In this short brief, Jim O’Dwyer, Senior Consultant at AEGIS Protective Services, explores whether early identification of smokers and timely NRT support could help reduce agitation and escalation in NHS Emergency Departments.

Identifying smokers early

Could a Simple Triage Question Reduce Violence in Emergency Departments?

Violence and aggression in Emergency Departments remain a persistent challenge across the NHS. Staff working in A&E environments regularly encounter patients who are distressed, frightened, intoxicated, in pain, or frustrated by long waiting times — all well-recognised triggers for behavioural escalation.

However, it would appear that one potential trigger isn’t always considered during early patient assessment: nicotine withdrawal.

Many NHS Trusts undertake some form of violence and aggression risk assessment when patients present to Emergency Departments. These assessments typically consider factors such as intoxication, mental health crisis, previous history of aggression, or signs of escalating distress.

Yet, anecdotally, smoking status is not commonly identified as part of early violence risk screening.

This may represent a missed opportunity for prevention.

Nicotine withdrawal can increase agitation

Nicotine dependence is powerful. Withdrawal symptoms can begin within a short period after a smoker stops using tobacco and commonly include:

  • irritability
  • agitation
  • restlessness
  • anxiety
  • difficulty concentrating

Research has shown that nicotine withdrawal can significantly increase irritability and frustration. Studies examining smoking cessation and nicotine withdrawal have consistently demonstrated increases in anger and aggression-related mood states during withdrawal periods.

For example, research published in the journal Psychopharmacology found that nicotine deprivation significantly increased irritability and aggressive responding in dependent smokers (Denson et al., 2011).

Similarly, studies of hospitalised smokers have found that nicotine withdrawal symptoms frequently develop during inpatient stays and can contribute to patient distress and agitation.

In the context of a busy Emergency Department — where patients may already be anxious, uncomfortable, or waiting for extended periods — these symptoms can compound existing stress.

Nicotine withdrawal alone may not cause violence, but it can lower frustration tolerance and increase behavioural volatility in already pressured environments.

Smoke-free hospitals create a predictable challenge

The NHS rightly operates smoke-free hospital environments. Patients are generally unable to leave clinical areas to smoke, particularly when undergoing assessment or treatment.

However, for regular smokers this can create an immediate withdrawal situation that staff may not anticipate.

In many cases, staff only become aware of a patient’s smoking status after agitation has already begun, when the individual asks to leave the department to smoke.

At that stage, staff may be managing escalation rather than preventing it.

Early identification allows supportive intervention

A simple triage question — “Are you a smoker?” — could allow staff to identify patients who may struggle to abstain from nicotine during their time in hospital.

Early identification would allow clinicians to consider supportive measures such as Nicotine Replacement Therapy (NRT), including:

  • nicotine patches
  • nicotine gum or lozenges
  • nicotine inhalators
  • nicotine oral sprays

These options are widely used in hospital smoking cessation programmes and can significantly reduce withdrawal symptoms.

In some settings, regulated vaping products are also used as harm-reduction tools to support nicotine management in smoke-free environments.

Providing support early may help patients manage withdrawal symptoms while remaining within smoke-free hospital policies.

A preventative violence-reduction opportunity

The NHS Violence Prevention and Reduction Standard emphasises identifying triggers and implementing preventative measures wherever possible.

From this perspective, recognising nicotine withdrawal as a potential agitation trigger fits squarely within a preventative approach to violence reduction.

Supporting patients to manage nicotine dependence while receiving care may not only improve patient comfort but could also reduce behavioural flashpoints for frontline staff.

A small question with potentially meaningful impact

Emergency Departments are complex, high-pressure environments, and no single intervention will eliminate violence against healthcare staff.

However, small preventative measures that address predictable behavioural triggers can make a difference.

Identifying smokers early and offering support to manage nicotine withdrawal may represent a simple and practical step towards safer Emergency Departments for both staff and patients.

Is that happening now at your NHS Trust?

References:

Denson, T. F., et al. (2011). Nicotine deprivation increases aggression in smokers. Psychopharmacology.

Hughes, J. R. (2007). Effects of abstinence from tobacco: valid symptoms and time course. Nicotine & Tobacco Research.

NHS England. Violence Prevention and Reduction Standard.

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