Managing a smoke-free inpatient environment for patients who smoke

No Smoking, smoke-free, sign

As more and more hospitals eliminate smoking on their grounds, including Vancouver Coastal Health, health professionals will benefit from reduced exposure to second-hand smoke. At the same time, they have to help patients adapt to forced abstinence. Many smokers with mental illness want to quit but may not be ready to give up tobacco at the time of hospitalization, and taking cigarettes away is another loss of autonomy to which inpatients must adjust. This raises ethical questions among staff, and compounding the ambivalence toward smoke-free policies is anxiety about symptom exacerbation or even aggression related to forced abstinence. One study of a general psychiatry inpatient service found that forced tobacco abstinence was in fact associated with unplanned discharge and seclusion (1). However, research on outpatients with schizophrenia found that acute nicotine abstinence was associated with a transient increase in negative but not positive symptoms (2).

The restlessness and anxiety that patients in nicotine withdrawal experience may nevertheless be interpreted as psychotic exacerbation. A study in an emergency psychiatric setting showed that nicotine replacement is effective in patients with schizophrenia (3). The authors found that compared to placebo, a 21-mg nicotine patch led to a 23% reduction at 24 hours in the Agitated Behavior Scale. This is similar to the effect of a dose of antipsychotic, suggesting that managing nicotine withdrawal may reduce use of sedating medication.

At the BC Psychosis Program beginning November 20th, newly admitted patients are not able to smoke, and it is important for them to be prepared for this when they arrive. We suggest that patients who smoke and are traveling from distant communities by medical transport receive nicotine replacement en route. All smokers at BCPP receive nicotine replacement therapy, and only when they have independent passes off grounds will they be able to use tobacco products if they choose to do so.

References

1. Prochaska JJ, Gill P, Hall SM. Treatment of tobacco use in an inpatient psychiatric setting. Psychiatr Serv. 2004;55:1265–1270. Full text

2. Dalack GW, Becks L, Hill E, Pomerleau OF, Meador-Woodruff JH. Nicotine withdrawal and psychiatric symptoms in cigarette smokers with schizophrenia.
Neuropsychopharmacology. 1999;2:195-202. Full text

3. Allen MH, Debanne M, Lazignac C, et al. Effect of nicotine replacement therapy on agitation in smokers with schizophrenia: a double-blind, randomized, placebo-controlled study. Am J Psychiatry. 2011;168:395–399. Full text

(Photo: flickr.com/hmoong)