An unholy alliance of quangos with an authoritarian agenda, are riding roughshod over the will of patients, doctors and nurses in demanding a total ban on smoking in psychiatric hospitals.
As of June 2015, 9% of psychiatric hospitals have banned smoking both inside and outside. 83% of units only permit smoking outside. 63% prohibit e-cigarettes. Public Health England (PHE), sponsored by the Department of Health, and with the backing of the National Institute for Health and Care Excellence (NICE), are pressing for 100% ban, inside and outside.
PHE believes the lower life expectancy of all smokers is a “health inequality” to tackle. PHE hates anyone smoking, but with mental health in-patients, they have discovered some easy targets. These people are atomised, captive, and distressed, often lacking the ability and means to rebel. In ‘Smoking Cessation in Secure Mental Health Settings: Guidance for Commissioners’, PHE menacingly says “admission to a secure mental health unit can be an opportunity to intervene” (p.4) and re-informs staff how to do their jobs properly, including that they stop smoking themselves (p.22-23).
There are many reasons to oppose the ban. It deters smokers from seeking voluntary assessment if they are developing mental illness since treatment appears unbearable. Secondly, smoking is a comfort for troubled people who are at their most distressed and vulnerable. Taking this freedom away is cruel. Thirdly, a ban creates conflict between patient and staff at a time when the patient urgently needs to somehow trust those who are detaining them. Without that trust, the chances of recovery are severely impaired. Fourthly an asylum is a place to get mentally well, they shouldn’t promote physical fitness over and above that goal. Fifthly a ban is horribly illiberal because the ward becomes one’s living quarters – it’s like saying you can’t smoke in your own home. For more on these common-sense objections, see my article here.
Some say that smoking harms other non-smoking patients. But this isn’t true in a hospital if smoking was only permitted in a designated room, or outside – non-smokers are already protected. Furthermore, the potential for violence if a nurse confiscates a patient’s cigarettes could undermine the harmony and smooth running of a good psychiatric clinic, freaking out observing non-smokers as well. Smoking bans represent turmoil for all patients and staff.
PHE’s intervention has not yet been widely discussed in society as the ban is bypassing Parliamentary debate. Sadly when it was reported by BBC News, they misleadingly said that smoking reduces the effectiveness of mental health medication by up to 50%. Rightly we don’t permit the use of illegal drugs or alcohol in asylums because they certainly do interfere with good medicine. Policies like bag searches, room searches, monitoring and surveillance, even breathalysing, take place in clinics to enforce this. If tobacco did interfere with medication, it would be a strong argument for restriction. But it’s a bluff.
PHE think increased frequency of dosage is a problem because they state it costs £40m extra per year when they want to make savings. But this bean-counting approach is irrational because the NHS mental health budget is £32bn per year – saving only £40m won’t lead to a new golden age of wealth in the system. Furthermore, as the RCP report says (8.5), the real world financial saving may only be £12m if generic anti-psychotics are deployed.
Also e-cigarettes don’t contain PAHs (an organic compound) yet are also viewed negatively, suggesting the objection to smoking is moralistic rather than scientific.
Two thirds of in-patients smoke, up to 88% for psychosis sufferers, because tobacco is a form of self-medication. Schizophrenics suffer extreme cognitive impairment around abilities such as learning, memory, and attention. Tobacco helps these areas in sufferers.
Similarly with depression, cigarette smoking mimics effects of antidepressant drugs. Whilst tobacco is not a medium or long-term solution, all smokers will attest that smoking reduces anger and stress in the immediate short-term. As the majority of mental health patients are only staying in hospital briefly, smoking is helpful. If you are treating someone for depression or anxiety, the one thing that’s guaranteed to make them more depressed or anxious is to take away their cigarettes! Advice is one thing, but a blanket ban is quite another.
PHE bizarrely claim their policy promotes choice because patients would like to quit smoking at the same rate as wider society. Certainly if the individual wants help to quit, all available support should be given. But a blanket ban will also target those who don’t want to give up. It’s not choice then, it’s coercion. ‘Empowering the patient’ really means ‘all power to PHE’.