## BMJ Debates Smoking Bans in Psychiatric Units

Continuing on the theme of smoking bans in psychiatric hospitals, the BMJ has been holding a debate about smoking in psychiatric units. On one side Deborah Arnott and the president of the Royal College of Psychiatrists, and on the other a retired GP, Michael Fitzpatrick. The case for smoking bans began with a remarkable assertion:

In Britain today about one third of cigarettes are smoked by someone with a mental disorder, and smoking rates among people with serious mental illness are triple that of the general population.1

That makes it sound like a lot people who smoke are mentally disordered (and this was probably the intention). But a little maths might help:

If Ng is the number of smokers in the general population, and they smoke at the rate R cigs/yr, and Nm is the number of smokers with mental disorders, and they smoke at the rate 3R  cigs/yr then the total number of cigarettes smoked/yr is Ng.R + Nm.3.R, and the ratio of the number of cigarettes smoked by people with mental disorders to the total smoked is:

Nm.3.R  / ( Ng.R + Nm.3.R ) = 1/3

Simplifying this equation, Nm/Ng = 1/8. Or, one smoker in 8 has a mental disorder. However, according to MIND, “1 in 4 people in the UK will experience a mental health problem each year.” Which suggests that smokers are half as likely to suffer from mental disorders than the general population. Which shouldn’t be too surprising if smokers can alleviate mental disturbance (depression, anxiety, grief) by smoking, and non-smokers cannot and so require induction into psychiatric units. This also suggests that as the prevalence of smoking falls, the prevalence of mental disorders will rise.

Anyway, we then learn that:

Smokers with mental health disorders are as motivated to quit smoking as the general population,1

However, since most of the population doesn’t smoke, they have no motivation whatsoever to quit smoking. And since the remaining smokers carry on smoking, it would appear that they have little motivation to quit either. Thus the general population’s motivation to quit smoking is even less than that of smokers, and so smokers with mental health disorders are less motivated to quit smoking than most smokers. Which shouldn’t be too surprising, given that smoking alleviates mental disturbance.

…is it a step too far to prevent inpatients from smoking outdoors as well, and in so doing effectively force them to quit smoking?

Yes. It’s a step too far.

The introduction of smoking bans in psychiatric units was tested in court:

The Court of Appeal concluded that smoking could not be considered a fundamental human right and went on to say that “a person may do as he pleases in his own home, no-one can expect such freedom when detained in a secure hospital.

To what extent are mental patients “detained”? Are mental hospitals prisons? Aren’t a great many mental patients there of their own choice, just like hospital patients who have chosen to enter hospitals to receive treatment?

We then learn of the ill effects of the 2007 smoking ban:

Since smoking indoors was prohibited, inpatient psychiatric services in the UK have implemented smoking breaks every 1-2 hours.5 Currently, heavily addicted service users are forced into nicotine withdrawal several times a day, exacerbating rather than reducing potential conflict.

The 2007 indoor ban not only exacerbated conflict by forcing patients into periodic withdrawal, but also required staff supervision of the new smoking breaks. The adoption of both indoor and outdoor smoking bans is expected to lead to…

…better engagement with therapy, improved respiratory function and sleep patterns as well as less cannabis use and fewer violent incidents related to smoking.5 In addition, the policy freed staff time previously spent supervising smoking, estimated at nearly three hours a ward each day7; this time can now be used more productively and therapeutically with service users.

That’s to say that banning smoking indoors and outdoors will give back to the staff the time to treat patients that was lost through the 2007 indoor ban, and hence result in better engagement with therapy. There will obviously be fewer incidents related to smoking, because nobody will be allowed to smoke. There isn’t actually any gain, so much as a recovery of some of what was already lost.

In short, the purpose of the outdoor ban is to rectify the ill-effects of the indoor smoking ban.

The last line is a purely emotional pitch:

We should no longer condone patients smoking themselves to death while in our care.

How many smokers die while in psychiatric care? And how many of those deaths are directly attributable to smoking? I would imagine that, apart from those patients that remain in psychiatric care for their entire lives, very few mental patients ever “smoke themselves to death”.

The case against smoking bans was then rather weakly made. The principal line was that mental patients were autonomous adults, and smoking bans deprived them of their autonomy, and treated them like children. Smoking bans were “heartless and inhumane”.

These were perfectly reasonable points. But what was perhaps noteworthy was that such considerations were entirely absent from the case made for outdoor smoking bans. The antismokers were completely indifferent to the freedom and autonomy of their patients. Perhaps this is because treating people like children is what they always do as a matter of course.

## About Frank Davis

smoker
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### 11 Responses to BMJ Debates Smoking Bans in Psychiatric Units

1. Smoking Lamp says:

The Antismokers are not interested in actual evidence or facts. They are ideologically opposed to smoking and will force that worldview on everyone in increments. They are especially interested in accelerating their comprehensive bans to reach their global tobacco free goal. Causing harm, increasing stress, and ignoring choice are mainstays of their campaign. The sad fact is they are the ones with mental illness. Smoking bans in psychiatric hospitals should be rejected. Outdoor bans in all facilities should be rejected as well. They tobacco control machine most be exposed for its abuses and stopped in its tracks.

2. jaxthefirst says:

Errr – shouldn’t the word “debate” be in inverted commas in your title, Frank? The BMJ (and their ASH colleagues) don’t do “debate” – they only do Instructions Which Must Be Obeyed Or Else!

• Some French Bloke says:

“The BMJ (and their ASH colleagues) don’t do“debate” – they only do Instructions Which Must Be Obeyed Or Else!”

Global corruption is the name of the game, until… well the rest is up to us, since they’ll obviously never come clean on their own accord.

3. lysistratatheoriginal says:

Most patients are in mental hospital on a ‘voluntary’ basis for shortish-term stays of a week or so – self-referral because of a change in symptoms or a particular episode (e.g. the ups and down of bipolar syndrome). They are perfectly capable of managing their illness, often with the help of family and friends, and recognise when they need their medication sorted out and/or a place of safety. It would be interesting to see if there is sound research available on whether there have been statistically significant reductions in self-referrals by patients who smoke. I suspect there have. Which if so would be an abomination.

• rattyariel says:

I have severe recurrent clinical depression, PTSD and anxiety disorder, and in the 70s and 80s I had a constellation of life-threatening eating disorders. So I am no stranger to the psych hospital environment, although it has been more than a decade since I’ve been in one. Up to the early 90s, smoking was allowed everywhere except for one’s own room. I can vouch for how comforting it was to sit in the community/day room with other patients and have a smoke, and talk, and just plain relax. Then somewhere in the 90s (’94? ’95?) when I voluntarily admitted myself into the depression unit of a New York City hospital I’d been in before, I underwent a body search. What were they looking for? I thought they were looking for sharp objects or something. Well, they were, but they were also looking for….CIGARETTES. Yes, cigarettes had been banned on the depression unit. You could only smoke if you had a pass to walk on the hospital grounds, or go to the cafeteria. However, for the first three days of your hospital stay, you were confined to the unit so you couldn’t smoke. This led to new patients who smoked getting extremely upset, anxious, tearful and even more depressed, which led to them hiding in their rooms and sleeping as much as they could, instead of mingling in the community room with others or participating in therapeutic activities. Your mind wasn’t focused on acclimating to the strange new environment, and on strategies to get better. It was focused on missing your cigarettes, which, before you’d entered the hospital, you’d had no idea would be confiscated.
The community room, which, when smoking was allowed, had been an enjoyable place to hang out – probably the most therapeutic place on the unit! – was now pretty much empty, except for one or two nonsmokers. The rest of us smokers took a lot of one-hour passes a day to go outside and smoke. This screwed up the therapeutic schedule – the groups and such – which, in this particular hospital were VERY well-run and helpful. When one could smoke during the groups, no one missed a single group. But at least in this hospital, passes trumped everything else. So the whole therapy thing was compromised.
Then when you were seeing your in-hospital psychiatrist and counselor, a ridiculous amount of time was spent trying to analyze why you were a smoker and convince you to stop. Hey – didn’t matter that the reason you came into the hospital was because you wanted to kill yourself because, oh, maybe some REALLY HORRIBLE STUFF had happened to you, your entire life had fallen apart, and/or your messed-up brain was convincing itself that you wanted to die.
Later on, in the early 2000s, a few hospitals in NYC experimented with having “smoking times.” You could go in a small “smoking room” four times a day, after meals and your evening snack, for 15 minutes, and have one cigarette. I must admit it did help a bit – it was something to look forward to, and people in the smoking room acted far friendlier and chattier than they were out on the unit. However, I hear these “smoking times” have now been banned.
There are several times over these ten years that I have needed to go into the hospital because my depression/PTSD has gotten really bad. I haven’t gone, because psych units in this city, and the entire hospital properties to which they’re attached, banned smoking ten years ago. In fact, just this weekend I came really close to dialing my mental health provider’s Crisis Line. This particular Crisis Line will send someone to get you and take you to the Crisis Center, which is basically an independent Medicaid-run small hospital where you can get intensive treatment for a week or two. As of last year, this was the only mental health setting in this city where one could smoke. But now, smoking has been completely banned on the entire property, both inside and outside. So no way am I EVER calling that Crisis Line, only to be carted off to be forced to stop smoking.

• Lepercolonist says:

Terrific writing, rattyariel. I enjoyed this article from someone who has had to suffer through this horrible no-smoking campaign.

• rattyariel says:

Thank you so much, Lepercolonist :)

4. wobbler2012 says:

I’ve said it before and I’ll say it again, depriving someone of something that helps them in their greatest time of need takes a special kind of bastard. These people make me sick.

5. Clicky says:

6. slugbop007 says:

Public Health won’t like this. The latest find from NASA:
http://www.theweathernetwork.com/news/articles/comet-spews-equivalent-of-500-bottles-of-wine-per-second/59477/
Ban that Comet!