Follow the smoke and you may find a patient with mental illness. Mental health patients smoke 44% of U.S. cigarettes and represent an estimated 200,000 of the 443,000 smoking-related deaths in the U.S. annually, according to the Centers for Disease Control and Prevention.
Smoking bans exist in most public places, but on many hospital grounds, this group is permitted to light up. Concerned for their health, nurses at NewYork-Presbyterian Hospital-Payne Whitney Westchester in White Plains, extended a smoking ban to the outside campus and created a smoking cessation program in an attempt to reverse the statistics.
Embedded in Culture
use, the most common shared condition that those with major mental disorders have, has been allowed, accepted, and even encouraged in mental health settings. It has been a reward for good behavior and a means of socialization. The prevailing attitude has been that people with mental illness have so few enjoyable things in life why take this pleasure away?Linda Espinosa, RN
The past relationship between mental illness and smoking is complicated. Tobacco
The old attitude is short-sighted and uninformed, says Linda Espinosa, RN, MS, vice president of nursing and patient care services and initiative chairwoman. We are taking responsibility for their health and that of our staff by establishing a totally smoke-free environment, while providing them with coping skills and ways to replace the need to smoke, she says.
First Steps to Quitting
The CDC estimates 70% of people with mental illness want to quit smoking, a figure comparable to the general population, and that they can be successful with the assistance of targeted smoking cessation strategies, adequate support, and the use of nicotine replacement therapies.
In 2008, Espinosa created a task force across disciplines that includes nurses, physicians, pharmacists, social workers, psychosocial rehabilitation specialists, and other staff, and formed subgroups to research literature about treatments for nicotine withdrawal. They created staff and patient education programs, smoking policies, and methods to prevent problems that might occur with cessation, and designed a marketing campaign.
We didnt want just a smoke-free environment; we wanted to help patients [and staff] quit smoking, and included them early on in the discussion, Espinosa adds.
On each unit, administrative senior staff nurses and patient care directors implemented the recommendations of the work group. These included the framework of the five As to help people quit
Asking about tobacco use
Advising to quit
Assessing willingness to make a quit attempt
Assisting in the attempt to quit
Arranging for follow-up
Helping patients quit includes providing staff and patient educational opportunities, managing medications, and changing environments, says Patricia Ireland-Vincoli, RN, BSN, administrative senior staff nurse on the addiction recovery unit.
Because of a mandate by the Office of Alcoholism and Substance Abuse Services, the addiction recovery unit went smoke-free first in July 2008. Ireland-Vincoli touts the American Lung Association Power to Be Free program as a successful resource used to educate staff, who then teach patients about smoking cessation.
For three months before the smoke-free date, patients on the addiction recovery unit discussed strategies and coping measures during weekly group sessions with staff and certified alcohol and substance abuse counselors. Certain out-of-door areas were converted to nonsmoking areas for this group. Nicotine products such as the patch, gum, inhalers, and prescription medications were available to ease cravings.
Although some studies have found a link between smoking cessation and depression, todays correctly prescribed medications treat withdrawal and depression, says Espinosa. Dual agents, such as buproprion and nortriptyline HCL, for example, are antidepressants that treat symptoms of nicotine withdrawal, she says.
Moving Forward to Cessation
On the second chance unit where the majority of patients come from state mental institutions with a history of psychoses, the initial response to the smoking ban was a decrease in the activities of daily living by a few patients, says Derrick Jenkins, RN, administrative senior staff nurse.
When we created new reward strategies, such as patient-chosen movies with snacks and video game time, patients became motivated and their daily functioning ratings began to rise, Jenkins says. In place of escorted smoking walks, patients walk to the gym to exercise, play basketball, or throw Frisbees.
A Difficult Journey
Smoking literature suggests people with mental illness may be more prone to relapse, but staff support can help sustain their efforts to quit. Some patients [on the addiction recovery unit] tell us they quit while here but will resume smoking on discharge because they cant give up drugs or alcohol and smoking all at once, says Iriland-Vincoli. As healthcare providers, we have to offer healthy choices.
Patients who are referred to the unit are alerted before their admission that smoking is not permitted on campus.
Because healthcare professionals are aware of the related health risks of smoking, not acting is unacceptable, according to the American Psychiatric Nurses Association. Smoking cessation is an integral part of mental health treatment, and achieving health and wellness will require being tobacco-free.
On Nov. 20, 2008, NewYork-Presbyterian Hospital-Payne Whitney Westchester became a smoke-free campus on Great American Smoke-Out Day, an annual event sponsored by the American Cancer Society.
Patients and staff who thought they would never be able to quit are making progress and are happy about themselves, Jenkins says.