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Drop in violence associated with smoke-free policy at psychiatric hospital

June 14, 2017

New King's College London research reveals a 39 per cent drop in physical assaults -- both between patients and towards staff -- following the introduction of a smoke-free policy at the South London and Maudsley NHS Foundation Trust (SLaM).

Published today in The Lancet Psychiatry, the study has important implications for the introduction of smoke-free policies, not only in psychiatric hospitals but also in other institutions such as prisons.

Smoking within psychiatric hospitals has long been a cultural norm, and is thought to be a major reason why people with mental health problems die 15-20 years earlier than the general population. Despite this, smoke-free policies have previously been hampered by concerns, especially from hospital staff, that physical violence will increase.

In 2013, the National Institute of Health and Care Excellence (NICE) recommended the introduction of smoke-free policies in acute, maternity and mental health services, with on-site help for patients -- whether they want to stop smoking or not - to manage their withdrawal symptoms.

As part of SLaM's policy, smoking is prohibited in the buildings and grounds of its four south London hospitals, smokers are offered stop smoking treatment such as nicotine replacement therapy (NRT) and patients are allowed to use e-cigarettes.

The researchers from King's College London, SLaM, University of Nottingham and University of York, analysed incident reports of physical assaults 30 months before and 12 months after the smoke-free policy was introduced.

During this study period, there were 4,550 physical assaults, with 2,916 towards staff and 1,634 between patients.

Researchers found a 39 per cent reduction in the number of physical assaults per month following the introduction of the policy. This was after accounting for general and seasonal trends and a range of factors that could also have influenced the rates of violence. For example, the number of patients on the wards each month who were male, of a younger age and detained under the Mental Health Act.

Dr Debbie Robson, Senior Post-Doctoral Researcher in Tobacco Addiction at King's College London, said: 'Hopefully our findings will reassure staff that introducing a smoke-free policy does not increase physical violence as is often feared. We believe there are a number of possibilities why rates of violence actually decreased. Historically, cigarettes have been used as a tool to manage patient behaviour and patients often coerce their peers into handing over cigarettes. To support the introduction of the smoke-free policy SLaM invested in new treatment pathways for smokers and a staff training programme, which may have contributed to changing the culture of how staff and patients interact.'

Mary Yates, Nurse Consultant and smoke-free lead at the South London and Maudsley NHS Foundation Trust, added: 'Tobacco withdrawal often prompts restlessness, irritability and a fixation on finding opportunities to smoke, and hospital staff understandably mistake this as a sign of worsening mental health. Smoking during a period of tobacco withdrawal only serves to reinforce this misinterpretation, as patients will appear calmer and less irritable as nicotine levels are topped up. This is incorrectly taken as evidence that smoking is therapeutic and necessary to prevent agitation.'

This study was undertaken at the NIHR Collaboration for Leadership in Applied Health Research and Care (CLAHRC) South London, where a team of researchers are investigating ways to help people with severe mental illness to improve their physical health.
-end-
Notes to editors

For further media information please contact Jack Stonebridge, Senior Press Officer, Institute of Psychiatry, Psychology & Neuroscience, King's College London jack.stonebridge@kcl.ac.uk/ 020 7848 5377.

About King's College London

King's College London is one of the top 25 universities in the world (2016/17 QS World University Rankings) and among the oldest in England. King's has more than 26,500 students (of whom nearly 10,400 are graduate students) from some 150 countries worldwide, and nearly 6,900 staff. The university is in the second phase of a £1 billion redevelopment programme which is transforming its estate.

King's has an outstanding reputation for world-class teaching and cutting-edge research. In the 2014 Research Excellence Framework (REF) King's was ranked 6th nationally in the 'power' ranking, which takes into account both the quality and quantity of research activity, and 7th for quality according to Times Higher Education rankings. Eighty-four per cent of research at King's was deemed 'world-leading' or 'internationally excellent' (3* and 4*). The university is in the top seven UK universities for research earnings and has an overall annual income of more than £600 million.

King's has a particularly distinguished reputation in the humanities, law, the sciences (including a wide range of health areas such as psychiatry, medicine, nursing and dentistry) and social sciences including international affairs. It has played a major role in many of the advances that have shaped modern life, such as the discovery of the structure of DNA and research that led to the development of radio, television, mobile phones and radar.

King's College London and Guy's and St Thomas', King's College Hospital and South London and Maudsley NHS Foundation Trusts are part of King's Health Partners. King's Health Partners Academic Health Sciences Centre (AHSC) is a pioneering global collaboration between one of the world's leading research-led universities and three of London's most successful NHS Foundation Trusts, including leading teaching hospitals and comprehensive mental health services. For more information, visit: http://www.kingshealthpartners.org.

The National Institute for Health Research (NIHR): improving the health and wealth of the nation through research.

Established by the Department of Health, the NIHR:
  • funds high quality research to improve health
  • trains and supports health researchers
  • provides world-class research facilities
  • works with the life sciences industry and charities to benefit all
  • involves patients and the public at every step


For further information, visit the NIHR website http://www.nihr.ac.uk

King's College London

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