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Introduction
Tobacco smoking is the single most preventable cause of ill-health and death in Australia (Australian Institute of Health and Welfare, 2012). It contributes to more hospitalisations and deaths each year than alcohol and illicit drugs combined (Begg, Vos, Barker, Stevenson, Stanley, & Lopez, Reference Begg, Vos, Barker, Stevenson, Stanley and Lopez2007). Smoking still causes a higher burden of disease than any other risk factor, representing 7.8% of the total burden of disease.
A recent Cochrane Review showed that compared to usual care, smoking cessation counselling interventions that began during a hospital stay and included at least one month of supportive contact after discharge promoted smoking cessation (Rigotti, Clair, Munafo, & Stead, Reference Rigotti, Clair, Munafo and Stead2012). Adding nicotine replacement therapy (NRT) to the counselling programme significantly increased cessation rates over counselling alone. The effect of these interventions was independent of the patient's admitting diagnosis and was found in rehabilitation settings as well as acute care hospitals. A meta-analysis of smoking cessation interventions with individuals in substance abuse treatment or recovery demonstrated a 25% increased likelihood of long-term abstinence from alcohol and illicit drugs (Prochaska, Delucchi, & Hall, Reference Prochaska, Delucchi and Hall2004).
Efforts to reduce smoking are amongst the most beneficial interventions for human health (Maciosek, Coffield, Edwards, Flottemesch, Goodman, & Solberg, Reference Maciosek, Coffield, Edwards, Flottemesch, Goodman and Solberg2006; World Health Organization, 2009). Despite well-established treatment protocols for smoking cessation and strong evidence of efficacy and cost effectiveness, many doctors and hospitals still do not incorporate the treatment of nicotine dependence into their routine practices (Torrijos, & Glantz, Reference Torrijos and Glantz2006). Addiction treatment centres have lagged behind other health institutions in introducing tobacco cessation programmes. Indeed, in mental health and addiction treatment settings, failure to treat tobacco dependence has been rationalised by some as a clinical approach to harm reduction (Prochaska, Reference Prochaska2010). However, there is growing evidence that, with careful planning and a systematic approach, it is possible to reduce smoking in ‘difficult to treat’ smokers (Bittoun, Reference Bittoun2006; Bittoun, Nynycz, Ross, Foley, & Ross, Reference Bittoun, Nynycz, Ross, Foley and Ross2013). A recent study of 224 patients in a locked acute care mental hospital in the USA demonstrated a 20% quit rate at 18 months amongst those participating in a smoking cessation programme compared to just 7.7% in the control group (Prochaska, Hall, Delucchi, & Hall, Reference Prochaska, Hall, Delucchi and Hall2013). In addition, only 44% of the treatment group were readmitted compared to 56% of the controls.
The Tasmanian Department of Health and Human Services Alcohol and Drug Service (ADS) supports a 10 bed inpatient withdrawal unit (IPWU) in Hobart, serving the whole state. On 1 January 2011 the ADS, including the IPWU, became smoke-free. This paper describes the implementation plan and reviews the first year of a smoke-free policy in the IPWU in Tasmania. It also reports the smoking intentions of clients offered on-going NRT on discharge.
Aims
To describe the implementation and early evaluation of a smoke-free policy in an IPWU, in particular the smoking intentions of clients offered on-going NRT on discharge.
Methods
All prospective admissions to the IPWU were informed of the smoke-free policy at their assessment; this involves tobacco smokers agreeing to hand over all tobacco products for safekeeping during their admission period. This is part of the treatment agreement which clients sign prior to admission, and includes information on the support and treatment they will be offered to manage smoking cessation.
Depending on their score on the Heaviness of Smoking Index (Heatherton, Kozlowski, Frecker, Rickert, & Robinson,1989), clients were offered oral or topical nicotine replacement therapy (NRT). Using a flowchart based on the ABC Smoking Cessation Brief Intervention Framework (Zwar, Richmond, Borland, Stilman, Cunningham, & Litt, Reference Zwar, Richmond, Borland, Stilman, Cunningham and Litt2004), response to NRT was monitored and the dose/preparation was adjusted to achieve control of any withdrawal symptoms. Behavioural support was also provided by the nursing and medical staff.
Prior to discharge all clients on NRT were offered a one week supply of medication, with strong encouragement to attend their general practitioner for an ongoing supply and support.
Data was extracted from the clinical records of all clients admitted to the IPWU between 1 January and 31 December 2011. This included age, gender, length of stay, main substances being withdrawn from and comorbidities.
Results
A total of 221 clients were admitted to the IPWU in 2011, 150 (68%) men and 71 (32%) women. Their mean age was 40 (range = 18–75), and the average length of stay was 6 days (range = 1–21).
Sixty-seven per cent (149) of clients had associated mental health problems, most commonly depression and/or anxiety.
The primary substance being withdrawn from were: alcohol (64%), cannabis (19%), opioids (11%), amphetamines (5%) and benzodiazepines (1%). One hundred and thirteen (51%) of clients were dependent on two substances, 65 (29%) on three substances, 25 (11%) on a single substance and 18 (18%) on four or more substances. One hundred and seventy-nine (81%) were smokers. Of these the majority were long-standing smokers, most of whom consumed more than 20 cigarettes per day and had never attempted to stop smoking before.
One hundred and seventy (95%) of smokers accepted NRT, only nine (5%) electing to go ‘cold turkey’. Forty-one clients (19%) took early discharge against medical advice and missed the opportunity to discuss ongoing NRT. Only 2 (5%) of these clients cited the smoke-free policy as the reason for their leaving early. Of the 136 smokers who successfully completed their detoxification, 120 (88%) requested ongoing NRT.
Conclusions
This small study of a single IPWU in Tasmania shows that it is possible to introduce a smoke-free policy in a facility with an over-representation of ‘difficult to treat’ smokers.
Careful planning, widespread consultation and communication, coupled with comprehensive training of staff over the preceding year facilitated the introduction of the smoke-free policy. Despite catastrophising and therapeutic nihilism amongst some staff, there was no overall reduction in the number of clients requesting admission or being referred to the IPWU compared to the preceding year.
The success of a personally tailored, intensive approach to quitting, incorporating judicious use of multiple forms of NRT, often at maximum recommended dose, is reflected in the very small number of clients (two) who left early because of their desire to resume smoking.
The fact that 88% of smokers requested ongoing supplies of NRT is most encouraging – all clients were at liberty to resume smoking as soon as they left the IPWU. While recognising that an expressed intention to remain tobacco-free did not mean that all these clients would sustain their abstinence, for many this was their first or longest period of not smoking. Many clients expressed surprise and pride in the fact that they had succeeded in remaining smoke-free throughout their admission, giving them confidence for future attempts if they subsequently relapsed.
It is intended to follow up these clients, and ascertain if they have remained smoke-free, and for how long.
Acknowledgements
We would like to thank all the staff of the IPWU for their support, Karen Armstrong for compiling the database and Gwyneth Delpero for advice and comments.
Financial support
None.
Conflict of interest
None.
Ethical statements
The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008.
