Yes, it should. The ideal psychiatric inpatient unit, IMO, is inside a general hospital, and should be treated as a general hospital - smoking should be prohibited for everyone inside.
Where I work, (psychiatric unit for drug addiction inside a general hospital)it is banned. For patients, Nicotine patchs help with nicotine abstinence. We had no ethical problems - this is a rule for receiving treatment, if patients do not wish to follow this rule, of any other rule for that matter, they won't be accepted.
Even with the patch, they often complain of nicotine abstinence. This is then discussed with the patients, sometimes we increase patch dosage.
This is a very complex issue.
The vast majority of people with a serious and persistent mental illness smoke tobacco.
Boredom and social factors are probably one of the main reasons. Generally speaking, in western post-industrial cultures, tobacco smoking is most common amongst people from lower socio-economic status, and from backgrounds of disadvantage. However there is a considerable amount of evidence that nicotine counteracts some of the negative symptoms of psychotic disorders, and that nicotine also reduces some of the negative side effects of atypical antipsychotics.
Several years ago all the public hospitals here in Western Australia became no-smoking campuses. Previously, small smoking areas were provided outside the hospital buildings. Now you have to leave the hospital grounds to smoke.
This change in policy was relatively unproblematic in the general hospitals, but caused some unique challenges in our state psychiatric hospital. After the Psych Hospital went completely no smoking, we saw some unintended consequences-
Initially, assessing some patients became more difficult, as they would typically present whilst acutely unwell, and the first thing we did was denied them cigarettes. (Patients are offered nicotine patches or inhalers as a substitute).
We saw agitated patients acting out in ways they probably wouldn't have if they had allowed to smoke a cigarette.
Some psychiatrists also commented that it was harder to quickly assess mental state in someone who was experiencing anxiety and distress due to disruption of their normal nicotine consumption pattern.
These issues settled a bit over the first few months of the new policy, as patients who regularly are hospitalised got to know what to expect, and as staff got more practiced at managing substitution with other nicotine products.
We saw a slight increase in fire incidents, as even in locked wards cigarettes would sometimes be smuggled in, and now any patients who did have access to tobacco were smoking it surreptitiously.
There were a number of incidents involving patients doing things like breaking open inhalers, sprinkling in some tea leaves, and then setting fire to the leaves and inhaling the resulting fumes, or trying to extract nicotine from patches by soaking it in water and lemon juice.
While patches and inhalers are much safer delivery routes for nicotine than pyrolysis/inhalation (smoking) of tobacco, they don't perform the same way as a cigarette. Patches in particular are not as rewarding or immediate as inhalation routes of administration, and the continuous infusion means that people often end up consuming much more nicotine via patches than they are accustomed to via smoking. Inhalers are a probably a better replacement system as they continue the conditioned hand-to-mouth behaviour, and mimic the "smoke break" pattern of behaviour.
Perhaps a more significant consequence was that the most heavily nicotine dependent patients now found being in hospital even more unpleasant than usual.
We found that, on average, voluntary patients were choosing to discharge themselves from the hospital earlier than was the case before the no-smoking policy was introduced. While I heard a hospital administrator say something along the lines of "Good, less "bed-wasters" I am certain that some patients who would have benefited from a longer admission were leaving early because they wanted to be able to smoke.
We also observed an increase in involuntary patients who had unescorted ground access going AWOL, for the same reason.
After 5 years of total no-smoking policy, the hospital has (incrementally) reverted to pretty much the previous system.
Initially, nursing staff started ignoring patients from the open wards who smoked discreetly on the grounds. It was impossible to police, and these patients would just wander off the hospital grounds into the surrounding suburbs if prevented from smoking in a quiet corner of the grounds.
Nurses pointed out to the executive that they weren't security guards, and that expecting them to behave in this role was changing the nature of patients relationships with clinical staff.
After a period of tolerating smoking by patients from the open wards, staff in the closed (locked) wards began allowing patients to store tobacco in their locker, and to access it never they were granted ground access. This led to less surreptitious smoking in the ward, and less cigarette lighters being smuggled in. Most patients were happy to use patches or inhalers to maintain their dependence if they were allowed just one or two cigarettes per day.
A few months ago the hospital administration finally admitted defeat and there is now a small designated smoking area in the exercise yards of each locked ward, with a secure lighter.
All of our other public hospitals remain totally non-smoking, and inpatients on mental health wards must leave the grounds to smoke. For patients who are not allowed to leave the ward, this means no cigarettes at all. These are much smaller units, and so easier to control, than the massive specialist State Psychiatric Hospital.
I work in public health and disease prevention as well as mental health. I am acutely aware of the enormous health costs of tobacco smoking, and the benefits (personal and population level) of assisting people to quit smoking.
I also work in the field of treatment for drug dependence. Interventions to assist people to reduce or cease use of a drug of dependence are most effective (in terms of sustainable long term abstinence) when the person decides they want to change their substance use, not when such a choice is coerced. This particularly true of a legally available substance such as tobacco. Addiction to tobacco smoking is one of the hardest drug dependencies to quit. If we stop people diagnosed with serious mental illnesses from smoking during their admission (a few weeks, or even a couple of months) and then discharge them to the same environment that they are accustomed to smoking in, we should not be surprised when >95% of them revert to smoking again.
I do agree with you, Thiago, when you write that ideally all hospitals should be no-smoking zones. However I think there are more effective strategies we could implement to reduce the smoking rate amongst people suffering serious and persistent mental illnesses.
You wrote
I hope these posts are not viewed as adversial. I'm not trying to start and argument, and I do agree with the general public health goal of reducing the morbidity and mortality that is directly attributable to smoking tobacco.
However in this specific population I would suggest there are unique challenges and issues of concern to consider. If a total no smoking policy is to be adopted, these need to be understood and addressed by that policy. If it is simply introduced as a directive from above, with no support beyond provision of nicotine patches, gum or inhalers, it is likely to impact negatively on mental health treatment for a significant number of patients, but not result in a significant reduction in smoking rates within this population.
I hope these comments are useful food for thought.
regards,
Paul.
" However there is a considerable amount of evidence that nicotine counteracts some of the negative symptoms of psychotic disorders"
However, I think there is now good reason to suppose that smoking aggravates or triggers the positive symptoms, like cannabis and other drugs.
In my country, treatment programs routinely do not permit substance use of any form in in-patient care. I admit that nicotine dependence is one of the most difficult substances to wean off even when the client is motivated. The issue of passive smoking, effect on other patients in in-patient care should also be considered when arguing the pros and cons of permitting smoking in in-patient care.
I work in an acute care inpatient environment - and Adult Psychiatric inpatient unit - the the United States. In the last several years we were required by law to convert to a no-smoking policy. Prior to this we had a "smoking room" on the unit where the inpatients who were smokers could go to smoke a cigarette at specified times per day. The smoke still managed to work it's way out into most of the rest of the unit though - and you could always smell it on the patients' clothes. When the rule came down from above that there was not smoking ANYWHERE on hospital grounds - we decommissioned the smoking room and gave all smokers a patch plus prns of gum, lozenges or oral inhaler. We informed all patients about this before they were admitted and rarely did we have a problem with anyone leaving because of the policy (probably because all other local acute care facilities had to adopt the same no smoking policy). We thought that we would have a mass mutiny of patients - or at least a minor riot - and actually it didn't turn out that way. I remember one or two patients (who were voluntary admissions) complaining and leaving early because of the policy - but the vast majority of the patients grumbled but accepted the patches and inhalers, or gum or lozenges. We offer to send them home with their inhaler, or send them home with the amount of patches left in their hospital supply - if they want to try and quit. In the USA some of the nicotine replacement products are available over the counter, but others require a prescription. If they need a prescription, the insurance companies will often cover the cost, but if not, then the patient has to cover the cost themselves for anything that's available over the counter. ( a system that is NOT conducive to helping people quit smoking). We generally do not use varenicline because we are afraid of the possible CNS related side effects in our population. A lot of times patients don't have a desire to quit smoking - and we accept that - since we are acute care, we figure that we will leave it to their outpatient provider to work on motivational interviewing for tobacco cessation. We have had a couple of folks smuggle in cigarettes, but it's pretty easy to catch anyone trying to smoke on the unit - they are warned the first time - and discharged the second time if they smoke on the unit. They can smoke if they go on pass away from the hospital - but no one is allowed to smoke on hospital grounds - so security will stop them (or any other patient - psychiatric or otherwise) if they are caught. Mostly the no smoking policy - with nicotine replacement for smokers - has worked a whole lot better than I thought it would.....and since it's now pretty much the law of the land in our state - we don't stick out as being "bad guys". I'm in favor of it because I'm a nonsmoker and have had to put up with second hand smoke my entire life - starting with my parents - and I'm asthmatic. I'm concerned with patients not quitting smoking as a result of this policy - but I'm not sure that's the point - I think that the lack of second hand smoke for the rest of the patients and staff in the hospital is more the point.
Sally
its hard work to start with but ultimately it works and if this is law of land , you are not for blame. My experience on medium secure forensic units in UK , its well taken by patients and they don't seem another other option but to try NRT. Though we have seen some patients trying to smoke the 24 hour supply in an hour when they are off the ward or some patients asking for more leave just because they want to go out and smoke.
the problem here is that you can not force or coarce an individual to quit a habit even talkless of a dependency. what I advocate is gradual withdrawal and then posible abstinence. the individual should then be taken away or get separated from the place where the substance is available after the inpatient care.
Hi Anthony,
A colleague just published on this topic, looking at mental health patients in the emergency department context:
Donley, E. R. (2014). Managing Risk of Difficult Behaviours in the Hospital Emergency Department: the Use of Cigarette Breaks with Mental Health Patients. Social Work in Mental Health, 12 (1), 36-51.
Euan interviewed staff from a range of disciplines re actual practice and reasons and noted that, despite public health policy establishing hospitals as smoke-free, staff regularly allowed cigarette breaks to manage risk associated with difficult behaviours. Despite agreeing with the philosophy of hospitals being smoke-free, staff reported barriers including: being time limited, limited resources, poor compliance from patients, and that a personal crisis for the patient is not an appropriate time therapeutically to enforce smoking bans.
Hope this is useful.
Hi Melissa, thanks for the reference. Would you have a pdf file available? Cheers. John
Hi Melissa,
I would also be interested to see a PDF of the article.
Paul.
Hi John and Paul,
I am attaching the pdf now. Let me know if there is an problem with the upload.
Euan will be pleased at the interest - cheers!
Melissa
I am Working on a inpatient psychiatric unit (Adult Psychiatric inpatient unit ) and we are going to began with the banned of consumption of tobacco in the coming weeks, I'd like some initial advice and, if possible some written information to give for patient s about this issue before they will be admitted. At this moment we have a "smoking room" on the unit where the patients who were smokers could go to smoke a cigarette at specified times per day
Hi Melissa,
Thanks for the article- greatly appreciated.
Hi Ignacio,
Here's some tobacco-cessation advice from a harm-reduction perspective;
Smoking cigarettes is one of the hardest habits to break- it is very deeply conditioned.
Some people stop "cold" first attempt, but if you have been a smoker for many years repeated failed attempts is a far more likely outcome, at least initially.
I think most "quitting" guides actually set you up to fail. They are too simplistic, and assume "will-power" and some motivational catch-phrases will override conditioned autonomic behaviours.
If you have spent years conditioning yourself to smoke, you should spend a few weeks or even a couple of months preparing to quit. So, instead of stopping cold, you need to modify the way you are smoking, make yourself more consciously aware of your smoking, and reduce the frequency with which you smoke. Don't tell yourself or anyone else that you are quitting. Just decide you are going to cut down.
There are some simple tricks to help with this- for example;
> Progressively delay your first cigarette of the day until as late as you can, and you will smoke less per day.
> Reduce your opportunity to smoke "on auto-pilot", (ie, when you pull out a cigarette and light it unthinkingly). Ways to do this include-
* stop smoking inside the house and whilst driving or walking anywhere,
and
* switch to roll-your-own tobacco.
If you have to stop the car, go outside, and/or roll one up, you have to make the conscious decision to have a smoke.
If you follow the two steps above, you will probably find yourself smoking considerably less cigarettes per day. (When I started only smoking outside and stopped smoking in my car it reduced my cigarette consumption by about 1/3).
Be aware of how often you smoke. If you go outside for a "smoke-break" every hour or so, try to space your smoking a bit further apart, BUT don't abandon your breaks. Practice going outside when you would normally have a cigarette, but don’t light one up. Just stand in the sunshine and breathe deeply. Watch the world go by. See if you can skip one "smoke-break" a day in this way, (so you go twice as long as usual between two of them). But if you feel like having a cigarette 1/2 an hour later, do so, and don't beat yourself up about it. Once you are comfortable skipping one smoke, try spacing them progressively further apart.
Buy a tin. Put however many cigarettes you normally smoke a day in there each morning, and you'll notice anytime you are smoking more or less than usual. Don't beat yourself up if you smoke more than your daily quota on a busy or stressful day, or when socialising, but feel proud on those days when you still have smokes left in your tin by the time you go to bed. Slowly reduce how many cigarettes you take in your tin each day.
The object of these exercises is to make you more aware of your smoking, and to regain enough control to only have a cigarette when you want to, not when the conditioned hand-to-mouth autonomic pattern asserts itself.
These exercises should reduce how many cigarettes you have a day, which (even if you never stop smoking) means you'll be doing yourself less harm and spending less money. You will probably be surprised at how comfortable you can feel with only 3 to 5 cigs on an average day.
Cutting down in this way over two or three months will significantly reduce your body’s level of dependence on nicotine, so that if and when you do stop smoking the withdrawals and cravings won't be as serious or last as long.
I thoroughly recommend Pavel Somov's excellent harm-reduction guide to quitting smoking;
http://www.goodreads.com/book/show/12335515-the-smoke-free-smoke-break
.
Pavel uses mindfulness meditation combined with similar strategies to the ones I've outlined above, and he is a great writer as well.
Paul.
"The object of these exercises is to make you more aware of your smoking, and to regain enough control to only have a cigarette when you want to, not when the conditioned hand-to-mouth autonomic pattern asserts itself."
I'm struggling a bit trying to understand the overall theoretical rationale. Is it
a) Conversion of smoking from an automatic subcortical process to a cortically-controlled one?
b) Counter-conditioning or deconditioning of a conditioned response?
c) Extinction of a conditioned response?
What an insightful question, Anthony! Can we go for the classic multiple choice option of "d) All of the above"?
Also, while 'c)' might be a rationale it is less likely to work in and of itself since people tend to substitute a coping aid with another one, even if they are more mindful in their approach to stressors and routines...
And 'b)' would not be 'counter-conditioning', ideally, since a goal is greater empowerment; deconditioning fits though.
Thank you for the reminder to think about underlying mental processes.
"Can we got for the classic multiple choice option of "d) All of the above"?"
No.
My apologies if someone else has already interjected this point, but a long-standing body of work has examined the role of P50 gating deficits in schizophrenia, and the effects of nicotine in attenuating gating deficits. People with schizophrenia (at least) most likely derive real and quick benefit from nicotine, and I am not sure that it is obvious that the bioavailability of nicotine to serve this function is identical between smoked tobacco and, say, a patch.
This is not to say that smoking cessation isn't the ideal outcome, all else being equal; however, for many hospitalized psychiatric patients, there is probably a combination of both "typical" habituation & dependency issues, along with symptom-specific self-medication, present in an inpatient psychiatric context. I say this only to lend support to previous commenters that the issue of absolute smoking bans in psychitric settings is quite complex.
Here is a ling to Google Scholar search results on the topic, if anyone is interested. I should also add the caveat that this is not a research topic I have worked on directly - I simply add it as information.
http://scholar.google.com/scholar?hl=en&as_sdt=1,33&q=p50+schizophrenia+nicotine&scisbd=1
Christopher, thanks for the link and information. I am aware of some of the work on schizophrenia and nicotine.
An interesting question, at least to me, is whether the act of smoking (holding the cigarette, bringing it to the lips, inhaling, etc.) helps the person with schizophrenia stay "focused"? - if we assume that the person with schizophrenia has difficulty staying focused on the reality at the time. What are your thoughts on this?
Could it be a bit like talking and using your hands (gesturing) at the same time? John
Hello,
I am responsible for a psychiatric intensive care unit (adults) and we have banned smoking in recent years for patients in the unit and during the accompaniments in the park in the presence of caregivers. After the period of implementation of this measure, caregivers took the experience to manage smoking cessation and substitution treatments. Patients complain that deprivation but the majority tolerate this regulatory decision as it is applied to all. From my perspective it generates less frustration and conflict that allow a limited number of cigarette which is an opportunity for negotiation and tensions. We conducted a study (soumited to press) comparing smoking and non-smoking inpatients (good clinical matching on all criteria) observing the criteria of risk of violence (Brosët Violence Checklist, time of seclusion, day of violence monitoring protocol). The differences were not significant. Similarly, for smokers inpatients, intensity of smoking was not correlated with those criteria of violence. Some patients expressed to have had a positive experience of withdrawal from tobacco, realizing it was possible despite a difficult context, what they never imagined possible. Mortality from tobacco of our patients being so high, it became impossible not to act during hospitalization, witch is often a time where patients increase their consumption and influence each other to smoke. In the past, my opinion was different and focused on the respect of freedom of patients. Today I think we have a responsibility to the future of the physical health of our patients.
fyi, when I opened the psychiatric unit at the Allen Pavilion in 1988, part of Columbia-Presbyterian medical center, we were, to the best of my knowledge, the first non-smoking psychiatry service in New York State.
"To assist someone quit smoking, or reduce their habit, empowers an individual in other areas of his/her life also."
Only if it is successful!
In my experience people don't decide to quit using an addictive substance until they experience consequences (legal, family, work, medical) and they also are not able to make the decision to quit while they are still using the addictive substance. Tobacco use doesn't really create any significant consequences except for medical and by then it is often too late to change the end result of that consequence. I think it is imperative that health professionals - especially mental health professionals, provide patients with an environment where they are free of all addictive substances and are then able to make better decisions about whether they are ready to quit smoking or not. I believe that all inpatient/residential programs should be tobacco free and provide education and treatment to encourage tobacco cessation. This is really no different than not allowing alcohol or drug use while the person is in the program and encouraging abstinence after discharge.
Our 90-day inpatient dual-diagnosis (substance abuse and mental illness) treatment program has been tobacco free since 2000. The longer we have been doing this the better we have become in getting people with serious mental illness to make the decision to stay away from tobacco after discharge. Prior to going tobacco free about 56% of people successfully completed the 90 day program. We now have 80% successfully completing. Going tobacco free actually improves outcomes.
I have worked in an inpatient acute psychiatric facility for eight years. I have been in the area of psychiatry for approximately eighteen years. I can attest that cigarettes bring out the worse in our patients. The environment ceases to be a therapeutic milieu. Patients have offered sexual favors to each other to obtain a cigarette. The facility has since complied with the federal law and stopped inpatient cigarette smoking. Well, the patients decided to open the electrical outlets to ignite their cigarettes they received from family members. The result was the unit went up in flames. A patient hid a lit cigarette in the mattress. Fortunately, no one was hurt. The nurses and other staff members were able to rescue all of the patients. In addition, staff members have been physically injured when doling out cigarettes to patients. Is offering cigarettes to mentally ill patients a healthy way of rendering care?
I think that discussions of allowing cigarette smoking on inpatient psychiatric units needs to the cease. The focus needs to be on smoking cessation. In the area of psychiatry, care received by the patient is not only for mental illness, it is also for addiction. Why are we engaging in this debate about whether or not psychiatric patients should or should not smoke? We are healthcare providers and as such, the topic of discussion should be on health preservation. The patients need to be guided towards healthy changes, and smoking is not one of them.
Dear Anthony
The mentally ill are a group more vulnerable to smoking . The impact of smoking in this population was , for many years , neglected , due to failure to recognize that smoking is a form of addiction , the gap in perception of medical complications that habit and limited knowledge about the association between smoking and psychiatric disorders
Studies show that the prevalence of smoking in people with psychiatric disorders is higher than in the general population , including higher levels of tolerance and dependence
The patient shall have the right to smoke , even in closed environments such as hospitalization ( matter of legal right ) . The release of cigarette use can , in turn , be used as a guarantee that patients follow treatment recommendations and participate in various therapeutic activities offered . The smoke passes , therefore, be seen as an instrument that soothes and facilitates social interaction of patients . It is believed that the ban on cigarettes would increase the aggressiveness of patients
Am I hearing that we are, in a therapeutic environment we are bargaining with care? Take your medications and your will be allowed to smoke, eventhough it is not healthy. Psychiatric patients need guidance, assistance and directions, not bargaining, amd most of all unhealthy one. Psychiatric medications are very potent, why do we want to had to medical dilemmas.
Dear Paula
Smoking is an addiction to drugs maintained by a variety of processes , ranging from physiology and behavioral conditioning to international policies
Quitting smoking is not about a simple sudden decision to become a " regular smoker " in a "non -smoking " . Until an individual actually decides to quit, he runs a subtle way, full of comings and goings . They are called " stages of change " , which were well described by Prochaska and Di Clemente :
1. Pre- contemplative stage : in this stage the individual does not intend to quit smoking in the next six months. Patients are those who see more pros than cons to smoking , who deny the dangers of smoking to health ;
2 . Contemplative stage : seriously intend to quit smoking within the next six months, but in fact , is ambivalent . Find some more cons than pros to smoking but if in doubt , do not stop ;
3 . Preparing for action : Want to seriously stop the course of the next month. Starts intuitively using behavioral techniques to get rid of smoking. Postpones the first cigarette of the day , reducing the number of cigarettes smoked etc. . Made at least one attempt to quit smoking in the last year ;
4 . Action: The individual stopped smoking ;
5 . Maintenance : Even six months after the individual has left the tobacco . This period does not occur passively , just leaving things as they are . The individual uses behavioral mechanisms of adaptation to the environment without cigarettes , and may even change their daily routine ( like going to take no more coffee, for example ) .
The concept of these phases is important in view of the treatment , the intensity, duration and type of intervention should suit the stage of change of the patient. Individuals at a later stage should benefit from more intense and types of action-oriented intervention. Individuals in an initial process of change ( pre - contemplative , for example) should require less intensive types and more extensive programs , so you can follow them through the quitting and moving them successfully to the stage of cycle action.
Every patient requires individual approaches and we should always use common sense
Dear Nelson
In light of using common sense, it is well known to a psychiatric nurse practitioner that addictive behaviors do not end overnight. It is the aesthetic of the profession that affords one this knowledge. One is not implying that addictive behaviors should be arbittrarily and abruptly end. However, it has to be continuously addressed in order to elicit a behavioral change. Do you feel that there is a correlation between addiction and compulsion? Do you feel that one's environment lends to addictive/compulsive behaviors? And finally, are you a smoker?
Dear nelson,
Ban or not tobacco psychiatric hospitalization has nothing to do with the motivational approach to addictions. Similarly it prohibits consumption of alcohol and cannabis, cocaine also even for patients who are at precontemplative stage. The usefulness of the tobacco ban does not impose a withdrawal but lucidly take a consistent approach to health, and the opportunity for patients to question their behavior and may be moving their motivational stage.
Dear Paula
Thanks for your opinion.
By the way I am not a smoker.
Regards
Concerning the ethical aspects of banning tobacco from these units, absolutelly yes. Non-smoker patients and staff would support this. On the other hand, abiding to the same rules than other medical patients in the hospital makes the psychiatric patients less different, and this is good. In relation to the practical issues, I have been working for twenty years in brief hospitalization units, and had no relevant problems with banning tobacco. No riots, in particular. Actually, some small problems did happen, mirroring those derived from banning substances in the outside world (in particular, small-scale kind of "traffic"), whose relevance is very much smaller than the consequences of smoking. In addition of the known passive smoking, I have direct notice of very serious fire incidents derived from allowing smoking.
Most patients do not stop smoking after release, but a few do. This is worthy. Moreover, patients have the opportunity to realize that they can stop smoking, and to try new approaches to this end previously unknown to them. This may move a few cases from pre-contemplative to further stages.
A hospital setting is a closed setting with people there who have to live and work with people in the same milieu. One person's 'rights' can not infringe on another person's 'right' if it is indeed a legitimate 'right'. Each 'right' is balance by a similar 'responsibility'. Access to fresh healthy air is a 'right' for all people and is balanced by the responsibility to do what we can to keep the air healthy.
Arguing that smoking is a 'right' is to argue that only some people have 'rights' as the 'right' of the others in the environment to clean healthy air is denied. Non-smokers' rights to have fresh clean air free of second hand smoke has led to laws in Canada limiting where people can smoke. Hospitals and all public spaces are now smoke free.
While smoking is an addiction, and more prevalent in people with mental illness, and is an activity that people are legally free to engage in, I think it is a stretch to argue that smoking is a right as this infringes on the rights fo everyone around the smoker.
One concern that has not been mentioned is that people with mental illness often continue to smoke to blunt the effect of the medications. Research by Dr. Cheryl Forchuk found this to be the case. When a smoker ceases smoking, the effect of the medication is much stronger, requiring an adjustment in dosage. It is interesting the the interaction of smoking with medication and subsequent impact on recovery has not been part of this discussion.
Hi Elsabeth,
>
I do agree, although if a designated smoking area is set up appropriately, someone exercising their legal right to smoke tobacco should not impact upon non-smokers.
>
Actually, if you scroll up the discussion you'll see a couple of people have mentioned that nicotine ameliorates some of the negative side effects of anti-psychotics. It also appears to reduce the severity of some of the negative symptoms of schizophrenia.
Regards,
Paul.
This journal article maybe of intersest.
Article Evaluation of a smoke-free forensic hospital: Patients' pers...
Hi Elsabeth,
This issue of living and working in the same milieu is actually very important. Oddly for different reasons over time staff 'rights' seem to regularly get challenged on the clean air issue in practice.
15 years ago when I worked in public inpatient psychiatry there was very much a disease model in place to conceptualise psychiatric illness, and the perspective that patients who smoked were doubly disabled by their psychiatric symptoms and their substance dependence. There was an implicit perspective that we had to live with it as staff.
Most of the assessment work and discharge planning I conducted seemed to be on the veranda while people chain smoked. A greater sense of the 'rights' of staff to clean air then would have been useful. Staff who entered the work place as non-smokers often took up the culture of the environment.
There are different challenges under a recovery model, now very strong in policy in Australia and increasingly being operationalized. While there is more hope in the approach for patients, and greater client-centred practice/individualised care planning, I witness the risk that there can be some disempowerment of staff. Staff pick up on the changed power differential in the model. There can be an interpretation of the paradigm shift as one that is less valuing of staff training and professional knowledge. This can make it harder for staff to assert 'rights', including a right to a smoke free environment.
Here is some food for thought from a Canadian mental health nurse now
living in Australia.
In Vancouver British Columbia Canada smoking has been banned in public parks in 2010. Arguably this law will be difficult to enforce but it does exist.
The province of British Columbia already has has laws in place banning smoking in any indoor public areas, at bus stops and next to public doorways and windows. Vancouver also has a bylaw banning smoking on outdoor restaurant patios.
In contrast , when walking in the streets in Melbourne , it is common to "share the same air" as smokers.
I believe that if the tide is turning from a focus on the civil rights of smokers to the
rights of the children and adults who choose not to engage in this legal activity, we
might need to consider the rights of workers.
Thank you Debra, Yes - useful to get these perspectives and updates from different countries.
It would also, indeed, be easier to support consumers with mental illness to make healthy lifestyle shifts if there was a broader public health normalisation of this change. Perhaps in Australia was have not gone far enough with bans on smoking in restaurants and workplaces, and the (quite disturbing) images on cigarette packaging?
It will be interesting to see how they monitor and enforce the laws in British Columbia over time.
Here in Perth, (Western Australia), smoking has been banned in cafes, restaurants and bars for some years. Recently the local Government has banned smoking in all pedestrian malls in the City. Smoking is now banned on all beaches.
In the US it is not allowed even in the hospitals. It is however important to realize that most patients with psychiatric disorders have nicotine dependence
We evaluated the implementation of a smoke-free policy in a high secure mental health inpatient facitily. The journal article attached describes staff experience and attitudes.
We evaluated the implementation of a smoke- free policy in a high secure mental health inpatient facility. This journal article describes the staff experience.
There are studies which show that patients with schizophrenia smoke as it helps them either with their symptoms or to reduce the level of antipsychotic medications. it is extremely difficult for schizophrenia patients to stop smoking. I feel that there should be separate area for patients to smoke, but every patient should be offered treatment for smoking cessation.
"There are studies which show that patients with schizophrenia smoke as it helps them either with their symptoms or to reduce the level of antipsychotic medications"
And studies that don't. The most pertinent fact is surely that most start smoking long before they start getting symptoms of the disease. So the idea that smoking, like cannabis, causes schizophrenia, at least in those with a genetic liability, needs to be taken very seriously.
Well... given the fact that you are usually in crises when you are in a psychiatric unit and given the fact, that it is not wise to make life-alterning changes when you are in crisis: could there be a time that is worse to try to quit smoking?
I think: banning smoking from (especially locked) wards is counter-productive: banning smoke from the ward: that should be the goal at hand. So I think balkonies where smoking is possible is the best solution.
I think it is important to recognize that when psychiatric units are tobacco free, no one is expecting anyone to "quit" smoking. They are just providing a safe environment, free of tobacco where people can have nicotine replacement to help deal with nicotine withdrawal and a lot of education about why it would be good for them to consider using this time to quit smoking. This is sending a consistent message about what is best for their recovery and overall health. I don't think anyone would consider suggesting that people addicted to alcohol or other drugs should be able to continue using these substances even though they are in "crisis" and usually use these to manage their affect and mood.
As far as smoking is concerned, I think there should be several settings. In general hospitals and psychiatric hospitals it should be generally forbidden, even for patients with drug addiction. But there should be also low level settings for people who are no inpatients and have a heavy and combined (multiple drugs) drug addiction, where it is allowed to smoke. In Switzerland we have very good experience with the so called zokl`s (Zürcher heroine consume location). These are low level locations for people with very heavy or multiple drug addictions including heroine, where they are allowed to take methadone or heroine under professional guidance. Of course these people are also allowed to smoke. These locations aim to prevent HIV, AIDS and hepatitis and people who get their methadone or heroine there must have regular contact with a physician from this institution. In some cases it is possible to reduce or even stop the drug abuse. And many of the drug addicts who are treated there are able to work again. We must not forget that there are some people who are as heavily ill that they can`t stop all abuse at once.
The average length of stay in an acute psychiatric inpatient unit in Victoria, Australia is under two weeks. People are admitted for illnesses that have crossed a threshold of severity/acuity/risk. The question is whether much can be achieved for long term health of such patients by imposing controls on smoking for a short period when they are feeling their worst. Educating is important and offering choices is important but in the end we should be pragmatic. Isn't that what recovery is all about? When we attempted to be smoke free unit, there was no mutiny, just a lot of contraband entering the unit and occasional fires.
It is illegal to smoke on wards in the UK anyway but banning it entirely is a step too far. Some patients undoubtedly suffer ill health through smoking and some of the products of tobacco smoke interfere with the metabolism of medication but the comfort of a smoke is for some patients one of the last personal freedoms they have. Let them smoke in designated areas where they don't impinge on the sensitivities on non-smokers and a plague on all health fascists!
Dear Friends,
Good answers ALL! -- reflecting knowledge of the health risks associated with tobacco smoke, the complexities of dealing with concurrent disorders (in this case "addiction to nicotine" and "another mental disorder" [i.e., the "reason" that the patient is currently institutionalized]), and care/concern for the rights and well-being of the psychiatric patient. As one who has both specialized in the clinical treatment of individuals with concurrent disorders and written several clinical textbooks dealing specifically with the drugs and substances of abuse, I would, however, offer a slightly different perspective.
For almost 50 years now, the adverse effects of tobacco smoke (BOTH mainstream and side-stream) have been well documented in the research literature with concerns centered largely around lung/respiratory damage ranging from chronic irritation (and associated smokers cough and/or exacerbation of chronic obstructive pulmonary disease) to lung cancer. These toxicities occur in both the smoker as well as those who inhale side stream (or second hand) tobacco smoke. THUS, it is patently illogical, if not unethical, to allow or facilitate tobacco smoking within a health care setting (e.g., inpatient psychiatric units).
That said, as mental health care clinicians we are also concerned with the mental well-being of our patients and taking away their cigarettes may cause some significant amount of distress. This can be readily dealt with today by the substitutive use of nicotine replacement therapies (e.g., gums, patches, sprays, etc). In addition, the use of electronic cigarettes (e-cigarettes) can assuage the patients craving for nicotine while also relieving some of the behavioral issues related to the physical activity of "smoking" a regular cigarette --- ALL while significantly reducing, if not totally eliminating, the toxicity associated with tobacco smoke.
I hope that this helps . . . both your patients and yourselves to be healthier.
Sincerely,
Lou
The worse I have experienced as regards this issue is when the staff compelled a patient who just stopped smoking to restart. Smoking should absolutely be banned from inpatient wards but also from outside the hospital. It looks really bad when people in white coats smoke behind the hospital corner!
Did anyone predict this?? (Incidentally, the excess mortality of the mentally ill was spotted centuries ago long before smoking came into the picture)
"New research into the impact of a smoke-free policy at the trust reveals a 39 per cent drop in physical assaults - both between patients and towards staff.
The research was led by King's College London and was published in The Lancet Psychiatry. The study has important implications for the introduction of smoke-free policies, not only in psychiatric hospitals but also in other institutions such as prisons.
Smoking within psychiatric hospitals has long been a cultural norm, and is thought to be a major reason why people with mental health problems die 15-20 years earlier than the general population. Despite this, smoke-free policies have previously been hampered by concerns, especially from hospital staff, that physical violence will increase.
In 2013, the National Institute of Health and Care Excellence (NICE) recommended the introduction of smoke-free policies in acute, maternity and mental health services, with on-site help for patients - whether they want to stop smoking or not - to manage their withdrawal symptoms.
As part of SLaM’s policy, smoking is prohibited in the buildings and grounds of its four south London hospitals, smokers are offered stop smoking treatment such as nicotine replacement therapy (NRT) and patients are allowed to use e-cigarettes.
The researchers from King’s College London, SLaM, University of Nottingham and University of York, analysed incident reports of physical assaults 30 months before and 12 months after the smoke-free policy was introduced.
During this study period, there were 4,550 physical assaults, with 2,916 towards staff and 1,634 between patients.
Researchers found a 39 per cent reduction in the number of physical assaults per month following the introduction of the policy. This was after accounting for general and seasonal trends and a range of factors that could also have influenced the rates of violence. For example, the number of patients on the wards each month who were male, of a younger age and detained under the Mental Health Act.
Dr Debbie Robson, Senior Post-Doctoral Researcher in Tobacco Addiction at King’s College London, said: ‘Hopefully our findings will reassure staff that introducing a smoke-free policy does not increase physical violence as is often feared'."
Is it ever ethical to impose bans on people who already have their dignity and liberty taken away from them?
The risks of tobacco smoke are voluntary risks. Neuroleptics are dangerous too but patients rarely have choice on whether they take that risk. Perhaps we should ban them instead.
Many people naively believe that they live in a free world
Or in other words have the freedom of choice,
BUT – this is a BIG MISTAKE
The ban on smoking is an infringement of one of the very few
real freedoms.
And in relation to patients - smoking is often the very last pleasure
remaining in their lives. Do not take it from them.
"Is it ever ethical to impose bans on people who already have their dignity and liberty taken away from them?"
So you would regard it as unethical to intervene with someone with dementia? So no confinement to a care home, no medication, they should be allowed to roam the countryside if that is what they want.
"So you would regard it as unethical to intervene with someone with dementia?"
What has that got to do with denying someone the last free choice and dignity they have?
It is unethical to deny people free choice, most certainly.
"It is unethical to deny people free choice, most certainly"
Can we have a list of any laws that do not depend on denying people free choice?
"Can we have a list of any laws that do not depend on denying people free choice?"
For what purpose?
""Can we have a list of any laws that do not depend on denying people free choice?"
For what purpose?"
All laws restrict the freedom of some people in the wider interests of other people or society in general. eg, Stop at a red light. I do not think there is any exception to this, so I do not in fact think anyone will be able to compile such a list, or even give one good counter-example.
"It is unethical to deny people free choice, most certainly."
Blind adherence to this principle can result in destructive farce:
"Deborah, who has the build of an eight-year-old, lives in a family-run care home... My other sister and I recently applied to the Court of Protection for powers of attorney to allow us to decide on Deborah's welfare and finances. The rules seem designed to prevent scheming relatives from abusing the vulnerable but not to help family members look after their loved ones. The most irritating feature was a bone-headed insistence that Deborah offer her consent to the measure, a demeaning pantomime given our repeated explanations, backed by medical evidence, that she cannot speak and understands only love, not money. Yet as The Times reported yesterday, the authorities seem all too ready to assume that vulnerable adults have given their consent when it comes to unpleasantness, such as sexual assault".
Edward Lucas The Times July 28 2017 p 25
Vaping should be allowed, if not encouraged in situations where every other therapeutic intervention has failed dramatically. A good starting point would be to watch the documentary "A billion lives". :-)
It would be odd indeed if we were to assess capacity on those who lack it most. The Mental Capacity Act 2005 works on the sensible concept that all people are to be taken to possess capacity unti shown otherwise. It is ethically unsound by all recognsied standards to do it the other way around.
Even those with very severe psychotic disorders possess sufficient capacity to make decisions for themselves including those involving life theatening conditions, see Re C. (Adult Refusal of Treatment [1994] 1 All ER 819.
If patients wish to smoke, providing they do not do it indoors then they have every right to, while it may be incumbent on medical staff to discourage them from this habit it is utterly unacceptable to deny them the rights to chose and a fundamental breach of medical ethics to intervene where their intervention has been denied.
We had to implement the smoking ban because of the spreading covid crisis in all departments of the hospital including the closed psychiatric ward. To my opinion the ban works very well. Only few patients are complaining about the ban. All smokers have been offered smoking cessation aids including nicotine patches, varenicline, and counceling already years before starting the absolute ban. But legal advocates now are arguing for free will and the right of self determination. Is there really a human right for self harm? I also doubt a free will of heavy tobacco addicts choosing or not choosing to smoke.
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