Estratègies de control del tabaquisme i polítiques de fum ambiental del tabac en l’àmbit de la salut mental

[cat] ANTECEDENTS La prevalença de tabaquisme en els pacients ingressats en unitats hospitalàries de salut mental pot arribar fins a un 80% i poden arribar a morir uns 25-30 anys de mitjana abans que la població general, habitualment per malalties causades o agreujades pel tabac. No obstant, l’abordatge del tabaquisme als centres de salut mental ha estat habitualment ignorat i d’altra banda, les lleis de prohibició de fumar han estat més permissives amb les unitats d’ingrés de psiquiatria. OBJECTIUS 1. Examinar les estratègies de control del tabaquisme implementades a les institucions d'hospitalització psiquiàtrica de Catalunya i identificar àrees de millora. 2. Avaluar el nivell de fum ambiental del tabac (FAT) a les unitats de salut mental hospitalària de Catalunya segons el tipus de normativa de control del consum de tabac. 3. Comparar la percepció de nivell de FAT per part de treballadors i pacients amb els resultats obtinguts mitjançant una mesura objectiva i descriure la preferència per les diferents normatives de control del consum de tabac. 4. Avaluar la possible associació entre malestar psicològic i exposició al FAT en la població adulta espanyola. METODOLOGIA Les dades d’aquesta tesi provenen de tres estudis transversals diferents. En el primer estudi es va utilitzar una enquesta sobre quatre dimensions del control del tabaquisme (intervenció clínica sobre el consum de tabac, formació i compromís dels professionals, control dels espais on es permet/prohibeix fumar i comunicació de les normatives sense fum). L’enquesta es va enviar als caps d’unitats d’ingrés hospitalari i centres de dia en salut mental de Catalunya (n=186). En el segon estudi es va mesurar el nivell de FAT a les unitats hospitalàries de salut mental de Catalunya (n=64) mitjançant les PM2.5 (partícules aèries PM2.5, com a marcador de l’exposició ambiental). A la vegada, es va passar una enquesta als pacients i professionals d’aquestes unitats (n=600 i n=575, respectivament) sobre l’exposició percebuda al FAT i sobre les preferències per diferents tipus de normatives de control del consum de tabac als dispositius de salut mental. El tercer estudi utilitza les dades de població adulta mai-fumadora (n=11.214) de la Encuesta Nacional de Salud de España (2011-2012). RESULTATS El control del tabaquisme als dispositius de salut mental era generalment baix, especialment quant a la intervenció clínica en el consum de tabac sobre aquests pacients, la manca de disponibilitat de fàrmacs per deixar de fumar i la poca formació dels professionals en aquest tema. Aquests resultats eren especialment baixos en el cas dels Centres de Dia. D’altra banda, es va detectar que només aquells dispositius amb normatives de prohibició de fumar tant en els interiors com en els exteriors tenien nivells de PM2.5 dins dels nivells recomanats per l’OMS i que els dispositius que permetien als pacients fumar a zones exteriors o interiors podien doblar o quintuplicar aquests nivells recomanats. No obstant, els professionals i pacients tenien una baixa percepció d’estar exposats al FAT. En el cas dels professionals, aquesta percepció d’estar exposats al FAT era més baixa en metges que en infermeres, en canvi els metges tenien una prevalença de consum de tabac per sota de la població general i les infermeres per sobre. Així mateix, una majoria de pacients i professionals apostaven per deixar fumar als pacients als exteriors dels dispositius, tot i que no als interiors. Finalment, es va detectar que l’exposició passiva al FAT a la llar podria augmentar el malestar psicològic de les persones mai-fumadores. CONCLUSIONS El control del tabaquisme als dispositius de salut mental hospitalaris és baix. Aquells dispositius que prohibeixen fumar en interiors i exteriors són els únics que protegeixen adequadament del FAT. Els professionals i els pacients generalment infravaloren el nivell de FAT als interiors dels dispositius hospitalaris, i per tant el seu efecte perjudicial sobre la salut. Això podria tenir alguna influència en la major preferència per normatives de prohibició de fumar menys restrictives. El FAT podria afectar el malestar psicològic dels pacients ingressats en dispositius de mitjana i llarga estada, on encara es permet fumar als interiors.[eng] Smoking prevalence can rise to 80% in patients admitted in mental health wards. However, tobacco control has usually been neglected in mental health settings. OBJECTIVES a) To examine tobacco control strategies undertaken in psychiatric units in Catalonia, b) to objectively evaluate the levels of second-hand smoke (SHS) in these units, c) to compare objectively assessed SHS to self-reported levels of exposure to SHS of patients and staff; and to describe preferences for different types of smoking bans, and d) to examine the potential association between SHS exposure and psychological distress. METHODS The data derives from three cross-sectional studies. For the first objective we used a questionnaire sent to the managers of mental health units (n=186). For the second and third objective we measured the level of SHS in the mental health wards of Catalonia (n=64) through the measurement of PM2.5 as a marker of SHS. At the same time, we administered a questionnaire to the inpatients and professionals of these 64 wards (n=600 and n=575, respectively) about their self-perceived exposure to SHS and their preference on different types of smoking bans. For the last objective we used a sample of adult never-smokers (n=11,214) from the Spanish National Health Interview Survey (2011-2012). RESULTS Tobacco control in mental healthcare services was usually low, especially with respect to the clinical intervention on patients’ tobacco use and the lack of professionals’ training in this field. Moreover, it was found that only those services with total smoking bans had levels of PM2.5 concentrations within the WHO recommended levels. The services with partial bans implemented (allowing smoking only outdoors or allowing indoor smoking) were two or five times over the recommended WHO levels. However, patients and professionals had a low perception of being exposed to SHS at harmful levels. A majority of patients and professionals agreed with allowing patients smoke outdoors. Finally, we found that passive exposure to SHS is associated with psychological distress in never-smokers exposed to SHS in their homes. CONCLUSIONS Tobacco control in hospital mental health services is low. Only wards with total smoking bans protect against SHS. Patients and staff generally underestimate the level of SHS in the wards. This could influence the preference of patients and staff for less restrictive smoking bans. SHS could affect psychological distress of patients in medium- and long-stay patients units, where smoking is still allowed indoors

The right to smoke and the right to smoke-free surroundings: international comparison of smoke-free psychiatric clinic implementation experiences

In Scandinavia, people with a severe mental disorder have a reduced life expectancy of 15-20 years compared with the general public. Smoking is a major contributor, and smoke-free policies are increasingly adopted in psychiatric clinics around the world. We compared potential facilitators and barriers among staff and management, for the implementation of smoke-free psychiatric clinics

Deconstructing myths, building alliances: a networking model to enhance tobacco control in hospital mental health settings

Life expectancy for people with severe mental disorders is up to 25 years less in comparison to the general population, mainly due to diseases caused or worsened by smoking. However, smoking is usually a neglected issue in mental healthcare settings. The aim of this article is to describe a strategy to improve tobacco control in the hospital mental healthcare services of Catalonia (Spain). To bridge this gap, the Catalan Network of Smoke-free Hospitals launched a nationwide bottom-up strategy in Catalonia in 2007. The strategy relied on the creation of a working group of key professionals from various hospitals the - early adopters - based on Rogers' theory of the Diffusion of Innovations. In 2016, the working group is composed of professionals from 17 hospitals (70.8% of all hospitals in the region with mental health inpatient units). Since 2007, tobacco control has improved in different areas such as increasing mental health professionals' awareness of smoking, training professionals on smoking cessation interventions and achieving good compliance with the national smoking ban. The working group has produced and disseminated various materials, including clinical practice and best practice guidelines, implemented smoking cessation programmes and organised seminars and training sessions on smoking cessation measures in patients with mental illnesses. The next challenge is to ensure effective follow-up for smoking cessation after discharge. While some areas of tobacco control within these services still require significant improvement, the aforementioned initiative promotes successful tobacco control in these settings. (C) 2016 SESPAS. Published by Elsevier Espana, S.L.U

The role of middle managers in tobacco control after a national smoke-free hospital campus ban

Background: Much of the recent health services research on tobacco control implementation has explored general views and perceptions of health professionals and has rarely taken into account middle management's perspectives. We state that middle managers may facilitate the implementation of smoke-free campus bans and thereby improve their effectiveness. The aim of this study was to assess middle managers' behaviors to enforce a new national smoke-free hospital campus ban, to evaluate their perceptions of the level of compliance of the new regulation, and to explore their attitudes towards how smoking affects the work environment. Methods: We used a cross-sectional survey, conducted online to evaluate middle managers of a general hospital in Catalonia, Spain. Close-ended and open-ended questions were included. Results were analyzed by using quantitative and qualitative methods. The managers' open opinions to the proposed topics were assessed using UCINET, and a graph was generated in NetDraw. Results: Sixty-three of the invited managers (78.7 %) participated in the survey. 87.2 % of them agreed that the hospital complied with the smoke-free campus ban and 79.0 % agreed that managers have an important role in enforcing the ban. They also perceived that smoking disturbs the dynamics of work, is a cause of conflict between smokers and non-smokers, and harms both the professional and the organization images. However, 96.8 % of respondents have never given out fines or similar measures and their active role in reminding others of the policy was limited; in addition, 68.2 % considered that hospitals should provide tobacco cessation treatments. Smoker middle managers were more likely than non-smokers to perceive that smoking has little impact on work. Conclusions: Middle managers play a limited role in controlling tobacco consumption; smokers are less prone to think that smoking disturbs work dynamics than non-smokers. Tailored training and clear proceedings for middle managers could encourage more active roles

Exposure to secondhand smoke in the home and mental health in children: a population-based study

OBJECTIVES: To examine the association between exposure to secondhand smoke (SHS) in the home and mental health among children. METHODS: Cross-sectional study of 2357 children representative of the Spanish population aged 4-12 years in 2011-2012. Duration of SHS exposure in children was reported by parents. Probable mental disorder was defined as a score>90th centile in the parental version of the Strengths and Difficulties Questionnaire (SDQ). Statistical analysis was performed with logistic regression and adjusted for sociodemographic variables, lifestyle, neighbourhood environment and family characteristics, including parental mental health. RESULTS: Among study participants, 6.9% (95% CI 5.7% to 8.0%) were exposed to SHS in the home for <1 h/day and 4.5% (95% CI 3.5% to 5.5%) for ≥1 h/day. Compared to children not habitually exposed to SHS, the multivariate ORs for probable mental disorder were 1.49 (95% CI 0.85 to 2.62) for SHS exposure<1 h/day and 2.73 (95% CI 1.38 to 5.41) for SHS exposure≥1 h/day (p for linear trend=0.002). The corresponding ORs for attention-deficit and hyperactivity disorder (ADHD) were 2.18 (95% CI 1.30 to 3.64) for <1 h/day exposure and 3.14 (95% CI 1.63 to 6.04) for ≥1 h/day exposure (p for linear trend<0.001). No association was found between SHS and the rest of the components of the SDQ. CONCLUSIONS: Among children, SHS exposure in the home during ≥1 h/day is associated with a higher frequency of mental disorder. This association was mostly due to the impact of SHS on ADHD

Perception of electronic cigarettes in the general population: does their usefulness outweigh their risks?

Objective: To describe and compare the perceptions of the general population about the harmful effects of electronic cigarettes (e-cigarettes) on users and on those passively exposed to e-cigarettes and the perceptions about e-cigarette usefulness for reducing or eliminating tobacco smoking. Design, setting, and participants: We analysed cross-sectional data from a longitudinal study of a representative sample of the general adult (≥16 years) population of Barcelona, Spain (336 men and 400 women). The fieldwork was conducted between May 2013 and February 2014. We computed the percentages, adjusted OR and their corresponding 95% CI among participants with some awareness of e-cigarettes (79.2% of the sample). Primary and secondary outcome measures: We assessed the perception about harmfulness for e-cigarette users and for passively exposed non-e-cigarette users, as well as the perception of usefulness for smokers of cigarette cessation and reduction

Secondhand smoke risk perception and smoke-free rules in homes: a cross-sectional study in Barcelona (Spain)

Objective: to describe the voluntary adoption of smoke-free homes in Spain among general population and to identify variables associated with its voluntary adoption. Methods: cross-sectional study of a representative sample (n=731) of the adult population (>26 years) of Barcelona, Spain, in 2013-2014. We defined smoking rules inside the households as complete indoor rules (when smoking was not allowed inside the house), and partial or absent indoor rules (when smoking was allowed in some designated places inside the house or when smoking was allowed everywhere) and described them according to the perceived risk of the secondhand smoke (SHS) exposure. We calculated the prevalence and prevalence ratios (PR) according to sociodemographic variables. Results: 57.4% of households had complete indoor smoke-free rules. The prevalence of households with complete indoor rules was higher among women (PRa: 1.15; 95% CI 1.00 to 1.33), married (PRa: 1.18; 95% CI 1.01 to 1.38), never-smokers (PRa: 2.68; 95% CI 2.06 to 3.50) and in households where a minor lived (PRa: 1.40; 95% CI: 1.20-1.65). Believe that breathing tobacco smoke from smokers is dangerous for non-smokers (PRa: 1.77; 95% CI: 1.06-2.97) is associated with the voluntary adoption of complete indoor smoke-free home. Conclusions: risk perceptions of SHS exposure were associated with the voluntary adoption of indoor smoke-free homes

Multimodal treatment for smoking cessation with varenicline in alcoholic, methadone-maintained, and psychotic patients: A one-year follow-up

Introduction: Numerous studies have evaluated the efficacy and safety of varenicline for smoking cessation in smokers in the general population and, to a lesser extent, among the psychiatric population. However, few studies have evaluated varenicline in patients with other addictions. The present study was conducted to assess outcomes of a multimodal treatment for smoking cessation intervention with varenicline in a sample of alcohol and substance use disorders and patients with psychotic disorders. Methods: This was a prospective, multicenter study. The patient sample comprised alcoholics in remission, methadone-maintained patients, and patients with psychotic disorders, all of whom wanted to stop smoking. All participants received multimodal treatment for smoking cessation therapy (psychological therapy plus varenicline). Smoking abstinence and changes in the psychopathological state of patients were assessed at predefined time points during a 12-month follow-up. The probability of tobacco abstinence after one year of treatment was computed using Kaplan-Meier life tables. Results: The probability of abstinence at one year was 0.225 (95% CI: 0.143- 0.319). By group, the probabilities were as follows: patients with psychotic disorders 0.254 (95% CI: 0.118-0.415); alcoholics 0.237 (95% CI: 0.098- 0.409); and methadone-maintained patients 0.177 (95% CI: 0.065-0.335). Patients with previous quit attempts had a higher probability of achieving abstinence at one year (p<0.01). Conclusions: The results of this study support the use of multimodal treatment with varenicline in patients with alcohol addiction in remission, patients on methadone maintenance, and patients with stable psychotic disorders. Previous smoking cessation attempts were predictive of smoking cessation success in these patients

Motivation and main flavour of use, use with nicotine and dual use of electronic cigarettes in Barcelona, Spain: a cross-sectional study

Objective This study seeks to describe current e-cigarette users' patterns of use including primary motivation for use, dual use, use with nicotine and principal flavour used, according to individuals' sociodemographic characteristics and conventional tobacco consumption in Barcelona, Spain. Design, setting and participants This is a cross sectional study of adult (≥18) current e-cigarette users of Barcelona (n=600), recruited in 2015. Researchers calculated percentages and ORs with their 95% CIs of users' e-cigarette use with nicotine, primary motivation for use and preferred flavour. The analyses were stratified by sociodemographic variables including sex, age and level of education and by patterns of e-cigarette use and past and current conventional tobacco use. Results The most prevalent motivation for using e-cigarettes was to reduce tobacco smoking (48%, n=288), followed by quitting smoking (39.2%, n=235), and to use e-cigarettes in places where tobacco smoking was prohibited (10.2%, n=61). The most prevalent primary flavour used was tobacco (49%, n=294), followed by fruit (19.5%, n=117). People younger than 25 years old (OR=4.36, 95%CI 1.99 to 9.57) were more likely than older people to use them where smoking cigarettes was prohibited. A greater proportion of those in the youngest age group preferred fruit flavour compared with older individuals (29.3%, n=41). Conclusions Younger users of e-cigarettes and non smokers are more likely to use flavours other than tobacco and to use e-cigarettes mainly for recreational purposes

Conocimiento y percepción de la nocividad del cigarrillo electrónico en población adulta de Barcelona

Objetivo: Describir el conocimiento y la percepción de nocividad de los cigarrillos electrónicos (ecigarrillos) en la población de Barcelona en 2013-2014. Métodos: Se utilizaron los datos del seguimiento (n = 736) de un estudio de cohortes de una muestra representativa de la población adulta de la ciudad de Barcelona. Resultados: El 79,2% de los participantes manifestó conocer el e-cigarrillo. El grado de conocimiento medio fue de 4,4 puntos sobre 10, con diferencias estadísticamente significativas según edad, nivel de estudios, consumo de tabaco y dependencia de la nicotina. La mayoría de los participantes conocieron los e-cigarrillos por los medios de comunicación clásicos (57,8%). El 47,2% de los participantes opinaba que los e-cigarrillos son menos nocivos que los cigarrillos convencionales. Conclusión: La publicidad de los e-cigarrillos en los medios de comunicación debería regularse debido a la escasa evidencia científica sobre su utilidad y sus potenciales efectos adversos