Cigarette smoking, nicotine dependence, and motivation to quit smoking in South African male psychiatric inpatients

Smoking is the leading cause of preventable death, associated with about 6 million deaths worldwide each year, with many of these deaths occurring prematurely [1]. People with serious mental illness die an average of 25 years earlier than the rest of the population [1, 2] and a large proportion of this health disparity can be attributed to smoking-related causes [3]. Mentally ill persons are twice as likely to smoke, to smoke more heavily and to be more nicotine-dependent than the general population [4]. Smoking rates are even higher in individuals with severe mental illnesses such as schizophrenia and bipolar disorder, of whom between 30% and 70% respectively, consume more than 20 cigarettes per day [5].

Besides a reduced life expectancy and other health-related issues, smoking has a profound social impact. One major impact is financial burden as people with mental illness spend a disproportionate amount of their income on cigarettes while struggling to afford food or other essential daily needs [6, 7]. Moreover, smoking adversely affects health and life-long cigarette smokers have a higher prevalence of conditions such as malignancy, cardiovascular disease and chronic obstructive pulmonary disease [8], increasing chronic morbidity and mortality. The relationship between smoking and mental illness seems to be bi-directional, with each contributing to the other. Thus the presence of smoking relates to higher incidences of poor mental health, while those with poor mental health have a greater likelihood of being smokers [9]. In that study, women who smoked were up to 1.6 times more likely to have poor mental health while those with poor mental health were more than twice (odds: 2.1) as likely to smoke. A Dutch study has shown earlier ages of onset for depression and anxiety disorders in those who started smoking at an earlier age after controlling for relevant confounders [10]. In contrast, smoking cessation has been associated with reduced depression, anxiety and stress, with improved quality of life even in the absence of mental illness [11]. Smoking also increases metabolism of various antipsychotic agents, thus resulting in lower serum concentrations of antipsychotic medication and other medications metabolized by the cytochrome P450 system [12]. This may result in sub-therapeutic levels of treatment, with compromised benefit to the patient and greater potential for acute relapses of psychotic symptoms in e.g. schizophrenia [12]. Many of the smoking-induced changes are dose–response related and reversible after cessation.

There is no consensus whether people with mental health problems are less likely than those unaffected to want, or be able, to quit smoking. One theory is that mentally ill people belong to a category of so-called ‘hardcore’ smokers defined as daily, long-term smokers who, despite extensive knowledge of the health hazards of smoking and substantial social pressure to quit, are completely unwilling or unable to do so [13]. On the one hand, there is indeed a moderate amount of evidence suggesting that mentally ill persons find it difficult to quit smoking, which may be explained by a number of factors. To some of the patients, smoking offers a sense of control of symptoms and freedom in a setting of limited control [14]. Smoking also gives the patients sense of identity and encourages friendship, in an otherwise socially isolated and often stigmatized group [14]. In addition, inpatient environments may promote smoking behavior through boredom and peer pressure [14]. On the other hand, there is some evidence that mentally ill persons are as motivated to quit, and benefit from smoking cessation treatments and interventions as much as the general population [15]. However, these patients have in the past been less likely to receive such interventions [16] stemming from untested perceptions among health care workers that, because of multiple impairments, quitting smoking may present particular challenges for them [17].

Although global and South African prevalence of smoking has decreased in the general population as a result of anti-smoking regulations and extensive public campaigns [18‐20], rates have declined much less, if at all, in people with mental disorders [21].

Data related to smoking cessation in South Africa, particularly in mentally ill patients, is conspicuously lacking and thus the aim of this study was to evaluate the rate of smoking, nicotine dependence, and motivation to quit the habit in a sample of South African acute-care male psychiatric inpatients. The aligning of local legislation with the World Health Organization Framework Convention on Tobacco Control [22] has made smoking in public spaces increasingly difficult. The most recent Tobacco Control Amendment Act (63 of 2008) prohibits tobacco smoking in a public place, or within a prescribed distance from a window of, ventilation inlet of, doorway to or entrance into a public place [23‐26]. Most health care facilities in South Africa are not yet compliant, but if applied, this law positions hospitalization as an excellent opportunity for mental health workers to play a guiding role in reducing rates of smoking within this key population.

In this study aiming to examine the rate of, motivation and proffered advice to quit smoking in acutely ill psychiatric male patients, we had several important findings. First, an overwhelming majority of the patients (n = 106; 91%) were classified as active smokers, a large proportion (n = 87; 75%) smoking on a daily basis. This is nearly three times the rate (32%) reported among the local general male population [31]. Our findings are consistent with past research [3, 16] in demonstrating exceedingly high rates of smoking in psychiatric patients. The high rate in our sample may be partly explained by the high numbers of schizophrenia diagnoses given the known association between the two [32, 33].

Second, dependence on tobacco, as reflected by the FTND scale, appears to be high with almost 56% of smokers showing high or very high nicotine dependency compared to less than 20% reported in the general population [34]. The mean FTND score in our study (5.4) is also higher than in the general population but comparable to the 4.6 and 6.2 reported by Solty et al. [35] and De Leon et al. [36] respectively in psychiatric samples.

Third, a positive perception regarding smoking was predominant among the smokers suggesting that most may not be currently contemplating quitting. Thus our finding that a majority had attempted to quit the habit in the year preceding the study was somewhat contrary. The finding is, however, consistent with past research [35, 37] and adds to the evidence that, like the general population, patients with mental illnesses are motivated to quit. Given that provider counseling doubles the likelihood that a smoker will quit [38], clinicians should therefore utilize the increasingly smoking-restricted environments provided by psychiatric hospitals to motivate these patients towards cessation. Yet, smoking cessation counseling appears to be a low priority even in the behavioral healthcare setting [39‐41].

Consistent with the above observation, our fourth key finding was that although a majority of the smokers made efforts to quit, only a minor proportion received advice on smoking cessation from any health worker. This important finding is not unique to our study. Studies have repeatedly shown that patients with severe mental illnesses were less likely to receive advice and interventions to aid in smoking cessation [42‐44]. Solty et al. [35], for example, reported much lower rates (36.2%) of patients provided with smoking cessation advice than found in our study. The finding could explain, at least partly, why declines in smoking prevalence observed in the general population have not been replicated in psychiatric populations [16].

This study has some limitations. The sample was restricted to male acute inpatient services at a single setting thus limiting the generalizability of the findings to other subpopulations e.g. females and outpatient. Given the nature of the sample, reliability of the responses is unknown although we endeavored to exclude clinically unstable subjects. The study was also limited by an emphasis on primary psychiatric diagnoses yet comorbidity, a common phenomenon in psychiatric patients, may substantially impact on various aspects related to smoking including prevalence, nicotine dependence and thoughts of quitting [35, 45]. Lastly, the sample size was a restriction on the performance of more interrogative analyses involving, for example, the relationships between psychiatric diagnoses and smoking/cessation. A longer observation time would certainly have yielded a larger sample size, but owing to logistical and institutional restrictions, data collection was limited to two months.

In summary, our findings confirm that, similar to populations elsewhere, rates of cigarette smoking and tobacco dependence among South African psychiatric inpatients is exceedingly high. While many of these patients are motivated to quit and have made recent efforts in that regard, information that can support them in this endeavor seems inadequate as few were provided with pertinent advice echoing concerns that clinicians underutilize their considerable influence in helping patients adopt the healthier lifestyles. Given the detrimental impact that smoking has on health, therapeutic intervention and cessation efforts should be an integral part of available mental health care. As such, clinicians should utilize institutional smoking restrictions, similar to policies recently implemented at Stikland Hospital, to motivate psychiatric patients towards quitting and reducing smoking prevalence among these patients as has been achieved in the general population. Ideally, these efforts should extend beyond the inpatient setting given the increasing shift towards outpatient and community based mental health care.