Patients who participated in a smoking-cessation program during hospitalization for mental illness were able to quit smoking and were less likely to be hospitalized again for their psychiatric conditions, according to a new study by researchers at Stanford and UC San Francisco.
The findings counter a longstanding assumption held by many mental-health experts that smoking serves as a useful tool in treating some psychiatric patients.
Smoking among such patients has been embedded in the culture for decades, with cigarettes used as part of a reward system. Indeed, clinicians sometimes smoke alongside patients as a way of creating a rapport with them, said Judith Prochaska, PhD, MPH, associate professor of medicine at the Stanford Prevention Research Center who led the study while an associate professor at UCSF. The result is that psychiatric patients are among the country’s most prolific smokers and among those most likely to die of smoking-related ailments, Prochaska said.
Nearly half of the cigarettes sold in the United States are to people with psychiatric or addictive disorders, according to data from the U.S. Centers for Disease Control and Prevention. And the average life expectancy for people with severe mental illness is 25 years less than that of the general population, and their leading cause of death is chronic illness, mostly tobacco-related.
The study is the first to examine the impact of a stop-smoking intervention in adult psychiatric patients. It was published online Aug. 15 in the American Journal of Public Health.
Co-authors of the study are Stephen Hall, MD, director of acute services at Langley Porter Psychiatric Institute; Kevin Delucchi, PhD, professor of biostatistics in psychiatry; and Sharon Hall, PhD, professor of psychiatry, all of UCSF.
Debunking Myths About Smoking Benefits
It has long been thought that if these patients quit smoking, it would be detrimental to their recovery – that they would lose a critical crutch for coping with stress, Prochaska said.
However, she pointed out that the daily cycle of nicotine withdrawal that a smoker experiences creates a great deal of stress, and that mental-health providers are well-equipped to assist patients with developing healthier forms of coping.
The new study showed that a simple intervention that included periodic contact with a counselor, written and computerized materials and the use of nicotine patches could support – rather than harm – the patients’ mental health, she said.
Study at UCSF Inpatient Facility
To test the effects of treating tobacco use among hospitalized psychiatric patients, the researchers initiated an intervention among 224 patients at the Langley Porter Psychiatric Institute, a smoke-free, locked mental hospital for acute care at UCSF.
Judith Prochaska, PhD, MPH
All patients who smoked at least five cigarettes daily prior to hospitalization were invited to participate. Few were ready to quit smoking, yet 79 percent agreed to participate. The patients had a range of psychiatric diagnoses, including depression, bipolar disorder and schizophrenia; three in four were actively suicidal. Half were randomly assigned to a treatment group, and the other half received the usual care.
All patients were offered nicotine patches or gum during their smoke-free hospitalization. Patients in the control group received a pamphlet about the hazards of smoking, with information on how to quit.
Participants in the treatment group completed a computer-assisted program with tailored feedback, received a print manual, met for 15 to 30 minutes with a counselor, and were offered a 10-week supply of nicotine patches, available when the participant became ready to quit.
All of the materials were tailored to patients’ readiness to quit, and the computer-assisted intervention was repeated at three and six months post-hospitalization to support participants through the process of quitting smoking. A copy of the computer printout was mailed to patients’ outpatient providers.
Success Based on Readiness to Quit
“A key aspect of the intervention is that we did not assume all patients were ready to quit,” Prochaska said. “We met them where they were at and worked with them over time. When they became ready to quit, we were there for them, and they could get the patches to help with withdrawals.”
Only a small number of patients – 16 percent – initially said they were prepared to quit when they enrolled in the study, though over time they became progressively more committed to the process, which is typical in these types of interventions, Prochaska said.
The participants all were contacted following hospital discharge at one week and at three-, six-, 12- and 18-month follow-ups. Quit rates were confirmed with breath samples or by a third party who knew the participant.
At the end of the 18 months, 20 percent of those in the treatment group had quit smoking, compared to just 7.7 percent in the control group, the researchers found. Moreover, there were fewer hospital readmissions among those in the treatment group – 44 percent, compared to 56 percent in the control group.
This is the first finding of its kind, and Prochaska said it needs to be replicated. But at a minimum, she added, treating patients’ smoking did not harm their mental health recovery and may have even enhanced it.
“I think some of the therapeutic contact that addressed participants’ tobacco dependence, and supported them with this major health goal, may have generalized to them feeling better about their mental health condition,” she said.
The patients’ diagnoses and the severity of their symptoms had no impact on intervention outcomes, the researchers found. “Assumptions we have made in the field – that these patients don’t want to quit, are too ill to quit or that quitting will hurt their mental health recovery – none of that held up,” she said.
What did influence outcomes were patients’ perceptions at the study start of how successful they would be with quitting and how difficult it would be to not relapse, as well as their level of nicotine dependence – the same factors that affect smoking-cessation results in the general population.
Prochaska and her colleagues are now following up with a larger trial involving more than 900 patients at Stanford Hospital & Clinics, Alta Bates Summit Medical Center in Berkeley, and UCSF’s Langley Porter.