BMJ  2006;333:407-408 (26 August), doi:10.1136/bmj.38944.382106.BE

Editorial

Exempting mental health units from smoke-free laws

Would worsen health inequalities for people with mental health problems

An estimated five million deaths worldwide will occur from tobacco consumption in 2006. This figure is projected to reach 10 million deaths annually by 2020.¹ Smoking is also the largest single cause of preventable illness and premature death in the United Kingdom, with 106 000 people dying of smoking related diseases in 2002² and more than 10 000 dying each year as a result of passive smoking.³ The Health Act 2006 will make all enclosed public and work places in England and Wales smoke-free environments and represents an important step forward for public health.

Consultation on exemptions to the Health Act continues until October 2006. Among proposed exclusions are mental health units that provide long term accommodation (defined as not less than six months) as well as prisons, care homes, and hospices. We applaud the government for not exempting mental health settings in their entirety as has happened in some other countries that have introduced smoke-free legislation. Making mental health units smoke free ensures improved physical health of mental health patients and protection of staff and patients from the effects of environmental tobacco smoke.

The prevalence of smoking is high among people with mental health problems. Nearly three quarters of people with schizophrenia, affective psychosis, and other mental health disorders who live in mental health settings are smokers,⁴ and they are more likely to be heavier and more dependent smokers than the general population.⁵ The prevalence of smoking is also significantly higher among people with diagnosed mental health problems who live in private households than in those without such a diagnosis, and a clear relation exists between the prevalence of smoking and the number and severity of depressive or anxiety symptoms.⁶

The consequence of these higher levels of smoking is a substantially greater risk of premature death from smoking related diseases than is seen in the general population.⁵ In a study from Finland, people with schizophrenia had an almost 10-fold greater risk of death from respiratory disease compared with the general population.⁷ The high levels of smoking among people with serious mental illness, combined with the fact that around one in two smokers dies prematurely,⁸ mean that the death toll from smoking far outweighs the 10% lifetime risk of suicide. Moreover, people with mental illness already experience high levels of social exclusion and health inequality, which are exacerbated by smoking.⁹ Heavy passive smoking is also associated with a 50-60% increased risk of coronary heart disease.¹⁰

Nicotine dependence fulfils the core criteria for mental disorder. It is therefore the most prevalent and deadly of all psychiatric disorders, but it is frequently neglected by mental health professions. Surveys in the UK have shown that around half of smokers with mental health problems would like to stop smoking, but they are less likely than the general population to be offered health promotion interventions such as smoking cessation.⁵ Smoking cessation treatments are extremely cost effective at reducing ill health and pro-longing life. Guidance and nationwide stop smoking services are available to health professionals who are trying to help patients with mental health problems stop smoking.¹¹

Arguments for excluding mental health settings from the new smoke-free legislation are that they are places of residence and that some patients are detained under the Mental Health Act. However, health and safety legislation places a duty on NHS employers to protect staff and patients from exposure to environmental tobacco smoke. Infringement of human rights, particularly for detained patients, is also cited as a reason to exempt mental health settings, but the Human Rights Act 1998 allows an individual choice only if that does not endanger others. Furthermore, this argument is not applied to other forms of drug misuse, and people are not allowed to drink alcohol or use illegal drugs in mental health units.

Last December, the Commons health select committee stated that "high levels of smoking in psychiatric institutions are not inevitable."¹² Smoke-free policies have succeeded in mental health settings¹³ in the UK, United States, Australia, and Canada¹⁴;no increases have been seen in aggression, discharge against medical advice, or use of "as needed drugs" in 90% of the sites that have imposed total bans on smoking.¹⁴ Such bans have caused fewer problems than anticipated, and policies applied in a consistent way to all patients were more effective than selective bans. Consistency, coordination, and full administrative support were essential for successful implementation of such bans.

The health select committee has proposed that psychiatric institutions in England and Wales should not be exempt from the Health Act 2006.¹² We strongly endorse this proposal and suggest that all mental health settings should introduce complete smoke-free policies. These policies should be introduced in a flexible and pragmatic way, and free and easily accessible support and treatment should be available for patients to stop smoking and manage withdrawal. A monitoring process should also be included to ensure appropriate transition.

The proposal to exempt mental health units where patients stay for more than six months appears arbitrary, will make enforcement difficult, and will exempt most NHS mental health units, since in 2006 almost half of psychiatric inpatients stayed longer than six months.¹⁵ Exemption from the Health Act will exclude mental health patients from mainstream health improvement strategies and exacerbate the inequality they already experience. These concerns also apply to other proposed exemptions such as those for prisons,¹³ especially as mental health problems and substance abuse are highly prevalent among prisoners.

Roehampton Community Mental Health Trust, Queen Mary's Hospital, London SW15 5PN
(jonathan_campion{at}yahoo.co.uk)

Department of Epidemiology and Public Health, University College London, London WC1E 6BT

St George's, University of London, London SW17 0RE

---

Competing interests: None declared.

References

1. World Health Organization. Tobacco: deadly in any form or disguise. Geneva: WHO, 2006. www.who.int/tobacco/wntd (last accessed 15 Aug 2006).
2. Department of Health. Smoke-free premises and vehicles. Consultation on proposed regulations to be made under the powers in the Health Bill, 2006. London: DoH, 2006.
3. Jamrozik, K. Estimate of deaths attributable to passive smoking among UK adults: database analysis. BMJ 2005;330: 812.[Abstract/Free Full Text]
4. Meltzer H, Gill B, Hinds K, Petticrew M. Economic activity and social functioning of residents with psychiatric disorders. OPCS surveys of psychiatric morbidity in Great Britain. Report No. 6. London: Stationery Office, 1996.
5. McNeill A. Smoking and patients with mental health problems. London: Health Development Agency, 2004.
6. Coultard M, Farrell M, Singleton N, Meltzer H. Tobacco, alcohol and drug use and mental health. London: Stationery Office, 2000.
7. Joukamaa M, Heliovaara M, Knekt P, Aromaa A, Raitasalo R, Lehtinen V. Mental disorders and cause-specific mortality. Br J Psychiatry 2001;179: 498-502.[Abstract/Free Full Text]
8. Doll R, Peto R, Boreham J, Sutherland I. Mortality in relation to smoking: 50 years' observation on male British doctors. BMJ 2004;328: 745.
9. Office of the Deputy Prime Minister. Mental health and social exclusion: social exclusion unit report. London: ODPM, 2004.
10. Whincup PH, Gilg JA, Emberson JR, Jarvis MJ, Feyerabend C, Bryant A, et al. Passive smoking and risk of coronary heart disease and stroke: a prospective study with cotinine measurement. BMJ 2004;329: 200-5.[Abstract/Free Full Text]
11. McNeill A, Owen L. Guidance for smoke-free hospital trusts. London: Health Development Agency, 2005.
12. House of Commons health select committee. Smoking in public places. First report of session 2005-6. London: House of Commons, December 2005. http://www.publications.parliament.uk/pa/cm200506/cmselect/cmhealth/485/485.pdf (last accessed 15 Aug 2006).
13. Tobacco Advisory Group of the Royal College of Physicians. Going smoke-free. The medical case for clean air in the home, at work and in public places. London: RCP, July 2005.
14. Lawn S, Pols R. Smoking bans in psychiatric settings? A review of the research. Aust N Z J Psychiatry 2005;39: 866-85.[CrossRef][ISI][Medline]
15. Mental Health Act Commission. Response to the Department of Health smoke-free regulations consultation, 10 August 2006. Published as Annex C of the MHAC Policy Briefing for Commissioners, policy briefing 14. www.mhac.org.uk/Pages/policybriefings.html (last accessed 17 Aug 2006).

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