Author ORCID Identifier

Year of Publication


Degree Name

Doctor of Philosophy (PhD)

Document Type

Doctoral Dissertation





First Advisor

Dr. Ellen J. Hahn

Second Advisor

Dr. Chizimuzo T. C. Okoli


People with mental illness (MI) are disproportionately affected by tobacco use compared to the general population. In fact, it is estimated that people with MI consume approximately 44% of cigarettes smoked in the United States. Moreover, the MI population is at greater risk for the negative social, economic, and health consequences associated with tobacco use and are reported to have 25-year shorter life expectancies than the general population. The impact of tobacco use is further noticeable among patients with MI who require psychiatric hospitalization. Quitting smoking in this population has been linked to fewer discharges against medical advice, better quality of life, and positive physical and psychological health outcomes. Thus, it is crucial to identify and address factors such as nicotine withdrawal (NW) that may hinder successful quit attempts among hospitalized patients with MIs. Given that many psychiatric facilities have tobacco-free policies, NW is an important phenomenon to consider when delivering tobacco treatment with this population.

The NW syndrome is a set of symptoms appearing after 24 hours of abrupt cessation or reduction of tobacco after prolonged duration of use. NW has been associated with impaired patient functioning, lower likelihood of quitting tobacco use, and compromising care during psychiatric hospitalization. Approximately 65% of patients hospitalized in a psychiatric facility with a tobacco-free policy experience NW syndrome. Nonetheless, NW among hospitalized patients with MI is modestly examined in the literature.

The purpose of this dissertation is to enhance our understanding of tobacco use and NW among hospitalized patients with MI. Specific aims are to: 1) scrutinize and synthesize the research literature examining NW among tobacco-using patients with MI to outline correlates pertinent to this phenomenon, identify gaps in the literature, and guide future research; 2) evaluate the psychometric properties of the Minnesota tobacco withdrawal scale (MTWS) in capturing NW severity in the MI population during psychiatric hospitalization; and 3) examine whether tobacco-using patients with certain psychiatric diagnoses (psychotic disorders and mood or anxiety disorders) experience varying NW severity, based on self-reported class of substance use (e.g., hallucinogens, inhalants, alcohol) within the year prior to their psychiatric admission.

Aim 1 was achieved by conducting a systematic review of the literature using the PsychINFO, MEDLINE, and CINAHL databases. The following correlates of NW among people with MI in community and hospital settings were identified: psychiatric diagnosis, sex, race, psychiatric symptom severity, alcohol and drug use, level of nicotine dependence, nicotine replacement therapy and varenicline administration, confidence in quitting, and levels of depression and anxiety. Aim 2 was achieved by conducting a reliability and validity analysis of the MTWS in a sample of psychiatric inpatients. The MTWS demonstrated adequate reliable and valid psychometric properties, and the measure may be recommended for use in clinical practice to identify patients experiencing NW. Aim 3 was achieved by performing a series of moderation analyses to examine the nature of the relationships between psychiatric diagnoses and NW severity, considering the patient’s substance use profile. Lower NW severity was observed among patients with psychotic disorders who reported using hallucinogens; inhalants; opiates; sedatives, hypnotics, and anxiolytics; stimulants; or poly-substances over the past year than those who did not use these substances. Higher NW severity was documented among patients with mood or anxiety disorders who reported using hallucinogens or sedatives, hypnotics, and anxiolytics over the past year compared to those patients who did not use these substances.

Considering the high prevalence of tobacco use among patients with MI compared to the general population, a tobacco-free psychiatric hospitalization poses a valuable opportunity to promote cessation. The results of this dissertation demonstrate a need for protocols to better identify NW, based on specific patients’ characteristics, in order to develop tailored interventions during psychiatric hospitalizations to limit barriers to cessation and consequences of tobacco use in this population.

Digital Object Identifier (DOI)

Available for download on Sunday, May 23, 2021