Implementing smoke-free policies in mental health inpatient units: learning from unsuccessful experience

The aim of this paper is to describe the introduction, trial and termination of a smoke-free policy in an acute mental health unit of a regional hospital, and to consider factors that may contribute to the success of such policies in other settings.

This analysis is based on key informant interviews and review of correspondence related to the trial, and examination of the relevant incident-reporting database.

Planning for implementation is described. The trial itself was terminated after 6 weeks due to perceived increases in aggression by patients towards staff working in the high dependency unit. Staff perceived that these episodes were directly related to these patients not being allowed to smoke. While there was an increase in events during the trial relating to two seriously ill individuals, examination of formal incident reports over a period of 2 years suggests little change in the overall number of incidents.

Despite clear public health benefits, implementation of a smoke-free policy may have untoward behavioural effects in institutional mental health settings. In addition, staff expectations and perceptions are critical. Salient factors appear to be preparation of staff and patients, appropriate training, avoidance of exceptions and inconsistency, considering alternatives to smoking to fill the gap created by the policy, and a culture of critical evaluation in practice. Such processes will facilitate understanding and cooperation so that mental health services are able to participate in important policy processes with implications for the health of patients and staff.