Friday 15 November 2013

A smoking ban for mental health workers at the workplace

To force a breakthrough in the smoking culture in psychiatry it should be prohibited for mental health staff to smoke in the work place. There I said it! (and yes I agree it should be like that everywhere in health care but in this blog I will focus on psychiatry).
Last time I said I would like to see a smoking ban for all mental health staff within hospital grounds and during home visits was when I arranged a meeting for mental health workers about psychiatry, health and sports. Many smokers weren’t pleased and that’s an understatement. Some were very annoyed and kind of hostile as if this was denying them a civil right. Many many health workers that smoke with patients say its good for bonding but its just an excuse to maintain the smoking culture.
It’s a challenge for patients to quit smoking in psychiatry where a lot of people smoke. They get discouraged. Mental health workers may often tell the patient that it’s too hard to quit with mental illness, that it stresses them out too much. And of course it’s quite an effort for them but I have seen enough to prove that it is not impossible. Sometimes I wonder if staff who smoke feel threatened by the brave attempts of patients who want to quit when they can’t manage to quit themselves.
Addiction to nicotine is the most common form of substance abuse in people with schizophrenia, who are more than three times more likely to be addicted to nicotine than the general population. The relationship between smoking and schizophrenia is complex. People with schizophrenia perceive certain benefits from smoking but at the same time it’s threatening their health and wellbeing in a serious way and can make antipsychotic drugs less effective. Heavy smokers often need higher doses of medication.
People with schizophrenia have a shorter life expectancy (up to 15-20 years shorter) than the average population and the main cause is smoking.

Over the years I have seen many people with mental illness die young because of smoking related diseases like heart failure, different forms of cancer, strokes, COPD. People in psychiatry can get help with quitting drinking, quitting street drugs, quitting benzo’s, quitting gambling… but there’s usually no specialised help for quitting or reducing smoking for people with mental health problems. Smoking doesn’t seem to have priority in the smoking culture of this specific field of health care with mental health staff having the highest percentage of smokers of all healthcare staff.
But with worrying statistics on physical health problems among people with mental illness we need clear measures. And mental health workers who are addicted to smoking should get over themselves and only practise their addiction outside the hospital gates and out of sight of patients, including in outpatients and in community settings. After all our goal is to improve and encourage health from a holistic point of view. Staff who smoke give the wrong message. Smoking should be banned and it should be the responsibility of managers in mental health care to enforce those bans.
I have been giving a “decrease-smoking-course” for people with mental illness for a few years now. The course is free. Most of the attendees have schizophrenia. There is always one chair for a mental health worker who wants to quit. They can attend the course during work hours. Thanks to the course we have a smoke free team now.
First it was called a “quit-smoking course” but we got very few subscribers. Quitting seemed a step too far for many. So we changed it to “decrease-smoking-course” which consisted of 10 sessions including a smoke break of 5 minutes. Soon we had a waiting list.
The first session was about smoking habits and keeping a smoking diary to get insight in smoking habits and coping. Many people started to smoke when they were admitted to a mental hospital for the first time. One of the patients started smoking when she was admitted with psychosis at age 27. She told us:
“Everyone, patients and nurses, seemed to smoke so I thought it might be helping and some nurses even promoted smoking by giving me a cigarette even though I didn’t smoke. And they took out the patients who smoked more often than the ones who didn’t smoke. So some started smoking to be with the others.”
Now at age 45 her GP told her she had to quit smoking because she had COPD. She joined the course and eventually managed to quit.
Most people who attend the course don’t quit but decrease a lot. That’s important improvement too. People who go from 60 to 10 cigarettes are not unusual. We involve psychiatrists, family, GP’s and mental health workers as supporters to make their resolution a success.
We notify and work closely with all people involved in their treatment and give information on how to offer support. The psychiatrist monitors blood levels especially when patients are taking Clozapine and sees the patient more frequently to adjust medication doses when needed. Smoking cessation can lead to higher plasma concentrations and potentially more side-effects. With Clozapine their levels can raise in a dangerous way.
Quitting smoking with this group should be monitored closely whether there is any exacerbation of symptoms or medication side effects, so possibly the dose of neuroleptic medication needs to be adjusted. Since quitting smoking is a challenge we make sure that the patients get extra support. Nicotine replacement methods may benefit their effort to quit.
Every mental health trust should offer specialised quit or reduce smoking support for patients and mental health workers.
I’m not promoting a smoking ban for patients. I’m very much against that. In the hardest times we shouldn’t force patients to quit. But I strongly believe that a healthier and more encouraging environment will help people to find the motivation to reduce or quit smoking and improve their wellbeing.
And that’s our job as mental health workers.


  1. This post brings back many thoughts I had during my first psych ward stay. The ward I was in wasn't on the ground floor, meaning that there was nowhere to go outside if you weren't allowed to leave the ward. However, smokers were taken downstairs to go for a cigarette everyday, some several times a day, but non-smokers had to stay indoors. I ended up being inside the ward for nine days, and didn't get to go outside at all during this time. Had I been a smoker, I would have been able to go outside, but as a non-smoker, I was made to stay inside.

    Also in that stay, there were many times where I was literally the only non-smoking patient. The ward had 17 beds and there were numerous times where I was the only non-smoker. Quitting smoking wasn't encouraged at all. The second hospital I was in (the one I'm currently in) do encourage those who want to quit and get them help, but they don't seem to help those who are addicted and don't want to quit. I know one patient who was able to quit with help from the staff here, but many others are just chain-smoking their way through the days, sometimes smoking out of boredom.

    I think the smoking ban is a good idea and also encouraging patients to 'decrease' rather than 'quit' is also a good idea. Best of luck with your groups!

  2. reading this blog post made me think of a friend who started smoking at the beginning of this year during a stay in a psych ward. she blogged about that, and about her wish to stop, here:

  3. Although many people with mental health problems say that they smoke to reduce their symptoms, they usually start smoking before their problems begin. Heavy smoking does not necessarily lead to fewer symptoms of mental health problems in the long term. Any short term benefits that smoking seems to have are outweighed by the higher rates of smoking-related physical health problems, such as lung cancer and heart disease, that are common in people with mental health problems.

  4. My (undiagnosed) bipolar symptoms worsened dramatically after I quit smoking; my alcohol consumption increased, and my family suffered too. Within four years I was suicidal and in a mental hospital.

    Yes, smoking could have led me to serious health conditions, but it may also have saved my life during the 30 years I had to struggle without any medical help. Additionally, the anti-psychotics and other meds I've replaced the smoking and alcohol with, have exacerbated my weight problem, threatening me with heart issues and giving me severe high blood pressure.

    I am uncomfortable with any moves to limit freedom to smoke for either staff or patients in mental health care. It helps people cope with high pressure situations that are more risky, in my opinion, than the long-term health consequences of smoking.

  5. "I have seen enough to prove it is not impossible."

    Lets analyse that statement that so much belief seems to pivot around.

    "I have seen enough..."
    Not a scientific basis to hang any belief on, especially when that belief may be based on preconceived ideals.

    "To prove it's not impossible..."

    Suggestive of one serious struggle that not many have overcome.

    "...but its just an excuse to maintain the smoking culture."

    One he'll of a generalisation and very Patronising. This statement is hard to square on a scientific or moral level.

    With respect to the staff they can fight their own corner but patients need vocal support as they have the least heard least respected voices regardless of intellectual/articulatory ability.

    Understand, I do not smoke, in fact I detest cigarettes, Indeed i understand and agree with the claims about health, but there are times and places to help someone be aware of smoking cessation and to support them in the process should they CHOOSE so to do. We must always remember, in fact mantra:
    Be person centered.
    These people are ill, not prisoners.

    A cautionary note Remember prohibition.

    From MY observations and listening with an open mind to inpatients whom, by their very nature in this country (UK) are in major crisis, it is blatantly obvious that they have more than enough on their plate trying to get well from the severest excesses of the illness of their mind (symptomatic of extreme stress) to be able to bear/tolerate/cope with the phenomenal stress of trying to quit smoking. Add to that the enforcement aspect and you have a recipe for an inability to restrain expression of anger and frustration. That person will be more susceptible to being violent and unlikely to be able to engage meaningfully or at all in therapeutic activity.
    Ironically however, this will be put down to personality or more likely their illness.
    Their hospitalisation will therefore be almost certainly longer, or worse they will (if legally permitted) self discharge with the inherent dangers that presents.
    Why? Because the single minded Health professional knows best!?

    1. P's
      Beat the boredom. Every day victim blaming? Blame the patient for smoking more because of boredom in an environment they are not allowed to leave.

    2. Nurse with Glasses made it clear her post is directed not at patients, but at staff. They need to not smoke around patients. Nurse with Glasses states clearly that the time of an admission is NOT the time to pursue smoking cessation w/ patients unless they express a need for this.

      I hope your listening skills are better than your reading and comprehension ones. You clearly have not 'listened' to what Nurse with Glasses is saying here- re read the last paragraph.

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