State Hospitals Struggle to Give Up Smoking

“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, Parks said.

Ban Means More Treatment Time

“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 them.

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 unit managers.

“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 emphasized.

Extensive Planning Time Needed

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 quitting.

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 smoking.

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 lighters.

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 hires.

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>.▪