"Smoking kills, and it kills seriously mentally ill people
early," Mary Diamond, D.O., said at the APA Institute on Psychiatric
Services in New Orleans in October.
About 75 percent of seriously mentally ill people are tobacco
dependent—over three times the rate among the general
population—yet 59 percent of public mental health facilities still
permit smoking, she said. Even some states that have banned cigarettes in
prisons continue to allow smoking in their mental hospitals.
"The goal of mental health systems is recovery, and smoking doesn't
promote recovery," said Diamond, chief psychiatric officer in
Pennsylvania's Office of Mental Health and Substance Abuse.
Historically, smoking has been viewed as a form of self-medication or at
least a minor comfort for patients in psychiatric hospitals. Cigarettes were
even manufactured at some hospitals and are sold at some today.
"Revenue from sales of tobacco provides discretionary income for
facilities," wrote Joseph Parks, M.D., and Peggy Jewell, M.D., last year
in a report for the National Association of State Mental Health Program
Directors (NASMHPD). Parks and Jewell also spoke at the institute."
Smoke breaks for staff and patients have become an 'entitlement,'
deserved, and protected, and one of the only times [patients] can practice
relating to each other and staff in a 'normalized' way."
Smoking's effects go beyond addiction and the well-known damage to the
body, Parks noted. Cigarettes are used by staff as a tool for coercion or
reward, he said. Their presence leads not to more docile patients but rather
to deleterious outcomes. Cigarettes form the basis of a black-market economy
and become a precursor to threats between patients. Anxiety rises as many
patients remain in a state of withdrawal awaiting the special break times when
they can go outside and smoke. That leads, in turn, to an increase in use of
seclusion and restraint when they grow agitated. Smoking also eats up about 15
percent of staff time, when staff members accompany patients out of doors,
"Making state facilities smoke free means a healthier environment,
less violence, more time for treatment, and less time for smoking—and
fewer wastebasket fires," said Parks, medical director of the Missouri
Department of Mental Health.
Changing a facility to smoke-free status is not a simple matter, however.
Incremental approaches seem unsatisfactory, he said. Smoking-cessation
programs are rarely offered, and even when they are, few patients attend
Directives from above can founder, as well. For example, an initial attempt
at institutional smoking cessation in Minnesota failed when the state's top
mental health leadership did not discuss the process with middle managers and
"Staff are the biggest source of resistance," said Parks. They
resent the loss of their own smoking privileges and the increased need for
policing contraband. Arguments about "freedom of choice," however,
ring hollow because "addiction is not a choice," he
At least a year's worth of planning will be needed to overcome that
resistance, said Jewell, who is medical director of Oklahoma's Department of
Mental Health and Substance Abuse Services. Preparation should begin with
discussions of the harmful health effects of smoking and the benefits of
Social and peer support is crucial, and ex-smokers have a lot of
credibility in that area, added Diamond. Institutions can enrich programs to
take up the time once devoted to smoke breaks. "Fresh-air breaks"
can give patients and staff time off the unit without the hazards of
Nine months before the changeover in Oklahoma, all employees were offered a
90-day, nicotine-replacement program and other help to quit smoking. The
department had a one-time cost of $25,000 for 3,775 employees, inducing about
15 percent of the employees to quit after this initial effort.
The department also spent $100,000 for nicotine-replacement patches for
8,864 patients, plus $2,500 for signs and posters about the policy change.
Quitting can even maintain the bond previously formed when staff and
patients smoked together if a staff member says, "I'm using the patch to
quit and so can you."
Benefits from a changeover to non-smoking include reduced sick call for
patients and less violence or disruptive behavior. However, Diamond noted,
costs in Oklahoma rose to repair disabled smoke detectors, toilets stopped up
by contraband cigarettes, and electrical outlets taken apart to serve as
In Texas, both employees and patients at Wichita Falls State Hospital were
unhappy at the prospect of change. The employees complained to the news media
about the proposed ban, but the administration had already contacted the press
about the change, which defused employees' complaints.
Patients' rights groups also opposed the ban but were outflanked when an
initially sympathetic legislature banned smoking in all public places. Despite
this initial resistance, there was no change in employee recruitment or
retention patterns after the change. In fact, a smoke-free workplace is now
considered a benefit to working at the hospital, and human-resources staff
emphasize the no-smoking policy up front to make it clear to potential
Although the policy applies equally to patients and staff, patient
violations should be viewed as treatment issues, but staff violations become
personnel matters, said Jewell.
A NASMHPD toolkit for hospitals transitioning to a no-smoking policy
is posted at<www.nasmhpd.org/general_files/publications/NASMHPD.toolkitfinalupdated90707.pdf>.▪