Achieving smoke-free mental health services in Scotland
Current position
In March 2006 the Smoking, Health and Social Care (Scotland) Act 2005 came into effect. It prohibits smoking in certain 'wholly or substantially enclosed premises', including most workplaces.
The Prohibition of Smoking in Certain Premises (Scotland) Regulations 2006 specifies that 'designated rooms' in psychiatric hospitals and psychiatric units are exempt from the legislation.
What are the options for the future?
In March 2006 the Smoking, Health and Social Care (Scotland) Act 2005 came into effect. It prohibits smoking in certain 'wholly or substantially enclosed premises', including most workplaces.
The Prohibition of Smoking in Certain Premises (Scotland) Regulations 2006 specifies that 'designated rooms' in psychiatric hospitals and psychiatric units are exempt from the legislation.
Option 1
- Retain the status quo (leaving the current exemption), or
Option 2
- Produce detailed guidance material without the need to amend existing legislation, or
Option 3
- Remove the existing exemption which permits smoking in designated rooms in psychiatric hospitals and psychiatric units, by amending the existing legislation.
We want to hear your views. Please take the time to complete the response form attached.
Second-hand smoke ( SHS): some key facts
Health risks of SHS
Exposure to SHS causes considerable ill health and premature death. In adults, there is a causal association with:
- chronic and acute breathing difficulties
- decreased lung function
- new cases of asthma and more severe asthma attacks
- increased risk of lung and nasal-sinus cancer, heart disease and heart attack.
And in infants and children, it causes:
- premature birth
- lower birth weight
- increased risk of sudden infant death syndrome
- slower lung growth
- respiratory infections
- middle ear infections
- new cases of asthma and more severe asthma attacks.
Recent research confirms that SHS exposure in the home accounts for the majority of SHS-related deaths. In Scotland, it is estimated that there are 745 SHS-related deaths every year associated with home exposure, compared with 10,700 in the UK and 72,170 in the EU countries.
In addition to the long-term effects, research suggests that SHS may trigger heart attacks in some people after only short periods of exposure.
Impact of smoke-free legislation in Scotland
Data from a national evaluation of the smoke-free legislation indicate that it has been a great success. After the ban was introduced there was:
- a very high level of compliance with the regulations
- an 86% improvement in air quality in bars
- a reduction in respiratory symptoms in bar workers
- a 17% reduction in heart attack admissions
- a 39% reduction in SHS exposure in non-smoking adults and children
- high levels of support for legislation among non-smokers
- increased support among smokers
- evidence of changing social norms about smoking behaviour
- an increase in smoking restrictions in the home.
Smoke-free policies in psychiatric hospitals and psychiatric units
The 'Moving Towards Smoke-free in Mental Health Services in Scotland' report looked at the experiences of psychiatric hospitals and psychiatric units which have gone smoke-free.
The key finding is that such policies can be introduced successfully with little or no negative impact. In general, staff anticipated more problems than occurred. After the policies were implemented, they were viewed much more positively. Fears of patients' behaviour and increased aggression were not justified and violent incidents were isolated events.
The main learning points were:
- Service users should be involved in implementing smoke-free policies - for instance, by joining working parties.
- Clear communication is required about why smoke-free policies are being introduced.
- It is also important to explain clearly why stopping smoking is important, and how people can get support to quit.
- Consistency, coordination and full administrative support are essential to a successful policy.
- Resources are required to plan and promote the policy.
- Policies that were introduced in one step were more successful. Phased-in approaches allow resistance to build up.
- Comprehensive bans that covered the buildings and grounds were more successful.
- Enforcing the policy is crucial. It is important to identify who should be enforcing and policing policies - this should not be left to staff. Guidance should be given on how to respond to service users who violate smoke-free policies or who ask to smoke.
- There is a lack of 'diversionary activities' in some settings which would help distract people from the desire to smoke.
Smoking and mental health service staff
There is also considerable evidence of high rates of smoking among professionals who work in mental health settings. Support to stop smoking for staff is important and can help to achieve a successful smoke-free policy.
Smoking and mental health problems: some key facts
The links between smoking and mental health are long-established. A recent study in Scotland has provided an overview of these links, as well as looking at the key issues involved in creating smoke-free mental health services.
The full report, 'Moving Towards Smoke-free in Mental Health Services in Scotland', can be read online at www.healthscotland.com/documents/2387.aspx .
Links between smoking and mental health
- Smoking rates are higher among people with mental health problems than in the general population. This is true among people with mental health problems living in the community, but is much more marked among people living in mental health units.
- Smokers with mental health problems are also more likely to smoke more heavily, and show signs of higher nicotine dependence. The heaviness of their smoking may be linked to the severity of their illness.
- The burden of smoking-related diseases among people with mental health problems is very significant. Studies have shown higher levels of heart disease and breathing conditions among people with psychiatric diagnoses. This is likely to be caused by their heavier smoking.
- People with mental health problems already experience high levels of social exclusion and health inequality, and these are exacerbated by smoking.
- It is not yet clear why people with mental health problems smoke more. For some diagnoses, smoking may be playing a role in the development of the illness.
- It is also possible that people with mental health problems smoke to self-medicate, or to lessen the side-effects of their neuroleptic medication. Smokers are prescribed higher levels of neuroleptic medication and many studies have shown that smoking increases the rate of metabolism of some, but not all, neuroleptic drugs.
Stopping smoking
- Many smokers with mental health problems do wish to stop smoking. Research suggests that they can and do quit successfully, particularly when provided with appropriate treatment. Access to Nicotine Replacement Therapy ( NRT) is very important for quit attempts and helping
with withdrawal. - Smokers with mental health problems and on certain neuroleptic medications such as clozapine should be monitored more closely than usual on quitting. For example, clozapine toxicity has been observed during the early stages of stopping smoking.
Definitions
The following terms are used in the relevant legislation and in this consultation pack.
Passive smoking
Passive smoking means breathing in other people's tobacco smoke.
Second-hand smoke
Second-hand smoke ( SHS) is other people's tobacco smoke, either from the burning tip of the cigarette or the smoke that is exhaled by the smoker. It is also known as environmental tobacco smoke ( ETS). ETS has been classed as a Class A (known human) carcinogen by the Environmental Protection Agency in the USA, in the same class as asbestos, arsenic, benzene and radon gas. A non-smoker living with a smoker is exposed to an average of about 1% of the tobacco being actively smoked.
Designated rooms
A designated room means a room which:
(a) has been designated by the person having the management or control of the no smoking premises in question as being a room in which smoking is permitted;
(b) has a ceiling and, except for doors and windows, is completely enclosed on all sides by solid floor to ceiling walls;
(c) has a ventilation system that does not ventilate into any other part of the no smoking premises in question (except any other designated rooms); and
(d) is clearly marked as a room in which smoking is permitted.
Psychiatric hospital
A psychiatric hospital means a hospital whose whole or main purpose is to treat persons with a mental disorder within the meaning of section 328 of the Mental Health (Care and Treatment) (Scotland) Act 2003. Examples include the State Hospital in Carstairs and Leverndale Hospital in Glasgow.
Psychiatric unit
A psychiatric unit means a hospital unit whose whole or main purpose is to treat persons with
a mental disorder within the meaning of section 328 of the Mental Health (Care and Treatment) (Scotland) Act 2003. An example would be the psychiatric service at the Southern General Hospital, Glasgow.
Distribution list
- NHS Boards
- Local Authorities
- Public Participation Fora ( PPFs)
- Patient Focused Patient Involvement groups ( PFPIs)
- Scottish Recovery Network
- Mental health service user groups
- Carers organisations
- SAMH
- RCN
- VOX
- HUG
- ACUMEN
- Alzheimers Scotland
- Depression Alliance.