Smoking in a Residential Treatment Facility: A Harm Reduction Approach

More than one in three adults with a mental illness smoke cigarettes, compared with about one in five adults with no mental illness, according to the US Centers for Disease Control & Prevention. Twenty percent of Americans smoke and one in five has mental illness.

Why is this important to you in your practice? Patients with a serious mental illness now die 25 years earlier than the general population.

And if you are trying to get an addict to quit smoking, it might help to point out that substance abusers who quit smoking are less likely to relapse. But it’s also good to remember that chronic alcoholics typically need a year of sobriety before they try to stop smoking.

Drug interactions can also make it harder to quit. Caffeine’s a good example. Do you have patients on medications to help them quit smoking who are complaining about being jittery? If so, you might suggest that they cut back on caffeine if they’re blaming their smoking cessation meds. If they’re used to drinking two cups of coffee, suggest they stop at one and see if that helps.

Valerie Mendralla, RN, MPH, nurse coordinator at Lake County Health Department in Vernon Hills, IL, spoke about a harm reduction approach to tobacco use in a residential treatment facility at the American Psychiatric Nurses Association 28th Annual Conference, held October 22-25, 2014, in Indianapolis, IN.

Mendralla works in Women’s Residential Services at Lake County Health Department and Community Health Center, a residential treatment program for chemically dependent women and their children. The facility has 16 beds, where patients sleep overnight, and stay for 60-90 days. They take substance abusers with no insurance or just Medicaid. Pregnant and intravenous drug-using women are given priority.

Mendralla said her facility’s Harm Reduction Approach “aims to get patients to the point of contemplating, ‘Yeah…I think I can quit.’” They focus on reducing how much patients smoke through a variety of tactics, including:

• Carbon monoxide readings
• Pack checks
• Nurse education
• Required weekly tobacco dependency group meetings
• Nicotine replacement therapy at no charge
• Tobacco Free Lake County
• Illinois Tobacco Quit Line
• Incentives

Mendralla said women who are worried about gaining weight if they quit smoking appreciate having access to a gym. To help patients deal with stress, the facility has a “smoke pit;” patients are required to write down every day if they have to go out to the smoke pit, noting why they do as well as what their mood was at the time. “After they do that for the week, you can start to identify patterns. Are they going out because they’re stressed or simply because they are done eating?” said Mendralla.

Pharmacotherapy for smoking cessation is associated with several challenges, said Mendralla. For example, patients will sometimes get irritated from the NicoDerm CQ® patch adhesive, which will leave a red square mark. Mendralla suggested applying the patch someplace other than an arm‑‑as long as it’s not on the patient’s face or neck, “It can go anywhere,” she said. “Some people have tried it on their thigh, and some people have tried it on their back side, and some claim it works better if it’s not on their arm.”

She also said that about 50 percent of her patients say that they have vivid dreams and sometimes nightmares, so they might take the patch off to sleep and as soon as they wake up, they put it right back on.