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Smoking ban in psychiatric hospital led to drop in violent assaults

BMJ 2017; 357 doi: https://doi.org/10.1136/bmj.j2952 (Published 19 June 2017) Cite this as: BMJ 2017;357:j2952

Smoking ban in psychiatric hospital

It's evident, that a smoke-free policy in hospitals is important to protect health. It may be confusing to add some other aspects to the article of D. Robson et al. [1]. Their conclusion is a reduction of physical assaults after introduction of smoke-free policies in Departments of Psychiatry. In addition, psychotic disorders are associated with high rates of cardiovascular diseases (metabolic complications induced by antipsychotics, physical inactivity, smoking, poor diet).

The authors are right, that smoking during a psychiatric hospital admission has been a “longstanding, accepted and expected norm”. The concept to prohibit smoking in psychiatric wards is not new. An Australian analysis from 2008 [2] concluded that a implementation may have untoward effects in institutional mental health setting, staff expectation and the importance an adequate preparation and training of the staff. Today, there are dramatic problems in financial and personal resources [2]. In a study [3] with the focus on acute suicide risk and the prevalence of smoking in psychiatric inpatients, the authors showed that 80.41% of the sample of patients was hospitalized due to acute suicide risk, including affective disorders (80.3%), substance abuse disorders (36.1%), anxiety disorders (19%), psychotic disorders (16.4%), and personality disorders (10.3%). Of this sample 45.9% were current smokers. Substance abuse and psychotic disorder diagnoses were significantly correlated with current smoking status (<.0001, .02) with 77.1% and 55.9%, respectively. Research into the association between suicide risk, smoking and mortality in the seriously mentally ill patients remains unclear.

Tobacco smoke is known to affect plasma levels of many drugs, including the antipsychotic clozapine. The effects of suddenly stopping smoking on patients who take clozapine can be severe, as plasma concentrations are expected to rapidly rise, potentially leading to severe toxicity [4].

The implementation of smoke-free policies in secure psychiatric units is complicated, needs resources (staff) and an intensive Therapeutic Drug Monitoring (TDM) for patients receiving clozapine and other atypical antipsychotics.

At the moment, I think a smoke-free policy in secure psychiatric wards will not reduce physical assaults: it's dangerous. Therapy of tobacco addiction is not the main point of acute psychiatric inpatient treatment.

1) Robson D et al. Effect of on physical violence in a psychiatric inpatient setting: an interrupted time series analysis. Lancet Psychiatry. 2017 Jun 14. pii: S2215-0366(17)30209-2. doi: 10.1016/S2215-0366(17)30209-2. [Epub ahead of print]
2) Gagea SH, , Olivia M Maynard OM.Smoke-free policies in psychiatric hospitals need resources. Lancet Psychiatry, online 15 June 2017.https://doi.org/10.1016/S2215-0366(17)30241-9
3) Lineberry TW et al. Population-based prevalence of smoking in psychiatric inpatients: a focus on acute suicide risk and major diagnostic groups. Compr Psychiatry. 2009 Nov-Dec;50(6):526-32. doi: 10.1016/j.comppsych.2009.01.004.
4) Gee SH et al. Effects of a smoking ban on clozapine plasma concentrations in a nonsecure psychiatric unit. Ther Adv Psychopharmacol. 2017 Feb;7(2):79-83. doi: 10.1177/2045125316677027.

Competing interests: No competing interests

21 June 2017
Detlef Degner
senior consultant, Psychiatry
Department of Psychiatry, Medical School of Georg-August University, Goettingen
Von-Siebold-Str5, D-37075 Göttingen, Germany