Public Health and Therapeutic Aspects of Smoking Bans in Mental Health and Addiction Settings

Investigations of the association between tobacco smoking and psychiatric disorders can be categorized into four areas of interest: smoking as self-medication, nicotine and vulnerability to mental illness, smoking and medication, and the impact of forced nicotine withdrawal.

Both neurobiological and psychosocial factors reinforce the use of nicotine in psychiatric populations. Nicotine is thought to interact with a number of neurotransmitter systems: serotonin, dopamine, glutamate, acetylcholine, and norepinephrine (3,7). There is growing evidence that nicotine functions to normalize two different physiological dysfunctions in schizophrenia, auditory sensory gating (8,9) and abnormal smooth-pursuit eye movements (7). In addition, the dopaminergic and glutaminic alterations created by nicotine are thought to improve negative symptoms (10). The link between smoking and depression has been attributed to the use of nicotine for alleviating dysphoric moods (11,12). Smokers who have a history of depression are more vulnerable to developing depression during nicotine withdrawal, and the withdrawal syndrome is more severe among these persons (7,13).

A strong correlation between nicotine use and other substance abuse also exists. Among all persons with a psychiatric diagnosis, those who abuse alcohol have the highest rates of smoking, in terms of having ever smoked (13). In a study of nicotine dependence and abstinence in schizophrenia, Ziedonis and colleagues (10) found that smokers had significantly higher rates of alcohol and drug abuse than nonsmokers and that heavy smokers had the highest rates of both alcohol and drug use disorders.

The subjective calming effect of nicotine is also thought to be particularly reinforcing for persons with psychiatric illness (14). It has been suggested that smoking reduces social inhibition and isolation and that it may provide an outlet for the expression of dependency needs among persons with schizophrenia (10,14). Van Dongen (14) found that for many people with persistent mental illness, smoking is a major part of their daily routine and is considered to provide some structure to a day with few activities. Moreover, smoking has long been considered an integral part of the psychiatric culture, and there exists an ingrained belief that persons with mental illness are not able or willing to quit smoking. As a result, this population has been largely excluded from the greater societal movement toward minimizing smoking, and health professionals who work with persons who have mental illness have taken a passive stance in talking to their patients about quitting smoking.

A few studies suggest that nicotine may increase one's vulnerability to mental illness. Ziedonis and colleagues (10) found that the onset of schizophrenia is significantly earlier among those who smoke. Another study reported that persons who smoke daily have an elevated risk of first-time occurrence of panic attack (15). Smoking has also been found to increase the risk of certain anxiety disorders during late adolescence and early adulthood (16). Other evidence suggests that smoking is associated with an elevated risk of depression (1,17,18). Finally, there is evidence that smokers are more vulnerable to other forms of substance abuse, with nicotine acting as a "gateway" drug (4,19).

Smoking cigarettes can reduce the blood concentrations of a number of psychiatric medications (3,20,21,22). Plasma neuroleptic concentrations can be up to 50 percent lower among heavy smokers, because smoking induces higher enzymatic activity, which accelerates the metabolism of these medications (3,21,22). Thus patients who smoke tend to receive significantly higher doses of neuroleptics (10,23,24,25). There is no evidence that specifically links the metabolism of neuroleptic medications to nicotine; rather, it is believed that the effect is produced by the tar in cigarettes (10). It is interesting that patients who are taking conventional antipsychotics are likely to smoke more, whereas patients who are taking atypical antipsychotics, such as clozapine, tend to smoke less (3).

Some studies have found that patients with schizophrenia who smoke have fewer parkinsonian symptoms than those who do not smoke (23,26), which suggests that smoking has a protective effect on dopamine systems (25). Other research has shown higher rates of tardive dyskinesia among patients with schizophrenia who smoke (1,27). However, the findings related to both parkinsonism and tardive dyskinesia are mixed and inconclusive. In a study by Linnoila and associates (20), smoking was associated with low plasma amitriptyline and nortriptyline concentrations, although there have been contradictory findings.

Forced nicotine withdrawal is associated with significant risks for psychiatric patients. Nicotine withdrawal produces physiological, behavioral, and subjective changes that present similarly to positive and negative psychiatric symptoms, side effects of medications, and alcohol or drug withdrawal (28). Thus there is a risk of misinterpretation and exacerbation of symptoms when psychiatric patients cease smoking (25,29,30). People with schizophrenia or a history of depression or anxiety report more severe withdrawal symptoms than do persons without these disorders (31). Smoking cessation can also precipitate a relapse of depression among smokers who have a history of depression and can increase anxiety for some patients (28).

Because smoking increases the metabolism of neuroleptic medications, forced smoking cessation may alter the blood concentrations of various psychiatric medications and may result in dangerously high drug concentrations and problematic side effects (32).

Policies that ban smoking in inpatient psychiatric or addiction settings are either "total," which means that no smoking is allowed within the facility or on passes, or "partial," which means that smoking is allowed in the facility or on passes. Our literature search yielded seven investigations of the impact of total bans in inpatient psychiatric settings, listed in Table 1, and seven on the impact of partial bans, which are listed in Table 2 (33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49). In addition, three investigations examined the impact of bans in outpatient waiting rooms or day hospital programs; these studies are also listed in Table 2. We retrieved two studies of total bans and three of partial bans in addiction settings. The impact was assessed either through chart reviews or through structured questionnaires, and the behavioral indicators included the use of restraints or seclusion, the occurrence of assault or injury, the number of calls to security, discharges against medical advice or elopements, medication changes, and records of illicit smoking in patients' rooms. The Ward Atmosphere Scale and the Overt Aggression Scale were the most common instruments used. However, published studies have not been consistent in the use of behavioral indicators, and some studies collected no objective data. Thus the use of meta-analytic methods was precluded by the lack of uniform dependent variables across studies. The number of studies that used similar outcome measures was too small for their effect sizes to be reliably estimated.

In contrast with studies in psychiatric settings, the five studies on the impact of smoking bans in addiction settings focused mostly on the smokers' interest in quitting before and after the ban rather than on behavioral disorders and management issues arising from the policy. Joseph and colleagues (50), in two consecutive studies of total bans in residential programs, found an increase in the proportion of smokers who were interested in quitting after the ban (from 24 percent to 61 percent) and in the proportion of those who actually abstained from smoking (41 percent after the ban compared with 9 percent before the ban). No adverse effect on drug or alcohol treatment was noted (51).

Regarding partial bans, a survey of 19 program directors reported fewer complaints than anticipated, but nicotine treatment was not fully integrated into most programs (52). In another study, staff support for an emphasis on smoking cessation declined after the policy was implemented (53). Kempf and Stanley (54) compared two adolescent residential units, one with a total ban on smoking and one with a partial ban, and found no difference between the two units in rates of in initial rejection of the program or in dropout rates, with heavy smokers more likely to drop out from either unit.

The preponderance of evidence from the reviewed literature suggests that policies that ban smoking have no major long-standing untoward effects in terms of the behavioral indicators of unrest or noncompliance. One study found no association between scores on the Fagerstrom Tolerance Questionnaire (FTQ) or the Nicotine Withdrawal Checklist (NWC) and subjective anxiety (33), whereas another study found a negative association between FTQ scores and compliance with a nonsmoking policy (34). Indeed, the amount of support for the policies among patients and staff may actually be higher after the ban. However, these self-reports contrast with the results of three studies that showed that smoking resumed immediately after discharge or that motivation to quit was lower among patients whose smoking was restricted.