Hospital indicators and inpatient behavior in a psychiatric hospital that implemented the smoking ban

Abstract Objective: to compare hospitalization and discharge indicators, medication costs and patient behavior before and after the implementation of the smoking ban in a psychiatric hospital. Method: ecological, longitudinal and retrospective study carried out in a psychiatric hospital. Secondary data referring to 2142 hospitalizations were collected from medical records. The median test was used to compare the variables before and after the ban. Results: after the implementation of the ban, there was a reduction in bed occupancy rate in male units for mental disorders (from 88.8% to 48.4%) and substance dependence (from 94.4% to 42.8%). There was a reduction in the mean length of hospital stay in the male chemical dependency unit (from 13.5 to 12.6) compared to the female unit (from 14.7 to 19.5). There was a reduction in costs of psychotropic drugs and expectorants, episodes of verbal/physical aggressions and physical/chemical restraints. Conclusion: the smoking ban changed hospital indicators, reduced costs and improved patient behavior, contradicting the myth that it results in hostility. It is hoped that this study will help nurses to review their beliefs related to smoking cessation, as there were positive results for interpersonal relationships and for the management of mental health services.


Introduction
Smoking is a serious public health problem. Its prevalence is estimated to be 15% in the world population and 9.8% in Brazil (1)(2) . In the psychiatric population, the situation is even more concerning: one-third of Americans with mental disorders smoke tobacco and, in Brazil, the prevalence varies from 25% to 60%, depending on the mental health service investigated (2)(3)(4) .
The implementation of Brazilian Law no. 12.546/2011, which prohibits smoking in collective environments (public and private), is a challenge for mental health services, especially psychiatric hospitals, which have a higher prevalence of smokers and treat people with more severe tobacco dependence. In addition, the culture of smoking (using cigarettes as currency), inherited from asylums, is still common in these places (4)(5) .
As a result, there is still resistance to smoking bans in mental health services. Recent studies carried out in Iran and Italy show that professionals are skeptical about the successful implementation of a smoke-free policy in these places (5)(6) . A Brazilian study revealed that the fear that the ban could affect hospital indicators, reducing the number of admissions and increasing discharge on request, for example, is one of the reasons for resistance in psychiatric hospitals, especially in private and philanthropic institutions (7) .
Scholars argue that the smoking ban during psychiatric hospitalization is an opportunity for people with mental disorders to rethink this habit, receive guidance on appropriate strategies for coping with and maintaining abstinence, have their degree of dependence evaluated, and adhere to therapeutic recommendations (8) .
Although it is a challenge, there is scientific evidence of the benefits of smoking cessation for people with mental disorders: increased quality of life; improvement of anxiety and depression; reduction of aggressive behavior; reduction of drug relapse rates; improvement of physical symptoms; and reduced risk of heart disease and cancer (9) .
Another potential benefit is the reduction of medication costs for smokers, considering both clinical and psychotropic drugs, as there is scientific evidence of improvement in psychiatric symptoms. A study carried out in the United Kingdom with 13,846 people with serious mental illness revealed that physical comorbidities and smoking were associated with higher costs with medication and diagnostic and professional tests (10) . Considering this evidence, for the psychiatric population, smoking cessation is an advantage both for those who are no longer exposed to the harmful effects of smoking and for managers and government agencies that deal with health financing, as smoking habits affect the process of service management.
Considering the indispensability of smoking cessation in the psychiatric population, the legal requirement for a smoke-free policy in mental health services, and the smoking ban in these places as an opportunity for psychiatric patients to rethink the habit, this study fills a current gap, as the theme is still not thoroughly investigated in the Brazilian context, which limits the access of healthcare professionals working in mental health services to the knowledge of experiences carried out in the country.
Based on the above, the present study aims to test the hypotheses: 1) The smoking ban affects hospital indicators; 2) The smoking ban reduces aggressive behavior; 3) The smoking ban reduces costs with psychotropic drugs and expectorants.
This study aimed to compare hospitalization and discharge indicators, medication costs and patient behaviors before and after the smoking ban in a psychiatric hospital.

Type of study and period
Ecological, longitudinal, and retrospective study, carried out in 2020 with secondary data obtained from September 2017 to August 2018. The study is classified as ecological because exposure and outcome were obtained from aggregated data (hospital indicators that refer to a group of individuals). It is classified as longitudinal because it compares, over time, groups of individuals hospitalized, before and after the implementation of the smoking ban.
Finally, the study is also retrospective, as the data obtained refers to a period prior to data collection (past data) (11) .

Study setting
The study was carried out in a philanthropic

Population, sample, and selection criteria
The study population is composed of people who were hospitalized in the psychiatric hospital before and after the implementation of the smoking ban. The sample consisted of patients discharged from psychiatric hospitalization between September 2017 and August 2018. Therefore, data referring to 2142 hospitalizations were analyzed.
Inclusion criteria: having been discharged from the hospital between September 2017 and August 2018.
Individuals from the residents unit and those discharged from hospitalizations in the clinical unit were excluded. As the present study is ecological, the identification variables were not analyzed.

Data collection
After approval by the Research Ethics Committee, the IT team and the responsible pharmacy technician were requested to provide the data for the instrument "Hospital Indicators and Medication Costs" (ICM). The data provided referred to all public and private inpatient units, except for the clinical unit.

To fill out the instrument "Identification of Patients'
Behavior and Care Actions recorded in the medical records", the IT technical team was asked to identify patients discharged from psychiatric hospitalizations in

Results
There were 2142 psychiatric admissions from September 2017 to August 2018 in the studied hospital.
Hospital indicators and data obtained from electronic medical records refer to this universe. Table 1 shows a comparison of hospital admission considering two periods: before and after the implementation of the smoking ban.
Oliveira RM, Santos JLF, Furegato ARF.  Due to the significant reduction in hospitalizations in some units, Table 1 compares not only the absolute numbers (hospitalizations and patient-days) but also the bed occupancy rate, to allow comparisons between units. In the female unit, in turn, there was statistical evidence of a reduction in the number of hospitalizations only when the test considered the variables in isolation ( Table 1).

The analysis of the five inpatient units together
showed statistical evidence of a reduction in the mean length of hospital stay after the implementation of the ban.
The separate analysis of the units showed a reduction in the length of stay in male units, with statistical significance only in the substance dependence unit. The female unit, in turn, showed the opposite trend, with an increase in the length of hospital stay ( Table 2). Table 2 shows the comparison of hospital discharge indicators before and after the smoking ban.
(continues on the next page...) Rev. Latino-Am. Enfermagem 2022;30:e3548. The analysis of the hospital discharge indicators showed a reduction in the number of discharges with improvement in the five units, which is in accordance with the reduction in the number of hospitalizations when comparing the two periods ( Table 2).
Although there is no statistical significance, there was an increase in the number of discharges on demand in the private unit and in the male unit for psychiatric disorders, contrary to the trend of the other units, in which there was a reduction in this type of discharge (Table 2).
There is statistical evidence of a reduction in evasion in the male unit for substance dependence, both in the median test considering the variable isolated and in the test with the set of variables. Table 3 compares the costs of psychotropic drugs and expectorants in the six months before the ban and the six months after it.

Discussion
To our knowledge, this is the first Brazilian study to analyze a psychiatric hospital by comparing hospital indicators, medications costs, and behavior of inpatients before and after the implementation of a smoking ban.
The study results are important as they show the    admissions and, consequently, the hospital budget (7) .
From these results, the question that arises is: what can explain the reduction in bed occupancy rates only in male units? It can be inferred that this occurred due to the higher prevalence of smokers among men, as evidenced in other studies (2,4,12) .
As for the length of hospital stay, the only unit with a reduction in this variable was the one intended for the hospitalization of men with disorders related to the use of psychoactive substances (alcohol and illicit drugs).
This result is in line with an American study (n=255) carried out in a psychiatric hospital with a smoking ban, which found that people with substance use disorders have shorter lengths of hospital stay when compared to those with other psychiatric diagnoses (8) .
As shown in American studies, due to the high prevalence of smokers among users of alcohol and other drugs, people with substance use disorders may see cigarettes as an alternative to compensate for the withdrawal from other substances during psychiatric hospitalization. In this sense, the prohibition of smoking in mental health services can be difficult for this public (13)(14) .
A study carried out in the United Kingdom analyzed 4,223 psychiatric hospitalizations and found results that contradict those of the present study regarding the reduction of the length of hospital stay after the implementation of the smoking ban (15) . These differences in results are understandable, since the studies are carried out in countries with different cultures and with different times and approaches to anti-smoking laws.
Despite the reduction in the length of hospital stay in the male unit for substance use disorders, there was also a reduction in discharges on request and evasion in this unit.
This suggests that hospital discharge decisions were made by the interdisciplinary team and not by the inpatients.
These results are important, as the fear of an increase in discharges on request and evasion is one of the main arguments of professionals who are against the smoking ban. This was evidenced in the statements obtained in a qualitative Brazilian study and in two quantitative studies carried out with professionals from Australia and Qatar, in which 93% and 73% of professionals, respectively, used this argument to defend their point of view regarding smoking bans (7,(16)(17) .
This reduction in discharges on request and evasion after the implementation of the smoking ban still raises the question: did users of alcohol and other drugs get some kind of privilege in the psychiatric hospital after the implementation of the smoking ban?
Qualitative research carried out in the same setting as the present study showed that, after the implementation of the smoking ban, inpatients started exchanging belongings (clothes, hygiene products, etc.) and sexual favors for hidden cigarettes (7) . The area where the unit for substance users is located allows them to access the outside world (by jumping over the wall) and return to the hospital before the nursing team notices their absence.
These outings could help them obtain cigarettes outside the hospital and then sell them to people hospitalized in other units.
Likewise, a British study revealed the existence of a trade of objects used for smoking during psychiatric hospitalization, since fights between patients were preceded by theft or disagreement during sales/exchanges of cigarettes and lighters (18) .
Regarding spending on psychotropic drugs and expectorants, the hypothesis that smoking bans favor less spending on these items was confirmed. Although no statistical difference was evidenced, which can be understood by the reduced number of months compared (six months before and six months after the implementation of the ban), it is noted that expenditure on expectorants had an average reduction of 20%.
A Spanish study carried out in a psychiatric inpatient service with 276 patients showed that 48% of smokers presented with cough, 41% with expectoration, and 36% had a diagnosis of chronic bronchitis. Among nonsmokers, the prevalence of these conditions was less than 3% (19) . This result is an example of the physical harm caused by smoking, which is widely reported in the scientific literature and in publications of government bodies (2,9) . Therefore, it is expected that the smoking ban in mental health services leads to a reduction in expenses with expectorants, as smoking cessation is associated with improvement in physical health, including respiratory symptoms.

Scientific evidence obtained in American and Italian
studies addressing the physical harm caused by smoking among people with mental disorders shows that smoking is one of the factors associated with the reduction in the life expectancy of this population and the high prevalence of somatic comorbidities (20)(21) . During the COVID-19 pandemic, European authors revived this discussion, expressing that smoking is an important risk factor for COVID-19 complications in this population (22) .
As for psychotropic medication costs, the amount spent on the antipsychotics oral haloperidol and Oliveira RM, Santos JLF, Furegato ARF. For this reason, smokers usually receive higher dosis of psychotropic drugs when compared to non-smokers.
Furthermore, tobacco increases the metabolism of psychotropic drugs, reducing their concentration in the bloodstream and consequently requiring higher dosis to reach the therapeutic effect (23)(24)(25) . This scenario explains the higher costs with psychotropic drugs when smoking is allowed in a mental health service, and the decrease in costs when smoking is prohibited. Studies conducted in Australia and Qatar show that the main argument against the smoking ban is the belief that patients will become more agitated and aggressive towards the team due to nicotine withdrawal (nine out of 10 professionals have these fears) (16)(17) . The confirmation of the hypothesis of a decrease in episodes of aggression with the implementation of the smoking ban provides answers to the concerns of the professionals. It is interesting to note that studies carried out in Qatar and England show that professionals who received training in the approach to smoking in the psychiatric population were more in favor of the smoking ban than those who did not, demonstrating the potential of continuing education (16,26) .
A British study carried out in 12 psychiatric inpatient wards found that, after the implementation of smokefree policies, there was a decrease in the frequency of incidents such as physical violence against staff (from 58.4% to 20%) and verbal aggression (from 25% to 20%). However, conflicts between patients due to the concealment of cigarettes and negotiations between them increased from 2% to 10% (27) . Likewise, a second British study revealed a 39% reduction in physical aggression after the implementation of the smoking ban, even after controlling for confounding variables (gender, age, psychotic disorders, and judicial hospitalization) (28) . Two systematic literature reviews confirmed that smoking bans are not associated with increased physical and verbal aggression in mental health services. These reviews included studies carried out in Australia, Canada, the United States, and England (29)(30) .

A review of the scientific literature published in
Cochrane found no evidence that smoking cessation worsens the mental health of psychiatric patients. In addition, there is evidence that nicotine withdrawal is associated with an improvement in anxiety and depression (31) . drug costs, and patient behavior before and after the implementation of the smoking ban, the present study offers nurses a new perspective on the anti-smoking law.
By providing scientific evidence that the implementation of the ban is associated with a reduction in verbal and physical aggression and in physical and chemical restraints, the present study contradicts the myth that the smoking ban leads to an increase in aggressive behavior.