Serious mental illness and smoking cessation

Persons with serious mental illness (SMI) are faced with substantial challenges to their health. This population is two to three times more likely to smoke cigarettes than persons who do not suffer from mental illness. In particular, young adults are at high risk for vulnerability to both SMI and cigarette smoking. Although there are proven methods for smoking cessation, both pharmacologic and non-pharmacologic interventions show limited usefulness for SMI who smoke. Alternative health care options as well as support groups and physical exercise are discussed as methods that may be useful in smoking cessation. Finally, integration of smoking cessation programming into existing mental health treatment services may offer the greatest opportunity for client success.     

Australian mental health care practitioners’ practices and attitudes for encouraging smoking cessation and tobacco harm reduction in smokers with severe mental illness

Reducing the burden of physical illness among people living with severe mental illnesses (SMI) is a key priority. Smoking is strongly associated with SMIs resulting in excessive smoking related morbidity and mortality in smokers with SMI. Smoking cessation advice and assistance from mental health practitioners would assist with reducing smoking and smoking‐related harms in this group. This study examined the attitudes and practices of Australian mental health practitioners towards smoking cessation and tobacco harm reduction for smokers with SMI, including adherence to the 5As (ask, assess, advise, assist and arrange follow up) of smoking cessation. We surveyed 267 Australian mental health practitioners using a cross‐sectional, online survey. Most practitioners (77.5%) asked their clients about smoking and provided health education (66.7%) but fewer provided direct assistance (31.1–39.7%). Most believed that tobacco harm reduction strategies are effective for reducing smoking related risks (88.4%) and that abstinence from all nicotine should not be the only goal discussed with smokers with SMI (77.9%). Many respondents were unsure about the safety (56.9%) and efficacy (39.3%) of e‐cigarettes. Practitioners trained in smoking cessation were more likely (OR: 2.9, CI: 1.5–5.9) to help their clients to stop smoking. Community mental health practitioners (OR: 0.3, CI: 0.1–0.9) and practitioners who were current smokers (OR: 0.3, CI: 0.1–0.9) were less likely to adhere to the 5As of smoking cessation intervention. The results of this study emphasize the importance and need for providing smoking cessation training to mental health practitioners especially community mental health practitioners.     

Adaptation of a sustained care cessation intervention for smokers hospitalized for psychiatric disorders: Study protocol for a randomized controlled trial

BackgroundIndividuals with serious mental illness (SMI) smoke at disproportionately higher rates than those without SMI, have lifespans 25–32 years shorter, and thus bear an especially large burden of tobacco-related morbidity and mortality. Several recent studies demonstrate that smokers with SMI can successfully quit smoking with adequate support. Further evidence shows that using technology to deliver sustained care interventions to hospitalized smokers can lead to smoking cessation up to 6 months after discharge. The current comparative effectiveness trial adapts a technology-assisted sustained care intervention designed for smokers admitted to a general hospital and tests whether this approach can produce higher cessation rates compared to usual care for smokers admitted to a psychiatric inpatient unit.MethodsA total of 353 eligible patients hospitalized for psychiatric illness are randomized by cohort into one of two conditions, Sustained Care (SusC) or Usual Care (UC), and are followed for six months after discharge. Participants assigned to UC receive brief tobacco education delivered by a hospital nurse during or soon after admission. Those assigned to SusC receive a 40-min, in-hospital motivational counseling intervention. Upon discharge, they also receive up to 8 weeks of free nicotine patches, automated interactive voice response (IVR) telephone and text messaging, and access to cessation counseling resources lasting 3 months post discharge. Smoking cessation outcomes are measured at 1-, 3- and 6-months post hospital discharge.ConclusionResults from this comparative effectiveness trial will add to our understanding of acceptable and effective smoking cessation approaches for patients hospitalized with SMI.     

Evaluation of a Theory-Based Education Program to Motivate Nursing Students to Intervene With their Seriously Mentally Ill Clients Who Use Tobacco

Tobacco dependence is a major health problem for persons with a serious mental illness (SMI). Nurses working with psychiatric clients often lack the knowledge, ability, and confidence to offer their clients meaningful, effective help to quit smoking. The purpose of this study was to evaluate the effects of a tobacco education program on the perceived competence and motivation of baccalaureate nursing students (BSN) to intervene with SMI clients who use tobacco. The education program significantly improved the competence and motivation of BSN students to deliver cessation interventions to this vulnerable population of smokers.     

Transition to a smoke‐free culture within mental health and drug and alcohol services: A survey of key stakeholders

Tobacco smoking is common among people with mental illnesses, and they carry a higher burden of smoking‐related illnesses. Despite this, smoke‐free policies and systems for supporting cessation have proved difficult to introduce in mental health and drug and alcohol services (MHDAS). This paper examines the barriers to becoming smoke free within New Zealand services. Key informants, including staff, smoke‐free coordinators, and cessation specialists were interviewed. Of the 142 invited informants 61 agreed (42%) to participate in a telephone interview, and 56 provided useable data. Organizations had a permissive or transitioning smoking culture, or were smoke free, defined by smoke‐free environments, smoke‐free‐promoting attitudes and behaviours of management and staff, and cessation support. Most organizations were on a continuum between permissive and transitional cultures. Only eight services had a fully smoke‐free culture. MHDAS face many challenges in the transition to a smoke‐free culture. They are not helped by exemptions in smoke‐free policies for mental health services, staff smoking, negative staff attitudes to becoming smoke free, poor knowledge of nicotine dependence, smoking‐related harm and comorbidities, and poor knowledge and skills regarding cessation‐support options. Health inequalities will continue across both service and socioeconomic divides without a concerted effort to address smoking.     

Smoking cessation and serious mental illness: a service evaluation of a drop‐in stop smoking clinic on an acute in‐patient unit

Aims and objectives. To evaluate the effect of a stop smoking clinic on the quit rates of patients admitted to an acute in‐patient unit. Background. The relationship between poor physical health and severe mental illness is well established. High rates of smoking appear to play an important causal role in the excess morbidity and mortality in this population. Stop smoking interventions for the general population are clinically effective and cost‐effective. There is a small but promising evidence base for effective interventions to help people with a mental illness who wish to stop smoking but these have mostly been tested with community patients rather than acute in‐patients. Methods. A service evaluation of a drop‐in stop smoking clinic on an acute mental health in‐patient unit was conducted. Patients’ smoking status was measured at baseline and four weeks after their quit date using patient self‐report and an expired breath carbon monoxide reading. Results. Over a six‐month evaluation period, 46 patients set a quit date and 13 (28·3%) were abstinent at the four‐week follow‐up stage, verified by a carbon monoxide reading (χ² = 33, df = 1, sig p < 0·0001). Conclusions. This small‐scale evaluation has shown a drop‐in stop smoking intervention to be feasible, acceptable and associated with positive outcomes; further research with larger, more representative samples is required. Relevance to clinical practice. Enforcing smoke‐free legislation is a contentious issue on mental health in‐patient units, and there is a paucity of research to guide nursing practice in this area. An admission period in a smoke‐free environment provides a crucial opportunity to offer smoking cessation treatment. With appropriate resources, expertise and support, it appears possible to apply smoking cessation interventions that are successful within the general population to mental health patients during an acute admission.     

Pregnancy and the struggle to quit smoking

The negative effects of smoking during pregnancy are well documented. Health care providers typically advise pregnant women who smoke usually to quit for their health as well as for the health of their fetus. Most women are familiar with the need to stop smoking while pregnant. Hospitals offer various smoking cessation services. However, the literatures reveals a low uptake of smoking cessation services among pregnant women. The purpose of this paper is to explore the smoking cessation experience and feelings amongst women during pregnancy and assess smoking cessation intervention in antenatal care. Findings may provide health care providers a better understanding of this issue and help women overcome related challenges.     

Smoking practices among nursing students: a comparison of two studies

Findings of numerous studies that have explored the smoking practices of nurses reveal a high incidence of smoking that is incongruent with the health beliefs of the profession. Nurses who smoke are less likely to teach or positively influence patients who smoke. They may even undermine health teaching efforts of other health professionals. Studies of smoking practices of nursing students also reveal high incidences of smoking. Included among the determinants of this practice are lack of knowledge of the health effects of smoking, the academic setting, and the role that nursing education may play. In this comparison of two independent studies similar in design, smoking rates were similar to that of the female population and to registered nurses. Students who smoke either started smoking or increased their smoking in nursing school. They knew the health hazards of smoking and most had tried to quit in the past. Challenging opportunities exist for nurse educators to study and implement strategies to prevent smoking initiation and encourage cessation among future nurses.     

Program strategies for adolescent smoking cessation

School nurses who work with adolescents are in an ideal position to promote smoking cessation. This opportunity is important because research suggests teens who smoke are likely to become habitual smokers. This study characterizes adolescents' patterns and levels of smoking, describes adolescents' perceptions toward smoking, and delineates quit strategies that may prove helpful for adolescents who attempt smoking cessation. Results suggest adolescent smokers have highly variable patterns and levels of smoking. They fail to consider their future health and continue to be unaware of the harmful effects of smoking and the addictive nature of tobacco. Among adolescent smokers, there are few gender differences in perception of smoking. Therefore, gender specific cessation programs may not be necessary. The most effective quit strategy was the acquisition of information on contents of cigarettes and the health effects of smoking. Armed with these strategies, school nurses can provide leadership in the design and implementation of school based smoking cessation programs.     

Smoking Cessation Basics: An Essential Component of Radiation Therapy Clinical Practice

Tobacco addiction is among the top preventable health risks to combat cancer. Smoking is responsible for almost 30% of cancer deaths in Canada; it increases the risk of developing cancers of the lung, mouth, throat, larynx, cervix, pancreas, esophagus, colon, rectum, kidney, and bladder and in acute myeloid leukemia. Nonsmokers exposed to second-hand smoke are also at higher risk of developing lung cancer and other respiratory diseases. More than 300 nonsmokers die from lung cancer each year due to second-hand smoke. Smoking cessation programs can improve overall health and quality of life for cancer survivors. Most cancer patients would like to quit smoking, but they find it difficult. Advice and support from health care professionals can increase success. A cancer diagnosis may be the impetus required for patients to make that positive change in their lives. Studies have shown that continued smoking while receiving radiation therapy limits treatment efficacy. Additionally, smoking interferes with chemotherapy and can negatively affect wound healing. Smoking cessation is an evidence-based program; patients who quit smoking are less likely to experience recurrence of disease or additional primary cancers. Even brief interventions may be what the patient needs to assess the benefits of quitting. Many cancer health care professionals do not feel prepared to discuss smoking cessation with their patients. A large number of cancer patients survive more than 5 years past their diagnosis, making smoking cessation an even more important focus in long-term disease management and improving the length and quality of life for these patients. The aim of this directed reading is to assist radiation therapists to support their patients who smoke and integrate smoking cessation into clinical practice.     

Review of perinatal partner-focused smoking cessation interventions

One of the primary barriers to smoking cessation among pregnant women who smoke is having a partner who smokes. Prenatal tobacco exposure has been demonstrated to negatively affect infant health outcomes. Many smoking cessation interventions have been targeted at women who smoke in pregnancy, although research has indicated that one of the main barriers to cessation is lack of partner support. The family systems theory frames prenatal smoking cessation interventions in an inclusive manner for the woman and her partner. The aim of this article is to review smoking cessation intervention studies for partners of pregnant women. Efforts to promote smoking cessation among pregnant women should be inclusive of partners, recognizing that partners influence maternal prenatal health behaviors.     

Provision of preventive services for cancer and infectious diseases among individuals with serious mental illness

Individuals living with serious mental illness (SMI) have increased mortality chiefly because of a higher prevalence of chronic disorders, including some cancers and infectious diseases. Although increased prevalence of these disorders may be attributable to lifestyle and risk behaviors, there is evidence that they may not be appropriately addressed by health professionals. We conducted a review of the literature describing preventive services for cancer and infectious diseases provided to individuals with SMI. Most studies demonstrated a 20%-30% reduced likelihood of breast, cervical, and colorectal cancer screening, or immunizations for influenza and pneumonia, in patients with SMI compared with those without SMI. This is most common in those with the most severe forms of SMI. HIV and hepatitis were more commonly screened for in people with SMI than the general population, likely because of the increased risk for these disorders within this group, but there were still substantial proportions of individuals with SMI who had never received a screening, or had not received a recent screening, for these disorders. The mental health nursing profession has an opportunity to address the disparity in care for cancer and infectious diseases, as well as other physical disorders, experienced by mental health consumers. With systemic support and ongoing education, mental health nurses may be capable of conducting or recommending screening for disorders and providing lifestyle advice. These practices may help to reduce the increased prevalence of chronic disease in SMI populations.     

Smoking cessation and serious mental illness

A focus group methodology was employed to identify personal, social, and environmental factors that affect smoking cessation in persons with serious mental illness. Four focus groups were held: two for those who had attempted to quit smoking and two for those who had never attempted to quit. Smoking is central to daily survival in patients with serious mental illness. Social and environmental reinforcement can both assist and hinder efforts to stop smoking. Smoke-free environments influence decisions to quit smoking if positive social comparisons with nonsmokers occur. Peer modeling and interpersonal connections with nonsmokers can offer links to forming supportive nonsmoking relationships.     

Nurses, smoking, and the workplace

The purpose of this study was to examine attitudes and experiences of nurses regarding smoking and smoking cessation in the workplace. Eight focus groups were conducted with current or former smokers (n = 60). A questionnaire provided information about smoking history. Content analysis revealed six themes: taking breaks, stress and smoking, social support from colleagues, hiding smoking from patients and their families, impact of workplace smoking restrictions, and challenges to smoking cessation in the workplace. Nurses who smoke were perceived as taking more breaks and spending less time with patients than those who do not smoke. These findings document the impact of smoking among nurses in the workplace. Strategies are needed to support smoking cessation efforts of nurses as an important occupational health issue.     

Mental health nursing and physical health care: A cross‐sectional study of nurses' attitudes,practice, and perceived training needs for the physical health care of people with severe mental illness

Mental health nurses have a key role in improving the physical health of people with a serious mental illness, however, there have been few studies of their attitudes or the extent of their involvement in this work. The aim of this study was to examine mental health nurses' attitudes to physical health care and explore associations with their practice and training. A postal questionnaire survey including the Physical Health Attitude Scale for mental health nurses (PHASe) was used within a UK mental health trust. The 52% (n = 585) of staff who responded reported varying levels of physical health practice; this most frequently involved providing dietary and exercise advice and less frequently included advice regarding cancer screening and smoking cessation. Having received post‐registration physical health‐care training and working in inpatient settings was associated with greater reported involvement. More positive attitudes were also evident for nurses who had attended post‐registration physical health training or had an additional adult/general nursing qualification. Overall, the attitudes of mental health nurses towards physical health care appear positive and the willingness of nurses to take on these roles needs to be recognized. However, there are areas where nurses in our sample were more ambivalent such as cancer screening and smoking cessation.     

Screening for Symptoms of Postpartum Traumatic Stress in a Sample of Mothers with Preterm Infants

People with serious mental illness are at high-risk for physical illnesses and premature death, and nurses can contribute to ensuring mental health services address these risks. There is very little research examining the role of nurses in mental health who provide physical health care. To identify the levels of participation in physical health care of people with serious mental illness (SMI), a national Internet-based survey of nurses working in mental health in Australia was conducted (n = 643). The survey included an adapted version of the Robson and Haddad Physical Health Attitude Scale. Data were analysed through comparison of frequencies, correlations, principal components analysis, and Mann-Whitney tests. Nurses reported regular physical health care in 12 of the 17 tasks presented to them. The three most common self-reported physical health care activities were inquiring about consumers’ contact with GPs, doing physical assessments, and providing information on drug use and lifestyle. Although some practices were less common (e.g., contraceptive advice) nurses who provided one type of care tended to do other types as well. In addition, credentialing in mental health nursing was associated with slightly more regular engagement in all practice domains except screening and assessments. Nurses in mental health in Australia may be engaged in improving physical health of consumers with SMI more than is assumed.     

Alcohol consumption and smoking status: the role of smoking cessation.

Cigarette smoking is common among persons with alcohol dependence or abuse with as many as 80% of persons who are alcohol dependent also being smokers. Not only is smoking common in persons with heavy alcohol consumption, but also nicotine dependence appears more severe in smokers with a history of alcohol dependence. This combined exposure to both tobacco smoke and alcohol results in major health consequences including additive risks for some diseases such as head and neck cancers. Although modest alcohol consumption has some positive health benefits, smoking typically negates these benefits. The cellular mechanisms impacted by combined smoking and alcohol exposure are poorly understood, but molecular epidemiology approaches are providing insights regarding the importance of effects on oxidant/antioxidant pathways and on metabolic pathways involving the cytochrome P450 system. Given the prevalence of smoking in the alcohol dependent population, smoking cessation in this group has the potential for tremendous impact. In recent years, smoking cessation approaches have been initiated in this population, but much work remains in order to define the optimal smoking cessation strategies for persons in alcohol treatment programs.     

Supporting older people to quit smoking

Until recently there has been little attention paid in health policy and practice to older people who smoke. But this is changing because of the increasing numbers of current mid-life smokers who continue the habit into older age and because evidence is growing of the health benefits of smoking cessation for people with lung disease. Nurses can play a key role in providing information on the benefits of smoking cessation in later life, and giving advice and support with smoking cessation.     

Smoking-related health behaviors of employees and readiness to quit: basis for health promotion interventions.

This report describes patterns of cigarette smoking and interest in smoking cessation programs among employees in a public worksite (n = 6,000) and a private worksite (n = 14,000). Of the 622 employees who attended an employee assistance program (EAP) orientation, 110 (18%) were current smokers. A significantly greater proportion of public employees smoked cigarettes, smoked more heavily, and evaluated their health more poorly compared to private employees. Smokers in both sites were over-represented in unskilled positions. Regardless of worksite, respondents who smoked had similar desires to quit or cut down and were annoyed by the comments of others, felt guilty about smoking, awakened with a desire to smoke, and felt they had a smoking problem. Overall, more than one third of individuals were interested in joining a smoking cessation program. Occupational health nurses may use these findings to design and implement smoking cessation interventions in their workplaces.