SLaM went completely smokefree on 1 October 2014.
Patients, carers, staff and all other visitors are not allowed to smoke on any SLaM sites including all wards, buildings, grounds and vehicles.
There are no designated areas where the use of cigarettes is allowed.
If you smoke, we will support you to make a quit attempt or to temporarily abstain whilst in hospital.
The Trust wants to reduce harm to patients, staff and everyone else who visits our sites. We want to create healthy environments that promote wellness.
As an NHS organisation, we have a duty to protect and care for both the mental and physical health of our patients. This includes supporting smokers to stop smoking.
People with mental health problems are more likely to smoke and to smoke more heavily than the general population and this is one of the reasons that they have poorer physical health and a lower life expectancy than the general population. We want to reduce this unacceptable health inequality.
Before we went smokefree, our inpatient services spent approximately four hours a day facilitating smoking through activities such as helping to buy cigarettes or escorting patients to smoking areas. Reinvesting this time into facilitating healthy therapeutic activities is beneficial to both staff and patients.
Our decision to go smokefree is in line with The Health Act (2006) and The National Institute for Health and Care Excellence (NICE 2013) guidelines which state that all hospital sites, including mental health hospitals, should be 100 per cent smokefree.
Following assessment, all of our patients who smoke are provided with support.
Depending on the severity of their nicotine dependence, smokers are offered nicotine replacement therapy and/or behavioural support to manage nicotine withdrawal symptoms whilst they temporarily abstain from smoking. By offering nicotine replacement therapy to all patients we are ensuring that no one is forced to experience the effects of nicotine withdrawal.
Smokers who want to take the opportunity to make a quit attempt whilst in hospital will be referred to a specialist tobacco dependence treatment adviser.
Prior to planned hospital admissions patients are advised that smoking is not permitted in the hospital or grounds and they are offered support to temporarily abstain or quit. This will include Nicotine Replacement Therapy (NRT) and behavioural support. Patients are asked not to bring tobacco, cigarettes, lighters or matches with them to hospital.
For unplanned admissions patients are not allowed to keep tobacco, cigarettes, lighters or matches on their person. If they arrive to hospital with a carer or family member they are asked to take the prohibited items home. If they are unaccompanied when they arrive at hospital staff store the items and return them when the patient is discharged.
If a patient struggles to stay smokefree staff review their care plan and consideration will be given to adjusting their Nicotine Replacement Therapy and increasing the amount of behavioural support provided.
Patients in community settings are informed about the Trust’s smokefree policy and offered a referral to their local smoking cessation service. Those who are receiving treatment are asked to ensure that they do not smoke for one hour prior to or during their treatment session. The reason for this is that we want to protect staff from the harmful effects of second hand smoke. Also some of the cancer causing components of tobacco, continue to increase in the air after a cigarette is extinguished.
Our aim is to develop a culture where smoking is viewed as unacceptable across our sites and for people to respect this. However, shifts in culture and behaviour do not happen instantly. In the early days of going smokefree we anticipate that there will be some breaches of our policy.
In a situation where an individual is breaching the policy, a staff member may approach the person to let them know that the Trust is now smokefree and that there are excellent smoking cessation services that we can put them in touch with if they wish.
We have let people know about the Trust going smokefree in several ways. These include:
- explaining what smokefree means and what support is available in our publications, e-news bulletin, website, intranet and on banners and TV screens in receptions and public areas
- producing leaflets with specific information for staff, patients and carers
- contacting stakeholders such as partner organisations and commissioners to brief them on the change and answer any questions
- visiting wards to brief staff and patients and identify any potential issues and answer questions
- holding Q&A sessions at different hospital sites to answer questions and get feedback
- installing new signage, which will highlight that smoking is not allowed anywhere on Trust premises.
- including information about smokefree to the staff induction so that new staff are fully advised of the policy
- briefing local media
- including information about smokefree and the support available in outpatient letters so that patients know of the policy in advance of attending appointments.
Evidence from SLaM wards which had previously gone smokefree is that a complete ban leads to a reduction in smoking related violence and aggression, rather than an increase.
In SLaM’s Behavioural and Developmental Clinical Academic Group (CAG), where smokefree was piloted, there was:
- a reduction in the number of violent incidents associated with smokefree status
- a reduction in the use of supervised confinement episodes to manage smoking related conflict
- a reduction in the use of promoting safer and therapeutic services (PSTS) techniques to manage smoking related conflict
- the complete elimination of the use of rapid tranquilisation in response to smoking related conflict.
Partial smoking bans – where people can smoke in certain places or at certain times – can be more frustrating for some patients and lead to more conflict as there are grey areas for people to dispute. Inconsistent enforcement of a complete smokefree ban can also cause disputes.
The Department of Health recommends a combination of intensive behavioural and psychological support alongside medication to minimise nicotine withdrawal symptoms and help with cravings. Effective medication includes Nicotine Replacement Therapy (NRT), bupropion and varenicline.
There are currently eight different NRT products available. These are patch, gum, lozenge, sublingual tablet, nasal spray, inhalator, mouth spray and mouth strips. All of the products are absorbed through the skin, nose or mouth.
These medicines work well on their own but are more effective alongside behavioural and psychological support from a trained stop smoking advisor.
No particular NRT product is significantly better than another and it is the patient’s choice about which product to use, in discussion with staff.
NRT has been tested extensively and all products approximately double the chance of long term abstinence from smoking when compared to having no support.
There are no safety concerns with the long term use of NRT and smokers rarely become addicted. NRT is safe to use in people who smoke and is recommended by NICE to be used during periods of temporary abstinence or whilst trying to cut down.
Because the tar in tobacco smoke speeds up the metabolism of mental health medicines, when patients reduce or stop smoking, medication doses need to be reviewed and sometimes be lowered. NRT does not interact with any mental health medications or affect the blood levels of medication.
There are very few restrictions about who can use NRT. Smokers over the age of 12 can use NRT (although there is very little research in the efficacy of NRT in young smokers). Using NRT is always safer than smoking.
E-cigarettes are battery powered devices that deliver nicotine via inhaled vapour. They do not contain tobacco, so the user is not exposed to poisonous gases that are in tobacco smoke.
Devices come in many shapes or forms, sometimes resembling cigarettes, but others resemble pens or gadgets.
E-cigarettes can be disposable, rechargeable in packs or the cartridges can be refillable.
E-cigarettes can be purchased by patients or brought into services by visitors.
Patients should only use disposable e-cigarettes in designated and discrete areas such as hospital grounds and single bedrooms. They should not be used in communal indoor areas, ward gardens or any other places where patients or staff congregate.
E-cigarette users must store their e-cigarette safely and securely, should not share products with others for infection control reasons and should not use them near oxygen/naked flames.
E-cigarettes must be disposed of in a designated bin so that the battery and plastic can be recycled, in line with EU regulations.
We recommend that only disposable e-cigarettes are used on Trust sites, following guidance from the Department of Health which highlights that improper handling of batteries and chargers for rechargeable devices carries this risk of fire or explosion.
However, if a rechargeable e-cigarette is deemed necessary for service users – either to prevent relapse to smoking or because of long-term use prior to the introduction of this policy – a care team can allow their use but only if an appropriate protocol for use, charging, storage and disposal is in place.
E-cigarettes were first introduced onto the market in the UK in 2004 so there have been no long-term health studies. Experts suggest that e-cigarettes are expected to be much less harmful than tobacco cigarettes.
There are concerns that:
- e-cigarettes resemble ordinary cigarettes and therefore re-normalise smoking – although there is currently no evidence to support this
- simply replacing some cigarettes with e-cigarettes may offer little benefit – although reducing tobacco use is always a good thing
- some e-cigarettes are produced by the tobacco industry
- they are not tightly regulated in terms of their content and delivery
- there is a potential fire risk with re-chargeable devices, for example if an incorrect charger is used or if the devices is left to charge for extended period.
Because the tar in tobacco smoke speeds up the metabolism of mental health medicines, when patients reduce or stop smoking, medication doses need to be reviewed and sometimes be lowered. This applies to patients using e-cigarettes to reduce their tobacco use.
E-cigarettes are not currently licensed by the Medicines and Healthcare Products Regulatory Agency (MHRA) so the pharmacy is unable to issue them.
Regulations are being introduced in England through the EU tobacco products directive and manufacturers can apply for an MHRA licence for e-cigarettes which will allow them to be used for smoking cessation. The first MHRA licensed e-cigarettes are likely to come out towards the end of 2014; other regulations are unlikely to be in place before 2016/7.
Some clinicians and patients believe that smoking helps with stress, anxiety, low mood and symptoms of psychosis but there is not any clear or consistent evidence to support this.
However, there is emerging evidence that when patients with psychosis, depression and anxiety are supported to stop smoking, with psychological support and either NRT or other medication, on average their mental health symptoms actually improve.
Tobacco smoke also reduces the effectiveness of some medicines, which means a smoker needs a higher dose of medication compared to a non-smoker. When someone completely stops smoking their medication can be reviewed and the dosage lowered in some instances.
Is there a risk that the Trust being smokefree will discourage voluntary admissions and attendance at outpatient appointments and lead to an increase in emergency admissions?
Other mental health settings that have introduced a comprehensive smokefree policy have not seen any evidence of this.
Yes, it is legal for the Trust to go completely smokefree – banning smoking in workplaces and enclosed public spaces is covered by legislation, introduced in England in July 2007.
Banning smoking in our grounds is a recommendation of the National Institute of Health and Social Care Excellence (NICE).
It is not an infringement of a service user’s human rights for the Trust to be smokefree. This argument has been legally tested and was upheld by the Court of Appeal in 2008 after Rampton Hospital in Nottinghamshire went smokefree. It ruled that a hospital is not the same as a home environment and is instead a place that should support the promotion of health and wellbeing. Therefore patients can be prevented from smoking for health and security reasons.
During and after smokefree is introduced, we will monitor how effectively it is being implemented across the Trust and work with staff, patients and carers to address any particular issues.
There will be an initial review after three months and a more detailed review after the first 12 months. There is a feedback process in place to which includes reporting from key organisational meetings, including the patients’ forum, staff forum and regular nursing and senior management meetings.
You can send any feedback or suggested improvements on how smokefree is being implemented by email to firstname.lastname@example.org
If you have any additional questions about smokefree please email email@example.com