Smoking and mental health - NCSCT

Population strategies to prevent smoking in mental disorders 6
enforcing smoke-free treatment environments. It was also argued that imposing
smoking bans on long-stay patients living on mental health trust premises, and
those detained under the Mental Health Act, infringed human rights and rights
of privacy. On the other hand, proponents of smoke-free policy argued that to
exempt mental health settings from the law would worsen and, moreover,
institutionalise existing health inequalities.
The outcome of the debate in England was not to grant exemptions for mental
health settings but to allow an additional year, to July 2008, in which to prepare
to comply with the legislation. 69 Northern Ireland adopted the same approach,
but, in Scotland and Wales, mental health settings were exempted from smokefree
legislation.
A survey of all 72 English NHS mental health trusts in 2007 revealed that by
that time all respondents (79%) had in fact implemented indoor smoke-free
policies, although with variation as to the extent of inclusion of outdoor areas. 70
Almost all respondents reported perceived challenges specific to implementation
of smoke-free legislation in mental health trusts, particularly in relation to
safety risks (such as fires caused by covert smoking) and policy enforcement. 70
However, a review of 26 international studies found that concerns raised before
implementation, eg smoke-free policy might lead to an increase in aggression or
number of seclusions, discharge against medical advice or use of as-needed
medication, generally proved unfounded when the policy was introduced. 71
Another review, of 22 international studies, concluded that smoke-free policies
had no longstanding untoward effect on patients in terms of behavioural
indicators of unrest or compliance, 72 although there are reports of
complications arising from abrupt forced abstinence among highly nicotinedependent
patients 73 (see Chapter 5). It is now recognised that smoke-free
policies in mental health settings, although in theory an opportunity to promote
cessation at the point of hospitalisation, have to be complemented by
comprehensive cessation or abstinence support for smokers if they are to be
successful. 71,72 There is also evidence that complete and rigorously enforced
smoke-free policies in psychiatric settings are easier to implement, and more
effective, than approaches that are incomplete and leave room for
interpretation, 71,74 eg facilitation of smoking breaks for patients, which require
staff to escort smokers off and back on to the ward, are disruptive and can lead
to an untoward fixation on regularly facilitated smoking breaks, which then
come to take priority over other therapeutic activities. 75 There is also evidence
that, after admission to treatment environments in which partial smoke-free
policies are implemented, patients who smoke may alter their smoking
behaviour. 76
A study of 135 inpatients in England found that 14% increased their
consumption of cigarettes, 23% decreased consumption and two patients
relapsed to smoking during admission. Boredom and stress, and using smoking
as a means to socialise, were the main reasons given for increased smoking. 76
Similar results have been reported in other studies, showing that people who are
© Royal College of Physicians 2013 117