May 1st, 2013

Smoking bans at facilities are more common

After initial controversy, the practice of prohibiting smoking in inpatient psychiatric facilities has taken hold.

In decades past, many considered smoking one of the few indulgences allowed patients. So when psychiatric facilities began prohibiting tobacco about a decade ago, they faced resistance, and in some cases, lawsuits.

The tide has turned: 2011 survey results from the Research Institute of the National Association of State Mental Health Program Directors show that of respondents, almost 80 percent of state psychiatric facilities prohibit smoking – up from about 40 percent in 2006.

The culture has changed, says Massachusetts Department of Mental Health Commissioner Marcia Fowler, M.A., J.D. “There was a point in time when cigarettes were used as a reward. That notion of having privileges for people engaged in seeking treatment is really outdated. These are adults who are suffering with an illness; they are engaging in treatment. It’s really not about reward and punishment – it’s about mutual, shared decision making,” she says.

Recent Centers for Disease Control and Prevention data indicates adults with mental illness have a smoking rate 70 percent higher than those without mental illness.

At one time, tobacco bans appeared punitive because of the perception that patients lived in inpatient facilities for a lifetime and it was their “home.”

“In the past, the state hospitals were really more long-term care, and people were there for many, many years. But that has changed,” says Mary Louise McEwen, superintendent at Maine’s state-run Riverview Psychiatric Center, which has been tobacco-free for about seven years. “The average length of stay has gone down dramatically.”

Facilities now have greater emphasis on recovery and return to the community.

Before becoming superintendent at Riverview, McEwen was superintendent at the state’s Dorothea Dix Psychiatric Center when it banned tobacco use about a decade ago – and then lifted the ban a few years later. However, McEwen says Dorothea will renew its tobacco-free policy this July.

McEwen says it was difficult for her to reverse the smoking ban at Dorothea, but at that time, because of the campus’ size and setup, there were safety concerns. Among them, a type of black market taking place outside the facility, with people in the community selling cigarettes to patients who had outside privileges. “The clients were really being taken advantage of,” McEwen says. “It was a safety issue and also an exploitation issue.”

Dorothea has since implemented tighter controls, says McEwen. “I’m really excited that they are willing to try (to go smoke-free) again.”

At Riverview, the policy has gone well, McEwen says. Clients have a number of cessation tools made available to them and healthier alternatives are promoted, like visits to a local gym.

“I think a lot of psychiatric clients, my observation is, they smoke just out of boredom. If we can work with them on other types of coping mechanisms or leisure activities instead of smoking, they will develop other positive habits.”

In Connecticut, the state-run Connecticut Valley Hospital had planned to go tobacco-free and started a gradual process of reducing smoking areas and hours over several years – but the process was postponed in 2007 after several patients filed a lawsuit.

“The arguments were on the one side, that smoking was a right and this was people’s home,” says David M. Howe, LCSW, director of recovery and consumer affairs, Connecticut Valley Hospital. “To our argument, which was that smoking is not a choice – smoking is an addiction and this is not home, this is a healthcare facility. That argument prevailed and when (court proceedings) were closed, we went ahead with the rest of our tobacco-free environment project.”

Connecticut Valley went tobacco-free in 2009, after engaging a “Tobacco Congress” on campus, which included all stakeholders and meeting weekly to discuss policy. Howe says it was determined through research that nicotine replacement was the single best evidence-based practice for helping people quit and the department began nicotine replacement treatment and offering peer supports.

Connecticut Valley uses an integrated care approach, emphasizing health and wellness and activities to promote health and reduce stress. Rather than focus on problems or disabilities, “Our focus has changed to, ‘What’s right about your life?’” Howe says.

Massachusetts also has a portfolio of activities designed to promote health and wellness, with smoking cessation treatment – which includes counseling, education and nicotine replacement therapy – as a cornerstone of that initiative.

Massachusetts Department of Mental Health-operated facilities went tobacco-free in 2009. “Individuals with serious persistent mental illness die 25 years younger than the general population,” says Fowler. This fact is in part due to smoking-related diseases. “We really recognized that we had to do something to stop that trajectory,” she says.

Many private and not-for-profit centers are also tobacco-free.

The Brattleboro Retreat, a not-for-profit mental health and addictions treatment center in Vermont, became tobacco-free about four years ago, says Chief Medical Officer Frederick Engstrom, M.D. “Smoking is terrible for your health,” Engstrom says. “As a healthcare institution, to be facilitating smoking is morally reprehensible. So we all knew it was the right thing to do.”

Prior to the ban, Brattleboro sometimes attracted patients from Maine, who were seeking the closest available facility that still allowed smoking, he says.

But going smoke-free hasn’t resulted in a decrease in patients. “There are times, when people find out it’s smoke-free, they say, ‘No, I’m not going in,’” he says. “But what we don’t hear about are those who are happier with it being smoke-free. My guess is that it either balances out or they outnumber those who don’t come because of smoking.”

Initially, the move was controversial, Engstrom says, in part because those who battle addiction have a high smoking rate. “The age old question is, ‘Do you take care of one addiction at a time?’ But there was pretty good evidence that there’s really no harm in doing cigarettes at the same time; it probably benefits. I think that, if anything, it has helped people’s recovery, rather than hindered it.”

By Pamela Berard

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