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.

Vancouver park ban limits options for mentally ill

Land of the Free. Acknowledgements to
KateB

Removing stigma is one of the reasons given for including mental health facilities in non-smoking policies. This is a professional concern of the Royal College of Psychiatrists, who perhaps have reason to fear the stigmatisation of mentally ill people. There are more smokers among mentally ill people than among the general population.

If the Royal College of Psychiatrists doesn't want mentally ill people to have to cope with the additional stigma of smoking, it should perhaps address its own views about the meaning of stigma. Does it, for example, approve of the denormalisation of smoking, and by association the marginalisation of smokers? Does denormalisation or stigma help anyone's mental health?

In this piece, for example, the writer points out that his local council's recent decision to ban smoking in Vancouver beaches and parks prejudices the recreational opportunities for people with schizophrenia because more of them are smokers. I have sympathy with this view.


Several of those who comment on this article say that mentally ill people should apply nicotine patches to themselves before going to the park. For their own health too, of course: why should 'normal' people be forced to encounter a filthy habit when in the park, just because some mentally ill person doesn't have the will power to stop smoking?

What's wrong with these people? What harm does it do if someone smokes in a park? Surely you should not legislate against lawful and peaceful behaviour in a park? And how does it hurt anyone if someone who is mentally ill retains a degree of autonomy?

Would the Royal College of Psychiatrists denounce such a ban on the reasonable public health grounds that under no circumstances should people be denied the peaceful use of recreational public places?

Deliberately stigmatising smoking is at the bottom of these moves. Having told us that smoking is unhealthy, they want to stop smokers taking a walk in the park. This is not to do with public health, which should welcome smokers walking in a wholesome environment, but because nobody wants children to see smokers clearly enjoying their peaceful smoke in the park.

Meantime, meet the man who promotes smoke-free apartments in West Holywood, whose strategy is making smoking socially unacceptable. (This article admits that 'no one knows the science behind the assertion that "there is no safe level of secondary smoke".' But it doesn't stop the ban advocates pushing for outdoor bans.) I really don't get this thing about making smoking socially unacceptable. Everywhere I go there are people smoking in groups outside pubs. At the supermarket checkout I serve groups of people crates of beer and tobacco.

These people haven't made smoking socially unacceptable, they've made it officially unacceptable. Or, to put it another way, they have made it unacceptable to the people who matter in society, and they want us to believe that they are interested in reducing inequalities.