Smoking bans threaten mental health: Opinion, Australia

This writer asks why comprehensive smoking bans are imposed on mentally ill people, when at least at this point in our history nobody would think it right to impose such a comprehensive ban on the rest of the community. Both the circumstances of a person's incarceration in mental health facilities and the fact that they may not get home for a period of days, weeks or months, to say nothing of their existing mental anguish and the effects of any medication, make somebody's stay in a mental health facility possibly one of the least suitable times to deprive them suddenly of nicotine and expect them to get by on patches at best.


There do seem to be people out there in the caring profession who find the opposite and who knows but they may be most sincere in their views. But bringing in a comprehensive ban that will force psychologically disturbed people to withdraw suddenly from nicotine would be controversial even if implemented in a single unit. The current trend is for health departments to encourage if not legislate for the provision of comprehensive smoke-free mental health service, affecting all units everywhere.  People who run these departments are not medics, they are officials, who seem to be motivated by targets and ideologies dressed up as care for patients.


The comments on this story are instructive too, especially the one that points out that 'nicotine replacement is not an alternative to smoking, it's an aid to give up smoking'. In the eyes of tobacco control, nicotine replacement is a form of 'harm reduction': i.e. anything is better than smoking (as long as it's not made in China with cartridges of course) and we'll give you nicotine patches because you really want to give up smoking, don't you – most smokers do, after all! One reader says:

We should not be allowing or encouraging people to utilise pathological coping mechanism when they are facing a crisis. When alcoholics and heroin addicts are admitted we provide healthier alternative and encourage them to reduce their dependence. 

But this is a false parallel. No one is admitted to psychiatric care because he or she is a smoker. Drug and alcohol abuse signify addictions of a completely different order from a nicotine habit. There is no reason that any patient should be compelled to give up smoking. Allowing smoking areas need not undermine the ward experience for everyone else. It's just a matter of will.


To finish let's have another story about Champix (comments disabled). Sorry it's from the Daily Mail. The MHRA (medicines regulators) are convinced that people who react to Champix have underlying problems (even though most reports I have read concerned people without any history of psychological problems I can't pretend to have read enough to be certain of this). This will account for ASH Scotland's keenness to recommend Champix to those in mental health facilities.

Progress to smoke-free mental health: Scottish Government rides roughshod over consultation findings

A mental health project has given its ringing endorsement to work currently being done to create a smoke-free mental health service in Scotland.

Freedom to Choose Scotland has issued a press release on this project following last week's Written Answers. In answer to Richard Simpson MSP, Health Secretary, Shona Robison gave this answer (emphasis added):

In March 2010, following extensive consultation with key stakeholders, we announced that new guidance would be prepared to help mental health residential service providers move towards establishing smoke-free environments. The aim of this guidance, which is being developed by NHS Health Scotland in consultation with key stakeholders and service users, will be to drive change at a pace which is acceptable to individual services, and, most importantly, to the service users themselves.

As we stated in the press release, supported with references, the consultation results in no way endorsed this course of action, with over 50 per cent of respondents (including over 80 per cent of patient groups) voting to retain the smoking ban exemption that has existed for psychiatric facilities since the smoking ban came in, and only 12 per cent of respondents voting for 'guidance' (meaning effectively bringing in changes to smoking provisions laid down by health boards piecemeal and through the back door). The notion that this is intended to do anything recommended by patients on this issue is breathtakingly inaccurate.

Also referred to in the press release is mention of 'residential' service providers. The public consultation did not refer to any difference between acute and continuing care patients, although an earlier consultation with service providers found that almost half had reservations with imposing a smoking ban on continuing care patients even though most of them thought a ban would be appropriate for acute patients. The word 'residential' (rather than 'clinical') suggests strongly that a comprehensive smoking ban for all services including continuing care services is now planned.

Digital Feat pronounced the following in their account: 

In January 2009, the Scottish Government consulted stakeholders, service users and the public on the best way to achieve smoke-free mental health services in Scotland. The consultation sought views on the production of detailed guidance without the need to amend existing legislation. As no clear consensus emerged on how to move towards smoke-free mental health services, guidance was viewed as a solution which avoided legislative bureaucracy and could effect change quickly.

Author Duncan doesn't observe that many people in the consultation expressed open disagreement with the very idea of smoke-free mental health services. In other words although respondents were asked whether they wanted to keep the current exemption, it seems clear from the rest of the consultation that the question was how, not whether, mental health services should go smoke-free. Duncan clearly has no problem with further change being managed a) in spite of service users' wishes, clearly expressed in the Consultation, and b) without being subject to Parliamentary scrutiny.

Freedom to Choose (Scotland) last year mounted a petition on this consultation in 2009. Our final submission to the Public Petitions Committee is here. The petition was closed in September 2009 without any of its concerns being publicly aired. Why am I surprised?

They never listen.

Update on NHS Grampian ban

The decision to ban smoking throughout NHS Grampian sites has been deferred for six months following concerns that it would not be enforceable, the BBC has announced. Freedom to Choose (Scotland)'s misgivings about the legality and enforceability of the measure have been vindicated.

Other health boards have acknowledged that there is no legal grounding to the ban. This article has come out today: the site manager of Ninewells Hospital in Dundee is quoted saying:

we can only ask them to respect our policy on smoking but if they say they don't respect it, and ask ‘What are you going to do about it?', then we have to walk away.

Furthermore yesterday another story came out yesterday from Cornwall with much the same message.

The Scottish Government has other ideas and asserts that NHS Grampian is acting within its powers. This implies that the smoking ban legislation has always been capable of being applied outdoors without further primary legislation. Yet NHS Grampian today decided that enforceability was too big a problem to force on its workforce and the Grampian public, at least until further discussions have taken place.

Last year the Scottish government held a consultation that was designed to engineer Scottish mental health services in a no-smoking direction. This would have had the result of removing the exemption that currently applies to smoking rooms in psychiatric units, but further questions were added in the mental health consultation asking respondents whether smoking should be banned outdoors too.

Meanwhile the NHS and Health Scotland have run a seminar on Health Improving Health Services – health services with a vengeance. Ridden with jargon about working together, it refers to 'the discussion of how we make hospitals exemplar centers for health and wellbeing'; 'asking for and valuing patient feedback', and finally 'clarifying, and then enforcing, our stance on issues such as smoking on hospital grounds'. Quite a confusion of objectives here. But the seminar does demonstrate that the effort to make hospitals smokeless zones is government-led.

The issue is simple. The NHS is there to deliver medical treatment to sick people. It employs people to treat patients and otherwise service the hospital. There seems no good reason to employ any of the staff as exemplars in public health. It makes no economic sense for staff to challenge visitors to the hospital for smoking, nor does it help anyone's health. Threatening disciplinary action against staff who possess tobacco and expecting them not to smoke in break-times on shifts that can extend to 12 hours marks an extraordinary departure from normal conditions of service.

Threatening to withdraw treatment from patients who smoke on a blanket basis, or depending whether they observe no-smoking requirements in hospital, is discriminatory treatment: not a decision made on clinical grounds.