Lighten up, and let the patients light up

With the introduction of the ban on smoking in ‘enclosed public spaces’ set to come into force in Wales on 2 April and in England on 1 July, the debate has moved on from one over the rights and wrongs of the proposals to one over how best to ensure their smooth implementation.

The proposals are laid out in the Health Act 2006 and cover premises that are ‘enclosed’ or ‘substantially enclosed’ and which are either open to the public or are workplaces. Such a definition includes places like pubs, clubs, sports venues and hospitals. It will be a criminal offence punishable by a fine for an individual to smoke, or for a manager to allow smoking, in any place covered by the Act.

Those still wishing to smoke will have to go to that great ‘unenclosed public space’ previously known as outdoors. The spectacle of cold, shivering smokers huddled together outside many workplaces today will soon be seen outside pubs, restaurants and shops, too. The rationale seems to be that such people can opt to leave and smoke if they wish. They can smoke outside and/or at home, just not in certain designated premises. However, it is here that the issue and the surrounding debate gets even more odious and illiberal than that which surrounded the Health Act’s journey to the statute book.

For many people, ‘home’ is also a public space and a workplace and it may also be a place they are not allowed to leave – for example, consider those individuals confined to psychiatric residential or nursing care institutions. Recognising that this might pose a problem, it has been decided that those resident in long-stay care institutions, defined as places where normal residency is six months or over, will still be allowed to smoke indoors in designated smoking rooms. However, given that the average length of stay on a psychiatric ward is 58 days, most hospital psychiatric units will not qualify for such an exemption, and therefore the smoking room will have to go (1).

This scenario has caused a lot of debate, given that many of the patients affected will be detained against their will under the Mental Health Act and therefore may not be allowed to leave the psychiatric unit, let alone the grounds of the hospital. Surveys have found that 70 per cent of psychiatric patients smoke, with around 50 per cent of them heavy smokers – meaning that many people deprived of their liberty will also be deprived of a cigarette (2). In recognition of the practicalities and rights issues involved in all of this, the government has given psychiatric units a one-year extension, until July 2008, in order to provide some secure outdoor smoking area before the law will be applied to them.

Working as a mental health social worker from 1995 to 2001, I spent a considerable amount of time on psychiatric wards, and can confirm that the smoking room plays a significant role in the ‘normal’ culture of these environments. Such rooms were frequently smoke-filled, smelly and busy, while the other cleaner rooms were more or less deserted.

Contrary to much lay belief, psychiatric wards are rarely the hub of therapeutic activity or tranquillity. In reality, for those in acute crisis they can be frightening and threatening and, for those more settled, extremely boring places to be. The smoking room is sometimes the only real place where social interaction can occur and where boredom can be alleviated.

Thinking back on those six years of practice, I cannot recall any serious discussion with colleagues over the dangers the smoking room posed to the health of either patients or staff. And in my recent or current contact with people involved with mental health user/survivor groups I have had no discussions about the effects of smoking on patient health. Of course, I may have just conveniently forgotten such conversations. After all, there has certainly been a move within both social work and nursing to view clients/patients who smoke as toxic agents hazardous to the health of staff (3).

However, recent surveys have found that most psychiatric nursing staff not only disprove of a ban, but 60 per cent believed that staff should smoke with patients in order to break down barriers and build some therapeutic rapport (a view also supported by 78 per cent of patients) (4). And as one ex-patient put it, while it is clearly true that smoking is not good for you, giving up may not be a priority when you’ve just tried to throw yourself under a train or your children have recently been taken into care (5).

So it is worth asking just where the demand to restrict further the activities of detained patients has come from. It is likely that the focus by the health promotion industry and government on ‘raising awareness’ has played a part. With the dangers of passive smoking routinely cited as a major detriment to health, it is not surprising that many health professionals have started expressing concern, even though the dangers from passive smoking are grossly exaggerated, often driven by a failure to distinguish between absolute and relative risk (6).

In addition, evidence contrary to the health promotion agenda may be cursorily mentioned, but that does not deflect from the plan to pursue government policy. For example, a recent Kings Fund paper – the subtitle of which claimed that it was about ‘debating smoke-free policies in psychiatric units’, and which cited evidence both for and against the ban – was mostly concerned with how best to implement the smoke-free environment (7).

However, perhaps the most distasteful argument in favour of banning smoking on psychiatric wards is from those who advocate it on ‘anti-discriminatory’ grounds. In a reply to the article cited above by the ex-patient protesting about the ban, Louis Appleby, UK national director for mental health, claims that failure to apply the legislation to psychiatric patients would be to treat them unfairly. Apparently, if ‘normal’ patients can have a smoke-free environment then ‘what message would an exemption for mental health wards send out about the importance of the lives of mental health patients?’ (8).

It might sound commendable. Yet this is the ‘mental health czar’ who is in favour of the Mental Health Bill that was debated in the House of Lords this week, a Bill that proposes medicating mental health patients against their will in the community and indefinite hospital detention for some even if they will gain no medical benefit from it (9). What message does that give out about the value you place on the lives and rights of mental health patients, Louis?

Those subject to the mental health system already have major parts of their lives controlled by professionals. Now it looks like they will lose control of one more minor aspect of their lives: smoking. The government’s view may be that while people may be mad to smoke, the truly mad can do without cigarettes. The government and the health promotion industry should lighten up, and let the patients light up.

Ken McLaughlin is a senior lecturer in social work at Manchester Metropolitan University, England.

(1) ONS survey cited in King’s Fund press release

(2) Cited in K. Jochelson (2006) ‘Smoke-free legislation and mental health units: the challenges ahead’, British Journal of Psychiatry, no. 189, pp.479-480

(3) Nursing a grudge against smokers, by Brid Hehir

(4) Cited in K. Jochelson (2006) ‘Smoke-free legislation and mental health units: the challenges ahead’, British Journal of Psychiatry, no. 189, pp.479-480

(5) The unfair smoking ban will mean fuming on the wards, Guardian, 7 February 2007

(6) For a useful discussion see Michael Fitzpatrick (2001) The Tyranny of Health: Doctors and the regulation of lifestyle, London: Routledge

(7) K. Nicholson and B. Majrowski (2006) Clearing the air, King’s Fund

(8) See letter from Louis Appelby, Guardian, 14 February 2007

(9) Scare in the community, by Ken McLaughlin