Smoking and mental health - NCSCT

9
Ethical and legal aspects
9.1 Context
Smoking among people with mental disorders is common; indeed, as the data in
Chapter 2 demonstrate, people who report mental health symptoms are about
twice as likely to smoke as people who do not. These smokers are also more likely
to be heavily addicted, and to find quitting difficult. This strong association
between smoking and mental disorders may reflect in part the effect of
underlying common neurobiological mechanisms, but is likely to be due in much
larger part to psychosocial influences. These include beliefs that smoking helps to
manage the symptoms of the mental illness or the side effects of treatment for
that illness, the stress and symptoms of mental illness (including the effects of
stigma, relative social isolation and higher unemployment rates), more frequent
exposure to others’ smoke and smoking behaviours, higher rates of alcohol and
other drug dependency among people with mental disorders, and the attitudes of
healthcare and social work professionals towards smoking and clients.
This last, which can range from tacit acceptance and failure to challenge
smoking, to endorsement or active promotion of smoking through sharing of
cigarettes or other activities creating a culture of smoking, presents a particular
ethical challenge. Before the Health Act 2006 was enacted, a survey found that up
to a third of mental health professionals were opposed to a ban on smoking in
mental health premises. 1 Mental health workers were often willing to share
cigarettes with their clients and to use them as bargaining tools; cigarettes
sometimes came to be used as a kind of informal currency in mental healthcare
settings, much as in prisons.
Currently, where healthcare contacts happen in the home rather than in
hospital, health workers may be inhibited from addressing smoking from fear of
jeopardising the relationship with their patient. Where services require the
patient or client to come to a clinic or other health facility, mental health workers
may not wish to raise smoking from fear of putting them off attending. Where
the patient is admitted or detained in a mental healthcare setting, the need to
give some sense of home, privacy and independence may trump concerns with
the lawfulness of smoking in a public place, the needs of others, or the physical
health of the patient him- or herself. These and other considerations, which can
182 © Royal College of Physicians 2013