Smoking cessation strategies and treatments

1. Giving up is harder if you have an anxiety disorder.

Yes I can believe that, especially when people are under more pressure to quit precisely at those times when they are being treated for other mental illnesses.

2. Royal College of Physicians recommends prioritising those with mental health problems for smoking cessation treatments.

Well yes, I can see that they want to ensure that mental health patients have the same access to smoking cessation services as everyone else, and that they have worse physical health records in which heavy smoking might play a part. However the requirement to stop smoking at times of crisis imposed as a national strategy creates an agenda that does not necessarily prioritise the patient's mental health: indeed the patient's longevity is a higher priority than helping to resolve the patients' mental and emotional state. Yes it may be a worthwhile goal to live longer, but in the chaos that comes with a mental health disorder, meeting other people's priorities, however well intended, should be less important than addressing the mental health disorder. This might be the right time to give up smoking (probably quite unlikely in most cases), but that should be a decision for the patient and the clinician, not a requirement.

RCP President Dinesh Bhugra talks of wanting to 'improve people's lifestyles and reduce health-risk behaviours, thereby preventing  physical illness and reducing the [financial] burden of mental illness on society'. Shouldn't his first duty be to reduce the burden of mental ill health on those directly afflicted and their families? He really seems to feel that any kind of illness is a result of bad lifestyle choice!

Prioritising people with mental health problems for smoking cessation treatments is perhaps inevitable, especially if they are in hospital, without the freedom of movement required to obtain smoking materials. I work part time in a supermarket and sell tobacco on every shift. Since starting work there in 2004, I've sold about three or four packs of Ni-Quitin. They are not an everyday purchase item, and are accessed more through pharmacies and GPs than shops. If patients are in a psychiatric hospital, and tobacco is unavailable, they may still not be willing recipients of nicotine replacement treatments but if they want any nicotine intake there's no choice. This situation is not tolerable on ethical grounds.

Since we know, from the first link as well as from common sense, that people with anxiety disorders find it harder to stop smoking, why do medics seem to think it's right to require it of patients when they are hospitalised?

More involuntary psychiatric admissions since smoking banned, says Canadian study

A study in Toronto that appears to be the first of its kind suggests that the smoking ban deters many patients from seeking treatment in psychiatric units. A walk-in emergency unit found it had to detain patients who needed treatment but were unwilling to submit to a no-smoking regime; other patients refused treatment but did not meet the required criteria for involuntary admission.

Involuntary treatment involves the removal of their freedom for an indefinite period. Having to give up smoking during such a period adds complications to an already upsetting if not downright traumatic experience. Many times I have wondered at the conscience of people who pick on those detained, quite probably bewildered and confused souls as targets for their conviction that the way to save humanity from itself is to stop everyone smoking. This is touched on in the article: 'what I haven't seen is the investment in resources to help these individuals when they are stable outpatients'. No: sock it to them when they are vulnerable and have no choices. Many clinical staff and academics have reservations about this.

It is clear that many of those at most risk are those outside hospital, who become aware that admission to hospital will involve them giving up smoking. (See Letters to the Department of Health.) The news that walk-in appointments are found to result in more involuntary admissions is very bad news, if it means that people are deterred even from seeking an assessment or help in an emergency.

It appears that not much work has yet been done to investigate whether people are being deterred from treatment on the grounds that they won't be able to smoke while hospitalised.

Letters to the Department of Health

This is a long post but the correspondence is informative on the real-life implications of smoke-free mental health services. The correspondence is real but the name given of the letter-writer is fictitious (Mr Gordon at the Department of Health is not fictitious and will be known to anyone who has ever written to the Department of Health in London on matters related to the smoking ban!)

1st letter, August 2010

Dear Mr Gordon

Please register a formal complaint about my treatment by the Department of Health regarding denial of access to healthcare.  I believe my rights are being breached with no justification and in a way that is disproportionate to an argument of protection of public health.  I am being harmed by inhumane treatment and removal of my rights to make my own lifestyle choices.

It appears that healthcare is not a human right when smokers are concerned but rather a privilege for good boys and girls who have only fashionable vices or can be forced to comply with lifestyle engineering from people who don't even know them or have their best interests in mind.

You have been unable to provide evidence to support your claims that second hand smoke presents a health risk to workers and the general public.  Nor am I aware of any reason why I would be forced to stay in a place that would subject bystanders to potential harm when twenty first century technology is quite capable of creating comfortable, non-offensive and segregated (if necessary) environments for all.  The marginalisation of smokers is particularly harmful when incarceration without relief and involving forced withdrawal leads to suicidal thoughts.

It seems unlikely that independent scientific evidence can support such forced treatment when air quality standards for workplaces are not breached by levels of smoke in a particular environment, when expert opinion   [English translation] considers there to be no risk and when all evidence is assessed as a whole rather than cherry picked from marketing reports for the cessation industry.

As you know, I use electronic cigarettes and you are also considering closing the harm reduction market so there will be no options left for me other than to smoke (there is evidence that NRT is ineffective and a scandalous drain on health services and potential quitters).  When I am experiencing a psychotic episode I smoke to feel normal and more stable, I do not know yet if electronic cigarettes will have the same benefits so it's important for me to know that I will not be forced to withdraw from smoking if I'm in a psychiatric hospital.

The smokefree scam is clearer now that outdoor bans are planned, the harm reduction market is up for closure and government grants fund dodgy lobbyists for social engineering projects.  It's clearly not about health and not justifiable under the European Social Charter.  If anyone bothered to do real research they'd discover that quit rates declined as the cessation industry grew.

Apart from incidental conflicting interests, AstraZeneca have a presence on the DH Scientific Committee on Tobacco and Health - serving to prove that this is about vested interests and brand wars, not public interest.

I look forward to hearing from you

H Johnson

*****

Later in August

Our ref: DE***********

Dear Ms Johnson, 

Thank you for your recent emails about secondhand smoke, smokefree legislation and human rights.

I realise that you disagree with the Government’s position on the dangers of secondhand smoke, but medical and scientific evidence shows that exposure to secondhand smoke increases the risk of serious medical conditions such as lung cancer, heart disease, asthma attacks, childhood respiratory disease, sudden infant death syndrome and reduced lung function.

The evidence base that secondhand smoke harms health is substantial and indisputable.   It has been reviewed extensively over many years, both in this country by the Government’s independent Scientific Committee on Tobacco and Health (SCOTH) and overseas. 

In June 2006, the US Surgeon General published a report that examined a great deal of evidence and found that even brief secondhand smoke exposure can cause immediate harm.  The report says the only way to protect non-smokers from the dangerous chemicals in secondhand smoke is to eliminate smoking indoors and that exposure of adults to secondhand smoke has immediate adverse effectson the cardiovascular system and causes coronary heart disease and lung cancer.

The US Surgeon General concluded that: 

•                                  secondhand smoke causes premature death and disease in children and adults who do not smoke;
•                                  children exposed to secondhand smoke are at an increased risk of sudden infant death syndrome (SIDS), acute respiratory infections, ear problems and more severe asthma.  Smoking by parents causes respiratory symptoms and slows lung growth in children;
•                                  exposure of adults to secondhand smoke has immediate adverse effects on the cardiovascular system and causes coronary heart disease and lung cancer; and
•                                  the scientific evidence indicates that there is no risk-free level of exposure to secondhand smoke.

 The Surgeon General said on the publication of the report that:

The scientific evidence is now indisputable: secondhand smoke is not a mere annoyance.  It is a serious health hazard that can lead to disease and premature death.

The World Health Organization (WHO) has classified tobacco smoke as a known human carcinogen.  The US Environmental Protection Agency classified secondhand smoke as a “class A” human carcinogen, along with asbestos, arsenic, benzene and radon gas.

In 2004, the WHO’s International Agency for Research on Cancer’s report Tobacco Smoke and Involuntary Smoking reviewed the evidence of the health risks associated with smoking and secondhand smoke.

In March 2005, the BMJ published research that gave an estimate of 617 workplace deaths a year in the UK caused by secondhand smoke, which equates to two worker deaths each working day of the year.  This research is available on the web at Smokefree England.

In July 2005, the Royal College of Physicians also published a comprehensive report on secondhand smoke (pages 43-49 look at deaths from exposure to secondhand smoke).  This report is available on the web at Smokefree England. 

You also suggest that the Department of Health is infringing your human rights through smokefree legislation in mental health settings.

In July 2006, the Department of Health published a consultation on the smokefree regulations to be made under the Health Act 2006, including proposals for residential mental health settings.  The majority view from respondents to the consultation who addressed the issue of smoking in residential mental health settings was that there should either not be any exemption to permit smoking within residential mental health units, or that any exemption should be time-limited.  This view was shared by stakeholders including the Royal College of Psychiatrists, Cancer Research UK, the Royal College of Physicians, the British Medical Association and many NHS organisations that responded to the consultation.

For this reason, the regulations laid before Parliament provided a time-limited exemption from smokefree legislation for 12 months only.  Therefore, since 1 July 2008, it has been against the law to smoke in any enclosed or substantially enclosed part of any mental health establishment.  This includes smoking by patients, visitors or members of staff, and includes all residential mental health units, regardless of whether they provide acute or long-term services. 

The 12-month time-limited exemption for residential mental health units provided them with the opportunity to develop appropriate outdoor space for smokers if they needed to, and to implement smokefree policies in their units, given that the initial proposals for residential mental health units were different.

Smokefree mental health settings ensures that mental health patients receive  treatment in an environment that is equal, in health terms, with other patients in the NHS (the NHS has been smokefree since 31 December 2007), as well as tackling the institutional use of tobacco and the clear health inequality that mental health patients suffer because of smoking.

More generally, with regard to human rights, the Government believes that people should have the choice to smoke, but believes it is also right that people are both made aware of the major health risks of smoking and also provided with support to quit.

Importantly, the Government believes that at the same time, it is right that others should be protected from exposure to hazardous secondhand tobacco smoke.  This is what is being achieved through this legislation, where smoking is eliminated in virtually every enclosed public place and workplace in this country.

The smokefree provisions of the Health Act 2006 are consistent with what many other Governments are doing to protect people from the harmful effects of secondhand smoke.  Smokefree legislation is not only very effective in protecting health, but is also very popular. 

You suggest that the Government is planning to introduce outdoor smoking bans.  I can assure you that the Government has no current plans to introduce a ban on smoking in outdoor and/or non-enclosed public areas.

You also suggest that smokefree legislation is denying you access to healthcare.  The Government is not denying you access to healthcare, as the NHS offers support and treatment of smoking cessation through its Stop Smoking Services.  I am afraid that it is not the Department of Health’s responsibility if you choose not to use these services and/or treatments.  

Any complaints you have relating to breaches of your human rights should be directed to the Human Rights Commission as you have already done. 

As there is nothing further I can add on these matters, I am afraid that any further correspondence you send on these issues will be logged, but you may not receive a reply.

Yours sincerely, 

Cameron Gordon 

Customer Service Centre 

Department of Health

****

Even later in August

Dear Mr Gordon

I've had some time to think a bit more about your response to my complaint:

Please register a formal complaint about my treatment by the Department of Health regarding denial of access to healthcare.  I believe my rights are being breached with no justification and in a way that is disproportionate to an argument of protection of public health.  I am being harmed by inhumane treatment and removal of my rights to make my own lifestyle choices.

Here are some thoughts:

Your appeal to authority

The World Health Organisation has evidence that people are more likely to get cancer from mobile phones than second hand smoke:

A tale of two studies   

The International Agency for Research on Cancer (IARC) is a well-respected body set up by the World Health Organisation. It has conducted many large epidemiological studies into possible carcinogens. Let's take two of them. We'll call them Product X and Product Y.

There were two major findings for Product X. They were:

    Odds ratio: 1.40 (1.03-1.89)

    Odds ratio: 1.15 (0.81-1.62)

There were also two major findings for Product Y. They were:

    Odds ratio: 0.78 (0.64-0.96)

    Odds ratio: 1.16 (0.93-1.44)

You will notice that each study found one small but significant finding and one small but non-significant finding. In the case of Product Y, however, that significant finding suggested a protective effect. 

None of these findings are particularly strong, but – if you had to pick – you would say that Product X was the most likely to be the real carcinogen, right? After all, both findings for Product X show a potential increased risk, and the largest of them is not only statistically significant but is more than twice as large as Product Y's.

But that's not how these findings were reported at all. The WHO issued a press release saying that there was no conclusive evidence that Product X caused cancer and blamed "biases and errors" for the study's findings. The WHO also issued a press release for Product Y, saying that it definitely did cause cancer and blamed weaknesses in the study for its failure to show this more clearly. 

Consequently, the BBC reported that Product X "does not appear to increase the risk" of getting cancer, but reported that Product Y represented "a definite, although small, risk" of getting cancer.

So why would the weakest associations be hyped up while the stronger associations were downplayed?

Product Y is passive smoking. Product X is a mobile phone. 

Why is the Department of Health not protecting us from mobile phones by banning their use?  Maybe it's something to do with bribes from the pharmaceutical industry?  

The report from Royal College of Physicians is a marketing report for the cessation/pharmaceutical industry.  Does not assess all evidence, cherry picks and ignores scale, perspective and harms caused by removal of self determination and informed choices.

Death estimate - assumptions and guesses.  No death certificates here.

Stakeholders

Royal College of Psychiatrists, Cancer Research UK, the Royal College of Physicians, the British Medical Association and many NHS organisations  ... I don't remember voting for them and they all work closely with pharmaceutical interests who coincidentally produce cessation products - conflicting interests.  'Stakeholders' can determine how I'm allowed to live my life, what I'm allowed to do if I want to stay alive in your society and who is allowed to profit.  Can [I] set up an organisation and call myself an authority so I can be a stakeholder in their healthcare and citizen rights?  The point would seem to be that pharmaceutical company interests are stakeholders and cessation industry interests are stakeholders and I'm a commodity to be rented out to stakeholders, not an individual to be allowed free will.

Smokefree mental health settings ensures that mental health patients receive  treatment in an environment that is equal, in health terms, with other patients in the NHS (the NHS has been smokefree since 31 December 2007), as well as tackling the institutional use of tobacco and the clear health inequality that mental health patients suffer because of smoking.

I wouldn't be in that situation if I wasn't sectioned to be detained, that doesn't correspond equally to the liberty of other patients to remove themselves from the smoke free environment.  I'm not an institution and it's my choice to smoke if I want to, you are an institution with clear institutional blindness and prejudice towards certain groups of people, including smokers but not mobile phone users.  Your totalitarian behaviour such as the control of smokers makes smoking a desirable behaviour for some of us.  The world is a pretty shit place when we have to share it with intolerant busybodies and smoking offers respite.  I  was already sick of the idea of being restricted to smoking in the rain if I was lucky enough to get a member of staff to take me walkies, the next time you lock me up you'd better make sure I'm sedated the whole time because this dog intends will bite [sic] without home comforts – like smoke and a comfy spot.

The Government believes that people should have the choice to smoke

Where?  Where can I smoke if you override private property rights and exclude me from municipal property?

You suggest that the Government is planning to introduce outdoor smoking bans.  I can assure you that the Government has no current plans to introduce a ban on smoking in outdoor and/or non-enclosed public areas.

Actions speak louder than words:

And a call from your 'stakeholders' 

The Government is not denying you access to healthcare

I wouldn't choose to use NHS services but the government has incarcerated me twice without consent.  Your 'places of safety' force withdrawal from smoking so are not somewhere I would choose to stay.  I do not want to stop smoking when I am ill, I smoke partly to improve mental stability, therefore you will not allow me to access healthcare without harming my mental state.  You imply that it's a simple matter of submitting to use of cessation products.  I do not want to stop smoking when I am ill, cessation products do not work most of the time and treatment for mental health issues should not be reliant on acceptance of  compulsory addiction treatment.

Apparently ex smokers are three times more likely to get lung cancer too so that may also be an outcome of forced withdrawal.  Quitters are more likely to get diabetes and become fat (and fat people are next in line after smokers and drinkers as the new 'niggers').  Do you have pills to offset these problems caused deliberately by your removal of choices?

Even if you could prove to a court that second hand smoke has measurable health risks, higher than mobile phones which you allow, can you prove that the only answer is to remove my freedom to make my own informed choices?  Is it proportionate to exile smokers from indoor areas or treat them like dogs when you lock them up or remove the rights of property owners to decide who they wish to cater for?

As you have decided what choices I'm allowed without consultation or consideration and you've determined how I must live in order to be able to qualify for human rights I'm seeking legal advice.

H Johnson

Smoking cessation can damage your health

A study reported in 2007 that found that abrupt smoking cessation can kill is worth repeating here in the interests of balance. Usually the message about quitting is that you can't lose, but nothing is ever simple.

Dominic Lawson's story in the previous post of a middle-aged man suffering a fatal stroke during his time in hospital after being forced to leave all his tobacco at the door provides a case in point. On one hand he is a 'typical' case of a smoker who dies prematurely following a stroke. On the other he is a heavy smoker who is going through the trauma of a small operation, who has been suddenly and unwillingly deprived of tobacco. Presenting smokers with the trauma of forced withdrawal when they are already facing hospitalisation and possible surgery is barbarism in my book, even without the clear possibility of an adverse health outcome or death.

So far I haven't found many further references to this, but here is one.

H/tip Kin_Free.