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Impact of a total smoking ban in a high secure hospital

  • Irene Cormac (a1), Sandra Creasey (a1), Ann McNeill (a2), Michael Ferriter (a1), Bernard Huckstep (a1) and Karen D'Silva (a1)...
Abstract
Aims and method

To assess the impact of a total smoking ban in a high secure psychiatric hospital. Staff and patients were surveyed before and after implementation. Data were collected on untoward incidents, seclusions, nicotine replacement therapy and changes in psychotropic medication.

Results

Of the 298 patients in the hospital for the evaluation period, 72.8% were smokers before the ban. There were no significant differences in rates of seclusion before and after the ban and only one significant comparison (P =0.01) showed an increase in untoward incidents for smokers. There were no significant increases in the use of psychotropic medication after the ban.

Clinical implications

With adequate preparation, it is possible to implement a total smoking ban in a high secure psychiatric setting without serious negative consequences.

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Copyright
This is an Open Access article, distributed under the terms of the Creative Commons Attribution (CC-BY) license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.
Corresponding author
Irene Cormac (irene.cormac@nottshc.nhs.uk)
Footnotes
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Declaration of interest

None.

Footnotes
References
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1 Action on Smoking and Health. Facts at a Glance: Smoking and Disease. ASH, 2007 (http://www.ash.org.uk/files/documents/ASH_94.pdf).
2 Campion, J, Lawn, S, Brownlie, A, Hunter, E, Gynther, B, Pols, R. Implementing smoke-free policies in mental health inpatient units: learning from unsuccessful experience. Australas Psychiatry 2008; 16: 92–7.
3 Meltzer, H, Gill, B, Petticrew, M, Hinds, K. OPCS Surveys of Psychiatric Morbidity in Great Britain, Report 3: Economic Activity and Social Functioning of Adults with Psychiatric Disorders. HMSO, 1995.
4 Coulthard, M, Farrell, M, Singleton, N, Meltzer, H. Tobacco, Alcohol and Drug Use and Mental Health. TSO (The Stationery Office), 2002.
5 Williams, JM, Ziedonis, DM, Abanyie, F, Steinberg, ML, Foulds, J, Benowitz, NL. Increased nicotine and cotinine levels in smokers with schizophrenia and schizoaffective disorders is not a metabolic effect. Schizophr Res 2005; 79: 323–35.
6 Rowe, K, Clark, JM. The incidence of smoking amongst nurses: a review of the literature. J Adv Nursing 2000; 31: 1046–53.
7 Dickens, GL, Stubbs, JH, Haw, CM. Smoking and mental health nurses: a survey of clinical staff in a psychiatric hospital. J Psychiatr Ment Health Nurs 2004; 11: 445–51.
8 Cormac, I, Ferriter, M, Benning, R, Saul, C. Physical health and health risk factors in a population of long-stay psychiatric patients. Psychiatr Bull 2005; 29: 1820.
9 National Patient Safety Agency. Defining Research. NPSA, 2007 (http://www.red.mmu.ac.uk/documents/res_files/ethics/NRES_leaflet_Defining_Research-1.pdf).
10 Department of Health. Code of Practice: Mental Health Act 1983 – Revised 2008. TSO (The Stationery Office), 2008.
11 Hempel, AG, Kownacki, R, Malin, DH, Ozone, SJ, Cormack, TS, Sandoval 3rd BG, et al. Effect of a total smoking ban in a maximum security psychiatric hospital. Behav Sci Law 2002; 20: 507–22.
12 Cormac, I, Brown, A, Creasey, S, Ferriter, M, Huckstep, B. A retrospective evaluation of the impact of total smoking cessation on psychiatric inpatients taking clozapine. Acta Psychiatr Scand 2010; 121: 393–7.
13 Cormac, I, McNally, L. How to implement a smoke-free policy. Adv Psychiatr Treat 2008; 14: 198207.
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BJPsych Bulletin
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  • EISSN: 1758-3217
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Impact of a total smoking ban in a high secure hospital

  • Irene Cormac (a1), Sandra Creasey (a1), Ann McNeill (a2), Michael Ferriter (a1), Bernard Huckstep (a1) and Karen D'Silva (a1)...
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eLetters

Smoking and mentally ill

Pratish B Thakkar, Consultat Forensic Psychiatrist
21 October 2010

Patients with mental health problems smoke significantly more, have increased levels of nicotine dependency and are therefore at even greater risk of smoking-related harm than the general population. (2)

We surveyed the smoking habits of inpatients of adult open wards and compared them with that of the national population. The statistics for thenational populations were obtained from: www.ash.org.uk/files/documents/ASH_106.pdf and Smoking and drinking among adults, 2008, General Lifestyle Survey 2008, Office for NationalStatistics, Jan 2010. The patients were surveyed with regards to their smoking habits.

The overall smoking prevalence for the inpatients (65%) was three times the national (21%). Addiction to nicotine can be measured by noting how long after waking person smokes his 1st cigarette. 35% of inpatients and 16 % of the general population smokers had their cigarette in first 5 minutes. 57 % of general smokers and 70 % inpatient smokers said they would find it hard to go for a whole day without smoking. Worryingly, 78% of the inpatients smokers said that they smoked more when they are admitted. The reasons given by inpatients, for increased smoking whilst admitted, included boredom, that smoking reduces side effects and it causes weight loss. Thankfully more that half (60%) of the patients expressed a desire to cut down smoking. It can be concluded that inpatients smoke more and are more addicted than the general population

Following this survey we have recommended that the patients should beoffered advice on smoking cessation at the time of the admission and discharge. Treatment should also be offered routinely, particularly, as a review of smoking cessation treatments for people with mental illness concluded that pharmacological aids that are given to the general population can be equally effective in helping people with mental illness to stop smoking. (3) However, care must be taken to avoid adverse medication interactions and to monitor anti-psychotic medication in particular as cigarette consumption declines.

It is our view that boredom as an excuse for smoking should be challenged with structured occupational therapy programme. We also feel that patient should be encouraged to manage their weight by attending a gymnasium and could be helped from advice form a dietician.

We would like to know if other readers have had a similar experience especially it is known that there are plans to percolate the smoking ban down to lower levels of security. The corresponding author is aware that some the health care wings in prison are also now smoke free.

References

1 Irene Cormac, Sandra Creasey, Ann McNeill, Michael Ferriter, Bernard Huckstep, and Karen D’Silva Impact of a total smoking ban in a high secure hospital The Psychiatrist 2010 v. 34, p. 413-417.

2 Mental health and smoking. A position statement. Faculty of Public Health, London, 2008.

3. Campion J, Checinski K & Nurse J. Review of smoking cessation treatments for people with mental illness. Adv Psych Treat 2008; 14: 208-216

4 Smoking and drinking among adults, 2008. General Lifestyle Survey 2008, Office for National Statistics, Jan 2010. www.statistics.gov.ukstics.gov.uk
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Conflict of interest: None Declared

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Smoking, a new risk issue

Sajid Muzaffar, Speciality Registrar
09 October 2010

Promotion of a smoking free life style is laudable and from public health point of view a desirable policy but use of the powers of Mental Health Act to enforce such a policy is neither helpful to patient management nor ethically defensible. Smoking ban in secure settings creates a new ethical and legal dilemma for the clinicians. If a patient on leave breaks the ban and smokes on hospital grounds, are we to stop or suspend the leave because the patient smokes, which would be ethically questionable way of application of the Mental Health Act, or are we to ignore the smoking behaviour from the leave considerations, in which case the enforcement of ban becomes hard.

The smoking ban creates a new risk area. Tobacco acquires the same status as illegal drugs and patients may end up smuggling smoking materialinto the wards and smoking in their rooms creating additional fire risks.

It remains to be seen if the smoking ban leads to any longstanding change in the patient’s smoking behaviours.

Are we able to get away with making illegal, what the law of this country regards legal because we are dealing with a group of people with mental illness? Is this another proof of Foucault's(1) assertion that the mentally ill are the new age lepers and another example of Pinels description a Psychiatric hospital(2)?

Reference(1)Foucault,M. (1961). 'Madness and Civilisation, A history of insanity inage of reason' Roulegde(2005)

(2)'He (a psychiatrist) must threaten little but do what he says; andif he is disobeyed punishment must follow immediately and with close confinement'-(Philippe Pinel 'Medicolegal treatise on Mental Alienation' 1809)
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