RESEARCH

An audit of a smoking cessation programme for people

with an intellectual disability resident in a forensic unit
Verity Chester
Department of Psychiatry, St John’s House Hospital, PIC LD Services, Diss, UK
Fatima N Green
Department of Nursing, St John’s House Hospital, PIC LD Services, Diss, UK
Regi T Alexander
Department of Psychiatry, St John’s House Hospital, PIC LD Services, Diss, and Honorary Visiting Clinical Fellow,
University of Leicester, UK

Abstract
This paper briefly reviews the literature on smoking and smoking cessation programmes for people with intellectual disability, and describes
the baseline audit of such a programme for patients resident in a forensic service. The audit describes the prevalence of smoking, its
significant associations and the effect of an intervention programme. In total, 79 patients participated in the audit, 48 of whom were smokers
on admission (60.8%). Roughly a third of smokers gave up during their hospital stay (N = 15). Those who did not give up significantly reduced
the number of cigarettes they smoked per day. Female smokers appeared less likely to give up than men. Length of stay and treatment with
anti-psychotic medication were not significantly linked to smoking behaviour. A simple smoking cessation programme with an emphasis on
health education and nicotine replacement therapies appeared to be effective in cutting down smoking rates and tobacco consumption in this
population. One should be cautious about generalising the conclusions to all forensic hospital services for people with intellectual disability, as
the audit was limited by the lack of a control group and conducted in a single service.

Key words
intellectual disability; learning disabilities; smoking cessation; forensic services; medium secure units; substance misuse; health promotion

Introduction were designed primarily as a general health screen of this

Smoking is the world’s largest single cause of preventable
illness, causing more than five million deaths each year
(WHO, 2007). However, in the UK the number of people
smoking has been in decline since the 1970s. According
to data gathered by the Smoking Toolkit Study (West,
2010), the recent ban on smoking in most public places has
encouraged approximately 400,000 people to quit the habit.
The prevalence of smoking has therefore fallen to its lowest
recorded level, with only 21% of people (aged 16 or over)
currently identified as smokers (Office of National Statistics,
2009). Unfortunately, this type of data is not available
specifically on smoking and smoking cessation among those
with intellectual disabilities. Studies which have investigated
the prevalence of smoking in this group have reported
contradictory findings, rates ranging from roughly one per
cent to 37% (Table 1, overleaf). Many of these studies
population, rather than to investigate smoking specifically.
The Sainsbury Centre for Mental Health (2006)
investigated smoking cessation provisions for those with
an intellectual disability, as part of a wider study of health
inequalities faced by this population. Using focus groups
and interviews, they found that people with intellectual
disabilities had great difficulty in voicing and asserting their
health care needs. Service provision was at best patchy,
and people with an intellectual disability were less likely to
be screened, asked about their smoking status or offered
smoking-related advice. Kalyva (2007) suggested that the
view that people with intellectual disabilities do not smoke,
drink or take drugs is still widely endorsed among health
care professionals at all levels.
It is important to note that those with intellectual
disabilities are not a homogeneous group of people and

10.5042/amhid.2011.0014

Advances in Mental Health and Intellectual Disabilities Volume 5 Issue 1 January 2011 © Pier Professional Ltd 33
An audit of a smoking cessation programme for people with an intellectual disability resident in a forensic unit

Table 1: Research findings on the prevalence of smoking in people with intellectual disability
Study Sample characteristics Prevalence Comments/associations

Beange 202 adults with intellectual disability 6.4 % The intellectually disabled group had lower
et al (1995) living in institutional, group homes or levels of smoking than the general
community settings population

Burtner 749 people with intellectual disabilities 20.5% Patterns of behaviour closely resemble
et al (1995) residing in a state-operated facility those of general population

Rimmer 186 people with mild to severe 10% Residents in the group home settings
et al (1995) intellectual disabilities living in a smoked more cigarettes than those in
range of settings institutions or with family

Gress & Boss Students with intellectual disabilities 27%

(1996)

Hymowitz 136 adults who were seen at an 30% Mild Cigarette smoking enhances self-esteem,
et al (1997) intellectual disabilities clinic confidence and image, and serves as a
symbol of maturity and competence in this
group

37% Smokers were more likely to drink alcohol,

Borderline use other drugs and be sexually active

Tracy & 36 individuals with intellectual disabilities 36% Smoking prevalence higher in a population
Hosken (1997) living independently and receiving of people with intellectual disabilities than in
outreach support the general population

McGillicuddy 122 individuals with intellectual disabilities 23% This population misuses nicotine at a lower
& Blane (1999) level than general population

Blum Junior and senior high school students 27% Cigarette use associated with a lack of
et al (2001) familial closeness

Whitaker & 347 attending local Social Education SECs 1.15% Cigarette use initiated as a result of peer
Hughes (2003) Colleges (SECs) pressure or to improve image, and reasons
for continued smoking included habit,
234 students who attended the technical Technical difficulties in stopping and that it relieves
college College 2.99% stress

Taylor 435 people attending four social services 6.2% reported Those with mild disabilities were more likely
et al (2004) day centres in a large urban area being current to smoke than those with more severe
smokers disabilities and they also reported smoking
more heavily

The highest percentage of smokers was

found among those living in hospital (28.6%,
two of seven) while those living with parents
were the least likely to smoke (2.6%, six of
232) (continued)

34 Advances in Mental Health and Intellectual Disabilities Volume 5 Issue 1 January 2011 © Pier Professional Ltd
An audit of a smoking cessation programme for people with an intellectual disability resident in a forensic unit
Table 1: Research findings on the prevalence of smoking in people with intellectual disability (continued)
Study Sample characteristics
Emerson & 95 adolescents with learning disabilities
Turnbull (2005)
Kalyva (2007) 89 adolescents with mild learning
disabilities (compared with 124 typically
developing peers)
accordingly a number of factors influence the smoking
behaviours of this population. It has been reported that
those with intellectual disabilities in the borderline to mild
range are more likely to smoke than those with higher
degrees of intellectual disability (Kalyva, 2007; Taylor et al,
2004) and that place of residence affects smoking, patients
resident in the less restrictive, community or independent
living settings being more likely to smoke (Hymowitz et al,
1997; Tracy & Hosken, 1997; Rimmer et al, 1995).
Burtner and colleagues (1995) suggested that many
people with intellectual disabilities are unable to access
health messages about smoking because of difficulties in
reading, interpreting and understanding product labelling
and health campaigns, as well as reduced capacity to
understand the complications and implications of smoking.
As a result, this group is more susceptible to the health
risks, financial implications and stigma associated with
smoking (Steinberg et al, 2009). It is therefore necessary
that smoking awareness and cessation programmes should
be developed for people with an intellectual disability.
Only one published study has reported outcomes
from a smoking intervention programme developed for
this population (Tracy & Hosken, 1997). The study had a
small sample (N = 11) and was aimed specifically at those
who were living independently in the community. The
authors adapted an existing smoking cessation programme
and tailored it to the needs of those with intellectual
disabilities, as it was felt that the existing course relied on
levels of literacy and abstract thinking which would have
excluded this population. The results were encouraging,
55% of the sample either quitting smoking altogether or
significantly cutting down post-intervention. All patients who
participated in the programme demonstrated increased
knowledge and concern about the effects of smoking.
There has been little published work on smoking
behaviour or smoking cessation interventions for those with
intellectual disabilities who are treated in specialist forensic
inpatient hospitals. Patients treated in these services typically
have mild intellectual disability, offending behaviours and
multiple co-morbid diagnoses like severe mental illnesses,
personality disorders, other developmental disorders and
substance misuse (Alexander et al, 2010; Plant et al, 2010;
Advances in Mental Health and Intellectual Disabilities Volume 5 Issue 1 January 2011 © Pier Professional Ltd
Prevalence Comments/ associations
14% Smoking closely associated with experience
of poverty and mental health
29.2% (11.2% Those with mild learning disabilities smoked
regular, 18% more than those without any disability
occasional)
Alexander et al, 2002; Halstead, 1996). It is therefore
plausible that the smoking behaviour of those treated in
these settings is more similar to that of those treated in
general psychiatric inpatient units, in which 70% are smokers
and 50% heavy smokers (Jochelson & Majrowski, 2006).
It has been suggested that there is a culture of smoking
ingrained in psychiatric settings (Jochelson & Majrowski,
2006), where smoking has a social function for patients
(Peele, 1988) and is a means by which staff can control
behaviour (Olivier et al, 2007). This topic has recently been
reviewed in more detail (Campion et al, 2008).
Smoking is particularly problematic for psychiatric
inpatients. It has been suggested that it could be a causative
factor for mental illness (Arehart-Treichel, 2003) and is
linked to increased severity of psychotic illness, poorer
outcomes and more frequent hospital admissions (Aguilar
et al, 2005). Nicotine can alter the metabolism of many
antipsychotic drugs, potentially altering their efficacy and
contributing to resistance (el-Guabaly et al, 2002; Burtner
et al, 1995). For this reason many people who are on
antipsychotic medication use nicotine as a form of self-
medication, to reduce negative side-effects (Lyon, 1999),
leading some authors to suggest that a stay in a psychiatric
hospital can lead non-smokers to become smokers (Lawn
et al, 2002). Despite these concerns, smoking remains a
neglected issue in psychiatry, in both mental health and
intellectual disability fields. Facilities are reluctant to target
smoking prevention or treatment (Olivier et al, 2007)
despite lack of evidence that psychiatric patients are any less
capable of cutting down than the general population (Smith
& Grant, 1989).
Aims of the research
The aims of the research were:
to describe the smoking cessation programme in place
in an intellectual disability inpatient forensic service in
the UK
to carry out a baseline audit that establishes the
prevalence and significant associations of smoking in
this group and describes the effect of the intervention
programme.
35
An audit of a smoking cessation programme for people with an intellectual disability resident in a forensic unit

Method Health information from primary care

The audit of the smoking cessation programme was carried
out in a forensic inpatient service for people with intellectual
disabilities in the East of England. The service included
medium and low secure, as well as locked rehabilitation beds.
The smoking education and cessation programme
The smoking education and cessation programme is one
element of the nursing-led physical health awareness
programme and its contents are the same for all the units
within the service. The key elements of the programme are
as follows.
Health information provision
One-to-one sessions. Patients can discuss and obtain
information on smoking cessation in one-to-one sessions with
their named nurse.
Group sessions
All patients (not just smokers) can access the on-ward
smoking information group, which is quarterly and includes
seven sessions on smoking and related health issues. The
sessions are tailored specifically to the abilities of the patients,
and the course materials do not rely heavily on literacy or
abstract thinking skills. The sessions consist of a variety of
teaching resources, such as group discussions, quizzes, videos,
group work and pictures. The group is flexible to the needs
and interests of participants, and the sessions are based on
themes including what is smoking, why people smoke, what
smoking does to your health, passive smoking and what to do
about smoking.
Patients can obtain relevant brochures from their local GP
surgery and can make appointments with a specialist smoking
cessation nurse. If requested, nicotine replacement therapy
is provided for those assessed as suitable by the specialist
nurse.
The ‘smoking timetable’
A ‘smoking timetable’ is in place in the units which restricts
the number of cigarettes that patients can smoke to one
per hour during waking hours. All inpatients resident in the
service during one week in July 2009 were included in the
audit, which was carried out by one nurse at each of the four
sites within the service. Information was sought from case
notes, the patient and the nurse in charge on the six audit
standards which are listed in Box 1, below.
Data was analysed using SPSS – version 16. Between-
group comparisons were made using Chi Square for
categorical variables and t test for continuous variables.
Results
The audit of the smoking education and cessation
programme
In total, 79 patients participated in the audit and their
characteristics are described in Table 2, below.
Figure 1, opposite, is a flowchart that shows the smoking
status of the patients, from the point of admission to the
point of the audit.
At the point of admission 60.8% were smokers (N = 48).
However, 15 (31%) of the smokers on admission had given
up while resident in the service, which meant that at the
time of the audit 41.8% (N = 33) were smokers. None of

Box 1: Audit standards

• All patients should be provided with information about smoking and smoking cessation as part of individual sessions
• All patients should be provided with information about smoking and smoking cessation as part of group sessions
• All patients should have access to smoking cessation information from primary care
• All patients should have access to smoking cessation advice, including advice on nicotine replacement, from primary care
• Those assessed as suitable should receive nicotine replacement therapy
• All patients should be aware of the ‘smoking timetables’ which regulate their tobacco consumption

Table 2: Patient characteristics

Patient demographics Results

Gender Male 53 (67.1%)

Female 26 (32.9%)
Level of security Medium 28 (35.4%)
Low 38 (48.1%)
Rehabilitation 13 (16.5%)
Median duration of stay 21.8 months

36 Advances in Mental Health and Intellectual Disabilities Volume 5 Issue 1 January 2011 © Pier Professional Ltd
An audit of a smoking cessation programme for people with an intellectual disability resident in a forensic unit
Figure 1: Smoking status of patients from admission to audit
All patients
79
Non-smoker on admission
31
Non-smoker at time of audit Attempted to stop smoking
31 29
those who were non-smokers at admission had become a
smoker at the time of the audit. Thus there was a statistically
significant shift in patients’ smoking status between these two
points (X2 (1) = 36.60, p< 0.001).
There were no significant differences regarding gender
and smoking status at admission, but male smokers were
significantly more likely than female smokers to give up;14 of
the 34 men quit smoking, compared with only one of the 14
women (X2 (1) = 36.60, p< 0.05).
There were no statistically significant differences in median
age or duration of stay between the smokers and non-
smokers (p> 0.05).
There was a significant relationship between the level
of security in which a patient was resident and smoking.
Patients treated on medium secure wards were significantly
more likely to be smokers than those in lower levels of
security (X2 (1) = 4.213, p< 0.05). Only three of the 19
smokers on the medium secure ward gave up smoking,
compared with 12 of the 29 smokers in low secure or
rehabilitation wards, a finding which, though not statistically
significant, is worth noting.
Of the patients who participated in the audit, 46 were
receiving anti-psychotic medication, but there was no
Advances in Mental Health and Intellectual Disabilities Volume 5 Issue 1 January 2011 © Pier Professional Ltd
Smoker on admission
48
Made no attempts to stop
smoking 19
Successfully stopped smoking
15
Still smoking at time of audit
14
Less than 3 attempts to stop
11
3 or more attempts
3
significant relationship between anti-psychotic medication and
smoking status (p> 0.05).
Figure 2, overleaf, details the audit standard compliance,
as reported by both patients and staff.
The disparity between staff and patient reports may be
due partly to the fact that when the audit questions were put
to both smokers and non-smokers, as many non-smokers
reported ‘No’ answers to questions about their awareness
of smoking cessation programmes. Indeed, comparison of
patients who gave up smoking while in the service (N = 15)
with those who did not (N = 33) showed no statistically
significant differences on any of the audit standards (p> 0.05).
Despite the availability of the smoking cessation
programme, 33 patients were still smokers at the time of
the audit. Of this group, 19 had made no attempt to stop
smoking, whereas 14 had attempted to quit. Despite not
giving up completely, this group had significantly reduced
their daily consumption of cigarettes. Before admission, the
mean number of cigarettes smoked each day was 30.65,
which had fallen to 10.95 a day at the time of the audit (Z =
-4.328, p< 0.001).
As part of the audit we recorded patient comments on
smoking and the smoking cessation programmes. Looking
37
An audit of a smoking cessation programme for people with an intellectual disability resident in a forensic unit
Figure 2: Audit standard compliance
100% 100%
89.5%
65.7%
53.8%
41.5%
Provided and Provided Access to
received 1:1 and received information
information group from Primary
sessions Care
specifically at the group of smokers on admission who had
made no attempts to quit, many said that they enjoyed
smoking and didn’t want to give up. Of the 14 patients who
had made attempts to quit yet were unsuccessful, many had
successfully cut down, and credited the smoking routine as
the reason. Looking at the whole sample of smokers, when
asked what had helped them cut down, many demonstrated
awareness of smoking and its effects on health, mentioning
concern about their own health or that of a family member.
Another common theme was the routine of the smoking
timetable. Other factors included willpower, other interests,
nicotine patches, moving to a new setting or a low-stress
environment. When patients were asked specifically for their
views on the smoking timetable, the majority did not express
any opinion, but those who did were evenly split between
those in favour and those against. When patients were
asked about the prospect of a total smoking ban, 18 patients
broadly welcomed the idea, but 13 were against it. Many in
the latter group felt they would not be able to cope.
Discussion
The sample for this audit was drawn from a single forensic
service and it is therefore difficult to generalise the
conclusions, either to secure hospital services for people
with intellectual disabilities, or indeed to the larger group of
people with intellectual disability. The audit is also limited
by the lack of a control group. However, it is one of the
first studies to measure smoking education and cessation
programmes among those treated in forensic learning
disability settings. There are approximately 1800 secure beds
38 Advances in Mental Health and Intellectual Disabilities Volume 5 Issue 1 January 2011 © Pier Professional Ltd
100% 100% 100%
58.5% Staff report
51.7%
Patient report
Access to Access to Aware of
nicotine nicotine smoking time
replacement replacement table
– offered or – received
requested replacement
for people with learning disabilities, spread between the
ten Strategic Health Authorities in England (Alexander et al,
2010), and it would be useful to explore whether other units
have similar experiences.
Smoking – prevalence and associations
The audit indicates that more than 60% of the patients were
smokers at the time of admission. This prevalence figure
is almost double that reported from Tracy and Hosken’s
community sample in 1997 (36%), three times that for the
general population (21%) and rather close to that for general
psychiatry patients (70%) (Jochelson & Majrowski, 2006).
However, roughly a third of the smokers in the service gave up
the habit during admission, reducing the prevalence of smoking
in this group to just over 40% at the time of the audit.
Many of the conventionally accepted associations between
smoking and psychiatric patients, such as non-smokers
becoming smokers while in hospital (Lawn et al, 2002), were
not borne out in this sample. Similarly, neither length of stay
nor being on antipsychotic medication was found to have
a bearing on smoking status. While Rimmer and colleagues
(1995) reported that people with intellectual disabilities living
in less restrictive environments (such as group homes) were
more likely to smoke, we found that patients who were
resident in the less restrictive low secure and rehabilitation
settings were less likely to be smokers than those treated in
medium secure wards. This may reflect different dynamics
within the hospital system and community settings, and once
again it would be useful to see whether these findings are
reflected in other centres of a similar nature.
An audit of a smoking cessation programme for people with an intellectual disability resident in a forensic unit
Smoking intervention programmes
It has been suggested that, although many psychiatric
inpatients would like to give up smoking, rates of cessation
among this population are low (Jochelson & Majrowski,
2006). McGillicuddy et al (2006) reported that many
people with intellectual disabilities want to give up smoking,
and Minihan (1999) suggested that many individuals with
intellectual disabilities indicate a desire to quit after a simple
recommendation to do so by a health practitioner. Despite
this, very few patients with intellectual disability are actually
identified as smokers or screened for smoking by physicians
(Steinberg et al, 2009).
Only one other published study has reported outcomes
from a smoking intervention programme developed for this
population (Tracy & Hosken, 1997). The components of
that programme were large and small group discussions,
short information-giving segments, videos, role playing and
a board game based on smoking education. The course
consisted of a weekly two-hour session over seven weeks.
With regard to post-intervention smoking behaviour, 55% of
Tracy and Hosken’s sample either quit smoking altogether or
significantly reduced their daily number of cigarettes. In our
sample, which was considerably larger, 31% gave up smoking
completely, and the majority of remaining smokers reduced
their daily number of cigarettes significantly, to about a third
of what they had been smoking before admission.
The Tracy & Hosken (1997) study was implemented
in a time-bound manner, while the intervention we
described is one element of an ongoing health-awareness
scheme implemented as part of the patients’ existing
nursing care plans. It is important to note that, despite
the qualitative differences between the two samples
and the interventions implemented, they reported
equally promising results. This suggests that those with
intellectual disabilities are keen to try to give up smoking,
and a significant proportion are successful.
Audit standards and recommendations
This baseline audit enabled us to make a number of
recommendations on how the smoking cessation programme
could be improved. One of the main issues clarified by the
audit was that, although roughly a third of the smokers had
given up the habit, patients were less aware than staff of the
availability of various components of the smoking cessation
programme. It was therefore proposed that an information
package that would provide information on smoking cessation
programmes available in the hospital and from primary care
should be designed for patients. It was also suggested that
smoking-related advice and treatments be incorporated into
the health action plans drawn up by the nursing teams. This
meant that there would be an audit trail, where the patient’s
primary nurse could create an action plan for patients who
are attempting to stop smoking, while documenting and
reviewing progress and related issues each month.
Advances in Mental Health and Intellectual Disabilities Volume 5 Issue 1 January 2011 © Pier Professional Ltd
The smoking ban legislation and the future
The Health Act (2006) ruled that all enclosed public areas
would become smoke-free. Many mental health units therefore
enabled patients to smoke in designated outside areas. Many
secure psychiatric hospitals took this opportunity to execute
complete smoking bans and many more are planning to follow
suit. Such policies are contentious. It has been suggested that
complete bans are ineffective in the long term, as patients
inevitably return to smoking after discharge (Lawn & Pols,
2005), and there is well-documented apprehension among
mental health staff about their implementation, because
adverse patient reactions to ‘no smoking’ rules are expected
(Cormac & McNally, 2008). However, in a recent review of
26 international studies which report on the effectiveness of
smoking bans in inpatient psychiatric settings, it was concluded
that, generally, more problems were anticipated than actually
occurred. There was no increase in aggression, use of
seclusion or use of required medication (Lawn & Pols, 2005).
Jochelson and Majrowski (2006) conducted a survey of staff
attitudes to patient smoking. It was reported that, collectively,
staff members held many attitudes which affected patients’
continued smoking, for example that it was a comfort to
patients who otherwise had ‘nothing else to live for’. Smoking
was also cited as a social activity, and many felt that cigarettes
were useful in controlling and defusing certain situations.
Another argument was that patients were being prevented
from smoking in their ‘home’. Many staff members were
smokers themselves, a factor which can significantly influence
patient smoking behaviour.
Data from the Smoking Toolkit Study (West, 2010)
suggests that the new smoking legislation in England has
helped more smokers to quit than ever before, prevalence
of smoking declining by 5.5% in the nine months post-ban
compared with 1.6% in the nine months before the ban.
Unfortunately, assessing the effect of the new smoking
legislation on our patients’ smoking behaviour was beyond
the scope of a baseline audit of the smoking cessation
programme. The experience was that many of the smokers
in the service were keen to try and stop smoking, and a
significant proportion were successful. Indeed, we endorse the
view of Olivier et al (2007) that a stay in a psychiatric hospital
provides patients with a safe and timely opportunity to quit.
Conclusions
The audit of the smoking cessation programme
showed a statistically significant shift in patients’
smoking status, as 31% of those who were smokers
on admission gave up smoking. Among those who did
not give up completely, the daily number of cigarettes
smoked fell to about one third of what they had been
smoking previously.
There was no suggestion that those on anti-psychotics
or those staying longer in hospital were more likely to
be smokers.
39
An audit of a smoking cessation programme for people with an intellectual disability resident in a forensic unit
Female smokers appeared to be less likely than men to
give up smoking.
There is a disparity between patients and staff in their
perception of the availability of the smoking cessation
programme, patients being less aware than staff.
Patient comments suggest that many of them felt that
the ‘smoking timetables’ were helpful in cutting down
their tobacco consumption. There were mixed views
and anxiety about a total smoking ban.
The findings need to be viewed with caution, as the
study was conducted in a single service and limited by
the lack of a control group.
What do we know already on this topic?
Smoking among those with intellectual disabilities
must be viewed in the context of the wider health
inequalities experienced by this group.
The prevalence of smoking in this group is affected
by the confounding variables of degree of intellectual
disability and place of residence.
One study has reported outcomes from a smoking
intervention tailored specifically to the needs of those
with intellectual disabilities.
What more does this study contribute?
In patients with intellectual disabilities and offending
behaviours resident in a forensic unit, the prevalence
of smoking is higher than in those in the general
population and more comparable to those in general
psychiatric settings.
A smoking education programme tailored to the needs of
those with intellectual disabilities appears to be effective in
aiding people to either cut down or give up smoking.
Acknowledgements
The authors are grateful to Sam Popple, Lisa Tabornar and
Alison Brown for their help in completing the audit.
Address for correspondence
Regi T Alexander
St Johns House
PIC LD Services
Lion Road
Palgrave
Diss
Norfolk IP22 1BA
UK
01379 643334
regialexander@btinternet.com
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