Prevalence of smoking among psychiatric patients in outpatient department of tertiary care centre: A descriptive cross-sectional study

Even though psychiatric illness is a risk factor of smoking tobacco; only few studies have been conducted to estimate the prevalence of smoking among that patient group in Nepal. Our study aims to determine the prevalence of smoking among psychiatric patients in the outpatient department of tertiary care centre. A descriptive cross-sectional study was conducted in the psychiatric outpatient department of a tertiary care centre from 27th March to 27th May, 2022 following ethical approval from the Institutional Review Commit - tee (Reference number: 577/078-079). A convenience sampling technique was used to include 398 patients, who were assessed for tobacco use behaviour using a semi-structured questionnaire and nicotine depend - ence using the Fagerstrom Test for Nicotine Depend -


Sharma S et al. Prevalence of smoking among psychiatric patients
A descriptive cross-sectional study was conducted among patients visiting the psychiatric outpatient department (OPD) of Nepalgunj Medical College Teaching Hospital (NGMCTH), Kohalpur, Banke.The study was conducted from March 2022 to May 2022 after the ethical approval from the Institutional Review Committee (Reference number: 577/078-079).A person equal or more than 16 years of age and diagnosed by a consulting physician with any mental illness according to the ICD10 guideline were included in the study after obtaining consent.Patients older than 16 years requiring medical emergency or who do not have the mental capacity to provide consent were excluded from the study.A convenience sampling method was used.The sample size was calculated by using the following method: n= (Z² × p × q)/e² = 1.962×0.38×0.62(0.05)²= 362 Where, n= minimum required sample size z= 1.96 at 95% Confidence Interval (CI) p= prevalence taken as 38% from the previous study (5) q= 1-p e= margin of error, 5% The minimum sample size of 362 was taken.For sample size calculation, the prevalence of smoking in the previous study conducted at Tribhuvan University and Teaching Hospital (TUTH), Nepal was used. (6)The patient's specific demographic information and mental illness diagnosis were recorded from the patient's OPD ticket after verifying it with a consulting physician.Semi-structured questionnaire was developed to identify tobacco use behaviour and "Fagerstrom Test for nicotine dependence" instrument was used to estimated the degree of nicotine dependence. (7)articipants were defined as a current smoker if they had smoked 100 cigarettes in their lifetime and who currently smoke cigarettes.Participants were defined as a 'past smoker' if they had smoked at least 100 cigarettes in their lifetime but who had quit smoking at the time of interview.'Never smoker' were those study participants who had never smoked or who had smoked less than 100 cigarettes in their lifetime.Data collection was done with the help of "KoBo Toolbox", an android mobile application where semi-structured questionnaires were uploaded.Data were imported and cleaned in Microsoft Excel and analysed in Statistical Package for Social Sciences (SPSS) version 25.0.
The Confidence Interval was calculated along with frequency and percentage for binary data and mean with standard deviation for continuous data.
We calculated the score of nicotine dependence among current smoker by using the Fagerstrom Nicotine dependence tool.The prevalence of 'low' or 'low to moderate' nicotine dependence was 50 (48.08%)among 104 current smokers, while it was 26 (55.20%) among 48 past smokers.Similarly, 25 (24.04%) of current smokers and 14 (29.17%) of past smokers have "moderate" or "high" nicotine dependence (Table 3).
Of 398 study participants, 172 (43.22%) recalled being inquired by a healthcare professional about their smoking status during hospital visits to any department.
Out of 398 study participants, 378 (94.97%) acknowledged that smoking causes bodily illness when asked about their awareness of the harmful health effects associated with smoking.302 (79.89%) of 378 said that smoking causes lung cancer, while 241 (63.76%) said it causes unspecified respiratory disease.Another 57 (15.08%) of them said smoking causes heart disease.Among all current and past smokers who attempted to quit smoking, 17 (14.4%) revealed that counseling with a healthcare professional helped them quit smoking, while 97 (82.90%) said they tried to quit without assistance.Only 2 (1.7%) revealed they used nicotine replacement therapy.Among current smokers, 69 (66.30%) tried at least once to quit.
Similarly,73 (70.19%) of smokers admitted to have an intention to quit smoking.Among current smoker, 19 (18.27%) and 7 (6.73%) had an intention to quit smoking within the next month and the next 12 months, respectively.Remaining 31 (29.8%)revealed of having no intention to quit smoking.
Our study identified the prevalence of smoking among psychiatric patients to be higher than that of the general population of Nepal.In the general population, the prevalence of smoking is 17.1%. (2)(10) Combination of various psychological, social, and biological factors has been identified as the cause of the higher prevalence of smoking in psychiatric patients. (11,12)Gender differences in smoking prevalence present in the general population were consistent even in psychiatric patients.In the general population, 28% of males and 7.5% of female smoke tobacco. (13)n our study 46.47% of male participants while 10.96% of female participants were current smokers.(Table1.) Studies have identified that hormonal, cultural, and behavioural factors are linked with the differences in smoking among males and females. (14)A study done on the depressive patients in Tribhuwan University Teaching Hospital (TUTH), Nepal, (6) and another study done in the psychiatric outpatient department of BP Koirala Institute of Health Science (5) found that 37.2% and 38% of patients are current smokers, respectively which is higher than that of our study's finding.However, the study participants in those studies comprised a higher number of male patients which may have increased the overall prevalence of smoking in those studies.
The mean age of smoking initiation in our study participantsl was 18±5.3 years.A systematic review highlighted key factors like salient theme of feeling in control over smoking habit, and tendency to minimize the perceived severity of the risks associated with smoking, to have played role in smoking initiation among this age group. (15)e rate of awareness about hazards and diseases caused by smoking was higher or comparable among our study participants when compared with another study done among general population. (16,17)Poor awareness have been documented to be associated with lower quit attempts. (18)e rate of a quit attempt in our study was 66.3% (69) which was higher compared to a similar study done in Singapore, where 52% attempted to quit smoking. (8)imilarly, we also found that 26% (19) of current smokers in our study have the intention to quit smoking within one month, which is higher when compared with the study done in Singapore, where 10.6% of the respondents were ready to quit within one month.
However, despite higher quit attempts only 16% revealed to have received counseling or prescription for NRT to assist quitting smoking.It has been well documented that counseling from health care professional helps smoker to quit smoking more successfully.However research has indicated the presence of obstacles hindering the promotion of smoking cessation among mental health workers and health professionals.These barriers include a lack of confidence and practical knowledge necessary to engage in cessation interventions, the perception that patients are unwilling to quit, and the belief that cigarettes serve as a one of the few enjoyable aspects in their lives. (19)The prevalence of chronic diseases directly associated to smoking is higher in patient with psychiatric illness.Thus health services targeting this patient group to aid smoking cessation is essential.
In our study, the degree of nicotine dependence is lower than the studies conducted in other countries like Singa-It is essential to integrate the preventive health services for the patient suffering from the mental illness.Our study found that smoking prevalence is relatively higher among psychiatric patients, and those patients might benefit from the active smoking cessation advice.Smoking prevalence is increasing among women; however, there was a discrepancy regarding the inquiry about smoking status between males and females.Hence comprehensive smoking history of all patients visiting the psychiatric OPD, and routine preventive and cessation counselling should be ensured.
Authors fully self-funded the project without any external funding or financial support.
We would like to thank Dr. Mohan Belbase (Head of Department, Psychiatry, Nepalgunj Medical College, Kohalpur, Nepal) pore. (8)Similarly, our study participants have a relatively higher rate of intention to quit and quit attempt.Recent studies have concluded that readiness to quit, quit attempt, and duration of abstinence is less in patients with a higher degree of nicotine dependence and vice versa. (15,16)ere were few limitations to our study.Most of our data's validity depends upon the accuracy of the recall of the study participants.Our study was conducted in a hospital setting; thus, the true prevalence of smoking among psychiatric patients might differ in the community setting.Similarly, study participants, usually female, showed reluctance to admit to smoking, which might underestimate the prevalence of smoking among females.

least one quit attempt among current smoker 68 (65.38%) Service used for quitting smoking at least once among current smoker and past smoker
Sharma S et al.Prevalence of smoking among psychiatric patients