In my opinion, and as a former patient with schizophrenia, new public health policy may be in breach of the Hippocratic Oath that used to compel medical professionals to "first, do no harm".
Since I drew attention to one NHS Trust's decision to ban outdoor smoking in psychiatric units, my worst fears are unfolding. Several others have now followed East Lancashire's lead: Oxford, Mersey, South London and Maudsley, with more to follow as 'Public Health England' (PHE) and the 'National Institute For Health and Care Excellence' (NICE) demanding a total outdoor ban across the country.
Forcing patients to quit smoking when they're in the middle of a mental breakdown is intolerably cruel. There is no worse time or place that mental patients would cite as a desirable opportunity to quit. It also appears as a form of vengeance from public health quangos since the indoor ban that developed from 2008 has done little to change patient's behaviour once they get better: after discharge, the majority resume their smoking habit. Sadly public health types are now arguing more must be done to intervene post-discharge. Can patients never determine their own lifestyle choices?
PHE claim that people with serious mental illnesses (SMIs) have shorter lives on average than 'normal' people. For the SMI group, average life expectancy is 20 years less than the general population. PHE blames this on the fact the majority of them smoke, and say this is a "health inequality" that must be tackled. One review of the literature even says that the earlier mortality amongst mentally ill smokers is a "national scandal", revealing the zeal with which the public health lobby want to combat this. However there are some logical problems with these claims.
The average life expectancy in the UK is 79 for men, 83 for women. For those who smoke 20 or more cigarettes a day, this drops by an average of 10 years. For many long-term smokers, this decrease of 10 years is an acceptable trade-off for them continuing to indulge a habit they relish - so smoking can be a rational choice for them, whether PHE like it or not. But for the SMI group to suffer a 20 year decrease suggests that something else happens - not just the effect of their smoking habit that would only account for a 10 year decrease. The answer is not mysterious. Dr Seena Fazel, of the Department of Psychiatry at Oxford University, accounts for the SMI higher mortality rate thus:
'High-risk behaviours are common in psychiatric patients, especially drug and alcohol abuse, and they are more likely to die by suicide. The stigma surrounding mental health may mean people aren't treated as well for physical illness when they do see a doctor. Many causes of mental health problems also have physical consequences and mental illness worsen the prognosis of a range of physical illnesses, especially heart disease, diabetes and cancer. Unfortunately, people with serious mental illnesses may not access healthcare effectively.'
An important point to stress is that the 20 year average decrease is a 'mean average', i.e. it locates an average point between someone who commits suicide in their 20s with someone with an SMI who lives to 90. It therefore produces a figure that is open to misinterpretation that can be used to scaremonger. Furthermore the ineffective access to physical healthcare by those with SMIs can be attributed to their generally lower socio-economic status, or more idiosyncratic factors emanating from their condition such as a fear of doctors. To blame the 20 year drop entirely on smoking, as PHE and NICE do, is therefore wrongheaded. It is also physically dangerous to the extent that smoking bans cause a misery that might increase suicide rates among those with SMI.
It is worth asking why PHE and NICE are singling out the SMI group for an anti-smoking intervention when the evidence suggests it is no more harmful for that group than it is for any other part of the population. PHE actually imply that smoking sustains SMI. They even suggest tobacco eradication could even cure mental health conditions, a bizarre proposition. For example, they say that once the period of nicotine withdrawal symptoms is over, anxiety and depression go down. But this is a sleight of hand. Those admitted to hospital do not have mild anxiety or depression - rather they are having repeated acute panic attacks or manic depression. Smoking cessation has no positive effect on these serious conditions in a way that a strained office employee may be deceiving himself in the belief a cigarette lowers his general stress levels. PHE can only make this argument by illegitimately shifting the ground from dealing with SMI to normal day-to-day anxiety. That should not belong in a dialogue about smoking bans in psychiatric units.
PHE make a claim that is open to misinterpretation - that anti-psychotic medication is up to 50% less effective in smokers. In truth, the medication is just as effective, it is just that with heavy smokers, the frequency of dosage has to be increased as polycyclic aromatic hydrocarbons (PAHs) - not the nicotine - in the consumed tobacco metabolises the medication faster than with non-smokers (who only number 12% of patients with psychotic disorders). According to the Royal College of Psychiatrists, the monetary saving, even if 100% of in-patients successfully quit, would only be £12m if generic medication was deployed. And that's out of a mental health budget of £35bn per year. One wonders why this huge budget cannot absorb this relatively tiny cost-increase of treating smokers - what else is it for?
The invasion of public health policy into what was almost becoming a humane system of psychiatric care has created massive problems on the ward. Due to the role played by PAHs, total smoking cessation can be very dangerous when mixed with starting or increasing a course of anti-psychotics. The journal Current Psychiatry notes that symptoms that accompany this unholy alliance include extreme fatigue, myoclonus, orthostatic hypotension, seizure, sialorrhea, somnolence, tachycardia, and worsening psychiatric symptoms. Smoking cessation may therefore be in breach of the Hippocratic Oath for medical professionals that held 'first, do no harm'.
In addition, since the indoor smoking ban came in, cases of self-harm have rocketed by 56% in the UK. Meanwhile in the USA, where state-run units in 35 of the 50 states now have some form of outdoor ban, patient-on-patient violence has risen by an average of 22% and up to a whopping 390% in Austin, Texas. Furthermore average durations of stay have increased by nearly 90%.
Both the Guardian newspaper and the Labour Party attribute this sorry picture to governmental funding cuts. However the system is only under monetary strain because more people are now being sectioned than before. As a quantity of money, mental health funding has risen in the UK, but the 'real terms' financial cut - that is in relation to the number of patients, has been 8% over the past five years. This is because the number of patients is increasing: in the last year alone, there was a 10% increase in the number of detainees. Whilst it is true that the system is struggling to cope with this social trend, an individual patient doesn't think in terms of a staff pay cut, or that the art therapy room hasn't the resources for you to paint a stone purple. What they experience is a smoking ban that is adding to their woes and lack of exercisable autonomy - that is the main reason for the deterioration in quality of stay.
Sadly public health types only regard smoking as a form of nicotine dependency. They honestly believe the effect of their daft bans can be mitigated with nicotine replacement therapies and, amongst the really radical (not many), with e-cigarettes. But tobacco is much more than a nicotine-hit. It's not just that smoking is far more pleasurable than nicotine substitutes, nor that it helps alleviate the side effects of medication, and indeed certain psychotic symptoms such as attention deficit, learning, anxiety and depression. Tobacco also has a long history of being associated with freedom, and this is what the mentally ill chiefly yearn for. Whether or not smoking really is a good way to express freedom is technically irrelevant - the important point is that it has this cultural symbolism and feel. E-cigarettes, as a new innovation, lack this history. There are no films, TV programmes, nor music I can think of that depict vaping as cool.
The natural companion to the sense of freedom is friendship with other people. Thus sharing a smoke with other patients and staff used to be part of one's social activity. It had the massive benefit of breaking down barriers by being a shared experience. As such, it genuinely did aid recovery. It is therefore no surprise to those of us familiar with human nature that self-harm and patient-on-patient violence has risen since the bans: take away the cigarettes, and you inevitably turn people against each other. Tell them this is only a consequence of their diseased brain, and they increasingly hate themselves. This then appears to psychiatrists as a worsening mental health condition, hence the increase in duration of stay.
To conclude, the goal of achieving 'health equality' through bans is clearly delusional. It is an 'end' that cannot be achieved, and it is folly to attempt it. Those with SMIs are clearly being discriminated against - their negative health consequences from smoking are no worse than for any other smokers. PHE cannot yet get away with imposing a total ban on the entire population. But what they have found is that by putting the SMI group on the frontline, they can take society down this road because this community is atomised, captive, and powerless to resist. The deluded behaviour of PHE and NICE is causing immense suffering and must be stopped. Mental health patients ought to be protected by society, not become the targets for the latest public health fad that wouldn't wash if deployed in wider society. For that reason, I urge readers to 'like' the facebook page 'Campaign Against Smoking Bans In Psychiatric Units' at http://www.facebook.com/casbipu and sign the petition at https://www.change.org/p/duncan-selbie-chief-executive-of-public-health-england-don-t-ban-smoking-in-mental-health-facilities that can end this.