Smoke-free policies in the psychiatric population on the ward and beyond: A discussion paper

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Abstract

Healthcare facilities from a number of countries have or are in the process of implementing smoke-free policies as part of their public health agenda and tobacco control strategy. Their main intent is to prevent the harmful effects of environmental tobacco smoke on employees and patients. However, these protection policies are often implemented before taking into account the specific needs of patients in psychiatric facilities and are clouded by a lack of knowledge, myths and misconceptions held by a variety of stakeholders. Consequently, the implementation of smoke-free policies tends to result in unintended and unfavourable consequences for this aggregate. Patients are forced to abstain from tobacco use during their hospitalization but have few options to address their dependence upon discharge. The development and implementation of such policies should not occur in isolation. It requires thoughtful consideration of the needs of the affected population. Recommendations are presented on the role of nurses in lobbying for policy changes. As well as strategies for policy makers and administrators that should accompany such a policy in psychiatry.

Introduction

Health care facilities in a number of developed countries are in the process of implementing smoke-free policies which are framed within a larger tobacco control strategy. The main purpose of the policy is to protect individuals in these facilities including patients, residents, staff, contractors, students/trainees, volunteers and the general public from the harmful effects of exposure to second-hand smoke (Parle et al., 2005, Winnipeg Regional Health Authority, 2004).

While implementation of such policies on most inpatient units occurs with minimal concern, there is an ongoing debate about whether or not to exempt psychiatric inpatient units. In the United States all hospital buildings were to become smoke-free in 1992, including psychiatric inpatient units (Prochaska et al., 2004), although a recent US survey indicated that many psychiatric hospitals still allow patients to smoke (Matthews et al., 2005). The United Kingdom is currently in the process of implementing smoke-free environments in public and work places in England and Wales (Campion et al., 2006, McNally et al., 2006). The smoking ban came into force on 1 July 2007 (Wilkinson, 2007), however, its application in psychiatric settings is still a matter of debate amongst some clinicians who argue that it might not be entirely beneficial and that some patients in psychiatry should be exempt (Arnone and Simmons, 2007). The trend towards 100% smoke-free health care facilities began in Canada in 2003 and continues to spread across the country (Parle et al., 2005).

There is an increased interest in addressing tobacco use among the psychiatric population, which is encouraging. However, there is a reluctance to implement a smoke-free policy in psychiatric inpatient units. Concerns regarding a rise in behavioral disruptions and greater mental stress by patients are raised as reasons for maintaining a smoking policy. Further, where smoke-free policies exist, there tends to be little or no implementation of smoking cessation strategies that enable the patient to remain a non-smoker for longer than their brief hospital stay (el-Guebaly et al., 2002). Rather, the primary goal of a smoke-free policy is the protection of individuals in that institution from second-hand smoke.

The purpose of this paper is to discuss the insights obtained as a result of the decision to implement a smoke-free policy in psychiatry at a tertiary care facility in Canada. The factors that influence the reluctance to implement a smoke-free policy for psychiatric inpatients and the lack of a holistic view of their health needs when such a policy is implemented will be discussed. The myths and misconceptions held by the various stakeholders, policy makers and employees that play a role in the development and implementation of such a policy will be highlighted. A discussion of the factors that should influence the development of a smoke-free policy and the role of the psychiatric nurse is provided with recommendations for a more comprehensive approach (the term psychiatric nurse refers to nurses working with individuals who have a serious and persistent mental illness in either an inpatient, outpatient or community setting).

Finally, the authors hope to encourage more dialogue between the world of tobacco control, the mental health, addictions and self-help/advocacy communities. Interaction between these communities with respect to tobacco control is in its infancy. However, such interaction is critical if successful strategies are to be developed and implemented to decrease tobacco use among individuals with serious and persistent mental illness.

Section snippets

Tobacco use in the psychiatric population

In the last decade, published literature demonstrates a growing awareness and concern about the high rates of tobacco use among individuals with mental illness as compared to the general population. A United States population-based study that examined associations between type and the likelihood of smoking concluded that individuals with mental illness were about twice as likely to smoke as other persons (Lasser et al., 2000). Based on American and Australian studies, smoking prevalence rates

Myths and misperceptions of smoke-free policies and the psychiatric population

The perception that smoking is an acceptable cultural norm for individuals with mental illness has been a long held belief by society and health care providers. Smoking has been a part of the psychiatric culture for many years with providers often joining patients to smoke as a way to establish a therapeutic relationship or to reward desired behavior (Dickens et al., 2004). Consequently, both patients and staff developed a very convoluted relationship with tobacco. The idea of imposing smoking

Development of smoke-free policies

In Canada, smoke-free policies were developed after a decision in 2002 by the Ontario Workers’ Compensation Board in Ontario to accept a claim by a hospitality employee who developed and subsequently died of lung cancer (despite never being a smoker). Consequently, other provincial governments made amendments to their Health Protection Acts out of concern that they may be liable for future claims if legislation to protect workers from the effects of tobacco smoke were not implemented (Province

Implementation of smoke-free policies

Several factors need to be taken into account by policy makers and psychiatric nurses when considering the implementation of smoke-free policies in psychiatry. A review of 26 international studies on smoking bans in psychiatric inpatient settings concluded a number of measures need to be considered in order to introduce effective smoking bans. A multi-level, multidisciplinary approach was recommended. It included significant consultation and collaboration with all stakeholders, developing

Recommendations

The literature on smoking cessation in the psychiatric population is increasingly calling for those in the mental health and addiction communities and we would add the tobacco control and self-help/advocacy communities, to address the issue of tobacco use in individuals with mental illness (el-Guebaly et al., 2002, Parle et al., 2005, Ziedonis and Williams, 2003).

Australian researchers argue that imposing bans on inpatient units is only part of a larger strategy needed to address the high rates

Conclusion

Over the last decade the international community has come to accept the dangers of second-hand smoke and has passed legislation to ban smoking in public places indoors (including workplaces) due to pressure from special interest groups and the general public. Unfortunately, individuals with mental illness have only partially benefited from this movement, although this is understandable given the long history of tobacco use in the psychiatric population.

Few recognize how ignoring tobacco

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      For instance, those who smoke for social reasons can be taught social interaction skills in a group setting, and those with certain personality characteristics can undergo intervention in individual settings. It should also be noted that, although implementing a smoke-free policy with psychiatric inpatients is more challenging than with the general population,70,71 it is not impossible and can benefit the patients.72 Using different analytic methods, we obtained some interesting results in terms of the same factor affecting the development of smoking behavior and the cessation process differently.

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