'Secret smoking'

No Smoking?
No Smoking?

The Mental Health Foundation has this month published the results of a survey which suggests the ban on smoking in inpatient units has been highly problematic, and has lead to ‘secret smoking’. You can read the full report here on the Mental Health Foundation website.


I began working as a CPN when the ban was introduced – and, certainly initially, I felt very sorry for the colleagues I had left on the PICU of a Regional Secure unit who had to tell patients with very limited access to outside that they were forbidden to smoke. I am not a smoker, however I can imagine that if I smoked and found myself in very distressing circumstances, and in an unfamiliar environment, I would find smoking a source of comfort and reassurance.


Unhappy Staff:

The Mental Health Foundation report suggests that attempts to ban smoking are simply driving the habit underground. They found that only a minority of wards in England have introduced the ban successfully. 85% of 109 respondents to the survey said the ban, which came into effect in July 2008, had not been implemented effectively. The rise of “secret smoking” has lead to safety concerns: the risk of fire, and also the risk that patients who are very unwell may become aggressive to staff when told they may not smoke.


Members of staff are reportedly unhappy to take on an additional policing role, when they are already faced with the problems of holding people against their will and persuading them to take medication. Some staff members said they felt they had no choice but to break the law and ‘turn a blind eye’ to smoking, especially when patients were acutely unwell, and in units which lack an appropriate outdoor space to allow people to smoke. The ban was also felt to be a drain on resources as staff members were needed to escort patients off the unit to smoke.


Unhappy Patients:

There are questions that need to be asked about the effect the ban has had on the wellbeing of patients. Whilst it may be the case that a smoke-free environment is a healthier one in terms of the physical effects of smoke, Vicki Nash, of the mental health charity Mind, said: “Forcing people to stop smoking abruptly on admission to hospital when they are already likely to be distressed is inappropriate and could heighten anxiety”. According to Mind, people with mental health problems are twice as likely to smoke as the general population – which means that this ban is very difficult for a high proportion of patients.


Happy Tsar:

Despite all of this the government’s mental health tsar said he had visited many trusts where a ban had been smoothly implemented. Louis Appleby, the National Director for Mental Health, said other research had shown that although implementing the smoking ban had posed challenges, most trusts believed it had been done successfully. Professor Appleby said: “I have visited many trusts who have implemented the ban with little or no difficulty. Mental health wards are being transformed for the better and going smoke-free is part of this. We believe that mental health staff and patients deserve the same healthier, smoke free environment as the rest of the NHS and there are no plans to change the policy.”


Hospital or Prison?

Prison inmates are allowed to smoke in their cells, as prison is classed as a ‘home’. Does it seems odd that there is greater freedom in prison that in a mental health setting? May be not! Prison inmates also have the right to refuse medication.

On July 28th 2008 there was a nine hour rooftop protest at Ashworth Hospital in response to the smoking ban. The Liverpool Echo reported that an Ashworth source said: “It just went cold turkey on July 1. After that it was no smoking for anyone anywhere on the premises. We’ve got lags coming in who are used to prison life and have that prison mentality, and now they have lighters and cigarettes confiscated when they come through these doors. They don’t like it and you could see trouble had been brewing because they didn’t take kindly to it. We’ve been waiting for something like this to happen.”

I’m not sure I would take kindly to the smoking ban either if I had been admitted to hospital from my own home. Even if I wanted to give up smoking I am not sure that the day of my admission to a psychiatric hospital would be the best time!


What do you think?

Pictures from Flickr (click images to see more from these photographers)

1.  by get down

2.  by Penseri

3. by Mot

9 thoughts on “'Secret smoking'

  1. I totally agree with the imposition of a smoking ban in workplaces such as inpatient units. I would not choose to work in an environment where smoking was permitted as I value my own physical health. I would also suggest that some client’s share this view. We are fortunate in that the unit I work in has a spacious courtyard that affords both smokers and non-smokers their own ‘breathing !’ space. Clients are not forced to give up smoking when they are admitted to the unit but are asked to confine their smoking to the outside area.

    To ‘turn a blind eye’ to clients who smoke indoors is not an option. What next? Letting the client who could only cope at home when he had had ten cans of Stella Artois a night have an in-patient drinking session in the privacy of his own room ? Let’s be practical, we have a duty of care to protect those in our care and our employers have a duty of care to protect us, the workers. Smoking in an in-patient unit can have disastrous consequences for all concerned and I place safety above all else.

    The risk to myself and others posed from passive smoking and fire outweighs the cited concern from some employees that client’s become aggressive when told they cannot smoke. I would probably stand a better chance of dealing with such a situation than fighting fire or lung cancer?

  2. I suspect I am not alone in feeling some ambivalence re this subject.
    I don’t agree that ‘turning a blind eye’ is the right thing to do but I can understand why staff are sometimes reluctant to enforce this. On a secure type unit you are already involved in controlling aspects of someones life & this would probably feel like a control too far.
    For better or worse, smoking has always been part of the culture of inpatient units, this is where I acquired my own heavy smoking habit(now an ex smoker btw)
    I was suprised by how badly affected I was when I gave up smoking. I experienced nightmares and some pretty intense anxiety/ panic. From this perspective I really can empathise with someone admitted to an in-patient unit who is then told they have to add tobacco abstinence to all of the other problems thay have to deal with.
    Julie – you ask why we don’t allow space for someone with a ten can Stella/ night habit. We do in practice often have to attend to the withdrawal that is likely to follow in these circumstances.
    I also don’t feel that a smoking ban makes fire any less likely – I suspect that covert smoking is probably more dangerous?

  3. I don’t think anyone would disagree that it would be a good thing for people to stop smoking, but to actually force someone to do it while they’re in the middle of the worst possible crisis is one could endure? It’s just inhumane. Most smokers find it tough enough to give up at the best of times.

    Here’s a patient’s view of the issue.

    It just smacks of punishment. A lot of people do not choose to be in a mental hospital. And the old “oh no, they’re violent!” aspect of it doesn’t hold up much, either, when a lot of patients deemed to be a “risk to others” are so because of acute aspects of their mental illness. I fell under the heading of “risk to others” when I was in hospital. I hate the way it is written up in the media as if a lot of patients are deliberately violent, as if it’s just the person that they are. It’s true for some, but not for many others.

    Smoking is comforting, let’s face it. If you have a room for people to smoke, then why not let them smoke? It may help to alleviate the awful stress of being in hospital, help the patients feel more human and give them something which isn’t completely controlled by the staff. It helps patients bond with others, as it forces them together, to relax, to scab fags from each other. The only thing I really had when I was in hospital was smoking. Naturally when I left I had a more extreme habit than before, but I wouldn’t have changed that. There was absolutely nothing else to do.

    And for those in mental hospitals, it is home, for a certain time, at least. You wouldn’t ban smoking at home, so why on a ward?

    Under such stressful circumstances, being plowed with sometimes unfamiliar and unpredictable drugs, nicotine withdrawal is the last thing a patient needs and it is only going to exacerbate already distressing symptoms of mental illness. I have been an irritable, moody, aggressive wrench when I’ve tried to give up smoking. Considering my diagnosis, that could easily be mistaken for hypomania. And some people who are in a mental hospital are already undergoing withdrawal from other substances.

  4. By Coincidence I have just been reading something about the link to smoking and schizophrenia below:

    Study Helps Confirm Role of Kynurenic Acid in Schizophrenia and Why Smoking Relieves Symptoms

    (Great Neck, N.Y. – June 15, 2009) — Levels of a substance called kynurenic acid (KYNA) are elevated in the brain and cerebrospinal fluid of people with schizophrenia and Alzheimer’s disease, and KYNA had been suspected of a role in the cognitive dysfunction characteristic of both these disorders. Now, studies by NARSAD Investigator David Bucci, Ph.D., and colleagues in Dartmouth College’s department of psychological and brain sciences, have shown that elevated concentrations of endogenous KYNA interfere with contextual learning and memory. The findings were reported in the March 19 online edition of the journal Behavioural Brain Research.

    In Dr. Bucci’s experiments, rats received injections of solutions of l-kynurenine (L-KYN), the precursor for KYNA. Administration of L-KYN has been shown to produce clinically relevant increases in KYNA concentration. The treated rats exhibited impaired contextual fear memory compared to control rats. In an experiment in which the rats were trained to discriminate between two different training environments, one in which foot shock was delivered and one that was not paired with foot shock, both groups eventually learned the discrimination, but learning was slower in L-KYN-treated rats.

    KYNA acts on molecules called nicotinic acetylcholine receptors, the receptors affected by smoking. People with schizophrenia smoke much more than people in the general population, which has suggested that they use nicotine as a form of self-medication. Dr. Bucci and his team have shown that that acute nicotine administration in laboratory rats reduced their KYNA levels.

    Dr. Bucci wrote: “It is interesting to consider the possibility that cigarette smoking may be used by those with schizophrenia to attenuate cognitive and sensory deficits. Future studies in rat models should examine the capacity for nicotine treatment to reduce the deficits produced by upregulation of brain KYNA.”


  5. I am a reformed (although never very heavy) smoker who gave up in 2000. I think the smoking ban is actually a fundamental assault on service users’ civil liberties as the wards are – in effect – their homes for the duration of their stay there. By all means have a smoking cessation service for those people who want to give up, and keep communal areas smoke free (or have a separate smoking room)but surely there would be very little fire risk with modern systems of smoke alarms, sprinklers etc. The whole thing sounds very paternalistic to me and I hate to think how much staff and service user energy is wasted on this rather than on getting people better. We are all mortal after all so maybe there are more important things than everyone living to 95 in perfect physical health…

  6. I trained at All Saints Hospital which was an old asylum type hospital. The smoke was so heavy it used to hang in curtains from the ceiling, and everybody, staff and patients would stink of it. Many of my old colleagues have died young, and I feel sure that the constant passive and active smoking that went on has something to do with it. So although I do really sympathise with the withdrawal people go through, I am not in favour of enabling smoking in a unit. Perhaps the answer is much greater access to the outside. This would have other benefits as people would have more space for exercise and maybe activities like gardening. Or maybe the aylum traditional brass bands!

  7. I have to say that I too feel some ambivalence on this subject. On the one hand there is this notion that just because some one has a mental health problem, they should not be treated any differently to othere in the community and to do so (in any other situation!) would be considered as socially excluding, stigmatising and labelling – so why should the law be any different? Surely we can’t ask for people experiencing mental health difficulties to be treated the same as everyone else in society except for the smoking ban! Why all of a sudden are there exceptions?
    On the other hand I understand how difficult it is to go cold turkey and some evidence suggests that it might be easier to withdraw from heroin than nicotine!It might also prevent some people agreeing to voluntary admission to hospital because of this – are we going to see an explosion of sectioned admissions as people refuse to engage with treatment? and what about the affects of smoking cessation and neuroleptic/anti-psychotics?
    In my early days of nurse training we often spent time talking to people as they relaxed with a cigarette, and the conversations were informative and useful, it was often a part of the relationship building process.
    I would like to see space outside for people who smoke, so that they can continue to do so if they wish. but we also need to think about smoking cessation for all people (staff and patients)and offer education and information, then let people make up their own minds! As afterall, it’s not easy to stop smoking otherwise there wouldn’t be so many products on the market to help people stop!

  8. echoing many thoughts really.

    while i understand why the smoking ban was enforced i would also like to share a few experiences.

    one time i was walking past the toilets on the unit i work on and i could smell smoke.

    a few minutes later i sit down next to him and very calmley and politley ask him not to smoke on the unit, reminding him that he has leave to the buildings courtyard.
    im not sure what happened in the next four or five seconds but then i find myself bieng screamed at and called every name under the sun.
    and he is insistant that he wasn’t smoking and im just targeting him.
    this then became a three day saga of coucelling and mediation with threats to kill me and accusations of racism.
    and ultimatley the service user loosing his tribunal and remaining detained for another 6 months due to the incident.

    a couple of months on i find myself wondering what the point of all of that was.
    i cant promise that next time i walk past the toilet and smell smoke i wont just carry on walking.

    one time i was specialling outside a secluded service users room.
    while in seclusion on my clinic they are not allowed to smoke.
    i was sitting there for about 2 hours before relief came for me.
    2 hours of listening to this guy bang and scream and cry because he just wanted a cigarette.
    i find myself asking would it have been so bad if i had just passed him a cigarette, would that have really done any harm?
    no one else was even in the room.

    just thoughts.

  9. on the flip side of the coin the old smoking rooms have now mostly been turned into activity areas and stocked up with art supplies and other such goodies.

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