Three-fourths of patients in mental hospitals are addicted to cigarettes, a fact that has traditionally been accepted by hospital administrators as either inevitable or relatively harmless. In the latest issue of Psychiatric News, the National Association of State Mental Health Program Directors (NASMHPD) declares this tolerance of smoking unacceptable, and sets out a plan for making hospitals smoke-free.
The NASMHPD is aware that patients and staff will stubbornly resist a smoking-ban, so it promulgated a "toolkit" to help directors overcome opposition. Some of the objections that the toolkit anticipates are, "Smoking calms patients", "Smoking breaks offer unique opportunities", and "A smoking ban will just complicate treatment of more serious drugs and mental issues." The counter for the first objection is that hospitals that have banned smoking actually report fewer disciplinary incidents. In these smoke-free facilities, it is rarer for staff to resort to restraint and seclusion, and patients to engage in aggressive behavior. To the second objection, the toolkit offers alternatives to the prized smoking break. Fresh-air breaks offer the same opportunity for bonding and entertainment, without the deleterious health consequences. The last objection is met with two responses, that smoking IS a dangerous drug, and that quitting smoking concurrently with other drugs offers a synergistic benefit. While it may seem that patients should focus on one drug at a time, recent studies have suggested that it is easier to quit nicotine and alcohol at the same time than sequentially.
While there will certainly be opposition to smoking bans, there is strong evidence that they can be implemented effectively; 41% of state hospitals have successfully instituted smoking bans. The toolkit offers the example of the Riverview Psychiatric Center, which managed to make the transition to smoke-free this year. Riverview faced multiple legal challenges by patients claiming that the ban abridged their right to refuse treatment, but it was able to defeat all of these challenges in court. The hospital did not rush into the ban after winning in court. Four months of preparation, with frequent staff meetings and patient information sessions, preceded the ban. Even once implementation started, it was gradual. Smoking breaks were cut back, and patients were evaluated for their motivation to quit and the method that they would prefer. The slow but steady method worked. There was no increase in behavioral problems and 1/3 of the staff managed to quit, along with numerous patients.
Fear of disrupting the status quo is not a good justification for sending a message to patients that smoking is not a problem, and for subjecting staff to hazardous working conditions. Yes, many patients may resume smoking once they leave the hospital, but even those who resume will do so knowing that they were able to stop for some time, and that their doctors are firmly opposed to all forms of drug dependence.
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