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.