Implementing smoke-free policy in healthcare settings is generally popular but not always so in mental healthcare.
Up to a third of mental healthcare staff oppose a smoking ban in their workplace and the inclusion of psychiatric wards in any smoke-free legislation has been described as 'unrealistic and unethical' by some mental health organisations.
The government is considering the exemption of some mental health settings from future smoke-free legislation under proposals opened to consultation in July.
Arguments for exempting mental health units from smoke-free policy often make reference to human rights and the fact that many patients are resident in hospital for extended periods and often against their will. But is there a right not to consume tobacco smoke for those sectioned in a mental health unit or working there?
It has been argued that smoking occupies a unique place in the culture of psychiatric care. In mental health settings, smoking rates are high among patients and staff. Smoking rooms are frequently the social hub of a mental health unit and smoking is often a major source of structure and activity to the patients' day. Studies have reported that mental health staff may often use cigarettes to appease or engage patients.
Surveys of mental health staff suggest resistance to smoke-free policy may, to some extent, reflect the fear that smoking is a stabilising factor and cigarettes keep patients calm. However, reviews of research carried out on the effects of smoking bans have demonstrated that staff tend to predict more adverse effects than actually occur and that they develop a much more positive view after the ban is in place. Smoking bans have rarely been found to lead to increased aggression and adverse incidents and have a positive effect on ward functioning in many cases.
The effect of any policy will, of course, depend largely on how it is implemented. Is it simply 'handed down' from the trust board after a cursory 'consultation'? Or is the policy framed within the context of a wider initiative of health promotion that encourages staff and patient ownership and facilitates new skills and approaches to care?
There is evidence that the latter would be welcomed and that staff often see bans as an opportunity to learn new clinical skills and offer more support in smoking cessation.
Smoking is part of the culture in mental healthcare and its removal inevitably threatens long-standing rites and traditions that are perceived to maintain stability. In this way, the mental healthcare system is as addicted to cigarettes as any individual patient. And quitting is never easy.
Andrew Hayes is tobacco policy manager for London regional public health group. Professor Salman Rawaf is director of public health at Wandsworth teaching primary care trust. Lisa McNally is health psychologist at Wandsworth tPCT, firstname.lastname@example.org