The move to making NHS estates smoke-free has been enshrined in policy for a number of years. The desire to stop people smoking is clearly linked to potential health benefits, yet hospitals continue to “collude” with individuals to enable them to carry on smoking. Travelling around hospitals you often see patients being wheeled outside to smoke, or staff turning a blind eye to patients or colleagues smoking. This is not just in mental health settings.
However, the banning of smoking in mental health settings has been subject to considerable debate, for example:
- The 53rd Maudsley debate: “This house believes that smoking should be banned in psychiatric hospitals“
- The salient argument by leading mental health blogger @Sectioned_: “A total smoking ban for detained psychiatric patients stinks of coercion“
- Various smoke-free hospital blogs on The Mental Elf.
Arguments span health, legal and human/civil rights domains. However, one key point you often hear against implementing smoke-free policies are fears about a potential increase in violence as a result. This blog focuses on a systematic review by Spaducci and colleagues, which investigates violence that is related to the introduction of smoke-free policies. It’s worth noting that the title of this review is somewhat general and misleading: “Violence in mental health settings: A systematic review”.
A systematic approach was undertaken with the review reporting to PRISMA guidelines and registered on PROSPERO. However, it’s interesting that the PROSPERO registered review has a slightly different name from this publication (Does the implementation of smoke-free policies in mental health settings increase violence? A systematic review). This is an update of a previous review conducted in 2005 by Lawn & Pols, which included 26 papers from 1998 to 2002. In this review it is not clear, although papers dating as far back as 1996 were included. A narrative synthesis approach was undertaken.
- 11 studies were included, most originated from the US.
- All included studies were observational
- 7 cross-sectional studies
- 4 cohort studies
- The studies reported on:
- Physical violence
- Decreased in 1 study
- No change in 3 studies
- Increased in (the short-term) 2 studies
- Verbal violence
- Decreased in 3 studies
- Increased in 2 studies (temporary increase in 1 study)
- Combination of physical/verbal violence
- Decreased in 3 studies
- No change in 1 study
- Increased in 1 study
- Physical violence
- The dates of policy implementation ranged from 1991 to 2014.
- Whether or not smoking bans are linked to violence clearly needs to be considered in more depth. The findings of this narrative review appear inconclusive, and certainly combining verbal abuse and violence, and policies which ranged from total bans to partial ones into one paper complicated this. An expression of frustration at not being able to smoke, is not the same as becoming physically violent.
- It also remained unclear whether it was the smoking ban in isolation that was linked to violence. Although some of the papers tried to differentiate between smokers (and variants of this) and non-smokers, it remained unclear whether the violence was triggered by the policy or other factors.
- There is also an issue with the reporting of findings (particularly of violence), with no-change and decreases being grouped together in the reporting.
Smoking has long been a currency on wards, given by staff to reward good behaviour; a trigger for disharmony when you have run out; or means for you to be bullied or threaten by other patients. In some places the only way to get outside is during cigarette breaks. Banning smoking on wards in some regards is similar to banning drugs or alcohol, we know that these things continue regardless of the policies, and how rigorously the policies are implemented has its own perils and pitfalls. There remains the unanswered human rights questions if you are detained under the Mental Health Act is this another violation of your rights, of course the same could be said of other legal substances.
The observational studies focused on the short period of time following the introduction of the smoke-free policy changes. It may be that staff consistently implement the policy at these times. Patients have been made aware that things are changing and so are prepared. Systems have been put into place to provide additional smoking cessation expertise, and nicotine replacement therapies are available. What these studies don’t tell us is what happens after this point; do staff become inconsistent, leave or are they replaced by agency/bank staff, do patient groups change, are cessation systems maintained? Is this compounded when staff leave the premises to smoke only to return to breathe their fumes over you? I have heard of organisations after a period of implementation reverting back to smoking policies over safety fears. These fears may be related to concerns about violence increasing, but also other risks, for example, fires as patients hide lighters and smoke secretly. It is also clear that the role of vaping needs to be considered across the NHS; potentially safer, will this help resolve some of the issues associated with Nicotine Replacement Therapy (NRT).
It remains perplexing that at a time when smoking cessation services in the community are being reduced, that the demands to stop patients smoking in hospital are increasing. The risk of restarting smoking on discharge are real, these can have a huge impact on the metabolisation of antipsychotics potentially causing relapse and a return to hospital.
Although this review provides a useful summary of the literature, the simple answer remains: we probably don’t know the impact of smoking bans on the broader safety of mental health wards.
Spaducci G, Stubbs B, McNeill A, Stewart D, Robson D. (2018) Violence in mental health settings: A systematic review. International Journal of Mental Health Nursing, Volume 27, Issue 1, February 2018, Pages 33-45.
Lawn, S., & Pols, R. (2005). Smoking bans in psychiatric inpatient settings? A review of the research. Australian and New Zealand Journal of Psychiatry, 39(10), 866-885.
53rd Maudsley Debate: “This house believes that smoking should be banned in psychiatric hospitals”.
Good carton here in The Times https://www.thetimes.co.uk/article/nhs-seeks-ban-on-smoking-in-hospital-grounds-cwwstb0kv
A total smoking ban for detained psychiatric patients stinks of coercion @Sectioned_ blog, 7 Nov 2015.
Spaducci G, Robson D, Stubbs B, Stewart D. Does the implementation of smoke-free policies in mental health settings increase violence? A systematic review. PROSPERO 2016 CRD42016036328