Implementing a smoking ban: Tips for success
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The prevalence of tobacco use among psychiatric patients is up to 4 times greater than that of the general population.1 Increasing numbers of psychiatric facilities have implemented policies that ban smoking to eliminate secondhand smoke, achieve a cleaner environment, encourage healthier lifestyles for patients and staff, and reduce patient smoke breaks, which allows more time for treatment.2 The potential benefits of tobacco-free psychiatric institutions has led some clinicians to call for the total exclusion of tobacco from psychiatric and addiction settings.3
New Hampshire Hospital is a 152-bed acute inpatient psychiatric facility that has approximately 2,400 patient admissions per year. Most patients have psychotic or mood disorders, often with a co-occurring substance use or personality disorder. We report our experience in planning and implementing a campus-wide “total” smoking ban—a ban on all tobacco products in the hospital building and on hospital grounds.
Implementation and results
Our hospital’s interdisciplinary Tobacco-Free Campus Task Force developed specific recommendations and a timeline for implementing the total smoking ban. Hospital staff voiced concerns that banning smoking would lead to increased episodes of aggressive behavior. We reviewed data on the use of seclusion and restraints, patient assaults, and smoking contraband before and after initiating the total smoking ban. We found no evidence of an increase in the use of seclusion or restraints or in patient assaults with staff injury after implementing the smoking ban. However, we did see an initial increase in smoking contraband. These rates peaked and then tapered to pre-smoking ban rates within 2 years.
Why we succeeded
Several factors contributed to the successful implementation of our total smoking ban:
- Hospital administration supported having a smoke-free campus, and executive leadership allowed staff to develop strategies, programs, treatment options, and groups to maximize the possibility of success.
- Extensive communication with outside agencies, advocacy groups, and care providers allowed for discussion of potential difficulties, such as concerns regarding individuals not having access to tobacco during their hospital stay and how this could affect their treatment.
- The hospital’s Tobacco-Free Campus Task Force helped develop strategies that allowed for an effective transition to a smoke-free campus, such as increasing the number of smoking cessation groups for patients and staff and eliminating the sale of tobacco products at the hospital’s visitor shop.
- Extensive preparation, clear timelines, and achievable goals created a positive climate for a “culture of change.”
If you are considering a total smoking ban at your facility, we recommend the following steps:
- set a clear target date
- allow adequate time for hospital staff and administration to develop strategies for implementation
- make sure hospital administration is supportive
- involve all hospital disciplines—psychiatry, nursing, rehabilitation, psychology, social work, etc.
- address staff concerns regarding patient and staff safety
- ensure adequate nicotine replacement therapy options for patients and staff
- anticipate an initial increase in smoking-related contraband
- understand there may be differing opinions regarding the smoking ban, but remain committed to the change.
Dr. Folks is a consultant to Independent Medical Experts Consulting Services and Medical Care Management Corporation.
Drs. de Nesnera and Rauter report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
1. Morisano D, Bacher I, Audrain-McGovern J, et al. Mechanisms underlying the comorbidity of tobacco use in mental health and addictive disorders. Can J Psychiatry. 2009;54(6):356-367.
2. Etter M, Khan AN, Etter JF. Acceptability and impact of a partial smoking ban followed by a total smoking ban in a psychiatric hospital. Prev Med. 2008;46(6):572-578.
3. Moss TG, Weinberger AH, Vessicchio JC, et al. A tobacco reconceptualization in psychiatry: toward the development of tobacco-free psychiatric facilities. Am J Addict. 2010;19(4):293-311.