Sign up for alerts

Autumn 2008 | Vol 12 No 1

Focus

No ifs, ands or butts

The smoking ban debate rages on

By Astrid Van Den Broek

“Some people say they stole our dignity by stepping in and going smoke-free, but how dignified is it to be on an oxygen machine?”

“I have zero tolerance for zero tolerance.”

These statements by two clients of the mental health system in Ontario reflect two perspectives on the smoke-free psychiatric facility debate that rages across the country, pitting respect for client rights, personal freedom and choice against considerations of client health and workplace safety.

Increasingly, over the past six years, individual hospitals and integrated health authorities from Newfoundland to British Columbia have declared their sites 100 per cent smoke-free. However, in some locations, exceptions continue to be made for inpatients of psychiatric facilities. For example, the 2006 Smoke-Free Ontario Act, which bans smoking in enclosed spaces, includes an exemption allowing controlled smoking areas in residential care settings.

“Part of the reason that exemption was put in the Act is that we have patients who have been in hospital for years, so in many ways it is their home and residence,” says David Simpson, program manager for Ontario’s Psychiatric Patient Advocate Office. “However, the government set the standards so high in terms of the equipment that needs to be used, that it’s not affordable for hospitals to retrofit rooms with the proper ventilation for people to smoke indoors.” Also, since municipal bylaws vary on what constitutes an outdoor smoking shelter, some facilities provide outdoor shelters and others extend the smoking ban to hospital grounds. Simpson notes that at one Ontario hospital where there is a total ban, a patient who went offsite in search of cigarettes was struck by a bus and died. “Aren’t there ethical issues entwined in that?” asks Simpson.

At the Mental Health Centre in Penetanguishene, Ontario, which banned smoking anywhere on its 225 acres in 2003, a patient at the centre’s maximum-security Oak Ridge facility launched a court challenge. “One of the arguments was that for longer-term patients, the facility was considered to be a residence and patients should have residential smoking privileges,” says Dan Parle, the centre’s former director of planning and public information. “Although the judge had some sympathy for the argument, he was clear that the hospital was not a home and that the rights of the entire community were superior to those of the claims for individual, residential smoking privileges.”

Home or not, however, some consider it inhumane to force people to go through nicotine withdrawal while they’re in the throes of a mental health crisis. According to Dr. Richard O’Reilly, a psychiatry professor at the University of Western Ontario in London, smoking bans contradict involuntary admission principles and inflict unnecessary suffering on inpatients. “It is a widely held principle that when we certify people into psychiatric hospitals we do it in the least intrusive way,” says O’Reilly, who is also a clinician. “However, when we stop patients from smoking, we aren’t using the least restrictive alternative. In fact, we precipitate them into nicotine withdrawal, which is an extremely distressing condition.”

Beamer Smith, first vice chair of the Ontario Association of Patient Councils, agrees: “While there are accommodations that can be made, some psychiatric facilities have chosen a path that, regardless of intent, feels like punishment; yet hospitals of this type should deal in compassion.”

Simpson links smoking restrictions to disruptive behaviour and punitive measures. “We hear from patients that a lot of behavioural issues start because they’ve been denied a smoke. Some have smoked for decades and suddenly, because they need mental health treatment, that’s the end of it. They engage in acting-out behaviour and may end up in seclusion or restraints, which creates health and safety risks for patients and staff.”

O’Reilly agrees that many of his patients do not want to use nicotine replacement therapy, become more agitated as they withdraw from nicotine and some smoke illegally on the wards, creating a fire hazard. Consequently “clinicians are forced into situations where they prematurely allow patients to have off-ward privileges.”
Parle, however, draws parallels between tobacco, alcohol and other substances. “Psychiatric hospitals have never had drinking rooms on the wards. Instead, for alcohol and drug addiction, hospitals provide good cessation support. Why should tobacco be any different?”

Ron E.*, an inpatient at Penetanguishene who smoked two packs a day for over 30 years, agrees: “Every once in a while, people with addictions get a chance to quit and move on. If you don’t take advantage of it, the chance goes away and it may never come back again.” In fact, says Ron, “When the hospital implemented this decision to go smoke free, it saved my life.”

For Parle, “the ethical choice is not to look the other way and say, ‘Yes, smoking is a dangerous addiction that might ruin patients’ finances and health and will most likely cause an early death, but we’re going to have nurses escort patients outdoors to pursue this addiction.’ That should never have happened at hospitals in the first place.” Instead, Parle cites three reasons why psychiatric hospitals should implement smoking bans: as an ethical use of scarce health care resources; as an expression of the physician’s credo – First, do no harm; and as an aggressive corrective to the high rates of smoking among psychiatric patients.

Simpson, on the other hand, believes that patients deserve the opportunity to exercise choice. “They’re adults,” he says. “Nursing staff should tell them the health risks of smoking and give them all the information they need to make an informed decision about whether they’re going to smoke or not.” Smith agrees: “When someone comes to be treated for a ‘thing,’ they should only be treated for that ‘thing,’ unless they voluntarily accept another treatment. Any smoking cessation should be truly voluntary and exclusive of any other treatment.”
Simpson considers it unfair to “put nurses into the role of being enforcers for non-smoking,” or have hospitals bring in municipal bylaw enforcement officers to threaten patients, many of them on low incomes, with fines of $110 for illegal smoking, which he says has happened in some locations.

O’Reilly suggests it’s neither helpful nor humane to insist that patients stop smoking immediately. “Many severely ill patients live impoverished lives and say they get pleasure from coffee and cigarettes. While we should try to improve their lives more globally, that’s something to do when they’re out of hospital; but when they’re in hospital, to take away, in some cases, both things that they like, I think that’s mean.”

Smith agrees: “Often the only comfort a person gets, particularly in their time of most need, is their habits.” In fact, says Smith, “Often the only outside air a client gets is on a smoke break. Smoke breaks can be a time of networking and reflection, both of which are beneficial to wellness.”

Simpson expresses concern that some patients will avoid seeking mental health care and treatment because of non-smoking policies. However, Parle counters that, whatever your addiction, you may want to avoid hospitals, but sooner or later, if you’re in a mental health crisis, you will come. He notes that the Mental Health Centre Penetanguishene experienced no change in occupancy rate or referral pattern after its 2003 total smoking ban.

O’Reilly, who as a clinician deals primarily with involuntary admissions, says that although people may be restricted from smoking in inpatient units, the majority resume smoking when they leave hospital, and for those who go from a fairly restrictive situation to being discharged, the resumption of smoking can interfere with the effectiveness of their antipsychotic medication dose. Critics and proponents alike agree that government funding of nicotine replacement therapy and other smoking cessation aids, including counselling, should be extended to outpatients.

*not his real name