Should Mentally Ill Patients Be Allowed to Smoke?

Smoking has long been tolerated in psychiatric institutes, but administrators want to ban the habit

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Quitting smoking is hard enough on its own, but studies show the challenge is even greater if you suffer from a mental illness — which is why many treatment facilities still allow patients to smoke, even encouraging the habit by using cigarettes as a reward for complying with tests or therapies.

According to the Centers for Disease Control and Prevention (CDC), around 31% of cigarettes in the U.S. are smoked by people with mental illness. And the New York Times details the long-standing tradition of smoking in mental health facilities, along with the growing controversy triggered by administrators’ attempts to now change course and ban cigarettes.

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People with mental illness are 70% more likely to smoke than those who are not mentally ill— and at least 50% less likely to quit successfully. This includes people with depression and anxiety disorders as well as those with schizophrenia and bipolar disorder.  The more disabling the mental illness is, the higher the smoking rates are, with about 88% of people with schizophrenia being regular smokers.

Those who run psychiatric hospitals and other facilities for the mentally ill are familiar with the high rate of lighting up among their patients, and there is even evidence explaining why smoking is so appealing to those with mental illness. Research shows that nicotine can have antidepressant and antipsychotic effects— and advocates for the mentally ill also maintained that it would be cruel to deprive patients of one of the few pleasures they enjoyed while hospitalized.

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So despite the known health hazards of smoking, including the risk of heart disease, stroke and lung cancer, administrators accepted the habit as a necessary evil, often turning a blind eye to health risks in favor of the more immediate benefit of having patients comply with treatments.

The Times reports:

Dr. Thomas R. Frieden, director of the CDC, said hospitals had historically resisted going smoke-free, fearing it would interfere with treatment. “In my very first job as an aide in a psychiatric hospital,” he said, “if patients behaved better they got additional cigarettes…”

Smoke breaks were even used to persuade patients to get medical care. “We had a couple of patients who needed important CAT scans and M.R.I.’s, and that’s how we did it,” said Dr. Schoener LaPrairie, a former staff psychiatrist.

The lenient smoking policies are taking a toll, however, and the article notes that a recent report from the National Association of State Mental Health Program Directors  showed patients in these facilities are dying on average 25 years sooner than the general population, many from smoking-related diseases. That trend is prompting administrators to re-evaluate their smoking policies, with many hospitals trying to ban or at least rein in smoking.

But the bans may be only marginally effective in protecting patients from tobacco-related health problems; the trend toward shorter stays in mental health facilities means patients stop only temporarily, and start lighting up again once they leave.

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Supporting patients with smoking-cessation therapies, however, has had mixed results. Patches and gum can help in some cases by providing the therapeutic benefit of nicotine with far less risk.  And a small preliminary study in Italy suggests that e-cigarettes, which deliver nicotine without the accompanying tar and smoke of tobacco, can cut cigarette consumption by 50% in about half of people with schizophrenia, even if they weren’t trying to quit.

Chantix (varenicline) and Xyban (bupropion) can be used for most patients, but these medications present additional problems for the mentally ill. Xyban, for example, can’t be mixed with certain antidepressants and Chantix, which is roughly twice as effective as other methods, carries the risk of intensifying or even causing psychiatric symptoms.

So facilities are left with few good options. “I am ambivalent about this,” says Harold Pollack, professor of social service administration at the University of Chicago and an expert on substance use disorders.  “I am a strong proponent of aggressive tobacco control policies,” noting that both of his in-laws died early and  suffered from lung cancer and that cigarettes take a disproportionate toll on the mentally ill. “Given this reality, I certainly would oppose all-too-common behavioral control strategies that use cigarettes as incentives or rewards within psychiatric settings. Yet there is another side.  I am uncomfortable with the level of coercive paternalism exemplified by that policy. People have a legal and moral right to smoke, even though this is often a foolish and self-destructive choice. To completely ban smoking strikes me, on balance, as an unduly severe infringement of patient autonomy. We wouldn’t physically prevent heart failure patients from smoking. We shouldn’t do this to mentally ill patients, either.”

Dr. Mark Willenbring, former director of the treatment and recovery division of the National Institute on Alcoholism and Alcohol Abuse and current head of Alltyr, a treatment program in Minnesota, agrees that the question is complex and that we don’t have good research about how to help the mentally ill quit.  Because nicotine can affect the way some antipsychotic medications are metabolized, even suppressing their effectiveness, he says there’s a good argument that it should permitted during short stays among those who plan to continue smoking, to ensure that doctors reach the accurate dose of the drugs that their patients need.

However, he says, “On balance, I favor anything that discourages smoking since it is the single most destructive thing you can do to your body. So I would tend to say no, residential facilities should not allow smoking. At the same time, there needs to be a lot more research on how to help people with severe mental illness stop smoking and remain abstinent.” As some mental health hospitals start to implement no smoking policies, some of that research may just be getting started.

27 comments
EKeller
EKeller

Those who are self-medicating need the nicotine, not the smoke. Nicotine not only relieves depression and anxiety, it enhances concentration, recall, and attention. It also helps to counteract some of the side effects of anti-psychotic medication.  Since it is not the nicotine that causes smoking-related diseases, it makes sense to offer nicotine maintenance therapy to smokers who cannot or will not quit. The nicotine needs to be at high enough levels to prevent the onset of the cognitive impairments and mood disturbances that drive so many back to smoking. Nicotine patches at twice the highest available level of nicotine have been tested and found both safe and more effective, but the FDA has not approved anything higher than 22 mg. of nicotine.  This is where the electronic cigarette can be very beneficial. Many smokers that wanted to quit and turned to e-cigarettes found they still had strong cravings at first; but once they switched to a higher concentration of nicotine and/or a device that delivers vapor more effectively, they lost all desire to smoke.

AngelaKarhu
AngelaKarhu

I'm the mother of a precious young man who was recently diagnosed paranoid schizophrenic.  The fact that he smokes is the least of my concerns.  I'm focused on the serious side effects of the multiple antipsychotic medications that have been administered in order that he may enjoy some kind of normal life.  Some of these side effects are the possibility of him developing diabetes, obesity, hypertension, hypercholesterolemia, or tardive dyskinesia.  As time goes on more drugs will be added to combat the side effects and on and on.  Smoking is not something I would ever promote; however, it's just not a battle I can take on right now.  I believe my son has a greater risk of dying young from cardiovascular disease than from a smoking related illness.

JohnPaulVergaraArocena
JohnPaulVergaraArocena

for instance., when i was a student of BSN, i see a lot of psychiatric patient in a mental institution who'm smoke even they are on medication therapy for their illness. And i made a personal research regarding on drug interaction. Nicotine doesn't have any concern either interaction on major tranquilizers. however, to those people who has a chronic smoker it may mock the symptoms of psychological disorder because of withdrawal syndrome. 

Seven
Seven

My brother is a 100% service connected Veteran and an inpatient at a northeast Veteran's hospital. He suffers from  post traumatic stress disorder, depression and schizo affective disorder. He's an alcoholic and cigarette smoker. If he wasn't living in a facility he'd easily smoke upwards of 4 packs of cigarettes a day and drink quite heavily, which he did until our parents admitted him 11 years ago.  That said it was determined decades ago that his smoking was a form of self medication, and likely his alcohol abuse as well. At the hospital where he resides the patients are permitted to have 3 smoking breaks a day with a 2 cigarette limit per break. Of course he'd love to smoke more. Much of his smoking is defiance as he knows how much all of our family members despise tobacco, this only makes him want to smoke more. What irks me is that he purchases cigarettes through the VA and the US government encourages this as it's another way to procure revenue for them. I won't go so far as to say my brother is a medical ginea pig, but I do know that many studies are done on Veteran's without their consent or obvious knowledge and I suspect tobacco use and side effects data has been gleaned by the VA. My brother has emphysema in one of his lungs but will never stop smoking. When he was not allowed to smoke and I took him out on gate pass he'd look for discarded cigarette butts on the sidewalk to smoke.  I won't go so far to say smoking for him and those like him should be banned but I would be fine with him only being allowed to smoke 3 cigarettes a day.
As repulsive as I see tobacco use to be he does have the right to smoke and as so many of his life joys are no more I see no harm in allowing this for him. 

thomasvesely
thomasvesely

should mentally deranged people be permitted to guide public policy ?

thomasvesely
thomasvesely

an idiot apparatchik in australia thought we should have a non smoking army.

there is no shortage of idiots or apparatchiks.

neilgoldmanmd
neilgoldmanmd like.author.displayName 1 Like

In the 1980's I wrote the regulations for banning smoking on the inpatient psychiatric unit which I ran.  The secret was to first stop the staff from smoking on the unit, the second was to have the physicians and staff evaluate the patients and make a diagnosis of tobacco dependence if it existed.  With the diagnosis we were then able to treat the dependence with the assortment of nicotine replacement medications which were available along with the needed supportive psychotherapies.  Patients continued to come to our psychiatric unit even when we were perhaps the first and only non smoking inpatient unit in NYC at that time.  There are no problems if the proper diagnosis is made and appropriate treatment is offered.

CJTweed
CJTweed

@neilgoldmanmd 

Science and research has made significant progress since the 1980's. It has been indicated that nicotine alone can have positive and therapeutic benefits for not only this population but others as well. Treatments like the e cigarette that deliver nicotine without cancer causing smoke in a nontoxic solution have been shown to be pleasurable as they mimic smoking. Patches and lozenges do not. I see this as no more than an incentive for these patients as a chocolate treat would be for a child or a cup of coffee is looked forward to. I applaud the researchers that approach this issue in a scientific and unbiased way in order to be beneficial to the overall health of those that they serve.

neilgoldmanmd
neilgoldmanmd

@CJTweed @neilgoldmanmd 

I agree, but smokers are not a homogenious group.  Some welcome the opportunity to stop smoking and some benefit from the nicotine in all the different forms.  However allowing smoking cigarettes on an inpatient treatment unit whether for addictions or for psychiatric problems is not appropriate for the patient or for the others on the unit.  By acknowleding the problem we can better respond with the appropriate treatment.

CJTweed
CJTweed

@neilgoldmanmd @CJTweed

Smokers like alcoholics share one common thing, for the smoker it is addiction to nicotine. In an ideal world it would be excellent if all of us could just make the best healthiest choices for ourselves but that is simply magical thinking. Addicts will and do decide to not get treatment for deadly addictions if faced with a purely non smoking environment. *Edgewood Addiction Treatment Centre

"— which is why many treatment facilities still allow patients to smoke, even encouraging the habit by using cigarettes as a reward for complying with tests or therapies."

Now, with the e cigarette, there is significantly less harmful option for these patients. Therefore, the patients can vape according to doctors orders without affecting any other patient. While smoking visitors will just have to white knuckle it til they get to some designated place off property;)

P.S. this is not scientific just my experience. When switching to vaping I wanted tobacco flavour and the strongest nicotine. Now I, like others prefer a flavour with significantly lower nicotine by using e liquid (70%PG 30%VG 6 mg Tahitian Vanilla).

This could be an excellent treat for these patients who probably would also not require as much nicotine. There are all kinds of yummy dessert flavours!!

Also, inhaled PG was studied by Dr. Oswald H. Robertson who discovered that it had germicidal properties. Many of us found that we don't get colds and flu anymore!

http://www.internationalvapersclub.com/diy-juice/propylene-glycol-safety-articles-information-t344.html

tryingdownstream
tryingdownstream like.author.displayName 1 Like

@neilgoldmanmd Wonderful! Your work was advanced for its time! As a former smoker with a mental illness I have quit, and I would not like to be subjected to the dirt and secondhand smoke of others. I have done a few projects in this field in the last 5 years. People with mental illness die so young and most have so little education about this. Since most people with mental illness live outside of hospitals programs need to be implemented in the community too.  

CJTweed
CJTweed

@tryingdownstream @neilgoldmanmd 

I would imagine that implementation of e cigarettes will also be directly related to decreases in fire related death and injury among this population as well as others.

HaroldMaio
HaroldMaio

Your experince is with a lmited sample, as such it is valid.

LisaKoopman
LisaKoopman

The #1 goal is treatment. Health. Smoking should of been banned a long time ago. Period. But with that, it should be easier to get adults the treatment we know they need. Smoking or no...

raysny2001
raysny2001 like.author.displayName like.author.displayName like.author.displayName 3 Like

I have seen clients refuse to go to a psych ward or a drug/alcohol rehab when they needed to because they would not be allowed to smoke.

HaroldMaio
HaroldMaio

You have, and that is a limited sample. So long as the research aknowledges how limited the sample is, I have no objections.

LisaKoopman
LisaKoopman

@raysny2001 I have been in places like this as a teen. A long time ago. :-) but still... The #1 goal is treatment. Health. Smoking should of been banned a long time ago. Period. But with that, it should be easier to get adults the treatment we know they need. Smoking or no... We all know people who need treatment, but since they are adults, they have a choice... :-/

HaroldMaio
HaroldMaio like.author.displayName 1 Like

  • People with mental illness are 70% more likely to smoke than those who are not mentally ill
Perhaps those studied, but all of us? I highly doubt it. Harold A. Maio, retired Mental Health Editor

CJTweed
CJTweed

@HaroldMaio

Yes, all of us. The study was done by the CDC as the author indicates.

"The report is based on information from the National Survey on Drug Use and Health, which interviewed 138,000 adults in their homes from 2009 to 2011"

http://www.nyaprs.org/e-news-bulletins/2013/psychsmokeNYAPRS.cfm

HaroldMaio
HaroldMaio

@CJTweed "All of us?" None of my acquaintances with schizophrenia are smokers, and each one holds a doctoral degree. The sample is far more specific than "all of us".

HaroldMaio
HaroldMaio

@CJTweed I do not know how the individuals were selected. I do not know the backgrounds of those individuals. Withouy tyah inv formation, I have no way to confirrm the fidnings, to whom to apply them.

Do I believe a great many people were addicted to tobacco by doctorrs and mental institutions? I do. Are there doctors in institutions presently protesting taking tobacco away? There are.

Harold khmaio@earthlink.net

CJTweed
CJTweed

@HaroldMaio @CJTweed

The study was done on 138,000 Americans from across America, meant to be a fair representation of all of us. Doctoral degree or not your friends must just be the 30%

Are you saying that the CDC study is not representative enough to be relevant and therefore reported?

http://www.cdc.gov/vitalsigns/SmokingAndMentalIllness/index.html