Smoking and mental health - NCSCT

Smoking and mental health
presenting mental health problem as the key priority for each patient, and the
need to do so without resort to coercive means, inasmuch as this is possible. A
balance needs to be struck that permits a reasonably flexible approach to be
taken, which encourages smoking cessation (or temporary abstinence) without
resort to force or threat. Exactly how this balance is to be struck requires
judgement and experience, eg taking into account the needs and welfare of staff
and other patients, how far should a mental health institution seek to
accommodate patients’ smoking by allowing staff to accompany patients outside
to smoke? And how far should institutions mitigate the effects of going outside
in terms of exposure to the elements or managing security risks by building
shelters or secure outdoor smoking areas? There is no precise and one-size-fitsall
answer to these questions. But the central principle here is clear, which is that
smoking is hazardous to health, including mental health, and a well-thought-out
care plan needs to reflect best practice in smoking cessation as part of good care.
9.4 Access to treatment for smoking
Turning from policy towards clinical management of the smoking behaviour of
patients, we now need to consider access to treatment by smokers with mental
disorders. Starting from the obvious premise that smoking is just as important a
health risk in someone with a mental disorder as it is in anyone, there is no
reason to place any barriers in the way of someone who wants to quit. Thus
someone with a mental disorder, in or out of formal mental healthcare, should
have the same access to advice, counselling, cessation pharmacotherapies and
harm reduction interventions as the general population. One troubling feature of
the Foster case cited above is that the court did not acknowledge the difference
between taking away cigarettes as removal of a privilege, and denying access to
NRT as a treatment. An opportunity to help a young man to quit smoking was
missed. In light of the CL and Chadwick Lodge cases, it appears sensible to
ensure that alternative sources of nicotine are readily available, and where
appropriate prescribed, for smokers obliged to abstain from smoking while in
smoke-free facilities. However, as the CL case shows, careful consultation is
needed before such policies are adopted, because nudges and incentives can be
acceptable, but coercion is not. 6
This approach does no more than suggest that we integrate smoking cessation
support into mental healthcare, especially in residential settings. However, we
may go further; given the evidence that we have on not only the higher
prevalence of smoking in people with mental health problems but also the
greater difficulties that they face in quitting, it is arguable that making treatment
accessible and effective requires specific additional investment. The need for
support is greater; the type of intervention needed may be more intensive or of
longer duration. Smoke-free policies in mental health institutions, as in other
public places, are justified because of the health and wellbeing of non-smoking
186 © Royal College of Physicians 2013