Mirrabrook: A Truly Smoke Free Mental Health Inpatient Unit

Published 29 May 2017. Last updated 8 April 2021.

Mirrabrook Mental Health Unit introduced a new policy to help nicotine-dependent consumers quit smoking during their inpatient stay. It was supported by staff training, Nicotine Replacement Therapy (NRT) and carbon monoxide monitoring.


To eliminate the unofficial practice of smoking leave in Mirrabrook Mental Health Unit.


  • Reduces the rate of smoking in mental health consumers.
  • Maintains compliance with the NSW Health ‘Patient Leave from Acute Inpatient Unit’ policy.
  • Supports the gradual return of mental health consumers to the community.
  • Enhances consumer care and reduces the risk of smoking-related illnesses.
  • Provides education to nurses so they can help consumers quit smoking.
  • Supports staff morale, satisfaction, health and wellbeing.


Smoking is associated with the greatest burden of health and disability in Australia. It is estimated that approximately half of all long-term smokers will die from smoking-related causes1. While the average smoking rate in Australia is around 22%, it is significantly higher among people with a mental illness, at between 70-80%. People with a mental illness also smoke more cigarettes per day than the rest of the population2.

Following the introduction of the NSW Health Smoke Free Health Service Policy in 20083, an unofficial leave system had crept into practice within the Mirrabrook Mental Health Unit at Shellharbour Hospital, where nearly all nicotine-dependent patients were given unescorted leave to smoke. This ‘smoking leave’ as it was known, began to create issues at all levels of the organisation, which impacted the safety and care of both staff and patients. It also added to workload of nursing staff and impacted their therapeutic relationship with consumers.

Research shows that people who smoke metabolise antipsychotic medications faster than non-smoking patients4. As a result, allowing consumers smoking leave where they would often smoke five or six cigarettes in a 15-minute period, adversely impacted their treatment and recovery. It also heightened nicotine dependence and created peaks and troughs of nicotine withdrawal, making the smoker even less likely to quit and leading to higher levels of agitation and aggression in the unit5.


In January 2016, the team at Mirrabrook made the decision to ban smoking leave and revert back to the true definition of leave, which is designed to support the gradual return of mental health consumers to the community. Prior to implementation, consultation with consumer peer workers, district Quit coordinators and health promotion officers was undertaken. Training was provided to staff, including a three-day smoking cessation workshop, a one-day nicotine addiction workshop and NRT education sessions. Notices were placed around the unit and to all relevant stakeholders, advising them of the change.

Once the project was implemented, there were no exceptions to the new policy. Carbon monoxide monitors were used during the admission process and again several times during the withdrawal process, to show consumers the positive effects of quitting to their health. Nurses ensured there was enough NRT available for consumers and provided boiled lollies to supplement the effects of NRT . Medication charts were rewritten to include NRT and additional activities were made available to distract consumers from their withdrawal.

Project status

Sustained – The project has been implemented and is sustained in standard business.

Key dates

January 2016 – August 2016

Implementation site

Mirrabrook Mental Health Unit, Shellharbour Hospital, ISLHD


The project was supported by the Illawarra Shoalhaven Drug and Alcohol Services Quit Coordinator and the ISLHD District Health Promotions Officer, who provided invaluable education, training and support to staff and consumers. The Shellharbour Hospital Pharmacy also helped meet NRT needs and provided usage data for analysis.


  • A truly smoke free environment was established at Mirrabrook three months following implementation, with a full evaluation undertaken in August 2016.
  • In the pre-implementation period from August 2015 to January 2016, smoking-related aggression caused an average of 2.7 incidents per month. In the post-implementation period from February 2016 to July 2016, there were 1.3 incidents per month – a 50% reduction in smoking-related aggression incidents.
  • Incidents of smoking in the unit (i.e. smuggling of contraband) decreased from seven in June 2015 to one in June 2016.
  • Staff and consumer surveys were conducted two months post implementation, with results showing mostly positive feedback in relation to the project.
  • An activity follow (where a staff member follows a nurse on the floor and records their activities) was conducted in July 2015 and February 2016. Results showed an increase in time spent on direct care to consumers, from 26% in July 2015 to 91% in February 2016.
  • The next phase of the project will be to focus on referring consumers to the NSW Quitline during the discharge process, to ensure they remain smoke free in the community.
  • It is anticipated that a survey will be sent to discharged consumers who identify as nicotine dependent during their admission, to see whether abstaining from nicotine during their stay has motivated them to remain smoke free.
  • This project will be rolled out across the remaining six inpatient units within the ISLHD Mental Health Service, starting with the Eloura Unit at Shellharbour Hospital in 2017.

Lessons learnt

  • While the project was initiated and driven by the nursing team, it quickly gained the support of medical and senior management teams. Collaboration between these teams was integral to its success.
  • There was a great deal of anxiety and fear among consumers when the change was announced. The team used open communication and respect with consumers to help them adapt to the change.


  1. NSW Department of Health. Tobacco Action Plan 2005-2009. North Sydney: NSW Health; 2005.
  2. Benowitz NL. Nicotine safety and toxicity. New York: Oxford University Press; 1998.
  3. NSW Department of Health. Managing Nicotine Dependence : A Guide For NSW Health Staff. North Sydney: NSW Health; 2015.
  4. Lyon E. A review of the effects of nicotine on schizophrenia and antipsychotic medications. Psychiatric Services 1999; 50(10): 1346-1350.
  5. Lawn S, Campion J. Achieving smoke-free mental health services: lessons from the past decade of implementation research. International Journal of Environmental Research and Public Health 2013; 10(9): 4224-4244.


Robyn Macgregor
Nursing Unit Manager, Mirrabrook Mental Health Unit
Shellharbour Hospital
Illawarra Shoalhaven Local Health District
Phone: 02 4295 2545


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