Smoking and mental health - NCSCT

Smoking and mental disorders: special circumstances 7
smoking. Nicotine replacement therapy (NRT; patches or lozenges) was widely
used by patients, and in some cases for several months. In the 4 months after the
policy was introduced, contraband tobacco and illicit ignition sources were
found on seven occasions; there were no incidents of hostage taking or concerted
indiscipline. Plasma levels of clozapine increased significantly after smoking
cessation in previous smokers, necessitating increased monitoring and dose
reductions. 12
Key contributors to successful implementation included: high level
management and clinician support; clear policies and strong leadership; financial
resources for staff training, use of cessation medication, psychotropic medication
monitoring, signage and additional staff complement at the time of
implementation; staff training in cessation support; and prescribing cessation
medications in advance of going smoke free. In 2009 the UK Supreme Court
rejected a human rights legal challenge to the Rampton Hospital policy 13 (see
also Chapter 9).
Other reported examples of success include Wathwood Hospital, a 56-bedded
medium secure unit in England, where 90% of patients were smokers before
implementation of a total smoke-free policy. 14 In the year after implementation
there was no significant increase in rates of aggression or use of tranquillisers,
and there was a reduction in conflict that previously had arisen over access to the
smoking room. NRT was used by 54% of patients. Of these, 20% continued to
use NRT a year after policy implementation. Four of twenty-three previous
smokers treated with clozapine sustained a significant rise in plasma levels,
necessitating dose reduction, after policy implementation.
At Mount Vernon Hospital in the USA, a total smoke-free policy was
implemented in buildings and grounds in 1998. In a retrospective study of
records from a sample of 140 of the 367 patients in the facility, there was a
significant decline in disruptive behaviour and verbal aggression in moderate-toheavy
smokers, a 61% reduction in heavy smokers of ‘sick calls’ for physical
complaints and, regardless of pre-ban smoking status, patients’ body weight
increased. 15 Use of NRT and bupropion medication was reported to be low (data
not given). It was reported that staff and family members brought contraband
tobacco into the hospital, necessitating periods of ‘lock down’ (full closure and
movement restriction), and the use of more thorough search procedures.
7.1.5 Maintaining a smoke-free environment
Support from security staff is crucial in maintaining a smoke-free environment
in forensic psychiatric settings. 16 During policy implementation, confrontation
between patients and staff can be avoided by adopting a low-key approach to
searches, by avoiding additional searches and giving patients various options for
disposal of smoking materials. After the implementation, clinical and security
staff should remain vigilant in case attempts are made to smuggle contraband
© Royal College of Physicians 2013 133