Commentary doi: 10.1111/1753-6405.12649 Smoke-free mental health inpatient facility policies in Australia: variation across states and territories Marguerite Thomas,1 Robyn Richmond1 School of Public Health and Community Medicine, University of New South Wales C reating smoke-free environments in mental health inpatient facilities is a goal that public health authorities are increasingly supporting.1 By international standards, Australia is leading the way in adopting such policies.1-3 The Australian National Tobacco Strategy 2012-2018 includes an action (Action 6.5.7) to “Ensure that mental health services and drug treatment agencies are smoke free”,4 and federal, state and territory health ministers endorsed this strategy in 2012.4 Smokefree environment policy and legislation is generally the responsibility of state and territory governments so implementation of this action is predominantly enacted in state and territory policy and legislation This is similar to the way in which countries that have ratified the World Health Organization Framework Convention on Tobacco Control may implement the articles differently within their own legislations.5 The prevalence of smoking by mental health inpatients is considerably higher than in the general population, with more than two-thirds of inpatients in Australian public mental health units with psychotic illness reporting being current smokers.6 Implementation of smoke-free environments in mental health inpatient settings can be difficult and controversy often surrounds these policies.7-9 The issues surrounding smoke-free policies in non-inpatient mental health settings vary considerably, as patients are not confined to the unit and can access areas to smoke outside the facility, thereby minimising the occupational risk of exposure for staff and other patients Given these variations, this commentary focuses on smoke-free policies as they apply to inpatient units only Reviewing the evidence on the characteristics of smoke-free inpatient mental healthcare policies and implementation processes that are associated with greater success can inform the next iteration of policy development Now that the National Tobacco Strategy is halfway through its lifespan, it is timely to reflect on how states and territories have interpreted and incorporated the action of ensuring mental health inpatient services are smoke-free in relevant policy and legislation What smoke-free policies apply? We reviewed smoke-free policies and related documents that are publicly available on the health department websites of the states and territories (jurisdictions).10-17 The findings from this review are summarised in a table that is available as a supplementary file (available online) There is notable variation in the policies between jurisdictions State and territory strategic plans All state and territory strategic plans for tobacco control reviewed recognised people with mental illness as a priority group for tobacco control interventions.18-23 However, only the NSW Tobacco Strategy 2012-16 included an action to review and fully implement a smoke-free healthcare policy in inpatient mental health facilities.18 Smoke-free indoor policies applicable to all healthcare facilities All jurisdictions have policies and/or legislation that mandate that indoor areas of healthcare facilities must be smoke-free Indoor areas are covered in various ways across the jurisdictions by smoke-free workplace legislation, legislation prohibiting smoking in enclosed public places, and generic hospital-wide smoke-free policies Smoke-free outdoor policies applicable to all healthcare facilities Half the jurisdictions – Queensland (Qld), South Australia (SA), Tasmania (Tas.) and the Australian Capital Territory (ACT) – have policies or legislation mandating that all healthcare facility grounds are totally smoke-free.24-26 In New South Wales (NSW), designated outdoor smoking areas may be created on hospital grounds at the discretion of local health district chief executives through creation of a by-law.27 In the Northern Territory (NT), up to two designated smoke-free areas for patients can be created on hospital grounds at the discretion of hospital district executives.28 In Western Australia (WA), there is a policy mandating that all hospital grounds are smoke-free, however there are guidelines exempting some mental health patients that are discussed in a later section.29 In Victoria (Vic.), local health services may determine whether to implement smoke-free policies on hospital grounds and it is reported that most hospitals have created smoke-free outdoor policies.30 Half the jurisdictions have legislated smoke-free buffer zones ranging from three to five metres around health service building entrances and/or grounds; these include NSW, Vic., Qld and Tas.25,27 While these generic healthcare system policies not explicitly address whether mental health facilities may have designated outdoor smoking areas, there is no indication they are exempt Smoke-free indoor policies specific to mental health facilities Indoor smoking bans in mental health facilities are enacted through generic healthcare facility-wide bans Both the Vic and NSW smoke-free mental healthcare guidelines say smoking is banned in indoor areas of health services by workplace health and safety legislation and tobacco control legislation There is a potential exemption in Victoria, where the Tobacco Act 1987 has a provision that mental health facilities can apply to have designated indoor smoking areas However, all exemptions to smoke-free indoor bans were revoked on July 2015.31 Smoke-free outdoor policies and guidelines specific to mental health facilities Three jurisdictions have specific guidelines addressing creation of outdoor smoke-free environments in mental health facilities The Victorian Chief Psychiatrist released guidelines in 2012 supporting the creation of smoke-free mental health facilities stating that while exemptions for mental health facilities in smoke-free precincts This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made 2017 Online Australian and New Zealand Journal of Public Health © 2017 The Authors Commentary may be sought, they are discouraged on the grounds that having a hospital-wide ban sends an unambiguous message that everyone has the right to receive care in a smoke-free environment.30 In NSW, nonmandatory guidelines released in 2009 provide comprehensive advice to local health district executives on best practice in implementing smoke-free policies in mental health facilities.32 WA has guidelines that allow for involuntary mental health patients over the age of 18 to be exempt from the hospital-wide policy so that they may smoke in designated outdoor smoking areas.33 The WA guidelines are an example of the fluidity of these policies Initially mental health facilities weren’t exempt from the generic hospital policy introduced in 2008 However, in 2013 the guideline permitting exemptions was released are effective in ensuring that staff are not exposed to particulate matter that exceeds the safety threshold indicated by the World Health Organization.2 In summary, the majority of smoke-free healthcare policies published by state and territory health departments not explicitly address mental health facilities Where policies did address mental health facilities, they were not mandatory or provided facilities with exemptions to generic hospitalwide smoke-free policies Implications of the evidence on current smoke-free mental healthcare policies The smoke-free polices reviewed all broadly include statements that the policy aims are twofold These are: 1) to protect staff, patients and visitors from the harmful effects of second-hand smoke; and 2) to encourage smokers to quit.24-27,29,34,35 Several reviews suggest several key characteristics of smokefree policies associated with greater chances of achieving these policy aims.1,36-38 There is evidence that total smoking bans in mental health facilities are more successful in achieving both policy objectives than partial smoking bans.36,39,40 Total smoking bans prohibit smoking in both indoor and outdoor areas, whereas partial bans typically prohibit smoking in indoor areas and allow for the creation of designated outdoor smoking areas.1 A Dutch study found that 87% of psychiatric facility staff surveyed reported being exposed to tobacco smoke in facilities with partial smoking bans and concluded that only complete smoking bans would protect staff from exposure.41 It has also been shown that only total smoking bans There is some evidence that total smoking bans may better support patients’ attempts to quit smoking.40 A recent systematic review found that while there was no evidence of a significant increase in quit rates for patients, studies in facilities with comprehensive restrictions that provided combined pharmacological and behavioural therapy had more positive outcomes, including significant reductions in cigarette consumption three months post-discharge, increased quit attempt rates and increased self-reported intention to quit.40 There is evidence that patients may increase their cigarette consumption in units with partial bans.1 Patients have reported it is easier to quit when no-one else smokes;42 however, discharge planning for ongoing management of nicotine dependence is essential to supporting cessation for patients.43 smoke-free Given the pervasive culture of smoking in mental health facilities and that mental health inpatients have very high smoking rates,52,53 this population is disproportionately affected by smoke-free policies Consequently, there is a need for targeted strategies to support mental health facilities to adopt total smoke-free policies The 2009 Guidance for Implementing Smoke-free Mental Health Facilities in NSW32 is arguably the best example from all the jurisdictional policies and guidelines of a guideline promoting targeted evidencebased strategies for mental health facilities However, these guidelines are limited by the fact that they are not mandatory Overall, while half the jurisdictional policies are implicitly consistent with evidence that total smoke-free policies are more effective than partial smoke-free policies, in general, these policies not explicitly mandate that mental health facilities must be completely smokefree environments, nor they provide guidance on how to achieve this There is evidence that partial bans may place patients in a state of chronic nicotine withdrawal if they are only able to smoke periodically.1,44-46 While it is often argued that it is cruel to prevent patients from smoking in inpatient facilities, it is arguably crueller to place them in a state of intermittent nicotine withdrawal and to neglect assisting them to quit long term Furthermore, smoking breaks in facilities with partial bans can be a fixation for patients and disruptive to therapy.47 Concerns about increased patient aggression after the introduction of smoke-free policies are not realised in inpatient facilities with well-implemented policies and, in fact, reduced aggression, coercion and threats from patients towards staff and other patients have been reported.48,49 Finally, partial bans not address the pervasive culture of smoking within mental health facilities, which is a known barrier to successful policy implementation.1,50,51 Another factor the literature suggests is strongly associated with achieving smokefree mental health facilities is adequately managing nicotine dependence.1,36,46,50,51,54 Management of nicotine withdrawal should be part of routine clinical practice in mental health facilities with a smoke-free policy Failure to manage nicotine dependence may result in increased potential for patient aggression and violence.55 Additionally, all clinicians working in a smoke-free facility should be trained in providing brief intervention for smoking cessation to patients who smoke or are recent quitters Clinicians should follow the recommendations of the Royal Australian College of General Practitioners’ Supporting Smoking Cessation: a guide for health professionals.56 This entails training in provision of nicotine replacement therapy (NRT)57 as well as the ability to deliver or provide a referral to a behavioural therapy service.58 Given the evidence that partial bans are not as effective at achieving the two main goals of smoke-free policies in mental health facilities, it is noteworthy that only half the jurisdictions have policies that stipulate facilities must be totally smokefree Furthermore, the jurisdictions that have implemented total bans have done so using generic hospital-wide policies or legislation, which not provide detailed advice addressing the particular challenges mental health facilities face in going totally Encouragingly, the majority of jurisdictions have policies and/or clinical guidelines in place stipulating that nicotine dependence must be managed and cessation support provided.59-63 These policies and guidelines also typically include provisions for staff to obtain NRT at reduced or no cost.24-26, 64 Supporting staff to quit is important, as it has been shown that staff who smoke are less supportive of smoke-free policies.48 This suggests that at a policy level there is wide-spread recognition of the need to Australian and New Zealand Journal of Public Health © 2017 The Authors 2017 Online Commentary manage nicotine dependence and provide cessation support through evidence-based interventions What the policy context means for implementation The evidence suggests that one of the most important drivers of successful implementation of smoke-free policies in mental health facilities is consistent support for the policy at all levels of the organisation from frontline staff to health service executives.36 The lack of consistent and explicit recognition at a policy level of the need to support mental health facilities to be totally smoke-free is arguably reflected in the inconsistent implementation and enforcement of smoke-free policies in some mental health facilities There is evidence that despite facilities having smoking bans in place, smoking still occurs frequently.36 For example, one study in a facility that had implemented a total smoking ban three years prior found 83.5% of smokers surveyed reported smoking while admitted.65 In another study in a facility that had implemented a total smoking ban four years prior, 152 occasions of staff and patients smoking on facility grounds were witnessed and more than 2,000 cigarette butts were collected during a nine-day period.66 It has also been shown that inpatients often not receive optimal levels of NRT and that psychiatric nurses often not feel adequately trained to effectively support patients to quit.3,42,47,49,65-68 However, there is encouraging evidence that patients report having more positive attitudes towards smoking bans after implementation than they predict before implementation.69 There are also generally less issues with implementation than staff predict.36 In particular, concerns about increased aggression are not often realised.36,48 It is clear that staff need to be comprehensively engaged and supported for implementation to be effective (particularly for staff who smoke).1,42,69 There is evidence that staff generally support smoke-free policies.1,42,48,70 The long-standing historical acceptance of smoking within mental health inpatient facilities has created a complex and contentious environment for the implementation of smoke-free policies This culture has resulted in inconsistent support for facilities to be smoke-free at both the front-line and policy levels While 2017 Online this commentary focuses on Australia, similar concerns have been documented in New Zealand71 and internationally.72 Tobacco smoking is the leading cause of preventable death in psychiatric populations.3,45 Furthermore, mental health facility staff have a right to work in smokefree environments.73 There is a public health obligation to address this neglected issue and make a genuine explicit commitment at a policy level to support mental health facilities to be smoke-free environments Generic hospital-wide smoke-free policies that not address the complexities of this context are insufficient to effect real change Hospital-wide policies should be complemented by clear and practical guidelines to support implementation of smoke-free policies in mental health facilities Involvement of front-line staff throughout the policy development process is integral to ensuring that their perspectives and expertise inform policy Engagement of front-line staff in the policy process also has the added benefits of addressing staff concerns and misperceptions, as well as creating shared responsibility for the policy that may in time slowly erode the pro-smoking culture in mental health facilities Acknowledgements The authors wish to acknowledge and thank Dr Jo Mitchell, Ms Audrey Maag and Ms Rhonda Matthews from the NSW Ministry of Health for reviewing drafts of this paper References Lawn S, Campion J Achieving smoke-free mental health services: Lessons 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Drug Alcohol Depend 2010;110(3):177-82 46 Prochaska JJ Ten critical reasons for treating tobacco dependence in inpatient psychiatry J Am Psychiatr Nurses Assoc 2009;15(6):404-9 47 Ratschen E, Britton J, Doody GA, McNeill A Smoke-free policy in acute mental health wards: Avoiding the pitfalls Gen Hosp Psychiatry 2009;31(2):131-6 48 Hehir AM, Indig D, Prosser S, Archer VA Implementation of a smoke-free policy in a high secure mental health inpatient facility: Staff survey to describe experience and attitudes BMC Public Health 2013;13:315 49 Hollen V, Ortiz G, Schacht L, Mojarrad MG, Lane GM Jr, Parks JJ Effects of adopting a smoke-free policy in state psychiatric hospitals Psychiatr Serv 2010;61(9):899-904 50 Schroeder SA, Morris CD Confronting a neglected epidemic: Tobacco cessation for persons with mental illnesses and substance abuse problems Annu Rev Public Health 2010;31:297-314 1p following 314 51 Olivier D, Lubman DI, Fraser R Tobacco smoking within psychiatric inpatient settings: Biopsychosocial perspective Aust N Z J Psychiatry 2007;41(7):572-80 52 Solty H, Crockford D, White WD, Currie S Cigarette smoking, nicotine dependence, and motivation for smoking cessation in psychiatric inpatients Can J Psychiatry 2009;54(1):36-45 53 Lineberry TW, Allen JD, Nash J, Galardy CW Populationbased prevalence of smoking in psychiatric inpatients: A focus on acute suicide risk and major diagnostic groups Compr Psychiatry 2009;50(6):526-32 54 Lawn S, Campion J Factors associated with success of smoke-free initiatives in Australian psychiatric inpatient units Psychiatr Serv 2010;61(3):300-5 55 Lawn S, Pols R Nicotine withdrawal: Pathway to aggression and assault in the locked psychiatric ward? Australas Psychiatry 2003;11(2):199-203 56 Royal Australian College of General Practitioners Supporting Smoking Cessation: A Guide for Health Professionals Melbourne (AUST): RACGP; 2011 57 Stead LF, Perera R, Bullen C, Mant D, Lancaster T Nicotine replacement therapy for smoking cessation Cochrane Database Syst Rev 2008;(1):CD000146 58 Baker AL, Richmond R, Kay-Lambkin FJ, Filia SL, Castle D, Williams JM, et al Randomized controlled trial of a healthy lifestyle intervention among smokers with psychotic disorders Nicotine Tob Res 2015;17(8):946-54 59 ACT Health Department Clinical Guidelines and Procedures: Management of Nicotine Dependence Canberra (AUST): Government of the Australian Capital Territory; 2011 60 NT Department of Health Clinical Guidelines for the Management of Nictoine Dependent Inpatients Darwin (AUST): Northern Territory Government of Australia; 2009 61 NSW Ministry of Health Managing Nicotine Dependence: A Guide for NSW Health Staff Sydney (AUST): State Government of New South Wales; 2015 62 Queensland Department of Health Smoking Cessation Clinical Pathway Brisbane (AUST): State Government of Queensland; 2014 63 WA Department of Health Clinical Guidelines and 64 65 66 67 68 69 70 71 72 73 Procedures for the Management of Nicotine Dependent Inpatients Perth (AUST): State Government of Western Australia; 2013 WA Department of Health Guidelines for the Provision of Assistance to Nicotine Dependent Staff Perth (AUST): State Government of Western Australia; 2013 Stockings EA, Bowman JA, Bartlem KM, McElwaine KM, Baker AL, Terry M, et al Implementation of a smoke-free policy in an inpatient psychiatric facility: Patient-reported adherence, support, and receipt of nicotine-dependence treatment Int J Ment Health Nurs 2015;24(4):342-9 Wye P, Gow LB, Constable J, Bowman J, Lawn S, Wiggers J Observation of the extent of smoking in a mental health inpatient facility with a smoke-free policy BMC Psychiatry 2014;14:94 Wye P, Bowman J, Wiggers J, Baker A, Carr V, Terry M, et al An audit of the prevalence of recorded nicotine dependence treatment in an Australian psychiatric hospital Aust N Z J Public Health 2010;34(3):298-303 Wye P, Bowman J, Wiggers J, Baker A, Carr V, Terry M, et al Providing nicotine dependence treatment to psychiatric inpatients: The views of Australian nurse managers J Psychiatr Ment Health Nurs 2010;17(4):319-27 Filia SL, Gurvich CT, Horvat A, Shelton CL, Katona LJ, Baker AL, et al Inpatient views and experiences before and after implementing a totally smoke-free policy in the acute psychiatry hospital setting Int J Ment Health Nurs 2015;24(4):350-9 Wye P, Bowman J, Wiggers J, Baker A, Knight J, Carr V, et al Total smoking bans in psychiatric inpatient services: A survey of perceived benefits, barriers and support among staff BMC Public Health 2010;10:372 Glover M, Fraser T, Bullen C, Wallace-Bell M, McRobbie H, Hadwen G Transition to a smoke-free culture within mental health and drug and alcohol services: A survey of key stakeholders Int J Ment Health Nurs 2014;23(2):183-91 Zabeen S, Tsourtos G, Campion J, Lawn S Type of unit and population served matters when implementing a smoke-free policy in mental health settings: Perceptions of unit managers across England Int J Soc Psychiatry 2015;61(7):700-10 Sullivan DH, Rees MA Smoking bans in secure psychiatric hospitals and prisons J Law Med 2014;22(1):22-30 Correspondence to: Ms Marguerite Thomas, School of Public Health and Community Medicine, University of New South Wales, Sydney, NSW 2052; e-mail: marguerite.thomas@unswalumni.com Supporting Information Additional supporting information may be found in the online version of this article: Supplementary Table 1: Smoke Free Mental Health Facility Policy across Australian States and Territories Australian and New Zealand Journal of Public Health © 2017 The Authors 2017 Online