More Training Needed on Smoking Cessation

By Kirn, Timothy F. | Clinical Psychiatry News, May 2008 | Go to article overview

More Training Needed on Smoking Cessation


Kirn, Timothy F., Clinical Psychiatry News


Too many mental health professionals view the treatment of psychiatric patients who smoke as a primary care issue, according to a leading researcher in the field.

"But our patients do not necessarily receive regular primary care," says Judith J. Prochaska, Ph.D., of the department of psychiatry at the University of California, San Francisco. Furthermore, "primary care doctors may think our patients are too stressed out and too complicated to address tobacco with them."

Because of her concern about the care of these patients, Dr. Prochaska and colleagues conducted a national survey of psychiatry residency programs and found that only half of the programs offer smoking-cessation training. Of those that do offer such training, the median duration of training was just 1 hour (Acad. Psychiatry 2006; 30: 372-8).

A couple of years earlier, she reviewed the records of 250 inpatients hospitalized from 1998 to 2001 at San Francisco's Langley Porter Psychiatric Institute, which became 100% smoke-free in 1988-one of the first psychiatric hospitals in the country to do so. In that review, Dr. Prochaska found that patient smoking status was not included in the treatment planning of any of the 105 patients who were smokers. Just over half (56%) of patients who smoked had been given nicotine replacement in the hospital, but only one patient had been encouraged to quit, referred for cessation therapy, or given nicotine replacement on discharge.

One particularly interesting finding was that the smokers who were not given nicotine replacement were more than twice as likely as nonsmokers and those given nicotine replacement to leave against medical advice (Psychiatr. Serv. 2004; 55: 1265-70). The study led to the hospital's interest in doing more to address nicotine dependence among its patients.

Tobacco use in psychiatry is an issue that is moving increasingly to the fore. The American Legacy Foundation has funded the Smoking Cessation Leadership Centerto direct a plan aimed at increasing access to smoking-cessation services for people with mental illness. The leadership center already has put together a coalition of nearly 30 organizations, including the American Psychiatric Association.

CLINICAL PSYCHIATRY NEWS recently spoke with Dr. Prochaska about the importance of smoking-cessation treatments for patients with mental illness, particularly in the in patient setting.

CLINICAL. PSYCHIATRY NEWS: How important are smoking-cessation efforts on inpatient units?

Dr. Prochaska: They are critical. Our patients smoke at high rates and tend to be heavy smokers. With a smoke-free unit, the effective management of patients nicotine withdrawal is critical. But in general, [encouraging cessation] is not something that inpatient staffers consider. They see a patient who is agitated, depressed, anxious, or cannot sleep, and they think it is a psychiatric disturbance. They do not think "this is a pack-a-day smoker who no longer has access to cigarettes."

CPN: How do you respond to arguments that smoking has benefits for individuals with mental illness and, in fact, helps hospitals manage inpatients?

Dr. Prochaska: Psychiatric hospitals that permit patient smoking report upward of 4 hours per day managing the smoking breaks, dealing with fights over cigarettes, and cycling patients through the discomfort of nicotine exposure and withdrawal. What insurance company wants to pay for this staff time? What liability do hospitals face if patients initiate smoking during this acute time of vulnerability?

When units have gone smoke-free, they have not seen all the unrest that people anticipated--such as the increased use of medications, restraints, seclusion, oragainst-medical-advice discharges--when nicotine withdrawal is managed. …

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