Community Ment Health J DOI 10.1007/s10597-014-9823-7
BRIEF COMMUNICATION
Patient Management and Psychopharmacological Treatment Associated to Smoking Ban in an Acute Psychiatric Unit Daniel Berge´ • Anna Mane´ • Francina Fonseca Alba Toll • Ana Merino • Victor Pe´rez • Antoni Bulbena
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Received: 12 January 2014 / Accepted: 11 December 2014 Ó Springer Science+Business Media New York 2014
Nicotine Smoking-ban Cigarettes
Abstract This study investigates differences in terms of clinical and treatment management in psychiatric hospitalization associated to smoking ban. We collected data regarding medication, socio-demographic and admission characteristics from all patients admitted to an acute psychiatric hospital before and after a smoking ban was in force. We also assessed a limited sample of patients before and after the ban regarding nicotine dependence, motivation to quit smoking and attitudes towards the ban. More number of leaves of absence and movement restrictions during the ban period occurred in comparison to the preban period. On the contrary a lack of significant differences in terms of hospital stay (duration, rate of voluntary admissions and voluntary discharges), use of sedatives and doses of antipsychotics was found. A period of adjustment regarding the deal with leave of access and facilitate nicotine replacement treatment may help future psychiatric facilities planning smoking free policies.
Keywords Psychiatry
D. Berge´ (&) A. Mane´ F. Fonseca A. Toll A. Merino V. Pe´rez A. Bulbena Institute of Neuropsychiatry and Addictions, Hospital del Mar, Psichiatry, Passeig Maritim 25/29, 08003 Barcelona, Spain e-mail: [email protected]
A. Bulbena e-mail: [email protected]
A. Mane´ e-mail: [email protected] F. Fonseca e-mail: [email protected] A. Toll e-mail: [email protected] A. Merino e-mail: [email protected]
Introduction More than 60 % of patients with severe mental disorders are smokers and 35 % of them smoke more than 20 cigarettes per day, which is considered an important mortality risk factor (Olivier et al. 2007; Salokangas et al. 2006). Tobacco use is estimated to shorten life expectancy by 12–13 years in mentally ill smokers. Some authors have suggested that severely mentally ill patients—especially psychotic patients—presenting cardiovascular risk factors or having a first cardiovascular event are not treated with the same therapeutic effort as the general population (Mitchell and Lord 2010). Tolerance for smoking in psychiatric wards may be considered an example. Some of the reasons cited to continue with such
D. Berge´ A. Mane´ F. Fonseca V. Pe´rez A. Bulbena IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain A. Mane´ V. Pe´rez Centro de Investigacio´n Biome´dica en Red de Salud Mental, Barcelona, Spain A. Bulbena Department of Psychiatry, Universitat Auto`noma de Barcelona, Barcelona, Spain
V. Pe´rez e-mail: [email protected]
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permissiveness are: smoking may help patients tolerate the hospital stay better; psychiatric smoker patients may become anxious or aggressive if they are not allowed to smoke; or abrupt smoking cessation may cause increased restlessness and strong disagreement in most patients (Etter et al. 2008). Polycyclic aromatic hydrocarbons (PAHs) are potent inducers of the hepatic cytochrome P-450 (CYP) isoenzymes 1A1 and 1A2 and cause some antipsychotic drugs— mainly olanzapine and clozapine—to be metabolized faster. Therefore, in a smoking cessation setting, a dose adjustment may be required for some antipsychotic drugs in order to avoid the risk of toxicity (Haslemo et al. 2006; Kroon 2007; Lowe and Ackman 2010). Involuntarily hospitalized patients may also be forced to quit smoking, which has ethical implications. Some authors encourage sympathetic tolerance towards those suffering a severe mental illness. Other studies cite smoking as a way to establish a better patient-psychiatrist relationship, and smoking is also used as a reward for patients (Dickens et al. 2004). Non-smoker inpatients, visitors and staff may easily become passive smokers in psychiatric wards, causing justified complaints or even worsening respiratory disorders (‘‘Council of Scientific Affairs, American Medical Association’’ 1994). Several smoking bans have been implemented in psychiatric wards all around the world. Whereas the smoking ban started nationwide in 1992 in the United States, European countries—and specially Spain—have delayed the start of the ban for years. In Spain the smoking law 42/2010 (Ley 42/2010, 30 diciembre 2010) expressly forbids smoking in all health centers including psychiatric hospitals, with the exception of medium- and long- stay psychiatric hospitals, where special indoor or outdoor smoking places can be designated. Nevertheless, the Spanish smokefree regulations have been progressively implemented in the different psychiatric units between 2012 and 2013. Previous studies performed in smoke-free psychiatric units have detected either positive outcomes, negative outcomes or no changes. Only a few studies have reported negative outcomes in the form of increased attempts to break the ban and increased verbal aggressiveness. On the contrary, the majority of the studies have reported no changes in seclusion rates, prescriptions of as-needed medication, aggressive behaviors or physical restraints and positive outcomes such as a reduction in conflicts related to cigarette use (Moss et al. 2010). Most studies are focused on staff expectancies and on the extent to what such expectations are fulfilled. However, few studies assess objective measurement variables such as changes in medication patterns or other measurable clinical management variables.
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The present study reports objective outcomes in terms of patient management and characteristics, number of stays and medications in an acute psychiatric hospital in Barcelona before and after the implementation of a smoking ban, in order to objectively examine differences between the two periods.
Methods Data were collected from all patients admitted to an acute psychiatric hospital before and after the smoking ban came into effect. Our acute psychiatric hospital is composed of a general acute psychiatric ward with 74 beds, and an acute dual ward with 11 beds. We collected data regarding the admission period (duration, voluntary vs. involuntary admission, type of discharge, leaves of absence, diagnosis according to the International Classification of Diseases-9 [‘‘WHO|International Classification of Diseases (ICD)’’ 2010]; socio-demographic data, patient management during hospital stay (movement restrictions based on mechanical body restraints and other severe incidences) and medication regimen for all patients admitted to both the acute psychiatric ward and the dual psychiatric ward during their stay in two different and equivalent time periods. Leaves of absence could be a short walk around the hospital of 1–3 h length, a 12 h day off since morning till afternoon or a permission to spend the weekend at home. First were included all patients discharged from January the 1st to April the 30th 2012, when the smoking ban had not come into effect yet. Secondly were included all patients admitted from January the 1st to April the 30th 2013 after the smoking ban came into effect. The smoking ban started on January the 1st 2013. Three months before the implementation of the smoking ban, a team constituted by several nursing supervisors, nurses, clinical assistants and a psychiatrist implemented a short program to evaluate staff attitudes towards the ban, anticipate difficulties, achieve consensus among the staff and inform and support the patients and relatives on the new smoke-free regulations. To this purpose, several meetings were held with all levels of staff and inpatients. After the ban implementation, smoking cessation was performed using a nicotine replacement therapy (NRT). The acquisition of this treatment was at the discretion of the patients or their relatives. Smoking was permitted and recorded for the patients that were allowed to leave the hospital for short periods. Medication was classified into two groups: sedatives (including benzodiazepines and zolpidem) that were converted to lorazepam equivalents (Chouinard 2004), and antipsychotics (all antipsychotics including those administered to enhance sedation), that were converted to 100 mg chlorpromazine equivalents) (Andreasen et al. 2010). For
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amisulpride, clotiapine, levomepromazine, paliperidone, periciazine and zuclopentixol we used the equivalent rates reported by Gardner et al. (2010). Long-acting injectable antipsychotics were registered by dividing the total dose by the time elapsed between administrations. Due to the existing evidence on the interaction of PAHs with clozapine, an additional analysis was carried out only for this antipsychotic. By computing the dose of sedatives we aimed to elucidate whether more sedation was needed after the smoking ban (all patients were included), whereas by computing the dose of antipsychotics we aimed to find out whether different doses of antipsychotics were needed in patients who were usually treated with antipsychotics (only patients on antipyschotics were considered). We also assessed nicotine dependence and motivation to quit smoking in patients before and after the smoking ban. All patients staying in the hospital the week before and 1 month after the start of the smoking ban were evaluated using the Fagerstro¨m Test for Nicotine Dependence (Heatherton et al. 1991) to assess dependence on nicotine. The Richmond selfreported questionnaire (Co´rdoba et al. 2000; Richmond et al. 1993) was used to assess motivation to quit smoking. Between-groups comparisons were performed using the Chi-square test for categorical data and Student’s t test to compare the means for continuous data. Data was analyzed using PASW Statistics v18.0 software (IBM, SPSS Inc.). The authors state that there are no known conflicts of interest. All authors certify responsibility for the content of this manuscript.
Results A total of 299 admissions (248 in the acute ward and 51 in the dual ward) of 266 different patients were recorded from January to April 2012, while 282 admissions (233 in the acute ward and 49 in the dual ward) of 248 different patients were recorded from January to April 2013. The incidence of the different disorders was as follows: schizophrenia (any subtype) was the most frequent diagnosis (35.5 % in 2012 and 36.9 % in 2013) followed by manic or mixed states in bipolar disorder (12.7 % in 2012 and 7.8 % in 2013), unipolar or bipolar depression (9.7 % in 2012 and 14.9 % in 2013), psychosis not otherwise specified (9.4 % in 2012 and 12.1 % in 2013), personality disorders (11.0 % in 2012 and 7.4 % in 2013), drug related disorders (9.0 % in 2012 and 9.2 % in 2013) and others (12 % in 2012 and 11.1 % in 2013) without significant differences between periods (Chi-square: 10.598, p = 0.478). We also included subjects in the main diagnostic groups of psychosis versus non-psychosis, thus obtaining a group-diagnosis of psychosis in 46.8 % of the subjects in the 2012 period and 50 % in the 2013 period (Chi-square: 0.587, p = 0.444).
There were no significant differences between periods in age (pre-ban period: mean age: 43.63 ± 15.75 years vs. ban period: mean age: 43.72 ± 15.54 years; t = -0.067, p = 0.946). Gender (pre-ban period: 59.2 % males vs. ban period: 56.7 % males; Chi-square = 0.360, p = 0.548), rates of involuntary admission (pre-ban period: 49.8 % vs. ban period: 53.5 %, Chi-square = 0.801, p = 0.371), voluntary discharge (pre-ban period: 5.0 % vs. ban period: 6.7 %, Chi-square = 0.780, p = 0.377) or length of stay (pre-ban period: 25.46 ± 21.28 days vs. ban period: 24.19 ± 22.08 days, t = 0.708, p = 0.479). After splitting the sample into dual ward patients and acute ward patients, no significant differences were observed between periods in these variables (results not shown). The total number (1.083 vs. 1.477; p = 0.02) and average number (3.67 ± 6.2 vs. 5.31 ± 9.4; p = 0.014) of leaves of absence per patient was higher during the ban period, although there were no significant differences in the rates of patients granted a leave of absence [pre-ban period: 176 (59.7 %) vs. ban period: 159 (57.2 %), Chi-square = 0.359, p = 0.549]. There were no leave of absence in the dual ward. During the ban period, as compared to the pre-ban period there were significantly more movement restrictions (pre-ban period: 93 vs. ban period: 142, Chi-square = 12.105, p = 0.001), more admissions requiring movement restriction [pre-ban period: 39 (13.0 %) vs. ban period: 55 (19.5 %), Chisquare = 4.466, p = 0.035] and more different patients requiring a movement restriction [pre-ban period: 32 (12.1 %) vs. ban period: 52 (20.8 %], Chi-square = 7.074, p = 0.008). These differences disappeared when the sample was splitted into the general acute psychiatric ward and the dual psychiatric ward [Acute Ward: pre-ban period: 37 (14.9 %) vs. ban period: 48 (20.6 %), Chi-square = 2.665, p = 0.103; Dual Ward: pre-ban period: 2 (3.9 %) vs. ban period: 7 (14.3 %), Chi-square = 3.278, p = 0.089]. Most of the subjects requiring movement restrictions had a diagnosis of psychotic disorder in both periods of time [pre-ban period: 21 subjects with psychosis and requiring movement restriction (65.6 % of those requiring movement restrictions) vs. ban period: 30 (57.7 %), Chi-square = 0.523, p = 0.470]. There were no differences between periods in the number of repeated movement restrictions per patient [pre-ban period: 2.28 ± 2.8 repeated restrictions vs. ban period: 3.47 ± 6.0 repeated restrictions, t test = -1.05, p = 0.299] or in the duration of movement restrictions (pre-ban period: 15.55 ± 13.8 h vs. ban period: 15.59 ± 21.4 h; t test = -0.017, p = 0.986) except for the dual ward (pre-ban period: 47.50 ± 17.7 h vs. ban period: 13.25 ± 9.8 h; t test = 3.906, p = 0.005). As regards the medication, no significant differences were observed between periods in sedative doses (pre-ban period: 3.48 ± 6.0 lorazepam equivalents mg/day vs. ban period: 3.73 ± 6.5 lorazepam equivalents mg/day, t test = -0.468,
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p = 0.640) or in chlorpromazine equivalent doses (pre-ban period: 3.53 ± 2.9 clorpromazine equivalents 100 mg/day vs. ban period: 3.95 ± 4.1 clorpromazine equivalents 100 mg/day, t test = -1.301, p = 0.194). If we split the sample into general psychiatric acute ward and the dual hospitalization ward, results did not change significantly (results not shown). When clozapine was analyzed separately, there were neither significant differences in antipsychotic doses (pre-ban period: 292.68 ± 151.2 mg clozapine/ day vs. ban period: 194.4 ± 162 mg clozapine/day, t test = 1.781, p = 0.085). Nicotine dependence and motivation to quit smoking were assessed in 63 of the 82 patients who stayed in the hospital 7 days before the ban took effect and in 60 of the 74 patients hospitalized exactly 1 month after the ban came into effect. The rest of the patients could not be assessed because they have been granted a leave of absence (9 and 5 patients in the pre-ban and ban period respectively); refused to participate; presented a poor clinical state making assessment impossible even with assistance (8 and 7 patients in the pre-ban and ban period assessment day respectively), or had a severe language barrier (2 and 2 subjects on the pre-ban and ban period assessment day respectively). Thirty six patients (57.1 %) in the pre-ban period and 31 (51.7 %) in the ban period were smokers (Chi-square = 0.372, p = 0.542). Among smokers, 23 subjects (69.7 %) in the pre-ban period and 23 subjects (85.2 %) in the ban period presented a moderate to high nicotine dependence (comprising scores 3 to 4 in the Fagerstrom Test for nicotine dependence), without significant differences between periods (Chi-square = 1.991, p = 0.158). Twenty two subjects (64.7 %) in the pre-ban period and 16 subjects (59.3 %) in the ban period had none or doubtful motivation to quit smoking (scores 0–5 in the Richmond Motivation test to quit smoking), without significant differences between periods (Chi-square = 0.190, p = 0.663). When asking patient’s agreement with the smoking ban (‘‘Do you agree with the smoking ban?’’: Yes/ no/doesn’t know), only 23.5 % of the smoker subjects agreed with the ban before it was applied, whereas more than half of them (51.7 %) agreed once the ban was in force (Chisquare = 7.095; p = 0.029). Similarly, when asked about the benefits of the smoking ban (possible answers were ‘‘good for everyone’’/‘‘bad for everyone’’/‘‘neither good or bad’’), only 14.7 % of the smokers thought that the ban would be beneficial for everyone before it came into force, whereas after the ban this answer was given by the 51.7 % of the smokers (Chi-square = 11.229, p = 0.004). During the ban period, only 24.1 % of the smokers reported to use nicotine chewing gums or nicotine patches (the acquisition of these treatments was at the patient’s or relatives’ discretion). Among the patients that were allowed to leave the hospital for short periods, 82.4 % of them reported smoking fewer cigarettes per day, 11.8 % reported to smoke the same
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amount and 5.9 % reported to smoke more cigarettes than before the admission.
Discussion The comparative study between the pre-ban period and the smoking ban period performed at our psychiatric acute hospital revealed a lack of significant differences in terms of hospital stay (duration, rate of voluntary admissions and voluntary discharges), use of sedatives and doses of antipsychotics. On the contrary, there were more leaves of absence and movement restrictions during the ban period in comparison to the pre-ban period. Although this is not consistent with the results obtained in most studies, previous authors have found an increase in disturbing behaviors, verbal assaults or need for seclusion after smoking bans (Lawn and Pols 2005). There are several possible explanations to this finding. First, differences may be due to the fact that there were more severe and aggressive patients in the second period, which may have occurred by chance. However the absence of significant diagnostic differences between groups does not support this hypothesis. Second, our patients scarcely used nicotine replacement treatments (NRT) in comparison to other studies (Prochaska et al. 2004) (24 % of our smoker inpatients vs. 56 % in Prochaska’s study), and the increase in nicotine replacement therapy prescriptions during the smoking-ban was much lower than in other studies (Scharf et al. 2011). The low rates of NRT prescriptions may be explained by the fact that the cost of nicotine patches and chewing gums had to be assumed by the patients or their relatives, and also by the fact that more than half the patients were granted temporary leaves, which meant that their tobacco use could not be controlled. Third, there were more leaves of absence during the smoking-ban, probably because smoker inpatients were more prone to apply for them, and when leaves were denied, verbal assaults and disturbing behaviors may have occurred, thus requiring movement restrictions. Similarly to other studies, we did not find a significant increase in the use of sedatives after the ban. Other studies have used the volume of as-needed medication (PRN) as a way to measure the increase in the use of sedatives (Lawn and Pols 2005). However, we decided to consider the total amount of sedatives administered rather than considering only those administered as-needed, since many as-needed medications become regular medication when frequently required, and thus the total volume of benzodiazepines and zolpidem administered may be a more reliable measure. With respect to differences in the prescription of antipsychotics between both periods, it is important to take into account that PAHs has metabolic inducing properties,
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which are especially noticeable in clozapine and olanzapine. Cormac et al. 2010 reported a significant increase in clozapine levels, despite the trend to reduce doses after the introduction of the smoking ban. A higher risk of clozapine or olanzapine toxicity after smoking cessation has also been observed (Lowe and Ackman 2010). Given the results of these reports, a decrease in antipsychotic doses was expected in the smoking ban period, which did not occur. The reasons for the lack of differences between periods found in our study may rely on the wide variety of antipsychotics prescribed, of which olanzapine and clozapine represented only a small part. When clozapine was analyzed separately, we found a decrease—although not significant—in the average dose administered after the ban. The small sample size of this subsample may also explain this lack of significance. We also pooled clozapine and olanzapine together, and a dose decrease was not observed in the ban period (results not shown). The frequent use of olanzapine for occasional sedation and not only as a regular antipsychotic medication makes it difficult to interpret these results. Also, the fact that almost 60 % of the patients were granted leaves of absence (daily or in the weekends) may have turned an antipsychotic dose adjustment unnecessary in most of the subjects. The rate of smokers in our sample (an estimation of about 50 and 60 % in the first and second period respectively) is within the range of the majority of previous studies in hospitalized patients (Lawn and Pols 2005), although some studies report lower rates (Prochaska et al. 2004). As compared to studies in community samples, the rates of smokers and level of nicotine dependence reported among smokers was also similar, especially as to the subsamples of patients with severe mental illness (schizophrenia and bipolar disorder) (McClave et al. 2010). Studies in intermediate and long-term mental health facilities show slightly higher rates of smokers (about 67 %) than in our sample (Smith et al. 2013). It is to notice that there were no significant differences in the rate of smokers or level of nicotine dependence between periods, making both periods comparable. Our study is one of the few studies to assess motivation to quit smoking using structured instruments in inpatients of psychiatric units during the start of a smoking ban. The rate of smokers with poor or no motivation to quit was around 60 %, with no significant differences between periods. The rate of smokers highly or moderately motivated to quit were around 40 %. Other studies that used simple questions (i.e. ‘‘Did you want to quit smoking before the ban?’’) found that less than 50 % of the smokers admitted to an intermediate or long-term psychiatric facility were interested in quitting smoking (Smith et al. 2013). Studies that only measured attempts to quit smoking as a measure of motivation found lower rates (2 % before the ban and 18 % during the ban) (Etter et al. 2008). Most
of the studies employing structured instruments used questionnaires based on the transtheoretical model, while a few of them were based on the contemplation ladder. The former assessed patient’s intention to change basing on a five-stage categorical model (precontemplation, contemplation, preparative, in the action and maintenance) (Lando 1982), whereas the latter were based on a more dimensional model (Biener and Abrams 1991). The studies considering the transtheoretical model in inpatient units with ongoing free-smoking policies found either slightly more patients in the precontemplation stage (around 70 %) (Stockings et al. 2012) or similar rates (Carosella et al. 1999) to those observed in our study. It is interesting to highlight that these rates are approximately similar to those found in non-psychiatric populations according to some authors (Siru et al. 2009, 2010). The studies using the contemplation ladder found largely higher rates of patients motivated to quit smoking (Reichler et al. 2001). To date, these differences have been attributed to the variability of the evaluating models (Herzog et al. 2000). Although other authors have found that inpatients in a smoke-free hospital are more motivated to quit smoking (Shmueli et al. 2008), the results obtained in this study do not support this hypothesis. Two main reasons may explain these differences. Firstly, our sample included two groups of patients who were evaluated only once, regardless of the time of admission, whereas in the Shmueli’s study patients were evaluated at admission and at discharge (paired sample). Secondly, a control group was not included in Shmueli’s study (i.e. patients admitted to a smoke-free hospital), and thus, differences may be due to the hospitalization per se, and not necessarily to the fact that the hospital was smoke-free. Finally, most smoker inpatients disagreed with the smoking-ban before it came into effect and expected its effects to be negative or neither positive nor negative. On the contrary, once the ban started, most smokers agreed with the ban and thought it was beneficial to everyone. These results are consistent with those obtained in previous studies, where both patients and hospital staff found fewer problems regarding the ban than they had expected before it came into effect (Lawn and Pols 2005). Notwithstanding, this study is not free of ethical considerations. First, the right to smoke of the patients is clearly below the obligation of institutions to provide smoking free environments for patients and staff (REF). However, this may become less clear if an alternative to smoke is not provided or int the case of compulsory admission. In Spain, treatment for withdrawal symptoms is considered as part of the medication of a patient with alcohol or opioid dependence entering the hospital for any reason. However, in this hospital, nicotine replacement treatment had to be assumed by the patients themselves.
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This issue may not be so relevant in private hospitals or if only voluntary admissions are considered. Supporting this hypothesis, more than 80 % of smoker inpatients who were granted permits to leave reported having reduced the number of cigarettes during the leave. This study may have several limitations. First, the study periods only comprised 4 months, and the ban period coincided with the first months of implementation. The ban period may correspond to the adaptation period for both patients and staff, and the negative effects of the ban may not become evident until adjustment strategies are fully applied. The studies considering longer periods of time that reported different outcomes may support this hypothesis (Lawn and Pols 2005). A third assessment after 1 year from the start of the ban might shed light on this issue. The second main limitation to this study is that the design and data of our study do not allow us to know whether the increase in movement restrictions is limited to the group of smoker inpatients or can be applicable to all inpatients. There are two considerations that would make this limitation unimportant. On the one hand, a generalized level of tension in the ward due to the smoking ban would cause an increase in movement restrictions not only among the smokers. On the other hand, if the increase in movement restrictions was a result of an increase in permit denials to smoker inpatients, this could also be extrapolated to non-smoker patients, since the latter may realize that other patients are being granted leaves of absences and as a result they may also want to ask for a leave. The third limitation refers to the two evaluation periods. As stated in the method section, the data regarding medication, movement restriction and admission characteristics were extracted for all patients evaluated during the first 4 months of 2012 and 2013, whereas the data regarding nicotine dependence and the questionnaires to assess motivation to quit were assessed and performed in punctual evaluations in two time periods before and after the smoking ban. Thus, correlations between nicotine dependence and movement restriction or medication could not be computed. To sum up, our data indicate an increased number of movement restrictions during the first months of implementation of the smoking ban. The fact that nicotine replacement treatment was only prescribed to a minority of smokers and that there was not an increase in the use of sedatives or antipsychotics drives to two possible overlapping explanatory hypotheses: first, an adaptation period until a compensatory medication adjustment and other measures are fully applied would be necessary. Second, the smoking ban may have driven to an increase in the number of grants of leave of absence that may have led to subsequent applications for leave of absence by patients not allowed to. Thus, an increase in the number of applications for leaves may have contributed to an increase in movement restrictions.
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Further studies taking longer study periods after the ban may clarify this issue. Meanwhile, actions should be implemented to achieve shorter adjustment periods and reduce conflicts related to leave of absence applications in psychiatric units planning to introduce smoking bans.
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psychiatric hospital. Drug and Alcohol Review, 20(2), 231–237. doi:10.1080/09595230120058623. Richmond, R. L., Kehoe, L. A., & Webster, I. W. (1993). Multivariate models for predicting abstention following intervention to stop smoking by general practitioners. Addiction, 88(8), 1127–1135. Salokangas, R. K. R., Honkonen, T., Stenga˚rd, E., Koivisto, A.-M., & Hietala, J. (2006). Cigarette smoking in long-term schizophrenia. European Psychiatry, 21(4), 219–223. doi:10.1016/j.eurpsy.2005. 07.008. Scharf, D., Fabian, T., Fichter-DeSando, C., & Douaihy, A. (2011). Nicotine replacement prescribing trends in a large psychiatric hospital, before and after implementation of a hospital-wide smoking ban. Nicotine & Tobacco Research, 13(6), 466–473. doi:10.1093/ntr/ntr026. Shmueli, D., Fletcher, L., Hall, S. E., Hall, S. M., & Prochaska, J. J. (2008). Changes in psychiatric patients’ thoughts about quitting smoking during a smoke-free hospitalization. Nicotine & Tobacco Research, 10(5), 875–881. doi:10.1080/14622200802027198. Siru, R., Hulse, G. K., Khan, R. J. K., & Tait, R. J. (2010). Motivation to quit smoking among hospitalised individuals with and without mental health disorders. The Australian and New Zealand Journal of Psychiatry, 44(7), 640–647. doi:10.3109/00048671003627413. Siru, R., Hulse, G. K., & Tait, R. J. (2009). Assessing motivation to quit smoking in people with mental illness: A review. Addiction, 104(5), 719–733. doi:10.1111/j.1360-0443.2009.02545.x. Smith, P. H., Homish, G. G., Kozlowski, L. T., Spacone, C., Trigoboff, E., & Joffe, S. (2013). Effects of a complete smoking ban on inpatients at an intermediate to long-term psychiatric facility. Community Mental Health Journal, 49(2), 193–198. doi:10.1007/s10597-012-9532-z. Stockings, E., Bowman, J., McElwaine, K., Baker, A., Terry, M., Clancy, R., et al. (2012). Readiness to quit smoking and quit attempts among Australian mental health inpatients. Nicotine & Tobacco Research, 15(5), 942–949. doi:10.1093/ntr/nts206. WHO|International Classification of Diseases (ICD). (2010). World Health Organization. http://www.who.int/classifications/icd/en/. Accessed 5 Oct 2013.
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BRIEF COMMUNICATION
Patient Management and Psychopharmacological Treatment Associated to Smoking Ban in an Acute Psychiatric Unit Daniel Berge´ • Anna Mane´ • Francina Fonseca Alba Toll • Ana Merino • Victor Pe´rez • Antoni Bulbena
•
Received: 12 January 2014 / Accepted: 11 December 2014 Ó Springer Science+Business Media New York 2014
Nicotine Smoking-ban Cigarettes
Abstract This study investigates differences in terms of clinical and treatment management in psychiatric hospitalization associated to smoking ban. We collected data regarding medication, socio-demographic and admission characteristics from all patients admitted to an acute psychiatric hospital before and after a smoking ban was in force. We also assessed a limited sample of patients before and after the ban regarding nicotine dependence, motivation to quit smoking and attitudes towards the ban. More number of leaves of absence and movement restrictions during the ban period occurred in comparison to the preban period. On the contrary a lack of significant differences in terms of hospital stay (duration, rate of voluntary admissions and voluntary discharges), use of sedatives and doses of antipsychotics was found. A period of adjustment regarding the deal with leave of access and facilitate nicotine replacement treatment may help future psychiatric facilities planning smoking free policies.
Keywords Psychiatry
D. Berge´ (&) A. Mane´ F. Fonseca A. Toll A. Merino V. Pe´rez A. Bulbena Institute of Neuropsychiatry and Addictions, Hospital del Mar, Psichiatry, Passeig Maritim 25/29, 08003 Barcelona, Spain e-mail: [email protected]
A. Bulbena e-mail: [email protected]
A. Mane´ e-mail: [email protected] F. Fonseca e-mail: [email protected] A. Toll e-mail: [email protected] A. Merino e-mail: [email protected]
Introduction More than 60 % of patients with severe mental disorders are smokers and 35 % of them smoke more than 20 cigarettes per day, which is considered an important mortality risk factor (Olivier et al. 2007; Salokangas et al. 2006). Tobacco use is estimated to shorten life expectancy by 12–13 years in mentally ill smokers. Some authors have suggested that severely mentally ill patients—especially psychotic patients—presenting cardiovascular risk factors or having a first cardiovascular event are not treated with the same therapeutic effort as the general population (Mitchell and Lord 2010). Tolerance for smoking in psychiatric wards may be considered an example. Some of the reasons cited to continue with such
D. Berge´ A. Mane´ F. Fonseca V. Pe´rez A. Bulbena IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain A. Mane´ V. Pe´rez Centro de Investigacio´n Biome´dica en Red de Salud Mental, Barcelona, Spain A. Bulbena Department of Psychiatry, Universitat Auto`noma de Barcelona, Barcelona, Spain
V. Pe´rez e-mail: [email protected]
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permissiveness are: smoking may help patients tolerate the hospital stay better; psychiatric smoker patients may become anxious or aggressive if they are not allowed to smoke; or abrupt smoking cessation may cause increased restlessness and strong disagreement in most patients (Etter et al. 2008). Polycyclic aromatic hydrocarbons (PAHs) are potent inducers of the hepatic cytochrome P-450 (CYP) isoenzymes 1A1 and 1A2 and cause some antipsychotic drugs— mainly olanzapine and clozapine—to be metabolized faster. Therefore, in a smoking cessation setting, a dose adjustment may be required for some antipsychotic drugs in order to avoid the risk of toxicity (Haslemo et al. 2006; Kroon 2007; Lowe and Ackman 2010). Involuntarily hospitalized patients may also be forced to quit smoking, which has ethical implications. Some authors encourage sympathetic tolerance towards those suffering a severe mental illness. Other studies cite smoking as a way to establish a better patient-psychiatrist relationship, and smoking is also used as a reward for patients (Dickens et al. 2004). Non-smoker inpatients, visitors and staff may easily become passive smokers in psychiatric wards, causing justified complaints or even worsening respiratory disorders (‘‘Council of Scientific Affairs, American Medical Association’’ 1994). Several smoking bans have been implemented in psychiatric wards all around the world. Whereas the smoking ban started nationwide in 1992 in the United States, European countries—and specially Spain—have delayed the start of the ban for years. In Spain the smoking law 42/2010 (Ley 42/2010, 30 diciembre 2010) expressly forbids smoking in all health centers including psychiatric hospitals, with the exception of medium- and long- stay psychiatric hospitals, where special indoor or outdoor smoking places can be designated. Nevertheless, the Spanish smokefree regulations have been progressively implemented in the different psychiatric units between 2012 and 2013. Previous studies performed in smoke-free psychiatric units have detected either positive outcomes, negative outcomes or no changes. Only a few studies have reported negative outcomes in the form of increased attempts to break the ban and increased verbal aggressiveness. On the contrary, the majority of the studies have reported no changes in seclusion rates, prescriptions of as-needed medication, aggressive behaviors or physical restraints and positive outcomes such as a reduction in conflicts related to cigarette use (Moss et al. 2010). Most studies are focused on staff expectancies and on the extent to what such expectations are fulfilled. However, few studies assess objective measurement variables such as changes in medication patterns or other measurable clinical management variables.
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The present study reports objective outcomes in terms of patient management and characteristics, number of stays and medications in an acute psychiatric hospital in Barcelona before and after the implementation of a smoking ban, in order to objectively examine differences between the two periods.
Methods Data were collected from all patients admitted to an acute psychiatric hospital before and after the smoking ban came into effect. Our acute psychiatric hospital is composed of a general acute psychiatric ward with 74 beds, and an acute dual ward with 11 beds. We collected data regarding the admission period (duration, voluntary vs. involuntary admission, type of discharge, leaves of absence, diagnosis according to the International Classification of Diseases-9 [‘‘WHO|International Classification of Diseases (ICD)’’ 2010]; socio-demographic data, patient management during hospital stay (movement restrictions based on mechanical body restraints and other severe incidences) and medication regimen for all patients admitted to both the acute psychiatric ward and the dual psychiatric ward during their stay in two different and equivalent time periods. Leaves of absence could be a short walk around the hospital of 1–3 h length, a 12 h day off since morning till afternoon or a permission to spend the weekend at home. First were included all patients discharged from January the 1st to April the 30th 2012, when the smoking ban had not come into effect yet. Secondly were included all patients admitted from January the 1st to April the 30th 2013 after the smoking ban came into effect. The smoking ban started on January the 1st 2013. Three months before the implementation of the smoking ban, a team constituted by several nursing supervisors, nurses, clinical assistants and a psychiatrist implemented a short program to evaluate staff attitudes towards the ban, anticipate difficulties, achieve consensus among the staff and inform and support the patients and relatives on the new smoke-free regulations. To this purpose, several meetings were held with all levels of staff and inpatients. After the ban implementation, smoking cessation was performed using a nicotine replacement therapy (NRT). The acquisition of this treatment was at the discretion of the patients or their relatives. Smoking was permitted and recorded for the patients that were allowed to leave the hospital for short periods. Medication was classified into two groups: sedatives (including benzodiazepines and zolpidem) that were converted to lorazepam equivalents (Chouinard 2004), and antipsychotics (all antipsychotics including those administered to enhance sedation), that were converted to 100 mg chlorpromazine equivalents) (Andreasen et al. 2010). For
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amisulpride, clotiapine, levomepromazine, paliperidone, periciazine and zuclopentixol we used the equivalent rates reported by Gardner et al. (2010). Long-acting injectable antipsychotics were registered by dividing the total dose by the time elapsed between administrations. Due to the existing evidence on the interaction of PAHs with clozapine, an additional analysis was carried out only for this antipsychotic. By computing the dose of sedatives we aimed to elucidate whether more sedation was needed after the smoking ban (all patients were included), whereas by computing the dose of antipsychotics we aimed to find out whether different doses of antipsychotics were needed in patients who were usually treated with antipsychotics (only patients on antipyschotics were considered). We also assessed nicotine dependence and motivation to quit smoking in patients before and after the smoking ban. All patients staying in the hospital the week before and 1 month after the start of the smoking ban were evaluated using the Fagerstro¨m Test for Nicotine Dependence (Heatherton et al. 1991) to assess dependence on nicotine. The Richmond selfreported questionnaire (Co´rdoba et al. 2000; Richmond et al. 1993) was used to assess motivation to quit smoking. Between-groups comparisons were performed using the Chi-square test for categorical data and Student’s t test to compare the means for continuous data. Data was analyzed using PASW Statistics v18.0 software (IBM, SPSS Inc.). The authors state that there are no known conflicts of interest. All authors certify responsibility for the content of this manuscript.
Results A total of 299 admissions (248 in the acute ward and 51 in the dual ward) of 266 different patients were recorded from January to April 2012, while 282 admissions (233 in the acute ward and 49 in the dual ward) of 248 different patients were recorded from January to April 2013. The incidence of the different disorders was as follows: schizophrenia (any subtype) was the most frequent diagnosis (35.5 % in 2012 and 36.9 % in 2013) followed by manic or mixed states in bipolar disorder (12.7 % in 2012 and 7.8 % in 2013), unipolar or bipolar depression (9.7 % in 2012 and 14.9 % in 2013), psychosis not otherwise specified (9.4 % in 2012 and 12.1 % in 2013), personality disorders (11.0 % in 2012 and 7.4 % in 2013), drug related disorders (9.0 % in 2012 and 9.2 % in 2013) and others (12 % in 2012 and 11.1 % in 2013) without significant differences between periods (Chi-square: 10.598, p = 0.478). We also included subjects in the main diagnostic groups of psychosis versus non-psychosis, thus obtaining a group-diagnosis of psychosis in 46.8 % of the subjects in the 2012 period and 50 % in the 2013 period (Chi-square: 0.587, p = 0.444).
There were no significant differences between periods in age (pre-ban period: mean age: 43.63 ± 15.75 years vs. ban period: mean age: 43.72 ± 15.54 years; t = -0.067, p = 0.946). Gender (pre-ban period: 59.2 % males vs. ban period: 56.7 % males; Chi-square = 0.360, p = 0.548), rates of involuntary admission (pre-ban period: 49.8 % vs. ban period: 53.5 %, Chi-square = 0.801, p = 0.371), voluntary discharge (pre-ban period: 5.0 % vs. ban period: 6.7 %, Chi-square = 0.780, p = 0.377) or length of stay (pre-ban period: 25.46 ± 21.28 days vs. ban period: 24.19 ± 22.08 days, t = 0.708, p = 0.479). After splitting the sample into dual ward patients and acute ward patients, no significant differences were observed between periods in these variables (results not shown). The total number (1.083 vs. 1.477; p = 0.02) and average number (3.67 ± 6.2 vs. 5.31 ± 9.4; p = 0.014) of leaves of absence per patient was higher during the ban period, although there were no significant differences in the rates of patients granted a leave of absence [pre-ban period: 176 (59.7 %) vs. ban period: 159 (57.2 %), Chi-square = 0.359, p = 0.549]. There were no leave of absence in the dual ward. During the ban period, as compared to the pre-ban period there were significantly more movement restrictions (pre-ban period: 93 vs. ban period: 142, Chi-square = 12.105, p = 0.001), more admissions requiring movement restriction [pre-ban period: 39 (13.0 %) vs. ban period: 55 (19.5 %), Chisquare = 4.466, p = 0.035] and more different patients requiring a movement restriction [pre-ban period: 32 (12.1 %) vs. ban period: 52 (20.8 %], Chi-square = 7.074, p = 0.008). These differences disappeared when the sample was splitted into the general acute psychiatric ward and the dual psychiatric ward [Acute Ward: pre-ban period: 37 (14.9 %) vs. ban period: 48 (20.6 %), Chi-square = 2.665, p = 0.103; Dual Ward: pre-ban period: 2 (3.9 %) vs. ban period: 7 (14.3 %), Chi-square = 3.278, p = 0.089]. Most of the subjects requiring movement restrictions had a diagnosis of psychotic disorder in both periods of time [pre-ban period: 21 subjects with psychosis and requiring movement restriction (65.6 % of those requiring movement restrictions) vs. ban period: 30 (57.7 %), Chi-square = 0.523, p = 0.470]. There were no differences between periods in the number of repeated movement restrictions per patient [pre-ban period: 2.28 ± 2.8 repeated restrictions vs. ban period: 3.47 ± 6.0 repeated restrictions, t test = -1.05, p = 0.299] or in the duration of movement restrictions (pre-ban period: 15.55 ± 13.8 h vs. ban period: 15.59 ± 21.4 h; t test = -0.017, p = 0.986) except for the dual ward (pre-ban period: 47.50 ± 17.7 h vs. ban period: 13.25 ± 9.8 h; t test = 3.906, p = 0.005). As regards the medication, no significant differences were observed between periods in sedative doses (pre-ban period: 3.48 ± 6.0 lorazepam equivalents mg/day vs. ban period: 3.73 ± 6.5 lorazepam equivalents mg/day, t test = -0.468,
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p = 0.640) or in chlorpromazine equivalent doses (pre-ban period: 3.53 ± 2.9 clorpromazine equivalents 100 mg/day vs. ban period: 3.95 ± 4.1 clorpromazine equivalents 100 mg/day, t test = -1.301, p = 0.194). If we split the sample into general psychiatric acute ward and the dual hospitalization ward, results did not change significantly (results not shown). When clozapine was analyzed separately, there were neither significant differences in antipsychotic doses (pre-ban period: 292.68 ± 151.2 mg clozapine/ day vs. ban period: 194.4 ± 162 mg clozapine/day, t test = 1.781, p = 0.085). Nicotine dependence and motivation to quit smoking were assessed in 63 of the 82 patients who stayed in the hospital 7 days before the ban took effect and in 60 of the 74 patients hospitalized exactly 1 month after the ban came into effect. The rest of the patients could not be assessed because they have been granted a leave of absence (9 and 5 patients in the pre-ban and ban period respectively); refused to participate; presented a poor clinical state making assessment impossible even with assistance (8 and 7 patients in the pre-ban and ban period assessment day respectively), or had a severe language barrier (2 and 2 subjects on the pre-ban and ban period assessment day respectively). Thirty six patients (57.1 %) in the pre-ban period and 31 (51.7 %) in the ban period were smokers (Chi-square = 0.372, p = 0.542). Among smokers, 23 subjects (69.7 %) in the pre-ban period and 23 subjects (85.2 %) in the ban period presented a moderate to high nicotine dependence (comprising scores 3 to 4 in the Fagerstrom Test for nicotine dependence), without significant differences between periods (Chi-square = 1.991, p = 0.158). Twenty two subjects (64.7 %) in the pre-ban period and 16 subjects (59.3 %) in the ban period had none or doubtful motivation to quit smoking (scores 0–5 in the Richmond Motivation test to quit smoking), without significant differences between periods (Chi-square = 0.190, p = 0.663). When asking patient’s agreement with the smoking ban (‘‘Do you agree with the smoking ban?’’: Yes/ no/doesn’t know), only 23.5 % of the smoker subjects agreed with the ban before it was applied, whereas more than half of them (51.7 %) agreed once the ban was in force (Chisquare = 7.095; p = 0.029). Similarly, when asked about the benefits of the smoking ban (possible answers were ‘‘good for everyone’’/‘‘bad for everyone’’/‘‘neither good or bad’’), only 14.7 % of the smokers thought that the ban would be beneficial for everyone before it came into force, whereas after the ban this answer was given by the 51.7 % of the smokers (Chi-square = 11.229, p = 0.004). During the ban period, only 24.1 % of the smokers reported to use nicotine chewing gums or nicotine patches (the acquisition of these treatments was at the patient’s or relatives’ discretion). Among the patients that were allowed to leave the hospital for short periods, 82.4 % of them reported smoking fewer cigarettes per day, 11.8 % reported to smoke the same
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amount and 5.9 % reported to smoke more cigarettes than before the admission.
Discussion The comparative study between the pre-ban period and the smoking ban period performed at our psychiatric acute hospital revealed a lack of significant differences in terms of hospital stay (duration, rate of voluntary admissions and voluntary discharges), use of sedatives and doses of antipsychotics. On the contrary, there were more leaves of absence and movement restrictions during the ban period in comparison to the pre-ban period. Although this is not consistent with the results obtained in most studies, previous authors have found an increase in disturbing behaviors, verbal assaults or need for seclusion after smoking bans (Lawn and Pols 2005). There are several possible explanations to this finding. First, differences may be due to the fact that there were more severe and aggressive patients in the second period, which may have occurred by chance. However the absence of significant diagnostic differences between groups does not support this hypothesis. Second, our patients scarcely used nicotine replacement treatments (NRT) in comparison to other studies (Prochaska et al. 2004) (24 % of our smoker inpatients vs. 56 % in Prochaska’s study), and the increase in nicotine replacement therapy prescriptions during the smoking-ban was much lower than in other studies (Scharf et al. 2011). The low rates of NRT prescriptions may be explained by the fact that the cost of nicotine patches and chewing gums had to be assumed by the patients or their relatives, and also by the fact that more than half the patients were granted temporary leaves, which meant that their tobacco use could not be controlled. Third, there were more leaves of absence during the smoking-ban, probably because smoker inpatients were more prone to apply for them, and when leaves were denied, verbal assaults and disturbing behaviors may have occurred, thus requiring movement restrictions. Similarly to other studies, we did not find a significant increase in the use of sedatives after the ban. Other studies have used the volume of as-needed medication (PRN) as a way to measure the increase in the use of sedatives (Lawn and Pols 2005). However, we decided to consider the total amount of sedatives administered rather than considering only those administered as-needed, since many as-needed medications become regular medication when frequently required, and thus the total volume of benzodiazepines and zolpidem administered may be a more reliable measure. With respect to differences in the prescription of antipsychotics between both periods, it is important to take into account that PAHs has metabolic inducing properties,
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which are especially noticeable in clozapine and olanzapine. Cormac et al. 2010 reported a significant increase in clozapine levels, despite the trend to reduce doses after the introduction of the smoking ban. A higher risk of clozapine or olanzapine toxicity after smoking cessation has also been observed (Lowe and Ackman 2010). Given the results of these reports, a decrease in antipsychotic doses was expected in the smoking ban period, which did not occur. The reasons for the lack of differences between periods found in our study may rely on the wide variety of antipsychotics prescribed, of which olanzapine and clozapine represented only a small part. When clozapine was analyzed separately, we found a decrease—although not significant—in the average dose administered after the ban. The small sample size of this subsample may also explain this lack of significance. We also pooled clozapine and olanzapine together, and a dose decrease was not observed in the ban period (results not shown). The frequent use of olanzapine for occasional sedation and not only as a regular antipsychotic medication makes it difficult to interpret these results. Also, the fact that almost 60 % of the patients were granted leaves of absence (daily or in the weekends) may have turned an antipsychotic dose adjustment unnecessary in most of the subjects. The rate of smokers in our sample (an estimation of about 50 and 60 % in the first and second period respectively) is within the range of the majority of previous studies in hospitalized patients (Lawn and Pols 2005), although some studies report lower rates (Prochaska et al. 2004). As compared to studies in community samples, the rates of smokers and level of nicotine dependence reported among smokers was also similar, especially as to the subsamples of patients with severe mental illness (schizophrenia and bipolar disorder) (McClave et al. 2010). Studies in intermediate and long-term mental health facilities show slightly higher rates of smokers (about 67 %) than in our sample (Smith et al. 2013). It is to notice that there were no significant differences in the rate of smokers or level of nicotine dependence between periods, making both periods comparable. Our study is one of the few studies to assess motivation to quit smoking using structured instruments in inpatients of psychiatric units during the start of a smoking ban. The rate of smokers with poor or no motivation to quit was around 60 %, with no significant differences between periods. The rate of smokers highly or moderately motivated to quit were around 40 %. Other studies that used simple questions (i.e. ‘‘Did you want to quit smoking before the ban?’’) found that less than 50 % of the smokers admitted to an intermediate or long-term psychiatric facility were interested in quitting smoking (Smith et al. 2013). Studies that only measured attempts to quit smoking as a measure of motivation found lower rates (2 % before the ban and 18 % during the ban) (Etter et al. 2008). Most
of the studies employing structured instruments used questionnaires based on the transtheoretical model, while a few of them were based on the contemplation ladder. The former assessed patient’s intention to change basing on a five-stage categorical model (precontemplation, contemplation, preparative, in the action and maintenance) (Lando 1982), whereas the latter were based on a more dimensional model (Biener and Abrams 1991). The studies considering the transtheoretical model in inpatient units with ongoing free-smoking policies found either slightly more patients in the precontemplation stage (around 70 %) (Stockings et al. 2012) or similar rates (Carosella et al. 1999) to those observed in our study. It is interesting to highlight that these rates are approximately similar to those found in non-psychiatric populations according to some authors (Siru et al. 2009, 2010). The studies using the contemplation ladder found largely higher rates of patients motivated to quit smoking (Reichler et al. 2001). To date, these differences have been attributed to the variability of the evaluating models (Herzog et al. 2000). Although other authors have found that inpatients in a smoke-free hospital are more motivated to quit smoking (Shmueli et al. 2008), the results obtained in this study do not support this hypothesis. Two main reasons may explain these differences. Firstly, our sample included two groups of patients who were evaluated only once, regardless of the time of admission, whereas in the Shmueli’s study patients were evaluated at admission and at discharge (paired sample). Secondly, a control group was not included in Shmueli’s study (i.e. patients admitted to a smoke-free hospital), and thus, differences may be due to the hospitalization per se, and not necessarily to the fact that the hospital was smoke-free. Finally, most smoker inpatients disagreed with the smoking-ban before it came into effect and expected its effects to be negative or neither positive nor negative. On the contrary, once the ban started, most smokers agreed with the ban and thought it was beneficial to everyone. These results are consistent with those obtained in previous studies, where both patients and hospital staff found fewer problems regarding the ban than they had expected before it came into effect (Lawn and Pols 2005). Notwithstanding, this study is not free of ethical considerations. First, the right to smoke of the patients is clearly below the obligation of institutions to provide smoking free environments for patients and staff (REF). However, this may become less clear if an alternative to smoke is not provided or int the case of compulsory admission. In Spain, treatment for withdrawal symptoms is considered as part of the medication of a patient with alcohol or opioid dependence entering the hospital for any reason. However, in this hospital, nicotine replacement treatment had to be assumed by the patients themselves.
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This issue may not be so relevant in private hospitals or if only voluntary admissions are considered. Supporting this hypothesis, more than 80 % of smoker inpatients who were granted permits to leave reported having reduced the number of cigarettes during the leave. This study may have several limitations. First, the study periods only comprised 4 months, and the ban period coincided with the first months of implementation. The ban period may correspond to the adaptation period for both patients and staff, and the negative effects of the ban may not become evident until adjustment strategies are fully applied. The studies considering longer periods of time that reported different outcomes may support this hypothesis (Lawn and Pols 2005). A third assessment after 1 year from the start of the ban might shed light on this issue. The second main limitation to this study is that the design and data of our study do not allow us to know whether the increase in movement restrictions is limited to the group of smoker inpatients or can be applicable to all inpatients. There are two considerations that would make this limitation unimportant. On the one hand, a generalized level of tension in the ward due to the smoking ban would cause an increase in movement restrictions not only among the smokers. On the other hand, if the increase in movement restrictions was a result of an increase in permit denials to smoker inpatients, this could also be extrapolated to non-smoker patients, since the latter may realize that other patients are being granted leaves of absences and as a result they may also want to ask for a leave. The third limitation refers to the two evaluation periods. As stated in the method section, the data regarding medication, movement restriction and admission characteristics were extracted for all patients evaluated during the first 4 months of 2012 and 2013, whereas the data regarding nicotine dependence and the questionnaires to assess motivation to quit were assessed and performed in punctual evaluations in two time periods before and after the smoking ban. Thus, correlations between nicotine dependence and movement restriction or medication could not be computed. To sum up, our data indicate an increased number of movement restrictions during the first months of implementation of the smoking ban. The fact that nicotine replacement treatment was only prescribed to a minority of smokers and that there was not an increase in the use of sedatives or antipsychotics drives to two possible overlapping explanatory hypotheses: first, an adaptation period until a compensatory medication adjustment and other measures are fully applied would be necessary. Second, the smoking ban may have driven to an increase in the number of grants of leave of absence that may have led to subsequent applications for leave of absence by patients not allowed to. Thus, an increase in the number of applications for leaves may have contributed to an increase in movement restrictions.
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Further studies taking longer study periods after the ban may clarify this issue. Meanwhile, actions should be implemented to achieve shorter adjustment periods and reduce conflicts related to leave of absence applications in psychiatric units planning to introduce smoking bans.
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