Staff at mental health hospitals have long believed that tobacco helped calm patients, when in fact the nicotine only covered symptoms of withdrawal.
Smoking in mental health institutions—from psychiatric hospitals to drug and alcohol rehabilitation facilities—has long been tolerated with the thought that taking away tobacco would leave patients agitated and unruly.
But the downside is real: even patients who don’t smoke can’t fully escape it. High smoking and second-hand exposure rates among the mentally ill are recognized as one reason those with mental health diagnoses die 15 to 20 years sooner than the rest of the population. Among those with serious mental illness—conditions like schizophrenia—the years of lost life are even higher, according to the National Institute of Mental Health.
Now, a new study from King’s College in London finds that smoking can be curbed in psychiatric hospitals. Rather than trigger a rise in violence, smoke-free policies substantially reduced it—which could lead to improvements in health and quality of life for mental health patients.
“Hopefully, our findings will reassure staff that introducing a smoke-free policy does not increase physical violence as is often feared,” Debbie Robson, senior post-doctoral fellow in Tobacco Addiction at King’s College, said in a statement.
In 2013, the United Kingdom's National Institute of Health and Care Excellence (NICE) called for smoke-free policies in acute, maternity, and mental health settings. Patients who smoked were given assistance to quit, even if they did not request it, to manage withdrawal. Smokers are given help, such as nicotine replacement therapy, and patients can use e-cigarettes.
Researchers from King’s College and 2 other institutions examined incident reports for 4 South London hospitals, covering a period of 30 months before and 12 months after the smoke-free policy began. The study period captured 4550 physical assaults, including 2916 toward staff and 1634 between patients.
Reporting in Lancet Psychiatry, the researchers found a 39% reduction in the number of physical assaults per month after the policy started, after adjusting for seasonal trends and other factors such as the age and gender makeup of a ward.
The study noted that steps to help patients manage withdrawal were critical.
“Tobacco withdrawal often prompts restlessness, irritability, and a fixation on finding opportunities to smoke,” said Mary Yates, nurse consultant at the South London and Maudsley National Health Service Trust. “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 nicotine enter the system.
But allowing smoking to continue is not the answer—helping patients to quit properly is, the authors found. They said that the findings have implications for other institutions, such as prisons, and also for health systems that care for large numbers of poor, mentally ill persons. Tobacco remains the top cause of lung cancer, which is the leading cause of cancer deaths in the United States.
Robson D, Spaducci G, McNeill A, et al. Effect of implementation of a smoke-free policy on physical violence in a psychiatric setting: an interrupted time series analysis [published online June 14, 2017]. Lancet Psych. 2017; DOI: 10.1016/S2215-0366(17)30209-2.