Smoking Ban Implementation in Psychiatric Inpatient Hospitals: Update and Opportunity for Performance Improvement

Special Article - Tobacco and Smoking Cessation

J Fam Med. 2015; 2(5): 1039.

Smoking Ban Implementation in Psychiatric Inpatient Hospitals: Update and Opportunity for Performance Improvement

Ortiz G* and Schacht L

National Association of State Mental Health Program Directors Research Institute, Inc. (NRI), USA

*Corresponding author: Ortiz G, National Association of State Mental Health Program Directors Research Institute, Inc. (NRI), 3141 Fairview Park Drive, Suite 650, Falls Church, USA

Received: October 15, 2015; Accepted: November 20, 2015; Published: November 23, 2015

Abstract

Objectives: To determine the incidence and prevalence of smoking bans in psychiatric inpatient hospitals. To evaluate the differences between hospitals that prohibit and those that allow smoking on the identification of smoking risks, availability of educational resources, treatments offered, and documentation of the patients’ smoking status in the continuing care plan. To identify opportunities for performance improvement for the psychiatric care provided to patients.

Methods: A survey on smoking policies and practices was completed by 165 hospital directors and quality assurance managers. Cross-tabulation and frequency determined the incidence and prevalence of smoking bans. Chisquare analysis tested for differences between hospitals that prohibit and hospitals that allow smoking and the characteristics under study.

Results: The incidence and prevalence rates of smoking bans were 70% and 79%, respectively. Significant differences between hospitals prohibiting and allowing smoking were found in the identification of smoking risks during formal screenings.

Conclusion: The incidence and prevalence rates of smoking bans continue at an increased rate, as evidenced by more psychiatric hospitals enacting smoking bans and removing barriers to policy implementation. Psychiatric hospitals that have not adopted smoking bans may not be aware of their readiness to enact a formal tobacco-free policy, given their similarity to hospitals that prohibit smoking. However, hospitals included the patients’ smoking status in the continuing care plan at a very similar low rate. Hospitals could maximize the reporting of the Hospital Based Inpatient Psychiatric Services (HBIPS) performance measure including patients’ smoking status at discharge and treatments into the next level of care recommendations to heighten awareness of the risks for smoking and promote continuation of tobacco cessation treatments.

Keywords: Smoking cessation; Smoking ban implementation; Smoking ban incidence; Smoking ban prevalence; Psychiatric inpatient hospitals; Performance improvement

Introduction

Compared to the general hospitals in the United States, psychiatric inpatient hospitals have been slower to implement tobacco control standards [1]. It is estimated that 36% of adults with mental illness use tobacco products compared to 18% of adults in the general population, and 31% of all cigarettes are smoked by adults with mental illness [2], a significant contributor to early mortality and chronic disease [3]. Motivators for tobacco control include requirements from accrediting entities [4], health concerns for patients and hospital staff [5,6], and effects of secondhand smoke [7]; while challenges include the assumed therapeutic effects of smoking on patients with mental illness [8,9], resistance from patients and hospital staff9, and lack of training and resources [10]. Research has demonstrated that it is possible to ban smoking in psychiatric inpatient hospitals [11,12]. Reports from 2006 and 2008 showed a continuing trend toward increased numbers of psychiatric inpatient hospitals adopting tobacco-free policies (from 41% to 49%, respectively). These reports, however, also indicated that a group of hospitals do not intend to adopt such policy [13,14] in spite of the adverse effects of smoking [15], the fact that the consequences of smoking are more challenging for individuals with psychiatric illness [16], and that individuals with mental illness have substantial quit rates [17].

A study comparing data from 2008 and 2011, found a significant movement in adopting smoking bans in psychiatric inpatient hospitals and examined the penetration of the critical components of smoking cessation care (such as assessment of smoking at admission, provision of smoking cessation treatments, availability of smoking cessation resources, and follow-up after discharge) [18]. However, the study did not compare the penetration of the critical components of the smoking cessation care by hospital type (prohibiting versus allowing smoking). This comparison is critical as hospitals that still permit smoking could compare their own delivery of the critical components of smoking cessation care, with hospitals prohibiting smoking, and could incite a motivation for a smoking ban implementation. Moreover, continued monitoring of the smoke-free policy status in psychiatric inpatient hospitals is necessary to evaluate changes that are driven by states, local entities, or hospitals themselves.

In 2011, 165 psychiatric inpatient hospitals completed a survey on smoking policies and practices. This research determined the incidence and prevalence rates of smoking bans in psychiatric inpatient hospitals, and evaluated the differences between hospitals that prohibit and allow smoking on the critical components of smoking cessation care, particularly the promotion and education about the risks of smoking, the availability of educational resources, the smoking cessation treatments offered, and the frequency with which psychiatric inpatient hospitals included the patients’ smoking status in the patient’s continuing care plan at discharge. The study also offers implications for performance measures addressing this significant health issue and for improving the quality of psychiatric inpatient care.

Methods

Instrument

The Smoking Policies and Practices in State Psychiatric Hospitals Survey was developed in 2006 by a group of medical directors, quality improvement managers, and researchers based on an interest from state mental health agencies and state medical directors to identify the status of their state psychiatric inpatient hospitals in the general movement toward a non-smoking environment [19]. The instrument was pilot tested by a group of psychiatric hospitals and a decision was made to create separate versions of the instrument: one for hospitals allowing smoking and one for hospitals prohibiting smoking. In 2008, the two survey versions were merged back into one instrument and questions related to current smoking policy, smoking cessation treatment options, aftercare plan, and referrals for smoking education were added. In 2011, the survey went through additional scrutiny and questions with little to no variation, high missing data, and unclearly structured were rephrased or deleted from the instrument. The updated instrument was pilot tested by seven psychiatric hospitals, recommendations were incorporated and a more refined instrument was developed. The major addition to the instrument was information related to the patient’s smoking status on the aftercare plan. Therefore, the final version of the instrument contains 22 items that collect data on hospital’s demographics, current smoking policy, smoking cessation practices, and outcomes and barriers of enacting a smoke-free policy.

An electronic version of the instrument was created using SNAP Surveys and distributed to a group of psychiatric hospitals directors and quality assurance managers. Four email reminders were sent to non-responders over a two-month period.

Sample

State psychiatric inpatient hospitals were identified using and combining two data sources. A list of psychiatric inpatient hospitals from the National Association of State Mental Health Program Directors Research Institute, Inc. [NRI – a non-profit organization devoted to issues of the public mental health system [20]] database was reconciled with a list from the National Association of State Mental Health Program Directors [NASMHPD - the only national association to represent state mental health commissioners/directors and their agencies [21]] member’s directory. Two-hundred and six psychiatric inpatient hospital directors and quality assurance managers were identified through the sources and invited to participate in a survey on smoking policies and practices. Staff from psychiatric inpatient hospitals was excluded if the hospital was serving only children less than 12 years of age, if the hospital has closed or merged at the time of the study, or if the contact information for the hospital’s director and/or quality assurance manager was not available. Data collection spanned from October to December 2011.

Psychiatric inpatient hospitals were categorized as “smoking prohibited” if smoking was banned on all hospital premises (defined as building, balconies, patios, courtyards, areas adjacent to exit doors, parking areas, and lawns), there were no designated smoking areas on the campus except for those not covered by the smoke-free policy, and the policy applied to patients, visitors, and staff members. Hospitals not meeting the non-smoking definition above and that allow smoking indoors or outdoors were classified as “smoking allowed.” As hospitals could serve multiple populations, and for analysis purposes, they were categorized according to the age group served: youth (12-17 years), adult (18-64 years), geriatric (65 years and older), and forensic.

Statistical analysis

Descriptive statistical analyses were calculated for the hospital’s demographic characteristics by type of hospital: smoking prohibited and smoking allowed, and for the total hospital population. Crosstabulation analysis determined the incidence (or conversion) rate of smoking bans. To calculate the conversion rate, the smoking status for a hospital in 2011 was linked with the smoking status for the hospital in 2008. Frequency analysis determined the prevalence of smoking bans in 2011. Chi-square analysis evaluated differences between psychiatric hospitals that prohibit and allow smoking on selected characteristics: promotion and education of patients about the risks of smoking, availability of educational resources that describe the risk of smoking, smoking cessation treatments offered while receiving psychiatric inpatient care, and inclusion of the patient’s smoking status on the continuing care plan. All comparisons were based on p< 0.05 (two-sided). Statistical analyses were conducted using SPSS version 22.0. Approval was received from the NRI Institutional Review Board.

Results

Data from 165 distinctive psychiatric inpatient hospitals representing 44 states, territories and the District of Columbia were used for analysis for an 80% response rate. Seventy-four percent of participating psychiatric inpatient hospitals served adult populations and 47% served only one population type. The majority of hospitals serving adults provided acute (36%) or a combination of acute and long-term care services (30%). Table 1 summarizes the demographic characteristic by hospital’s smoking status and for the total population. In 2011, 79% of hospitals have adopted a smoke-free policy.