Should psychiatric hospitals completely ban smoking?

Quitting improves health

Smokers with mental health disorders are as motivated to quit smoking as the general population,1 and quitting has been shown to improve mental as well as physical health. Quitting also enables smokers to take lower doses of neuroleptic drugs and hence experience fewer side effects.1

Despite all this, smokers in psychiatric hospitals are less, rather than more, likely than other smokers to be offered help to quit.1 In the past two decades, during which the prevalence of smoking throughout society has fallen by a quarter, smoking rates among people with serious mental illness have barely changed.1

Prohibiting smoking indoors is clearly justified to protect non-smoking patients and staff, but is it a step too far to prevent inpatients from smoking outdoors as well, and in so doing effectively force them to quit smoking?

The legal position was tested in the English courts when Rampton secure hospital went smoke-free. The Court of Appeal concluded that smoking could not be considered a fundamental human right and went on to say that “a person may do as he pleases in his own home, no-one can expect such freedom when detained in a secure hospital.”3 However, is this position morally justified, and does it work?

Nicotine replacement therapies

Some smokers with psychiatric disorders think that smoking can help them to manage their symptoms and relieve stress and don’t want to quit.1 We respect that view but point out that smoking has no positive effect, and any perceived benefits primarily relate to relief from cravings.1

Maudsley patients are given access to nicotine replacement therapies within 30 minutes after arrival at the ward.8 They can also use electronic cigarettes, which deliver the nicotine but seem to carry a fraction of the harm.9 We should no longer condone patients smoking themselves to death while in our care.

Moral autonomy

According to UK medical ethical authorities, “the central principle” in this matter is that “smoking is harmful to health.”10 But this is a platitude not an ethical principle. The key ethical principle is that for moral autonomy it is more important to make “wrong” choices than to obey instructions. As Emmanuel Kant, the great philosopher of the Enlightenment, put it, “It is so easy to be immature. If I have a book to serve as my understanding, a pastor to serve as my conscience, a physician to determine my diet for me, and so on, I need not exert myself at all.”11

Depriving psychiatric patients of their autonomy—their right to make choices relating to their health—means treating them like children and is degrading to their humanity.

Psychiatric patients are as aware as everybody else in the modern world that smoking is not good for health. Yet a relatively high proportion of such patients continue to smoke, and smoke relatively heavily, with deleterious consequences for their health and life expectancy. Many people with mental illness, perhaps to an even greater extent than people in good mental health, think that they derive pleasure from smoking and enjoy smoking with others; if deprived of cigarettes, they may become irritable.

Restrictions may deter seeking help

Academic authorities disparage claims made by smokers with mental illness about the benefits of smoking (relief of depression, anxiety, and “stress” and solidarity with other smokers) and the adverse consequences of abstinence (anxiety, delayed recovery) as “myths” and “false attributions.”12

Smoking restrictions already imposed in psychiatric services have caused distress to patients and conflict with staff. In response, antismoking campaigners propose even more coercive measures (stricter “enforcement”) and more intensive therapeutic programmes (such as nicotine replacement).10 As several former patients have observed, this approach is heartless and inhumane and likely to deter people with mental illness from seeking access to services.13 14 15 16 17

Patients attend psychiatric hospitals for treatment of their mental illness, not for programmes of moral improvement or health promotion. It is illegitimate for medical authorities to treat a patient’s admission as an “opportunity” to impose behaviour restrictions in pursuit of wider health goals that the patient may not share.

Boot camp or spa hotel?

Nicola Lees, deputy chief executive of a Bradford mental health trust, justifies a total smoking ban on the grounds that in pursuit of the goal of “long term behavioural change,” the trust “aims to provide a healthy environment to receive care and work in, and create outside spaces that promote wellbeing.”18 Providing psychiatric treatment seems to be low priority for Lees, who seems to be uncertain whether she is running a boot camp or a spa hotel.

Smokers in mental hospitals complain of the lack of purposeful activity in overcrowded and understaffed wards, and of the boredom, frustration, and inactivity from which smoke breaks provide some respite. It is ironic that there seems to be no lack of resources for smoking cessation programmes in mental health services at a time when there are regular reports of cuts in services, staff shortages, reductions in beds, and complaints that “morale is at an all-time low.”19 20

Psychiatric health workers should concentrate their energies on the treatment of mental illness and leave decisions about wider health matters to those entitled and qualified to make them—the patients.