Thursday, 12 November 2015

Why psychiatric patients should not be forced to quit smoking

I spoke at the Maudsley debate on banning smoking outdoors in psychiatric hospitals yesterday. This is more or less what I said...

I’ve never been in a psychiatric hospital and I don’t smoke any more. But it’s because I used to smoke that I know how enjoyable it is, what a comfort it can be, and how difficult it is to give up. Let’s be blunt about it - giving up smoking is a miserable experience. It makes you miserable even if you are fully committed and totally prepared for your quit attempt. Being forced to quit by somebody else when you least expect it must be worse. Being forced to quit when you have been taken from your home and put in unfamiliar new surroundings with total strangers must be almost unbearable. And forcing somebody through all that when they are suffering from a serious mental illness and are at the lowest point in their lives is, I will argue, vindictive and inhumane.

Why should they be put through this? According to the proposition it is because smoking is bad for their health. Smokers live shorter lives, on average, than nonsmokers. But this is true of all smokers, not just those who are suffering from mental health problems. Why, then, are they picking on them?
I think the answer is simple. It’s because they can - because they are easy targets. The medical establishment would happily ban us all from smoking if they could, but that prize is not yet in reach, and so they have turned their attention to those who are already under the government’s total control. 

In the recent BMJ head-to-head, the proposition said:

‘Some smokers with psychiatric disorders think that smoking can help them to manage their symptoms and relieve stress and don’t want to quit. We respect that view but point out that smoking has no positive effect’. 

The obviously contradicts the views of thousands of people with a mental illness who smoke, not to mention the billion or so smokers around the world who keep buying a product that supposedly has no positive effect. More to the point, it goes against the evidence that Simon and Deborah cite in their article - a 2013 report from the Royal College of Physicians which found, and I quote, that ‘nicotine can relieve symptoms of anxiety, depression, schizophrenia and ADHD’.  

Rather than attributing false consciousness to millions of people, let’s be honest and say that the problem with smoking is not that it has no positive effect, it is that it has negative effects. If smoking wasn’t bad for your health, most of you would be smokers, as you would have been if we were holding this debate in 1950. Most of you are not smokers because you are prepared to sacrifice the pleasure of smoking for the chance of better health in the future. You are making a personal trade off and psychiatric patients should be allowed to make their own trade off.

Their trade off may be different to yours, but then their circumstances are very different. It’s well known that people with mental illnesses are much more likely to smoke than the general population, with rates of up to 90% amongst people with schizophrenia. Although smoking rates have fallen in general over the years, there has not been much of a decline amongst people with mental illnesses. Perhaps the proposition think that people with mental illness are more susceptible to those colourful cigarette packs that we keep hearing about, but a more obvious conclusion to draw is that people with a mental illness get a greater benefit from smoking than the average person, and indeed there is good evidence that symptoms, particularly for schizophrenia, are alleviated by smoking. But even if smoking didn’t have particular neurobiological benefits for people with mental illnesses, it would still be a source of pleasure and comfort for them. It would still give them something to enjoy and look forward to during those long, traumatic days on the ward. And even if Simon and Deborah deny the benefits of smoking, I trust they do not deny that the existence of withdrawal symptoms which are strong enough to make 19 out of 20 quit attempts end in failure.

And so, added to the other problems that the patient suffers from, they will be forced to endure withdrawal in their new home - and never forget that this is now their home. Whether this results in the kind of violence seen repeatedly in prisons around the world when smoking bans have been introduced remains to be seen, but it will certainly lead to resentment, anger and a breakdown in trust between staff and patients before they’ve even got to know each other. The patient will know that there is a place outside where they could smoke and they will know that they are forbidden from doing so for no other reason than that their captors have decided that it’s for their own good. Not for the good of their mental health, which is the only reason they are there, but for their long term physical health - the benefits for which will be practically nil in any case because the majority of psychiatric patients resume smoking almost as soon as they are discharged.

In 2006, when the medical establishment was pushing for a ban on smoking inside psychiatric hospitals, the King’s Fund released a report supporting the ban, in which it said:

‘To those who are concerned that the proposed Health Bill infringes smokers’ rights, it is important to point out that the ban will prohibit only indoor smoking and that patients will still be able to smoke outdoors’.

How quickly we move on. How quickly these little assurances turn to dust. 

It also said:

‘The choice to smoke or to quit must ultimately be a private decision for the individual, and given that many psychiatric patients are detained compulsorily, it is right that proper consideration is given to the degree of choice that they will be able to exercise.’

That should be nothing more than an obvious truism. It is a choice for the individual. It is an abuse of power for medics to use the fact that they have custody of somebody to force them to act against their will and, in most instances, against their interests.
This is really quite simple. A psychiatric patient smoking outdoors is causing no harm to anybody. In a liberal society, that is the end of the story. A ban cannot be justified. Clearly there are people who don’t smoke, who hate smoking and apparently don’t understand anything about smoking, and they will always think that smokers are making the wrong choice, but that’s not their decision to make and it does not justify the use of coercion. Please show that you still want to live in a liberal and humane society by voting against this motion.


We lost by one vote. There should be a video of the event online soon.

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