Purpose: To develop recommendations for healthcare professionals at risk for exposure to secondhand (SHS) and thirdhand smoke (THS) while providing home-based services to patients with severe mental illnesses (SMIs), such as schizophrenia.

Summary: Healthcare professionals who provide services to those with SMIs have the potential to be exposed to SHS and THS. Smoking rates in persons diagnosed with schizophrenia are significantly higher compared to the general population (up to 90% versus approximately 30%). According to one study, only 31.5% of patients with SMIs are likely to have smoke-free homes. Currently there are no guidelines available for minimizing the effects of SHS and THS on healthcare professionals. Strategies for minimizing the effects are proposed.

Conclusion: Literature dealing with the effects of SHS, potential occupational hazards of exposure, and the results of anti-public smoking laws to address the problem were reviewed. The health hazards of THS exposure are an emerging area. Data are limited on alternative strategies for healthcare professionals to minimize SHS and THS exposure. Suggestions to minimize exposure are provided.

Healthcare professionals serving community-based patients with a mental illness diagnosis may face unanticipated health consequences. One particular challenge is exposure to secondhand smoke (SHS) and thirdhand smoke (THS). In a comparison of smoking prevalence in those with a severe mental illness (SMI) compared to the general population, rates for persons with schizophrenia ranged from two to four times that of the general population (approximately 45% − 88% vs. 20%).1 Exposure to SHS and THS can pose a hazard for healthcare professionals who make frequent and/or prolonged visits to the houses, apartments, and other living arrangements for this population. This commentary will (1) identify the prevalence of smoking in persons with a SMI diagnosis, (2) outline the role of the pharmacist as a member of the healthcare team, and (3) describe strategies for healthcare professionals providing home-based services to minimize exposure risk.

A literature search was conducted for peer-reviewed studies on exposure to tobacco smoke, focusing on SHS and THS. Databases searched included Ovid, Google Scholar, MEDLINE, and PubMed (all 1965 to August 2012) using search terms asthma, environmental tobacco, mental illness, pharmacist, schizophrenia, secondhand, severe mental illness, smoke, smoking cessation, thirdhand, and tobacco. The search was limited to studies published in English. Articles were selected for further evaluation if the individuals or study populations were exposed SHS or THS and experienced health-related adverse events. References from publications identified by these criteria were reviewed for any additional reports.

Studies have shown that persons with a mental illness tend to have a higher prevalence of smoking. A survey of a cross-sectional representative population of smoking prevalence and smoking behaviors and a comparison between persons with a mental illness diagnosis and those without (n = 8,417 total sample) found that the cohort with a mental illness diagnosis were more likely to be smokers.2 The authors further divided the population with a mental illness diagnosis into two groups: general mental illness and SMI. They then identified smoking prevalence and behaviors in these three groups. Rates were highest for those with a SMI diagnosis: SMI (51.2%) versus general mental illness (26.4%) and the population with no mental illness diagnosis (18.7%). In addition, this study found that only 31.5% of those with a SMI are likely to have smoke-free homes compared to 60.9% of the general population (OR = 0.29; 95% CI = 0.16–0.55). Limitations of this study were lack of identification of the diagnoses associated with the two categories of mental illnesses and use of a self-report survey tool consisting of a single item to assess mental illness.2 

A population-based incident case-control study design of adults ages 21 to 63-years old (n = 521 case patients, n = 932 control patients) in Finland sought to determine if an association existed between environmental tobacco smoke (ETS) and the development of asthma. Researchers evaluated the potential impact of the presence or absence of pets and mold in the home and/or workplace. They found that the risk of asthma in this adult population was related to workplace ETS exposure during the most recent 12-month period of surveillance (OR = 2.16).3 This risk was greater in individuals who reported exposure to ten or more cigarettes a day. The 6-section self-assessment questionnaire included active smoking and ETS in addition to personal, dietary, health, and home and work environmental information. The authors reported that the combination of recent ETS and the duration of exposure increased the risk of asthma in this population.3 Considering the prevalence of smoking in persons suffering from a SMI, particularly schizophrenia,4 it is not unreasonable to anticipate healthcare professionals making home visits to this population would be at an increased risk of developing respiratory-related complications. In addition, these findings may apply to healthcare professionals who make longer home-based visits with this population or who have made these visits for many years in terms of higher risk.

Indoor air quality was evaluated in a variety of settings in Sri Lanka. The authors specifically recommended mechanical ventilation, changes in building construction, and segregated areas.5 How air quality changed with the implementation of smoking restrictions was evaluated longitudinally as these bans were implemented in the hospitality industry. Pre-intervention air quality levels were compared to partial and complete smoking ban implementation. The complete ban resulted in a SHS exposure reduction.6 

The consequences of ETS exposure, particularly on women's health, were studied. Using survey methodology, exposure to ETS and respiratory symptoms were evaluated (n = 346). No significant differences were found in living conditions, presence or absence of pets, or contributory family history. Significantly higher rates were found for the occurrence of nasal congestion (OR = 3.47; 95% CI = 1.38–9.01), nasal secretions (OR = 3.48; 95% CI = 1.38–9.02), and sinusitis (OR = 2.88; 95% CI = 1.22–6.89) in the group exposed to ETS. The authors concluded passive smoking could be a risk factor for illness and work absenteeism. The authors recommended more education on this form of indoor air pollution.7 

Demographic factors (age and gender) to SHS exposure and impaired lung function were evaluated by Brunst et al. They studied the relationship between environmental sensitization, SHS exposure (hair cotinine levels), and impaired lung function (measures of forced expiratory volume). Predictably, SHS exposure and reductions in lung function were positively correlated. Girls with early childhood sensitization (identified with positive skin testing), and high SHS exposure were at greater risk of decreased lung function in later childhood compared to nonsensitized children (boys and girls). Among the findings were decreased flow rates in boys with asthma and girls without asthma. The authors also considered family history of asthma/allergies and early and continued environmental allergen exposure.8 

Another unanticipated exposure risk is lead, a component of tobacco smoke. Lead levels were compared in three groups of U.S. adults (aged 17 years or older): former and current smokers and persons exposed to environmental smoke and lead levels. The demographic for the third group (environmental exposure) were working and aged 17 to 64 years old. The authors reported both active and passive smoking were associated with increased blood lead levels.9 Similar finding were reported with children. Increased lead levels in children (ages 4–16) were reported based on a sample of U.S. children (n = 5,592 meeting inclusion criteria) that participated in a national survey. Using cotinine as a surrogate marker for SHS exposure, the mean blood lead levels were 38% higher in the cohort with high cotinine levels.10 

An emerging risk for healthcare professionals is thirdhand smoke (THS), defined as the residual “tobacco smoke contamination that remains after the cigarette is extinguished.”11 Particulate toxins are deposited onto every surface in the environment. Researchers and healthcare professionals are concerned about the interaction between the SHS and other indoor air pollutants. In terms of exposure, opening a window or using a fan to redirect smoke or smoking in another room was determined to be inadequate protection.12 Another aspect of THS concerning to healthcare professionals is the chronicity of THS in the environment, whether the current residents smoke or not. Matt and colleagues evaluated whether THS was still present in housing after cleaning and preparing for new residents following a 2-month vacancy. Samples of nicotine levels for adults and cotinine urine levels for children (aged 4 years and older) were taken from the homes of smokers (n = 100) and nonsmokers (n = 50). Higher nicotine levels were found in nonsmokers that moved into residences previously occupied by smokers compared to those in homes of nonsmokers. The authors observed THS is “ubiquitous and pervasive wherever tobacco has been smoked.”13 

The pharmacist brings expertise to the team caring for the person diagnosed with a SMI in the area of medication knowledge. The pharmacist, in a variety of healthcare settings, can serve as a resource to assist in smoking cessation, and pharmacists are interested in providing this service.14–16 Pharmacists have facilitated telephone-based smoking cessation programs.17 Community-based programs have been successful.18 Cost-effectiveness was demonstrated with a one-on-one pharmacist counseling initiative.19 

Pharmacist contributions to the treatment team also include helping achieve optimal patient outcomes, if smoking cessation is a goal, by conducting a thorough review of all medications the patient is receiving, evaluating potential concerns about the treatments that may include appropriate dosing, potential drug-drug interactions, and potential adverse effects that may occur with medication adjustments, particularly in persons with SMI.20 The pharmacist can answer a variety of medication-related questions, such as the mechanism of action of the proposed agent, expected therapeutic effects and the timeline, and strategies to manage side effects, if applicable. In addition, the pharmacist can function as a source for evidence-based literature. These contributions were demonstrated in a community-based multidisciplinary team program for assertive outreach. The collaborative relationship within the mental health team and the pharmacists' contributions, including providing unbiased evidence-based literature, were recognized by patients and staff in one mental health community team setting.21 

Currently recommendations for the mitigation of SHS exposure for healthcare professionals providing home visits for those with a SMI diagnosis who smoke are lacking. Some potential strategies include facilitating smoking cessation programs, meeting outside the patient's residence, asking the patient to refrain from smoking in the presence of the healthcare professional, or installing special air filters in the room(s) frequently used by the healthcare professional. The most effective way to protect a healthcare professional is avoidance of SHS exposure.22 

Many individuals with a mental illness diagnosis are interested in smoking cessation. One study reported 94.7% of the individuals noticed warnings on the health effects of smoking through television advertising compared to 92.7% of the general population. This study also showed that while 47.3% of those with a SMI diagnosis believe they will be smoking within a year, 37.3% were seriously considering quitting within the next 6 months. Considering the well-studied health benefits of smoking cessation, patients who are willing to attempt smoking cessation should be encouraged to do so.2 A 2002 literature review found that studies of persons with a diagnosis of schizophrenia had small clinical samples. Quit rates ranged from 35% to 56%.23 Two studies using the same methodology reported quit rates of 12% and 16.7% for persons on atypical antipsychotics. The authors noted clinicians should be direct when asking their patients if they are considering smoking cessation.23 The World Health Organization (WHO) policy recommendations note that “elimination of smoking from the indoor environments is the only science-based measure that adequately protects health.”22 

Asking the patient to refrain from smoking in the presence of the healthcare professional is one option to limit SHS on home-based visits. However, the effects of THS would still be present. Smoking cessation is preferred due to the health benefits associated with a smoke-free lifestyle. Another possible strategy for home-based visits at the patient's residence would be to conduct meetings with those who smoke outside. The 2007 WHO guidelines note levels of SHS outdoors are generally lower than levels indoors.22 The primary disadvantage to this strategy would be weather-dependent conditions. In addition, factors such as wind direction (e.g., wind blowing in the direction of the nonsmoker), the amount smoked during the meeting, and the proximity of walls or coverings that could confine cigarette smoke could be limitations.22 

Use of special air filters was studied. Results from research on use of high-efficiency particulate air (HEPA) cleaners were reviewed. Continuous use on 'medium speed' resulted in a reduced level of particulate matter and an increase in symptom-free days for children in the study.24 Several limitations were found. The study population was children with asthma living with a smoker (n=126), and there was no difference in hair nicotine or urine cotinine noted between the intervention (air filter) group compared to the control group. The authors theorized that the short duration of air filter use (6 months) limited the benefit of the filters. In addition, continuous unit use was not assessed for all families. The authors did not report if cost was a barrier, but the filtration unit used in the study retails for approximately two hundred dollars, excluding replacement filter costs. Additional limitations included other room ventilation factors (e.g., room size and number of windows), sample size, and SHS exposure risk outside the home.24 It should be noted that the 2007 WHO policy recommendations do not regard ventilation or filtration as effective methods for reducing pollutants.22 

Several limitations are acknowledged in this commentary. First is the limited scope of the articles reviewed. Most of the articles focused on specific population subsets and may not be generalizable to healthcare professions providing home-based services. The lack of focus on community-based healthcare professionals serving those with SMI may represent an unrecognized at-risk population.

General guidelines to eliminate or minimize exposure to SHS or THS for healthcare professionals serving patients with a SMI diagnosis in home-based programs have not been recognized or addressed. This commentary provides a review of selected literature, role of the pharmacist as a member of the healthcare team, and suggestions to help minimize healthcare professional exposure to SHS and THS.

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Author notes

This work was presented as a poster at the 15th Annual Meeting of the College of Psychiatric and Neurologic Pharmacists (CPNP), April 29–30, 2012, Tampa, FL.

Financial Disclosure: No similar work by the authors is under review or in press. No funding was requested or received in conjunction with this manuscript. The authors report no known or suspected conflicts of interest related, but not limited, to consulting fees, paid expert testimony, employment, grants, honoraria, patents, royalties, stocks, or other financial or material gain involved with or pertaining to the subject matter of this manuscript.