Helpful or Harmful for People with Mental Illness?
Reprinted from the "Tobacco" issue of Visions Journal, 2007, 3 (4), pp. 26-27
While it would be irresponsible to suggest advocating the use of tobacco, it would be equally irresponsible for medical authorities to ban smoking in hospital facilities without taking into account the effects a ban would have on a number of patients/wards.
I am a member of the Nanaimo Mental Health and Addictions Advisory Council that meets once a month to deal with mental health issues facing the community. The advisory council is composed of about 25 people, including people with a mental health issue, family members and service providers from non-profit agencies and from the Nanaimo Mental Health Services of the Vancouver Island Health Authority (VIHA). We monitor the state of care, identify gaps in service, and ensure services are evaluated based on the needs of people with mental health and/or addiction issues.
In 2005, newspapers reported that VIHA Public Health was going to impose a smoking ban1 on all their properties and in their facilities. This ban would have included the psychiatric wards and their smoking areas. This became a major topic for the advisory council.
The council approached VIHA in advance of their decision, with a view to having input into the decision-making process. The council was concerned that the unique needs of people with mental illness were not being addressed or accommodated. One council member had learned that, when an indoor smoking ban was placed in Canadian penitentiaries, discussions took place with inmate groups prior to implementing the ban.2 And, Halifax’s Capital Health engaged over 500 people, including those dealing with a mental health issue, in a community consultation to discuss mental health strategy.3
It has never been the advisory council’s position to oppose the ban; we simply wanted to have some input—and we were assured by VIHA that our input would be granted. VIHA’s position was repeatedly released through the media—but we were not invited to the table.
Our council began doing its own research, which, in the end, proved to be most insightful. Among others, we consulted with Dr. Jill Williams, a psychiatrist in New Jersey who specializes in schizophrenia and tobacco issues. We were staggered to learn that 44% of the tobacco consumed in the United States is consumed by people with a mental health issue.4 Furthermore, tobacco use is the leading cause of premature death among people with mental illness or addiction.5 And, interestingly, research has shown that nicotine may reduce symptoms in people who have schizophrenia.5
Through our research, a number of concerns arose. For example, if nicotine replacement was going to be offered in hospital, would VIHA institute a program for tobacco users once they were released from the hospital? Also, would people voluntarily admit themselves to hospital if they knew they couldn’t smoke? Is it humane to have someone go through nicotine withdrawal while they’re also experiencing a psychiatric crisis?
Our advisory council wanted VIHA to consider these impacts and consequences. But to get VIHA to come to the table, we had to twice write letters requesting involvement in the discussions of a smoking ban. The second letter was copied to the BC Minister of Health and our two Nanaimo MLAs, in addition to VIHA personnel and the board. We finally received a response advising that VIHA was “keen to work with key stakeholder groups such as yourselves to develop joint and pragmatic solutions to the challenging issues such as this.”
A special meeting with the VIHA chief medical officer, director of Mental Health and Addictions and regional manager of Tobacco Control took place in Nanaimo on September 9, 2005, with our council and other interested parties.
At the meeting, we presented the research by Dr. Williams recommending using a nicotine nasal spray as nicotine replacement therapy (NRT), coupled with psychosocial support.6
Our council also supplied information on a 12-step program developed for the state of New Jersey.7 The program addresses issues such as establishing leadership groups, creating a time plan, conducting staff training, providing recovery assistance for nicotine dependent staff, educating patients in a psychiatric ward setting, providing medication for those dependent on nicotine, and developing support groups.
We also raised a legal issue—more as a question than a fact. A Nanaimo lawyer I had interviewed prior to the meeting thought there could be a conflict between the Canadian Charter of Rights and Freedoms’ security-of-person clause as it may pertain to involuntarily committal to psychiatric wards and VIHA’s ability to enforce a smoking ban against patients under those circumstances. This is an issue that can only be decided by a court challenge.
VIHA, as a consequence of this meeting, decided to postpone implementing their smoking ban. Subsequent to that meeting, however, the council learned that a number of psychiatric wards on Vancouver Island were implementing smoking bans on their own. A call was made to VIHA, who immediately contacted the hospitals and cancelled their individual initiatives.
The smoking ban issue died with no communication between VIHA and our council for the next year. In December 2006, another newspaper article indicated that the issue of a smoking ban on VIHA property had again risen. My request to make a 10-minute presentation at the January 31, 2007, VIHA board meeting in Nanaimo was granted. My presentation had a simple message: any program put in place that affect patients on VIHA property must accommodate the trials a person with a mental illness undergoes.
My voluntary involvement in the mental health field over the past five years has led me to believe that, without a doubt, there is no accommodation made for how mental illness affects a person. People with a mental illness are expected to use their brain to complete government forms, which mentally healthy individuals can have difficulty with; they are expected to behave properly, when the body organ that governs behaviour is under attack; and they are expected to make healthy, rational decisions, when their brain may not be healthy or rational. There is no accommodation made for a brain in disarray. Accommodation needs to be made for an illness that is both unique and, at times, devastating. A blanket ban on smoking on VIHA property would not accommodate the issues of mental illness.
Our council still hasn’t taken a position on a smoking ban. It may very well be that smoking on psychiatric wards will always be required. At the same time, who can argue the health benefits of anyone with a mental illness not smoking?
Ideally, we would like VIHA to study the issue of tobacco and mental illness in depth and to share their findings with us, since we don’t have the resources to do this type of research. Then, when we are all better informed, we could hopefully work together with VIHA on an acceptable approach, leading to a well-thought-out program.
About the authorRon is Chair of the Nanaimo Mental Health and Addictions Advisory Council, Director of the Nanaimo branch of the BC Schizophrenia Society, and President of Open Minds Open Windows Society. He has been diagnosed with a bipolar illness
Vancouver Island Health Authority. (n.d.). Health Services 3-year plan: 2005/06 –2007/08 (Section 4.1.1). www.viha.ca/about_viha/accountability/health_services_plan.htm
Correctional Service of Canada. (2005, July 12). CSC announces plan to further reduce exposure to second-hand smoke in all federal correctional facilities (News release). www.csc-scc.gc.ca/text/releases/05-07-12_e.shtml
Capital Health. (2005, March 7). Mental health strategic planning – Community consultation (News story). Halifax: Author. www.cdha.nshealth.ca/newsroom/NewsItems/NewsDetail (see Archives).
Lasser, K., Boyd, J.W, Woolhandler, S. et al. (2000). Smoking and mental illness: A population-based prevalence study. JAMA: The Journal of the American Medical Association, 284(20), 2606-2610.
Williams, J.M. & Ziedonis, D. (2004). Addressing tobacco among individuals with a mental illness or an addiction. Addictive Behaviors, 29(6), 1067-1083. www.quitnownc.org/pdfs/williams2004.pdf
Williams, J.M., Ziedonis, D.M. & Foulds, J. (2004). A case series of nicotine nasal spray in the treatment of tobacco dependence among patients with schizophrenia. Psychiatric Services, 55(9), 1064-1066.
Stuyt, E.B., Order-Conners, B. & Ziedonis, D.M. (2003). Addressing tobacco through program and system change in mental health and addiction settings. Psychiatric Annals, 33(7), 447-456.