Jornada de tabac i salut mental (2009). Xarxa Catalana d'Hospitals sense Fum // Departament de Salut.

1. Guidelines for Tobacco Management in
Mental Health Settings
Miriam Gunning
Co-ordinator Irish Tobacco free
Hospital Initiative (TFHI)
19th March 2009
I want to quit

2. Background to the Irish situation
2004 Tobacco legislation & exempted premises
Duty of care to staff V rights of clients
Variation in settings – no exemption if part of general
hospital facility
Little guidance for exempted premises
Lack of resources
Concerns in relation to litigation

3. Acute MH units in general
Hospital facility
Facilities for MH
clients only
(inc. acute care
facilities)
Residential
Long term
Care centres
Community residential
care units for MH clients
(hostels)
Day care facilities
For MH clients
(day hospitals)

4. Legislation in Ireland
Mental Health Services are exempt from the workplace
smoking ban because they can be considered a patient’s
home
Acute Mental Health units attached to a general hospital
are not exempt
Smoking is permitted for patients only – not for staff
Mental health units can choose to implement the indoor
smoking ban and are encouraged to do so

5. Process used in Ireland
Jan – Mar 2006 - Research best practice, agree
membership of expert group & draft discussion
document
April 2006 – 1st Expert group meeting & 1st draft of
guidelines, email consultation process
May 2006 – National Workshop, wide consultation
process, updated document & email consultation
process
Sept 2006 – 2nd Expert group meeting, updated
document & email consultation process
Nov 2006 – Agree final document content & layout

7. ENSH Project Aim & objectives
To develop “Consensus Management Guidelines” for
smoke free psychiatric / mental health services
To identify and analyse existing European guidelines
for smoke free psychiatric / mental health services
To identify management models of good practice in
psychiatric / mental health hospitals from within
participating European Partners
To make recommendations on a common set of
management guidelines for European psychiatric /
mental health services

8. Countries that participated
EASTERN EUROPE
ROMANIA
NORTHERN EUROPE
DENMARK
IRELAND
(Scotland)
(Translated guidelines from Sweden & Denmark)
WESTERN EUROPE
GERMANY
BELGIUM
FRANCE
SOUTHERN EUROPE
SPAIN

9. Project plan
December 2006 - June 2007
Engage psychiatric/mental health services
Develop survey tool
Survey participating psychiatric / mental health services
Review literature
to assess the range, gaps and effectiveness of European
smoke-free legislation and management guidelines in
relation to psychiatric and mental health services
Review and return feedback from survey
Translate identified materials
Participate at expert workshop to discuss findings and
agree draft European Recommendations
Review feedback on draft recommendations
Agree final draft

10. Smoking rates by mental health disorders (HDA 2004)

11. Smoking rates
Mc Neill 2001 - different psychiatric disorders
40% of people diagnosed with neurotic disorders (e.g.
depression, anxiety disorder, phobia, obsessive
compulsive disorder) are smokers
The more neurotic symptoms a person has the higher
the smoking level
Smoking prevalence is highest in those with diagnosed
psychotic disorders.
88% of Schizophrenia patients smoke with over 50%
being heavy smokers (>20 cigarettes/day)
Over 70% of patients living in psychiatric hospitals and
institutions smoke

12. Smoking Legislation - UK
Long-stay care institutes where patients are resident
for more than 6 months are allowed to have designated
smoking places
The average length of stay on a psychiatric ward is 58
days (Jochelson, 2006) implying most psychiatric units do
not qualify for such an exemption
Psychiatric units have been given a one-year extension
until July 2008 to provide secure outdoor smoking
areas (Draft Statutory Instrument 2007 No.)

13. Smoking Legislation - France
Total smoking ban introduced in February 2007
includes psychiatric hospitals and units
Patients and staff are only allowed to smoke outside
The only exception will be for long stay units where
smoking will be permitted in patients’ rooms as these
are considered their private space

14. Literature findings
Keizer and Eytan, 2005
Many patients who enter as non-smokers leave as
smokers
Jochelson and Majrowski (2006)
Banning indoor smoking throws up the debate of the
right of the individual to smoke versus the right of other
patients and staff not to work in a smoky atmosphere

15. King’s Fund report (2006)
The right of staff to work in a safe work environment.
The right of patients to choose their lifestyle.
The right of patients to smoke against the right of nonsmoking patients

16. King’s Fund report (2006)
Against
Lack of indoor smoking in residential units may be
perceived as a breach of a patient’s rights
Staff have preconceived ideas of impracticality, and
expect an increase in abusive behaviour.
Severe withdrawl and relapse is more common amidst
the mentally ill (Glassman et al, 1990)
A new episode of major depression may appear up to
six months after cessation in those suffering from
depression (Covey et al, 1997; Glasman et al, 2001)
During tobacco cessation patients can relapse to other
drugs

17. Findings
Health promotion should be considered part of mental
health services
Total indoor bans compared with partial bans are less
likely to result in aggressive behaviour (Jochelson and
Majrowski, 2006)
Indoor smoking bans do not prevent patients from
smoking
Patient resistence has not been experienced where nosmoking policies have been implemented
Patients conform when policies are clarified
It is difficult to motivate patients to quit when smoking is
allowed indoors

18. Findings contd.
Staff accept the no-smoking policies when they are
enforced
Cigarette consumption is reduced when it is more difficult
to smoke
Patients become calmer and sleep better
When staff don’t smoke it creates a ripple effect
A smoking ban is an opportunity to ask about tobacco use
and give a short counselling session
There is no proof that smoking cessation increases the
effects of schizophrenia
Serious smoking-related diseases and mortality are more
common in schizophrenics due to their high smoking
prevalence and heavy smoking rates (Brown et al, 2000)

19. Effectiveness of smoking bans in
psychiatric units
Willemsen et al, 2004 (Holland)
87% of individuals in psychiatric units exposed to ETS
when no ban on smoking
Even where a general smoking ban existed, where
smoking was meant to be confined to designated
areas, non-compliance resulted in a high exposure to
ETS
Only when a complete ban was implemented was
compliance high and employees sufficiently protected
from ETS

20. Jochelson 2006
reported 60% of psychiatric nursing staff disapproving of
the ban beliving staff should smoke with patients in
order to break down barriers, a view supported by 78%
of patients
US (el-Guebaly, 2002) & Canadian Research
(Willemsen, 2004)
supports smoke-free policies in psychiatric units with
careful planning and consistency by all staff
Patten et al, 1995
Fewer than expected adverse effects anticipated by staff
were produced on implementing a smoke-free policy

21. Role of psychiatric nursing staff in
aiding smoking cessation
Psychiatric nurses ideal to aid their patients in quitting
smoking
Nurses, especially those who smoke themselves, appear
reluctant to advise their patients to quit (Pelkonen and
Kankkunen, 2001)
This reluctance stems from nurses’ respect for their patients’
rights to make their own decisions
Nurses are often with patients who have been sectioned and
smoking aids interaction between them and such patients
Lawn and Condon (2006) found that nurses have to be
properly trained to be more effective in supporting patients’
quit attempts

22. Smoking cessation support for
psychiatric patients
All patients should be advised to quit (Swedish
Psychologists Against Tobacco, 2005)
West el al 2000 (England) suggested the following evidence
based guidelines
brief interventions for smoking cessation should be
given to all patients identified as smokers
More intensive smoking cessation support should also be
available during a patient’s period of hospitalisation
Support should be provided through specialist trained
staff or if not through primary healthcare staff with
smoking cessation counselling skills

23. Pharmacological aids for psychiatric
patients
The psychiatric illness with which a patient suffers must be
taken into consideration prior to describing bupropion as it
can be contra indicated
Two or more strategies tend to be better than using only
one method of intervention, which applies to the
population as a whole
On being discharged from a psychiatric unit, smoking
cessation support should be continued (Jochelson, 2006),
and patients whose medication is linked to their
smoking/non-smoking need additional monitoring and
advice

24. Training for health professionals
Staff need to be trained in intervention methods to maximise
the benefits they can offer to smokers
A variety of training practices are in operation across Europe,
within hospitals and community health services
The European Network of Smoke Free Hospitals (ENSH)
assessed the current available smoking cessation services
within European hospitals in 15 countries (McLoughin,2006a,b)
The report considered it necessary to tailor smoking
cessation training for specific groups such as mental health

25. Summary - psychiatric services
can work effectively by being smoke-free without adverse patient
effect
National smoking legislation could be expanded to include
psychiatric institutes with special considerations taken into account
Psychiatric services should be supported to go smoke-free indoors
Need to raise awareness about the problems of smoking in the
mental health services and bring about cultural change
Psychiatric services need a well-thought out tobacco policy
It is difficult to get patients to quit as long as it is permitted indoors

26. Summary - psychiatric patients
Designated secure outdoor smoking facilities should be
provided for patients
Adequate smoking cessation support needs to be
provided for patients when they are resident in
psychiatric units and should continued when they leave
the unit
Smoking cessation support needs to be adapted to the
specific clinical needs of a patient
Cigarettes should not be used as rewards
Patients should be asked about their tobacco use and
offered brief smoking cessation intervention
NRT should be supplied to patients

27. Summary - psychiatric staff
Staff have a strategic role to play in supporting smoking
cessation in patients
Staff need to be trained in smoking cessation counselling
Psychiatric staff need support to help them quit smoking
Staff should have separate smoking facilities to patients
Staff should avoid smoking in front of patients and
visitors

28. Conclusion
It’s cynical to treat the psychiatric
disorder and leave the patient to
die from smoking!
Thank you for listening!