Sign up for alerts

Autumn 2008 | Vol 12 No 1

A view from CAMH

Dr. David Goldbloom

 

Among the people I see with severe and persistent mental illnesses such as schizophrenia or bipolar disorder, I always ask about cigarettes; in contrast to the rest of Canadians, the majority of these individuals smoke. We then calculate together the cost per month of their tobacco dependence. It is not unusual for one-third or more of their income, if they are on public assistance, to go “up in smoke.” Quite apart from the obvious short-term and long-term physical health consequences of smoking, the economic burden on the individual, and the difficult choices that result, are staggering.

And yet I am old enough to recall days not so many years ago when “good behaviour” on inpatient psychiatric units was “rewarded” with cigarettes. Until recently, our inpatient units had smoking rooms where people would both congregate socially and puff constantly. Staff would sometimes justify smoking for these individuals as “their only pleasure.” So institutional culture both rationalized and encouraged smoking among people with mental illnesses and/or addiction to other substances without concern for their broader health needs and their personal fulfillment needs.

In addition, smoking may meet a need beyond its own addictive properties, whether it is quelling anxiety or counteracting the side-effect of a medication. Some individuals may be genetically either more vulnerable to addiction to cigarettes or more resistant to smoking cessation interventions.
Meanwhile, public health and society at large leapfrogged ahead of the addictions and mental health communities, legislating against and shaming smokers. Smoking sections on airplanes and in restaurants and hotels have effectively disappeared, and the Canadian climate tests the hardiness of the committed smoker standing outside a building in February.

Several years ago, CAMH took the plunge and closed its inpatient smoking rooms, eliminating smoking in the hospital (and freeing up the real estate for other purposes). But rather than simply implement a ban, CAMH trained its staff in smoking cessation techniques and made it feasible for nurses to implement nicotine replacement. Interesting discussions occurred at the level of ethics and safety before we took this step. Some predictions of the outcome were dire. But we asked ourselves how, as the Centre for addiction and mental health, we could turn a blind eye to the addiction that kills more Canadians than any other?

Smoking poses many questions regarding health, culture, economics, free will, free choice and institutional/governmental intervention. This issue of CrossCurrents touches on a number of them.

David S. Goldbloom, MD, FRCPC
Executive Editor, CrossCurrents;
Senior Medical Advisor,
Education and Public Affairs, CAMH
Professor of Psychiatry, University of Toronto