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Smoking cessation and community mental health
programmes------ 32
5. Chapter IV5.1. Implication to Nursing Practice ---------------------------
36
5.2. Recommendations and Conclusions
---------------------- 36
6. References ------------------------------------------------------------ 38
7.Appendix
Summary of Reviewed Papers
Abstract
Background: Nurses play a large role in smoking cessation (TFN, 2010).Accordingly, some good advice from nurses to patients who smoke
significantly increases the likelihood of those smokers quitting. Studiesobserved that smokers who received smoking cessation information fromtheir nurses were almost 50 percent more likely to quit than smokers withno nursing intervention.
Aims: This paper attempts to look into the smoking cessationinterventions by nurses to mental health patients, to determine the extentof their effectiveness, and the factors underlying their success as well astheir limitations.Methodology: Ten primary articles or literatures were carefully chosenas subject for the review. Keywords included: nursing intervention,smoking cessation, tobacco use, psychiatric disorders and mental health
patientsFindings: Smoking cessation interventions were identified and explored:treatment session attendance and smoking reduction signifiesrelationship; healthcare providers, including nurses, held sympatheticattitudes about their role and their clients role in smoking cessation;social and environmental corroboration can either assist and/or hinderefforts to stop smoking; peer modeling and interpersonal connections withnonsmokers can offer links to forming supportive nonsmokingrelationships; and integration of cognitive-behavioral therapy withstandard smoking cessation strategies appears to result in higher quit
rates. Yet, treatments that come off in the general population work forthose with severe mental illness appear approximately equally effective
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and exercise as well can assist in smoking cessation. Thus, saidinterventions may be done even to outpatients and special populationshave distinctive smoking cessation needs, and it indicates more researchis substantially needed.Implications: Smoking is increasing among mental health patients, both
in-patients and out-patients. Mental health patients vary, and theirsmoking behavior differs across categories. Different group of mentalhealth patients requires different nursing intervention. Nurses have toundergo training to develop knowledge and skills on smoking cessationintervention among mental health patients.Recommendations and Conclusions: A continued study regardingnursing interventions on smoking cessation among mental health patientsshould be conducted. Study should not only limit to nursing, but ratherexplore the possibility of integrating other activities and supportmechanisms. Nurses should be given training to address the need forspecial knowledge and skills on smoking cessation among mental healthpatients. Health care institutions should advocate a smoke-freeenvironment, and health care workers, particularly nurses, should makean effort to become role model for their patients.
CHAPTER I
Introduction
Mental health patients are accordingly victims of tobacco. As
personally observed, people with severe mental illness are addictive to
smoking; having no cigarette at hand makes them restless in a way that
they will even try to find dog-ends of a cigarette on the streets. In a report
by the U.S. based Action on Smoking (2010), smoking rates among mental
health patients are its height, yet they get inadequate help in trying to
quit, says Francesca Nelson.
Tobacco fumes are likely to affect you like a thick fog when you pay
a visit into any mental health unit. As the report further said that smoking
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prevalence among people with conditions such as depression is about
twice that of the rest of the population. It showed that more than seven in
10 people with schizophrenia are addicted to cigarettes, compared to
solely 27% of the general population. Yet most professionals working with
mental ill people disregard this issue, despite the fact that the
dependence will put their smoker patients at risk.
The same paper revealed that preventing suicides has been the
latest focus in mental health guidelines and which is at disturbingly at
high-level. However, people with schizophrenia are more likely to
precipitately die from a physical ailment, such as smoking-related
conditions of the heart, lung and chest.
As it has been observed, it quit appear though cannot be assumed
that smoking can cause depression nor depression could be the cause for
one to yield on smoking. An associate professor of psychiatry at the
University of Michigan in the US, Gregory Dalack pointed out in the report
that smokers are more apt than non-smokers to experience major
depressive disorders. On the contrary, people with major depression
history are more expected to become addicted smokers.
As admitted and mostly experiential that vast majority of health
practisioners working with this patient group do not see it as their duty to
help people stop smoking. This must be different in the health care setting
and demonstrate that to pull off a total change in approach; something
has got to be done.
Thus, mental health practisioners have a vital role to take part in
encouraging and supporting smokers attempts to stop.
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Aims of the Research
This study attempts to investigate the smoking cessation
interventions by nurses to mental health patients, to determine the extent
of their effectiveness, and the factors underlying their success as well as
their limitations. Intervening on tobacco use by health care workers will
make a huge positive change not only for their mental health but physical
as well.
Likewise, this paper will look into how exceptional a nurse position
in terms of acting as role models to their patients. This will also
subsequently challenge its significant impact on patients smoking
behaviour and its risk associated tobacco-related diseases.
Thus, this research will explore different literatures in line with the
selected primary articles that will substantiate the review to better
understand the comparison of the various smoking cessation strategies
among mental health patients in several health care settings. This review
will feature the efficiency of the different nursing interventions that can be
utilized in planning care both mentally and physically.
The research question was formulated with the application of the
PICO format. Moreover, by the end of this study the following research
questions shall be delivered:
What are the different nursing interventions concerning
smoking cessation that has been effectively existing for
mental health patients?
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How can nurses deliberately handle the determinants and
dilemmas in their role to support the smoking cessation
interventions for mental health patients?
Background
Prevalence of Smoking among Mental Health Patients
Citing various papers, the McNally and the London Development
Center (2009) reported the incidence of smoking among mental health
patients. Accordingly, smoking rates are significantly prevalent among
those with mental illnesses compared with the general population
(Coultard et al, 2000). This seems to be particularly the case among
psychiatric in-patients of whom 74% of are smokers (Meltzer et al, 1996).
Not only are mental health service users more likely to be smokers,
but also they are more likely to be profound smokers. Illustrative of this is
data from a survey in the US, which suggested that around 45% of all the
cigarettes smoked are consumed by individuals with a psychiatric disorder
(Lasser et al. 2000).
Furthermore, smokers with a mental health condition seem to
increase the amount smoked over time. From a random sample of British
adults examined by Ismail et at al (2000), it was evident that people with
a mental disorder were about 30% more likely to have increased their
cigarette smoking over the preceding year.
The report further bared that mental health service users are a
heterogeneous group, and smoking rates do vary across diagnostic
categories. The highest smoking prevalence would seem to be among
those living with schizophrenia, with Hughes et al. (1986) reporting a
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smoking rate of 88% within this group. A later study found 68% of
patients with schizophrenia who smoked to be classed as profound
smokers (25 or more cigarettes daily) (Kelly & McCreadie, 1999). Notably,
this latter study also found that the average age when patients with
schizophrenia started smoking was the same as in the general population,
namely mid-teens. A total of 90% of patients who smoked had started
smoking before their illness commenced.
Smoking and Mental Illness
In a similar report by Rethink (2010) citing various work, it was
revealed that a proportionally great figure of people with mental illness
smoke. They cited in (Glassman 1999) that the smoking rate in the
general population is just above 20%; while in relative amount of people
with schizophrenia who smoke may be as soaring as 90%.
The report by Rethink also revealed many reasons why people
smoke. It has been revealed that people with mental illness may find good
effects from smoking above all the common reasons. Smoking for people
with mental illness has its positive effects and it includes the following:
Nicotine intensifies alertness. Thus, boost concentration, thinking and
learning; and people with schizophrenia may benefit from it as illness
or medication leads to cognitive problems.
Nicotine can aid relaxation, and it can also lessen negative feelings
such as anxiety, tension, and anger. Consequently, smoking may help
people with mental illness deal with stressful circumstances.
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Nicotine might have an antidepressant effect. In part of the brain, it
stimulates dopamine production and therefore may help negative
symptoms of schizophrenia, such as lack of motivation, lack of energy,
and flat mood.
Nicotine may bring down positive symptoms for a short period, for
instance hallucinations.
Suggested indication that smoking is associated with reduced levels of
antipsychotic induced Parkinsonism.
Smoking can help to ease boredom and provide a framework for the
day.
Smoking can enrich social interaction, something that may be of
particular benefit to people with negative symptoms.
Also in the same report, Rethink presented the many reasons why
anyone would like to give up smoking and accordingly people with mental
illness may have all the significant reasons to quit. Smoking for people
with mental illness obviously has negative effects, hence includes:
Even following suicides are discounted, premature death rates are
higher for people with mental illness than for the general population.
Deaths for most are due to cardiovascular and respiratory problems
and smoking is considered to contribute towards this.
It stimulates enzymes in the liver for substances are found in tar in
cigarrettes, accordingly metabolism increases some antipsychotics,
including clozapine, fluphenazine, haloperidol and olanzapine. This
results in higher doses being needed.
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Suggested evidence of smoking may increase some side effects of
antipsychotic medication, including akathesia (restlessness) and
tardive dyskinesia (slower involuntary movements).
Smoking set a serious financial burden on the smoker, who, as a
person with severe mental illness, is likely to be on a low income.
Participation in some activities for heavy smokers may find it difficult to
where smoking is not permissible, thus adds to social exclusion
experienced.
Nurses Role in Smoking Cessation
The Tobacco Free Nurses Initiative (2010) said nurses contribute a
great role in smoking cessation. Accordingly, some good quality advice
from nurses to patients who smoke appreciably increases the probability
of those smokers to quit, as per several articles in a special issue of the
July-August 2006 Nursing Research journal, the Tobacco Free Nurses
Initiative reported.
The Nursing Research articles contain tobacco cessation information
including original research evaluating methods for treating tobacco
dependence. For example, one study observed that smokers who received
tobacco cessation information from their nurses were almost 50 percent
more likely to quit than smokers with no nursing intervention. The report
also notes that nurses often care for underserved people, who are
inexplicably affected by tobacco use.
It has been stated that Nurses are considered the largest group of
health care professionals that can possess an expanded influence on
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smoking cessation. To treat tobacco dependence, experts recommended
widespread training of nurses to deliver interventions to patients. They
also recommended examining the prevalence of smoking among health
care providers themselves, citing research that shows health care
providers who smoke are less likely to intervene on behalf of their
patients who smoke (TFN, 2010).
Although smoking rates are high among patients with schizophrenia
and some other psychiatric disorders, researchers have not adequately
studied how smoking correlate to mental health problems (Murphy et al,
2003). In new reports, investigators begin to concentrate on these issues.
In addition, the said study tried to consider associations between
smoking and health-related quality of life, subsequently other researchers
analysed data from a large German health survey conducted from 1997 to
1999 that involved interviews with 4181 individuals (36.2% smoked, and
9.4% were nicotine dependent [20 cigarettes/day]). It was found out that
nicotine-dependent respondents reported poorer quality of life and
greater one-month and one-year disability rates than never-smokers. Plus,
it resulted that more than half of nicotine-dependent participants met
criteria for at least one other mental disorder.
In a similar study, Yager (2003) commented that smoking was
associated to depression only within recent historical cohorts -- perhaps
because countless people stopped smoking as they became aware of
smoking's deleterious health effects, whereas individuals with mood
disorders might have been more likely to carry on smoking due to
nicotine's effects on mood (e.g., depression might re-occur when
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previously depressed patients stop smoking). Likewise, underlying
relations between nicotine dependence and other mental disorders may
not be as straightforward, although some evidence implies that nicotine
may contribute to the onset of anxiety disorders.
In whichever event, the strong association between smokings, low
quality of life, and increased disability draw attention to that smoking
among mental health patients is a significant public health concern.
Therefore, these patients necessitate improved nursing interventions for
smoking cessation as studies have perceived.
CHAPTER II
Literature Review
Research Methodology
A computerised search was conducted to identify relevant studies. A
search procedure was written after consultation with a librarian. Then the
data retrieval was conducted by searching the databases CINAHL
(Cumulative Index for Nursing & Allied Health Literature), Medline, and
Cochrane (Cochrane Collaboration 2011). Keywords that were included in
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the search were: nursing intervention, smoking cessation, tobacco use,
psychiatric disorders and mental health patients. Full-linked articles from
these databases in addition to those located via a hand search of
references and of web-based resources (e.g., http://ash.org) were
integrated for review if they met the criteria of being research focused,
authored or coauthored by nurses, and reporting smoking cessation
related data associated with mental health patients, nurses and/or
settings. Articles were limited to English language, but no year restrictions
were imposed.
The study only covered nursing interventions on smoking cessation
of mental
health patients. Targeted group was defined to have severe mental illness
and characterized as any nonorganic disorder with psychotic features that
result in a substantial disability, including schizophrenia, schizoaffective
disorder, bipolar disorder or delusional disorder (WHO, 1990); thus
excludes patients with learning disabilities, and dementia. Other articles
on nursing intervention that do not pertain smoking cessation were
deemed excluded in the search.
Review of Related Literatures
From the variety of available literatures, ten primary studies were
carefully chosen as subject for the review and sought comparisons of
interventions with each other. Details of the papers reviewed are
presented in the following discussion:
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Baker et al. (2006) conducted a study on a randomized controlled
trial of a smoking cessation intervention among people with a psychotic
disorder. Participants of the study were 298 smokers with a non-acute
psychotic disorder who were recruited from Sydney, Australia and the
Newcastle region of NSW, Australia. Referrals were acknowledged from
community health agencies (82.2%), inpatient psychiatric units (8.3%),
and the Neuroscience Institute of Schizophrenia and Allied Disorders
schizophrenia register (7.0%). Participants engaged through inpatient
units were contacted 2 months post discharge and invited to take part.
Inclusion criteria were at least 18 years of age, who smokes at least 15
cigarettes per day, and diagnosed of a psychotic disorder; plus,
expression of interest in quitting smoking among participants was also
expected. Exclusion criteria were medical conditions that would rule out
use of nicotine patches, being intensely psychotic (reassessed participants
1 month post screening), and exhibit an acquired cognitive impairment.
The study of Baker et al. (2006) found out that while there were no
general differences between the treatment group and comparison group
in abstinence rates, a notably elevated proportion of smokers who
stopped smoking after the complete treatment sessions at each of the
follow-up circumstance (point-prevalence rates: 3 months, 30.0% versus
6.0%; 6 months, 18.6% versus 4.0%; and 12 months, 18.6%versus 6.6%).
In addition, all treatment sessions accomplished by smokers were also
found more liable to have attained ceaseless abstinence at 3 months
(21.4% versus 4.0%). Also, one-half of those who completed the
intervention program achieving a 50% or greater reduction in daily
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cigarette consumption across the follow-ups resulted in less than one-fifth
of the comparison subjects was relatively a sound dose-response
associated between treatment session attendance and smoking reduction
status. Hence, no evidence of any associated relapse in symptoms or
functioning.
The study also stated that these findings exhibit support in the
utilization of nicotine replacement therapy and above motivational
interviewing or cognitive behavior therapy smoking cessation intervention
amongst individuals with a psychotic disorder. Yet for those who do not
respond to presented interventions needs further developed and efficient
interventions.
A separate study was conducted by Faulkner et al. (2007) on the
suitability of physical activity programme within a smoking cessation
service for individuals with severe mental illness (SMI). There were 109
participants with SMI who were receiving smoking cessation treatment
accomplished a survey assessing perceived interest in physical activity
and a 24-item decisional balance questionnaire reflecting possible pros
and cons of becoming more physically active.
The study revealed that most of the participants (63 percent)
reported being fascinated in assistance in becoming more active. The
highest rated advantages reported in the study were It would improve my
health or reduce my risk of disease and It would improve how I feel
about myself. However, often accounted barriers were the cost and being
active by oneself. The study also put forward that several individuals with
SMI in search of treatment for smoking cessation may also be open to
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assistance in becoming more physically active. Furthermore, both
advantages and disadvantages among the interested individuals were
more common than those who were not. In this way, the study offers
initial support for the acceptability of adding physical activity as a
smoking cessation strategy with SMI individuals. Thus, relevant barriers
dealt with will said to be crucial in incorporating physical activity within
this smoking cessation service.
Similarly, Arbour-Nicitopoulos et al. (2011) investigated the
potential role of exercise in women with severe mental illness (SMI). They
used semi-structured interviews of 12 women diagnosed with SMI and
receiving smoking cessation treatment were conducted. The study
revealed that the participants perceived three roles for exercise in
assisting smoking cessation addressing fears with pre-existing chronic
health conditions, emotion management and distraction, and weight
management. Yet generally, participants in the said study identified
health care providers (HCPs) as needing to take part in a supportive role
in integrating exercise into smoking cessation challenges. The study
findings support a promising role for exercise in facilitating smoking
cessation among women with SMI and therefore foster HCPs to consider
developing referral links with exercise specialists to facilitate smoking
cessation in women with SMI.
A study that differs in setting investigates on community mental
healthcare providers attitudes and practices related to smoking cessation
interventions for people living with severe mental illness was conducted
by Johnson et. al (2009). However, the study was not exclusive for nurses,
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rather for healthcare providers employed by Vancouver Community
Mental Health Services eight community mental health teams and 14
contracted community agencies. Using self-administered questionnaires,
the study deliberated respondents smoking status, and attitudes related
to the provision of smoking cessation support, confidence in providing
smoking cessation intervention, and smoking cessation practices.
It was revealed in the study that of the total 282 of 871 mental
healthcare providers responded to the survey, 22 percent of whom were
existing smokers. Besides, the care providers who were more apt to
engage their clients in tobacco-related interventions were those who held
compassionate approach about their role and their clients role in smoking
cessation, who were never or former smokers, who were healthcare
professionals rather than paraprofessionals, who had reasonably more
confidence, and who had more experience working in the mental health
field.
In this study the healthcare providers working in community-based
mental health have an unfortunately smoking prevalence rate that
surpass that of the regions general population and did not endow with
optimal smoking cessation support to their clients. Hence, the study
proposes required strategies that confidently reinforce care providers to
engage is smoking cessation activities and that hold up a change in
attitudes about the role of tobacco use in mental health.
Another study by Snyder et al. (2008) identified the factors that
affect smoking cessation among individuals with serious mental illness
(SMI). In their paper on smoking cessation and serious mental illness,
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Snyder, McDevitt and Painter (2008) involved 25 clients from two
psychiatric rehabilitation centers in Midwestern city in the United States. A
focus group methodology was employed to identify personal, social, and
environmental factors that affect smoking cessation in persons with SMI.
The study held four focus groups: two for those who had attempted to
give up smoking and two for those who had never attempted to stop.
Nonetheless, they have discovered that smoking is crucial to daily survival
in patients with serious mental illness as this is true for care providers
who had this kind of patients who concluded that social and
environmental corroboration can both support and impede efforts to stop
smoking. Therefore, smoke-free environments as stated influence
decisions to quit smoking if positive social judgments with nonsmokers
take place. Also, peer modeling and interpersonal connections with non-
smokers can present links to supportive non-smoking relationships
formation.
In 2002, a parallel study was made by el-Guebay et al. (2002)
regarding smoking cessation approaches for persons with mental illness
or addictive disorders. The study undertook critical review of large health
care and other databases from various sources with span from 1991 to
2001.
The paper revealed that majority of interventions used a
combination of medication and educational and cognitive-behavioral
methods. As stated the studies of individuals with schizophrenia typically
drawn in small clinical samples and post-treatment quit rates ranged
from 35 percent to 56 percent. Two studies replicating one anothers
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approaches reported six-month overall quit rates of 12 percent, compared
with 16.7 percent for patients taking atypical antipsychotics and 7.4
percent for patients taking conventional antipsychotics. Accordingly, the
utilization of clozapine resulted in smoke reduction.
The studies of individuals with depression as compared to the
schizophrenia group involved bigger, media-recruited samples of smokers
and may signify a broader range of morbidity. At the end of treatment,
quit rates in these studies ranged from 31 percent to 72 percent and from
11.8 percent to 46 percent at 12 months. In addition, the combination of
cognitive-behavioral therapy with typical smoking cessation strategies
resulted in higher quit rates for individuals with history of major
depression. In one study the bupropion efficiency for smoking cessation
was found to be independent of any history of depression or alcoholism.
The study suggests that generally, even though psychiatric
populations quit rates may be lower than those of non-psychiatric
populations, the reasons for smoking cessation, such as health concerns
and costs, are comparable. Unfortunately, it is expected that among
psychiatric patients they have poorer outcomes for smoking cessation
strategies because of the alleged use of nicotine for self-medication in this
populace. As concluded in the study, smoking cessation efforts for this
populace should involve more dedicated strategies, and care workers
should be more direct in asking patients about their interest in quitting
smoking. Thus relatively, smoking cessation tends to be a lengthier
process for persons with mental illness while concise interventions can
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raise the figure of quitters and a good cost-effective staff training is an
essential investment.
On another literature, Banham and Gilbody (2010) made a related
inquiry on the subject. In their paper on smoking cessation in severe
mental illness, the authors explored on bibliographic databases for
pertinent studies and independently extracted data. Studies that were
included are randomized controlled trials (RCTs) of smoking cessation or
reduction conducted in adult smokers with SMI. Their study compared the
usual cared interventions and placebo and consequently come up with
the primary outcome as smoking cessation and secondary outcomes were
smoking reduction, change in weight, change in psychiatric symptoms
and adverse actions.
Similar with other study conducted, smoking reduction data were
too varied for meta-analysis, but results were generally constructive. The
said trials propose few adverse events and all recorded psychiatric
symptoms and mainly significant changes favored the intervention groups
over the control groups. Hence, the study suggests that treating tobacco
dependence is effective in patients with SMI. Besides, treatments that
works in the general population work for those with SMI and seems
approximately equally effective and thus concluded that treating tobacco
dependence in patients with stable psychiatric conditions does not
aggravate mental state.
In 2006 out-patient setting, Hall et al. (2006) made an inquiry into
the effectiveness of a staged care intervention to cut down cigarette
smoking among psychiatric patients in out-patient treatment for
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depression. Using a randomized clinical trial, the study included
assessments at baseline and at months 3, 6, 12, and 18. They had a large
number of three hundred twenty-two patients in mental health outpatient
treatment who were diagnosed with depression and smoked one or more
cigarette a day during the week participated. In the study however, the
yearning to quit smoking was not a prerequisite for participation. As they
go along, staged care intervention participants received computerized
motivational feedback at baseline and at 3, 6, and 12 months and a 6-
session psychological counseling and pharmacological cessation
treatment program were offered. Plus, a short contact control participants
received a self-help guide and referral list of local smoking-treatment
providers. The findings of the study revealed that abstinence rates among
staged care intervention participants exceeded those of short contact
control participants at months 12 and 18. Moreover, considerable
differences favoring staged care intervention also were found in
occurrence of a quit attempt and severity of abstinence goal. Therefore,
the study suggests that individuals in psychiatric treatment for depression
can be supported in smoking cessation through use of staged care
interventions and that smoking cessation interventions used in the
general population can likewise be implemented in psychiatric outpatient
settings.
A different and exceptional study was made on psychiatric nurses
ethical stance on cigarette smoking by patients was conducted by Lawn
and Condon (2006). The study interestingly focused on determinants and
dilemmas of the nurses role in supporting cessation.
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The research was carried out with inpatient and community nursing
staff of a public, government-funded mental health service within a
metropolitan area of Australia with a populace of almost one million
people. The information gathered here outline part of a much larger data
set, based on in-depth open-ended interviews performed with 26
multidisciplinary staff from inpatient and community psychiatric settings.
Also, interviews were audio-taped then transcribed, coded and
thematically analysed using a constant comparative, grounded theory
approach. The study interviewed seven psychiatric nurses: three from a
community mental health team (two ex-smokers and one non-smoker),
two from an acute locked ward (one ex-smoker and one non-smoker), and
one each from an extended care ward (current smoker) and acute open
ward (current smoker).
The study revealed that the majority participants in the study were
able to express the ethical principles on which they based their values and
decisions about patients smoking. Nearly all were thoughtful, concerned
and very aware of the conflicts inherent in their ethical decisions and
subsequent actions and inactions and they valued the chance to discuss
these issues. Additionally, as part of cultural change in psychiatric
services as stated in the paper, concerning the issue of patient smoking, it
was recommended that nurses are supported in illustrating their values
and the ethical principles on which they make decisions and act. In this
way, they emphasized that promoting a learning environment where there
is active conversation among nurses so that they can find the way
through the dilemmas caused by their role would seem vital. However, the
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nursing profession entails intrinsic challenge of care, where impossibility
in the interpersonal therapeutic relationship with patients must be
discussed, understood and resolved. On the other hand, in view of the
ethical decision-making in isolation will not bring about change, but needs
to be one of a number of strategies to address smoking by patients and
staff within psychiatric settings. Psychiatric nurses are preferably placed
to challenge the established culture of smoking within psychiatric settings
if they have the will, leadership and support to do so.
Lastly, a study of Doolan and Froelicher (2006) made an
investigation on the efficacy of smoking cessation intervention among
special populations. Although the study covers a broad base of subjects,
however, it included those with psychiatric diagnosis. The study made a
comprehensive review of available database from different US National
Libraries covering the period 2000 to 2005.
The study bared that smoking prevalence is roughly 41% for those
with psychiatric conditions and is much higher among certain subsets of
the poulace, among are those with schizophrenia and bipolar disorder.
The study further revealed that little is known about the response of this
group to smoking cessation interventions because psychiatric conditions
are often exclusion criteria for smoking cessation clinical trial
participation. Also, two clinical trials were identified in the study and one
focused on participants with posttraumatic stress disorder; and one on
participants with schizophrenia. Equally these studies were successful
initially at evocatively reducing the smoking rates within the intervention
group as compared with the control group. Nevertheless, in both cases,
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this success was not continued to the point of long-term follow-up. The
diminished result size occurring between the completion of the cessation
intervention and the long-term follow-up indicates that these smokers
might need interventions of longer period to achieve successful long-term
smoking cessation. As a result, the study further bore that in the case of
smokers with psychiatric diagnoses, cessation rates for intervention
groups were not statistically better than those for control groups in any of
the current clinical trials. Therefore, the study suggested that these
special populations have a inimitable smoking cessation needs, and thus
highly needs more research.
Chapter III
Discussion of Findings
Based on the foregoing literatures, a range of discussions of the
various findings and their analysis are hereby arrived as follows:
The study Baker et al. (2006) has failed to prove the existence of
the difference of abstinence rate between the treatment group and
comparison group. Although, the study made it clear that smokers who
accomplished all handling sessions were also more likely to have achieved
continuous abstinence. With the use of nicotine replacement therapy plus
cognitive behavior therapy, it was proven in their study that there was a
strong relationship between treatment session attendance and smoking
reduction.
Faulkner et al. (2007) revealed that majority of the smokers found
interest in smoking cessation because they believed it will enhance their
health or lessen the risk of disease as well as improve how they believe on
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themselves. It also recognized expense and being active by oneself as the
most frequent barriers. However, the study suggests that numerous of the
individuals with SMI in search of treatment for smoking cessation may also
be open to assistance in becoming more physically active.
According to Johnson et. al (2009), the healthcare providers,
including nurses, who held compassionate attitudes about their function
and their clients role in smoking cessation, who were never or former
smokers, who were healthcare experts than paraprofessionals and who
had comparatively have more confidence, and who had more experience
working in the mental health field were more likely to engage their clients
in tobacco-related interventions. The study suggests that strategies that
reinforce the confidence of care providers to engage in smoking cessation
activities and that support a change in attitudes about the role of tobacco
use in mental health are required. This study strengthens the argument
on the important role of nursing intervention on smoking cessation.
However, intervention on smoking cessation can be more effective
by understanding its underlying factors. This was the study by Snyder,
McDevitt, and Painter (2008). In their paper, the authors identified
personal, social, and environmental factors that affect smoking cessation
in persons with serious mental illness. It was revealed that smoking is
crucial to daily survival in patients with serious mental illness, and that
social and environmental reinforcement can either aid and/or hinder
efforts to stop smoking. Also, peer modeling and interpersonal
connections with nonsmokers can propose links to forming supportive
nonsmoking relationships. The paper claims that nursing intervention on
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smoking cessation may be sustained if it is supported by a positive
environment and influences outside of the healthcare service.
The same observations were arrived by the study of el-Guebay et al.
(2002). Their paper revealed that majority of interventions regarding
smoking cessation used a combination of medication and educational and
cognitive-behavioral approaches. The integration of cognitive-behavioral
therapy with standard smoking cessation strategies appears to result in
higher quit rates for persons with a history of major depression. The study
also emphasizes the positive environment to support smoking cessation
as it founds out that when staff members quit smoking, it may provide
positive role modeling for patients and increase staff willingness to
provide smoking cessation support and intervention. Although, it was also
revealed that smoking cessation tends to be a lengthier process for
persons with mental illness.
The study of Banham and Gilbody (2010) suggests that treating
tobacco dependence is effective in patients with SMI. Treatments that
work in the general population work for those with severe mental illness
and appear approximately equally effective. This means that there is no
need for a special treatment on smoking cessation intervention for mental
health patients. It was even found out that that treating tobacco
dependence in patients with stable psychiatric conditions does not worsen
mental state.
Arbour-Nicitopoulos et al. (2011) made a claim on the potential role
of exercise as smoking cessation intervention to in women with severe
mental illness (SMI). It was revealed that there are three roles for exercise
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in assisting smoking cessation: addressing fears with pre-existing chronic
health conditions, emotion management and distraction, and weight
management. In this situation, health care providers (HCPs) are suggested
to integrate exercise into smoking cessation attempts by considering
developing referral links with exercise specialists to facilitate smoking
cessation in women with SMI. This again proves that successful smoking
cessation intervention may not be limited to nurses or health care
providers alone.
Smoking cessation intervention may be done even to outpatients.
Hall et al (2006) made an inquiry into the effectiveness of a staged care
intervention to reduce cigarette smoking among psychiatric patients in
out-patient treatment for depression. It was found out that abstinence
rates among staged care intervention participants exceeded those of brief
contact control participants at months 12 and 18. The further suggests
that that individuals in psychiatric treatment for depression can be aided
in quitting smoking through use of staged care interventions and that
smoking cessation interventions used in the general population can be
implemented in psychiatric outpatient settings. This findings support the
previous claim on the use of the same intervention to general public as
effective for the mental health patients.
However, the role of the nurses in smoking cessation intervention
among mental health patient has involved a lot of argument. This was
revealed by Lawn and Condon (2006) having both identified determinants
and dilemmas. The study revealed that nurses were able to articulate the
ethical principles on which they based their values and decisions about
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patients smoking. As part of cultural change in psychiatric services,
regarding the issue of patient smoking, it is recommended that nurses are
supported in clarifying their values and the ethical principles on which
they make decisions and act. Psychiatric nurses are ideally placed to
challenge the entrenched culture of smoking within psychiatric settings if
they have the will, leadership and support to do so. Henceforth, it is
suggested that this particular knowledge and skills must be developed
among nurses in order for them to effectively intervene in the smoking
cessation efforts.
Smoking issues are not only found among mental health patients.
Doolan and Froelicher (2006) investigated on smoking cessation
intervention among special populations including psychiatric patients. It
was revealed that smoking prevalence is observed to be high in those
with psychiatric conditions, such as those with schizophrenia and bipolar
disorder. As the study further revealed, little is known about the response
of this group to smoking cessation interventions because psychiatric
conditions are often exclusion criteria for smoking cessation clinical trial
participation. The study further revealed that in the case of smokers with
psychiatric diagnoses, cessation rates for intervention groups were not
statistically better than those for control groups in any of the recent
clinical trials. It is suggested that these special populations have unique
smoking cessation needs, and more research is highly needed. This
however contradicts previous claim that the same intervention on
smoking cessation may be used for both general public and mental health
patients.
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Other studies however claim specific nursing approach on smoking
cessation among for mental health patients.
People with schizophrenia and schizoaffective disorder
For schizophrenic patients, study intervention in this population
typically involves two or more therapies, commonly a behavioral therapy
coupled with a pharmacological therapy. NRT is effective for smoking
cessation treatment in people with schizophrenia, although quit rates are
less than expected in the general population (Williams and Hughes 2003).
Treatment with NRT patches (7mg and 14mg) significantly reduced
smoking behaviours in out-patients with schizophrenia in one randomized
controlled trial (RCT) (Cox et al 2004). Nicotine nasal spray (combined
with psychosocial support) has also been shown to turn out effective quit
rates (42%) and also reduce smoking frequency and amount maintained
over a 3-month period (Williams and Hughes 2003).
Combining nicotine patch (21mg/day) with treatment with an
atypical antipsychotic has been shown to significantly enhance the quit
rate (George et al. 2000). The use of a nicotine patch (22mg/day) over 32
hours led to smoking repression in heavy smokers with schizophrenia,
therefore, the effects of NRT can surface over a relatively acute time
period (Dalack et al. 1999). Evidence that NRT can be successfully used to
maintain smoking cessation long term in people with schizophrenia is
provided by a study by Horst et al. (2005). Of participants provided with
NRT (14, 21 or 42mg depending on nicotine level) during a 3-month open
label phase 36% achieved abstinence at 3 months. Abstinent participants
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(n=17) were then randomized to receive NRT or placebo, plus group
motivational sessions with a health educator; for a further nine months.
Notably 66% of the NRT group remained abstinent for the whole nine-
month period (compared to 0% of the placebo treated group). The
Smoking Reduction and Cessation for people with Schizophrenia:
Guidelines for General Practitioners developed in Australia recommends
use of NRT in this population (Strasser 2001).
Buproprion has given away some efficacy as an adjunctive
treatment to psychological therapy in smokers with schizophrenia. Evins
et al. (2001) investigated the effect of adding buproprion-SR (150mg/day)
to CBT for three months in 19 stable out-patients with schizophrenia who
wanted to quit smoking. Participants treated with buproprion exhibited
greater reductions in smoking (66% vs 11%), were more likely to be
abstinent (6% vs 0%), and experienced a greater stability of psychotic and
depressive symptoms compared to placebo. A follow-up study found these
effects persisted and actually strengthened two years later (Evins et al.
2004).
Although the use of varenicline for smoking cessation has been
shown to be effective in people with mental illness (Stapleton et al. 2007)
caution should be taken in using the treatment in those with
schizophrenia. In one case study of a patient with schizophrenia,
commencement of the treatment coincided with a psychotic relapse that
ended when use of the drug stopped (Kohen and Kremen 2007).
As with smokers with depression, the question arises whether
smokers with schizophrenia could benefit from more specialised smoking
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cessation therapies. Many specialised strategies have been trialed in this
population. A group smoking cessation programme modified for smokers
with schizophrenia (plus optional NRT) (Addington et al. 1998) was found
effective in a group of 50 out-patients, with quit rates of 42% at the end of
treatment and 12% at 6-month follow-up, comparable to rates in the
general population. The treatment was based on the American Lung
Association (ALA) Freedom from smoking programme. As there was no
control condition to compare these outcomes with, it is unclear whether
this treatment would have been more effective than the standard
programme. George et al. (2000) however compared the outcomes of a
standard ALA programme for smoking cessation with a specialised group
therapy programme with those with schizophrenia, including motivational
enhancement, relapse prevention, social skills training, and psycho-
education. They found no additional benefit of the specialized therapy
over the standard therapy. Baker et al. (2006) investigated the efficacy of
an eight-session, individually administered smoking cessation intervention
compared to a routine care comparison in a large sample (n=298) of
smokers with a psychotic disorder in the community.
The intervention consisted of NRT, MI, and CBT. Fifty percent of
those who completed the intervention programme achieved a 50% or
greater reduction in daily tobacco consumption, relative to 20% of the
control condition completers. Therefore this treatment approach was seen
to present additional benefits for smokers with schizophrenia.
It is thought that motivating smokers with schizophrenia to quit
smoking can be just as beneficial as offering quit support. Steinberg et al.
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(2004) assessed the efficacy of one 40-minute session of MI compared to
standard psycho-educational counseling (40 min) or advice only (5 min) in
smokers with schizophrenia in terms of affecting proactive quit smoking
behaviour. As hypothesised, participants who received the MI intervention
were more likely to contact a tobacco dependence provider (32% vs 11%
and 0%) and attend the first session of counselling (28% vs 9% and 0%)
within a month.
People with anxiety disorders
Research into effective interventions for smoking cessation in
smokers with anxiety disorders is still at an early stage, with few studies,
limiting the available evidence.
For smokers with panic disorder, it is suggested that it may be
useful to directly integrate smoking cessation within CBT. One such
combined integration has been developed by Zvolensky et al (2003). In a
small study (n=15) of smokers with PTSD, buproprion-SR (combined with
behavioural counselling) was effective in increasing quit rate. At the six-
month follow-up, four out of ten participants in the treatment group were
abstinent (compared to one out of five in the control group) (Hertzberg et
al. 2001).
People with bipolar disorder
There are no studies of tobacco dependence treatments specifically
in people with bipolar disorder. Buproprion should be used with caution in
this group as its antidepressant actions have the potential to precipitate a
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manic episode. Similarly, varenicline has been reported to induce a manic
episode in one patient with bipolar disorder, which subsided after
discontinuation of the drug (Kohen and Kremen 2007).
The withdrawal effect-fear of post cessation relapse
Many health professionals harbor reluctance to advise their mentally
unwell patients to quit smoking because of the view that this may add
undue stress to their system and precipitate an exacerbation of their
psychiatric condition (Lubman et al. 2007).
Patients with past or present mental health issues are also often
reluctant to make a quit attempt out of fear of psychiatric relapse (Lawn
et al. 2002). Because patients often view nicotine as a form of self
medication for their psychiatric symptoms, the belief that cessation will
reverse this effect is understandable. In fact while smoking may improve
psychiatric symptom profiles in the short term, continued use leads to
worsening psychiatric state. It can be understood that when the patient
experiences symptom relief after tobacco consumption, he/she is actually
experiencing relief from the nicotine withdrawal (that was worsening with
increasing time since the tobacco consumption), in addition to the
neurochemically rewarding effect of the drug. Large scale trials and meta-
analyses report that although negative withdrawal symptoms do emerge
after cessation, these clear within two to four weeks of withdrawal, and
smoking cessation has actually been shown to lead to improvement in
symptoms of anxiety and depression and general mental health (Mino et
al. 2000; Currie et al. 2007).
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Smoking cessation and community mental health programmes
Many cessation programmes around the world now cater for
smokers with mental illness. SANE Australia (2007) has developed a
factsheet for smokers with mental illness and a manual kit for workers in
cessation, addiction or mental health settings. The Tobacco and Mental
Illness Project, piloted in South Australia and now expanded to service all
of Australia, comprises worker training, workshops, resources and
information for smoking cessation and mental health. The project focuses
on three areas: awareness raising, policy and practice change and
smoking cessation/reduction programs (Ministerial Council on Drug
Strategy 2004).
In the United Kingdom a programme was recently developed to
address cessation support needs in people with mental health problems
(Edmonds et al. 2007). Mental health workers were first trained to deliver
cessation support to those with mental illness. During the training staff
were engaged to brainstorm factors that they thought were relevant to
smoking and mentally unwell patients in their experience.
Adapted material included: literature and research on smoking,
mental health and smoking cessation; why people with mental health
problems smoke; the general and specific barriers to quitting; and,
interactions between smoking and psychotropic medication.
One-to-one support for people with mental health problems was
then offered out of a community cessation service. The one-to-one model
was highly valued amongst users - it allowed flexibility in tailoring the
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support to individual needs of the target group and there was the freedom
for the participants to input into timing, location and frequency of support
sessions. Hence, they were able to access the treatment again if they
relapsed (after 6 months), were given the option to set their own follow up
dates, treatment length, and setting, which was different from their usual
structured mental health care. This therefore created a sense of control
and self empowerment amongst users (Edmonds et al. 2007).
Participants highly valued the personal support that was offered,
being treated like an individual. Support from someone experienced in
both the mental health and smoking cessation fields enabled a mental
health sensitive cessation programme that was considered useful for
users. Additionally, simply the supportive, listening qualities of the
individual therapists had a big impact on the users positive opinion of the
service (Edmonds et al. 2007).
The foregoing review supports the claims that there is prevalence of
smoking among metal health patients. This was supported by Coultard et
al. (2000) that smoking rates are significantly higher among those with
mental illnesses compared with the general population. The same was
observe in a related study that this seems to be particularly the case
among psychiatric in-patients of whom 74% of are smokers (Meltzer et al.
1996). This smoking rate is over three times higher than that found
among the general population the same paper added.
The review also revealed the importance of mental health patients
to seek intervention on smoking cessation as it is observed to an adverse
effect to their physical health. Accordingly, mental health service users
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generally exhibit poorer physical health and higher death rates than the
general population. In particular, people with schizophrenia exhibit a
life expectancy roughly 20% shorter than that of the general
population (Hennekens et al. 2005). A number of factors have been
hypothesized to underlie the high morbidity and mortality rates among
mental health service users. These include cigarette smoking, obesity,
diabetes and hypertension. Brown et al (2000) carried out a 13-year
prospective study of 370 community-based people with schizophrenia,
looking at who died and the causes of their death. The study revealed
that the standardized mortality ratio (SMR) for all cause mortality was
indeed significantly higher than expected for all age groups, and that
most of this excess mortality was due to cigarette smoking.
The physical impact of smoking among mental health service users
is not just limited to higher mortality rates. This group also exhibits higher
rates of many physical illnesses than the general population, including
many conditions directly related to smoking. For instance, Makikyro et al.
(1998) found respiratory disorders to be twice prevalent among women
with a psychiatric diagnosis than among the general female population.
The paper has also revealed that seemingly there is an association
between smoking and mental health. Aside from the review, research
evidence indicates that long-term smoking is actually associated with
adverse mental health effects. These effects include the onset and
worsening of depression (Pasco et al. 2008) and anxiety disorders
(Johnson et al. 2000). In several studies, the smoking and mental health
relationship did not seem to be bi-directional in that mental disorders
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during adolescence were not significantly associated with chronic
cigarette smoking during early adulthood.
In addition to predicting the onset of mental health problems,
smoking may also have adverse effects on the course of existing
conditions. For example, a study by Oquendo et al (2004) suggests that
smoking among mental health service users increases the risk of suicide.
The mechanisms hypothesized to underlie the effect of smoking on
mental health include the effects of smoking on serotonin levels (Malone
et al. 2003).
Chapter IV
Implication to Nursing Practice
Having considered the forgoing findings, the following implications
were arrived:
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That smoking has significantly increasing among mental health
patients than the general population. The same observation is shared by
both in-patients and out-patients;
Mental health patients are said to be heterogeneous. And as such,
smoking behavior varies across categories of patient according to
background, environment, mental illness, and the willingness to undergo
treatment;
Different group of mental health patients requires different nursing
intervention on smoking cessation. Some may require, aside from nursing
intervention, cognitive therapy, social support, a positive environment and
peer support, and may take a longer process;
That nurses have to undergo orientation and training to develop
knowledge skills on smoking cessation intervention among mental health
patients.
Recommendations and Conclusions
Based on the forgoing findings, therefore, the following
recommendations and conclusions were arrived:
In spite of the many studies conducted, there seems to be gap of
information regarding specific nursing intervention to particular mental
health patient or condition. Henceforth, it is recommended that a
continued study regarding nursing interventions on smoking cessation
among mental health patients be conducted. It is further suggested that
the study should not only limit nursing, but rather explore the possibility
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of integrating other activities and support mechanisms which may
facilitate the effectiveness of the nurses in this particular intervention.
Nurses, particularly those in the psychiatric area, should be given
training to address the need for special knowledge and skills regarding
nursing intervention on smoking cessation among mental health patients.
To support the effort of smoking cessation among mental health
patients, health care institutions should advocate a smoke-free
environment, thus reinforcing a positive environment. Health care
workers, particularly nurses, should endeavor to become role model for
their patients in order to encourage the latter to quit smoking.
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APPENDIX
SUMMARY OF REVIEWED PAPERS
Top Related