Smoking Ban - Putting the Boot into Mental Health Patients

Anti-Smoking groups are applauding the NSW government's decision to remove a smoking exemption for mental health facilities. The obvious question is, will it help patients? A third of mental health sufferers and two thirds of schizophrenics smoke but under the government plan, they have to quit or abstain while they are being treated. Is it really a good idea to put this extra unnecessary stress on people already confronting intense personal issues? Although nicotine is physically addictive, it also has a huge psychological dependancy that can make it extremely stressful to quit.

As a smoker I know about the compulsory need to reach for a cigarette regardless of the harms. Kicking nicotine addiction is simply not possible for many including myself especially during a time of stress. I don’t care how many anti-smoking groups or loud vocal nay-sayers harp on, I find it virtually impossible to quit. The idea of quitting whilst dealing with a major issue in my life is even more distant and I am sure this is the same for most long term smokers. And what bigger issue could one have to deal with than going to a psychiatric centre for a mental health problem? I could only imagine one worse scenario than having to deal with a mental health issue at a psychiatric hospital ... having to quit smoking as well.

Like most people, I understand the need for smoke free environments and designated outdoor smoking areas meet this need. But in a mindless and stupid attempt to appease anti-smoking groups, the NSW government has taken a Zero Tolerance approach and banned all smoking in mental health facilities. The alternatives ... quit smoking. This is just what someone needs whilst dealing with probably the biggest issue in their life. What a bunch of shit-for-brains.

It has been found, rather surprisingly, that nicotine has beneficial effects on brain function in schizophrenia (American Journal of Psychiatry, 1993;150(12):1856-61). Normally, people are able to adapt to background noise and disregard it, for example while having a conversation in a busy street. Recordings of brain activity show that this ability is impaired in people with schizophrenia, so they are more distracted by the surrounding environment. When they smoke, or use nicotine gum or patches, brain function normalises and they are less reactive to irrelevant sounds around them. When the nicotine is taken away, the problems return. -The Australian: Mentally Ill Smoke More And Quit Less.

Has anti-smoking hysteria gone too far? I remember when the idea of banning smoking in pubs was so far fetched, I just knew it couldn’t happen. It was the same when they first touted the idea of banning smoking in restaurants ... and offices ... and public transport ... and ... etc. So times change and we get used to it. I just want to know where the line is. 

In The Netherlands where you can buy and smoke cannabis in licensed coffee shops, they have banned tobacco smoking. Is this just anti-smoking fever gone mad or does it make sense? I’m still thinking about that one but what doesn’t make sense is removing designated outdoor smoking areas. Considering smoking is highly addictive, you would think the authorities would be more realistic. So what’s their solution ... more smoking bans. 

It’s obvious that the balance between the rights of a smoker being able to light up and the need to keep everyone else free from smoke is failing. This is especially true when anti-smoking zealots start to threaten the well being of people like they have with mental health patients. Can you see a pattern here? A group of fundamentalists with certain beliefs, forcing their views on the public through manipulation of the government. A group that is so desperate, they will ignore any harm caused by their suggestions and continue to ruthlessly push their agenda. A group that brushes off expert opinion and ignores the people they are supposed to be helping in favour of their own unqualified views. 

The common denominator is drugs and this time it’s nicotine. And their target is the patient being treated for mental health problems. The fundies just cannot let an opportunity pass to force some poor unwilling sucker to suffer like hell. The patient be damned. Who cares if they are treated successfully? Who cares if they check out because they can’t quit smoking? Who cares if it discourages patients from seeking medical help? At least they won’t smoke for a few days.

Tobacco Ban Leaves Mental Health Groups Fuming
Sydney Morning Herald
By Louise Hall - Health Reporter
March 2009

A BAN on smoking in all psychiatric facilities will go ahead despite vehement opposition from some members of the mental health community, who argue that strict anti-smoking rules will destabilise acutely ill patients and put staff at risk of violence.

NSW Health has ordered all facilities, including emergency psychiatric centres, to close designated outdoor smoking areas, confiscate tobacco products and supply free nicotine replacement therapy to staff and patients.

Anti-smoking groups say the department's decision to enforce its longstanding smoke-free policy in wards that had been granted an exemption will help to break down the "deep-rooted smoking culture" among mental health staff and patients.

The new guidelines will be implemented over at least six months to give workers, patients and visitors time to adjust and, ideally, to quit their habit, with the help of counselling and anti-smoking aids such as patches and pharmacotherapy. The director of NSW Health's Centre for Health Advancement, Liz Develin, acknowledged there was widespread hostility to the ban but said research in Britain, Canada and other Australian states showed careful planning and education can lower levels of patient distress.

About one-third of people with a mental illness smoke, rising to two-thirds for people with schizophrenia, compared to about 17 per cent of the general population.

"Some consumer groups see it as taking away a person's right but everyone has the right to be in a smoke-free environment," Ms Develin said.

The chief executive of the Cancer Council NSW, Andrew Penman, said arguments that people with psychiatric disorders smoke to self-medicate or relieve symptoms, stress and anxiety "are too easily used as excuses to justify inaction about smoking".

There was weak evidence that smoking improves the neurological functioning of people with schizophrenia, he said. But many of these patients want to quit and can quit to improve their overall wellbeing.

A spokesman for the Mental Health Council of Australia, Simon Tatz, said forcing a nicotine addict to endure withdrawal symptoms while battling an acute episode of mental illness may impose a disproportionate level of suffering on people who were already suffering enough.

"No one wants to defend smoking, but when you're dealing with people in extreme crisis, their mental health and wellbeing has to be the priority, not quitting smoking," Mr Tatz said.

Desley Casey, who has worked in the mental health field for 15 years and has been an acute psychiatric inpatient several times, said forcing people to quit when they are acutely unwell is inhumane and "goes against a patient's human rights".

She is concerned that some patients will not seek help or admit themselves to hospital if they know tobacco is banned.

Ms Casey disagreed that NSW Health had a duty of care to break the cycle of smoking and disadvantage. "Is it their duty of care to put someone through terrible nicotine withdrawal symptoms during psychosis?

"I'm a smoker and I would prefer to risk the dangers to my physical health than risk my mental health, which is far more precious to me."

Internal NSW Health documents show hospital administrators have expressed concerns that patients may abscond or become increasingly agitated or violent if not allowed to smoke.

But "in some circumstances smoking may be permitted on a case-by-case basis" if nicotine replacement therapy does not work or where "refusal may pose a significant risk of violence to a staff member, patient or another person", the draft guidelines outline.

The chief executive of the Richmond Fellowship of NSW, Fred Kong, said mental health workers often used tobacco to bond or develop relationships with patients, which could help their recovery. "I'm fearful that applying this sanction will interfere with the therapeutic relationship between staff and patients," Mr Kong said.

A review of 26 bans in psychiatric settings worldwide published in the Australian And New Zealand Journal Of Psychiatry in 2005 found there was "no increase in aggression, discharge against medical advice or increased use of as needed medication" linked to smoke-free policies.

Although there has recently been a big push to help psychiatric patients quit smoking whilst in medical care, searching through the internet I have found plenty of criticism of forced smoking bans. Most of it comes from doctors and those involved in the day-to-day operations who’s only concern is the well being of the patient. Being medical professionals, they obviously understand the danger of smoking but pragmatism wins out over the rigid dichotomy between anti-smoking rhetoric and the real world of mental health services. 

Although there is growing evidence that patients can quit smoking whilst keeping their place in treatment, there is equal opposition from those who work on the ground, doing the actual work. Treating a mental health patient is already extremely complex and unless we have perfected it recently then introducing additional, non related and non critical goals, cannot make the task easier. The losers are the patients and as usual, those who don’t easily adapt to a new system are merely statistics and left to fend for themselves.

Stopping Mentally Ill People From Smoking Is Cruel
Sydney Morning Herald - Opinion: Letters
By Dr Alvaro Manovel Randwick
March 2009

As a doctor I strongly support anti-smoking policies. But there are specific issues relating to mental health patients that make the move against smokers by NSW Health deplorable ("Tobacco ban leaves mental health groups fuming", March 19).

Mental health patients may be voluntary or involuntary. Voluntary patients may simply stroll off the hospital grounds to smoke. But involuntary patients are detained against their will in hospital under the Mental Health Act and are not allowed that liberty.

They are by definition so mentally disordered that the last resort of the act has been invoked because they may be a risk to themselves or others. These patients are frequently agitated and smoking is one method they use to calm down. In this state they lack the capacity to consider the benefit of stopping smoking, and this is clearly not the time in their lives to introduce intransigent non-smoking rules that only escalate their agitation.

In the past these patients were allowed to go outside to smoke escorted by security staff, but since the introduction of smoking bans they may no longer do so. In hospitals all over NSW these poor individuals are being physically restrained and given sedative drugs when their agitation escalates. This infringes the spirit of the Mental Health Act, which stipulates that it may be invoked to detain a person only when there is no less restrictive means of doing so. Clearly allowing them to smoke is far less restrictive than physical restraint and sedation.

We already make these patients suffer protracted stays in crowded emergency departments, due to the failure of NSW Health to provide beds for them. It is easy to imagine what effect this has on individuals who are at the lowest ebb of mental wellbeing. To add insult to injury they are now told that their last vestige of self control - to seek solace with a smoke - is being withheld, in what must seem an arbitrary and cruel act by their carers.

Doctors are placed in the unenviable position of choosing to restrain the individual or to let them out on their own, with the risk they may abscond and harm themselves. What a sad state we have sunk to.

Related articles: Mentally Ill Smoke More And Quit Less