Originally published in the RLC Newsletter, October, 2012
The Right to Smoke?
At this point, we all know the risks of smoking. We’ve heard about (and perhaps seen play out) the link to cancer and a variety of other health issues. We’re aware of the highly addictive nature of nicotine. Many of us 
also know that a higher percentage of people receiving services within the mental health system seem to smoke than those in the broader community, and that those same people tend to smoke more cigarettes on average than other smokers. Additionally, we’ve been told that smoking plays a major role in the fact that people in the mental health system die, on average, 25 years younger than most (although the role that psychiatric medications play in that same figure is most often ignored or misrepresented).
But what does that mean and more importantly, whatshouldthat mean about the right of people receiving mental health services to smoke and the role and responsibilities of providers in relationship to that question?
In Western Massachusetts, there are at least 10 hospitals that have in-patient psychiatric units. Only one of those 10 (Holyoke Medical) still allows people hospitalized there to smoke at all during their stay. That means that someone hospitalized against their will – who is already likely experiencing great loss and distress – also loses the freedom to smoke. This point is not to be minimized. Pause for a moment and imagine the sense of loss and trauma you might experience when being removed from your day-to-day life unexpectedly and not by your own choice.
This approach is only gaining steam. In August, one of the local providers of Community Based Flexible Supports (CBFS) also announced that they would begin a new policy of not hiring smokers (even those who smoke only in the privacy of their own home) as of January 2013 in large part because their employees reportedly have a responsibility to ‘role model’ healthy behavior. (Similar policies for people receiving services through CBFS have been suggested but not yet come to pass.)
There are several issues worth examining here, and they seem to include equal parts paternalism, invasiveness, and lack of acknowledgement of existing research and facts. First, many of the things we do as humans that get labeled as ‘bad’ in our culture (smoking, drinking, self-injury, eating large amounts, etc.) are those that we also know to be coping mechanisms. Given awareness of that, it’s a wonder why it would seem like a good idea to remove one of someone’s coping mechanisms when they’re already in such significant distress. These policies also unfairly target people without financial and other resources who don’t have a car to smoke in or as much choice about where they live, what job they have and so on.
It further seems that those making these decisions are ignoring a growing body of research that suggests:
- People who are experiencing ‘symptoms’ typically labeled Schizophrenia may also experience improvement in ability to pay attention and memory (Yale School of Medicine, June issue of The Archives of General Psychiatry) and a reduction in hearing voices (American Journal of Psychiatry 1993, volume 150) through the use of nicotine.
- There is an apparent link between medications commonly prescribed to people with psychiatric diagnoses and increases in the urge to smoke (Medical News Today, September 18, 2010)
- There is a link between nicotine patches (one of the most common smoking alternatives offered in hospitals) and vivid dreams, nightmares and difficulty sleeping (an undesirable effect for people already feeling off balance and/or having sleep disturbances) (Physiology & Behavior, 2006, Volume 88)
Practically speaking, it’s also commonsense that if one is heavily medicated and/or feeling hopeless and lacking energy, that it’s not unlikely they might turn to eating, smoking, drinking coffee and sleep. But is simply taking away that access the answer?
Perhaps there isn’t a literal ‘right’ to smoke in every setting, but if we recognize the real value that some people are able to find in it, or the way that our mental health treatments sometimes make it harder to stop, it certainly begs the question of how and why providers seek to meet their stated mission. Is this really about helping others be their best, healthiest selves or could it be connected to staffing ratios that make it difficult to accommodate people wanting to go out to smoke and/or health insurance savings for smoke-free environments?
Rather than turning a blind eye to the potential benefits of smoking and the potential harm of provider-endorsed treatments, why don’t we focus our energy on understanding and compassion? Rather than more force in a system where force and coercion are all too familiar, why not increase choice and access to activities like acupuncture, Reiki, yoga, hearing voices groups, peer respites and so many other offerings that may build hope and support new ways of coping?
Certainly, we would not advocate that people start smoking or that those who want to stop not receive help to do so. However, policies that ignore principles of self-determination and the trauma of being hospitalized against one’s will in favor of forced cessation and heavy-handed approaches have no place in any ‘helping profession.’ Providers need not take on the burden of being responsible for us in this way. This is not a ‘person-centered’ approach. Health by force provides only a brief illusion of wellness. There is a better way.