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.