August 21st, 2010

Smoking bans: the right step or an unnecessary burden for patients?

In May, Vermont State Hospital joined a growing number of psychiatric facilities to ban smoking from its grounds.

The trend is divisive in the field. Those in favor of the ban cite how smoking disproportionally shortens the lifespan of those with mental illness and also can interfere with the metabolism of medications. Others believe it may be too much for someone in the throes of a crisis to tackle smoking cessation, too.

A 2006 National Association of State Mental Health Program Directors survey of 222 facilities indicated that 41 percent had already banned smoking on the premises, but many more planned to move toward a no-smoking policy in the near future. Those in the field say it’s a trend with momentum.

Vermont State Hospital was one of just two Vermont facilities that hadn’t yet implemented a ban. Jaskanwar Batra, M.D., medical director at Vermont State Hospital – which previously allowed smoking in enclosed porches – says the primary reason for the ban is the high mortality and morbidity rates from smoking-related reasons that are disproportional for patients that suffer from mental illness. “That includes our experience at the hospital and a number of recent published studies about shortened life,” Batra says.

Smoking rates are much higher for people with mental illness, especially those with schizophrenia, which Batra says is the most common diagnosis at his facility. Smoking rates for that population are from 70 to 90 percent.

Elaine Alfano, deputy policy director at Bazelon Center for Mental Health Law, says the center believes the bans are a good idea, providing there is adequate support and programs to help people.

“I recognize that it’s very difficult for people who are in an institution to be motivated to stop smoking,” she says. “But it’s also certainly an opportunity to help people who are suffering from addictions.”

“A hospital setting or facility is supposed to be an active therapeutic environment. There should be interventions to help people,” Alfano says. “People with serious mental illness die on average about 25 years earlier than other people. That’s a really terrible statistic.”

Alfano says it’s important to look at what function cigarettes are serving. “Is it being used to help anxiety or with concentration? What does the individual get out of smoking? The treatment team should be really looking at ‘How can we provide healthier alternatives?’”

The National Alliance on Mental Illness (NAMI) has a policy on tobacco addiction and smoking cessation, but stops short of saying the organization opposes or supports bans.

“It’s been a lively issue within NAMI,” says Ron Honberg, J.D., NAMI’s director of policy and legal affairs.

NAMI’s policy “supports and encourages smoke free and tobacco free environments” and opposes any practice that uses access to smoking and tobacco as a form of coercion or reward. The policy states “at the same time, NAMI recognizes that the best time to provide and support smoking and other tobacco use cessation is not when consumers are in crisis because such treatment may exacerbate psychiatric symptoms and other conditions.”

“Therefore NAMI supports consumers in seeking smoking and other tobacco use prevention, cessation and recovery as essential to overall wellness in treatments and in programs available to the community,” and calls upon physicians and providers to implement educational and cessation programs, the policy states. NAMI offers an online program, Hearts and Minds, promoting overall wellness.

Honberg says studies suggest smoking may be the largest single contributor to the premature death rates of people with some forms of mental illness and continuing research shows significant interaction between smoking and smoking cessation and psychotropic medications.

But Honberg says more and more hospital stays are short-term and patients return to their communities. “And good smoking cessation programs in the community are far and few between.”

“This is clearly a very important issue to us,” Honberg adds. “And clearly smoking cessation has to be a big part of any holistic strategy on people with mental illness. But is banning smoking at the time when people are in acute crisis the best time to do it?” Batra says despite initial fears, Vermont State Hospital patients have reacted well to the change. “I think people know the ill effects of smoking; the education of the effects are far wider than these used to be. Also most people who smoke, they do want to quit.”

While a hospitalized person may be having a difficult time, “it’s also a time that they are taking care of themselves,” Batra notes. “So offering the whole package of care and giving people the time to have a fresh break from smoking, that’s our goal.”

The hospital began preparing patients and staff months before the ban was implemented, with group therapy sessions and by offering nicotine replacements. Discharged patients are directed to appropriate support and outpatient teams monitor the issue so that if a patient resumes smoking, medication can be adjusted.

In general, Batra says, “The fear of things going wrong ends up being exaggerated and most hospitals found it to go very smoothly.”

Alfano says some mental health workers have expressed concern that forcing patients to quit could result in patients acting badly. It also takes away the option of rewarding them with tobacco use for good behavior.

“But we shouldn’t be positively enforcing the bad habit,” Alfano notes. Furthermore, all of the bans that have taken place seem to be going well. “Nobody is reversing these smoking bans as far as I know. They are staying in place. It kind of reminds me what they have done with seclusion and restraint, trying to reduce and eliminate it. If the institution really sets its mind to doing that and very systematically approaching it, they’ve achieved very positive results that are better for both the consumers and the staff at the institution.”

By Pamela Berard

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