People with a mental health disorder are two to four times more likely to smoke cigarettes than those who don't. Hospitals have banned smoking on and off the premises. At many hospitals, the policy excludes psychiatric patients. A new study says it's time for a re-think.
When I started in the ER, it was conventional wisdom that mental health patients stayed calmer and were less prone to violence if permitted to step outside of the hospital to have a cigarette – accompanied by a security guard to make sure they didn't try to leave.
The patients who are admitted to the psychiatric ward tend to have serious conditions like schizophrenia, bipolar affective disorder and depression with suicidal thoughts. At the time of admission to hospital, some are quite agitated and prone to impulsive violence. Many smoke cigarettes, in part because they have higher rates of addiction to nicotine. Some studies have shown that nicotine has antidepressant and antipsychotic properties, and some psychiatrists say it's best to let people admitted to the psychiatric ward continue to smoke during their stay.
The new study – by researchers in the UK – turns conventional wisdom inside out. In 2013, the National Institute of Health and Care Excellence recommended hospital-wide smoke-free policies. As a result, the South London and Maudsley National Health Service Trust banned smoking in buildings and on the grounds of its four hospitals in South London. The researchers analysed incident reports of physical assaults in the 30 months before the smoking ban – and the 12 months after the ban was enacted. Over the 42-month pre-and post study period, there were 4,550 physical assaults – two thirds directed at hospital personnel and one third directed at patients. A little over 300 of the incidents involved psychiatric patients.
Here's the surprising result. As soon as smoking was banned, violent incidents did not go up; they went down a lot. There was a 39 per cent reduction in physical assaults per month.
As part of the smoking ban policy, all patients who stopped smoking were offered nicotine replacement therapy including gum, patches, puffers, and e-cigarettes. The researchers believe nicotine replacement is the key to the program's success, which goes against convention wisdom. The old assumption is that mental health patients become agitated and violent when deprived of cigarettes because they're missing the antidepressant or antipsychotic effect of nicotine or because they're angry about the deprivation.
The new hypothesis is that violent behavior in mental health patients is triggered by nicotine withdrawal. Letting them smoke does not quell violence so much as postpone it. When they smoke a cigarette, they get a hit of nicotine that calms them briefly by relieving withdrawal symptoms temporarily. But as soon as the effects of the cigarette wear off, the nicotine withdrawal symptoms come back, along with the agitation.
The non-smoking policy attracts critics who say that mental health patients admitted to hospital need all the help they can get – cigarettes included – in wrestling with personal demons. Most doctors instinctively laud the idea of stopping smoking – which is arguably the single habit most dangerous to one's health. But some acknowledge that people have a legal and moral right to smoke – foolish or not.
Forcing people to quit strikes some doctors as paternalistic and coercive. They argue that if we don't force patients with lung cancer to quit, why should we do so to people with a psychiatric diagnosis? They also say we need more research on how to help people with mental health problems to quit. This study helps move the needle a bit, but there's a lot more work to do.
Nevertheless, the study is important because it addresses a significant gap in meeting the health needs of people with serious mental health problems. More than eighty per cent percent of those with schizophrenia and bipolar affective disorder are smokers. People living with mental health problems and addiction tend to be very heavy smokers, which puts them at high risk of heart disease and stroke, chronic obstructive pulmonary disease, asthma and lung cancer. They live on average 25 years fewer than non-smokers.
Patients with mental health disease can quit if they receive smoke cessation medications and psychotherapy. Yet studies show that they seldom receive such programs – in large part because we think letting (perhaps even encouraging) them to smoke is the lesser of two evils – a myth that needs to be dispelled.
I strongly suspect that medical culture turns a blind eye to smoking and drinking in all marginal populations – not just people with mental health disorders – but indigenous patients and people who are homeless. It's an attitude that must change. Their lives depend on it.