric hospitalization.

METHODS

We studied the smoking behaviour of patients admitted to a non-smoking psychiatric ward, after monitoring them for smoking habits and helping them cope in order to modify their smoking behaviour. For a period of 12 months, we conducted a prospective study of simple smoking avoidance measures in the 2nd Department of Psychiatry of Attikon University Hospital in Athens.

RESULTS

From 330 admitted patients, 170 (51.5%) were smokers; they were monitored for their smoking habits and encouraged by the nursing staff to reduce smoking. The mean number of cigarettes per day (CPD) at admission was 32.2 (sd 22.1) and upon discharge 14.1 (sd 14.8) (t = 11.7, p < 0.001). Most of the smokers, 142 (83.5%), managed to reduce their cigarette consumption per day. Diagnosis did not affect the reduction or increase in CPD. The only factor that predicted reduction in CPD was the female sex.

CONCLUSIONS

Our findings indicate that seriously mentally ill psychiatric inpatients despite negative preconceptions and stereotypes respond well to simple measures aiming to reduce their smoking and modify their behaviour.

Tobacco smoking and mental illness: important considerations

Tobacco smoking is a contributory factor in the death of 50% of individuals who are regular or heavy smokers (The Office of Tobacco Control Ireland defines a regular smoker as someone who smokes 11-20 per day and a heavy smoker as someone who smokes 21 or more cigarettes per day). The World Health Organisation (WHO) regards tobacco smoking as the leading preventable cause of death worldwide. In Ireland, approximately 750,000 people smoke tobacco regularly (23.5% of the population) with 7,000 Irish people dying annually from smoking-related causes. Although there are no exact figures for prevalence rates of smoking in individuals with mental illness in Ireland, international studies unequivocally state that the prevalence of smoking is significantly higher in those with mental illness, with greater nicotine intake and increased prevalence of nicotine dependence also reported. Furthermore people with mental illness experience greater withdrawal symptoms and have lower cessation rates when attempting to stop smoking compared to the general population.

General physical health advice for people with serious mental illness

BACKGROUND

There is currently much focus on provision of general physical health advice to people with serious mental illness and there has been increasing pressure for services to take responsibility for providing this.

OBJECTIVES

To review the effects of general physical healthcare advice for people with serious mental illness.

SEARCH METHODS

We searched the Cochrane Schizophrenia Group's Trials Register (last update search October 2012) which is based on regular searches of CINAHL, BIOSIS, AMED, EMBASE, PubMed, MEDLINE, PsycINFO and registries of Clinical Trials. There is no language, date, document type, or publication status limitations for inclusion of records in the register.

SELECTION CRITERIA

All randomised clinical trials focusing on general physical health advice for people with serious mental illness..

DATA COLLECTION AND ANALYSIS

We extracted data independently. For binary outcomes, we calculated risk ratio (RR) and its 95% confidence interval (CI), on an intention-to-treat basis. For continuous data, we estimated the mean difference (MD) between groups and its 95% CI. We employed a fixed-effect model for analyses. We assessed risk of bias for included studies and created 'Summary of findings' tables using GRADE.

MAIN RESULTS

Seven studies are now included in this review. For the comparison of physical healthcare advice versus standard care we identified six studies (total n = 964) of limited quality. For measures of quality of life one trial found no difference (n = 54, 1 RCT, MD Lehman scale 0.20, CI -0.47 to 0.87, very low quality of evidence) but another two did for the Quality of Life Medical Outcomes Scale - mental component (n = 487, 2 RCTs, MD 3.70, CI 1.76 to 5.64). There was no difference between groups for the outcome of death (n = 487, 2 RCTs, RR 0.98, CI 0.27 to 3.56, low quality of evidence). For service use two studies presented favourable results for health advice, uptake of ill-health prevention services was significantly greater in the advice group (n = 363, 1 RCT, MD 36.90, CI 33.07 to 40.73) and service use: one or more primary care visit was significantly higher in the advice group (n = 80, 1 RCT, RR 1.77, CI 1.09 to 2.85). Economic data were equivocal. Attrition was large (> 30%) but similar for both groups (n = 964, 6 RCTs, RR 1.11, CI 0.92 to 1.35). Comparisons of one type of physical healthcare advice with another were grossly underpowered and equivocal.

AUTHORS' CONCLUSIONS

General physical health could lead to people with serious mental illness accessing more health services which, in turn, could mean they see longer-term benefits such as reduced mortality or morbidity. On the other hand, it is possible clinicians are expending much effort, time and financial resources on giving ineffective advice. The main results in this review are based on low or very low quality data. There is some limited and poor quality evidence that the provision of general physical healthcare advice can improve health-related quality of life in the mental component but not the physical component, but this evidence is based on data from one study only. This is an important area for good research reporting outcome of interest to carers and people with serious illnesses as well as researchers and fundholders.

Smoking topography and outcome expectancies among individuals with schizotypy

Compared to smokers in the general population, smokers with schizophrenia smoke more cigarettes per day and have higher nicotine dependence and biochemical indicators of nicotine intake. They also have more intense smoking topography and greater positive smoking expectancies. Little is known about the relationship between smoking and schizotypy, defined as the personality organization reflecting a vulnerability to schizophrenia-spectrum pathology. This study assessed schizotypy symptoms, smoking characteristics and behaviors, and smoking expectancies in young adults with psychometrically defined schizotypy and demographically matched controls without schizotypy. Smokers with schizotypy had higher nicotine dependence and smoked more cigarettes per week compared to control smokers. They were also more likely to endorse greater positive consequences (i.e., improved state enhancement, stimulation, social facilitation, taste/sensorimotor manipulation, reduced negative affect and boredom) and fewer negative consequences of smoking. Smokers with schizotypy and control smokers did not differ on smoking topography or carbon monoxide levels. This is the first known study to investigate relationships between these smoking-related variables in smokers with schizotypy. Individuals with schizotypy possessed certain smoking-related characteristics and smoking expectancies similar to those with schizophrenia. This offers preliminary insight into unique smoking-related factors among individuals with schizotypy and highlights the importance of continued research in this area.

Readiness to quit smoking and quit attempts among Australian mental health inpatients

INTRODUCTION

Mental health inpatients smoke at higher rates than general population smokers. However, provision of nicotine-dependence treatment in inpatient settings is low, with barriers to the provision of such care including staff views that patients do not want to quit. This paper reports the findings of a survey of mental health inpatients at a psychiatric hospital in New South Wales, Australia, assessing smoking and quitting motivations and behaviors.

METHODS

Smokers (n = 97) were surveyed within the inpatient setting using a structured survey tool, incorporating the Fagerström Test for Nicotine Dependence, Reasons for Quitting Scale, Readiness and Motivation to Quit Smoking Questionnaire, and other measures of smoking and quitting behavior.

RESULTS

Approximately 47% of smokers reported having made at least one quit attempt within the past 12 months, despite nearly three quarters (71.2%) being classified as in a "precontemplative" stage of change. Multinomial logistic regressions revealed that self-reporting "not enjoying being a smoker" and having made a quit attempt in the last 12 months predicted having advanced beyond a precontemplative stage of change. A high self-reported desire to quit predicted a quit attempt having been made in the last 12 months.

CONCLUSIONS

The majority of smokers had made several quit attempts, with a large percentage occurring recently, suggesting that the actual quitting behavior should be considered as an important indication of the "desire to quit." This paper provides further data supporting the assertion that multimodal smoking cessation interventions combining psychosocial and pharmacological support should be provided to psychiatric inpatients who smoke.

Genetics of schizophrenia and smoking: an approach to studying their comorbidity based on epidemiological findings

The association between schizophrenia and tobacco smoking has been described in more than 1,000 articles, many with inadequate methodology. The studies on this association can focus on: (1) current smoking, ever smoking or smoking cessation; (2) non-psychiatric controls or controls with severe mental illness (e.g., bipolar disorder); and (3) higher smoking frequency or greater usage in smokers. The association with the most potential for genetic studies is that between ever daily smoking and schizophrenia; it may reflect a shared genetic vulnerability. To reduce the number of false-positive genes, we propose a three-stage approach derived from epidemiological knowledge. In the first stage, only genetic variations associated with ever daily smoking that are simultaneously significant within the non-psychiatric controls, the bipolar disorder controls and the schizophrenia cases will be selected. Only those genetic variations that are simultaneously significant in the three hypothesis tests will be tested in the second stage, where the prevalence of the genes must be significantly higher in schizophrenia than in bipolar disorder, and significantly higher in bipolar disorder than in controls. The genes simultaneously significant in the second stage will be included in a third stage where the gene variations must be significantly more frequent in schizophrenia patients who did not start smoking daily until their 20s (late start) versus those who had an early start. Any genetic approach to psychiatric disorders may fail if attention is not given to comorbidity and epidemiological studies that suggest which comorbidities are likely to be explained by genetics and which are not. Our approach, which examines the results of epidemiological studies on comorbidities and then looks for genes that simultaneously satisfy epidemiologically suggested sets of hypotheses, may also apply to the study of other major illnesses.

Are "social drugs" (tobacco, coffee and chocolate) related to the bipolar spectrum?

BACKGROUND

Across all ages and cultures, mankind has always used substances in order to induce pleasurable sensations or desirable psychophysical states. These substances, notably caffeine, tobacco, alcohol and chocolate, can be labeled 'social drugs'.

METHODS

We analyzed the social drug habits of 562 patients suffering from mood disorders, according to DSM-IV-R criteria (major depressive episode, recurrent depression, bipolar type I and II disorders and depression not otherwise specified). The sample was also divided into bipolar and non-bipolar according to Hypomania Check-list 32 (HCL-32), which proposes a broader concept of hypomania and soft bipolarity, comprising the spectrum of bipolar disorders proper, along with other, "softer" expressions of bipolarity intermediate between bipolar disorder and normality.

RESULTS

Using HCL-32 criteria, but DSM-IV-R criteria, a link was confirmed between bipolar spectrum and substance use including social drugs such as tobacco and coffee.

LIMITATION

Observational correlational study.

CONCLUSION

This study is in support of earlier theoretical formulations within the framework of the Pisa-San Diego collaboration.

A randomised controlled trial linking mental health inpatients to community smoking cessation supports: a study protocol

BACKGROUND

Mental health inpatients smoke at higher rates than the general population and are disproportionately affected by tobacco dependence. Despite the advent of smoke free policies within mental health hospitals, limited systems are in place to support a cessation attempt post hospitalisation, and international evidence suggests that most smokers return to pre-admission smoking levels following discharge. This protocol describes a randomised controlled trial that will test the feasibility, acceptability and efficacy of linking inpatient smoking care with ongoing community cessation support for smokers with a mental illness.

METHODS/DESIGN

This study will be conducted as a randomised controlled trial. 200 smokers with an acute mental illness will be recruited from a large inpatient mental health facility. Participants will complete a baseline survey and will be randomised to either a multimodal smoking cessation intervention or provided with hospital smoking care only. Randomisation will be stratified by diagnosis (psychotic, non-psychotic). Intervention participants will be provided with a brief motivational interview in the inpatient setting and options of ongoing smoking cessation support post discharge: nicotine replacement therapy (NRT); referral to Quitline; smoking cessation groups; and fortnightly telephone support. Outcome data, including cigarettes smoked per day, quit attempts, and self-reported 7-day point prevalence abstinence (validated by exhaled carbon monoxide), will be collected via blind interview at one week, two months, four months and six months post discharge. Process information will also be collected, including the use of cessation supports and cost of the intervention.

DISCUSSION

This study will provide comprehensive data on the potential of an integrated, multimodal smoking cessation intervention for persons with an acute mental illness, linking inpatient with community cessation support.

Nicotine replacement prescribing trends in a large psychiatric hospital, before and after implementation of a hospital-wide smoking ban

OBJECTIVE

We examined prescribing patterns for nicotine replacement therapies (NRTs) in a large psychiatric hospital, before and after the implementation of a smoking ban.

METHOD

We extracted 5 years of NRT utilization data from hospital pharmacy records. The ban went into effect on January 1, 2007. Data reflect NRT prescriptions from 2 years before and 3 years after the ban, and N = 30,908 total inpatient hospital admissions.

RESULTS

The monthly rate of total NRT prescriptions increased after the ban from M = 254.25 (SD = 126.60) doses per month to M = 4,467.52 (SD = 1,785.87) doses per month (>1,700% increase, p < .0001). After the smoking ban, clinicians prescribed higher doses of transdermal (but not oral) NRT (Tukey, p < .0001). Comparisons of NRT prescribing across hospital units tentatively suggested that patients being treated on the substance use disorders unit were prescribed more doses of NRT, as well as higher doses of NRT compared with patients on other units. Analysis of trends over time showed no apparent downward trend for NRT usage during the 3 years following the smoking ban, suggesting that clinicians continued to treat nicotine dependence after smoking was restricted.

CONCLUSIONS

Clinicians are more likely to identify and treat symptoms of nicotine withdrawal when smoking is restricted. Hospitals should consider monitoring prescriptions for NRT as part of their ongoing quality assurance practices so that patients receive aggressive treatment of nicotine withdrawal symptoms--an essential component of high-quality patient care.

Medical comorbidities increase motivation to quit smoking among veterans being treated by a psychiatric facility

PURPOSE

This study determined if comorbidities predicted motivation to quit smoking among smokers treated in a primarily psychiatric Veterans Affairs facility.

DESIGN AND METHODS

A cross-sectional study was conducted with a convenience sample of smokers (N = 117).

FINDINGS

Multivariate analyses showed a history of arthritis, diabetes, lung disease, or stroke predicted motivation to quit smoking (p < .05). Having a history of high blood pressure, heart disease, or cancer was not associated with motivation to quit smoking.

PRACTICE IMPLICATIONS

Relating smoking behavior to the patient's medical comorbidities may increase motivation to quit smoking among veterans.

General physical health advice for people with serious mental illness

BACKGROUND

There is currently much focus on provision of general physical health advice to people with serious mental illness and there has been increasing pressure for services to take responsibility for providing this.

OBJECTIVES

To assess the effects of general physical health advice as a means of reducing morbidity, mortality and improving or maintaining quality of life in people with serious mental illness.

SEARCH STRATEGY

We searched the Cochrane Schizophrenia Group Trials Register (November 2009) which is based on regular searches of CINAHL, EMBASE, MEDLINE and PsycINFO.

SELECTION CRITERIA

All randomised clinical trials focusing on general physical health advice.

DATA COLLECTION AND ANALYSIS

We extracted data independently. For binary outcomes we calculated risk ratio (RR) and its 95% confidence interval (CI), on an intention-to-treat basis. For continuous data we estimated mean difference (MD) between groups and its 95% CI. We employed a random-effects model for analyses.

MAIN RESULTS

For the comparison of physical healthcare advice versus standard care we identified five studies (total n = 884) of limited quality. For measures of quality of life one trial found no difference (n = 54, 1 RCT, MD Lehman scale 0.00 CI -0.67 to 0.67) but another did (n = 407, 1 RCT, MD Quality of Life Medical Outcomes Scale - mental component 3.7 CI 1.7 to 5.6). There was no difference between groups for the outcome of death (n = 407, 1 RCT, RR 1.3 CI 0.3 to 6.0), for the outcome of uptake of ill-health prevention services, one study found percentages significantly greater in the advice group (n = 363, 1 RCT, MD 36.9 CI 33.1 to 40.7). Economic data were equivocal. Attrition was large (> 30%) but similar for both groups (n = 884, 5 RCTs, RR 1.18 CI 0.97 to 1.43). Comparisons of one type of physical healthcare advice with another were grossly underpowered and equivocal.

AUTHORS' CONCLUSIONS

General physical health could lead to people with serious mental illness accessing more health services which, in turn, could mean they see longer term benefits such as reduced mortality or morbidity. On the other hand it is possible clinicians are expending much effort, time and financial expenditure on giving ineffective advice. This is an important area for good research reporting outcome of interest to carers and people with serious illnesses as well as researchers and fundholders.

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.

An exploration of mental health nursing students' experiences and attitudes towards using cigarettes to change client's behaviour

Using cigarettes to change client behaviour is a common, yet little studied, practice in mental health care. A questionnaire survey was used to explore mental health nursing student's experiences and attitudes to this practice. The sample was four cohorts of mental health nursing students (n= 151). Of them, 84% had experienced the practice of using cigarettes to change client behaviour in acute wards (73%), rehabilitation wards (28%) and elderly care (14%). Cigarettes were used to change client behaviour in areas such as attending to personal hygiene (57%) or engaging in the ward routine (39%). However, items such as leave (60%) or drinks (tea and coffee) (38%) were also reportedly used. Of the respondents, 54% inferred that the practice did not work well with 46% stating it was not written up in care plans; 52% felt it was an ad hoc practice, 60% inferred that at times it was used as a punishment while 55% intimated that they felt bad withholding cigarettes. There are ethical and moral dilemmas around using lifestyle risk factors as rewards or using client's nicotine addiction as a means of controlling behaviour. The question of whether this intervention should ever be used, given its associated health risk, requires more critical debate in clinical practice.

Smoking expectancies and intention to quit in smokers with schizophrenia, schizoaffective disorder and non-psychiatric controls

Cigarette smoking expectancies are systematically related to intention to quit smoking in adult smokers without psychiatric illness, but little is known about these relationships in smokers with serious mental illness. In this study, we compared positive and negative smoking expectancies, and examined relationships between expectancies and intention to quit smoking, in smokers with schizophrenia (n=46), smokers with schizoaffective disorder (n=35), and smokers without psychiatric illness (n=71). In all three groups, reduction of negative affect was rated as the most important smoking expectancy and intention to quit smoking was systematically related to concerns about the health effects and social consequences of smoking. Compared to the other groups of smokers, those with schizoaffective disorder were more concerned with social expectancies and with the immediate negative physical effects of smoking. Results of this study suggest that challenging positive smoking expectancies and providing more tailored information about the negative consequences of smoking might increase motivation to quit smoking in smokers with schizophrenia and schizoaffective disorder, as has been found with non-psychiatric smokers.

The impact of opening a smoking room on psychiatric inpatient behavior following implementation of a hospital-wide smoking ban

BACKGROUND

Psychiatric patients are significantly more likely to smoke than mentally healthy persons, presenting a challenge for inpatient psychiatric care when smoking bans are instituted.

OBJECTIVE

To assess the impact of opening a smoking room within a psychiatric unit following a hospital smoking ban.

STUDY DESIGN

A staff survey and a chart review of 180 inpatient admissions before and after the opening of a smoking room.

RESULTS

Patient records revealed no significant differences between recorded indices of disruptive patient behavior before or after the smoking room opening. The staff survey identified a perceived beneficial impact on unit atmosphere, where less time was spent discussing smoking privileges and off-unit privileges were granted more appropriately.

CONCLUSIONS

Implementation of a smoking room failed to reduce indices of disruptive patient behavior. Despite the absence of objective evidence, the attitude among staff was in support of allowing patients to smoke on the unit.