Running head: Smoking Cessation Process

Smoking Cessation in Psychiatric Patients

Amanda M. Mathy
Ferris State University

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Smoking Cessation for Psychiatric Patients

Change is the one constant in health care. Although that may sound ironic, change occurs
frequently throughout health care whether it pertains to policies, technology, tasks, evidence, or
jobs. While researchers continue to study the health of the patients, better methods of care will
always be implemented. A rather new finding for better patient care is focused on psychiatric
patients and how therapy affects the patients overall well-being. Individual and group therapy,
such as substance abuse, goals, and stress and anxiety groups, allows the patient to express his or
her feelings in a comfortable setting without being judged by others. An effective group therapy,
substance abuse, provides a key component of treatment planning, which is smoking cessation
(Morris, Waxmonsky, May, Giese, & Martin, p. 7, 2010). With outstanding statistics among the
psychiatric patients, researchers have found that smoking tobacco has an enormous impact on
psychiatric patients.
About 200,000 of the 435,000 annual deaths from smoking in the U.S occur among
patients with mental illness and/or substance use disorders, according to the Substance Abuse
and Mental Health Services Administration (Morris, Waxmonsky, May, Giese, & Martin, p. 6,
2010). The psychiatric group is targeted because most patients have an altered mind-set that
doesnt allow them to think clearly about actions or consequences. These patients lack the
smoking education and resource availability. To increase the awareness of smoking cessation,
psychiatric facilities should implement a smoking cessation program for all new admits that
smoke. The program will help educate patients about the consequences of tobacco, increase their
overall health, and decrease their chance of relapsing. The smoking cessation program has a
purpose because mentally ill patients need to quit, want to quit, and can quit if they have
encouragement and support (Morris, Waxmonsky, May, Giese, & Martin, p. 5, 2010). Although

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smoking cessation programs have been in progress throughout the years and decreased the
proportion of smokers in Western countries form 45% in the 1960s to 23-30% in the 2000s,
patients with psychiatric illnesses continue to smoke and do not add to the outstanding statistics
(Aubin, Rollema, Svensson, & Winterer, p. 271, 2012).
This change can happen if staff members, especially the nurse manager, take the initiative
to make a plan. The nurse manager should focus on emergence and think systematically
throughout these plans. It is important for the manager to balance the short-term and long-term
objectives, recognizes the dynamic, and complex nature of systems, and look at the bigger
picture according to Yoder-Wise (p. 13, 2015). The managers purpose would be influenced by
the Hierarchy of Needs theory because he or she would motivate the hierarchy of patients needs,
which begins with the physiologic needs and the safety of patients (Yoder-Wise, p. 10, 2015).
Even though physiologic needs comes first, the nursing manager needs to be aware that safety is
priority for the patient, so promoting the smoking cessation change is important to the patients
health.
Clinical Need
First, the manager needs to determine what clinical activities are most important. In this
plan, the manager will survey the patients and staff members about the relevance of smoking
cessation and any unmet quality standards in the setting regarding nicotine (Yoder-Wise, p. 368,
2015). The research has shown that patients with mental illnesses use nicotine because of
biological, physiological, and social factors. Nicotine can impact the patient positively by acting
on dopamine, enhancing concentration and pleasure, and reducing the risk of antipsychoticinduced Parkinsonism (Morris, Waxmonsky, May, Giese, & Martin, p. 9, 2010). These effects
cause mental illness symptoms to decrease and consequently result in a higher rate of users.

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Tobacco can also relieve feelings of anxiety for a short period of time, which helps the patient
calm down. Social factors show that patients smoke because it makes them feel part of group and
it keeps them busy. For these reasons, the SAMHSA explains that patients with schizophrenia
have a 62-90% rate of using nicotine, major depression at a 36-80% rate, and bipolar mood
disorder at a 51-70% rate (Morris, Waxmonsky, May, Giese, & Martin, p. 5-8, 2010). The
negative of nicotine that patients are unaware of is nicotine withdrawal can mimic symptoms of
the illness as well as increase the blood levels of antipsychotics and antidepressant levels. It
remains a difficult task for patients to quit smoking, but therapy does help. The SAMHSA
explains that cognitive behavioral therapy and group therapy has been found to improve smoking
cessation rates for those with depression and schizophrenia (Morris, Waxmonsky, May, Giese, &
Martin, p. 10, 2010). From this research, the manager should start the planning phase of a
smoking cessation program in psychiatric facilities to improve patients health and decrease rates
of patient relapse. This means a smoking cessation group therapy session should take place four
times a week and divided up for three different stages of quitting, including the not ready,
preparing, and action stage.
Interdisciplinary Team
After the clinical activity is selected, the nurse should form a team with staff members
who would be involved with the smoking cessation plan. Each team member will have their own
responsibilities to make this plan effective, so its important for each member to be able to
communicate effectively and understand ones own role. In this program, the nurse, group leader,
psychiatrist, regular physician, case manager, and student nurse should be a part of the team. As
the nurse, the role is to assess the patients mood and change in behavior after the smoking
cessation therapy; the nurse will document this change and compare the clients mood from

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before the therapy to after the therapy. The group leader is in charge of leading the smoking
cessation group therapy four times a week for a half hour each group. They will be in charge of
educating the patient on the relevance, risks, rewards, obstacles, repetition, recommendations,
medication compliance, and coping mechanisms about smoking tobacco: For relevance,
motivational information such as family members will be provided; for risks, negative
consequences will be addressed, such as asthma, and risk for lung cancer; for rewards,
information on improved health, better image, money saved, perform better in physical activities,
and having healthier children will be given; and for obstacles, recognition and recommendations
to get past the withdrawal symptoms, fear of failure, weight gain, depression, and lack of support
will be introduced. The psychiatrist will be in charge of the first assessment for the new admit.
Although they may not feel tobacco cessation is part of their scopes and practice, they will
interview the patient about smoking and if the patient says yes, they will assess their willingness
to quit. Once that occurs, they will put them in a stage of therapy as the not ready, preparing, or
action group in order to answer their needs and promote efficient therapy. The psychiatrist will
determine the length of therapy needed and evaluate the patient after the course of treatment is
done determining if the treatment worked or not by using a survey and interview. The case
manager will provide resources and will plan for out-patient follow-up care. As for the student
nurses, the manager can add these members to the team whenever they are at the facility. Once
these members understand their role, they can start promoting teamwork and following plans for
the smoking cessation program (Morris, Waxmonsky, May, Giese, & Martin, p. 18-19, 2010).
Data Collection Method
The most effective data collection method for this process is the detailed flowchart. This
detailed flowchart will describe the steps used in the process by using boxes and directional

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arrows. Yoder-Wise explains that sometimes, just diagramming a patient care process in detail
reveals gaps and opportunities for improvement, which helps the smoking cessation program be
the most effective it can be (p. 369, 2015). The chart will first start with the new patient
admission and having the psychiatrist ask the patient if he or she smokes: If its a no, the
smoking cessation program is not applicable; if its a yes, the step process will be applicable.
After the yes, the psychiatrist will ask if the patient is quitting, thinking of quitting, or does not
want to quit: If quitting, the patient will be sent straight to the third group therapy, which is the
action phase; if thinking of quitting, the patient will be sent to the preparing phase of group
therapy; if not quitting, the patient will be sent to the not ready stage of therapy. The patient will
be in these stages for two weeks and be evaluated by the psychiatrist again every two days by
asking the same questions as used in the first interview process. The psychiatrist and care
provider will determine if the patient is ready to move on to the next level. If the patient is done
with the third group therapy, the directional arrow will point to the nurse, who will determine if
the patient is ready for the next step based on his or her own assessments. If yes, the next arrow
will point to discharge that the case manager and regular physician are in charge of. The
flowchart will continue after discharge by being evaluated by the regular physician. If relapse
occurs, the directional arrow will be brought to the top of the flowchart for the patient to start all
over while in the facility. Overall, I feel that this method will help team members stay organized
and on track with the next steps in the patients plan of care. The nurse manager will be able to
delegate specific boxes for roles of the team member and will be able to identify what area needs
to be improved or what areas went wrong in the specific patients process.
Outcome

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As health care staff members, the overall goal for improvement is to have the
psychiatric patient stop smoking. Because the patient is in a controlled setting, we believe the
patient will have the outcome of stopping smoking by the end of eight sessions; however, it is the
patients ability to continue this plan after hospitalization. In the in-patient setting, we want the
patient to not experience withdrawal symptoms and also be compliant with all medications. In
the out-patient setting, the major outcome is to not have the patient relapse in the first three
months. In recent findings smokers who have completed all eight treatment sessions were also
more likely to have achieved continuous abstinence at three months according to (Morris,
Waxmonsky, May, Giese, & Martin, p. 25, 2010). This means that all eight treatments are
necessary for patients success in the first three months of out-patient care, which is the highest
risk of relapse. To achieve this, the patient should be educated on smoking and be able to
identify consequences of nicotine, resources to prevent relapse, and any coping skills needed if
bored, depressed, or anxious. The overall outcome for this patient is to reach the termination
stage of The Stages of Change Model, which means the individual will not be tempted to smoke
and have 100% self-efficacy in changing his or her ways (Morris, Waxmonsky, May, Giese, &
Martin, p. 5, 2010).
Implementation Strategies
Implementing strategies for this process is associated with The Stages of Change Model
and The Self Determination Theory. The main course will be associated with The Stages of
Change Model and the 5 As of this mode. The model includes the precontemplation,
contemplation, preparation, action, maintenance, and termination stages. These stages will be
assessed by the psychiatrists in the beginning interview and determine which course the patient
should take. Overall, the team members will use the 5 As model, which is ask, advise, assess,

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assist, and arrange (Morris, Waxmonsky, May, Giese, & Martin, p. 14, 2010). First the
psychiatrists will ask about the tobacco status of the patient and all staff members will advise the
patient to quit. The psychiatrists will continue to assess the patient on his or her willingness to
make a quitting attempt, which will then place the patient in a group therapy session. The care
provider and nurse should assist the patient in his or her quitting efforts. The case manager and
physician will help with follow up arrangements to determine if the therapy was successful. The
manager uses The Self Determination Theory by having all staff members assist the patients in
becoming self-motivated and competent in order to make smoking cessation attempts. In order to
do these, the staff members will acknowledge the patients willingness to quit, support their
initiative to start the program, offer choices regarding psychotherapy and pharmacotherapy, and
provide relevant educational materials. Interventions the staff members will provide is encourage
healthy lifestyle and involvement with others, advising to avoid high-risk situations and choice
of nicotine chewing gum, and reinforcing benefits of quitting and consequences of continuing to
smoke (U.S Department of Health and Human Services, 2010).
Evaluation
In order to evaluate the goals of therapy sessions, the psychiatrist will have a survey and
smoking cessation form to have the patient fill out at the end of treatment. The patient will
answer what the effects of nicotine are, percentage chances of relapse, and what other activities
can be done instead of smoking. The patient will be evaluated on their teaching skills and the
open discussion they initiate with the psychiatrist. The psychiatrist will then evaluate them and
also obtain their vital signs, anxiety and depressed levels, and withdrawal symptoms. These
results will be compared to the results the patient had in the beginning assessment. This
information will be in the computer and will show up again if the patient relapses within the first

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three months. If the patient does relapse, we will consider the smoking cessation trial a fail. From
the detailed flowchart, we will be able to identify what went wrong and what changes could be
made to the process. The psychiatrist will also give the patient another survey about why they
relapsed. Overall, the vital signs, withdrawal symptoms, anxiety and depressed levels, and need
to smoke should be decreased after eight sessions of therapy. As for the statistics, the goal is to
drop down the percentage of tobacco users with schizophrenia from 62-90% to 40%, with major
depression from 36-80% to 25%, and bipolar mood disorder from 51-70% to 30% after the first
two years of the process (Morris, Waxmonsky, May, Giese, & Martin, p. 6, 2010).
Conclusion
For psychiatric patients, the mental illness will never be cured; however, the symptoms
and lifestyle changes can be treated. In order for this treatment to be effective, ways of living for
some patients need to be modified. For smokers specifically, the effects of nicotine can alter their
mental status and mimic symptoms of their psychiatric illness. If this is being done, the patient
and provider will never fully be able treat the illness with effective outcomes. Although they
have an altered mind-set and may not want to quit smoking at the first assessment, psychiatric
patients truly do want to quit. All these patients need is education, resources, and motivational
support from a smoking cessation program. Once they have this educational information and
self-motivation, the relapse statistics will decrease as well as overall mortality rates. Although
this smoking cessation process would be challenging, nursing managers and leaders are in the
perfect role to achieve this goal for patients. Although they are challenged in the health care field
with increasing change and uncertainty affecting their care, they can take the initiative to make a
change by bringing together a team to assess, plan, implement, and evaluate changes for the
process.

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10
References

Aubin, H., Rollema, H., Svensson, T., & Winterer, G. (2012). Smoking, quitting, and psychiatric
disease: A review. Neuroscience and Behavioral Reviews, 36(1), 271-284. doi:
10.1016/j.neubiorev.2011.06.007
Morris, C., Waxmonsky, J., May, M., Giese, A., & Martin, L. (2010). Smoking cessation for
persons with mental illnesses. Retrieved from http://www.integration.samhsa.gov/Smo
king_Cessation_for_Persons_with_MI.pdf
U.S Department of Health and Human Services.(2013). Helping smokers quit. Retrieved from
https://www.mvphealthcare.com/provider/qim/documents/smoking_cessation_guideline.p
df
Yoder-Wise, P. (2015). Leading and managing in nursing (4th ed., pp. 396).
St. Louis, Missouri: Mosby/Elsevier.