Smoking Cessation

C L I N I C A L I S S U E S

Smoking cessation and serious mental illness: a service evaluation of a

drop-in stop smoking clinic on an acute in-patient unit

Debbie Robson, Fiona Cole, Sally Jalasi, Bhimla Boojharut, Sharon Smith, Sibi Thompson, Martin Jones

and Mark Haddad

Aims and objectives. To evaluate the effect of a stop smoking clinic on the quit rates of patients admitted to an acute in-patient unit.

Background. The relationship between poor physical health and severe mental illness is well established. High rates of smoking

appear to play an important causal role in the excess morbidity and mortality in this population. Stop smoking interventions for the

general population are clinically effective and cost-effective. There is a small but promising evidence base for effective interventions

to help people with a mental illness who wish to stop smoking but these have mostly been tested with community patients rather

than acute in-patients.

Methods. A service evaluation of a drop-in stop smoking clinic on an acute mental health in-patient unit was conducted. Patients’

smoking status was measured at baseline and four weeks after their quit date using patient self-report and an expired breath carbon

monoxide reading.

Results. Over a six-month evaluation period, 46 patients set a quit date and 13 (28Æ3%) were abstinent at the four-week follow-up

stage, verified by a carbon monoxide reading (v2 = 33, df = 1, sig p < 0Æ0001).

Conclusions. This small-scale evaluation has shown a drop-in stop smoking intervention to be feasible, acceptable and associated

with positive outcomes; further research with larger, more representative samples is required.

Relevance to clinical practice. Enforcing smoke-free legislation is a contentious issue on mental health in-patient units, and there is

a paucity of research to guide nursing practice in this area. An admission period in a smoke-free environment provides a crucial

opportunity to offer smoking cessation treatment. With appropriate resources, expertise and support, it appears possible to apply

smoking cessation interventions that are successful within the general population to mental health patients during an acute

admission.

Key words: acute inpatient, mental health, smoking cessation

Accepted for publication: 15 April 2012

Authors: Debbie Robson, RMN, BSc, MSc, Research Nurse and

Tutor, Section of Mental Health Nursing, Institute of Psychiatry,

King’s College London, London and Honorary Nurse Consultant,

Surrey and Borders Partnership Trust, Surrey; Fiona Cole, RSW

CQSW ASW, Social Work Tutor, Brunel University, Middlesex; Sally

Jalasi, RMN, Staff Nurse, Surrey and Borders Partnership Trust,

Abraham Cowley Unit, Surrey; Bhimla Boojharut, Health Care

Assistant, Surrey and Borders Partnership Trust, Abraham Cowley

Unit, Surrey; Sharon Smith, Occupational Therapy Technician,

Surrey and Borders Partnership Trust, Abraham Cowley Unit,

Surrey; Sibi Thompson, RN, Ward Manager, Surrey and Borders

Partnership Trust, Abraham Cowley Unit, Surrey; Martin Jones,

RMN, PhD, Deputy Director of Nursing Trust, Barnet, Enfield &

Haringey Mental Health Trust, Trust Headquarters, St Ann’s

Hospital, London; Mark Haddad, RMN, RGN, PhD, Senior

Lecturer, School of Health Sciences, City University, London, UK

Correspondence: Debbie Robson, Research Nurse and Tutor, Section

of Mental Health Nursing, Institute of Psychiatry, King’s College

London, London, UK and Honorary Nurse Consultant, Surrey and

Borders Partnership Trust, Surrey, UK. Telephone: +44

0207848 0139.

E-mail: [email protected]

� 2012 Blackwell Publishing Ltd Journal of Clinical Nursing, 22, 405–413, doi: 10.1111/j.1365-2702.2012.04222.x 405

Introduction

The relationship between poor physical health and severe

mental illness (SMI) such as schizophrenia and bipolar

disorder is well established. People with SMI frequently have

coexisting long-term medical conditions, such as chronic

respiratory disease, cardiovascular disease and type 2 diabe-

tes (Osborn et al. 2007, 2008), and it has been estimated that

the life expectancy of people with SMI is reduced by

10–25 years (Newman & Bland 1991, Parks et al. 2006,

Chang et al. 2011). High rates of smoking appear to play an

important causal role in the excess morbidity and mortality in

people with SMI (Brown et al. 2000). The risk of many

diseases, in particular respiratory, cardiovascular disease and

some cancers in people with SMI could therefore be reduced

by providing appropriate smoking cessation support (Cam-

pion et al. 2008).

Background

Despite a steady reduction in the prevalence of smoking over

the past 50 years in the United Kingdom (UK) and other

industrialised nations, tobacco use remains the single greatest

cause of preventable illness and premature death in the world

(WHO 2009). Approximately 21% of the UK population are

current smokers (Health and Social Care Information Centre,

2010), which is similar to the current rates in the USA and

Australia (Centres for Disease Control and Prevention 2009,

McCarthy et al. 2010). The prevalence of daily smoking for

patients with major depression, bipolar disorder and schizo-

phrenia is estimated to be 57, 66 and 74%, respectively (Diaz

et al. 2009). The highest levels of smoking occur within

psychiatric in-patient settings. In a meta-analysis of 42

studies investigating the prevalence of smoking in people

with schizophrenia, 68% of in-patients were smokers com-

pared to 57% of community patients (de Leon & Diaz 2005).

People with SMI are likely to be heavier smokers (Kumari &

Postma 2005) and those who smoke are more likely to

experience more severe psychotic symptoms and have poorer

outcomes compared to non-smokers (Aguila et al. 2005).

National epidemiological survey findings indicate that

approximately 43% of cigarette smoking is by people with

a mental illness (Lasser et al. 2000, McManus et al. 2010).

Unlike in the general population, smoking prevalence is not

declining in the SMI population, exposing people with SMI

who smoke to additional health inequalities and social

exclusion.

Reducing rates of smoking in the general population has

been a longstanding public health goal, and there is consistent

evidence that providing dedicated services to help smokers

quit is both clinically effective and cost-effective (Raw et al.

2005). Primary Care Trusts (PCTs) in England are respon-

sible for providing smoking cessation services for people who

want to quit. Standard National Health Service (NHS) care

includes approximately 6 sessions of behavioural support and

pharmacotherapy based on a withdrawal orientated model

and emphasises the importance of complete abstinence (West

et al. 2000, McEwen et al. 2006a). The choices of medication

available to people attending NHS stop smoking services who

are motivated to stop smoking are usually based on patient

preference and include nicotine replacement therapy (NRT),

Bupropion and Varenicline. The effectiveness of pharmaco-

therapy and/or behavioural support for people in the general

population to stop smoking has been evaluated in over 200

randomised controlled trials (RCTs) including over 70,000

patients and has been shown to increase the chance of

quitting 2- to 4-fold, compared to placebo (Hughes et al.

2007, Stead et al. 2008, Cahill et al. 2012). NRT aims to

reduce withdrawal symptoms associated with stopping

smoking by replacing the nicotine from cigarettes; it is widely

used and has few side effects. Bupropion is an antidepressant

and a nicotine antagonist. Recent systematic reviews have

found it to be effective in helping people with schizophrenia

to stop smoking (Banham & Gilbody 2010, Tsoi et al. 2010),

but is also known to lower the seizure threshold, induce

mania and interacts with a number of psychotropic medica-

tions (NICE 2008). Varenicline is a nicotine acetylcholine

receptor partial agonist. Case reports indicate significant risks

of exacerbation of depression, bipolar disorder and suicidal

ideation whilst taking Varenicline and have led the Medicines

and Healthcare Products Regulatory Agency (2008) to

recommend that Varenicline should be used with care with

patients who have a history of psychiatric illness.

The National Institute for Health and Clinical Excellence

(NICE) recommends that NHS Stop Smoking Services in the

UK should aim to treat a minimum of 5% of their local

population of smokers in the course of a year and at least

35% of treated smokers who set a quit date should be

abstinent four weeks after their quit date (National Institute

for Health and Clinical Excellence 2008). Four-week quit

smoking rates are a mandatory monitoring requirement for

English NHS Stop Smoking Services and a means of tracking

service performance (Department of Health 2009). These

data are collected on a quarterly basis by patient self-report,

validated by an expired breath carbon monoxide (CO)

reading of <10 ppm. From April 2009 to March 2010,

757,537 people set a quit date with NHS Stop Smoking

Services in England and 49% had successfully stopped

smoking at the four-week follow-up stage (The Health and

Social Care Information Centre 2010).

D Robson et al.

� 2012 Blackwell Publishing Ltd 406 Journal of Clinical Nursing, 22, 405–413

In 2006, smoke-free legislation was introduced to ban

smoking in enclosed public areas or workplaces in England

(Health Act, 2006). Following an initial exemption, mental

health units in England and Northern Ireland have had to

comply with smoke-free legislation since July 2008. Imple-

mentation has been contentious and surveys since the ban

suggest that it is only being partially implemented, and that

mental health staff and patients remain ambivalent about its

utility and feasibility (Mental Health Foundation 2009).

Retrospective service evaluations of the impact of the

smoking ban in in-patient forensic settings in the UK have

been carried out (Cormac et al. 2010, Shetty et al. 2010), but

these do not report quit rates. An emerging evidence base

suggests that when smoking cessation interventions are

tailored to address the neurobiological, cognitive, affective

and social effects of SMI, a modest number of patients are

motivated and successful in stopping smoking. Uncontrolled

and controlled studies evaluating the efficacy of NRT or

Bupropion, in addition to psychosocial support, report quit

rates of between 6–18% at six-month follow-up amongst

community patients with psychosis (George et al. 2000,

2002, 2008, Evins et al. 2001, 2005, 2007, Baker et al. 2006,

Ashton et al. 2010). However, amongst UK acute in-patients

with SMI, we were unable to identify any published studies

prospectively evaluating a smoking cessation intervention.

The Department of Health (DH) in the UK recommends

that commissioners and providers should work together to

improve access to evidence-based smoking cessation treat-

ment for smokers from high-risk groups such as people with

mental illness. The DH also proposes that new, non-evidence-

based delivery models (such as drop-ins) should be piloted on

a small scale and be carefully evaluated before being adopted

as a significant part of the service (DH 2009).

This article reports the results of a prospective service

evaluation of a drop-in stop smoking clinic jointly developed

by a PCT and a Mental Health Trust in the UK, designed to

help patients on an acute mental health in-patient unit to stop

smoking. The aim of the study was to evaluate the effect of

the drop-in stop smoking clinic on the smoking status of

patients four weeks after their quit day.

Method

Setting and participants

The service evaluation took place on an acute in-patient unit of

a NHS Mental Health Foundation Trust in the south of

England between July 2008 and March 2009. This unit was

comprised of two 18-bedded acute admission wards and a

seven-bedded Psychiatric Intensive Care Unit, which serves a

population of approximately 395,000 people from four

districts (NHS Surrey 2008). White British ethnicity makes

up the largest percentage of the resident population (84Æ4%),

compared to the national average of 83Æ6% for the whole of

England, whereas people from an Asian background are the

largest minority non-white group in this area (NHS Surrey

2008). The PCT where the research was conducted is the least

deprived PCT and the third most affluent county in England

(NHS Surrey 2008). However, there are pockets of relative

deprivation and the in-patient site reported in this study admits

patients from two of the most deprived districts in the county.

All patients aged 18 and above who were resident on the in-

patient unit and who smoked during the evaluation period

were eligible to access the drop-in clinic on a voluntary basis,

either by self-referring or by referral from a member of staff.

Description of the service

A steering group was established to oversee the development,

management and evaluation of the drop-in clinic. Members

included the PCT tobacco control lead for mental health, two

Trust managers, a ward manager, a staff nurse, a pharmacist

and an honorary nurse consultant. The drop-in clinic was

held one day a week for six hours, over a six-month period.

The first three months of the drop-in clinic were staffed by a

specialist stop smoking advisor employed on a freelance basis

by the PCT. She had 10 years experience working in the field

of smoking cessation and a background in mental health

nursing and social work. The rationale for using an experi-

enced specialist stop smoking advisor employed by the PCT

to set-up the clinic was to try and have a positive impact on

the culture and practice of the unit staff. We wanted a

confident practitioner who had a proven track record of

success in helping patients with SMI to stop smoking and

who would hopefully inspire patients to use the service

and demonstrate to the unit staff that this was a worthwhile

and achievable task. The steering group also considered it

important that the stop smoking advisor should be external

to the in-patient unit to prevent conflict with competing ward

priorities and untoward incidents.

After the initial three months, the drop-in clinic was staffed

by three mental health in-patient workers, a staff nurse, an

occupational therapy technician and a health care assistant,

who worked in turn to staff the drop-in clinic on a rota basis.

Their time working in the drop-in clinic was ring-fenced and

funded by the Mental Health Trust. Prior to taking over the

running of the drop-in clinic (i.e. during the first three months

of the clinic), these three mental health workers attended a

Level 2 smoking cessation training course for mental health

professionals, run by the local PCT. They received 14 hours

Clinical issues Drop-in stop smoking clinic service evaluation

� 2012 Blackwell Publishing Ltd Journal of Clinical Nursing, 22, 405–413 407

of training delivered over two and a half consecutive days by

tobacco control specialists. The course is designed to provide

mental health professionals with knowledge, confidence and

skills to deliver smoking cessation advice on a one-to-one

basis and is compliant with the standards for training in

smoking cessation treatments recommended by the Health

Development Agency (HDA 2003) in the UK.

Staff running the drop-in aimed to deliver 6–8 sessions of

smoking cessation support based on the work developed and

described by Hajek (1989) and McEwen et al. (2006a) for

use in the general population and by McNally (2006) for

mental health patients. It was decided by the steering group

that because of the potential interactions of Bupropion with

some psychotropic medication and the lack of current

empirical evidence and potential risks of Varenicline in a

mental health population, patients would only be offered

NRT (patch, inhalator or lozenge). In addition to NRT, other

interventions used in the drop-in included engaging patients

in setting a flexible and collaborative quit date; monitoring

nicotine withdrawal symptoms, coping with physical, psy-

chological, social and behavioural aspects of stopping smok-

ing and relapse prevention. If a patient was discharged before

the intervention was completed, they had the option of

returning to the unit or being followed up by the PCT stop

smoking service.

Outcomes

Smoking status

The primary outcome for the study was smoking status

four weeks after the patient’s quit day. This was obtained by

patient self-report and validated by an expired carbon mon-

oxide (CO) reading taken each week by the drop-in staff, over

this four-week period. Expired breath CO reading is the most

commonly used biological marker of smoking status in both

research studies and clinical practice (Jarvors et al. 2005). CO

is a colourless, odourless gas inhaled by smokers from ciga-

rettes. CO is eliminated from the body within 24 hours of

stopping smoking; therefore, if a patient reports they have not

smoked in the previous 24 hours, an exhaled breath test can

confirm this (American Lung Association 1990). The propor-

tion of CO-verified patients was calculated by dividing the

number of treated smokers who reported continuous absti-

nence from smoking from quit day to the four-week follow-up

point and who had a CO reading of <10 ppm, by the total of

treated smokers (DH 2009).

Clinical and smoking characteristics

Demographic and clinical characteristics were collected from

case notes, and smoking characteristics were collected at

baseline by the drop-in staff using the Smoker’s Clinic

Questionnaire, a data collection tool used routinely by the

local PCT NHS Stop Smoking Service. This tool was used at

the first smoking cessation session to assess the patients’ level

of nicotine dependence and their motivation to smoke and

stop smoking. The Fagerstrom Test for Nicotine Dependence

(FTND) is the most widely used instrument to quantify

dependence (Heatherton et al. 1991) and been used to assess

dependency in studies of smoking cessation interventions in

mentally ill samples (George et al. 2000, Evins et al. 2005,

2007, Baker et al. 2006). Two of the items in the FTND (the

number of cigarettes smoked and time to first cigarette of the

day) are included in the Smoker’s Clinic Questionnaire. These

two questions have been identified to be valid and the most

predictive values of nicotine dependence and can be com-

bined to give a Heaviness of Smoking Index (HSI) score

(Heatherton et al. 1989, John et al. 2004). In mental health

samples, the scores derived from the HSI and FTND have

high agreement (kappa 0Æ60) (de Leon et al. 2003). Using the

HSI, dependence can be categorised into one of three groups:

low (0–1), medium (2–4) and high dependence (5–6).

Reasons for smoking are also elicited in the Smoker’s

Clinic Questionnaire, using some of the questions from The

Smoking Motives Questionnaire (SMQ) (West 2006).

Patients are asked to rate how often they use smoking to

help cope with stress, to socialise, to help with concentration,

because they will feel uncomfortable if they do not smoke, to

keep weight down and because they enjoy it (1 = not at all

and 5 = very much). The SMQ is used in the Smoking Toolkit

study (West 2006), a series of monthly surveys designed to

provide information on smoking and cessation patterns

amongst smokers in England. Its test–retest reliability has

been found to be generally high (McEwen et al. 2008) and

smoking motives elicited using the questionnaire have been

found to be correlated with a number of sociodemographic

variables (Fidler & West 2009).

The types of data used in this study are routinely collected

by the local PCT Stop Smoking Service and the Mental

Health Trust. Data were collated and analysed by a member

of the steering group who was independent to the drop-in

clinic staff. Ethical approval for service evaluations is not

required (McEwen et al. 2006b, NHS National Patient Safety

Agency 2008), although audit approval was obtained from

the Mental Health Trust’s Research & Development depart-

ment.

Analysis

Data were entered and analysed using SPSSSPSS version 15 (SPSS,

Chicago, IL, USA) and STATASTATA version 9 (Stata Corporation,

D Robson et al.

� 2012 Blackwell Publishing Ltd 408 Journal of Clinical Nursing, 22, 405–413

College Station, TX, USA). Demographic, clinical and

smoking characteristics are described using means and stan-

dard deviations for continuous variables and percentages for

categorical variables. The McNemar test (a paired version of

the chi-square test) was used to test if the number of patients

who stopped smoking was significantly different between

baseline and the four-week follow-up stage (McNemar 1947).

Results

During the six-month evaluation period, 46 in-patients used

the drop-in clinic and set a quit date. The demographic and

clinical characteristics are reported in Table 1.

Smoking characteristics

Participants smoked an average of 28 (SD 15Æ4) cigarettes a

day (range, 4–80) and their HSI score was 3Æ8 (SD 1Æ47).

Sixty-three per cent had previously tried to stop smoking on

at least one occasion, and the mean length of time for

previous abstinence was 48Æ7 days (SD 83Æ1). The highest

rated motive for smoking was to help cope with stress (mean,

4Æ2, SD 1Æ2): 79% of patients stated they did this ‘very much’

or ‘quite a bit’. The next highest rated motive reported was

the enjoyment of smoking (mean, 4Æ1, SD 1Æ2), followed by to

help with socialising (mean, 3Æ3, SD 1Æ4), and because they

would feel uncomfortable if they did not smoke (mean, 3, SD

1Æ5). Thirty-eight per cent of participants stated they were

either very or extremely determined to stop smoking, and

34Æ4% thought it was very or extremely important to stop

smoking. The most common reason given for wanting to stop

smoking was for health reasons: 70Æ4% gave this reason,

followed by cost (11Æ1%), pressure from others (11Æ1%), not

liking being addicted (3Æ7%) and that it was a bad example to

their children (3Æ7%).

Smoking status

Over the six-month evaluation period, 46 patients were

treated in the drop-in clinic and set a quit date. Thirteen

(28Æ3%) patients were abstinent at the four-week follow-up

stage, verified by a CO reading (v2 = 33, df = 1,

p < 0Æ0001); this was a statistically significant proportion

of those treated. Five of the ten patients with a diagnosis of

depression successfully quit, whereas 5 of 18 patients with a

diagnosis of schizophrenia, 2 of 11 patients with a person-

ality disorder and one of seven patients with a bipolar

disorder successfully stopped smoking.

The specialist smoking cessation advisor employed by the

PCT treated 27 patients in the first three months of the drop-

in and 10 (37%) patients quit at four-week follow-up. The

ward staff, new to smoking cessation work, treated 19

patients in the second three months of the evaluation and 3

(15Æ7%) patients quit. This difference was not statistically

significant (v2 = 2Æ48, df = 1, p = 0Æ11).

Discussion

This study is to our knowledge the first published UK

evaluation of a smoking cessation intervention, exclusively

for an acute mental health in-patient population. This

evaluation shows that these patients are motivated to stop

smoking and that a significant proportion find this achiev-

able. The participants in this evaluation were heavy smokers

[defined as smoking more than 25 cigarettes a day (Kelly &

McCreadie 1999)] and had a moderate level of tobacco

dependence. They were motivated to smoke for reasons

similar to those of smokers in the general population: data

collected from more than 2700 clients of London Stop

Smoking Services rated stress relief, boredom and enjoyment

highest (McEwen et al. 2008). The average length of stay on

the in-patient unit for our participants was similar to the UK

national average length of an in-patient stay, currently

reported as 78 days for men and 68 for women, as was the

proportion of those who were compulsorily detained (Health

and Social Care Information Centre 2011).

An in-patient stay in a smoke-free environment may be an

opportune time for initiating smoking cessation treatment

because of the intensity of exposure to nursing and medical

staff and the removal from usual environmental cues to

smoke (American Psychiatric Association 2006). Rigotti et al.

(2008) reported that delivering smoking cessation services to

in-patients with physical health conditions, such as cardio-

vascular disease has a positive impact. Pooling data from 17

RCTs, they found that cessation programmes initiated during

a hospital stay, and which included follow-up support for at

Table 1 Demographic and clinical characteristics

Variable n = 46

Gender

Female 28 (61%)

Age 36Æ6 (SD 12Æ8) Ethnicity

White UK 37 (80Æ4%) Diagnosis

Schizophrenia 18 (39Æ1%) Personality disorder 11 (23Æ9%) Depression 10 (21Æ9%) Bipolar 7 (15Æ2%)

Legal status detained under Mental Health Act 20 (43Æ4%) Mean length of admission 63 days

Clinical issues Drop-in stop smoking clinic service evaluation

� 2012 Blackwell Publishing Ltd Journal of Clinical Nursing, 22, 405–413 409

least one month after discharge, increased the odds of

stopping smoking by 65% at 6–12 months after hospital

discharge. Published studies of similar programmes in people

with SMI do not currently exist.

Despite recommendations to integrate smoking cessation

interventions into mental health services (Campion et al.

2008, DH 2009), there is lack of clarity about the role that in-

patient staff should adopt. The current evidence base for

effective interventions to help people with a SMI who wish to

stop smoking is derived from community patients rather than

acute in-patients. Also, the majority of studies to assess the

efficacy of smoking cessation interventions have been con-

ducted in research settings where the intervention is usually

delivered by a research nurse or trained smoking cessation

counsellor, not by a heath care professional responsible for

other aspects of the patients’ clinical care (Rigotti et al.

2008). It has been established that nurses who combine

smoking cessation work with other duties are less effective

than nurses who have a health promotion or an exclusive

smoking cessation role (Rice & Stead 2008). Our drop-in

clinic was a dedicated on-site service, staffed initially by a

specialist smoking cessation advisor and then by ward staff

following brief training. The specialist stop smoking advisor

treated more patients and achieved higher quit rates than the

ward staff; however, it is uncertain if this was as a result of

greater experience and specialist skills or her exclusive role in

concentrating on smoking behaviour. Nevertheless, the in-

patient staff were able to motivate patients to make a quit

attempt and this was successful for a small number, suggest-

ing that in-patient mental health staff whose role is varied

and challenging are able to integrate smoking cessation work

into their clinical practice when their time is protected.

Lawn and Campion (2010) surveyed 99 adult mental health

in-patient units across Australia to evaluate the implementa-

tion of smoke-free legislation. They reported that the factors

associated with greater success of implementing smoke-free

initiatives in mental health in-patient settings are clear,

consistent and visible leadership, cohesive teamwork, exten-

sive training for clinical staff, fewer staff smokers, effective use

of nicotine replacement therapies and consistent enforcement

of a smoke-free policy. In the current study, it appeared that

the consistent and visible leadership from the ward manager,

the cohesive teamwork of the three mental health workers

who ran the drop-in and the collaborative support from the

local PCT were integral to the success of the drop-in service.

Current guidelines recommend that general population

services should aim to achieve a CO-validated abstinence rate

of at least 35% four weeks after the person stops smoking

(National Institute for Health and Clinical Excellence 2008).

The local PCT NHS Stop Smoking Service responsible for

providing support to smokers in the general population

achieved a quit rate of 41% during the same time period as

our service evaluation (Health and Social Care Information

Centre 2009). The rate of 28% achieved in this service is

clearly lower than these general population targets and

results. But although mental health services should aim for

comparable quit rates between mental health service users

who smoke and smokers in the general population, there is a

paucity of evidence to guide our practice about what is an

achievable and realistic target. It is likely that smokers who

have mental illness will have more severe nicotine dependence

and greater ambivalence about stopping compared to smok-

ers in the general population (Tsoi et al. 2010), which may

be expected to limit the effectiveness of standard care

interventions.

The findings of this study need to be cautiously interpreted

because of its methodological limitations: this was uncon-

trolled study and hence vulnerable to subjectivity and bias.

The sample size was small and recruited from a single site;

therefore, it may not be representative or generalisable to

similar populations. The Mental Health Trust where the

study was conducted did not routinely record patient’s

smoking status at the time, so we are unable to report what

proportion of the in-patients were smokers and therefore

what proportion of smokers were interested in making a quit

attempt during their stay. We also did not collect any routine

data regarding the severity of symptoms of this sample of

patients and how this may have affected their desire to use the

drop-in clinic or influenced their ability to quit. Follow-up

data were only collected for four weeks after the patients quit

date, in line with national monitoring standards; therefore,

we do not know whether these quit attempts were sustained

beyond this time period. However, this study has generated

new knowledge at a local level and was conducted in a real

world as opposed to a research setting. The most robust

design for the evaluation of a new intervention or service is a

well conducted randomised controlled trial; however, a series

of studies may be required to progressively refine an

intervention before one embarks on a full-scale evaluation

(Craig et al. 2008). Compared to the large, robust evidence

base for smoking cessation interventions for smokers in the

general population, interventions to help people with SMI

have a smaller evidence base, and to date published studies

have focused on patients in community mental health

settings. Clinical interventions evaluated in the general

population provide an essential starting point on which

to build approaches specific to the needs of this particular

population. The challenge of taking evidence-based interven-

tions that are effective in smokers in the general population

and adapting them for mental health patients who smoke is

D Robson et al.

� 2012 Blackwell Publishing Ltd 410 Journal of Clinical Nursing, 22, 405–413

an important public health priority and the basis of this

study.

Conclusion

This service evaluation of a stop smoking drop-in clinic

highlights that patients in an acute in-patient unit are

interested in stopping smoking and that a significant propor-

tion find this achievable. Enforcing smoke-free legislation has

become a time-consuming and contentious issue on in-patient

units, particularly in the UK. However, an admission period

in a smoke-free environment provides a crucial opportunity

to offer smoking cessation treatment, although this will only

be viable with appropriate resources expertise and support.

This small-scale evaluation has shown a drop-in intervention

to be feasible, acceptable and associated with positive

outcomes; further research with larger, more representative

samples to guide our practice is required.

Contributions

Study design: DR; data collection and analysis: DR, FC, SJ,

BB, SS, ST, MH and manuscript preparation: DR, FC, BB, SJ,

ST, MT, MJ, MH.

References

Aguila MC, Gurpegui M, Diaz FJ & de

Leon J (2005) Nicotine dependence and

symptoms in schizophrenia: naturalistic

study of complex interactions. British

Journal Psychiatry 186, 215–221.

American Lung Association (ALA) (1990)

The Health Benefits of Smoking Ces-

sation: A Report of the Surgeon Gen-

eral. U.S. Department of Health and

Human Services, Boston, MA.

American Psychiatric Association (2006)

Practice Guideline for the Treatment of

Patients with Substance Use Disorders,

2nd edn. American Psychiatric Associ-

ation, Arlington, VA.

Ashton M, Miller C, Bowden JA & Bertossa

S (2010) People with mental illness can

tackle tobacco. Australian and New

Zealand Journal of Psychiatry 44,

1021–1028.

Baker A, Richmond R, Haile M, Lewin TJ,

Carr VJ, Taylor RL, Jansons S & Wil-

hem K (2006) A randomised controlled

trial of a smoking cessation interven-

tion among people with a psychotic

disorder. American Journal of Psychia-

try 163, 1934–1942.

Banham L & Gilbody S (2010) Smoking

cessation in severe mental illness: what

works? Addiction 105, 1176–1189.

Brown S, Barraclough B & Inskip H (2000)

Causes of the excess mortality of

schizophrenia. British Journal of Psy-

chiatry 177, 212–217.

Cahill K, Stead LF & Lancaster T (2012)

Nicotine receptor partial agonists for

smoking cessation. Cochrane Database

of Systematic Reviews, Issue 4, Art.

No.: CD006103.

Campion J, Checinski K, Nurse J & McNeill

A (2008) Smoking by people with

mental illness and benefits of smoke-

free mental health services. Advances in

Psychiatric Treatment 14, 217–228.

Centres for Disease Control and Prevention

(2009) Summary Health Statistics for

U.S. Adults: National Health Interview

Survey, 2008: Vital and Health Statis-

tics. U.S. Department of Health and

Human Services, Boston, MA.

Chang C-K, Hayes RD, Perera G, Broadbent

MTM, Fernandes AC, Lee WE, Hotopf

M & Stewart R (2011) Life expectancy

at birth for people with serious mental

illness and other major disorders from a

secondary mental health care case reg-

ister in London. PLoS One 6, e19590.

Cormac I, Creasey S, McNeill A, Ferriter M,

Huckstep B & D’Silva K (2010) Impact

of a total smoking ban in a high secure

hospital. The Psychiatrist 34, 413–417.

Craig P, Dieppe P, Macintyre S, Mitchie S,

Nazareth I & Petticrew M (2008)

Developing and evaluating complex

interventions: the new MRC guidance.

British Medical Journal 337, 979–982.

Department of Health (2009) NHS Stop

Smoking Services: Service and Moni-

toring Guidance 2009/10. Department

of Health, London.

Diaz FJ, James D, Botts S, Maw L, Susce

MT & de Leon J (2009) Tobacco

smoking behaviors in bipolar disorder:

a comparison of the general population,

schizophrenia, and major depression.

Bipolar Disorders 11, 154–165.

Evins AE, Mays VK, Rigotti NA, Tisdale T,

Cather C & Goff D (2001) A pilot trial

of buproprion added to cognitive

behavioural therapy for smoking ces-

sation for schizophrenia. Nicotine and

Tobacco Research 3, 397–403.

Evins AE, Cather C, Deckersbach T, Freu-

denreich O, Culhane MA, Olm-Ship-

man CM, Henderson DC, Schoenfeld

DA, Goff DC & Rigotti NA (2005) A

double-blind placebo controlled trial of

buproprion sustained release for smok-

ing cessation for schizophrenia. Journal

Clinical Psychopharmacology 25, 218–

225.

Evins AE, Cather C, Deckersbach T, Birn-

baum A, Horowittz J, Hsieh E, Freu-

denreich O, Culhane MA, Henderson

DC, Schoenfeld DA, Rigotti NA &

Goff DC (2007) A 12 week double-

blind placebo controlled study of

buproprion SR added to high dose dual

nicotine replacement therapy for

smoking cessation or reduction in

schizophrenia. Journal Clinical Psy-

chopharmacology 27, 380–386.

Fidler JA & West R (2009) Self-perceived

smoking motives and their correlates in

a general population sample. Nicotine

and Tobacco Research 11, 1182–1188.

George TP, Ziedonis DM, Feingold A, Pepper

Wt, Satterberg CA, Winkel J, Termine A,

Rounsaville BJ & Kosten TR (2000)

Nicotine transdermal patch and atypical

antipsychotic medications for smoking

cessation in schizophrenia. American

Journal Psychiatry 157, 1835–1842.

George TP, Vessicchio JC, Termine A, Bre-

gartner TA, Feingold A, Rounsaville BJ

& Kosten TR (2002) A placebo

controlled trial of buproprion for

smoking cessation in schizophrenia.

Biological Psychiatry 52, 53–61.

George TP, Vessiccho JC, Sacco KA, Wein-

berger AH, Dudas MM, Allan TM,

Cerissa LC, Potenza MN, Feingold A &

Jatlow PI (2008) A placebo controlled

Clinical issues Drop-in stop smoking clinic service evaluation

� 2012 Blackwell Publishing Ltd Journal of Clinical Nursing, 22, 405–413 411

trial of buproprion combined with nic-

otine patch in schizophrenia. Biological

Psychiatry 63, 1092–1096.

Hajek P (1989) Withdrawal-oriented ther-

apy for smokers. British Journal of

Addiction 84, 591–598.

HDA (2003) Standard for Training in

Smoking Cessation Treatments. Health

Development Agency, London. http://

www.hda.nhs.uk/documents/smoking_

cessation_treatments.pdf (accessed 1

April 2009).

Health Act (2006) Smoke-free (Premises and

Enforcement) Regulations. Available at:

http://www.legislation.gov.uk/ukpga/

2006/28/part/1 (accessed 1 April

2009).

Health and Social Care Information Centre

(2009) National Statistics on NHS Stop

Smoking Services in England April

2008 to March 2009. NHS Health and

Social Care Information Centre, Leeds.

Health and Social Care Information Centre

(2010) National Statistics on NHS Stop

Smoking Services in England April

2009 to March 2010. NHS Health and

Social Care Information Centre, Leeds.

Health and Social Care Information Centre

(2011) Mental Health Bulletin. Fourth

Report from Mental Health Minimum

Dataset (MHMDS) Annual Returns,

2010. NHS Health and Social Care

Information Centre, Leeds.

Heatherton TF, Kozlowski LT, Frecker RC,

Rickert W & Robinson J (1989) Mea-

suring the heaviness of smoking: using

self-reported time to the first cigarette

of the day and number of cigarette per

day. British Journal of Addiction 84,

791–800.

Heatherton TF, Kozlowski LT, Frecker RC

& Fagerstrom KO (1991) The Fager-

strom Test for nicotine dependence: a

revision of the Fagerstrom Tolerance

Questionnaire. British Journal of

Addiction 86, 1119–1127.

Hughes JR, Stead LF & Lancaster T (2007)

Antidepressants for smoking cessation.

Cochrane Database of Systematic

Reviews, Issue 1, Art. No.: CD000031.

Jarvors MA, Hatch JP & Lamb RJ (2005)

Cut-off levels for breath carbon mon-

oxide as a marker for cigarette smok-

ing. Addiction 100, 159–167.

John U, Meyer C, Rumpf H-J & Hapke U

(2004) Smoking, nicotine dependence

and psychiatric comorbidity – a popu-

lation-based study including smoking

cessation after three years. Drug and

Alcohol Dependence 76, 287–295.

Kelly C & McCreadie RG (1999) Smoking

habits, current symptoms, and premor-

bid characteristics of schizophrenic pa-

tients in NithSDale, Scotland. American

Journal of Psychiatry 156, 1751–1757.

Kumari V & Postma P (2005) Nicotine use

in schizophrenia: the self medication

hypotheses. Neuroscience and Bio-

behavioural Reviews 29, 1021–1034.

Lasser K, Boyd JW, Woolhander S,

Himmelstein DU, McCormick D &

Bor DH (2000) Smoking and mental

illness: a population-based prevalence

study. The Journal of American Medi-

cal Association 284, 2606–2610.

Lawn S & Campion J (2010) Factors asso-

ciated with success of smoke-free

initiatives in Australian psychiatric

in-patient units. Psychiatric Services 16,

300–305.

de Leon J & Diaz F (2005) A meta analysis

of worldwide studies demonstrates an

association between schizophrenia and

tobacco smoking behaviours. Schizo-

phrenia Research 76, 135–137.

de Leon J, Diaz FJ, Becon E, Guregui M, Ju-

rado D & Gonzalez-Pinto A (2003)

Exploring brief measures of nicotine

dependence for epidemiological surveys.

Addictive Behaviours 28, 1481–1486.

McCarthy M, Durkin S & Wakefield M

(2010) Smoking Prevalence and Con-

sumption in Victoria: Key Findings

from the 1998–2009 Population Sur-

veys. CBRC Research Paper Series

No.41. Centre for Behavioural Research

in Cancer, The Cancer Council Victoria,

Melbourne.

McEwen A, Hajek P, McRobbie H & West

R (2006a) Manual of Smoking Cessa-

tion: A Guide for Counsellors and

Practitioners. Blackwell Publishing Ltd,

Oxford.

McEwen A, West R & McRobbie H (2006b)

Effectiveness of specialist group treat-

ment for smoking cessation vs one-

to-one treatment in primary care.

Addictive Behaviours 31, 1650–1660.

McEwen A, West R & McRobbie H (2008)

Motives for smoking and their corre-

lates in clients attending Stop Smoking

treatment services. Nicotine and

Tobacco Research 10, 843–850.

McManus S, Meltzer H & Campion J

(2010) Cigarette Smoking and Mental

Health in England. Data from the

Adult Psychiatric Morbidity Survey

2007. National Centre for Social Re-

search, London.

McNally L (2006) Smoking and Mental

Health. Helping Smokers Quit in

Mental Health Settings. GASP, Bristol.

McNemar Q (1947) Note on the sampling

error of the difference between corre-

lated proportions or percentages. Psy-

chometrika 12, 153–157.

Medicines and Healthcare Regulatory

Agency (2008) Drug Safety Update.

MHRA, London.

Mental Health Foundation (2009) Death of

the Smoking Den. Mental Health

Foundation, London.

National Institute for Health and Clinical

Excellence (2008) Smoking Cessation

Services in Primary Care, Pharmacies,

Local Authorities and Workplaces,

Particularly for Manual Working

Groups, Pregnant Women and Hard to

Reach Communities. NICE. National

Research Ethics Service: Defining Re-

search. NHS National Patient Safety

Agency, London.

Newman SC & Bland RC (1991) Mortality

in a cohort of patients with schizo-

phrenia: a record linage study. Cana-

dian Journal of Psychiatry 36, 239–245.

NHS Surrey (2008) Public Health Annual

Report 2008. NHS Surrey, Leatherhead.

Osborn DPJ, Levy G & Nazareth I (2007)

Relative Risk of Cardiovascular and

Cancer Mortality in People With Severe

Mental Illness From the United King-

dom’s General Practice Research Data-

base. Archives General Psychiatry 64,

242–249.

Osborn DPJ, Wright CA, Levy G & King

MB (2008) Relative risk of diabetes,

dyslipidaemia, hypertension and the

metabolic syndrome in people with

severe mental illnesses. Systematic

review and meta-analysis. BMC Psy-

chiatry 8, 84.

Parks J, Sven S, Den D, Singer P & Foti ME

(2006) Morbidity and Mortality in

People with Serious Mental Illness.

National Association of State Mental

Health Programme Directors, Medical

Directors Council, Alexandria, VA.

Raw M, McNeill A & Coleman T (2005)

Lessons from the English smoking

treatment services. Addiction 100(Sup-

pl. 2), 84–91.

Rice VH & Stead LF (2008) Nursing inter-

ventions for smoking cessation. Coch-

D Robson et al.

� 2012 Blackwell Publishing Ltd 412 Journal of Clinical Nursing, 22, 405–413

rane Database of Systematic Reviews,

Issue 1, Art. No.: CD001188.

Rigotti NA, Munafo MR & Stead L (2008)

Smoking cessation interventions for

hospitalized smokers: a systematic re-

view. Archives of Internal Medicine

168, 1950–1960.

Shetty A, Alex R & Bloye D (2010) The

experience of a smoke-free policy in a

medium secure hospital. The Psychia-

trist 34, 287–289.

Stead LF, Perera R, Bullen C, Mant D &

Lancaster T (2008) Nicotine replace-

ment therapy for smoking cessation.

Cochrane Database of Systematic

Reviews, Issue 3, Art. No.: CD000146.

Tsoi DT, Porwal M & Webster AC (2010)

Efficacy and safety of bupropion for

smoking cessation and reduction in

schizophrenia: systematic review and

meta-analysis. British Journal of Psy-

chiatry 196, 346–353.

West R (2006) Defining and assessing nic-

otine dependence in humans. In

Understanding Nicotine and Tobacco

Addiction (Bock G & Goode J eds).

Wiley, London, pp. 36–51.

West R, McNeill A & Raw M (2000)

Smoking cessation guidelines for health

professionals: an update. Thorax 55,

987–999.

World Health Organisation (2009) WHO

Report on the Global Tobacco Epi-

demic, 2009: Implementing Smoke Free

Environments. WHO, Geneva.

The Journal of Clinical Nursing (JCN) is an international, peer reviewed journal that aims to promote a high standard of

clinically related scholarship which supports the practice and discipline of nursing.

For further information and full author guidelines, please visit JCN on the Wiley Online Library website: http://

wileyonlinelibrary.com/journal/jocn

Reasons to submit your paper to JCN: High-impact forum: one of the world’s most cited nursing journals, with an impact factor of 1Æ118 – ranked 30/95 (Nursing

(Social Science)) and 34/97 Nursing (Science) in the 2011 Journal Citation Reports� (Thomson Reuters, 2011)

One of the most read nursing journals in the world: over 1Æ9 million full text accesses in 2011 and accessible in over 8000

libraries worldwide (including over 3500 in developing countries with free or low cost access).

Early View: fully citable online publication ahead of inclusion in an issue.

Fast and easy online submission: online submission at http://mc.manuscriptcentral.com/jcnur.

Positive publishing experience: rapid double-blind peer review with constructive feedback.

Online Open: the option to make your article freely and openly accessible to non-subscribers upon publication in Wiley

Online Library, as well as the option to deposit the article in your preferred archive.

Clinical issues Drop-in stop smoking clinic service evaluation

� 2012 Blackwell Publishing Ltd Journal of Clinical Nursing, 22, 405–413 413

This document is a scanned copy of a printed document. No warranty is given about the accuracy of the copy.

Users should refer to the original published version of the material.