Type of Tobacco Bans
In order to implement a tobacco-free hospital setting, administrators in mental health and addictions treatment facilities must decide on what type of ban to implement. The options include a full ban, in which no smoking is permitted on units and the grounds of the hospital, or partial bans which designate certain areas and/or times when smoking is permitted. Although a partial ban may seem more attractive because of its less restrictive nature, partial bans can lead to patients trying to negotiate their cigarette smoking privileges with staff, which can result in an increased perceived value of cigarettes in the hospital setting.60
While some examples of complaints and verbal aggression have been associated with both partial and full bans, inconsistent enforcement of bans are a more common problems with partial bans,61
may lead to negative outcomes that could otherwise be avoided by the implementation of a full ban.61,62
In their review of twenty-six international studies reporting the effectiveness of smoking bans in psychiatric settings, Lawn and Pols2
concluded that inconsistent applications of bans across patient populations resulted in more damage and disruption for those hospitals that implemented partial bans as compared to full bans.
A full ban promotes consistency, as there is no confusion involved with this type of ban (“no ifs, ands or butts”; see ). Several studies have suggested that although staff, patients, and visitors may initially oppose a total tobacco ban, their attitudes changed to favor a smoke-free environment following the implementation of the ban.2,50,63
These findings suggest that implementing a total ban for all tobacco products provides the most positive results in a psychiatric setting. Therefore, this approach should be the long-term goal of all tobacco-free initiatives, with the caveat that implementation of partial bans may be used as a transitional step towards achievement of complete tobacco bans.
Evidence-Based Guidelines for Successful Implementation of Tobacco Bans in Inpatient Psychiatric and Addictions Treatment Settings
The New Token Economy: Increasing On-Unit Activities
Traditionally, psychiatric facilities have inadvertently promoted tobacco use, by deploying cigarettes as a means to modify behavior through the use of token economies.53,64
Token economies can facilitate clients to learn and perform desired behaviors. These types of economies have been explained as treatment delivery systems and as a means of providing learning principles in an attempt to focus on particular problems. LePage65
demonstrated that token economies may decrease the number of staff and patient injuries, and the improved safety environment allows staff members to focus their attention on treatment, rather than creating a dynamic of conflict which is ultimately counterproductive.
Since token economies are a useful means of modifying potentially disruptive behavior in a psychiatric setting, it might be reasoned that it would be beneficial to keep these economies in use. However, if a tobacco ban is implemented, administrators can introduce incentives other than cigarettes to motivate patients to follow the rules implemented on the ward and to reward good behavior. Such incentives could include privileges to leave the premises, movies, television, healthy food, internet and phone access, or increased visitors time, and other positive reinforcement approaches (e.g., draws for prizes of value once compliance with tobacco-free regulations are demonstrated). This would allow staff to use positive reinforcement techniques to modify disruptive and unwanted patient behaviors, without providing them with a harmful substance such as tobacco.
Patients in psychiatric hospitals may find themselves with extra time, and little activities to occupy this time, which can lead to boredom. Cigarette smoking provides an opportunity to temporarily leave the ward and facilitates socialization for psychiatric patients.66
Non-smokers are at risk for initiating cigarette smoking if admitted into a psychiatric ward where smoking is permitted, as a result of peer-pressure and boredom.6
When tobacco bans are put into place, the concern is that they may prevent the patients from connecting with one another, and increase boredom and inactivity. In fact, most studies (see ) suggest that the opposite occurs.
In an effort to decrease boredom and enhance other means of socialization, increased ward activities (programming) may offer the most viable solution. These activities could include entertainment options, such as books, television and movies, or providing access to the internet. In an effort to increase socialization, ward outings to local museums, parks, and the community would provide a change of scenery that could promote communication among the patients. Educational courses are another alternative to keeping the patients occupied, while at the same time stimulating their minds. Lastly, providing the patients with physical activities, such as sports and exercise classes may promote socialization, and a healthy lifestyle. All of these various activities can provide the patients with an alternative to smoking, and could be used a part of the token economy, as these activities could be considered privileges and offer a healthy option to cigarettes as the token economy item.
Consistency (“No ifs, ands or Butts”)
Although a total tobacco ban is the ultimate goal, in order to align values, policies and changes in clinical practice it may sometimes be beneficial to work with both advocacy and policy stakeholders in the treatment settings. For example, in a hospital with a deeply entrenched pro-tobacco culture, a multi-pronged approach emphasizing policy, advocacy, staff training and program development is needed to produce the required change management to implement such bans. To this end, it is imperative that the rules are strictly and consistently enforced across the board. This consistency approach must be followed at all levels of staff, ranging from management to clinical staff support.2,61
In the review by Lawn and Pols,1
one of their key findings to a successful ban was consistency, coordination, and full administrative support. One hospital that noted an increase in problems following the implementation of the ban, including aggression, discharge against medical advice or increased use of medication, may have been a result of the lack of the administrative process to provide consistent enforcement of the ban.29
The staff in this hospital did not comply with the ban, as unauthorized patients were permitted access to cigarettes.63
It is necessary for staff to comply with and enforce the tobacco ban, and failure to so will result in negative consequences.
Provision of Pharmacotherapies
Educating the patients on, and providing them with, pharmacotherapies is essential in helping them refrain from smoking. These include NRTs (e.g., transdermal nicotine patch (TNP), gum, spray, inhaler, and lozenge), sustained-release bupropion (Zyban®), and varenicline (Chantix®
in USA; Champix®
in Canada and Europe), which have all been found to increase likelihood of quitting in psychiatric populations.19,67
All these therapies are convenient for nurses to distribute to inpatients with other daily (psychotropic) medications (with bupropion SR and varenicline needing a prescription).
Prophylactic NRT is recommended for inpatient in psychiatric and addictions settings, as it may reduce rates of discharge against medical advice where smoking is forbidden.6,68
TNP may be the best option because it is only administered once a day which may increase compliance.69
In addition, TNP delivers a fixed dose of nicotine continuously,70
which provides partial replacement of plasma nicotine levels6
and can target the acute nicotine withdrawal syndrome,19,71
a frequent determinant of smoking relapse.23,72
Sustained-release bupropion SR is a weak catecholamine reuptake inhibitor and non-competitive ion channel site antagonist at the nicotinic acetylcholine receptor (nAChR),73
which has been proven to be an effective medication for smoking cessation in psychiatric population,73
especially if used in conjunction with behavioural therapy.74,75
Bupropion is currently the best studied treatment option for tobacco cessation in smokers with MHA disorders.40,73,74,76,77
Varenicline, an α4β2 nAChR partial agonist, has recently been added to the USPHS guidelines as a recommended first-line therapy19
and has also been shown to be a highly effective smoking cessation aid;76,78
comparative studies with bupropion SR have shown its superiority to this agent and placebo.79,80
While the typical side effects of varenicline are nausea and insomnia, severe adverse events have been reported, which include treatment-emergent psychosis, mania, impulsivity, agitation and suicidality.19
Physicians are advised to monitor their patients taking varenicline on a regular basis for the emergence of such neuropsychiatric symptoms.81
There are several on-going studies examining the safety and efficacy of varenicline in psychiatric smokers.19
Treatment with NRT, varenicline, and bupropion SR, are all possible strategies to alleviate the withdrawal symptoms commonly associated with smoking cessation once a ban is implemented, and such early treatment promotes self-efficacy in tobacco cessation efforts.19
Provision of Behavioral Support
While pharmacotherapies target the neurochemistry of tobacco addiction, concurrent behavioral support is required in order to teach coping strategies which can optimize cessation outcomes during the implementation of the ban, and increase the likelihood of long-term smoking cessation. Behavioral support can come in the form of self-help programs (increase motivation and improve readiness to quit, manage withdrawal symptoms, and preventative relapse measures),19
cognitive-behavioral therapy (CBT),40,82–84
contingency management (CM),85,86
and motivational interviewing (MI).87
It has been suggested that the estimated four hours per day it takes staff to provide cigarettes, should be reallocated to the delivery of cessation counseling services.6,68
MI is a standard behavioral treatment that can be utilized successfully in smokers with co-morbid mental illness.88
MI would be beneficial for this specific population, as their low readiness to quit may be a significant barrier to smoking cessation.19
While MI has demonstrated that it is an effective smoking cessation treatment,73,87,89
it may also influence smoking treatment-seeking behavior.19,88
In light of these findings, MI should be frequently employed to encourage smoking reduction and cessation in psychiatric and addiction hospitals.88,90
CBT should be delivered by a trained clinician, as opposed to staff member trying to incorporate the therapy into his or her regular duties.91
CBT involves individual and/or group counseling, and can range in length from brief (10 – 15 minutes) to intensive (50 – 60 minutes), conducted once to several times per week. CBT has been demonstrated to be an effective behavioral therapy for smoking cessation, as a strong positive correlation exists between amount of counseling and smoking abstinence.92
CBT has been modified for smoking cessation in individuals with co-morbid mental illness,7,87,93
and would have suitable applications in a psychiatric hospital.
CM is an alternative behavioral intervention that could be applied when implementing a smoking ban. The goal of CM is to utilize reinforcement procedures systematically in order to modify smoking behaviors in a positive and supportive manner.94
This treatment has been found to reduce smoking,86,95–97
but must be used with caution as smoking relapse is high once the contingencies are withdrawn.19
CM can be applied when the ban is initially implemented, but other treatments must be employed in order to maintain smoking cessation (e.g. CBT and relapse-prevention skills).
Monitoring of psychotropic medications during inpatient and outpatient treatment
Cigarette smoking can decrease the blood concentrations of several psychiatric medications.98–101
This is an important consideration when prohibiting cigarette smoking within psychiatric hospitals. Smoking increases hepatic enzyme activity (primarily the CYP 1A2 and, to a lesser extent the 3A4 isoenzyme systems), which accelerates the metabolism of psychiatric medications,99–101
and can lower plasma psychotropic drug concentrations.50
Examples of psychotropic medication affected in this manner include clozapine, haloperidol, olanzapine, tricyclic antidepressants (TCAs), valproate and caffeine.4
As a result of this smoking interaction with psychiatric medication, patients who smoke tend to take considerably higher doses of antipsychotic drugs.50,99–102
This effect is the result of the tar in cigarettes, rather than the nicotine itself.50,102
A tobacco ban may have significant implications for patients taking antipsychotics once they alter their smoking habits on the ward, or after they are discharged.6
There have been several reports of adverse reactions as a result of high concentrations of clozapine or olanzapine following smoking cessation.103,104
As a result, a stepwise daily dose reduction of about 10% until the fourth day since the last cigarette is recommended, in combination with therapeutic drug monitoring since each patient will react differently to smoking abstinence.6,105
In order to prevent problems, it is imperative to adjust the patient’s medication dosage accordingly and monitor them, in order to ensure these medications are working. Also, if these patients begin smoking after discharge, their medication dosage should be adjusted accordingly so continued monitoring of smoking status and medication response is extremely important.
Provision of Outpatient Services
While psychiatric wards with a tobacco ban provide an opportunity to initiate smoking cessation because of the policies directed against smoking and the increased awareness and availability of medications and behavioral therapies, most programs at this time focus on smoking cessation during hospitalization with less emphasis on long-term abstinence. In order to increase long-term smoking cessation success among psychiatric patients, it is imperative to work with patients while they are hospitalized and to monitor and treat these patients when they return back to the community. The risk of relapse is high; Olivier and colleagues6
have reported that the majority of patients return to smoking within five weeks of discharge. During hospitalization, staff can work with patients on enhancing motivation for long-term abstinence, developing skills to deal with triggers, cravings, and stress after release from the hospital, and examining benefits of not smoking that are experienced while in psychiatric units (e.g., more money, an easier time breathing). In order to prevent tobacco use relapse after release, improvements must be made both in discharge planning and linking clients to appropriate outpatient community resources so that adequate treatment support is continued post-discharge.6
Support should involve regular outpatient follow-up smoking cessation/relapse-prevention sessions and standard pharmacotherapy (e.g. NRT, bupropion SR, varenicline) of both brief and extended treatment based on the clinical situation.19
Thus, if the patients are sufficiently monitored after hospital discharge, the high rates of tobacco relapse associated with inpatient discharge in mental health and addictions treatment settings could be reduced.