Abstract
Background:
Rates of smoking in persons with mental illness are reported to be two times higher than those without mental illness in developed countries. We aimed to examine the prevalence and severity of tobacco use, and access to tobacco cessation services among tertiary care psychiatric in-patients in India.
Methods:
In this cross-sectional study, 500 consecutive adult in-patients in tertiary care with ICD 10 diagnoses, F20-59, were administered a sociodemographic and clinical proforma, Clinical Global Impression—Severity scale, Fagerstrom Test for Nicotine Dependence, Tobacco Craving Questionnaire, Reasons for quitting questionnaire, and Smoke Scale—Adults. Urine cotinine levels were estimated in the last 100 patients. Details of tobacco use and cessation interventions provided were obtained.
Results:
Overall prevalence of current tobacco use was 34.00%; 34.3%, 32.6%, 43.6%, and 16.7% in patients of F20-29, F30-39, F40-49, and F50-59 categories, respectively. Males used tobacco products at a significantly higher rate (44.85% vs. 17.58% in females) and were highly dependent. Smokeless tobacco use was reported in 20.5% and 18% of female patients with F20-29 and F30-39 diagnoses, respectively. More than half of the tobacco users were not asked about tobacco use and 89.4% of the users were provided no prior assistance for cessation at the time of assessment. Urinary cotinine levels were significantly greater for those who use smokeless forms than smokers or dual users.
Conclusions:
Nearly a third of psychiatric in-patients are current users of tobacco. Moderate to severe tobacco dependence was observed across psychiatric diagnoses. The assessment and interventions provided were suboptimal.
Keywords: Cessation, psychiatric in-patients, smokeless, smoking, tertiary care, tobacco use
INTRODUCTION
Rates of smoking among persons with mental illness in developed countries are reported to be two times that in persons without mental illness.[1] The rates are even higher among persons with severe mental illness (SMI) such as schizophrenia and bipolar disorder.[2,3] They smoke more cigarettes per day and are less likely to quit compared to the general population.[4] Whereas smoking rates in the general population have declined over the years, the decline in persons with mental illness has been significantly lesser than among those without mental illness.[5]
There are several explanations for the high rates of smoking among persons with any mental illness, SMI in particular. One of the most popular explanations is the self-medication hypothesis in schizophrenia, which attributes high rates of smoking in this population to perceived improvements in psychotic and cognitive symptoms with tobacco use.[6] Prospective studies, however, have indicated that tobacco use may increase the risk of subsequent development of schizophrenia in a dose-dependent manner.[7] A shared genetic background for both conditions (tobacco use disorder and schizophrenia) probably best explains the co-occurrence of these conditions.
In India, among persons aged 15 years and above, nearly 29% (42.4% men; 14.2% women) use tobacco in some or other form.[8] Smoking is the predominant method of use in men whereas smokeless tobacco use is more common among women. Overall, the smokeless form of tobacco use is the most common form of tobacco use.
A study conducted among males in a south Indian hospital out-patient setting reported that the rates of current smoking (38%) in schizophrenia were not more than the general population or non-psychiatric controls.[9] The prevalence of smoking was 24% in patients with mood disorders and 23% in patients with non-psychotic disorders. Higher rates (87.7% for persons with mental illness) have been reported in forensic settings as illustrated in a study from Madhya Pradesh, India,[10] as well as a study in the Bangalore prison.[11] In another study conducted at our center nearly a decade and a half back, 36% of psychiatric in-patients were current users of tobacco.[12] The smoking rates were low among women (<1%), whereas with smokeless tobacco use, the gender differences were more comparable. The study found that 65% of the current users were nicotine dependent. In this study, logistic regression showed an association between tobacco use and bipolar disorder.
Despite psychiatrists being equipped in terms of training in both biological and psychosocial management of addiction, even in developed countries, smoking cessation advice was offered to patients with SMI at comparable rates with the general population.[13] In India, the rates may be even lower because of the paucity of mental health professionals (MHPs) and large numbers of patients utilizing public hospitals; the time spent for consultation in both in-patient and out-patient care may be predominantly for the primary mental health condition rather than for tobacco cessation, yet the time during in-patient consultation may provide an opportunity to assess and intervene despite the diagnostic overshadowing.
In the context of premature mortality mainly due to cardiovascular causes among persons with mental illness, particularly SMI, tobacco cessation as part of the initiative to stem non-communicable diseases becomes relevant.
This study aimed to study the prevalence, severity of tobacco use, and access to tobacco cessation among patients admitted to a psychiatric in-patient facility in a tertiary mental health setting. The primary objective was to study the prevalence, whereas the secondary objectives included assessment of the severity of tobacco use including craving and access to lifetime as well as current tobacco cessation interventions among psychiatric in-patients. Other objectives included the assessment of exposure to passive smoking among psychiatric in-patients.
MATERIALS AND METHODS
This was a cross-sectional study of 500 consecutive adults admitted with an International Statistical Classification of Diseases and Related Health Problems-10 (ICD 10)—clinical diagnosis from F20-59 (clinically evaluated and diagnosed by two qualified psychiatrists) to the psychiatric in-patient facility of a tertiary care mental health setting in India. The sample size was calculated based on the findings of 36% prevalence in an earlier Indian study[12] with absolute precision of 5% for 95% confidence level, and the minimum sample size required is 354. The formula used for sample size calculation was as follows: n = 3.8416 * 0.36 * (1- 0.36)/(0.05 * 0.05) = 354.
The study was conducted between January and December 2016 at a 550 bedded tertiary care mental health setting that caters to patients from all over India, sometimes even from the neighboring countries. On average, 1200 to 1500 patients per year are admitted to the psychiatry wards with an average duration of stay of 2 to 3 weeks. Smoking is not permitted within the wards and in the hospital zone, yet with most admissions being voluntary, there is a chance of smoking outside the hospital zone. Written informed consent was obtained after the procedure was fully explained. All consenting patients aged 18 to 60 years of either gender were included. Patients with a significant head injury, with prominent cognitive deficits, those admitted primarily for other addictive disorders, and those with intellectual disabilities were excluded based on the clinical diagnosis of the treating clinical unit. All the in-patients are evaluated by two qualified psychiatrists—first by a senior resident followed by a consultant psychiatrist and they arrive at a final diagnosis by consensus. In cases of the lack of consensus, the decision is deferred to the unit head.
All the recruited patients were administered a predesigned sociodemographic and clinical proforma (that included smoking status assessment based on self-report), Clinical Global Impression-Severity scale (CGI-S),[14] Fagerstrom Test for Nicotine Dependence (FTND),[15] FTND-smokeless tobacco (ST)—modified for the tobacco cessation clinic intake proforma,[15,16] Tobacco Craving Questionnaire-Short Form (TCQ-SF),[17] the Reasons for quitting questionnaire (RFQ),[18] and Smoke Scale-Adults (SS-A).[19] The patients were interviewed anytime during their in-patient stay when they had consented. Urine cotinine levels could be estimated in the last 100 patients only (due to funding constraints) using the Agilent Liquid Chromatography-Mass Spectrometry Model 6460 Quadrupole, mass spectrometer. The medical records provided data regarding ICD-10 diagnosis recorded by the treating psychiatrist, duration of contact with MHPs, diagnosis of tobacco use made by the treating team, and information on any consultation or intervention of any kind (Nicotine Replacement Therapy (NRT), anti-craving medications, or counseling) that was provided for tobacco use. A semi-structured interview based on the 5As (Ask, Assess, Advise, Assist, Arrange) was administered to find out details about tobacco cessation interventions provided. The study was approved by the Institute Ethics Committee.
Statistical analysis: A licensed version of the Statistical Package for Social Sciences (SPSS 23) software was used for statistical analysis. The data were checked for normality using the Kolmogorov–Smirnov test. Data were expressed using descriptive statistics—median (interquartile range) for continuous variables, and frequency and percentage for categorical variables. Comparison between various groups was done using the Mann–Whitney U-test and Kruskal–Wallis test for continuous variables and Chi-square for discrete variables.
RESULTS
During the study period, 644 in-patients were approached by the first author during the days permitted from clinical work during his MD training program (consecutive admissions for those days), of whom, 59 could not be interviewed due to psychiatric instability, 18 could not be interviewed due to history of significant head injury, 13 patients who had received a diagnosis of severe intellectual disability so were excluded, 23 were discharged or transferred before the interview could be completed, 21 did not meet the age criterion, and 10 refused to provide consent.
Sociodemographic and clinical profile
Of the 500 patients recruited, 199 (39.8%) were female and 301 (60.2%) were male. More than half (54.6%) were married and most belonged to the Hindu religion (84.6%), about 48% of the patients had below the primary level of education and 44% were matriculated, 41% were employed outside their home and most of the patients came from a semi-urban background, about 47.6%. The ICD-10 diagnostic break-up of the 500 patients was as follows: F20-29—213 (42.6%), F30-39—242 (48.4%), F40-49—39 (7.8%), and F50-59—6 (1.2%). The SMI group included participants diagnosed with F20-29 (schizophrenia and related disorders) and F30-39 (mood disorder group) diagnoses, while the Common Mental Disorder (CMD) participants were from F40-59.
Prevalence of tobacco use: The prevalence of current tobacco use was 34% (170 out of 500, 95% CI: 25.2–42.8) among the in-patients. Exclusive smokeless tobacco users were mostly female (35 F, 1 M; 21% of the tobacco users) whereas exclusive smokers (68; 40%) and those who used both forms of tobacco were exclusively male (66; 39%). The prevalence of tobacco use (170/500) among diagnostic categories F20-29, F30-39, F40-49, F50-59 were 34.3% (73/213), 32.6% (79/163), 43.6% (17/39), and 16.7% (1/6), respectively. The distribution of smokers, smokeless users, and dual users in each diagnostic category were as follows: F20-29—32/73 (43.8%), 13/73 (17.8%), 28/73 (38.35%), F30-39—27/79 (34.2%), 20/79 (25.3%), 32/79 (40.5%), F40-49—9/17 (52.9%), 2/17 (11.8%), 6/17 (35.3%), and F50-59—0%, 1/1 (100%) 0% respectively.
For the passive smokers (69 out of 330 non-smokers), there was a significant difference between the genders (males: 49/164, females: 20/166; X2 (df) = 14.97 (1), P = 0.001). As illustrated in Table 1, between the tobacco users (n = 170) and non-users (n = 330), significant differences were observed in gender (P = 0.001), occupation (P = 0.001), and family income being higher in the tobacco users (P = 0.008). There was a significant difference in gender, all smokers 68 (100%) and dual users 66 (100%) were men, while among smokeless users 35 (97.2%) were women; occupation-wise, the majority of the smokers 57 (83.3%) and dual users 58 (87.9%) were employed while the majority of those who were unemployed were smokeless users 34 (94.4%), family income-wise, majority of smokers 37 (54.4%), and dual users 40 (60.6%) were earning Rs 20,000 to 40,000 per annum, while 21 (5.3%) of smokeless users had income less than Rs. 20,000 per annum [Table 2]. Among both tobacco users and non-users, around 80% had moderate to marked psychiatric illness on the CGI, and the remaining in both the groups had a severe psychiatric illness with no significant difference in severity between users and non-users [χ2 (df) = 0.397 (1); P 0.528]. The median duration of contact with the MHPs at the institute for tobacco users was 180 days (Inter Quartile Range: 45 -1095).
Table 1.
Sociodemographic profile of the psychiatric inpatients with the comparison of tobacco users and non-users
| Sociodemographic characteristics (n=500) | Tobacco users Frequency (%) | Tobacco Non-users Frequency (%) | Adj OR (95% CI) | UnAdj OR (95% CI) | Chi-square (P) |
|---|---|---|---|---|---|
| Age | |||||
| 18-30 | 92 (54.1) | 169 (51.2) | 1.44 (0.79-2.62) | 1.60 (0.95-2.68) | 4.14 (0.13) |
| 31-40 | 53 (31.2) | 88 (26.7) | 1.30 (0.68-2.50) | 1.76 (0.10-3.10) | |
| >40 | 25 (14.7) | 73 (22.1) | Reference | Reference | |
| Gender | |||||
| Male | 135 (79.4) | 166 (50.3) | 1.33 (0.69-2.60) | 3.81 (2.48-5.86) | 39.67 (0.001) |
| Female | 35 (20.6) | 164 (49.7) | Reference | Reference | |
| Marital status | |||||
| Ever Married | 94 (55.3) | 189 (57.3) | 1.17 (0.75-1.83) | 0.92 (0.64-1.34) | 0.18 (0.67) |
| Never married | 76 (44.7) | 141 (42.7) | Reference | Reference | |
| Religion | |||||
| Hindu | 138 (81.2) | 285 (86.4) | 0.69 (0.39-1.22) | 0.68 (0.41-1.12) | 2.31 (0.13) |
| Others | 32 (18.2) | 45 (13.6) | Reference | Reference | |
| Education | |||||
| Primary or lesser | 85 (50.0) | 158 (47.9) | 1.18 (0.77-1.80) | 1.09 (0.75-1.57) | 0.20 (0.65) |
| Matriculation and above | 85 (50.0) | 172 (52.1) | Reference | Reference | |
| Occupation | |||||
| Unemployed | 53 (31.2) | 242 (73.3) | 0.17 (0.10-0.32) | 0.17 (0.11-0.25) | 82.43 (0.001) |
| Employed | 117 (68.8) | 88 (26.7) | Reference | Reference | |
| Family income (per year in INR) | |||||
| <20,000 | 49 (28.8) | 68 (20.6) | 1.16 (0.60-2.24) | 0.98 (0.55-1.73) | 9.59 (0.008) |
| 20,000-40,000 | 87 (51.2) | 216 (65.5) | 0.49 (0.27-0.86) | 0.55 (0.33-0.91) | |
| >40000 | 34 (20.0) | 46 (13.9) | Reference | Reference | |
| Residence | |||||
| Rural | 58 (34.1) | 131 (39.7) | 0.66 (0.42-1.03) | 0.79 (0.54-1.16) | 1.49 (0.22) |
| Semi-urban/urban | 112 (65.9) | 199 (60.3) | Reference | Reference |
Table 2.
Comparison of demographical variables among the three groups (smokers, smokeless, and dual users)
| Sociodemographic characteristics (n=500) | Smokers Frequency (%) | Smokeless users Frequency (%) | Dual users Frequency (%) | Chi-square (P) |
|---|---|---|---|---|
| Age | ||||
| 18-30 | 41 (60.3) | 18 (50.0) | 33 (50.0) | 2.28 (0.69) |
| 31-40 | 19 (27.9) | 11 (30.6) | 23 (34.8) | |
| >40 | 8 (11.8) | 7 (19.4) | 10 (15.2) | |
| Sex | ||||
| Male | 68 (100.0) | 1 (2.8) | 66 (100.0) | 164.05 (0.001) |
| Female | 0 | 35 (97.2) | 0 | |
| Marital status | ||||
| Ever Married | 32 (47.1) | 24 (66.7) | 38 (57.6) | 3.89 (0.143) |
| Never married | 36 (52.9) | 12 (33.3) | 28 (42.2) | |
| Religion | ||||
| Hindu | 58 (85.3) | 25 (69.4) | 55 (83.3) | 4.20 (0.12) |
| Others | 10 (14.7) | 11 (30.6) | 11 (16.7) | |
| Education | ||||
| Primary or lesser | 35 (51.5) | 19 (52.8) | 31 (47.0) | 0.41 (0.81) |
| Matriculation and above | 33 (48.5) | 17 (47.2) | 35 (53) | |
| Occupation | ||||
| Unemployed | 11 (16.2) | 34 (94.4) | 8 (12.1) | 85.46 (0.001) |
| Employed | 57 (83.8) | 2 (5.6) | 58 (87.9) | |
| Family income (per year in INR) | ||||
| <20,000 | 15 (22.1) | 21 (58.3) | 13 (19.7) | 20.10 (0.001) |
| 20,000-40,000 | 37 (54.4) | 10 (27.8) | 40 (60.6) | |
| >40,000 | 16 (23.5) | 5 (13.9) | 13 (19.7) | |
| Residence | ||||
| Rural | 23 (33.8) | 10 (27.8) | 25 (37.9) | 1.06 (0.59) |
| Semi-urban/urban | 45 (66.2) | 26 (72.2) | 41 (62.1) |
Any form of tobacco use was 34.3% (73/213) in patients with Schizophrenia, schizotypal, and delusional disorders (F20-29; n = 213), 32.6% (79/242) in patients with Mood disorders (F30-39; n = 242), 43.6% (17/39) in Neurotic, stress-related, and somatoform disorders (F40-49; n = 39), and 16.7% (1/6) in the Behavioral syndromes associated with psychological disturbances and physical factors (F50-59; n = 6). For tobacco use across ICD-10 diagnostic categories, there were no significant differences between SMI and CMD group [c 2 (df) = 0.853 (2); P 0.653] or the two major SMI group (F20-29 and F30-39), for the forms of tobacco use [c 2 (df) = 1.941 (2); P 0.379].
The severity of tobacco use: Overall, among smokers, there was moderate to severe degree of dependence (FTND >5). The median level of nicotine dependence was not significantly different (P = 0.884) in the SMI and CMD groups among the smokeless users, 11.0 (10.0-12.0), whereas in the case of smokers, median FTND scores were significantly higher (P = 0.041) in the CMD group [6.0 (5.0 – 7.0)] when compared to those with SMI [5.0 (5.0-6.0)]. For smoking and smokeless forms of tobacco use, there was moderate to severe dependence in both the major SMI groups, with no significant difference in the severity of dependence for both forms in the two SMI groups (Mann–Whitney U-test, schizophrenia, and mood disorders, P = 0.991 and 0.726). Males used tobacco products at a significantly higher rate (44.85% use in males vs. 17.58% use in females) and were dependent on it to a greater degree [Median (IQR) FTND scores = 5.0 (5.0-6.0) for smokers and 11.0 (11.0 – 12.0) for smokeless tobacco users] as compared to females [FTND scores = 10.0 (8.0-11.0); smokeless]. Smokeless tobacco use was reported in 20.5% of female patients with F20-29 diagnoses and 18% of female patients with F30-39 diagnoses.
Craving and motivation to quit: There was no significant difference in the Mann–Whitney U-test in craving for the four dimensions of TCQ—emotionality, expectancy, compulsivity, and purposefulness between the two major categories of SMI. The median (IQR) for the four dimensions—Schizophrenia, schizotypal, and delusional disorders (n = 73) versus Mood (affective) disorders (n = 79) were 12.00 (11.0-13.0) vs 12.0 (9.0-14.0), 14.0 (13.0-15.0) vs 14.0 (13.0-15.0), 10.0 (90.-14.0) vs 10.0 (9.0-14.0), and 14.0 (11.0-14.0) vs 12.0 (11.0-14.0), respectively. Between SMI and CMDs for the four dimensions, the median (IQR) were as follows: 12.0 (10.0-13.0) vs 12.0 (12.0-13.25), 14.0 (13.0-15.0) vs 14.0 (10.75-15.0), 10.0 (9.0-14.0) vs 9.50 (7.0-10.0), and 12.0 (11.0-14.0) vs 12.0 (10.0-14.0), respectively. Smokers perceived a higher degree of craving in the dimensions of emotionality, compulsivity, and purposefulness than dual users. The median (IQR) for smokers vs dual users was observed to be 12.0 (12.0-14.0) vs 12.0 (9.0-12.0), 10.0 (9.0-15.75) vs 9.0 (8.0-10.0), and 14.0 (11.0-14.0) vs 11.0 (11.0-14.0) for the three dimensions, respectively. There was a significant difference in the same dimensions among smokers, smokeless tobacco users, and dual users. The Kruskal–Wallis test P value of the three dimensions were emotionality (0.003), compulsivity (0.02), and purposefulness (0.03). On post-hoc analysis, there was a significant difference (P < 0.05) noted between smokers vs dual users, but not between smokers vs smokeless users or smokeless vs dual users. There was a significant difference between the forms of tobacco use in items of self-control (intrinsic) and immediate reinforcement (extrinsic) The P value for self-control vs immediate reinforcement was 2.20 (1.80-2.40), 2.20 (2.05-2.60), 2.40 (2.20-2.60), P 0.026 vs 2.60 (2.40-2.80), 2.30 (1.80-2.60), 2.0 (1.80-2.60), P 0.001 among smokers, smokeless form users, and dual users, respectively. On post-hoc analysis, a significant difference (P < 0.05) was noted between smokers and dual users, and not between smokers vs smokeless users or smokeless users vs dual users.
Access to tobacco cessation: Nearly 59% (100) of the 170 tobacco users had not been asked about tobacco use according to their self-reports. Only 10.6% were provided assistance or any arrangement regarding tobacco cessation. The majority were not advised about fixing a quit date (152/170: 89.4%) and only 18 of the 170 (10.6%) were provided with NRTs or anti-craving medications. There was no significant difference in access to tobacco cessation services between smokers, smokeless users, and users of both forms (both for the last 1 year and lifetime). There was no significant difference in access to tobacco cessation services across the two diagnostic categories of SMI or between SMI and CMDs (both in the last 1 year and lifetime).
The case records of 86.8% (132/152) tobacco users with SMI and 88.2% (15/17) tobacco users with CMD did not document a diagnosis of and intervention for tobacco use. The records of 90.4% (66/73) of tobacco users with schizophrenia-related disorders and 83.5% (66/79) of tobacco users with mood disorders did not document diagnosis and intervention for tobacco use.
Urine cotinine: In the last 100 patients for whom urine cotinine was done, 34% were tobacco users. There was no significant difference (P = 0.815) between the SMI group (n = 86) and the CMD group (n = 14). There was a significant difference in median urine cotinine level (P = 0.03) between the three groups of tobacco users with the highest levels seen among the smokeless users—smokeless forms (n = 7) vs dual users (n = 17) vs smokers (n = 10) are 1367.99 (47.13-2215.99) vs 1143.97 (545.41-1911.64) vs 494.30 (404.84-550.07), respectively. The post-hoc analysis showed that a significant difference was noted between smokers and dual users (P = 0.04) only. However, there were no significant differences (P = 0.125) in the urinary cotinine levels of tobacco users of the two major SMI groups—1121.89 (524.28-2184.26) for the schizophrenia group (n = 13), and 687.58 (419.36-1158.73) for the mood disorder group (n = 18). There was a significant difference (P = 0.001) between non-tobacco users [median urinary cotinine of 33.10 (15.17- 88.71), n = 66] and tobacco users [778.40 (459.47-1380.46), n = 34].
DISCUSSION
The rate of tobacco use in psychiatric in-patients of 34% reported in this study is comparable to the 36% reported in the earlier study[12] from our center indicating that prevalence has been more or less constant over the last 10 years among admitted patients with mental illness. This finding contrasts with a reduction in tobacco use prevalence that has been observed in the general population in India, which reported a 6% reduction in tobacco use between Global Adult Tobacco Survey (GATS) 1 and GATS 2. However, the rates of tobacco use are substantively lesser than what has been reported in developed countries.[20]
The prevalence rate of 44.85% among males, though similar to the findings from Chandra et al.’s[12] earlier study from the same center, is higher than reported among out-patients in the study (31.6%) from Chennai.[9] In contrast, the rates in women are much higher (17% from 8% as noted in the earlier study) for any form of tobacco use. Most of the increase in prevalence in women seems to have been due to the use of smokeless tobacco rather than smoking which has remained the same at <1%.
In this study, there was a near-equal prevalence of tobacco use with both the diagnostic categories of mood disorders (32.6%) and schizophrenia and related disorders. There was a moderate to severe psychiatric condition in the study subjects, reflective of the study setting.
We have reported moderate to high dependence on smoking and smokeless forms of tobacco (as measured with FTND) in both the major diagnostic categories in this study. This is consistent with previous reports of heavy cigarette use and high dependence in SMI.[4,21] The degree of dependence on smoking is even higher with CMDs in our study. This also corresponds to previous findings of tobacco use in high amounts in anxiety disorders.[22,23]
Craving tobacco in SMI has been reported less frequently in literature.[24,25] In this study, there are no differences in craving for SMI and CMDs between the two categories of SMI. We have not come across any other study that has examined craving with different forms of tobacco use in psychiatric patients. Smokers had a higher degree of craving compared to smokeless tobacco users in our study. Differential patterns and degrees of craving to various tobacco-related cues were reported in a study from a deaddiction center in north India.[26]
It was also apparent from the results that patients were motivated to quit. Cultural acceptance of smokeless tobacco use or a greater awareness of smoking-related harms may differentially influence the motivation to quit. The motivation to quit tobacco among persons with mental illness has been reported to be like those without mental illness but may be different across the diagnostic groups.[27,28] Patients with mental illness are less likely to receive interventions and there are perceptions among health workers that because of multiple impairments, quitting may be difficult for them.[29]
An important finding in the study is the low rates of asking for, assessing of, and advice about tobacco use. Only around 10% of the patients were offered a quit date or pharmacological options for quitting. This is strikingly similar to findings in the general population in India,[30] and it has been observed that smokeless tobacco users are even less likely to receive any intervention.[31] It is pertinent to note that considering their training in motivational interviewing, psychiatrists are best placed to intervene, yet the results do not reflect this in practice. This could be because of several reasons including diagnostic overshadowing, the primacy of the reason for admission, lesser perceived competence in addressing tobacco use, and time constraints.
Ours is the only study that has examined the prevalence of passive smoking in psychiatric in-patients to date, and the findings are comparable to the GATS report for India of 2016-–2017.[8] The higher rates of passive smoking in our patients with CMDs could be possibly explained by their higher rates of employment in them and the time spent with co-workers increasing their risk of exposure.
The urine cotinine values obtained are comparable to those reported in previous studies from India, healthy volunteers[32] and persons attending a tertiary addiction treatment center.[33] The finding of urine cotinine levels being higher with smokeless forms of tobacco use compared to smoking is also consistent with the previous study in healthy volunteers.[32] Factors such as bioavailability, individual variations in metabolism, and dietary intake of nicotine that were not examined in the study may have influenced the findings.
The strengths of the study are the large sample size, the inclusion of consecutively admitted patients of both genders, the use of urine cotinine analysis for a subgroup of the patients, the evaluation of both forms of tobacco use, for both current use and dependence, and assessment of passive smoking for the first time in this population.
The limitations of the study include the following: use of multiple assessment scales and multiple subgroups for analysis, TCQ-SF and RFQ, have not been validated for smokeless tobacco users, the patients were evaluated after a varying number of days of admission (may have affected the craving and motivation to quit), exclusion of patients with psychiatric instability, absence of a control group, urine cotinine analysis was not done for all the patients, and the last use of tobacco before the cotinine sampling was not assessed. The findings of the study cannot be generalized to out-patients and community-dwelling patients.
CONCLUSIONS
Among psychiatric in-patients, the rate of tobacco use was observed to be 34%. Females used only smokeless forms of tobacco in the sample. Moderate to severe dependence was observed in both smoking and smokeless forms across psychiatric diagnoses. Even in a psychiatric in-patient setting assessment of tobacco use and interventions for tobacco cessation/reduction were suboptimal.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/ have given his/her/their consent for his/her/their clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Urine cotinine measurement for the last 100 patients was funded by the Centre for Addiction Medicine, Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bengaluru, India.
Conflicts of interest
There are no conflicts of interest.
Acknowledgements
The authors would like to acknowledge Dr. Mariamma Philip from the Department of Biostatistics for her assistance in statistics for the re-revised version.
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