Advocacy Guidelines for Restrictive Smoking Policies in Psychiatric Hospitals
PREAMBLE
Clearly smoking is a public health issue. The link between smoking and cancer, emphysema and a host of other related diseases is well documented. Over the past 20 years a definite link has also been made between exposure to second hand smoke and a similar range of diseases normally attributed to smoking. The Psychiatric Patient Advocate Office (PPAO) therefore, supports all efforts made by the Ministry of Health and Long Term Care to educate patients about the dangers of smoking, and to provide any assistance possible to those who choose to quit.
ISSUE
The Psychiatric Patient Advocate Office [PPAO] is aware that there are significant changes being made to smoking policies throughout the current and divested psychiatric hospitals. For a number of hospitals this has meant a movement towards either a smoke free environment or at minimum, restricting smoking to designated areas where outside ventilation is possible. Again, the PPAO appreciates the negative effects of smoking and the impact of second hand smoke on an individual's health. Any movement towards a more restrictive smoking policy should however, take into account the quality of life issues raised by such a significant change to the living environment for patients.
In taking this position we recognize that the group rights of non-smokers need to be protected. In practice this has lead a number of municipalities to enact legislation that restricts smoking in public places. While providing additional limits to when and where individuals can smoke it is important to note that neither municipal bylaws nor the " Tobacco Act" make the activity of smoking illegal. That decision is still left to the individual. What we ask is that each hospital in developing their smoking policy recognize that each patient continues to exercise their right to choose whether or not they wish to smoke.
DISCUSSION
As opposed to general hospitals (acute care), admission to psychiatric settings often involve longer periods of stay. Some patients are held on an involuntary basis or under an Ontario Review Board Order. Due to the severity of their illness, a significant number receive most of their treatment and rehabilitation in the hospital setting. Indeed some who live at the hospital for extended periods of time call it their home.
The relationship between smoking and mental illness is extremely complex. We know from both formal studies and informal observation that smoking is a significant part of the hospital culture. It is estimated that 70 to 80 percent of psychiatric hospital patients smoke, [as opposed to 22 percent of the adult population in Canada].[1] Some clients indicate that smoking has a calming effect on their nerves. Others suggest that smoking reduces the side effects of the psychotropic medication, [there is some research that validates this observation].[2] It is clear that there is a need for further research in this area.
In addition, we acknowledge that smoking is both physically and psychologically addictive, and that there are significant symptoms of withdrawal for those who attempt to quit. To further complicate matters there is a body of research that indicates that nicotine withdrawal is more pronounced for those who try to quit while on certain psychotropic medications.[3] Other research suggests that smoking may be contraindicated while on certain medications.[4] [5] Again, we are not arguing the merits or hazards of smoking only that it is a complex issue involving a number of variables that need to be taken into account when developing restrictive smoking policies.
As a consequence of the move towards more restrictive smoking policies in all hospital settings, the PPAO has developed a set of practice principles that will serve as our guide to advocacy interventions on behalf of patients. These principles are consistent with patients' basic rights as "residents" in psychiatric hospitals.
PRINCIPLES
- Choice
The primary principle of practice for any restrictive smoking policy is choice. This would in practice include providing regular access to smoking areas for those who wish to smoke while in hospital. In some situations this would require access to sheltered areas outdoors. It may also necessitate regular escorts for those patients who are involuntary or need supervision. - Consultation
A second principle of practice would involve the active engagement of patients in the development of policies and proceedures that effect their day to day living conditions in the hospital. In practice this would mean the active involvement of patients in any decisions to develop or make significant changes to existing smoking policies. - Discretion
A third principle of practice would involve a clear understanding that all hospital policies identify access to smoking as a matter left to the discretion of each individual. Smoking therefore, should not be seen as a privilege that can be taken away arbitrarily by staff. In practice this would mean that access to the smoking area would not be incorporated into any form of reward system, behavior program or treatment plan. - Cessation
A fourth principle of practice would involve making available a range of cessation programs for those patients who choose to quit smoking. These programs will be of particular importance in those hospitals that are moving towards a smoke free policy. They would include patient education, and access to smoking cessation aids when appropriate. This may also include access to counseling services. All of the above could be included in the individual care plan of each patient. Given the ministry's history of involvement in the distribution of tobacco to patients, it would be appropriate that these aids be available at no or minimal cost to patients.
Psychiatric Patient Advocate Office
55 St. Clair Avenue West 8th Floor, Box 28
Toronto, Ontario, M 4V 2Y7
Telephone: (416) 327-7000 1-800-578-2343
website: www.ppao.gov.on.ca
Footnotes:
[1] McNeill A, Smoking and mental health -a review of the literature. Unpublished Report. SmokeFree London Programme Dec. 2001;
[2] ibid.
[3] ibid.
[4] ibid.
[5] Desai HD, Seabolt J, Jann MW et al. Smoking in patients receiving psychotropic medications: a pharmacokinetic perspective. CSN Drugs; 2001; Vol.15: Issue 6: 469-94
