Stigmatising smoking as mental health policy

Hat tip to Pat Nurse: this interesting piece introduces the reader to a frightening world.  It is a world in which the goal of smoking cessation for people with psychiatric conditions has been so prioritised that 'the burden of stigmatizing denormalization policies imposed on vulnerable populations (e.g., individuals living with psychiatric illness) is justified by the (potential) benefits to that population'. The piece discusses the topic more humanely than the 2007 British Medical Journal article that was the subject of this post.

Stigmatizing involves portraying someone's activity as blameworthy, ethically unclean, and is not a practice that one would associate with a health service that purportedly cares for patients' mental or emotional wellbeing. Says the article: 'Interestingly, denomalization programs are antithetical to public health efforts which are focused on eradicating stigma – particularly around eliminating negative public perceptions of people who use illicit drugs'.[bold added]

Applying stigma to discourage the use of a legal drug would seem to be counter-productive in a mental health context. But Bayer and Stuber have published a study entitled Tobacco Control, Stigma and Public Health: Rethinking the Relations, in which they do think the unthinkable:

Much will depend on the nature and the extent of stigma-associated burdens and on how the antitobacco movement deploys stigmatization as an instrument of social control. For example, policies and cultural standards that result in isolation and severe embarrassment are different from those that cause discomfort. Those that provoke a sense of social disease are not the same as those that mortify. Acts that seek to limit the contexts in which smoking is permitted are different from those that restrict the right to work, to access health or life insurance, or to reside in communities of one’s choice.

Although they can see how the consequences could be serious and even counter-productive for people with mental health conditions, they seem happy to let the tobacco control community proceed anyway!

The extent to which the deployment of stigmatization exacerbates already-extant social disparities or has long-term counterproductive consequences for the effort to confront the epidemic of smoking-related morbidity must also be considered. And what is true for smoking may have broader applicability for other individual behaviors deemed unhealthy such as "overeating" and illegal drug use. [bold added]

How can people trying to fight the stigma suffered by the mental health community bring themselves to employ stigmatizing policies in order to pursue a tobacco control target? Surely targets are confused when stigma is employed against people for smoking but fought for any other condition in which a patient finds herself? How does that clarify things for a patient who might also be fighting stigma as a result of her condition, poverty, status as a single parent or illegal drug user?

It is now apparently respectable to stigmatize people for their own good, especially vulnerable people: as the Neuroethics article explains: 'Since people living with psychiatric illness have the highest incidence of smoking-related adverse health outcomes, they also stand to benefit disproportionately from denormalizing efforts.' The actual damage suffered by these people is not known but is considered to be probably 'worth it' in the pursuit of a tobacco-free world.

I don't share the goal of a tobacco-free world. But as I go about my business, smoking in (at!) the pub once every three weeks or so but otherwise not really thinking about it, there are people, perhaps parents, who find themselves suddenly being treated involuntarily in a psychiatric unit for several days, anxious about themselves, worried for their children and families, tormented by a psychiatric illness. In the way of their recovery is the requirement that they give up smoking while in the middle of this unbelievable mess, and in receipt of further head-messing medication. In the way of their recovery is an official policy that they are stigmatized for their smoking habit, and made to feel humiliation (read the fifth paragraph of the neuroethics piece). Is this really the business of mental health care? And is this what our populations want for their friends and relatives in mental health care?

It looks more like a policy to kick people hard: the lower they feel, the harder they are to be kicked.