Impact of a postdischarge smoking cessation intervention for smokers admitted to an inpatient psychiatric facility: a randomized controlled trial.

INTRODUCTION: Persons with a mental disorder smoke at higher rates and suffer disproportionate tobacco-related burden compared with the general population. The aim of this study was to determine if a smoking cessation intervention initiated during a psychiatric hospitalization and continued postdischarge was effective in reducing smoking behaviors among persons with a mental disorder. METHODS: A randomized controlled trial was conducted at an Australian inpatient psychiatric facility. Participants were 205 patient smokers allocated to a treatment as usual control (n = 101) or a smoking cessation intervention (n = 104) incorporating psychosocial and pharmacological support for 4 months postdischarge. Follow-up assessments were conducted at 1 week, 2, 4, and 6 months postdischarge and included abstinence from cigarettes, quit attempts, daily cigarette consumption, and nicotine dependence. RESULTS: Rates of continuous and 7-day point prevalence abstinence did not differ between treatment conditions at the 6-month follow-up; however, point prevalence abstinence was significantly higher for intervention (11.5%) compared with control (2%) participants at 4 months (OR = 6.46, p = .01). Participants in the intervention condition reported significantly more quit attempts (F[1, 202.5] = 15.23, p = .0001), lower daily cigarette consumption (F[4, 586] = 6.5, p < .001), and lower levels of nicotine dependence (F[3, 406] = 8.5, p < .0001) compared with controls at all follow-up assessments. CONCLUSIONS: Postdischarge cessation support was effective in encouraging quit attempts and reducing cigarette consumption up to 6 months postdischarge. Additional support strategies are required to facilitate longer-term cessation benefits for smokers with a mental disorder.

The impact of a smoke-free psychiatric hospitalization on patient smoking outcomes: a systematic review.

OBJECTIVE: Smoke-free policies have been introduced in inpatient psychiatric facilities in most developed nations. Such a period of supported abstinence during hospitalization may impact smoking behaviours post discharge, yet little quantitative evidence exists. The aim of this review was to provide the first synthesis of the research evidence examining the impact of a smoke-free psychiatric hospitalization on patients' smoking-related behaviours, motivation, and beliefs. METHODS: We conducted a systematic review of electronic databases PubMed, MEDLINE, PsycINFO, and EMBASE from inception to June 2013. Studies were included if they were conducted in an inpatient psychiatric facility with a smoke-free policy and if they examined any change in patients' smoking-related behaviours, motivation, or beliefs either during admission, post discharge, or both. Risk of bias was assessed using the Cochrane Collaboration Risk of Bias Tool. RESULTS: Fourteen studies were included in the review. Of the four studies that assessed change in smoking from admission to post discharge, two indicated a significant decline in cigarette consumption up to 3 months post discharge. Positive changes in motivation to quit and beliefs about quitting ability were identified in two studies. One study reported an increase in the rate of quit attempts and one reported a decline in nicotine dependence levels. CONCLUSIONS: A smoke-free psychiatric hospitalization may have a positive impact on patients' smoking-related behaviours, motivation, and beliefs, both during admission and up to 3 months post discharge. Further controlled studies with more rigorous designs are required to confirm this potential.

Small steps with big results.

March 3 marks the second NHS Change Day, which aims to inspire and encourage staff and the public to pledge to do something to improve care.

Who enrolled in a randomized controlled trial of quitline support? Comparison of participants versus nonparticipants.

INTRODUCTION: Understanding the characteristics of smokers who enroll in a trial of quitline support and those who decline could guide recruitment approaches and service delivery to better engage smokers and increase successful quitting. However, it is unknown whether factors such as smokers' perceived effectiveness of using quitting aids or self-exempting beliefs are associated with quitline uptake. We compared the sociodemographic characteristics, smoking behaviours, perceived effectiveness of using quitting aids, and self-exempting beliefs of participants and nonparticipants who were actively telephoned and offered quitline support as part of a randomized controlled trial. METHODS: Overall, 48,014 telephone numbers were randomly selected from the electronic telephone directory and contacted. A total of 3,008 eligible smokers were identified and invited to participate in a trial of quitline support. Consenting trial participants (n = 1,562) and nonparticipants (n = 500) completed a baseline interview. RESULTS: Multivariate analysis showed that the following factors were associated with trial participation: consumption of 21 or more cigarettes per day (odds ratio [OR] = 1.45 [1.07-1.99]), readiness to quit within 30 days (OR = 4.45 [3.20-6.19]) or 6 months (OR = 3.22 [2.46-4.23]), perceiving that calling the quitline was definitely (OR = 2.34 [1.62-3.39]) or partly effective (OR = 2.15 [1.63-2.83]), believing that using self-help materials was partly effective (OR = 1.50 [1.16-1.94]), thinking that nicotine replacement therapy was partly effective (OR = 1.38 [1.04-1.84]), perceiving that using willpower alone was partly (OR = 1.99 [1.48-2.67]) or not effective (OR = 2.60 [1.95-3.46]), and not holding a self-exempting belief (OR = 1.45 [1.11-1.89]). CONCLUSIONS: Increasing smokers' utilization of quitlines is likely to require changing their perceptions of the effectiveness of quitting strategies compared with using willpower alone and addressing self-exempting beliefs.

Readiness to quit smoking and quit attempts among Australian mental health inpatients.

INTRODUCTION: Mental health inpatients smoke at higher rates than general population smokers. However, provision of nicotine-dependence treatment in inpatient settings is low, with barriers to the provision of such care including staff views that patients do not want to quit. This paper reports the findings of a survey of mental health inpatients at a psychiatric hospital in New South Wales, Australia, assessing smoking and quitting motivations and behaviors. METHODS: Smokers (n = 97) were surveyed within the inpatient setting using a structured survey tool, incorporating the Fagerström Test for Nicotine Dependence, Reasons for Quitting Scale, Readiness and Motivation to Quit Smoking Questionnaire, and other measures of smoking and quitting behavior. RESULTS: Approximately 47% of smokers reported having made at least one quit attempt within the past 12 months, despite nearly three quarters (71.2%) being classified as in a "precontemplative" stage of change. Multinomial logistic regressions revealed that self-reporting "not enjoying being a smoker" and having made a quit attempt in the last 12 months predicted having advanced beyond a precontemplative stage of change. A high self-reported desire to quit predicted a quit attempt having been made in the last 12 months. CONCLUSIONS: The majority of smokers had made several quit attempts, with a large percentage occurring recently, suggesting that the actual quitting behavior should be considered as an important indication of the "desire to quit." This paper provides further data supporting the assertion that multimodal smoking cessation interventions combining psychosocial and pharmacological support should be provided to psychiatric inpatients who smoke.

Developmental and behavioural characteristics of children enrolled in a child protection pre-school.

AIM: The study aims to describe the developmental and behavioural difficulties in pre-school children who have experienced maltreatment and/or neglect METHODS: A retrospective medical file audit of all children assessed at the Cottage Family Care Centre, a child protection pre-school, between April 2004 and June 2010. Demographic characteristics, parent and teacher reports, and clinical and developmental assessment results were collated and analysed. RESULTS: The average age of the 55 children assessed was 36.3 months (ranging from 14 to 55.3 months). Fifty-five per cent were male and 65% were from disadvantaged families. A significant developmental delay in at least one domain and or a significant behavioural problem was identified in 91% of assessments. Overall (or global) delay was found in 38% and this was significantly more likely in girls (P = 0.03). Emotional and/or behavioural difficulties were reported in 85% of children. Internalising problem behaviours were more common than externalising problems. A diagnosis of an autism spectrum disorder was made in four children. In the six review assessments, regression was identified in three children. CONCLUSIONS: Children who have experienced maltreatment and/or neglect may present with developmental delays and behavioural problems. Language delays and internalising problems are characteristic. There are many features in common with primary developmental disorders. The presence of fearfulness and hypervigilance may provide a clue to diagnosis.

The delivery of preventive care to clients of community health services.

BACKGROUND: Smoking, poor nutrition, risky alcohol use, and physical inactivity are the primary behavioral risks for common causes of mortality and morbidity. Evidence and guidelines support routine clinician delivery of preventive care. Limited evidence describes the level delivered in community health settings. The objective was to determine the: prevalence of preventive care provided by community health clinicians; association between client and service characteristics and receipt of care; and acceptability of care. This will assist in informing interventions that facilitate adoption of opportunistic preventive care delivery to all clients. METHODS: In 2009 and 2010 a telephone survey was undertaken of 1284 clients across a network of 56 public community health facilities in one health district in New South Wales, Australia. The survey assessed receipt of preventive care (assessment, brief advice, and referral/follow-up) regarding smoking, inadequate fruit and vegetable consumption, alcohol overconsumption, and physical inactivity; and acceptability of care. RESULTS: Care was most frequently reported for smoking (assessment: 59.9%, brief advice: 61.7%, and offer of referral to a telephone service: 4.5%) and least frequently for inadequate fruit or vegetable consumption (27.0%, 20.0% and 0.9% respectively). Sixteen percent reported assessment for all risks, 16.2% received brief advice for all risks, and 0.6% were offered a specific referral for all risks. The following were associated with increased care: diabetes services, number of appointments, being male, Aboriginal, unemployed, and socio-economically disadvantaged. Acceptability of preventive care was high (76.0%-95.3%). CONCLUSIONS: Despite strong client support, preventive care was not provided opportunistically to all, and was preferentially provided to select groups. This suggests a need for practice change strategies to enhance preventive care provision to achieve adherence to clinical guidelines.

Shifting the focus from disease.

Rhiannon Beaumont-Wood was appointed the first ever director of nursing for Public Health Wales in April. She hopes the role will raise the profile of nurses and midwives, highlighting their contribution to improving health outcomes for the people of Wales.

Increasing the reach of quitlines through active telephone recruitment: do cold-called smokers differ from quitline callers?

INTRODUCTION: Only 1%-7% of smokers use quitlines annually. Active telephone recruitment ("cold calling") can enroll about 50% of community smokers to quitline services. However, whether cold-called smokers' characteristics differ from traditional quitline clients is unknown. To assess whether active telephone recruitment reaches new groups of smokers, New South Wales (NSW) Quitline callers were compared with cold-called smokers who received telephone counseling as part of a randomized controlled trial. METHODS: Data were extracted from the NSW Quitline database from September 13, 2005, to April 10, 2007, to coincide with the trial's recruitment period. Records (n = 18,584) of first-time quitline callers, who smoked daily, resided in NSW, Australia, and received telephone counseling were included. Cold-called participants who received telephone counseling (n = 695) were recruited by telephone from the electronic NSW telephone directory. Eligibility requirements were daily tobacco use, aged 18 or older, NSW resident, and English speaking. Smokers were eligible regardless of their quitting intention. RESULTS: Male smokers, older age groups, those living in nonmetropolitan areas, smokers who took longer to smoke their first cigarette after waking, consumed fewer cigarettes per day, and were less motivated to quit had greater odds of being referred to the quitline through cold calling. CONCLUSIONS: Active telephone recruitment enrolls new groups of smokers to quitlines. The reach of quitlines could be improved if quitlines incorporated cold calling into their recruitment strategies.

A randomised controlled trial of proactive telephone counselling on cold-called smokers' cessation rates.

OBJECTIVES: Active telephone recruitment ('cold calling') can enroll almost 45 times more smokers to cessation services than media. However, the effectiveness of proactive telephone counselling with cold-called smokers from the broader community is unknown. This study examined whether proactive telephone counselling improved abstinence, quit attempts and reduced cigarette consumption among cold-called smokers. METHODS: From 48,014 randomly selected electronic telephone directory numbers, 3008 eligible smokers were identified and 1562 (51.9%) smokers recruited into the randomised controlled trial. Of these, 769 smokers were randomly allocated to proactive telephone counselling and 793 to the control (ie, mailed self-help) conditions. Six counselling calls were offered to intervention smokers willing to quit within a month and four to those not ready to quit. The 4-month, 7-month and 13-month follow-up interviews were completed by 1369 (87.6%), 1278 (81.8%) and 1245 (79.9%) participants, respectively. RESULTS: Proactive telephone counselling participants were significantly more likely than controls to achieve 7-day point prevalence abstinence at 4 months (13.8% vs 9.6%, p=0.005) and 7 months (14.3% vs 11.0%, p=0.02) but not at 13 months. There was a significant impact of telephone counselling on prolonged abstinence at 4 months (3.4% vs 1.8%, p=0.02) and at 7 months (2.2% vs 0.9%, p=0.02). At 4 months post recruitment, telephone counselling participants were significantly more likely than controls to have made a quit attempt (48.6% vs 42.9%, p=0.01) and reduced cigarette consumption (16.9% vs 9.0%, p=0.0002). CONCLUSIONS: Proactive telephone counselling initially increased abstinence and quitting behaviours among cold-called smokers. Given its superior reach, quitlines should consider active telephone recruitment, provided relapse can be reduced. TRIAL REGISTRATION: Australian New Zealand Clinical Trial Registry; ACTRN012606000221550.

A randomised controlled trial linking mental health inpatients to community smoking cessation supports: a study protocol.

BACKGROUND: Mental health inpatients smoke at higher rates than the general population and are disproportionately affected by tobacco dependence. Despite the advent of smoke free policies within mental health hospitals, limited systems are in place to support a cessation attempt post hospitalisation, and international evidence suggests that most smokers return to pre-admission smoking levels following discharge. This protocol describes a randomised controlled trial that will test the feasibility, acceptability and efficacy of linking inpatient smoking care with ongoing community cessation support for smokers with a mental illness. METHODS/DESIGN: This study will be conducted as a randomised controlled trial. 200 smokers with an acute mental illness will be recruited from a large inpatient mental health facility. Participants will complete a baseline survey and will be randomised to either a multimodal smoking cessation intervention or provided with hospital smoking care only. Randomisation will be stratified by diagnosis (psychotic, non-psychotic). Intervention participants will be provided with a brief motivational interview in the inpatient setting and options of ongoing smoking cessation support post discharge: nicotine replacement therapy (NRT); referral to Quitline; smoking cessation groups; and fortnightly telephone support. Outcome data, including cigarettes smoked per day, quit attempts, and self-reported 7-day point prevalence abstinence (validated by exhaled carbon monoxide), will be collected via blind interview at one week, two months, four months and six months post discharge. Process information will also be collected, including the use of cessation supports and cost of the intervention. DISCUSSION: This study will provide comprehensive data on the potential of an integrated, multimodal smoking cessation intervention for persons with an acute mental illness, linking inpatient with community cessation support.

The effectiveness of an intervention in increasing community health clinician provision of preventive care: a study protocol of a non-randomised, multiple-baseline trial.

BACKGROUND: The primary behavioural risks for the most common causes of mortality and morbidity in developed countries are tobacco smoking, poor nutrition, risky alcohol use, and physical inactivity. Evidence, guidelines and policies support routine clinician delivery of care to prevent these risks within primary care settings. Despite the potential afforded by community health services for the delivery of such preventive care, the limited evidence available suggests it is provided at suboptimal levels. This study aims to assess the effectiveness of a multi-strategic practice change intervention in increasing clinician's routine provision of preventive care across a network of community health services. METHODS/DESIGN: A multiple baseline study will be conducted involving all 56 community health facilities in a single health district in New South Wales, Australia. The facilities will be allocated to one of three administratively-defined groups. A 12 month practice change intervention will be implemented in all facilities in each group to facilitate clinician risk assessment of eligible clients, and clinician provision of brief advice and referral to those identified as being 'at risk'. The intervention will be implemented in a non-random sequence across the three facility groups. Repeated, cross-sectional measurement of clinician provision of preventive care for four individual risks (smoking, poor nutrition, risky alcohol use, and physical inactivity) will occur continuously for all three facility groups for 54 months via telephone interviews. The interviews will be conducted with randomly selected clients who have visited a community health facility in the last two weeks. Data collection will commence 12 months prior to the implementation of the intervention in the first group, and continue for six months following the completion of the intervention in the last group. As a secondary source of data, telephone interviews will be undertaken prior to and following the intervention with randomly selected samples of clinicians from each facility group to assess the reported provision of preventive care, and the acceptability of the practice change intervention and implementation. DISCUSSION: The study will provide novel evidence regarding the ability to increase clinician's routine provision of preventive care across a network of community health facilities. TRIAL REGISTRATION: Australian Clinical Trials Registry ACTRN12611001284954 UNIVERSAL TRIAL NUMBER (UTN): U1111-1126-3465.

Testing the limits.

A steep rise in the number of HIV positive people has led to calls for routine screening in areas with a high incidence of the infection.

A special relationship.

Nurse specialists can make a world of difference to patients with rare diseases, who otherwise can struggle to get an accurate diagnosis and appropriate treatment.

Puppy power.

Dogs have been used for many years to help people who are blind or have hearing loss. Now they are being trained to help people with medical conditions such as cancer, diabetes, seizures, Addison's disease and narcolepsy.

A case for action on clots.

The NHS is paying large amounts of compensation to patients as a result of a failure to assess patients' risk of venous thromboembolism.

The NHS saved my life.

Personal experiences of good and poor care led to Ashley Brooks becoming a patient champion. He will speak about his work at a Nursing Standard conference next week

A cry for help.

Children's charity ChildLine has reported an increase in looked after children approaching them for help. Nurses in many settings can identify those in need.

Caring for new arrivals.

Community nurses can turn to a new resource on the health of migrant and travelling patients.

Total smoking bans in psychiatric inpatient services: a survey of perceived benefits, barriers and support among staff.

BACKGROUND: The introduction of total smoking bans represents an important step in addressing the smoking and physical health of people with mental illness. Despite evidence indicating the importance of staff support in the successful implementation of smoking bans, limited research has examined levels of staff support prior to the implementation of a ban in psychiatric settings, or factors that are associated with such support. This study aimed to examine the views of psychiatric inpatient hospital staff regarding the perceived benefits of and barriers to implementation of a successful total smoking ban in mental health services. Secondly, to examine the level of support among clinical and non-clinical staff for a total smoking ban. Thirdly, to examine the association between the benefits and barriers perceived by clinicians and their support for a total smoking ban in their unit. METHODS: Cross-sectional survey of both clinical and non-clinical staff in a large inpatient psychiatric hospital immediately prior to the implementation of a total smoking ban. RESULTS: Of the 300 staff, 183 (61%) responded. Seventy-three (41%) of total respondents were clinical staff, and 110 (92%) were non-clinical staff. More than two-thirds of staff agreed that a smoking ban would improve their work environment and conditions, help staff to stop smoking and improve patients' physical health. The most prevalent clinician perceived barriers to a successful total smoking ban related to fear of patient aggression (89%) and patient non-compliance (72%). Two thirds (67%) of all staff indicated support for a total smoking ban in mental health facilities generally, and a majority (54%) of clinical staff expressed support for a ban within their unit. Clinical staff who believed a smoking ban would help patients to stop smoking were more likely to support a smoking ban in their unit. CONCLUSIONS: There is a clear need to more effectively communicate to staff the evidence that consistently applied smoking bans do not increase patient aggression. There is also a need to communicate the benefits of smoking bans in aiding the delivery of smoking cessation care, and the benefits of both smoking bans and such care in aiding patients to stop smoking.