Drop in violence associated with smoke-free policy at psychiatric hospital

Published in The Lancet Psychiatry, the study has important implications for the introduction of smoke-free policies, not only in psychiatric hospitals but also in other institutions such as prisons.

Smoking within psychiatric hospitals has long been a cultural norm, and is thought to be a major reason why people with mental health problems die 15-20 years earlier than the general population. Despite this, smoke-free policies have previously been hampered by concerns, especially from hospital staff, that physical violence will increase.

In 2013, the National Institute of Health and Care Excellence (NICE) recommended the introduction of smoke-free policies in acute, maternity and mental health services, with on-site help for patients -- whether they want to stop smoking or not -- to manage their withdrawal symptoms.

As part of SLaM's policy, smoking is prohibited in the buildings and grounds of its four south London hospitals, smokers are offered stop smoking treatment such as nicotine replacement therapy (NRT) and patients are allowed to use e-cigarettes.

The researchers from King's College London, SLaM, University of Nottingham and University of York, analysed incident reports of physical assaults 30 months before and 12 months after the smoke-free policy was introduced.

During this study period, there were 4,550 physical assaults, with 2,916 towards staff and 1,634 between patients.

Researchers found a 39 per cent reduction in the number of physical assaults per month following the introduction of the policy. This was after accounting for general and seasonal trends and a range of factors that could also have influenced the rates of violence. For example, the number of patients on the wards each month who were male, of a younger age and detained under the Mental Health Act.

Dr Debbie Robson, Senior Post-Doctoral Researcher in Tobacco Addiction at King's College London, said: 'Hopefully our findings will reassure staff that introducing a smoke-free policy does not increase physical violence as is often feared. We believe there are a number of possibilities why rates of violence actually decreased. Historically, cigarettes have been used as a tool to manage patient behaviour and patients often coerce their peers into handing over cigarettes. To support the introduction of the smoke-free policy SLaM invested in new treatment pathways for smokers and a staff training programme, which may have contributed to changing the culture of how staff and patients interact.'

Mary Yates, Nurse Consultant and smoke-free lead at the South London and Maudsley NHS Foundation Trust, added: 'Tobacco withdrawal often prompts restlessness, irritability and a fixation on finding opportunities to smoke, and hospital staff understandably mistake this as a sign of worsening mental health. Smoking during a period of tobacco withdrawal only serves to reinforce this misinterpretation, as patients will appear calmer and less irritable as nicotine levels are topped up. This is incorrectly taken as evidence that smoking is therapeutic and necessary to prevent agitation.'

This study was undertaken at the NIHR Collaboration for Leadership in Applied Health Research and Care (CLAHRC) South London, where a team of researchers are investigating ways to help people with severe mental illness to improve their physical health.