Smoking and mental health - NCSCT

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Smoking and mental health full justification, rather than that the patients’ liberties are automatically curtailed with particular freedoms being granted ad hoc or as privileges. At the time of writing, patients of Chadwick Lodge hospital in Buckinghamshire are petitioning the High Court to overturn a ban on smoking on hospital premises outside and off hospital premises while escorted by a nurse. 4 The news report on this case quotes a spokesman for the hospital as saying that this was a part of a healthy lifestyle policy for patients, and also that the policy followed from the N case. Yet whereas Rampton is a high-security hospital and smoking outside is not possible for patients there, Chadwick Lodge is a medium-security hospital and smoking outside was, until the adoption of the policy, permitted. It will be interesting to see whether the approach in the CL case is followed. In the rather different context of a young offenders’ institution, an inmate was unsuccessful in challenging a decision of the governor to remove his cigarettes as part of a removal of privileges as a disciplinary measure (R(Foster) v HMP Highdown [2010]). In the criminal justice system, unlike in the hospital system, it is clearer that many ‘rights’ may be granted or suspended as part of the nature of detention. However, the interesting feature of this case was that the applicant argued that the punishment was unduly severe because it imposed withdrawal symptoms upon him, and he should have been given nicotine replacement therapy (NRT). It is interesting to speculate whether, had he succeeded, the approach that mental hospitals of the medium- or low-security type could take would be to ban smoking but supply NRT as part of treatment in a more systematic way than at present. (In the case of Shelley v United Kingdom [2008], the issue of provision of clean needles for harm reduction in illicit opiate drug use in prison was considered, with the English courts and the European Court of Human Rights concurring that there was no obligation to provide needles. The case is discussed in Coggon. 3 ) What these cases illustrate is that, from the point of view of the courts, the policies that hospitals (and prisons) may adopt to promote the health of their patients (and inmates) and protect the health of others (staff, other patients and inmates, visitors) must strike a careful balance which takes into account the overall purpose of the institution, the rights of those who live and work there, and, particularly in hospital settings, the need for careful consultation. The case law also illustrates the important fact that society at large has not reached a stable consensus on how far a smoking ban can be an important restriction on personal freedom and how far it may cause genuine distress, discomfort or suffering. 9.3 Population and individual arguments From a population perspective, there is no good reason to think that smoking is any less important to the health of a person with a mental disorder than to anyone else, or that quitting would be any less beneficial. Given that, for more or 184 © Royal College of Physicians 2013
Ethical and legal aspects 9 less any health inequality that we care to consider, people with mental health problems tend to be worse off than people without, we have a rather strong reason to think that helping people with mental health problems to quit smoking would improve their general health status too. It should also help with the mental health problem itself, given what we know about the causal relationship between physical and mental wellbeing in the medium to long term. We do not have good and compelling reasons to accept the apparently common belief that smoking in people with mental health problems is unimportant relative to their mental disorder, or that smoking is or has to be part of their fragile sense of self, or that trying to help them to quit is futile or bullying. The central ethical question is thus not at the population level; instead it is at the level of the individual client–healthcare worker and client–institution interaction. The vulnerability of patients with mental health disorders, be they in formal or informal care settings, voluntary or involuntary patients, is such that a holistic approach to their care is crucial. 5 Building and maintaining relationships is vital, as is acknowledgement of the multiple sources of stress and threats to wellbeing. Smoking will, often, be simply one source of health problems among many. It may not always be the health problem that takes priority. Yet it is not acceptable that it should never be a priority in the management of a given patient or group of patients. It is reasonable to expect that smoking cessation support should be included in care plans. It is not reasonable to implement an approach to smoking cessation that undermines its own objectives: a quit attempt that is the outcome of a forced choice may well fail as soon as coercion is removed (when the patient moves to a less formal environment or into the community). A homeless hostel that forbids smoking on the premises, even outdoors, may drive away some people who acutely need its help. On the other hand, it is not acceptable to sustain an environment that actively supports smoking or promotes it covertly through the support of an ‘informal economy’ of cigarettes, or the use of smoking rights and privileges as means by which staff may licitly or illicitly control and manage patients. It is not acceptable to manage inpatient or day-care facilities that may unwittingly encourage patients who were non-smokers or lapsed smokers to take up smoking. A somewhat similar issue concerns the different status of informally admitted and formally admitted patients (the latter group being those ‘detained under Section of the Mental Health Act’). Rules governing smoking at mental healthcare institutions will not normally differentiate between the two groups of patients. However, an informally admitted patient who finds him- or herself unable to smoke because of the institution’s smoke-free policy, or because he or she cannot be accompanied outside by a member of staff, where accompaniment is thought necessary, can choose to discharge him- or herself. Seeking to do so may lead to the patient being detained formally, or to losing voluntary treatment opportunities. This presents a difficult medical ethical challenge: the need to abide by the law and the institution’s policy regarding smoking, and the clinical value of helping patients stop smoking could conflict with the need to treat the © Royal College of Physicians 2013 185
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PDF not for circulation Smoking and
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Contents Members of the Tobacco Adv
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Contents 4.4.3 Attention deficit hy
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Contents 6.4.3 Staff knowledge 122
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Contents 10.5 Tobacco policy and me
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Contributors Anthony Aclet - Specia
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Contributors Jill Williams - Associ
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1 Mental disorders 1.1 What is a me
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Mental disorders 1 1.3 Common menta
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Mental disorders 1 1.4.4 Somatisati
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Mental disorders 1 In addition to s
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Mental disorders 1 not diagnosed un
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Mental disorders 1 Similar to many
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Mental disorders 1 12 Chang CK, Hay
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Mental disorders 1 52 Young S, Toon
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Smoking among people with mental di
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Neurobiological and behavioural mec
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Smoking cessation interventions for
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6 Population strategies to prevent
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Population strategies to prevent sm
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Smoking and mental disorders: speci
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Smoking and mental health - NCSCT

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