Dissertation p.sevilla

8/6/2019 Dissertation p.sevilla

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Smoking cessation and community mental health

programmes------ 32

5. Chapter IV5.1. Implication to Nursing Practice ---------------------------

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5.2. Recommendations and Conclusions

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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

Documents

Dissertation p.sevilla