Nicotine dependence in the mental disorders, relationship with clinical indicators, and the meaning for the user

OBJECTIVE: to identify the degree of nicotine dependence among patients with schizophrenia and other mental disorders hospitalized in a general hospital, correlating these indices with clinical indicators and the meaning for the user. METHOD: the study was performed in the psychiatric unit of a general hospital, interviewing 270 patients with mental disorders using a questionnaire and the application of the Fagerstrom test. A descriptive statistical analysis of the data and thematic analysis of the content were performed. RESULTS: among the 270 patients with mental disorders, 35.6% were smokers; of whom, 53.2% presented high or very high nicotine dependence. Of the 96 smokers, 32 (33.3%) were schizophrenic, among whom, 59.4% presented high or very high dependence. Higher levels of dependence were also found among the 59 elderly people (61.5%) and 60 subjects with somatic comorbidities (62.5%). Meanings of smoking for the subjects: helps to forget problems and face daily conflicts; alleviates side effects of the medications; self-control; distraction; part of life. CONCLUSION: more intense tobacco dependence among schizophrenic patients is justified due to it helping them to cope with the difficulties of the disease. Nurses occupy a strategic position in the care.


Introduction
Schizophrenia is a serious mental disorder that affects three out of every 10, 000 adults, of the global population. Despite the low incidence, the chronic course raises the prevalence to high levels, affecting 24 million people worldwide (1) .
Although delusions and hallucinations are the more recognized symptoms of schizophrenia in the clinical practice, negative symptoms and cognitive deficits are mostly responsible for the impairment of the social functioning of these individuals, with damage to work skills and social interaction (2)(3) .
Epidemiological studies and meta analyzes agree that, in addition to psychosocial impairments, there are impairments of the physical health of individuals with schizophrenia (higher occurrence of cardiovascular and metabolic diseases and cancer) and decreased life expectancy. Tobacco use (eight in every 10) is one of the factors contributing to increased occurrences of crises, suicide attempts and need for hospitalization (4)(5)(6)(7) . have a better quality of life (5) .

Nurses need to have technical and scientific
knowledge about the effects of tobacco use among people with mental disorders, as this knowledge can be converted into care practices (8) .
Therefore, this study aimed to answer the  Individuals who used tobacco were considered smokers, regardless of the frequency of the use (daily and occasional smokers), the quantity used, and the length of time since beginning this practice, so as to cover both beginners and long-term smokers (10) . 915 and Cronbach's α 0. 642) (11) . In convergent mixed methods, the quantitative and qualitative data were analyzed independently, however, with the triangulation of the information in the discussion (9) .  A total of 79% of the smokers believed that smoking reduces anxiety, 57.3% that it improves the mood, and 29.2% and that improves concentration.

Characterization of the personal, sociodemographic data and clinical indicators of the subjects
Tobacco was also used to alleviate the side effects of the psychiatric medications (4.2%).
The drugs make me a little sleepy, so I'll go and smoke. (S14)

Category 3 -Smoking gives pleasure
Tobacco was used for pleasure (28.1%) and as a distraction to pass the time (18.8%).

Discussion
This study supports the hypothesis that tobacco use is more common among individuals with mental disorders (by approximately one third) than in the other groups of the population, given that the current prevalence of smoking in the Brazilian population is 17.5% (12) .

Studies conducted in Australia, United States
and Israel show that the frequency of smoking among patients with mental disorders is approximately twice that found in people with no history of psychiatric illness (13)(14)(15) .
Although one third of the subjects in this study were smokers, this information was not registered in any patient records, despite nicotine dependence being a diagnosis recognized by the ICD 10 or DSM IV.
Studies in the United States and Switzerland, also on the absence of smoking registration in patient records, suggest that professionals do not worry about tobacco use in psychiatric hospitalization (13,16) .
In this study, an association was found between the use of tobacco, illicit substances and alcohol. A study with 745 schizophrenic patients hospitalized in psychiatric services of the state of Maryland, United States, found that those who were using large amounts of cigarettes per day were more likely to use alcohol and illicit substances. The association between tobacco and these substances is worrying because it increases the risk of the psychiatric patient developing somatic complications (cardiac, respiratory, hepatic, gastrointestinal and neurological), as well as changes in the behavior and sleep pattern (17) .
The results of the present study showed that tobacco dependence is more intense among individuals with schizophrenia, confirming the results of a metaanalysis performed with studies from 20 countries.
The meta-analysis also revealed that lower rates of the discontinuation of tobacco use are found among schizophrenic patients (4) . Recent studies conducted in the United States, Israel and Brazil also showed high levels of nicotine dependence among individuals with schizophrenia (17)(18)(19) .
The high level of nicotine dependence among subjects with somatic comorbidities is consistent with the knowledge that smoking is a risk factor for physical complications. A Brazilian study, with 100 patients who suffered acute myocardial infarction, showed that the smokers had a greater perception of the risk of becoming ill, as they sought professional help faster than the other subjects when faced with the myocardial infarction symptoms (20) .
The subjects with higher nicotine dependence, in the present study, felt less able to quit smoking. A study of 200 psychiatric patients in the United States revealed that the individuals with schizophrenia and schizoaffective disorder felt less motivated to quit smoking than the other subjects (21) .
An Australian study revealed that the patients with psychotic disorders used tobacco to confront the challenges originating from the mental disorder and the pharmacological therapy -relief from the collateral effects of the medications, reduction of the symptoms, and for pleasure and relaxation (22) . Although the psychiatric patients with more severe tobacco dependence are the ones who perceive the effects of smoking on their bodies and behavior, they are also the ones with a higher frequency of failed attempts to quit.
In some of the patient records of the subjects of this study, there were records reminding the nursing team to warn smokers about the times that smoking is allowed. This is recognition of the participation of nursing in the culture of smoking in psychiatric hospitalizations.
The continuous care provided by the nursing team, in the inpatient psychiatric units, allows them to become closer to the patients. Nursing actions, aimed at reducing smoking and promoting a healthier lifestyle among patients with mental disorders should be a priority.
An Australian study recommends that psychiatric patients should be given assistance to find resources that help them cope with the mental disorder. Interventions for the abandonment of substance use, including tobacco, may have more success when included in the therapeutic plan (22)(23) .
Nurses are key players in the multidisciplinary team, as they accompany the patients and know their behavior well, which can be used to help the patients become aware of the resources they have to cope with the disorder and the tobacco use. For this, nurses need to be prepared and willing to collaborate.

Conclusions
A higher level of nicotine dependence was associated with older age, the diagnosis of schizophrenia, and the presence of somatic comorbidities. Both the schizophrenic patients and the subjects with higher levels of dependence used tobacco to cope with the difficulties arising from the mental disorder -they reported that tobacco helps them to forget their problems and to confront everyday conflicts, provides relief from the side effects of the medication, and helps with self-control.
They also consider tobacco to be part of their lives.
Tobacco use by schizophrenic patients is a challenge for psychiatry. Nurses are in a strategic position to intervene in this context, with preventive and rehabilitative actions in the therapeutic plan of each patient under their care.