Achieving smoke-free mental health services: lessons from the past decade of implementation research

State of the literature discussing smoke-free policies globally: A narrative review

Despite the success of the Framework Convention on Tobacco Control (FCTC), most jurisdictions in the world do not have policies that create 100% smoke-free environments in indoor workplaces, indoor public places, public transport, or other public places. We conducted a narrative review of articles that discuss smoke-free policies and describe the state of the current literature. A search of peer-reviewed and gray literature, published between 1 January 2004 and 30 April 2022, was conducted using PubMed and EMBASE databases. We classified articles based on the location of the policy discussed (WHO region, World Bank income classification) and the environment that was being made smoke-free. Insights related to policy development and implementation, as well as compliance and enforcement, were also identified. The search identified 4469 unique citations; 134 articles met the criteria for inclusion and underwent data extraction by two independent coders. The sample included articles published in or about jurisdictions in each WHO region, in high- and low- and mediumincome countries, and articles that discussed policies regulating smoke-free indoor workplaces, indoor public places, public transport, outdoor/quasi-outdoor environments, and other (unspecified) public places. Some important insights from the literature related to smoke-free policy implementation included tobacco industry interference, the important role of civil society, and the need for effective communication, education, and leadership. Enforcement officials' awareness and training, stakeholders' attitudes and beliefs, and understanding social norms were identified as relevant determinants of effective smoke-free policies. There continue to be challenges for implementing smoke-free policies in jurisdictions throughout the globe, in high- and low- and middle-income countries. The literature includes insights to support 100% smoke-free policies in each environment that must be made smoke-free as per the FCTC.

Can improvement in delivery of smoking cessation care be sustained in psychiatry inpatient settings through a system change intervention? An analysis of statewide administrative health data

OBJECTIVE

This study evaluated maintenance of improved delivery of smoking cessation assistance in adult acute psychiatry inpatient units 3 years post statewide implementation of a system change intervention through analysis of a statewide administrative health dataset.

METHOD

Rates of documenting smoking status and providing a brief smoking cessation intervention (the Smoking Cessation Clinical Pathway) in all eligible Queensland public adult acute psychiatry inpatient units (N = 57) during the implementation phase (October 2015-September 2017) of a system change intervention were compared to the maintenance phase (October 2017-October 2020) using interrupted time series analysis.

RESULTS

Across implementation and maintenance phases, the percentage of discharges from psychiatry inpatient units that had a smoking status recorded remained high with the statewide average exceeding 90% (implementation phase 93.2%, 95% confidence interval = [92.4, 93.9]; and maintenance phase 94.6%, 95% confidence interval = [94.0, 95.2]). The percentage of discharges statewide with a completed Pathway stabilised during the maintenance phase (change in slope -3.7%, 95% confidence interval = [-5.2, -2.3]; change in level 0.4%, 95% confidence interval = [-7.0, 7.9]).

CONCLUSION

An evidence-based smoking cessation intervention implemented with a system change intervention resulted in sustained improvement in addressing smoking in adult inpatient psychiatry units up to 3 years post implementation.

A Qualitative Study of the Implementation and Continued Delivery of Complete and Partial Smoke-Free Policies Across England's Prison Estate

INTRODUCTION

In the United Kingdom, smoking among prisoners is up to five times more prevalent than the national average. Between 2015 and 2018, HMPPS introduced a complete smoke-free policy in all closed prisons, and a partial policy permitting smoking only in smoking shelters in open prisons.

AIMS AND METHODS

This study aimed to explore the views of stakeholders regarding the implementation and continuation of smoke-free policies, including the management of nicotine addiction during imprisonment and after release. Individuals with key strategic and/or operational roles in delivering smoke-free prison policies across England were purposively sampled to complete a semi-structured interview. Twenty-eight interviews were analyzed thematically.

RESULTS

The smoke-free implementation across the closed prison estate was viewed as a success, though there were reports of reduced availability of smoking cessation support since the roll out. Participants thought the majority of tobacco smokers living in closed prison environments were now using an electronic cigarette, typically as a temporary means to manage nicotine addiction until release. In open prisons the partial policy has been less successful; high rates of smoking resumption on moving from closed to open conditions were reported, with many participants arguing that the open estate should also go completely smoke free. It was envisaged that most prisoners would resume smoking on community release.

CONCLUSIONS

The smoke-free policies provide a unique opportunity to promote lifelong cessation in this highly disadvantaged group. However more could be done to adopt a consistent smoke-free policy across all prisons, and to support prisoners in quitting smoking and nicotine use during and after imprisonment.

IMPLICATIONS

Our results identify the urgent need for more work to explore rates and reasons for relapse to smoking on transfer to the open estate and after release. With the majority of smokers in the closed prison estate now using e-cigarettes to manage their nicotine addiction, one way to support long-term tobacco abstinence could be to place greater emphasis on this switching behavior as a way of reducing tobacco-related harm within this population.

Outcomes Among People With Schizophrenia Participating in General-Population Smoking Cessation Treatment: An Observational Study

OBJECTIVE

People with schizophrenia are much more likely than others to smoke tobacco, raising risks of disease and premature mortality. These individuals are also less likely to quit successfully after treatment, but the few existing clinical and observational studies have been limited by small sample sizes, and have generally considered specialized treatment approaches. In this analysis, we examine outcomes, service use, and potential explanatory variables in a large sample of people with schizophrenia treated in a general-population cessation program.

METHOD

Our sample comprised 3,011 people with schizophrenia and 77,790 controls receiving free nicotine replacement therapy through 400 clinics and health centres. We analysed self-reported 7-day abstinence or reduction at 6-month follow-up, as well as the number of visits attended and self-reported difficulties in quitting. We adjusted for demographic, socioeconomic, and health variables, and used multiple imputation to address missing data.

RESULTS

Abstinence was achieved by 16.2% (95% confidence interval [CI], 14.5% to 17.8%) of people with schizophrenia and 26.4% (95% CI, 26.0% to 26.7%) of others (absolute difference = 10.2%; 95% CI, 8.5% to 11.9%; P < 0.001). After adjustment, this difference was reduced to 7.3% (95% CI, 5.4% to 9.3%; P < 0.001). Reduction in use was reported by 11.8% (95% CI, 10.3% to 13.3%) and 12.5% (95% CI, 12.2% to 12.8%), respectively; this difference was nonsignificant after adjustment. People with schizophrenia attended more clinic visits (incidence rate ratio [IRR] = 1.15, 95% CI = 1.12% to 1.18%, P < 0.001) and reported more difficulties related to "being around other smokers" (odds ratio [OR] = 1.28; 95% CI, 1.11% to 1.47%; P = 0.001).

CONCLUSION

There is abundant demand for tobacco cessation treatment in this population. Outcomes were substantially poorer for people with schizophrenia, and this difference was not explained by covariates. Cessation remained much better than for unaided quit attempts, however, and engagement was high, demonstrating that people with schizophrenia benefit from nonspecialized pharmacological treatment programs.

A selective literature review exploring the role of the nicotinic system in schizophrenia

Nicotine use is more prevalent in patients with psychiatric disorders, especially those diagnosed with psychotic illnesses. Previously, this higher prevalence has been partially attributed to the potential ameliorative effects of nicotine on symptom severity and cognitive impairment. Some healthcare professionals and patients perceive there is a beneficial effect of nicotine on mental health. Emerging data show that the harm associated with nicotine in the population of patients with mental health conditions outweighs any potential benefit. This paper will review the evidence surrounding the nicotinic system and schizophrenia, with a focus on any causality between nicotine and psychosis.

Impact of smoking bans and other smoking cessation interventions in prisons, mental health and substance use treatment settings: A systematic review of the evidence

ISSUES

We conducted a systematic review to examine whether smoking bans alone are effective in achieving smoking cessation in people released from prison, and patients discharged from mental health or substance use settings.

APPROACH

We searched health, criminology and social science databases. Detailed search strings were used to combine terms related to smoking bans and cessation interventions in prison, mental health and substance use treatment settings. We used backward and forward snowballing and manual hand searching to find additional studies. Studies were included if they: were published between 1 January 2000 and 25 February 2022; included a complete smoking ban; measured people released from prison and/or mental health and/or substance use patients smoking post-release/discharge from a smoke-free facility; and reported smoking cessation intervention and/or smoking ban outcomes. Methodological quality was assessed using the Effective Public Health Practice Project's Quality Assessment Tool for Quantitative Studies and reviewed by two authors.

KEY FINDINGS

People released from prison, mental health and substance use in-patients who experience a smoking ban while incarcerated or in in-patient settings often relapse to smoking shortly after release or discharge. We found that although smoking bans alone do not promote cessation, multi-component interventions in combination with smoking bans can significantly increase cessation rates post-release/discharge provided they support participants during this time.

CONCLUSIONS

There is limited evidence to suggest tobacco bans alone in prison, mental health and substance use treatment settings are effective in achieving long-term smoking cessation. This review suggests that combining smoking bans and cessation interventions including pre- and post-release/discharge support can be effective in achieving smoking cessation.

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.

Attitudes of staff towards smoke-free environments in psychiatric hospitals in Germany

INTRODUCTION

Smoke-free environments have already been successfully introduced in hospitals world-wide. But despite convincing evidence of their success, many countries still struggle to make the necessary changes. Not only is the smoking prevalence higher amongst people with mental health problems and staff working in psychiatric units, but employees in psychiatry often resist the implementation of smoke-free policies. This study explores staff attitudes towards smoke-free environments in psychiatric hospitals in Germany and tries to identify barriers and opportunities for implementation.

METHODS

This cross-sectional online survey was carried out at eight psychiatric units of the state-owned healthcare company Vivantes Netzwerk für Gesundheit GmbH in Berlin, Germany, in 2019. A total of 448 members of staff were surveyed on their views towards creating a smoke-free environment in their workplace.

RESULTS

Psychiatric staff present contradictory attitudes towards implementing smoke-free regulations. On the one hand, a majority recognizes the need for smoke-free environments as they promote physical well-being of staff and patients. On the other hand, a majority opposes comprehensive restrictions like a complete smoking ban. Smokers are more likely than non-smokers to resist restrictive measures and show a tendency to only support those measures which they deem unlikely to affect their own smoking habits.

CONCLUSIONS

The contradictory attitudes towards implementing smoke-free regulations present an entry point to elicit behavior change and a shift in attitudes, for example in staff training on smoke-free environments. Staff who smoke, in particular, should be motivated to reflect on the contradiction that is presented by their private smoking behavior and their role as healthcare professionals.

Collaborative Learning: A Qualitative Study Exploring Factors Contributing to a Successful Tobacco Cessation Train-the-Trainer Program as a Community of Practice

Individuals with behavioral health conditions account for 50% of annual smoking-related deaths, yet rarely receive tobacco dependence treatment within local mental health authorities (LMHAs). As lack of training and knowledge are key barriers to providing tobacco dependence treatment, Taking Texas Tobacco-Free (TTTF) developed an iterative, 4–6-months train-the-trainer program to embed expertise and delivery of sustained education on tobacco-free workplace policies and practices in participating centers. We explore the employee “champions’” train-the-trainer program experiences using a community of practice (CoP) model to identify key contributors to successful program implementation. Across 3 different LMHAs, we conducted semi-structured individual and group interviews online at 2 time points. We interviewed each champion twice (except for 1 champion who dropped out between measurements); pre-implementation (3 group interviews; N = 4 + 4 + 3 = 11 champions); post-implementation (7 individual interviews and 1 group interview; 7 + 3 = 10 champions). Therefore, 11 champions participated in pre- and post-implementation interviews from July 2020–May 2021. Guided by an iterative, thematic analysis and constant comparison process, we inductively coded and summarized data into themes. Five factors contributed to successful program implementation: value of peer support/feedback; building knowledge, champion confidence, and program ownership; informative curriculum, adaptable to targeted populations; staying abreast of current tobacco/nicotine research and products; and TTTF team responsiveness and practical coaching/assistance. Champions reported the TTTF train-the-trainer program was successful and identified attitudes and CoP processes that effectively built organizational capacity and expertise to sustainably address tobacco dependence. Study findings can guide other agencies in implementing sustainable tobacco-free training programs.

Support and attitudes of Qatar mental health professionals to a proposed mental health inpatient smoking ban: Results of a cross-sectional survey

WHAT IS KNOWN ON THE SUBJECT?: Smoking is more common among people with serious mental illness, and it contributes to a reduced life expectancy. Several Western countries have successfully introduced smoke-free policies in inpatient mental health units. There is virtually no information about attitudes to smoking bans in mental health units from countries in the Middle East and North Africa region. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: We surveyed mental health professionals working in Qatar's main mental health service to determine support for and attitudes towards a proposed total smoking ban in psychiatric wards. Most staff who completed the survey supported an inpatient smoking ban. However, further analysis, both quantitative and qualitative, showed markedly ambivalent attitudes, that is staff simultaneously held attitudes that supported and opposed a smoking ban. Professionals who did not support a ban were more likely to have not received smoking cessation training in the last 5 years, to be a psychiatrist rather than a nurse or allied mental health professional, to be current smokers and to be a Middle Eastern and North African national. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Further staff training is necessary to achieve more consistent attitudes that support a total smoking ban and increase the likelihood of successful implementation. The attitudes in this study showed similarities and differences to those reported for mental health professionals in Western countries. This highlights that local research is necessary to help shape training and successfully implement smoke-free policies. ABSTRACT: Introduction Despite the fact that patients with serious mental illness (SMI) have high rates of smoking and an increased standardized mortality, there is virtually no information about attitudes to smoking bans in mental health units from countries in the Middle East and North Africa region. Aim To assess support for, and attitudes towards, a proposed total smoking ban in psychiatric wards among mental health clinicians in Qatar. Method Cross-sectional survey of mental health professionals working in Qatar's primary mental health service. Results The response rate was 68% (353/520). Support for a ban was assessed with a single-item question; 73% of respondents supported a ban with opposition significantly (p < .05) associated with being a current smoker, a Middle Eastern and North African (MENA) national, a psychiatrist versus a mental health nurse or allied health professional and not receiving smoking cessation training in the last 5 years. A 21-item questionnaire assessed attitudes to a total smoking ban. It showed marked ambivalence with multiple linear regression identifying MENA nationality, male gender and current smoking status as independent variables influencing attitudes. The most strongly held attitude supporting a ban was concern about passive smoking and against a ban was concern it may increase patient agitation. Qualitative data confirmed ambivalent views. Discussion The results show similarities and differences to research from other countries suggesting that cultural factors influence some attitudes to smoke-free policies. Implications for Practice Staff support and smoking cessation education are necessary to achieve more consistent staff attitudes to support smoke-free policies.

Inequity in smoking cessation clinical trials testing pharmacotherapies: exclusion of smokers with mental health disorders

OBJECTIVES

People suffering from mental health disorder (MHDs) are often under-represented in clinical research though the reasons for their exclusion are rarely recorded. As they have higher rates of smoking and nicotine dependence, it is crucial that they are adequately represented in clinical trials of established pharmacotherapy interventions for smoking cessation. This review aims to examine the practice of excluding smokers with MHDs and reasons for such exclusion in clinical trials evaluating pharmacotherapy treatments for smoking cessation.

DATA SOURCE

The Cochrane database of systematic reviews was searched until September 2020 for reviews on smoking cessation using pharmacotherapies.

STUDY SELECTION

Randomised controlled trials (RCTs) within the selected Cochrane reviews were included.

DATA EXTRACTION

Conducted by one author and independently verified by three authors.

DATA SYNTHESIS

We included 279 RCTs from 13 Cochrane reviews. Of all studies, 51 (18.3%) explicitly excluded participants with any MHDs, 152 (54.5%) conditionally excluded based on certain MHD criteria and 76 (27.2%) provided insufficient information to ascertain either inclusion or exclusion. Studies of antidepressant medications used for smoking cessation were found to be 3.33 times more likely (95% CI 1.38 to 8.01, p=0.007) to conditionally exclude smokers with MHDs than explicitly exclude compared with studies of nicotine replacement therapy.

CONCLUSION

Smokers with MHDs are not sufficiently represented in RCTs examining the safety and effectiveness of smoking cessation medications. Greater access to clinical trial participation needs to be facilitated for this group to better address access to appropriate pharmacotherapeutic interventions in this vulnerable population.

There's no smoke without fire: Smoking in smoke-free acute mental health wards

BACKGROUND

People who smoke with serious mental illness carry disproportionate costs from smoking, including poor health and premature death from tobacco-related illnesses. Hospitals in New Zealand are ostensibly smoke-free; however, some mental health wards have resisted implementing this policy.

AIM

This study explored smoking in acute metal health wards using data emerging from a large sociological study on modern acute psychiatric units.

METHODS

Eighty-five in-depth, semi-structured interviews were conducted with staff and service users from four units. Data were analysed using a social constructionist problem representation approach.

RESULTS

Although high-level smoke-free policies were mandatory, most participants disregarded these policies and smoking occurred in internal courtyards. Staff reasoned that acute admissions were not the time to quit smoking, citing the sceptres of distress and possibly violence; further, they found smoking challenging to combat. Inconsistent enforcement of smoke-free policies was common and problematic. Many service users also rejected smoke-free policies; they considered smoking facilitated social connections, alleviated boredom, and helped them feel calm in a distressing environment - some started or increased smoking following admission. A minority viewed smoking as a problem; a fire hazard, or pollutant. No one mentioned its health risks.

CONCLUSION

Psychiatric wards remain overlooked corners where hospital smoke-free policies are inconsistently applied or ignored. Well-meaning staff hold strong but anachronistic views about smoking. To neglect smoking cessation support for people with serious mental illness is discriminatory and perpetuates health and socioeconomic inequities. However, blanket applications of generic policy are unlikely to succeed. Solutions may include myth-busting education for service users and staff, local champions, and strong managerial support and leadership, with additional resourcing during transition phases. Smoke-free policies need consistent application with non-judgemental NRT and, potentially, other treatments. Smoking cessation would be supported by better designed facilities with more options for alleviating boredom, expressing autonomy, facilitating social connections, and reducing distress.

Staff attitudes to completely smoke-free policies and smoking cessation practices in a mental health setting

BACKGROUND

Mental health trusts in England were expected to become completely smoke-free and embed smoking cessation practices by 2018. Such policies are fraught with concerns and have received mixed support from mental health staff. Understanding staff attitudes to these practices prior to enforcement of the policy could help design an effective implementation strategy.

METHODS

A cross-sectional survey was conducted with clinical and non-clinical staff in a Mental Health Trust to understand smoking cessation practices and attitudes to the implementation of a completely smoke-free policy.

RESULTS

There were 631 responses. Most participants disagreed with the policy on wards (59.6%) and throughout all mental health settings (57.4%). Clinicians expressed significantly lower organizational policy support (P = 0.001) than non-clinicians (P = 0.001). Psychiatrists were more supportive of the organizational items than nurses and allied health professionals. Clinicians' attitudes towards smoking cessation practices were less positive for those who were current smokers (P < 0.001), but more positive for clinicians who had received or were interested in attending smoking cessation training (P < 0.001).

CONCLUSIONS

Partial and completely smoke-free policies remain unsupported by staff in mental health settings. Smoking cessation training appears to reinforce rather than alter attitudes towards smoking cessation.

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.

The effectiveness of interventions to increase preventive care provision for chronic disease risk behaviours in mental health settings: A systematic review and meta-analysis

Clinical practice guidelines direct mental health services to provide preventive care to address client chronic disease risk behaviours, however, this care is not routinely provided. The aim of this systematic review was to synthesise evidence regarding the effectiveness of interventions to increase provision of preventive care by mental health services; by care element (ask, assess, advice, assist, arrange) and risk behaviour (tobacco smoking, poor nutrition, harmful alcohol consumption, physical inactivity). Electronic bibliographic databases, Google Scholar, relevant journals, and included study reference lists were searched. Eligible studies were of any design with a comparison group that reported the effectiveness of an intervention to increase the provision of at least one element of preventive care for at least one risk behaviour in a mental health setting. Twenty studies were included, most commonly examining smoking (n = 20) and 'ask' (n = 12). Meta-analysis found interventions involving task shifting were effective in increasing smoking 'advice' (n = 2 RCTs; p = 0.009) and physical activity 'advice' (n = 2 RCTs; p = 0.002). Overall, meta-analysis and narrative synthesis indicated that effective intervention strategies (categorised according to the Effective Practice and Organisation of Care taxonomy) were: task shifting, educational meetings, health information systems, local consensus processes, authority and accountability, and reminders. The most consistent findings across studies were with regard to preventive care for smoking, while conflicting or limited evidence was found regarding other risk behaviours. While further rigorous research examining key risk behaviours is recommended, the findings may inform the selection of strategies for future interventions and service delivery initiatives.

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

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

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.

Smoking cessation in inpatient psychiatry treatment facilities: A review

•

Smoking rates are high among people with psychiatric illness.

•

Smoking cessation interventions are rarely available in inpatient psychiatry settings.

•

Smokers with psychiatric illness are just as interested in quitting smoking.

Background

Tobacco-related diseases are a leading cause of death among individuals with severe mental illness (SMI), yet interventions to address tobacco cessation are rare in inpatient settings where persons with SMI are hospitalized. While cigarette smoking rates have declined in the general population, they remain high in persons with SMI. Inpatient settings would be a prime location to intervene on tobacco consumption among persons with SMI. The objective of this review was to examine evidence of smoking cessation interventions in psychiatric inpatient facilities.

Method

Using narrative overview guidelines, we searched PubMed, PsycINFO, and CINAHL for smoking cessation RCT studies published between 1950 and 2018. Studies included had to have at least started in inpatient psychiatry settings. Examples of search terms included: smoking cessation in inpatient psychiatry, smoking cessation in inpatient mental health treatment facilities, and smoking cessation and mental health.

Results

Following the inclusion criteria, eight RCT studies were reviewed. One study was among adolescent psychiatric inpatient smokers ages 13–17, and 7 were among adult psychiatric inpatients with mean age 41 years. Treatment periods lasting 8 to 12 weeks started in inpatient settings and continued post discharge. A combination of behavioral and pharmacological interventions were used. Pharmacological interventions were nicotine replacement therapies, and at least one study used varenicline. At baseline, participants smoked an average of 18.1 cigarettes per day.

Conclusion

Smoking cessation in inpatient psychiatry settings is rare or delayed. There is a need for more tailored treatments among this population to help them quit smoking.

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

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

A Cluster-Randomized Clinical Trial Testing the Effectiveness of the Addressing Tobacco Through Organizational Change Model for Improving the Treatment of Tobacco Use in Community Mental Health Care: Preliminary Study Feasibility and Baseline Findings

INTRODUCTION

People with mental illness are more likely to smoke and less likely to receive tobacco treatment than the general population. The Addressing Tobacco Through Organizational Change (ATTOC) approach supports organizational change to increase tobacco treatment in this population. We describe preliminary study feasibility and baseline behaviors and attitudes among clients and staff regarding tobacco treatment, and assesse correlates of treatment of smoking.

METHODS

Preliminary accrual, engagement, and baseline data are reported from a cluster-randomized trial comparing ATTOC to usual care. Feasibility, thus far, was the rate of site and participant accrual and engagement (eg, participants remaining in the trial). Correlates of assessing smoking, advising cessation, and providing treatment were assessed.

RESULTS

Site and participant accrual is 80% (8/10) and 86% (456/533), and engagement is 100% and 82%. "Staff asking about smoking" was reported by 63% of clients and 38% of staff; "staff advising cessation" was reported by 57% of clients and 46% of staff; staff report "assisting clients with any medication" at most 22% of the time, whereas at most 18% of clients report receiving a cessation medication; 59% of clients want tobacco treatment, but 36% of staff think that it is part of their job. "Staff assisting with medications" is related to more training, believing treating smoking is part of their job, and believing patients are concerned about smoking (ps < .05).

CONCLUSIONS

This trial of training in tobacco treatment within mental health care is feasible thus far; self-reported rates of tobacco treatment are low and associated with clinician attitudes and barriers.

IMPLICATIONS

Evaluation of ways to help address tobacco use treatment in community mental health care is feasible and needed, including the use of technical assistance and training guided by an organizational change approach.

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.

Exploring mental health professionals' practice in relation to smoke-free policy within a mental health trust: a qualitative study using the COM-B model of behaviour

BACKGROUND

Smoking has played a significant role in the historical culture of mental healthcare settings. Mental health professionals (MHPs) often hold dismissive attitudes regarding the importance of smoking cessation in the context of mental healthcare. In 2007, English mental health inpatient buildings were required by law to become smoke-free, and healthcare trusts have more recently begun to implement comprehensive policies (i.e. smoke-free grounds and buildings) and staff training in response to national guidance. It is therefore important to explore MHPs practice around smoking, smoking cessation, and smoke-free policy adherence. This study aimed to explore these issues by using the COM-B (capability, opportunity, motivation, behaviour) model to systematically identify barriers to, and facilitators for, MHPs addressing smoking with their patients.

METHODS

Five focus groups with a total of 36 MHPs were conducted between March and August 2017. MHPs were recruited from one of the largest mental health trusts in Europe. Discussions were guided by a semi-structured guide. Responses were audio recorded, transcribed and coded using thematic analysis and the COM-B framework.

RESULTS

Addressing smoking with patients was undermined by MHPs' 1) psychological capability to recall training content, misunderstand the potential benefits of addressing patient smoking and harm reduction approaches; 2) physical opportunity in terms of time constraints, and easy accessibility of tobacco in the community; 3) social opportunity in terms of increased cultural value of tobacco following inpatient smoke-free policy implementation, and lack of support from colleagues to enforce the smoke-free policy; 4) automatic motivation, including intrinsic biases regarding patients abilities and motivations to quit, and 5) reflective motivation, including perceived job role and decision making processes related to addressing behaviours deemed more important than smoking. The main facilitating factors identified were MHPs' having opportunity in the form of patients asking directly for support, and MHPs having access to resources such as stop smoking services and spirometers.

CONCLUSION

Multiple barriers were identified across all key domains of the COM-B framework that undermine MHPs' practice regarding smoking cessation. Few facilitators were identified which may have implications for future smoke-free policy and clinical practice.

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.

Kick.it: The development of an evidence-based smoking cessation smartphone app

Currently, the evidence for mobile health (mHealth) smoking cessation interventions is limited and heterogeneous, warranting the need for innovative rigorously developed solutions. The aim of this study was to describe the development of a smoking cessation smartphone application (app) developed using evidence-based principles. The app (Kick.it) was designed using the Intervention Mapping framework, incorporating an extensive literature review and qualitative study, in combination with the Behavioural Change Taxonomy v1, the Theoretical Domains Framework, and the Persuasive System Design framework. Kick.it provides quit smoking education, skills training, motivational content and self-regulation functionality for smokers, as well as their social support network. By logging cravings and cigarettes smoked, users will create their own smoking profile, which will be used to provide tailored interventions. It hosts a social network to allow 24/7 social support and provides in-app tools to help with urges to smoke. The app aims to motivate smokers to retry if they slip-up or relapse, allowing them to learn from previous smoking cessation attempts. Rather than basing the app on a singular behavioral change approach, Kick.it will use elements stemming from a variety of behavioral approaches by combining methods of multiple psychological theories. The use of best-practice intervention development frameworks in conjunction with evidence-based behavioral change techniques is expected to result in a smartphone app that has an optimal chance of helping people to quit smoking.

Opinions of Hospitalized Patients with Mental Disorders and Patients in Basic Health Units in Brazil Regarding Tobacco Smoking

This study aims to investigate the opinions of psychiatric patients and the general population on the smoking ban in health service facilities. A cross-sectional study was carried out in a mental health outpatient care unit (MHOC; n = 126), a psychiatric hospital (PH; n = 126), and a basic health unit (BHU; n = 126). The participants in the hospital were less in favor of the smoking ban compared with those attending out-of-hospital units (MHOC, 84%; PH, 69%; and BHU, 100%). Subjects with four or more psychiatric admissions (odds ratio (OR), 3.24) and smokers (OR, 3.18) were most likely to agree that patients have the right to smoke in health service facilities. The psychiatric population was less tolerant of the smoking ban, reflecting the culture of smoking in mental health service facilities.

Complete smokefree policies in mental health inpatient settings: results from a mixed-methods evaluation before and after implementing national guidance

BACKGROUND

Tobacco smoking is extremely prevalent in people with severe mental illness (SMI) and has been recognised as the main contributor to widening health inequalities in this population. Historically, smoking has been deeply entrenched in the culture of mental health settings in the UK, and until recently, smokefree policies tended to be only partially implemented. However, recent national guidance and the government's tobacco control plan now call for the implementation of complete smokefree policies. Many mental health Trusts across the UK are currently in the process of implementing the new guidance, but little is known about the impact of and experience with policy implementation.

METHODS

This paper reports findings from a mixed-methods evaluation of policy implementation across 12 wards in a large mental health Trust in England. Quantitative data were collected and compared before and after implementation of NICE guidance PH48 and referred to 1) identification and treatment of tobacco dependence, 2) smoking-related incident reporting, and 3) prescribing of psychotropic medication. A qualitative exploration of the experience of inpatients was also carried out. Descriptive statistical analyses were performed, and the feasibility of collecting relevant and complete data for each quantitative component was assessed. Qualitative data were analysed using thematic framework analysis.

RESULTS

Following implementation of the complete smokefree policy, increases in the numbers of patients offered smoking cessation advice (72% compared to 38%) were identified. While incident reports demonstrated a decrease in challenging behaviour during the post-PH48 period (6% compared to 23%), incidents relating to the concealment of smoking materials increased (10% compared to 2%). Patients reported encouraging changes in smoking behaviour and motivation to maintain change after discharge. However, implementation issues challenging full policy implementation, including covert facilitation of smoking by staff, were reported, and difficulties in collecting relevant and complete data for comprehensive evaluation purposes identified.

CONCLUSIONS

Overall, the implementation of complete smokefree policies in mental health settings may currently be undermined by partial support. Strategies to enhance support and the establishment of suitable data collection pathways to monitor progress are required.

An Exploration of the Perspectives of Associate Nurse Unit Managers Regarding the Implementation of Smoke-free Policies in Adult Mental Health Inpatient Units

CONTEXT

In Adult Mental Health Inpatient Units, it is not unexpected that leadership of Associate Nurse Unit Managers contributes to successful implementation of smoke-free policies.

AIM

In light of challenges facing mental health nursing, and limited research describing their leadership and the role it plays in addressing smoke-free policy implementation, the aim of this study is to explore Associate Nurse Unit Managers perspectives' regarding the implementation of smoke-free policies, which were introduced on 1 July, 2015.

DESIGN, SETTING, PARTICIPANTS

Individual in-depth semi-structured interviews were undertaken six months post the implementation of smoke-free policies. In this qualitative descriptive study, six Associate Nurse Unit Managers working in a Victorian public Adult Mental Health Inpatient Unit, were asked eight questions which targeted leadership and the implementation and enforcement of smoke-free policies. Associate Nurse Unit Managers provide leadership and role modeling for staff and they are responsible for setting the standards that govern the behavior of nurses within their team. All participants interviewed believed that they were leaders in the workplace.

MAIN OUTCOMES

Education and consistency were identified as crucial for smoke-free policies to be successful. Participants acknowledged that the availability of therapeutic interventions, staff resources and the accessibility of nicotine replacement therapy were crucial to assist consumers to remain smoke-free while on the unit.

CONCLUSION

The findings from this research may help to improve the understanding of the practical challenges that Associate Nurse Unit Manager's face in the implementation of smoke-free policies with implications for policies, nursing practice, education and research.

Adapting, Pilot Testing and Evaluating the Kick.it App to Support Smoking Cessation for Smokers with Severe Mental Illness: A Study Protocol

(1) Background: While the prevalence of tobacco smoking in the general population has declined, it remains exceptionally high for smokers with severe mental illness (SMI), despite significant public health measures. This project aims to adapt, pilot test and evaluate a novel e-health smoking cessation intervention to assist relapse prevention and encourage sustained smoking cessation for young adults (aged 18⁻29 years) with SMI. (2) Methods: Using co-design principles, the researchers will adapt the Kick.it smartphone App in collaboration with a small sample of current and ex-smokers with SMI. In-depth interviews with smokers with SMI who have attempted to quit in the past 12 months and ex-smokers (i.e., those having not smoked in the past seven days) will explore their perceptions of smoking cessation support options that have been of value to them. Focus group participants will then give their feedback on the existing Kick.it App and any adaptations needed. The adapted App will then be pilot-tested with a small sample of young adult smokers with SMI interested in attempting to cut down or quit smoking, measuring utility, feasibility, acceptability, and preliminary outcomes in supporting their quit efforts. (3) Conclusions: This pilot work will inform a larger definitive trial. Dependent on recruitment success, the project may extend to also include smokers with SMI who are aged 30 years or more.

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.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Implementation of a Quit Smoking Programme in Community Adult Mental Health Services-A Qualitative Study

Little is known about the experiences of people with severe mental health difficulties in smoking cessation interventions. This study aimed to review the implementation of a smoking cessation programme across 16 community mental health day services. The aim was to establish the experience from both service user and facilitator perspectives and refine implementation for future groups. In-depth interviews were conducted with 20 service users and four focus groups held with 17 facilitators. Thematic analysis was used to analyse the data for emergent themes in relation to key enablers and barriers to implementation. Data from service users and facilitators revealed that implementation was enabled by an open and engaged recruitment approach; the resourcefulness of facilitators; programme materials and group-based format; combining the cessation programme with other and broader health initiatives; and participants' motivations, including health and money. Barriers included the structure of the service; the lack of a joined-up approach across the health services; literacy issues and the serial/logical process assumed by the programme. Barriers perceived as more specific to those with mental health difficulties included the use of smoking as a coping mechanism, lack of alternative activities/structure and lack of consistent determination. The tobacco free policy, implemented shortly before the programme, interestingly emerged as both a barrier and an enabler. In conclusion, although this group-based cessation programme in community mental health settings was well-received overall, a number of key barriers persist. A joined-up approach which addresses the culture of smoking in mental health settings, inconsistencies in smoking policies, and provides consistent cessation support, is needed. Care needs to be taken with the timing as overall it may not be helpful to introduce a new smoking cessation programme at the same time as a tobacco free policy.

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).

Addressing Tobacco Use Among Consumers and Staff at Behavioral Health Treatment Facilities Through Comprehensive Workplace Programming

Tobacco use is the leading cause of death and disability in the United States; cigarette smoking is the most common form of tobacco use. Smoking has become increasingly concentrated among individuals with behavioral health needs (e.g., persistent mental illness) and has led to increased morbidity and mortality in this group relative to the general population. Comprehensive tobacco-free workplace programs are effective in reducing tobacco use and cigarette smoke exposure among behavioral health consumers and the individuals who serve them. Taking Texas Tobacco-Free (TTTF) represents an academic-community partnership formed to address tobacco use among consumers and employees at behavioral health clinics across Texas via the dissemination of an evidence-based, multicomponent tobacco-free workplace program. Program components of TTTF include tobacco-free campus policy implementation and enforcement, staff education about tobacco use hazards, provider training to regularly screen for and address tobacco dependence via intervention, and community outreach. These components, the nature of the academic-community partnership, the process of behavioral health facility involvement and engagement, and the benefits and challenges of implementation from the perspectives of the project team and participating clinic leaders are described. This information can guide similar academic and community partnerships and inform the implementation of other statewide tobacco-free workplace programming.

Becoming tobacco-free: Changes in staff and patient attitudes and incident reports in a large academic mental health and addictions hospital

BACKGROUND AND OBJECTIVE

Complete tobacco bans in mental health facilities are thought to have the potential for adverse consequences. We evaluated staff and patient attitudes and adverse events associated with implementing Canada's largest, multi-site academic psychiatric hospital tobacco ban.

METHODS

A total of 1,173 staff and 422 patients completed an anonymous attitudes survey at prior to implementation (baseline), and 4-6 months and 10-12 months post-implementation. The tobacco-free initiative was implemented in a phased approach, allowing the prospective measurement of changes in attitudes and adverse outcomes such as agitation over a 1-year period.

RESULTS

We observed positive changes in staff and patient attitudes toward the tobacco-free policy for both staff and patients. Moreover, there was also a statistically significant decrease in patient agitation F (2, 99) = 3.25, p = .04, but no change F (2, 21) = 1.09, p = .35 in fire-related incidents.

DISCUSSION AND CONCLUSIONS

We observed positive changes in staff and patients attitudes and significant decrease in patient agitation during the first year of this tobacco-free hospital initiative.

SCIENTIFIC SIGNIFICANCE

During the first year of this tobacco-free psychiatric hospital policy, implementation of a tobacco-free environment in a large mental health and addictions setting was feasible and perceived as desirable by the majority of staff and patients surveyed and a decrease in incidents related to patient agitation was also observed. Further well-controlled studies with longer study durations are warranted. (Am J Addict 2017;26:183-191).

Impact of quitting smoking and smoking cessation treatment on substance use outcomes: An updated and narrative review

BACKGROUND

Historically, smoking cessation was thought to negatively impact substance use outcomes among smokers who use other substances. We sought to synthesize recent reports on this association.

METHODS

Google Scholar, PubMed, and Cinahl were searched for studies published from 2006 to March 29, 2016 that reported impact of smoking cessation treatment or quitting smoking on substance use or substance use disorder treatment outcomes in the general population and among those in substance abuse treatment. Studies were grouped by reported impact as follows: "positive" (i.e. improved), "null" (i.e. no change), or "negative" (i.e. worsened).

RESULTS

Twenty-four studies were included. Eighteen reported the impact of quitting smoking and six reported the impact of smoking cessation treatment intervention, independent of quitting, on substance use outcomes. Eleven studies (46%) reported solely positive impact; four (17%) reported solely null impact; eight (33%) reported mixed positive and null impact by analysis (combined and subgroup, n=1); substance (n=4); length of follow-up (n=2); and comparison group (n=1). One study (4%) reported mixed negative and null impact by ethnic group. No studies reported increased substance use.

CONCLUSION

Smoking cessation does not appear to have a negative effect, and often has a positive effect on substance use outcomes. Smoking cessation advice should be offered, without hesitation, to smokers who report substance use and those in treatment for substance use disorder.

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, Mental Illness, and Public Health

Tobacco use remains the leading preventable cause of death worldwide. In particular, people with mental illness are disproportionately affected with high smoking prevalence; they account for more than 200,000 of the 520,000 tobacco-attributable deaths in the United States annually and die on average 25 years prematurely. Our review aims to provide an update on smoking in the mentally ill. We review the determinants of tobacco use among smokers with mental illness, presented with regard to the public health HAVE framework of “the host” (e.g., tobacco user characteristics), the “agent” (e.g., nicotine product characteristics), the “vector” (e.g., tobacco industry), and the “environment” (e.g., smoking policies). Furthermore, we identify the significant health harms incurred and opportunities for prevention and intervention within a health care systems and larger health policy perspective. A comprehensive effort is warranted to achieve equity toward the 2025 Healthy People goal of reducing US adult tobacco use to 12%, with attention to all subgroups, including smokers with mental illness.

No Ifs, No Butts: Compliance with Smoking Cessation in Secondary Care Guidance (NICE PH48) by Providers of Cancer Therapies (Radiotherapy and Chemotherapy) in the UK

Background: Legislation preventing smoking in public places was introduced in England in July 2007. Since then, smoke-free policies have been extended to the majority of hospitals including those providing cancer therapies. Whilst studies have been conducted on the impact and effectiveness of hospital smoke-free policy in the UK and other countries, there have not been any studies with a focus on cancer care providers. Cancer patients are a priority group for smoking cessation and support and this study aimed to examine implementation of the National Institute Clinical Excellence (NICE) guidance (PH48) in acute cancer care trusts in the UK. Methods: Participants were recruited from UK radiotherapy and chemotherapy departments (total 80 sites, 65 organisations) and asked to complete a 15 min online questionnaire exploring the implementation of NICE guidance at their hospital site. Results: Considerable variability in implementation of the NICE guidance was observed. A total of 79.1% trusts were smoke-free in theory; however, only 18.6% were described as smoke-free in practice. Areas of improvement were identified in information and support for patients and staff including in Nicotine Replacement Therapy (NRT) provision, staff training and clarity on e-cigarette policies. Conclusions: While some trusts have effective smoke-free policies and provide valuable cessation support services for patients, improvements are required to ensure that all sites fully adopt the NICE guidance.

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.

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

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

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.

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.