Should psychiatric hospitals ban smoking completely?

In The BMJ this week, experts discuss whether hospitals should ban smoking for psychiatric patients outside as well as indoors.

Banning smoking in the outdoor areas of psychiatric hospitals as well as indoors helps patients to quit smoking and leads to better engagement with psychiatric treatment, argue Deborah Arnott, chief executive of Action on Smoking and Health, and Simon Wessely, president of the Royal College of Psychiatrists.

They explain that patients with serious mental health problems are likely to die up to 17.5 years prematurely, mainly because of smoking-related diseases. Smoking rates among people with a serious mental disorder are triple that of the general population.

It is the prevalent smoking culture on mental health wards that leads to patients taking up smoking and relapsing back to smoking after quitting, they say, adding that "we should no longer condone patients smoking themselves to death while in our care."

They argue that "smokers with mental health disorders are as motivated to quit smoking as the general population, and quitting has been shown to improve mental as well as physical health. Quitting also enables patients to take less of some types of neuroleptic drugs and experience fewer side effects."

Despite this, however, "smokers in psychiatric hospitals are less, rather than more, likely than other smokers to be offered help to quit."

They say one hospital trust piloted a smoke-free trial and found this led to better patient engagement with therapy, and saved the amount of time staff spent on supervising smoking, as well as less cannabis use and fewer violent smoking related incidents.

However, Michael Fitzpatrick, a former GP, argues that "even though they have mental illness, individuals should be entitled to make their own choices in matters affecting their health" and that "the exercise of their independent will is important to their recovery."

"Smoking restrictions already imposed in psychiatric services have caused distress to patients and conflict with staff," he explains. This approach is "heartless and inhumane" for patients as well as "degrading to their humanity." Furthermore, it will "likely to deter people with mental illness from seeking access to services."

He says smokers in psychiatric 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," and adds it is "ironic" that there appears to be no lack of resources for smoking cessation programmes when there are regular reports of cuts in services, staff shortages and reductions in beds.

He concludes that "patients attend mental hospital for treatment of their mental illness, not for programmes of moral improvement or health promotion," and suggests that "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."