Smoking in psychiatric hospitals

Last week the Mental Elf reviewed a research paper on the effects of smoke-free policies in psychiatric hospitals. It looks like some smokers manage to stay clear of cigarettes after being admitted to a hospital with a ban.

The debate about whether such bans are fair is complex and often heated, but can usually be boiled down to an argument between freedom (to smoke) and health (of the smoker and others). Contrary to my usual mindset, which is very freedom-orientated, I actually support smoking bans in psychiatric hospitals. I’d like to discuss why, not because I’m particularly ardent in my stance (in fact I used to be against them) but because it’s a tricky area in which I value both points of view. And before you ask, yes, I’ve been a smoker.

Firstly, let’s not forget – smoking is really, really dangerous. It wrecks the human body like nothing else, with smokers dying at least ten years before non-smokers on average. Furthermore, over a third of cigarettes are sold to people with mental illness, unfairly targeting a group that are already having a hard enough time.

Second, despite how many people feel, smoking doesn’t improve mental health conditions, it makes them worse. Smoking might appear to soothe naturally occurring anxiety but in reality it probably only relieves anxiety caused by needing a cigarette (if I had a cigarette now as a non-smoker, would I feel less anxious?). Moreover, quitting smoking while being treated for a mental health problem does not appear to make it worse if you get the right help – in fact, it seems to lead to a decrease in anxiety.

So from a health perspective, smoking is something we don’t want people to be doing for any reason. But should we be able to insist that they stop when in hospital?

Informal patients should be able to nip off the ward for a fag any time they like, but patients held under section aren’t free to leave. This is the most contentious area of the debate. I see both sides of the argument, but overall I think that if someone has been sectioned for the benefit of their health, it seems farcical to facilitate their hugely harmful addiction. Plenty of other behaviours and habits are seen as unacceptable in hospital, without such fierce criticism – drinking alcohol, using illegal drugs, gambling. Even though they can be a normal part of life when well, they’re not allowed in hospital because they aren’t helpful when unwell and it certainly isn’t within the remit of staff to spend time helping patients undertake them.  As a correlate, do we insist that patients have leave from hospital to be escorted to the local betting shop or off license?

Furthermore, facilitating smoking – which often involves nurses wasting hours of each day escorting people back and forth to smoking gardens or the front gate – sends out a bad message about mental health services, I think. When someone is admitted to a general hospital, they accept that the aim of the staff is to improve their health and that although they can smoke if they can make it outside, staff aren’t going to bend over backwards to help them. Plenty of people with physical health problems can’t leave hospital, just like people under section, because they’re too unwell but they don’t tend to feel like that’s unreasonable.

On the topic of rights, non-smoking patients have a right to nurses that aren’t spending their time facilitating the addictive and harmful behaviour of other patients, who then come back onto the ward covered in dangerous chemicals. Most of us have met patients who started smoking on psychiatric wards as a result of exposure to a cigarette-friendly environment, which has to stop.

I’ve worked in psychiatric hospitals both with and without bans. In places without bans, throngs of patient spent literally all day crowding around the nursing station, asking for smoking breaks. It consumed the nurses’ time, so they couldn’t do a range of other caring tasks, and led to a number of incidents of aggression when demands couldn’t be met. In psychological terms such ‘variable reinforcement’ regimes (i.e. only letting someone have something they ask for every so often in an unpredictable way) is a recipe for frustration.

However, in places with bans, in my experience patients are usually a bit annoyed when they’re admitted but usually accept fairly quickly that it doesn’t make sense for a hospital to be condoning smoking, they accept nicotine replacement therapy (which works pretty well), and do just fine. Counter to what you might expect, violence is not increased with total bans, and in at least one instance in the UK a smoke-free policy has halved it.

In summary, there is no perfect solution. We can either help very ill people harm themselves by smoking in the name of freedom, or restrict something they want to do in the name of health. The key for me is that the freedom to smoke isn’t as simple as just letting people smoke – it’s a freedom which has to be actively supported but has negative knock-on effects on patient health and mental state, staff time (including time with other patients), the image of mental health services as pro-health, and ultimately parity. And I haven’t lost any sleep because my patients don’t have access to something that will kill them when I’m meant to be looking after them.

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About Alex Langford
I am a psychiatrist (now an SpR) based in Oxford after 3 years working in South East London. Before I went into psychiatry, I used to be a general medical doctor, and I also have a BSc in psychology. I'm particularly interested in improving the public face of psychiatry, evidence based medicine, teaching and patient rights. Don't mention cricket unless you've got the next fortnight free to discuss it.

19 Responses to Smoking in psychiatric hospitals

  1. mitten91 says:

    Interesting article. I have been both a patient and a member of staff at a psychiatric hospital so have seen both sides of the coin, so to speak. When i was a patient, there was no ban implemented, (the patients under section were allowed to leave the ward!) but it seems the logical step to bring in compulsory nicotine replacement therapy!

  2. George says:

    Really interesting blog, thank you. I’m not utterly against it and can completely see your points. But I think uncharacteristically that I disagree and come down on the other side.

    The arguments for us to do everything we can to stop people smoking are many and persuasive – as you talk about there’s not many other single things we can do to improve our health more than stop smoking. And the argument that people sometimes *start* smoking on psych wards is an extremely important one – nobody wants that. Also the exposure of staff to smoke is a hugely important point – and a massive argument in favour of stopping too. (You could ask why we are not insisting staff also stop smoking, if we are doing this for their benefit, but that’s an argument for another time!)

    But … by extension, are you going to force people to eat healthy food? Will we ban all chips and desserts and chocolate, rich sauces and sugar in tea? It’s another really important area for those with mental health problems, and gaining weight is a huge issue, partly (perhaps mostly in inpatients) due to our interventions like medications and detaining people on wards. So are we going to force people to eat what we want them to? And force them to exercise? The arguments to my mind are similar, and would improve health if enforced, but we wouldn’t think of doing this as we’d regard it as coercive and unpleasant. People can choose to eat unhealthily if that’s what they want. Because people are free agents to decide not be healthy.

    It’s the lack of fairness that’s an issue to me too. One person, informal, can go out smoking when they want. Another person in the next bedroom can’t, as they are on a section. Another person, sick with COPD, lung cancer or pneumonia in the hospital next door is still not stopped from smoking. This is the argument people on my ward use with me often (indeed today) and I don’t feel like I really have a good answer.

    Also, isn’t there an argument that especially long stay places are in fact ‘places of residence’? The Kings Fund certainly debated this in this paper. http://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/clearing-the-air-debating-smoke-free-policies-psychiatric-units-karen-jochelson-bill-majrowski-kings-fund-18-july-2006.pdf

    In terms of the ward experience, I can only talk of my experience which is that the nurses are spending just as much time talking about not smoking than it would take to go for a cigarette break – but that is just my observation. Also that people are ok with it soon is not one that I have seen in practice at all. People just admitted are often in such deep crisis and enforced nicotine withdrawal right then, as soon as they walk through the door, perhaps against their will, is not something I want to add to that.

    I’m not really seeing the parallels with drinking and drug use either. Getting drunk or high is likely (admittedly not all the time, but likely) to impact very quickly on people’s feelings and behaviour that could lead to very negative consequences. I don’t see that a cigarette or two (or indeed 20) would have nearly the same effect. Not to mention drugs are illegal, while smoking isn’t. (Yet!)

    Another thing I think is vital is that we don’t really know (at least I don’t think we do, please correct me if I’m wrong) whether this really leads to long term quit rates. I know this paper and others says there’s some evidence for short term quitting, http://m.anp.sagepub.com/content/early/2014/05/09/0004867414533835.abstract but will it last? Presumably this is the most important question to ascertain if the benefits to health outweigh the downside of coercion? This study showed that people who wanted to quit asked for NRT more than those who didn’t – obvious of course, but my point is that not having a complete smoking ban doesn’t completely stop people being supported to quit. If they want. http://m.tobaccocontrol.bmj.com/content/early/2014/09/10/tobaccocontrol-2014-051712.short Again it’s only short term follow up, sadly. (I found the greater take up among those with more severe illness interesting)

    To my mind, there’s so so much we could do to improve physical health of people on an inpatient ward. Why start with something coercive? Isn’t it better to work *with* people to find what they want to do to improve their health? We can help people stop smoking with NRT and psychological support if they feel ready. Won’t that lead to more of a team working feeling, as opposed to something else we are putting on people from
    above?

    But as I said I’m totally seeing your argument and many extremely convincing points – I’ll be very interested in how this turns out. If it turns out that it helps people stop (really stop, in the long term) and people who’ve been through it are glad they did, I will change my mind.

    I’ll be so interested in other comments!

    • Hi Georgia,

      Good points. If you will allow some brief responses (I’m on nights):

      Forcing someone to eat healthily and exercise are different and they are commissions, versus the omission of preventing smoking. I reckon there’s a big difference between choosing not to actively helping people do something damaging – at great collateral cost (passive smoking, wasted nursing time, worse organisational reputation) – and actively forcing other healthy behaviours.

      That said, I don’t think providing only healthy food in psychiatric hospitals would be the worst idea in the world.

      I can’t argue with your experience of smoke-free wards being no calmer than smoking ones. I can only say that my own experience (and some of the research) is different.

      The paralels with drinking and gambling are clear to me. That fact that drinking changes someones mental state isn’t the point. All are legal activities, but none would ever be reasonably condoned (and FACILITATED at cost of time and effort) by nursing staff.

      The main argument you make is the main argument that has been made genrally, i.e. it’s not fair on sectioned patients. Firstly I echo my comments about physical health patients not being able to smoke (either by capacity or simple inability to move) and it not being seen as a catastrophe of human rights. Secondly, the logical solution to people having the capacity to smoke but not being allowed to leave to do so isn’t to repeal a smoking ban, but to alter a still largely non-capacity based MHA, surely.

      • George says:

        Really interesting point about a capacity based MHA and one I’d be in favour of. How would that stop this problem though? It’s a genuine question as I am not very knowledgable about the legalities of it. Wouldn’t it be the case that there would be plenty of people who didn’t have the capacity to decide about treatment for a mental health problem and therefore were detained, but perfectly able to decide to have a cigarette? Wouldn’t the situation then be exactly the same? I feel like I’m missing something … Could just be me being dim …

      • You’d potentially remove the problem of the group of people who have capacity to decide to leave to smoke but can’t. As you point out though, there would still be plenty of non-capacitous patients who couldn’t choose to leave to smoke and who would have their dangerous habit cut off by detention. In response to that, I can only say that the good far outweighs the bad, in a medical, pragmatic and possibly even purely ethical sense. In fact I think the question should be reversed – why should we allow smoking in hospitals? If you were starting with a blank slate, would you incorporate it (a habit which kills half the people who do it, in a hospital), and if so, why not drinking alcohol or gambling?

  3. Judy says:

    Speaking as a friend of a current patient…. for many people you have lost everything when you are an in patient and smoking may be the only enjoyable activity left. Lack of things to do and an inability to concentrate anyway may make smoking the only thing left to look forward to in a day. Just because you are an informal patient if you are on a locked or secure ward you won’t necessarily be able to go out whenever you want, you will have agreed leave and agreed to keep the ward rules. On the locked secure /wards I am aware of the only access to outside space, other than(irregular) garden leave, is for supervised smoking breaks. I think if you are forbidding smoking, then staff need to think about how they will structure the day and how people will get regular access to outside space, including in the evenings. . And then the complications for medication …….especially for things like clozapine ………Long winded way of saying that life as an inpatient is tough anyway, so think carefully about what you are doing to people’s days before you abolish smoking breaks.

  4. anon says:

    I would agree with the suggestion that the MHA needs to become more capacity based. I think the comparison with patients in general hospitals being restricted is different because, I’m assuming, they’ve consented to be there. A patient with full capacity to refuse treatment (and choose to smoke) can be locked up on a psychiatric ward – I think it is quite understandable if they don’t want to comply with hospital restrictions whether those are smoking or gambling or drinking alcohol.
    On the other hand, I support a full ban on the basis that in practice facilities for smokers on wards do not actually prevent smoke escaping into the rest of the ward and the needs of non-smoking detained patients of a smoke free environment should take priority. When I was a long stay detained patient (pre-smoking restrictions), there was a smoking room on the wards and air vents but the whole ward was always foggy with smoke. It was horrific for me as a patient with asthma detained against my will for months. Frequently the air vents were turned off because the smoking patients complained they were ‘noisy’ or made the ward cold. Non-smoking patients ended up being restricted to their bedrooms and unable to access the tv or activity rooms if they wanted to avoid smoke – and even in the dorms there were usually people smoking secretly. There was also no escape from the smoke if I was taken outside – either other patients were smoking, or staff were. This was the situation on smoking wards when there had been decades during which appropriate facilities could have been put in place to ensure non-smokers weren’t affected – if it couldn’t be managed before then why would any reassurances to non-smokers be convincing now, if smoking was to be allowed on wards?

  5. donnakemp says:

    Reblogged this on LYPFT Planning Care Network and commented:
    Some interesting insights on smoking in hsopital…….

  6. Judy says:

    and another thought…as an inpatiient, especially if detained, you lose pretty much all control over your life, while also being extremely ill and suffering enormously because of that illness. And now the hospital says you can’t smoke either………..I think all people in authority in hospitals, doctors, nurses, managers etc, should think about how they would feel….

  7. Judy says:

    and another thought. When on a locked or secure ward you will spend the vast majority of every day, looking at the same four walls and the same people, day after day after day. Smoking breaks at least give you an opportunity to be outside, see some greenery, feel the wind on your face………have a little change of environment. I think you need to focus on that before you start banning smoking.

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  9. I’m currently a service user and I used to stay at the Women’s ward in Purely short term when I was very unwell. They have a lovely garden and one table with a roof over it was the smokers spot and also where we would hang out with other patients to chat. I have good memories of sitting at that table looking at the garden and making small talk with the other ladies, occasional someone would do a tea or coffee run to the kitchen. Access to patches and stopping smoking services was always available and encouraged. I know quite a few patients who chose to try to stop smoking while there but still wanted to sit and chat outside sometimes, or have the odd sneaky one. The word here is CHOICE. Since the complete ban I just don’t know what Im going to do, I have been quite unwell and very depressed for at 4 months now and I would normally really push to be admitted (I have schizo affective disorder ) but the thought of being there and having to stop smoking at the same time as being really unwell is just too much for me. I don’t want to give up smoking yet, and if I ever do I want to be in a good place when I make this decision. I have discussed this with my nurses and even before the ban came in, but they just argue back with me and do what you did – bang on about long term health. Im just trying to get through the here and now and living a long life really is not a particularly encouraging thought for me anyway. This illness is exhausting and has wrecked my life. So despite my having recently been feeling quite suicidal I know that going into hospital will just make me angry and worse. I already have problems with addiction to alcohol, yes Im happy to give that up while in hospital and away from my routine and recognise the benefit in that, but stopping smoking on top of that? Are you the crazy people I have to ask? Do you know how stressful and emotional it is to stop smoking even for a ‘sane’ person?

    • Judy says:

      All great comments. Love it when peopel think that saying you know it will shorten your life is going to be a deterrent to someone who is suicidal.

  10. Debbie Mead says:

    Who made you god. My brother is severely mentally ill and under 37/41 section. He has asked for a tribunal so that he can be free to smoke outside the hospital grounds. The only one vice he has left. God help you all if you are ever in his shoes. You havent a clue what you are talking about. Lets just clense everyone and ban all bad things. We have natural choice which is god given, free will if you like. Dont penalise mental health patients more than they already are. My brother has little to look forward to and confines himself to a room all day. Having a cigarette allows him to see others and breaks up the hours of the day. Next time you reach for a bar of chocolate consider what it would be like to be told you cant have it. Shame on you

    • Judy says:

      Well said, i sometimes wonder if staff ever think about what it is like to be a patient. Had one say about a friend of mine who had to be taken back by police, ‘well I don’t make all this fuss about having to be here’.

  11. Annb3021 says:

    I have been a patient many times over in many different psych. wards. I have always worked at a psych. hospital. The ward I frequent now, does ALLOW smoking outside at SET times during the day, in an enclosed supervised outside courtyard. What I think is TOTALLY wrong, is when a patient acts up in any way, the staff takes away their smoking break. It just pisses me off, what do they TAKE away from the non-smoker who acts up?? Totally unfair in my book.

    • Judy says:

      One for the CQC, hospital would havce to justify why it isn’t a punishment, but is necessary for soemone’s care. Hospitals don’t ahev the right to punish patients.

  12. The EmHag says:

    i have been under mental health services since 1997, in & out of(mostly in) NHS psychiatric hospitals on section 3’s for 12 years & then in 4 different funded rehabilitation hospitals over the last 6 years, which, i think you can agree, means i’ve had my fair share of first-hand experience of the smoking/health/human rights problem/argument. i’ve been a regular smoker since the age of 14 & I HAVE FULL MENTAL”CAPACITY”, I LIKE SMOKING, I DO NOT WANT TO GIVE UP SMOKING! the hospital i’m in right now will be stopping us, the patients, from being able to go out in the courtyard to smoke in the next couple of months. i am stressing, panicking & extremely angry about this. IT IS A BREACH OF HUMAN RIGHTS! i believe that i should have the right to end my life but as i’m being forced to stay alive, i should at least be allowed the relief i personally get from smoking. i feel that, for me, it’s better than letting the nurses fill me up with PRN diazepam!

  13. Austin Ricketts says:

    I have read the article and several comments and it seems to me that the Hospitals/Doctors have forgotten they are paid for servicing there patients, that they work for us and are paid very well to fulfill our wants our needs. So instead of behaving like the paid service providers they are we allow them to impose there will ( not the law) on people ( my self included) at a time when they are at there lowest, filled with overwhelming stress,anxiety, feelings of self doubt, worthlessness, and the list goes on most of it worse!

    We are at our most vulnerable point of losing ourselves and instead of relieving some of those horrible thoughts/feeling you add to it! Instead you have taken a place that should be filled with kindness and understanding and replaced it with something that more resembles a prison they/you are more worried about something that might one day kill us a few years below the national average!
    when you should be thinking of how many people will we deter from asking for help because we are treating them like a number as we go down a check list provided by some overpaid board member with no medical training and whose sole concern is the bottom line and a bigger bonus

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