Turning of the tide: changing systems to address smoking for people with a mental illness

This article was downloaded by: [University of Newcastle (Australia)]On: 31 January 2012, At: 21:36Publisher: RoutledgeInforma Ltd Registered in England and Wales Registered Number: 1072954 Registeredoffice: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK

Mental Health and Substance UsePublication details, including instructions for authors andsubscription information:http://www.tandfonline.com/loi/rmhs20

Turning of the tide: changing systemsto address smoking for people with amental illnessB. Bonevski a , J. Bowman b , R. Richmond c , J. Bryant a , P. Wye b

, E. Stockings b , K. Wilhelm d , T. Butler e f , D. Indig f & A. Wodakd

a The Centre for Health Research & Psycho-oncology (CHeRP),Cancer Council New South Wales, University of Newcastle &Hunter Medical Research Institute, Callaghan, NSW, Australiab School of Psychology, Faculty of Science & IT, University ofNewcastle, Callaghan, NSW, Australiac School of Public Health and Community Medicine, University ofNew South Wales, Sydney, NSW, Australiad Alcohol and Drug Service, St. Vincent's Hospital, Sydney, NSW,Australiae National Drug Research Institute, Curtin University ofTechnology, Perth, Western Australia, Western Australiaf Centre for Health Research in Criminal Justice, (NSW JusticeHealth), Sydney, NSW, Australia

Available online: 09 Mar 2011

To cite this article: B. Bonevski, J. Bowman, R. Richmond, J. Bryant, P. Wye, E. Stockings, K.Wilhelm, T. Butler, D. Indig & A. Wodak (2011): Turning of the tide: changing systems to addresssmoking for people with a mental illness, Mental Health and Substance Use, 4:2, 116-129

To link to this article: http://dx.doi.org/10.1080/17523281.2011.555073

PLEASE SCROLL DOWN FOR ARTICLE

Full terms and conditions of use: http://www.tandfonline.com/page/terms-and-conditions

This article may be used for research, teaching, and private study purposes. Anysubstantial or systematic reproduction, redistribution, reselling, loan, sub-licensing,systematic supply, or distribution in any form to anyone is expressly forbidden.

The publisher does not give any warranty express or implied or make any representationthat the contents will be complete or accurate or up to date. The accuracy of anyinstructions, formulae, and drug doses should be independently verified with primarysources. The publisher shall not be liable for any loss, actions, claims, proceedings,demand, or costs or damages whatsoever or howsoever caused arising directly orindirectly in connection with or arising out of the use of this material.

Dow

nloa

ded

by [

Uni

vers

ity o

f N

ewca

stle

(A

ustr

alia

)] a

t 21:

36 3

1 Ja

nuar

y 20

12

Turning of the tide: changing systems to address smoking

for people with a mental illness

B. Bonevskia*, J. Bowmanb, R. Richmondc, J. Bryanta, P. Wyeb, E. Stockingsb,K. Wilhelmd, T. Butlere,f, D. Indigf and A. Wodakd

aThe Centre for Health Research & Psycho-oncology (CHeRP), Cancer Council New SouthWales, University of Newcastle & Hunter Medical Research Institute, Callaghan, NSW,

Australia; bSchool of Psychology, Faculty of Science & IT, University of Newcastle, Callaghan,NSW, Australia; cSchool of Public Health and Community Medicine, University of New SouthWales, Sydney, NSW, Australia; dAlcohol and Drug Service, St. Vincent’s Hospital, Sydney,NSW, Australia; eNational Drug Research Institute, Curtin University of Technology, Perth,Western Australia, Western Australia; fCentre for Health Research in Criminal Justice, (NSW

Justice Health), Sydney, NSW, Australia

(Accepted 26 November 2010)

Smoking tobacco is common among people with a mental illness. A number ofbehavioural and environmental factors underlie the high smoking prevalencerates. Evidence suggests that smokers with mental illness require additionaltargeted support to help them stop smoking. By using a selective review of theinternational literature, this article will argue that a systems-level changeapproach is an appropriate strategy, targeting settings and environments with anumber of advantages for reaching smokers with mental illness. Systems-levelchanges include:

(1) implementing a system of identifying and recording smoking status;(2) providing education, resources and feedback to promote staff intervention;(3) dedicating staff to provide tobacco-dependence treatment;(4) promoting organisational policies that support and provide tobacco-

dependence services.

Three settings will be discussed – mental health services, community social serviceorganisations and prisons. As a result of a history and culture where smoking wasused as part of the system, introducing changes in these settings has to date beenchallenging. However, with increased awareness of the detrimental health andfinancial consequences of smoking, the tide appears to be turning to a cultureincreasingly supportive of smoking cessation. We illustrate this trend using threeAustralian case studies where smoking is starting to be addressed throughchanges to systems.

Keywords: smoking; treatment; mental health; settings; systems

The burden of smoking and mental illness

Smoking rates among people with mental illness in many western countries are high(Lasser et al., 2000; Pickett, James, & Wilkinson, 2006). Depending on the type of

*Corresponding author. Email: [email protected]

Mental Health and Substance Use

Vol. 4, No. 2, May 2011, 116–129

ISSN 1752-3281 print/ISSN 1752-3273 online

� 2011 Taylor & Francis

DOI: 10.1080/17523281.2011.555073

http://www.informaworld.com

Dow

nloa

ded

by [

Uni

vers

ity o

f N

ewca

stle

(A

ustr

alia

)] a

t 21:

36 3

1 Ja

nuar

y 20

12

mental illness, smoking prevalence estimates range between 35 and 90% (Bakeret al., 2006; Lasser et al., 2000; Moeller-Saxon, 2008; Reichler, Baker, Lewin, &Carr, 2001). This is in comparison to around 20% in the general population(Australian Institute of health and Welfare [AIHW], 2008a; Centers for DiseaseControl and Prevention [CDC], 2009; Lasser et al., 2000). Because tobaccodependence is the most prevalent substance abuse disorder among individuals withmental illness (American Psychiatric Association [APA], 2006), these smokers sufferdisproportionally from tobacco-related death (Baker et al., 2006; Lasser et al., 2000),disease (Dalack, Healy, & Meador-Woodruff, 1998; Jha et al., 2006; Stroup,Gilmore, & Jarskog, 2000) and lower quality of life (Colton & Manderscheid, 2006).Of particular concern for smokers with mental illness is that tobacco use increasesthe rate at which many widely used psychiatric medications are metabolised,resulting in increased dosage requirements, medication and other health costs andmedication side-effects (Desai, Seabolt, & Jann, 2001; Goff, Henderson, & Amico,1992; Zullino, Delessert, Eap, Preisig, & Baumann, 2002). Finally, it has beenestimated that up to half of all cigarette purchases in the US are made by smokerswith a mental illness (Lasser et al., 2000). Facing a number of social disadvantagesincluding unemployment and high medical costs, the cost of cigarettes invariablyleads to financial stress and smoking-induced deprivation (McNeill, 2001; Siahpush,Borland, & Yong, 2007; Siahpush & Scollo, 2003).

Why are smokers with mental illness different?

Studies have shown that smokers who are likely to have a mental illness are often asmotivated to quit smoking as smokers in the general population, but they are lesslikely to be successful (Connor, Cook, Herbert, Neal, & Williams, 2002; Giskes, vanLenthe, Turrell, Brug, & Mackenbach, 2006; Kotz & West, 2009; Siahpush, Yong,Borland, Reid, & Hammond, 2009). Reasons underlying this lack of quitting successare multifactorial – while some literature has emphasised genetic and neurobiologicaldifferences (Rigotti 2002; Ziedonis, Kosten, Glazer, & Frances, 1994), this article willfocus on the behavioural and environmental factors that contribute to high rates ofsmoking.

One important factor in the lower rates of smoking cessation among people witha mental illness is the high proportion of people who have a co-morbid drug oralcohol problem, which is likely to reduce the success of quit attempts (Degenhardt& Hall, 2001). Smokers with a mental illness tend to be heavier smokers (Hickman,Delucchi, & Prochaska, 2010), resulting in higher levels of nicotine dependence, andthey smoke for longer durations (Okuyemi et al, 2006; Roddy, Antoniak, Britton,Molyneux, & Lewis, 2006; Siahpush, Heller, & Singh, 2005), having taken upsmoking at an earlier age and attempting to quit at a later age (Kumari & Postma,2005; McNeill, 2001). The social and environmental barriers to quitting smoking forthose with a mental illness include smoking social norms (Flint & Novotny, 1997)and greater likelihood of contact with environments that are permissive of smokingsuch as mental health services or prisons (Richmond et al., 2009; Robertson, 2000).There is also evidence that the tobacco industries have employed targetedapproaches to market cigarettes to individuals with mental illness – providing tax-free cigarettes to psychiatric facilities in some countries, funding research promotinga self-medication hypothesis for nicotine and marketing cheaper brands to ‘streetpeople’ (Apollonio & Malone, 2005; Prochaska, Hall, & Bero, 2008).

Mental Health and Substance Use 117

Dow

nloa

ded

by [

Uni

vers

ity o

f N

ewca

stle

(A

ustr

alia

)] a

t 21:

36 3

1 Ja

nuar

y 20

12

The need for a systems change approach targeting smokers with mental illness

Current population tobacco control approaches such as restrictions on advertising,restrictions on smoking in public places, telephone quitlines, mass media campaignsand increases in the price of cigarettes have had little impact on reaching thesubgroups of smokers with highest smoking rates (Durkin, Biener, & Wakefield,2009; Morris, Tedeschi, Waxmonsky, May, & Giese, 2009; Thomas et al., 2008).There is some evidence that some population approaches may have the negativeimpact of increasing the gap in smoking rates between those with a mental illness andsmokers without mental illness (Ceci & Papierno, 2005; Thomas et al., 2008). Ceciand Papierno (2005) argue that closing a disparity gap requires interventions uniqueto the disparate population. New evidence from Thornton et al. (2011) suggeststhat people with psychosis may not react to mass media campaigns in the same waythat other smokers do and that these advertisements may trigger smoking or craving.It is clear that there is a need to provide smokers, with a mental illness, withadditional support and appropriately targeted interventions.

One model for a targeted approach is to integrate tailored smoking cessationdelivery into existing networks and services used by smokers with a mental illness. Asystems change approach (Fiore, Keller, & Curry, 2007; McDaniel, Stratton, &Britain, 2009; Woods & Jaen, 2010; Ziedonis, Kosten, Glazer, & Frances, 2003) iscritical, given the need to change the smoking social norms entrenched in theseenvironments. This approach is also consistent with the World Health Organisa-tion’s (WHO) Social Determinants of Health Framework, which encourages thereorientation of environments in order to facilitate and support healthy behaviours(Marmot, 2005; Marmot, Friel, Bell, & Houweling, 2008).

System-change models extend beyond the clinical treatment of tobaccodependence to include the ‘denormalisation of smoking’ within these settings (Fioreet al., 2007; Hall & Prochaska, 2009; Ziedonis et al., 2003). Systems-level changes arepolicies and practices designed to integrate the identification of smokers andsubsequent offering and receipt of evidence-based cessation treatments into routinecare (Fiore et al., 2007). They can be direct such as training carers in briefintervention or indirect such as removing cost barriers to treatments. Adapting fromFiore et al. (2007), the core elements of system changes include:

(1) implementing a system of identifying and recording smoking status;(2) providing education, resources and feedback to promote staff intervention;(3) dedicating staff to provide tobacco-dependence treatment;(4) promoting organisational policies that support and provide tobacco-

dependence services.

Using a selective review of the international literature, this article will argue thata systems change approach is an appropriate strategy for targeting smokers withmental illness.

The advantages of a targeted systems-level approach to addressing smoking for people

with a mental illness

Models for integrating smoking cessation strategies (also referred to as nicotine-dependence treatment or smoking care depending on the setting) into mainstream

118 B. Bonevski et al.

Dow

nloa

ded

by [

Uni

vers

ity o

f N

ewca

stle

(A

ustr

alia

)] a

t 21:

36 3

1 Ja

nuar

y 20

12

care for mental illness have largely focussed on the mental health services setting(Hall & Prochaska, 2009; Ziedonis et al., 2003; Wye et al., 2011). In this article,we also consider two additional settings with potential for reaching smokers withmental illness: community social service or welfare organisations (CSOs) andprisons. CSOs are non-government, not-for-profit organisations that provide welfareservices in the communities in which they are based. They provide a range of socialservices including financial and family counselling, temporary accommodation,food and material aid, and child and family support to individuals in need (Bryant,Bonevski, Paul, O’Brien, & Oakes, 2010a). Some programs are mental healthservices which provide pragmatic support for those in the community livingindependently with mental illness. The prevalence of smoking among prisoners isnoted to be very high, as is the desire to quit (Belcher, Butler, Richmond, Wodak, &Wilhelm, 2006; Cropsey, Eldrigde, & Ladner, 2004). The advantages of targetingsmokers who have a mental illness through these settings are outlined below.

Wide access and reach

All three of these settings have wide reach into high-prevalence smoking populationswith high co-occurrence of mental illness. Community mental health services inAustralia reported nearly 6 million service contacts in 2006–2007 (Australian Bureauof Statistics [ABS], 2010), and offer advantages for care provision including regularcontact over extended periods of time (Smith et al., 2007). Within Australia, the CSOsector is large, with over 5809 not-for-profit organisations (ABS, 2010), estimating athroughput of more than 4.3 million people each year (Australian Council of SocialService [ACOSS], 2010). Those most in need are more likely to attend communitysocial services; e.g. indigenous people are almost seven times more likely to usecommunity services and the unemployed almost twice as much than theirrepresentation in the general community would suggest. Taking a conservativeestimate that 60% of clients smoke (Bryant, Bonevski, & Paul, 2010b), thepopulation reach of the social service setting would be over 2.5 million smokers peryear nationally. In prisons, like the other two settings, co-morbidities are common.Smoking prevalence rates of between 77 and 83% have been reported (Belcher et al.,2006; Butler & Milner, 2003; Cropsey et al., 2008; Hockings, Young, Falconer, &O’Rouke, 2002) in correctional facilities. Surveys have reported a 12-monthprevalence of any psychiatric disorder of 61% among prisoners (Butler & Allnutt,2003). Prisoners are less likely to attend community-based smoking cessation andhealth promotion programmes after release, so that time in prison is an especiallyvaluable opportunity to aid cessation efforts (AIHW, 2008b).

Clinical practice guidelines

Guidelines and recommendations exist to help guide mental health care providers inthe provision of tobacco-dependence treatment. The US practice guidelines forsmoking cessation recommend that smokers with mental illness should be providedthe same smoking cessation treatments as the general population (Fiore, 2008). TheAmerican Psychiatric Association encourages mental health clinicians to assesssmoking status with all patients and to assist smokers in quitting, supporting anintegrated approach (APA, 2006). Also in the US, the National Institutes of Health(National Institutes of Health [NIH], 2006) recommends tobacco treatment for

Mental Health and Substance Use 119

Dow

nloa

ded

by [

Uni

vers

ity o

f N

ewca

stle

(A

ustr

alia

)] a

t 21:

36 3

1 Ja

nuar

y 20

12

individuals with psychiatric or substance abuse disorders. Similar practice guidelinesand recommendations have been released in Australia and the UK (NSWDepartment of Health, 2005; West, McNeill, & Raw, 2000). Similarly, in the US,the National Commission on Correctional Health Care recommended that allprisoners be provided with a smoke-free environment and that smoking cessationprograms be offered to staff members and prisoners (Cropsey et al., 2008).

Appropriateness of role as providers of smoking care

Research conducted in Australia suggests that there is strong support for providingsmoking care – nearly three quarters of nurse managers reporting that smoking careshould be an integral function of their unit – although support seems to be linked toperceptions of patient readiness to quit (Wye et al., 2010a). CSO staff have alsoidentified a number of reasons why they are important providers of smoking care totheir clients: they have existing established contact with a large number of smokerswith mental illness, are uniquely placed to address smoking in a holistic wayalongside other issues faced by their clients, are in the position to providepersonalised and ongoing support, and staff agree that providing support to theirclients to stop smoking is an appropriate part of their role (Bryant et al., 2010a;Christiansen, Brooks, Keller, Theobald, & Fiore, 2010).

Acceptable to smokers to receive cessation support in this setting

There is evidence from the inpatient mental health service setting that patients findthe hospital setting appropriate for the provision of smoking care. Admission to a‘smoke-free’ mental health hospital is accepted by the majority of patients whosmoke, particularly if nicotine-dependence treatment is available (Prochaska,Fletcher, S.E. Hall, & S.M. Hall, 2006). Patients report that seeing other patientssmoking and being in a smoky atmosphere would make it difficult to quit (Dickens,Stubbs, Popham, & Haw, 2005). The majority of patients also reported that staffshould encourage patients who smoke to quit or cutback (Dickens et al., 2005).Similar positive responses have been reported from smokers in CSOs and prisons(Bryant et al., 2010a; Richmond et al., 2009). For example in a survey of smokers inan Australian prisoner population (n ¼ 914), three-quarters reported a desire to quitsmoking and 58% had an actual plan to give up (Belcher et al., 2006). A pilot studytesting the feasibility of a multi-component smoking cessation program in prisonfound that prisoners expressed an interest in participating and accepted referrals toappropriate quit support services (Richmond et al., 2006), and focus groups withprisoners revealed changing attitudes towards smoking with prisoners makingsuggestions for a range of acceptable cessation strategies within the prison system(Richmond et al., 2009).

Sustainability and cost-effectiveness

By changing the policies and practices of these settings, there is the potential tochange entire systems to reflect anti-smoking norms. Screening to identify and assesssmoking in mental health community service has been effectively implemented in theUS, with aims to follow-up with counselling and advice to quit (Mangurian et al.,2010). A study using the ‘5 A’s’ approach to smoking care was tested in six

120 B. Bonevski et al.

Dow

nloa

ded

by [

Uni

vers

ity o

f N

ewca

stle

(A

ustr

alia

)] a

t 21:

36 3

1 Ja

nuar

y 20

12

community mental health centres in the US with over 300 participants (Dixon et al.,2009). The results suggest that such a low intensity approach can promote abstinenceand smoking reduction over a 12-month period suggesting long term sustainability(Dixon et al., 2009). The cost-effectiveness of providing smoking cessation throughhealth services has been established. One analysis in the UK found that mostsmoking cessation strategies cost less than £1000 per life year saved, (Parrot,Godfrey, Raw, West, & McNeill, 1998) which falls below the NICE threshold forcost-effective health service treatments (Raftery, 2001). In some cases, the costsavings are more direct. In the US, medical care for prisoners consumes 11% ofcorrectional budgets and is expected to double in 10 years, in part because of highrates of smoking and associated medical conditions (Lamb-Mechanick & Nelson,2000). Decreasing smoking rates will ease the financial burden to each of thesesystems.

Systems-level challenges of smoking care provision

A multitude of evidence-based smoking cessation treatment options exist from briefinterventions to pharmacotherapies and behavioural counselling (Hatsukami, Stead,& Gupta, 2008). The challenge for these settings with high rates of mental illness andsmoking co-morbidities is implementing these treatments in a systematic andsustainable way. Therefore, despite the advantages outlined above, there continue tobe challenges in changing organisational culture, practices and systems as describedbelow. Wye et al. (2011) succinctly outline a range of barriers to smoking careprovision in the mental health setting, which are common to the CSO and prisonsettings. These include lack of staff training and skills, misperceptions aroundquitting interest and/or capacity, addressing that smoking is not a priority and therole of tobacco as therapy or currency.

The specific social and cultural context of prisons has its own normative values,processes and social relationships. Research has shown that tobacco is commonlyregarded as a currency in prisons (Lankenau, 2001; Richmond et al., 2009) and usedto settle payments for gambling, illicit drugs, and other goods and services includingsex (Richmond et al., 2009). A special problem for smoking care provision in prisonsis the specific stresses and tensions of prison life which lead to relapse. These includetransfers to another prison, court appearances, visits from partners who are smokersand receiving bad news from outside of the prison (Richmond et al., 2009). As in themental health setting, there are reports that people start smoking for the first time orincrease their smoking after entering prison (Cropsey et al., 2008).

Another important systems-level challenge to the provision of smoking care is thelack of comprehensive policies. In Australian CSOs’ guidelines, total smoking bansand nicotine-dependence treatment have not been systematically implemented norevaluated. In 2006, the Cancer Council, New South Wales (NSW), Australia,conducted a survey of staff and managers of more than 100 state-based communityservice organisations regarding their current smoking policies. Most (80%) servicessaid they had written smoking policies, most did not contain restrictions on smokingin all areas of the service, smoking outside of the service, smoking in cars andsmoking during ‘outings’ with clients. Instead, the policies outlined ‘designatedsmoking areas’. The existing policies also did not contain strategies for theirenforcement, important predictors of smoking policy success (Lipperman-Kreda &Grube, 2009). Also absent are organisational or sector-wide policies regarding

Mental Health and Substance Use 121

Dow

nloa

ded

by [

Uni

vers

ity o

f N

ewca

stle

(A

ustr

alia

)] a

t 21:

36 3

1 Ja

nuar

y 20

12

tobacco in the CSO sector. Currently, each individual service site develops andimplements its own policy. It is not unusual for a number of services or programsoperating under a single organisation to have vastly different smoking policies.Unlike US prisons, which have introduced total smoking bans, total bans have notbeen introduced in Australian prisons because of the definition of prisoner cells astheir ‘homes’ and thus their ‘right’ to smoke (Department of Corrective Services,2005). Smoking restrictions in some state prisons have been introduced but they arenot accompanied by smoking cessation support (Department of Corrective Services,2005). In Australia, there has been an increase in the proportion of non-smokingprisoners who reported sharing a cell with a smoker and an increase in theproportion of non-smokers feeling the effects of other people’ smoking (Butler,Richmond, Belcher, Wilhelm, & Wodak, 2007).

Overcoming the challenges: examples of systems-level changes in three settings

Historically, the combined effect of the challenges has led to an organisationalculture within these settings that is permissive of smoking, with tobacco playing acrucial role in social control, as surrogate currency and as a symbol of freedomand human rights (Lawn, 2004). More recently, these settings have displayedraised awareness of the negative consequences of smoking for their patients,clients, inmates and for the organisation as a whole. As a result, the tide appearsto be turning with these settings falling into line with other public institutions bystarting to address smoking. Examples in the general hospital setting suggest thatsystem-level changes can successfully increase rates of smoking cessation care forinpatients (Freund et al., 2009). Still, there are few empirical examples of systems-level changes in settings appropriate for smokers with mental illness. There is aneed for more rigorous research in this area. Following are three Australian‘research-in-progress’ case studies of systems-level changes in settings for smokerswith mental illness.

Example 1. Nicotine-dependence treatment in mental health services

Building on an extensive body of descriptive research undertaken in mental healthinpatients settings (Wye et al., 2009; Wye et al., 2010a; Wye et al., 2010b; Wye et al.,2010c) which helped identify barriers to system changes that needed to be addressedand opportunities for integrating smoking cessation support, a number ofintervention programs aimed at increasing the provision of smoking care to patientsare currently underway.

One study, by Wye et al., is implementing a systems-based model of interventionwithin mental health inpatient units in Australia. This model includes evidence-basedintervention strategies including an educational facilitator, the use of clinical leadersto drive change (Doumit, Gattellari, Grimshaw, & O’Brien, 2007), system changes tosupport the provision of smoking care (Grol, Wensing, & Eccles, 2005) and an auditfeedback loop based on unit medical record audit of documented smoking care(Jamtvedt, Young, Kristoffersen, O’Brien, & Oxman, 2006). As each of the unitsinvolved in the project has unique characteristics both in terms of patientdemographics and service provision, much consideration is given to each individualunit’s environment and ensure that intervention strategies are tailored to theirspecific needs.

122 B. Bonevski et al.

Dow

nloa

ded

by [

Uni

vers

ity o

f N

ewca

stle

(A

ustr

alia

)] a

t 21:

36 3

1 Ja

nuar

y 20

12

A randomised controlled trial (RCT) currently underway (by Stockings et al.,2009) will link hospital inpatient smoking care with post-discharge communitycessation support for smokers with a mental illness. This study aims to demonstratethat a multi-modal, integrated smoking intervention, delivered within the communityhealth service setting, will reduce smoking and encourage quitting behaviour inpeople with a mental illness following discharge from an inpatient psychiatric facility.This trial also aims to demonstrate that such an intervention is effective and feasible,and has the potential for wider systems change. Participants will be randomlyallocated to either an intervention arm, where they are offered several smokingcessation supports including extended provision of nicotine replacement therapy(NRT), telephone support, and self-help material or a control ‘treatment as usual’arm. Outcome data including smoking status, nicotine dependence, quit attempts andcutting down behaviour will be collected at one week, and two, four and six monthspost-discharge. Recruitment, intervention and follow-up are currently in progress.

Example 2. Tackling tobacco: delivering smoking care as part of usual care in CSOsettings

The Tackling Tobacco Program is an initiative of the Cancer Council NSW whichaims to work with CSOs to reduce smoking-related harm among the mostdisadvantaged population groups in NSW (Cancer Council NSW, 2006). Its mainfocus involves targeting seven subgroups with high smoking prevalence: low incomesingle-parent families, urban Aboriginals, individuals with a mental illness,vulnerable young people, people who are homeless, with drug and alcohol problems,or in prisons. The program incorporates a number of components, includingdelivering information seminars, providing CSO staff training and offering grants forfree NRT for CSOs. The aim is to facilitate systems change across the communitysocial service sector.

The program aims to be evidence-based and a number of action research projectshave been implemented in parallel with program delivery. Initially, formativequalitative research was conducted in order to explore the barriers and opportunitiesfor the delivery of smoking care within the CSO setting (Bonevski, Bryant, & Paul,2010; Bryant et al., 2010a; Bryant et al., 2010b). Results showed that theacceptability of providing and receiving cessation support in the community servicesetting was high and identified preferences for type of support. For example,recording client smoking status in case-notes was viewed as an acceptable smokingcare action by case-workers. Based on these findings, a smoking care interventionhas been developed in an attempt to address the perceived barriers and providepreferred types of support. The smoking care intervention pilot is currentlyundergoing a feasibility and acceptability trial within an outreach CSO program.

Following the feasibility trial, an RCT by Bonevski et al. (2010a) will assess theefficacy of smoking care provision within CSOs. The efficacy trial will build on workto date which has found that clients are motivated to quit but report needinginexpensive NRT, support from their case-worker and social support to help themquit (Bonevski et al., 2010). The efficacy trial will examine whether a case-workerdelivered motivational interviewing intervention coupled with free NRT andcomputer feedback, and a ‘quit buddy’ system will increase smoking cessation ratesin a large community centre-based CSO. The next step for the program is to workwith the community service sector to develop comprehensive smoking policies.

Mental Health and Substance Use 123

Dow

nloa

ded

by [

Uni

vers

ity o

f N

ewca

stle

(A

ustr

alia

)] a

t 21:

36 3

1 Ja

nuar

y 20

12

Example 3. ‘Breakfree’ smoking cessation support for prisoners

Systems change research in the prison setting has been buoyed by the inmates’ focuson healthy lifestyle activities (Belcher et al., 2006; Indig et al., 2010; Richmond et al.,2006; Richmond et al., 2009). Most inmates who smoke want to quit. The 2009 NSWInmate Health Survey reported that 75% of inmates were current smokers and ofthese, 85% indicated they would like to quit smoking (Indig et al., 2010). Over half(56%) of these prisoners reported attempting to stop smoking or reduce theirtobacco use in the past year, and a quarter planned to quit smoking in the next 3months.

Prisoners suggested a range of practical strategies to assist them to quit smokingin the correctional system including: offering smoke-free cells or smoke-free prisonwings, providing incentives for non-smokers, providing ready access to free or low-cost nicotine patches, provision of support for quitting from the prison clinic andprison officers and being allowed to have educational materials in their cells andproviding more opportunities to exercise. Prisoners contributed to the developmentof the smoking cessation booklet used to advise on quitting, called ‘Breakfree’.

An RCT of a multi-component intervention being undertaken by Richmondet al. (2006) is close to completion and will be the first RCT of a smoking cessationintervention in the prison setting. In that study, 436 prisoners were randomised toeither NRT, cognitive behaviour therapy (CBT) and nortriptyline (NOR) or NRT,CBT and placebo. Follow-up has been completed for three and six months and isdue for completion at 12 months in October 2010.

Summary and conclusions

The research shows that smokers with mental illness are interested in quitting.However, a range of factors increase the difficulty of successful quitting. Thesesmokers require additional targeted support and assistance to stop smoking. Systemschanges have the potential to increase rates of smoker identification andintervention, and subsequently to improve the health of people with mental illnessby facilitating quit attempts (Fiore et al., 2007). Systems-level changes also have thepotential to change the smoking social norms these smokers are familiar with, whichtend to be accepting of smoking. This article described three settings with greatpotential for system-wide changes for smokers with mental illness: mental healthservices, community social service organisations and prisons. Each of these settingshave wide and ready access to large numbers of people with a mental illness whosmoke, are appropriately placed to provide smoking care to their clients, andimportantly, are organisations with systems in place whereby smoking care can beintegrated into current usual care provision.

Despite the advantages of these settings, historically, smoking has been acceptedas part of normal routine and therapy and sometimes promoted, resulting in pro-smoking organisational culture. However, with policy directives and acknowl-edgement of the benefits of tobacco control, these settings are increasinglyencouraging smoking cessation and taking an anti-smoking position. Very littleempirical research is available though to drive these changes and there is an urgentneed for more robust trials of system-level changes in settings with smokers withmental illness. Lawn and Campion (2010) found that a number of factors wereassociated with the successful introduction of smoke-free initiatives within the

124 B. Bonevski et al.

Dow

nloa

ded

by [

Uni

vers

ity o

f N

ewca

stle

(A

ustr

alia

)] a

t 21:

36 3

1 Ja

nuar

y 20

12

mental health setting including clear, consistent and visible leadership, cohesiveteamwork, training opportunities for staff, fewer staff smokers, use of NRT andconsistent enforcement of a smoke-free policy. This article outlined three case studiesof trials currently underway, adapting some of those principles and with significantpromise in creating change in the three settings.

All systems have their nuances – for example, while the terms tobacco-dependence treatment and nicotine-dependence treatment are preferred in the mentalhealth services settings, smoking care is preferred in the CSO and prison settings.Thus tailoring interventions to the systems and individuals within the settings isimportant. However the core elements for implementing smoking care in thesesettings remain consistent across settings – recording smoking status, offeringcessation support, training staff, allocating dedicated smoking care leaders orchampions and implementing organisational smoking policies.

Finally, although the focus of this article is on changing systems for smokers withmental illness within high access settings, these smokers continue to require cessationsupport and encouragement when outside of these settings and in the generalcommunity. Thus strategies need to be developed that ensure their quit smokingsuccess is maintained and supported outside the settings of interest.

References

American Psychiatric Association (APA). (2006). Practice guidelines for the treatment ofpatients with substance use disorder (2nd ed.). Washington, DC: APA.

Apollonio, D.E., & Malone, R.E. (2005). Marketing to the marginalised: Tobacco industrytargeting of the homeless and mentally ill. Tobacco Control, 14, 409–415.

Australian Bureau of Statistics (ABS). (2010). Community Services. Cat no. 86960. Canberra:ABS.

Australian Council of Social Service (ACOSS). (2010). Australian community sector surveyreport (Vol. 1). National. 2010. Retrieved from http://www.csi.edu.au/uploads/31642/ufiles/ACOSS-Australian-Community-Sector-Survey-2010.pdf

Australian Institute of Health and Welfare (AIHW). (2008a). 2007 National drug strategyhousehold survey: First results. Drug Statistics Series number 20. Cat no. PHE 98.Canberra: AIHW.

Australian Institute of Health and Welfare (AIHW). (2008b). Australia’s Health 2008. Cat no.AUS 99. Canberra: AIHW.

Baker, A., Ivers, R., Bowman, J., Butler, T., Kay-Lambkin, F.J., Wye, P., . . . Walsh, R.A.(2006). Where there’s smoke there’s fire: High prevalence of smoking among some sub-populations and recommendations for intervention. Drug and Alcohol Reviev, 25(1), 85–96.

Belcher, J.M., Butler, T., Richmond, R.L., Wodak, A.D., & Wilhelm, K. (2006). Smoking andits correlates in an Australian prisoner population. Drug and Alcohol Review, 25, 343–348.

Bonevski, B., Bryant, J., & Paul, C. (2010). Encouraging smoking cessation amongdisadvantaged groups: A qualitative study of the financial aspects of cessation. Drugand Alcohol Review [Epub ahead of print]. doi:10.1111/j.1465-3362.2010.00248.x.

Bryant, J., Bonevski, B., & Paul, C. (2010b). Smoking and other health risk behaviours in acommunity social service organisation. Final Report for Bondi Anglicare, Sydney.Unpublished data.

Bryant, J., Bonevski, B., Paul, C., O’Brien, J., & Oakes, W. (2010a). Delivering smokingcessation support to disadvantaged groups: A qualitative study of the potential ofcommunity welfare organisations. Health Education Research, 25, 979–990. doi: 10.1093/her/cyq051.

Butler, T., Richmond, R., Belcher, J., Wilhelm, K., & Wodak, A. (2007). Should smoking bebanned in prisons? Tobacco Control, 16, 291–293.

Butler, T., & Allnutt, S. (2003). Mental illness among New South Wales Prisoners. Sydney,Australia: NSW Corrections Health Service. Retrieved from http://www.justicehealth.nsw.gov.au/publications/Mental_Illness_Among_NSW_Prisoners_2003.pdf

Mental Health and Substance Use 125

Dow

nloa

ded

by [

Uni

vers

ity o

f N

ewca

stle

(A

ustr

alia

)] a

t 21:

36 3

1 Ja

nuar

y 20

12

Butler, T., & Milner, L. (2003). The 2001 New South Wales Inmate Health Survey. Sydney,Australia: NSW Corrections Health Service. Retrieved from http://www.justice-health.nsw.gov.au/publications/Inmate_Health_Survey_2001.pdf

Cancer Council NSW. (2006). Lifting the Burden. Tobacco Control and Social Equity StrategyJuly 2006 to June 2011. 2006. Retrieved from www.cancercouncil.com.au/html/preven-tion/smoking_tobacco/tacklingtobacco/downloads/Lifting_the_burden.pdf

Ceci, S.J., & Papierno, P.B. (2005). The rhetoric and reality of gap closing: When the ‘‘have-nots’’ gain but the ‘‘haves’’ gain even more. American Psychologist, 60, 149–160.

Centers for Disease Control and Prevention (CDC). (2009). Cigarette smoking among adults –United States. Journal of the American Medical Association, 301, 373–375.

Christiansen, B.A., Brooks, M., Keller, P.A., Theobald, W.E., & Fiore, M.C. (2010). Closingtobacco-related disparities using community organizations to increase consumer demand.American Journal of Preventive Medicine, 38, S397–S402.

Colton, C.W., & Manderscheid, R.W. (2006). Congruencies in increased mortality rates, yearsof potential life lost, and causes of death among public mental health clients in eight states.Preventing Chronic Disease: Public Health Research, Practice and Policy, 3, 1–14.

Connor, S.E., Cook, R.L., Herbert, M.I., Neal, S.M., & Williams, J.T. (2002). Smokingcessation in a homeless population: There is a will, but is there a way? Journal of GeneralInternal Medicine, 17, 369–372.

Cropsey, K., Eldrigde, G., & Ladner, T. (2004). Smoking among female prisoners: An ignoredpublic health epidemic. Addictive Behaviors, 29, 425–431.

Cropsey, K., Eldrigde, G., Weaver, M., Villalobos, G., Stitzer, M., & Best, A. (2008). Smokingcessation intervention for female prisoners: Addressing an urgent public health need.American Journal of Public Health, 98, 1894–1901.

Dalack, G.W., Healy, D.J., & Meador-Woodruff, J.H. (1998). Nicotine dependence inschizophrenia: Clinical phenomena and laboratory findings. The American Journal ofPsychiatry, 155, 1490–1501.

Degenhardt, L., & Hall, W. (2001). The association between psychosis and problematic druguse among Australian adults: Findings from the National Survey of Mental Health andWell-Being. National Drug and Alcohol Research Centre. Technical Report No. 93, 2001.

Department of Corrective Services. (2005). Operations procedures manual. Smoke freeenvironment policy. Sydney: Government of New South Wales, 2005. Cat No: 22.25.

Desai, H.D., Seabolt, J., & Jann, M.W. (2001). Smoking in patients receiving psychotropicmedications: A pharmacokinetic perspective. CNS Drugs, 15, 469–494.

Dickens, G., Stubbs, J., Popham, R., & Haw, C. (2005). Smoking in a forensic psychiatricservice: A survey of outpatients’ views. Journal of Psychiatric and Mental Health Nursing,12, 672–678.

Dixon, L., Medoff, D., Goldberg, R., Lucksted, A., Kreyenbuhl, J., DiClemente, C., . . . Potts,W. (2009). Implementation of the 5 A’s of smoking cessation at community mental healthcenters effective for reduction of smoking by patients with serious mental illness? AmericanJournal on Addictions, 18, 386–392.

Doumit, G., Gattellari, M., Grimshaw, J., & O’Brien, M.A. (2007). Local opinion leaders:Effects on professional practice and health care outcomes. Cochrane database ofSystematic Reviews, Issue 1. Art no CD000125. Doi: 10.1002/14651858.CD000125.pub3.

Durkin, S.J., Biener, L., & Wakefield, M.A. (2009). Effects of different types of antismokingads on reducing disparities in smoking cessation among socioeconomic subgroups.American Journal of Public Health, 99, 2217–2223.

Fiore, M.C. (2008). Treating tobacco use and dependence: 2008 update. Clinical practiceguideline. Rockville, MD: US Dept Health Human Services, Public Health Service Rep.

Fiore, M.C., Keller, A.K., & Curry, S.J. (2007). Health system change to facilitate the deliveryof tobacco-dependence treatment. American Journal of Preventive Medicine, 33, S349–S356.

Flint, A.J., & Novotny, T.E. (1997). Poverty status and cigarette smoking prevalence andcessation in the U.S., 1983–1993: The independent risk of being poor. Tobacco Control,6(1), 14–8.

Freund, M., Campbell, E., Paul, C., Sakrouge, R., McElduff, P., Walsh, R.A., . . . Wiggers, J.(2009). Increasing smoking cessation care provision in hospitals: A meta-analysis ofintervention effect. Nicotine & Tobacco Research, 11, 650–662.

126 B. Bonevski et al.

Dow

nloa

ded

by [

Uni

vers

ity o

f N

ewca

stle

(A

ustr

alia

)] a

t 21:

36 3

1 Ja

nuar

y 20

12

Giskes, K., van Lenthe, F.J., Turrell, G., Brug, J., & Mackenbach, J.P. (2006). Smokers livingin deprived areas are less likely to quit: A longitudinal follow-up. Tobacco Control, 15,485–488.

Goff, D.C., Henderson, D.C., & Amico, B.S. (1992). Cigarette smoking in schizophrenia:Relationship to psychopathology and medication side effects. American Journal ofPsychiatry, 149, 1189–1194.

Grol, R., Wensing, M., & Eccles, M. (2005). Improving patient care: The implementation ofchange in clinical practice. Edinburgh: Elsevier.

Hall, S.M., & Prochaska, J.J. (2009). Treatment of smokers with co-occurring disorders:Emphasis on integration in mental health and addiction treatment settings. AnnualReviews in Clinical Psychology, 5, 409–431.

Hatsukami, D., Stead, L., & Gupta, P. (2008). Tobacco addiction. The Lancet, 371, 2027–2038.

Hickman, N., Delucchi, K., & Prochaska, J. (2010). A population-based examination ofcigarette smoking and mental illness in black Americans. Nicotine & Tobacco Research[Epub ahead of print]. doi: 10.1093/ntr/ntq160.

Hockings, B., Young, M., Falconer, A., & O’Rouke, P.K. (2002). Queensland Women Prisoners’Health survey. Queensland Department of Corrective Services, Brisbane Australia.Retrieved from http://www.correctiveservices.qld.gov.au/Publications/Corporate_Publications/Strategic_Documents/health_survey.pdf

Indig, D., Topp, L., Ross, B., Mamoon, H., Border, B., Kumar, S., & McNamara, M. (2010).2009 NSW Inmate Health Survey: Key Findings Report. Sydney: Justice Health.

Jamtvedt, G., Young, J.M., Kristoffersen, D.T., O’Brien, M.A., & Oxman, A.D. (2006). Auditand feedback:Effects onprofessional practice andhealth care outcomes.CochraneDatabaseof SystematicReviews. Issue 2.Art no: CD000259.Doi: 10.1002/14651858.CD000259.pub2.

Jha, P., Peto, R., Zatonski, W., Boreham, J., Jarvis, M.J., & Lopez, A.D. (2006). Socialinequalities in male mortality, and in male mortality from smoking: Indirect estimationfrom national death rates in England and Wales, Poland, and North America. Lancet, 368,367–370.

Kotz, D., & West, R. (2009). Explaining the social gradient in smoking cessation: It’s not inthe trying, but in the succeeding. Tobacco Control, 18, 43–46.

Kumari, V., & Postma, P. (2005). Nicotine use in schizophrenia: The self-medicationhypothesis. Euroscience and Biobehavioural Reviews, 29, 1021–1034.

Lamb-Mechanick, D., & Nelson, J. (2000). Prison health care survey: An analysis of factorsinfluencing per capita costs. Washington, DC: National Institutes of Corrections; 2000.Retrieved from http://nicic.org/pub/2000/015999.pdf

Lankenau, S.E. (2001). Smoke ‘em if you got ’em: Cigarette black markets in US prisons andjails. The Prison Journal, 81, 142–161.

Lasser, K., Boyd, J.W., Woolhandler, S., Himmelstein, D.U., McCormick, D., & Bor, D.H.(2000). Smoking and mental illness: A population-based prevalence study. Journal of theAmerican Medical Association, 284, 2606–2610.

Lawn, S.J. (2004). Systemic barriers to quitting smoking among institutionalised public mentalhealth service populations: A comparison of two Australian sites. International Journal ofSocial Psychiatry, 50, 204–215.

Lawn, S., & Campion, J. (2010). Factors associated with success of smoke-free initiatives inAustralian psychiatric inpatient units. Psychiatric Services, 61, 300–305.

Lipperman-Kreda, S., & Grube, J.W. (2009). Students’ perception of community disapproval,perceived enforcement of school antismoking policies, personal beliefs, and their cigarettesmoking behaviours: Results from a structural equation modelling analysis. Nicotine &Tobacco Research, 11, 531–539.

Mangurian, C., Miller, G.A., Jackson, C.T., Li, H., Essock, S.M., & Sederer, L.I. (2010). Statemental health policy: Physical health screening in state mental health clinics: The NewYork Health Indicators Initiative. Psychiatric Services, 61, 346–348.

Marmot, M. (2005). Social determinant of health inequalities. Lancet, 365, 1099–1104.Marmot, M., Friel, S., Bell, R., & Houweling, T.A.J. (2008). Closing the gap in a generation:

Health equity through action on the social determinants of health. Lancet, 372, 1661–1669.McDaniel, A.M., Stratton, R.M., & Britain, M. (2009). Systems approaches to tobacco

dependence treatment. Annual Reviews in Nursing Research, 27, 345–363.

Mental Health and Substance Use 127

Dow

nloa

ded

by [

Uni

vers

ity o

f N

ewca

stle

(A

ustr

alia

)] a

t 21:

36 3

1 Ja

nuar

y 20

12

McNeill, A. (2001). Smoking and mental health – A review of the literature. Retrieved fromhttp://www.ash.org.uk/files/documents/ASH_202.pdf

Moeller-Saxon, K. (2008). Cigarette smoking and interest in quitting among consumers at apsychiatric disability rehabilitation and support service in Victoria. Australian and NewZealand Journal of Public Health, 32, 479–481.

Morris, C.D., Tedeschi, G.J., Waxmonsky, J.A., May, M., & Giese, A.A. (2009). Tobaccoquitlines and persons with mental illnesses: Perspective, practice and direction. Journal ofthe American Psychiatric Nurses Association, 15, 32–40.

National Institutes of Health (NIH). (2006). State-of-the-science Conference Statement onTobacco. Use: Prevention, Cessation and Control. Retrieved from http://consensus.nih.gov/2006/tobaccostatementfinal090506.pdf

NSW Department of Health. (2005). Nicotine Dependent Inpatients (The Guide for theManagement of). Retrieved from http://www.health.nsw.gov.au/policies/

Okuyemi, K.S., Caldwell, A.R., Thomas, J.L., Born, W., Richter, K.P., Nollen, N., . . .Braunstein, K. (2006). Homelessness and smoking cessation: Insights from focus groups.Nicotine Tobacco Research, 8, 287–296.

Parrott, S., Godfrey, C., Raw, M., West, R., & McNeill, A. (1998). Guidance forcommissioners on the cost effectiveness of smoking cessation interventions. Thorax, 53,S2–S37. doi: 10.1136/thx.53.2008.S2.

Pickett, K.E., James, O.W., & Wilkinson, R.G. (2006). Income inequality and the prevalenceof mental illness: A preliminary international analysis. Journal of Epidemiology &Community Health, 60, 646–647.

Prochaska, J.J., Fletcher, L., Hall, S.E., & Hall, S.M. (2006). Return to smoking following asmoke-free psychiatric hospitalisation. American Journal of Addiction, 15, 15–22.

Prochaska, J.J., Hall, S.M., & Bero, L.A. (2008). Cigarette smoking among individuals withschizophrenia: What role has the tobacco industry played? Schizophrenia Bulletin, 34, 555–567.

Raftery, J. (2001). NICE: Faster access to modern treatments? Analysis of guidance on healthtechnologies. British Medical Journal, 323, 1300–1303.

Reichler, H., Baker, A., Lewin, T., & Carr, V. (2001). Smoking among in-patients with drug-related problems in an Australian psychiatric hospital.Drug andAlcohol Review, 20, 231–237.

Richmond, R., Butler, T., Belcher, J.M., Wodak, A., Wilhelm, K.A., & Baxter, E. (2006).Promoting smoking cessation among prisoners: Feasibility of a multi-componentintervention. Australian New Zealand Journal of Public Health, 30, 474–478.

Richmond, R., Butler, T., Wilhelm, K., Wodak, A., Cunningham, M., & Anderson, I. (2009).Tobacco in prisons: A focus group study. Tobacco Control, 18, 176–182.

Rigotti, N.A. (2002). Treatment of tobacco use and dependence. New England Journal ofMedicine, 346, 506–512.

Robertson, E. (2000). Hawaii State Hospital request to RJ Reynolds for cigarettes. Retrievedfrom http://www.tobaccodocuments.org/landman/522700931-0932.html

Roddy, E., Antoniak, M., Britton, J., Molyneux, A., & Lewis, S. (2006). Barriers andmotivators to gaining access to smoking cessation services amongst deprived smokers – aqualitative study. BMC Health Services Research, 6, 147. doi:10.1186/1472-6963-6-147.

Siahpush, M., Borland, R., & Yong, H. (2007). Sociodemographic and psychosocial correlatesof smoking induced deprivation and its effect on quitting: Findings from the InternationalTobacco Control Policy Evaluation Survey. Tobacco Control, 16(e2). doi:10.1136/tc.2006.016279.

Siahpush, M., Heller, G., & Singh, G. (2005). Lower levels of occupation, income andeducation are strongly associated with a longer smoking duration: Multivariate resultsfrom the 2001 Australian National Drug Strategy Survey. Public Health, 119, 1105–1110.

Siahpush, M., & Scollo, M. (2003). Smoking and financial stress. Tobacco Control, 12, 60–66.Siahpush, M., Yong, H., Borland, R., Reid, J.L., & Hammond, D. (2009). Smokers with

financial stress are more likely to want to quit but less likely to try or succeed: Findingsfrom the International Tobacco Control (ITC) four country survey. Addiction, 104, 1382–1390. doi: 10.1111/j.1360–0443.2009.02599.x.

Smith, S., Yeomans, D., Bushe, C.J.P., Eriksson, C., Harrison, T., Holmes, R., . . . Mynors-Wallis, S. (2007). A well-being programme in severe mental illness. Baseline findings in aUK cohort. International Journal of Clinical Practice, 61, 1971–1978.

128 B. Bonevski et al.

Dow

nloa

ded

by [

Uni

vers

ity o

f N

ewca

stle

(A

ustr

alia

)] a

t 21:

36 3

1 Ja

nuar

y 20

12

Stockings, E.A., Bowman, J.A., Wiggers, J.H., Baker, A.L., Carr, V.J., Terry, M.A., . . . Wye,P.M. (2009). An integrated smoking cessation intervention for mental health inpatients:From hospital to community. Paper presented at the conference Oceania Tobacco Control2009, Darwin, NT, Australia.

Stroup, T.S., Gilmore, J.H., & Jarskog, L.F. (2000). Management of medical illness in personswith schizophrenia. Psychiatric Annals, 30, 35–40.

Thomas, S., Fayter, D., Misso, K., Ogilvie, D., Petticrew, M., Sowden, A., . . . Whitehead, M.(2008). Population tobacco control interventions and their effects on social inequalities insmoking: Systematic review. Tobacco Control, 17, 230–237.

Thornton, L.K., Baker, A.L., Johnson, M.P., & Kay-Lambkin, F.J. (2011). Perceptions ofanti-smoking public health campaigns among people with psychotic disorders. MentalHealth and Substance Use, 4, 105–115.

West, R., McNeill, A., & Raw, M. (2000). Smoking cessation guidelines for healthprofessionals: An update. Thorax, 55, 987–999. doi:10.1136/thorax.55.12.987.

Woods, S.S., & Jaen, C.R. (2010). Increasing consumer demand for tobacco treatments. Tendesign recommendations for clinicians and healthcare systems. American Journal ofPreventive Medicine, 38, s385–s392.

Wye, P., Bowman, J., Wiggers, J., Baker, A., Carr, V., Terry, M., . . . Knight, J. (2010a). Anaudit of the prevalence of recorded nicotine dependence treatment in an Australianpsychiatric hospital. Australian New Zealand Journal of Public Health, 34, 298–303.

Wye, P., Bowman, J., Wiggers, J., Baker, A., Carr, V., Terry, M., . . . Knight, J. (2010b).Providing nicotine dependence treatment to psychiatric inpatients: The views ofAustralian nurse managers. Journal of Psychiatric and Mental Health Nursing, 17, 319–327.

Wye, P., Bowman, J., Wiggers, J., Baker, A., Knight, J., Carr, V.J., . . . Terry, M. (2009).Smoking restrictions and treatment for smoking: policies and procedures in psychiatricinpatient units in Australia. Psychiatric Services, 60, 100–107.

Wye, P., Bowman, J., Wiggers, J., Baker, A., Knight, J., Carr, V., . . . Terry, M. (2010c). Totalsmoking bans in psychiatric inpatient services: A survey of perceived benefits, barriers andsupport among staff. BMC Public Health, 10, 327. doi:10.1186/1471–2458–10–372.

Wye, P., Bowman, J., Wiggers, J., Freund, M., Wolfenden, L., & Stockings, E. (2011).Treating nicotine dependence in mental health hospitals. Mental Health and SubstanceUse, 4, 130–143.

Ziedonis, D.M., Kosten, T.R., Glazer, W.M., & Frances, R.J. (1994). Nicotine dependenceand schizophrenia. Hospital and Community Psychiatry, 45, 204–206.

Ziedonis, D.M., Williams, J.M., & Smelson, D. (2003). Serious mental illness and tobaccoaddiction: A model program to address this common but neglected issue. AmericanJournal of the Medical Sciences, 326, 223–230.

Zullino, D.F., Delessert, D., Eap, C.B., Preisig, M., & Baumann, P. (2002). Tobacco andcannabis smoking cessation can lead to intoxication with clozapine or olanzapine.International Clinical Psychopharmacology, 17, 141–143.

Mental Health and Substance Use 129

Dow

nloa

ded

by [

Uni

vers

ity o

f N

ewca

stle

(A

ustr

alia

)] a

t 21:

36 3

1 Ja

nuar

y 20

12