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

The issue of whether to exempt psychiatric units and other places of residence from indoor smoke-free regulations has vexed governments and legislators in other countries. Ireland has exempted psychiatric units, although employers can override this. Scottish smoke-free legislation covers psychiatric units, but institutions may if they wish provide an exempt designated smoking room only for residents. Legislators recognise that employers need to provide a safe working environment for employees, but have been uncertain about where to draw the line for residents confined to an institution.

Public health practitioners welcome the Health Act, arguing that it will reduce smoking and exposure to second-hand smoke and lead to a decline in smoking-related diseases in the general population. Smoke-free legislation complements the government's wider anti-smoking strategy, which ranges from free smoking cessation 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 (Reference Jochelson and MajrowskiJochelson & Majrowski, 2006) found that 43% had no plans to introduce smoke-free policies. However, as mental health patients spend on average 58 days as in-patients (Office for National Statistics, 2006: p. 122) most units will have to reconsider their position if the regulations pass unchanged into law.

STAFF AND PATIENT ATTITUDES TO SMOKING

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

In this context mental health practitioners’ concerns about the feasibility of banning smoking in psychiatric settings is not surprising. Respondents to the King's Fund survey feared that patients would abscond from their units or would refuse 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 that quitting smoking brought positive health benefits; however, many felt that their primary focus should be patients’ mental rather than physical health, and they believed that patients too 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 that smoking exacts on the health of psychiatric patients. Surveys of mental health patients show that up to 70% smoke and around 50% are heavy smokers, smoking over 20 cigarettes a day (Reference Meltzer, Gill and HindsMeltzer et al, 1996; Reference Kelly and McCreadieKelly & McCreadie, 1999; Reference Coulthard, Farrell and SingletonCoulthard et al, 2002; Reference McCreadieMcCreadie, 2003). The extremely high levels of smoking, in addition to high levels of obesity, cholesterol and hypertension in psychiatric populations, put them at particular risk of developing heart and respiratory diseases (Reference Joukamaa, Heliovaara and KnektJoukamaa et al, 2001; Reference Himelhoch, Lehman and KreyenbuhlHimelhoch et al, 2004; Reference Hennekens, Hennekens and HollarHennekens et al, 2005; Reference Kisely, Smith and LawrenceKisely et al, 2005).

EXPERIENCE WITH SMOKING BANS

The smoke-free legislation could provide a much-needed prompt to mental health services in England and Wales to take seriously the physical health of their users. Certainly an emerging body of evidence shows that it is possible to introduce smoking bans in psychiatric units. Psychiatric institutions have introduced partial bans, which ban smoking indoors or restrict smoking to designated places (inside or outside), and total bans, which prohibit smoking indoors and outdoors. Lawn & Pols (Reference Lawn and Pols2005) reviewed the findings of 26 international studies reporting on the effectiveness of smoking bans in in-patient psychiatric settings and found that simple smoking policies applied in a consistent way to all patients were more effective than selective or gradually introduced bans. The review found no increase in patient aggression in 75% of all study sites regardless of the type of ban and in 90% of sites imposing a total ban. Complaints and verbal aggression were associated with selective bans, which tended to focus staff and patient attention on negotiating smoking privileges and increased the possibilities for conflict. El-Guebaly et al (Reference El-Guebaly, Cathcart and Currie2002) conducted a review of 22 studies and, similarly, found that total and partial bans had no long-term impact on unrest or compliance by patients. A Dutch study found that compliance by staff and patients was better with a total than a partial ban, and that exposure to second-hand smoke declined more dramatically with total indoor bans (Reference Willemsen, Gort and Van SoelenWillemsen et al, 2004).

A few mental health units in England have introduced indoor smoke-free policies ahead of the proposed legislation. Some trusts have linked their smoke-free policies to clinical efforts to improve the quality of care for mental health patients and to introduce some health promotion work. The smoking status of 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 have prohibited smoking indoors and allow smoking outside; others have 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 times and 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 tried smoking 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 patients still had the opportunity to smoke outside. Staff believed that closing smoking rooms and removing cigarettes as a bargaining tool or reward helped prevent and resolve difficult situations and forced them to develop new ways of interacting with patients. The former smoking rooms were used for clinical activities or as patient lounges. One respondent commented that before the new regulations ‘patients were staying up in the night smoking and were unable to get up in the morning to attend to daily living skills, activities or therapeutic interventions’. Now the smoking room was used for activities that ‘stopped them being so bored’ and patients were more engaged in ward activities (Reference Jochelson and MajrowskiJochelson & Majrowski, 2006).

THE CHALLENGES AHEAD

In recent years the UK government has committed itself to reducing smoking and smoking-related diseases and to reducing health inequalities, in particular high smoking rates among social groups with lower incomes.

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

The proposed legislation will also require some immediate changes. Mental health institutions will need to consult with staff and patient groups about the smoke-free policy, and allow them to register their fears and objections. They will need to provide information for staff, service users and visitors about the policy, and education about the health effects of smoking and its interaction with medication and psychiatric conditions. Staff and patients will need access to nicotine replacement therapy, and advice and support on quitting. Mental health units 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 available instead. Some mental health units are housed in high-rise buildings without safe outside space and may argue that they should not have to implement the proposed legislation. However, Department of Health guidelines already suggest that service users should be able to access outdoor space, and that this is part of the therapeutic process (Department of Health, 2002: 6.1.5–6.1.7).

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