Nicotine use and patient‐directed discharge rate in psychiatric inpatients: A retrospective cohort

BACKGROUND AND OBJECTIVES: Disproportionate use of tobacco among psychiatric patients exacerbates psychiatric symptoms, increases suicide risk, alters therapeutic drug levels, and negatively affects adherence. Patient-directed discharge (PDD) rates are higher among patients who smoke, and smoking cessation treatments have been reported to reduce this risk. This study investigates the association of tobacco use and cessation treatments with PDD rates. METHODS: A retrospective analysis was performed on a random sample of 25,829 adult patients admitted voluntarily to inpatient psychiatric facilities nationwide. Exclusion criteria included medical discharge, electroconvulsive therapy, hospital stays longer than 29 days, and incomplete demographic or smoking status data. Binary logistic regression with a Firth correction assessed the associations between PDD rates and smoking status, smoking cessation treatments, demographic variables, comorbidities, and smoking use patterns. RESULTS: Smoking was significantly associated with an increased likelihood of PDD (χ² = 49.42, p < .0001, OR = 2.16). Nicotine replacement therapy (NRT) alone significantly reduced PDD rates (χ² = 8.16, p < .01, OR = 1.42), whereas bupropion and varenicline did not show significant effects. Smoking-related PDD rates remained elevated despite treatment compared to non-smokers (χ² = 22.02, p < .0001, OR = 1.86). DISCUSSION AND CONCLUSIONS: A significant association was found between smoking status and PDD rate. NRT alone was associated with lower PDD rates. SCIENTIFIC SIGNIFICANCE: This study is the first to investigate the association of individual smoking cessation treatments with PDD rates. Contrary to previous findings, the risk remained elevated despite treatment in our large national sample.