The Psychiatry SHO*

Smoking in psychiatric hospitals

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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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