Smoke-free legislation and mental health units: the challenges ahead

Under the proposed English Health Act regulations most mentalhealth units will have to be smoke-free, although patientswill be able to smoke outside. Implementing the regulationswill be challenging but may also be an opportunity for a moreholistic approach focusing on the physical and psychologicalhealth of patients.

INTRODUCTION

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INTRODUCTION

The Health Act 2006 introducing smoke-free public spaces hashad a stormy passage through the UK Parliament. Under the proposedregulations most mental health units in England and Wales willhave to ensure that wards and communal areas are smoke-free,although patients will be able to smoke outside. Only unitsthat ‘normally’ provide long-term residential accommodation, that is for over 6 months, will be exempt and can provide designatedsmoking rooms.

The issue of whether to exempt psychiatric units and other placesof residence from indoor smoke-free regulations has vexed governmentsand legislators in other countries. Ireland has exempted psychiatricunits, although employers can override this. Scottish smoke-freelegislation covers psychiatric units, but institutions mayif they wish provide an exempt designated smoking room onlyfor residents. Legislators recognise that employers need toprovide a safe working environment for employees, but have beenuncertain about where to draw the line for residents confinedto an institution.

Public health practitioners welcome the Health Act, arguingthat it will reduce smoking and exposure to second-hand smokeand lead to a decline in smoking-related diseases in the generalpopulation. Smoke-free legislation complements the government’swider anti-smoking strategy, which ranges from free smokingcessation services and mass media campaigns to restrictions on advertising of tobacco products and increased duty on cigarettes.

Mental health professionals are likely to be less supportive.A recent King’s Fund survey of 151 mental health units (Jochelson & Majrowski, 2006) found that 43% had no plansto introduce smoke-free policies. However, as mental healthpatients spend on average 58 days as in-patients (Office for National Statistics, 2006:p. 122) most units will have to reconsider their position ifthe regulations pass unchanged into law.

STAFF AND PATIENT ATTITUDES TO SMOKING

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STAFF AND PATIENT ATTITUDES...

Critics of the proposed regulations regard smoking as a ‘normal’part of being a mental health patient. A recent survey of staffand patients in an English psychiatric hospital found that 60%of staff believed that they should smoke with patients, asdid 78% of patients; 54% of staff (and 79% of staff who smoke)also believed that smoking had a therapeutic role and 93% believedthat patients would deteriorate without access to cigarettes(Stubbs et al, 2004; Dickens et al, 2005). In the King’sFund survey, staff commented that patients smoked to relieveboredom and stress, and to relax or ease social contact, andthat staff used cigarettes to create a rapport with patients,to offer comfort and support, or to manage threatening behaviour (Jochelson & Majrowski, 2006).

In this context mental health practitioners’ concernsabout the feasibility of banning smoking in psychiatric settingsis not surprising. Respondents to the King’s Fund surveyfeared that patients would abscond from their units or wouldrefuse to be admitted if smoke-free regulations were introduced.Repeatedly respondents stated that they believed the proposed legislation would provoke aggressive and agitated behaviour,verbal abuse and violence from patients. Staff recognised thatquitting smoking brought positive health benefits; however,many felt that their primary focus should be patients’mental rather than physical health, and they believed that patientstoo would prefer to prioritise their immediate need to relieve distress over their long-term health needs.

These concerns should not overshadow the very real toll thatsmoking exacts on the health of psychiatric patients. Surveysof mental health patients show that up to 70% smoke and around50% are heavy smokers, smoking over 20 cigarettes a day (Meltzer et al, 1996;Kelly & McCreadie, 1999; Coulthard et al, 2002; McCreadie, 2003).The extremely high levels of smoking, in addition to high levelsof obesity, cholesterol and hypertension in psychiatric populations, put them at particular risk of developing heart and respiratorydiseases (Joukamaa et al, 2001; Himelhoch et al, 2004; Hennekens et al, 2005; Kisely et al, 2005).

EXPERIENCE WITH SMOKING BANS

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EXPERIENCE WITH SMOKING BANS

The smoke-free legislation could provide a much-needed promptto mental health services in England and Wales to take seriouslythe physical health of their users. Certainly an emerging bodyof evidence shows that it is possible to introduce smokingbans in psychiatric units. Psychiatric institutions have introducedpartial bans, which ban smoking indoors or restrict smokingto designated places (inside or outside), and total bans, whichprohibit smoking indoors and outdoors. Lawn & Pols (2005)reviewed the findings of 26 international studies reportingon the effectiveness of smoking bans in in-patient psychiatricsettings and found that simple smoking policies applied ina consistent way to all patients were more effective than selectiveor gradually introduced bans. The review found no increasein patient aggression in 75% of all study sites regardlessof the type of ban and in 90% of sites imposing a total ban.Complaints and verbal aggression were associated with selectivebans, which tended to focus staff and patient attention on negotiatingsmoking privileges and increased the possibilities for conflict. El-Guebaly et al (2002) conducted a review of 22 studiesand, similarly, found that total and partial bans had no long-term impact on unrest or compliance by patients. A Dutch study foundthat compliance by staff and patients was better with a totalthan a partial ban, and that exposure to second-hand smokedeclined more dramatically with total indoor bans (Willemsen et al, 2004).

A few mental health units in England have introduced indoorsmoke-free policies ahead of the proposed legislation. Sometrusts have linked their smoke-free policies to clinical effortsto improve the quality of care for mental health patients andto introduce some health promotion work. The smoking statusof patients is recorded on their record when admitted, and the issue of smoking and quitting is raised at an appropriate time,and can be included in an agreed care plan. Some units haveprohibited smoking indoors and allow smoking outside; othershave a smoking room which is only for the use of patients,and offers no other activities, at the same time introducing clear policies controlling access to cigarettes, smoking timesand prohibiting bartering of cigarettes.

Far from being ‘impossible’ to implement smoke-free regulations, these units experienced relatively few problems.Certainly there were complaints from patients, and some triedsmoking in their rooms, but staff reported that patients ‘conformed’to the policy once they understood the reasons for it. Furthermore,there was no increase in aggressive incidents, as patientsstill had the opportunity to smoke outside. Staff believedthat closing smoking rooms and removing cigarettes as a bargainingtool or reward helped prevent and resolve difficult situationsand forced them to develop new ways of interacting with patients.The former smoking rooms were used for clinical activitiesor as patient lounges. One respondent commented that beforethe new regulations ‘patients were staying up in thenight smoking and were unable to get up in the morning to attendto daily living skills, activities or therapeutic interventions’. Now the smoking room was used for activities that ‘stoppedthem being so bored’ and patients were more engaged inward activities (Jochelson & Majrowski, 2006).

THE CHALLENGES AHEAD

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THE CHALLENGES AHEAD

In recent years the UK government has committed itself to reducingsmoking and smoking-related diseases and to reducing healthinequalities, in particular high smoking rates among socialgroups with lower incomes.

The smoke-free legislation offers a much-needed opportunityto help reduce the divide between the health of residents ofmental healthcare institutions and that of the general population.The debate over the legislation reveals the cultural and organisationalchallenges that have to be dealt with to make mental healthservices health-promoting. There are signs of change. A recent review by the Chief Nursing Officer called for a holistic approachto the physical, psychological and social health of mentalhealth patients. In addition, the new general practitionercontract should mean annual health checks for people with mentalillness, and an opportunity for general practitioners to directpatients to smoking cessation services.

The proposed legislation will also require some immediate changes.Mental health institutions will need to consult with staffand patient groups about the smoke-free policy, and allow themto register their fears and objections. They will need to provideinformation for staff, service users and visitors about thepolicy, and education about the health effects of smoking andits interaction with medication and psychiatric conditions.Staff and patients will need access to nicotine replacementtherapy, and advice and support on quitting. Mental healthunits will also have to assess their physical environment.Where units close smoking rooms, they will need to ensure that pleasant, communal spaces with leisure activities are availableinstead. Some mental health units are housed in high-rise buildingswithout safe outside space and may argue that they should nothave to implement the proposed legislation. However, Departmentof Health guidelines already suggest that service users shouldbe able to access outdoor space, and that this is part of thetherapeutic process (Department of Health, 2002: 6.1.5–6.1.7).

The proposed smoke-free regulations are a significant firststep towards changing the smoking culture of psychiatric units,and will make it easier for staff and patients to avoid second-handsmoke exposure and to cease smoking should they wish to doso. They also send a message to service users and their professionalcarers that their physical health is a matter of importance.

REFERENCES

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