Exempting mental health units from smoke-free laws
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On 1st February 2006, smoking was banned in NHS Argyll & Clyde
premises and grounds, almost 2 months before the implementation of new
legislation creating smoke-free enclosed public places throughout Scotland
(1).
Mental Health services in Renfrewshire decided not to "opt out" of
the ban on smoking that applied to the rest of the NHS (with the exception
of some psychiatric long stay wards). As far as we know, we were therefore
the first mental health service in Scotland, and possibly in the UK, to
implement such a smoking ban.
There was considerable resistance to this policy, and the
correspondence in these pages reflects opinions expressed to us at that
time. One senior manager wryly commented "I have never known so many
doctors trying to get smoking *into* hospitals".
Three facts determined our policy:
1. Environmental tobacco smoke is harmful to all who inhale it, and
we have a clear responsibility to protect patients, staff and visitors
from this risk
2. Ventilation systems and separate smoking areas are not effective
in removing tobacco smoke from buildings (2)
3. Partial smoking bans are ineffective (3)
We also noted that “almost half of smokers' most recent attempts to
stop involved no previous planning, and unplanned quit attempts were more
likely than planned ones to be successful" (4).
This policy has widely been accepted, at least for the prohibition of
smoking within buildings. Clinicians and managers might be interested to
know that (contrary to some peoples’ expectations):
• There hasn’t been a single assault on staff in relation to smoking
cessation, despite widespread (and stigmatising) fears of violence
prompted by nicotine withdrawal
• People don’t leave inpatient treatment en masse because they can’t
smoke
• there has been a five-fold increase in take-up of nicotine
replacement therapy for inpatients
• Our wards smell fresh, and our service users are far more active
both physically and socially than they were previously. Staff no longer
return home from work to find their clothes smelling of smoke
Smoking has become a damagingly ingrained part of "asylum culture".
We need to ensure that services do not underestimate the capacity of
service users to stop smoking, because of a stigmatising presumption that
“psychiatric patients” are different in this regard to the rest of us. We
are proud that service users and staff in Renfrewshire are in the vanguard
of a major progressive change in Scottish society, rather than being
dragged behind it.
The problem for mental health services isn’t just exposure to passive
smoking, but the more insidious “passivity smoking”- the stigmatising
presumption that nothing can be done to prevent it. Our experience
confirms findings in the international literature: smoking cessation can
be implemented in mental health units. In fact, doing so was much easier
to achieve than many of us had expected.
(1) http://www.clearingtheairscotland.com/background/index.html
(2) Leavell et al. BMJ 2006; 332 (7535): 227
(3) Tobacco Control 2004;13:180-185
(4) BMJ 2006; 332: 458-460
Competing interests:
None declared
Competing interests: No competing interests
Editor – I believe that Campion et al (1) are wrong to oppose the
exemption of mental health units from smoke – free laws.
We know that giving up smoking is difficult and that even patients
who are motivated to stop, and are supported by trained stop smoking
counselors and medication have
relatively low success rates. (2)
As a G.P. I offer advice on smoking cessation to all my patients but
I would never try to force someone who was mentally ill to stop smoking –
I would offer them the opportunity to give up smoking when they were
better.
Smokers with a history of major depression have been found to be at
increased risk of developing a new episode of depression for the next six
months after quitting (3) so surely an enforced abstinence during a
hospital admission cannot always be in the patient’s best interests?
People with severe mental illness suffer in a way that is beyond the
understanding of most of us and their priorities for the future may be
different to ours. Psychiatric admission may be stigmatizing and traumatic
and being forced to stop smoking could compound our patient’s distress
when they most need our help and understanding.
We can’t force patients with chronic obstructive pulmonary disease or
cerebrovascular disease to stop smoking so why should we impose this on
one of our most disempowered and vulnerable groups?
I agree that health workers also have rights but doctors and nurses
choose their profession and all occupations have risks. Our patients,
however, do not choose to have their lives blown apart by mental illness
or to be held under a section of the mental health act.
How do mental health service users feel about these issues? It would
be interesting to hear their views.
1.Campion J, McNeill A, Checinski K Exempting mental health units
from smoke-free laws. BMJ volume 333 26 August 2006
2.Sharma Sat, Lertzman M Nicotine Addiction e medicine.com updated
july 12 2006
3.Glassman AH , Lino SC, Fay Stetner MS et al. Smoking cessation and
the course of major depression : a follow up study. Lancet 2001 ; 357:
1929 - 1932
Competing interests:
None declared
Competing interests: No competing interests
Co-workers in the mental health section here at Royal Brisbane and
Women’s Hospital[RBWH] tell me they have, like the whole campus, gone
smoke free since the directive to do so came into “force” – June 30 2006.
It’s a good thing. The focus should be on the needs of “breathers”, who
should not be referred to as “non-smokers”, since the lesser thing should
not describe the better thing. Nicotine patches are being used
effectively, as near as I can tell.
Rejects from the campus, in the form of "non-patchers", some with IV
poles, can occasionally be seen getting booked as they stray from the
pavement surrounding the campus, back to within the official boundaries.
It's nice to see the area with benches under the trees available
again to breathers.
Competing interests:
None declared
Competing interests: No competing interests
I was very pleased to read Campion et al (2006) as the first article
I found that considers the issues of smoking cessation, long-term
hospitalization and the Mental Health Act. Some clarification is
necessary, though, adding to the very cogent and comprehensive responses
from other esteemed colleagues. I depart from a position as Nurses Manager
in a large psychiatric institution where approximately 180 patients with
chronic and enduring mental illness reside under the Mental Health Act and
at the discretion of the Mental Health Review Tribunal.
The NSW Health Policy Directive PO2005_375 [1] was welcomed and
supported with open arms and this organization began looking at ways to
facilitate smoking cessation amongst all the resident population.
Overarching the smoking cessation plans is the Occupational Health and
Safety requirement to provide a smoke-free environment and prevent
exposure to passive smoking for those staff and patients who do not smoke.
This hospital took the innovative stance of promoting and
implementing smoke cessation practices across all 8 units (approximately
180 medium and long-stay patients) of which four are locked. Units kept
documentary evidence of each patient’s smoking status and updated it
regularly demonstrating a significant decrease in smoking within the
chronic long-term population. There was however no data available
demonstrating any challenges, risks, or misadventures resulting from
neither the reduction nor the sudden cessation of smoking. All patients
whose smoking habit was suddenly ceased on the grounds of severe physical
impairment caused or exacerbated by smoking were reported as adjusting
over time. Some were prescribed NRT patches. Overall the program was
running very well and staff felt valued and useful in their caring role to
ensure the overall health and wellbeing of this population.
When I first started working here after 20 years in community care
and crisis work, I became aware of smoking cessation practices that I
found rather puzzling. Amongst these were the benevolent control of
patient owned cigarettes without an assessment of that patient’s capacity
to care for his/her own; a non-negotiable reduction to 15 cigarettes per
day distributed at regular times, one-by-one; no assessment of dependence
and withdrawal; no regular or consistent treatment of nicotine dependence;
the restriction of smoking to a narrow time span over the day starting
after breakfast; the withdrawal of cigarettes unless patients went to
programs; the cutting of cigarettes by 1/3; the offering of PRN medication
to patients who wanted a cigarette outside of regular times; the transfer
of a small number of highly resistive patients with severe (lethal) smoke
related conditions to locked units; and in a small number of unfortunate
cases the restraining, sedating and secluding of patients whose
determination to control their own choice (and right) to smoke led to
extreme anger and confrontation with staff.
The response sent by Faouzi Dib Alam [Exempting mental health units
from smoke-free laws should no longer be ignored, 31st August 2006]
summarises the current literature on the effect of smoking bans: they have
had insignificant effects on the functioning of units; created minor
management difficulties; there were no major behavioural disruptions; and
did not significantly affect the severity or improvement of symptoms.
However, no research has been conducted that measures a relationship
between sudden cessation and levels of distress; feelings of powerlessness
and intimidation; increased psychotic phenomena, depression or anxiety;
requests for PRN medication (and/or offer from staff); patient experiences
of stigma and discrimination; etc. The vulnerability to imposed practices
by patient’s who have no choice in where they live and seldom have a voice
in what happens to them.
It is quite common for staff to interpret withdrawal symptoms as
psychotic symptoms and treat them as such [2]. The association between
hostility, dependence and withdrawal is clear [3-5] and aggression is
recognized by patients and staff as a consequence of limit setting, rules
and “controlling” measures and attitudes. [2,6]. The response by T.
Everett Julyan [Exempt patients from smoking bans when acutely mentally
unwell, 29th August 2006) is more to the point. Is this the way we would
want to be treated? Would we impose these requirements on the many staff
who smoke on campus (who smoke at all)? We have accepted THC (delta-9
tetrahydrocannabinol) as a therapeutic drug in cancer pain and glaucoma.
We have learned a lot from the Prohibition days (and we know that today’s
drinking laws have only taken alcohol to the homes). We allow palliative
care patients to smoke and alcoholics to drive. Cigarettes, alcohol and
junk food are supported by the government, are legal, and provide a hefty
financial return.
The health cost of smoking is enormous, no doubt. But the question
begs: “What is driving us with people with mental illness?”. I will risk
saying that it is a puritanical “do good” position that assumes people
with a mental illness are not capable of looking after themselves and make
choices “a reasonable person would make”; the view that psychiatry is
responsible for the “whole” of the person with mental illness; that when
under the Mental Health Act the person “has no rights”. However, people in
the middle of a psychotic episode may be able to make decisions and give
consent; reasonable people can and do make terrible decisions (smoke,
drink, junk food, gamble …) and often give doubtful consent; and the
Mental Health Act does not allow for decisions that are not related to
treatment and containment of mental illness. If we were to consider
smoking cessation as a medical intervention it would have to be an
emergency before it would be approved by the Mental Health Review Tribunal
or a guardian would need to be appointed.
At this hospital we have considered all these questions, issues and
ethical dilemmas. We have acknowledged that people with a mental illness
have the same rights to success and failure as anyone else. We are now in
the process of implementing a smoking cessation program that considers two
priorities: protecting people from passive smoking and assessing
readiness, voluntariness and informed consent to quit. We see smoking
cessation with this vulnerable group as a medical intervention that
requires care and close monitoring and we are committed to considering
possible discharge plan and sustainability.
There is no “them” and “us” until the legislation applies to ALL
residential settings with all kinds of people, vulnerable or not,
including our own homes as this is where our long-term patients are. When
smoking becomes illegal total bans will make sense.
[1] NSW Health (2005) Smoke free workplace policy – progression of
the NSW Health, PD2005_375
[2] Duxbury, J. (2002) “An evaluation of staff and patient views of and
strategies employed to manage inpatient aggression and violence on one
mental health unit: a pluralistic design,” Journal of Psychiatric and
Mental Health Nursing, 9,325-337
[3] Fallon, J.H., Keator, D.B., Mbogori, J. and Potkin, S.G. (2004)
“Hostility differentiates the brain metabolic effects of nicotine,”
Cognitive Brain Research, 18(2),142-148
[4] File, S.E., Fluck, E. and Leahy, A. (2001) “Nicotine has calming
effects on stress-induced mood changes in females, but enhances aggressive
mood in males,” International Journal of Neuropsychopharmacology, 4(4),371
-376
[5] Cherek, D.R., Bennett, R.H. and Grabowski, J. (1991) Human aggressive
responding during acute abstinence: effects of nicotine and placebo gum,”
Psychopharmacology, 104(3),317-322
[6] Lawn, S. and Pols, R. (2003) “Nicotine withdrawal: pathway to
aggression and assault in the locked psychiatric ward?” Australasian
Psychiatry, 11(2),199-203
Competing interests:
This response is my personal opinion
Competing interests: No competing interests
In my experience, making smoking areas on inpatient psychiatric units
unattractive to discourage smoking would be ineffective.
I worked on a major mental health crisis ward in Florida for 4 years. The
smoking area was 2m x 4m furnished with rejected stained chairs and tables
with bare concrete on 3 walls. The fourth side was a coarse metal screen
since this smoking area was outside and open to the Florida heat, humidity
and mosquitos. It was a very unpleasant place to be. It was also the
busiest place on the ward and some patients would spend all their free
time there from 5am til midnight. When we had a high census, you could
smell tobacco smoke throughout the unit with all the doors closed.
Competing interests:
None declared
Competing interests: No competing interests
Editor,
Campion, McNeill & Chencinski raise their concerns about further worsening of health inequalities for people with mental health problems if smoke-free laws are exempted in mental health units (1). However, the relationship between smoking ban and health equality is not a straight forward one and there are a number of issues which need to be considered.
Heavy smoking is related to a perception of powerlessness and futility in the daily lives (2) and these are common experiences among individuals with mental health problems. Tobacco is viewed as a “chemical comforter” helping them to cope and maybe one of the ways to reduce the possible distress from the symptoms. Hospitalisation is already reinforcing the sense of powerlessness, especially for those detained under the Mental Health Act. Smoking ban in in-patient units, particularly in acute wards, is likely to exaggerate this feeling. There is a possibility that patients refuse to come to hospital informally because of the smoking ban, even in-patient treatment is the best option for them. As a result of this, patients may need to be detained under the Mental Health Act.
Psychiatric treatment has changed dramatically in the past decades, with an increased emphasis on treatment in the community and the view of service users. One of the reasons for this shift is to allow individuals with mental health problems to be managed in a less restrictive environment. This has shown to improve patients’ satisfaction (3). Without doubt, in-patient psychiatric treatment is still needed for more disturbed patients. Even so, these patients should be managed in an environment with minimal restriction if possible. Complete smoking ban in psychiatric units instead of providing alternative ways (e.g. well-ventilated smoking room) can be viewed as coercion (4) and possibly counter-therapeutic.
Even complete smoking ban in psychiatric units is endorsed, the attitude of staff in psychiatric unit is the key for successful implementation. A recent survey conducted in the UK has reported that nearly one in three psychiatric staff was against smoking ban in psychiatric settings (5). Nurses who felt mandated to enforce smoking bans believed this activity disrupted their relationships with patients and viewed tobacco control as a burden, even they clearly demonstrated knowledge of health consequences related to tobacco use (6).
Present evidence also suggests that most of the patients resumed smoking after they were discharged from smoke-free psychiatric unit (7). One of the aims of smoke-free units is to encourage cessation. In order to achieve this goal, a more structured longer term intervention should be available. The NICE recommends brief intervention for smokers (8) in a recently published public health intervention guidance but it is still too early to know how well the guideline is followed, especially among individuals with mental health problems.
Personally I do not smoke and I am more than happy to work in a smoke-free environment. However, with the current situation, complete smoking ban is likely to cause more problems rather than helping our patients to give up this addiction. Most researches focus on the pharmacological aspects of smoking in those with mental health problems. Ethnographic study exploring the meaning of this smoking subculture in individuals with psychiatric disorders may help to identify more suitable interventions for this group.
References
(1) Campion J, McNeill A, Checinski K. Exempting mental health units from smoke-free laws. BMJ 2006; 333: 407-408.
(2) Helman C. Culture, Health and Illness. London: Butterworth Heinemann, 2000.
(3) Johnson S, Nolan F, Pilling S, Sandor A, Hoult J, McKenzie N, White I, Thompson M, Bebbington P. Randomised controlled trial of acute mental health care by a crisis resolution team: the north Islington crisis study. BMJ 2005; 331: 559.
(4) House of Commons health select committee. Smoking in public places. First report of session 2005-6. London: House of Commons, December 2005.
(5) McNally L, Oyefeso A, Annan J, Perryman K, Bloor R, Freeman S, Wain B, Andrews H, Grimmer M, Crisp A, Oyebode D, Ghodse A. A survey of staff attitudes to smoking-related policy and intervention in psychiatric and general health care settings. Journal of Public Health 2006; 28: 192-196.
(6) Schultz A, Bottorff J, Johnson J. An ethnographic study of tobacco control in hospital settings. Tobacco Control 2006; 15: 317-322.
(7) Jonas J, Eagle J. Smoking patterns among patients discharged from a smoke-free in-patient unit. Hospital and Community Psychiatry 1991; 42: 636-637.
(8) National Institute for Health and Clinical Excellence (NICE). Brief interventions and referral for smoking cessation in primary care and other settings. London: NICE, 2006.
Competing interests:
None declared
Competing interests: No competing interests
Campion et al (Editorial 26 August) raise some important points about
detained patients and smoking, but miss a fundamental one. Patients
detained under the Mental Health Act cannot go home to smoke as everyone
else will be able to under new legislation. Therefore a smoking ban means
that they will have no access to tobacco at all, unlike the rest of the
population. However beneficial, this is surely unfair.
If it is argued that detained patients should be treated in this
manner then fairness demands that access to tobacco should be banned for
all. On health grounds this is the logical position, not the position
suggested in the editorial; the total banning of smoking in psychiatric
institutions. There can then be a debate about whether this is acceptable
in terms of governmental interference with personal freedom.
In making this argument for a different view I do not underestimate
the degree of harm caused to patients in psychiatric hospitals caused by
their smoking. As Campion points out, it is very considerable and, until
tobacco is banned for everyone, robust policies need to be in place to
reduce it.
Competing interests:
None declared
Competing interests: No competing interests
I read with interest the paper by Campion et al (2006) on exempting
mental health units from smoke-free laws. I believe that the government,
by allowing smoking in psychiatric units, will only increase stigma
towards psychiatric patients in a time the royal college of psychiatrists
is trying hard to reduce it.
It has been argued that hospitalization of smokers with mental illness in
smoke-free psychiatric units may lead to behavioural deterioration, but I
will present some evidence which refutes this argument.
In 1987, the Board of Trustees of Southwest Washington Hospitals (USA)
instituted a smoking ban in all of its facilities, including general
psychiatry unit. The changes were introduced successfully with minimal
impact on the successful function of the psychiatric service (Thorward et
al 1989). More so in 1994 Ryabik et al reported that implementation of a
smoking ban, establishing a smoke-free psychiatric service and abolishing
tobacco products created minor management difficulties on a locked
psychiatric unit (Ryabik BM et al,1994). The effects of prohibiting
cigarette smoking on the behavior of patients on a 25-bed psychiatric
inpatient unit were assessed immediately after implementation of a smoking
ban in the USA and two years later. No major behavioral disruptions were
observed after the ban. The number of calls for security assistance,
physical assaults, instances of leather restraints and of seclusions, and
discharges against medical advice did not increase significantly
immediately after the restriction on smoking or two years later (Velasco
et al 1996).
Signs and symptoms of nicotine withdrawal and alterations in
psychopathology were evaluated among acutely ill psychiatric patients
admitted to a hospital with a smoking ban. Despite subjects' reports of
feeling distressed and of experiencing nicotine withdrawal symptoms,
abrupt cessation of smoking did not significantly affect either the
severity or the improvement of psychopathological symptoms during
hospitalization. The authors concluded that no compelling reasons to
reverse the smoking ban were observed (Cedric M 1999).
In the current climate of growing concern for the harmful effects of
cigarette smoking and passive smoking and with supporting evidence for
smoking ban, exempting mental health units from smoke-free laws can no
longer be ignored.
Velasco, J., Eells, T.D., Anderson, R. et al. A two year folloe up on
the effects of smoking ban in an inpatient psychiatric service. Psychiatr
Serv 1996;47 (8): 869-871.
Cedric M. Smith, M.D., Cynthia A. Pristach, M.D. and Maria Cartagena, M.D.
Obligatory Cessation of Smoking by Psychiatric Inpatients Psychiatric
services. APA 50:91-94, January 1999.
Thorward, S.R., Birnbaum,. Effects of a smoking ban on a general hospital
psychiatric unit. Gen Hosp Psychiatry.1989 Jan;11(1):63-7.
Ryabik, B.M., Lippmann, S.B., Mount,R., Implementation of a smoking ban on
a locked psychiatric unit. Gen Hosp Psychiatry. 1994 May;16(3):200-4.
Competing interests:
None declared
Competing interests: No competing interests
EDITOR – Campion et al raises important issues regarding tobacco
consumption on psychiatric units, problems this can lead to in a highly
vulnerable group of patients, and the urgency with which smoking cessation
programmes in mental health settings are required (1). It is known that
psychiatric patients smoke at much higher levels than the non-mentally ill
populations, and also derive additional nicotine by – for example - taking
extra puffs and inhaling deeper. However Campion et al, in their
editorial, fail to raise a number of important issues, most notably that
patients with Schizophrenia smoke cigarettes for different reasons than
the normal population. Recent genetic linkage studies show evidence of
nicotinic receptor alpha-7 subunit involvement in both smoking and
schizophrenia (2). Further, most research on nicotine cessation
interventions – including Nicotine Replacement Therapies – are carried out
on non-mentally ill populations and lack generalisability in the mental
health settings (3).
At the most recent American Psychiatric Association Conference in
Toronto a symposium was dedicated to Nicotine Dependence and Schizophrenia
(4). Sensory gating deficits in Schizophrenia - which can be normalised by
nicotine - was raised as one possible cause for the high prevalence of
smoking in this population. These patients also tend to have reduced
nicotinic acetylcholine receptors, and nicotine may in fact be a form of
self-medication due its cognitive enhancing properties. Abstinence rate
amongst smokers with Schizophrenia was researched to be virtually nil
without intervention, and short-term rates of l0-40% were achieved with
nicotine replacement and psychosocial strategies. The symposium concluded
that the treatment of tobacco dependence in Schizophrenia requires long-
term strategies, combination of medication with psychosocial
interventions, and integration into the overall patient management with
the aim relapse prevention.
In absence of robust evidence based policies tailor made for specific
psychiatric diagnosis, and trained psychiatric staff to deliver these, an
enforced blanket ban on smoking is likely to be counter productive. It
could for example force patients to smoke discretely – and hazardously -
on psychiatric units. Under the circumstances, the proposed exemption for
units where inpatients are admitted for less than six months is an
acceptable strategy, as perhaps it could focus scarce resources on
rehabilitation settings. A more simple solution at present could lye with
making designated smoking areas unattractive, so they are no longer the
social hub of acute mental health units, as they remain in some
institutions.
References:
1. Campion J, McNeill A, Checinski K. Exempting mental health units
from smoke-free laws. BMJ 2006; 333:407-408 (26 August)
2. Ripoll N, Bronnec M, Bourin M. Nicotinic receptors and
schizophrenia. Current Medical Research & Opinion. 20(7):1057-74, July
2004.
3. The Medical Clinics of North America 88(6), November 2004.
4. American Psychiatric Association Conference 2006. Symposium number
81 (24 May). Abstracts access via:
http://www.sessions2view.com/apa_library
Competing interests:
None declared
Competing interests: No competing interests
Exempting mental health units from smoke-free laws; response to editorial correspondence
We thank all those who have responded to our recent BMJ Editorial
"Exempting mental health units from smoke-free laws"(1). In response, we
would like to make the following comments:
A) Self-medication; smoking is a recognised drug dependence and a
cigarette is the equivalent of the dirty syringe with the nicotine
delivered in a toxic cocktail of around 4,000 other smoke constituents, 60
of which are known carcinogens. Nicotine replacement therapies are the
least harmful nicotine delivery systems available of which there are now
six different forms (gum, patch, nasal spray, inhalator, lozenge and the
sublingual tablet) in varying strengths and flavours. If self-medication
for nicotine is part of the reason why people with mental health problems
have high levels of smoking, then it is important to realise that smoking
a cigarette is the most deadly known form of nicotine delivery.
B) Self reliance; empowerment can be enhanced by a smoking ban with
some patients experiencing increased sense of self esteem and mastery
following a ban(2). When a smoker learns how to cope with withdrawal
symptoms with the aid of nicotine replacement and that their daily routine
does not need to be structured around cigarettes, they are able to become
more confident that they can manage without them. We agree that it is
critically important that service users are consulted, involved and
supported in the transition to smoke free settings.
C) Exacerbation of mental illness after smoking cessation; there is
no clear evidence that stopping smoking exacerbates psychotic illness(3).
There are also no consistent reports that anxiety increases following the
first week of abstinence and it is suggested that smoking is chronically
anxiogenic rather than being anxiolytic(4).
D) Smoking cessation and potential medication toxicity; there are
links between smoking status and antipsychotic medication. Cigarette smoke
induces the metabolism of a number of psychotropic medications which means
that for some patients who have stopped smoking, although there is
potential danger of medication toxicity in the short-term, lower doses of
medication may be required in the longer term. The guidance referenced in
the editorial recommends that quit attempts be monitored carefully with
all relevant health professionals and care workers informed of the
treatment being given.
E) Smoking culture within mental health settings; the relationship
between nursing staff, other health professionals and their patients is
critically important(5). The smoking culture in mental health units was
demonstrated in a recent survey showing that 54% of mental health staff
believed that staff smoking with patients was of value creating
therapeutic relationships(6). Staff were found to experience more
difficulty with total bans since they continued to smoke during breaks(7).
There is even a suggestion that some mental health patients enter mental
health settings as non-smokers and emerge as smokers, due to the smoking
culture that still exists(7,8). We believe that condoning or encouraging
cigarette smoking in those with mental illness is unacceptable given the
huge impact of smoking on health. The question of why nicotine dependence
is treated differently from other drugs of misuse such as alcohol needs to
be considered. Self-medication with alcohol is also claimed for
psychiatric disorders but alcohol is not condoned or tolerated in mental
health settings. The analogy with alcohol is not perfect but the NHS is in
the position with smoking that it was with alcohol 15-20 years ago (for
staff as well as patient attitudes and behaviour).
F) Need for comprehensive smoking cessation support; research shows
that a proportion of smokers within mental health units want help with
stopping but are not being offered this help in a consistent way. They are
therefore unlikely to be aware that the NHS stop smoking services can
offer free and intensive support to smokers needing it.
G) Human rights: the Human Rights Act only allows an individual
freedom of choice to act when their actions do not endanger others. Non-
smoking service users and staff should not be exposed to the dangers of
passive smoking. The effects of environmental tobacco smoke on health are
now accepted and under the Health and Safety at Work Act, employers have a
legal duty to protect both patients and staff from environmental tobacco
smoke.
H) Research: more research is needed into both the reasons for the
relatively high levels of smoking among mental health patients and how
best to help them to stop.
I) Evidence for successful smoke-free policy implementation; there
are numerous examples showing clear evidence that implementation of a
smoke-free policy is possible in mental health settings (1,7,9,10).
Partial solutions like ventilation have been demonstrated not to eliminate
tobacco smoke and are no longer acceptable in other public places which
explains why the government is introducing the comprehensive smoke-free
law.
References:
(1) Campion J, McNeill A, Checinski K. Exempting mental health units
from smoke-free laws BMJ 2006;333:407-408
(2) Cooke, A. Maintaining a smoke-free psychiatric ward. Dimensions
in Health Service 1991;68:14-15.
(3) Smith CM, Pristach CA, Cartagena M. Obligatory cessation of
smoking by psychiatric inpatients. Psychiatric Services 1999;50:91-4.
(4) West R, Hajek P. What happens to anxiety levels on giving up
smoking? Am J Psych 1997;154:1589-92
(5) McNally L, Oyefeso A, Annan J, Perryman K, Bloor R, Freeman S,
Wain B, Andrews H, Grimmer M, Crisp A, Oyebode D, Ghodse A. A survey of
staff attitudes to smoking-related policy and intervention in psychiatric
and general health care settings. Journal of Public Health 2006;28:192-
196.
(6) Stubbs J, Haw C, Garner L. Survey of staff attitudes to smoking
in a large psychiatric hospital. Psychiatr Bull 2004;28:204-7.
(7) Hempel AG, Kownacki R, Makin DH et al. Effect of a total smoking
ban in a maximum security psychiatric hospital. Behavioral Science and the
Law 2002;20:507-22.
(8) Lawn SJ, Pols RG, Barber JG. Smoking and quitting: a qualitative
study with community-living psychiatric clients. Social Science and
Medicine 2002;54:93-104.
(9) Smith MJ (letter) Risks of "passivity smoking" BMJ
2006;333/7565/407
(10) Alam FD (letter) Exempting mental health units form smoke-free
units should no longer be ignored BMJ 2006;333:551-2.
Competing interests:
None declared
Competing interests: No competing interests