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Don't Take Away the Joy of Cigarettes From the Mentally Ill

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BSIP via Getty Images
BSIP via Getty Images

If Toronto Star columnist Rosie Dimanno's revelations about the new policies at the Centre For Addiction and Mental Health (CAMH) in Toronto aren't enough to result in an immediate change in its leadership, then the response by their director, Dr Catherine Zahn, is.

Ms DiManno's recent column described how CAMH is going totally smoke free. Not content to prevent patients from smoking on their grounds, they have now instituted a policy whereby patients are not even allowed to have tobacco on hospital property. If a patient wishes to go across the street for a smoke (a common occurrence at all smoke free hospitals) they cannot bring back the pack. They would have to buy a package of smokes, smoke one or more and then throw the rest away because the hospital will not allow them to keep cigarettes in their lockers.

I will get to Dr Zahn's rationale in a moment but first, buying cigarettes, smoking them and possessing them is legal for all citizens over the age of majority. And, of course, governments benefit from those purchases with the heavy taxes they put on them. So why are patients in a psychiatric facility being denied a right available to all other citizens?

Yes smoking is bad for you but, as I pointed out in an earlier blog, smoking may have a therapeutic benefit for people with schizophrenia which is why so many of them smoke. Being obese is a health hazard but I have not heard of obese people in hospital being denied the right to drink sugared soda pop or to even have it in their hospital rooms.

Do people with psychiatric illnesses deserve less civil liberties than others?

Dr Zahn in her blog that appears to have been written in response the the Star, argues that the hospital has good evidence for making this decision but she fails to provide one source for that evidence. She talks about evidence being used as the rationale for what they do but provides none. She refutes the claim that I made above that smoking can be beneficial but provides no evidence for that claim.

She claims that smoking is the leading cause of premature death amongst people with psychiatric illnesses but again no evidence. It is true that those with schizophrenia have significantly shortened lives but research has shown that it is because of the overall poor medical care that they get from doctors who do not want to treat them or ignore their physical complaints. Studies in both the UK and the US have demonstrated this as I pointed out in a blog post I did almost three years ago.

The smoking debate for psychiatric patients is not new and Dr Zahn might have looked at a publication from her own institution that discussed this issue in 2008. Dr Richard O'Reilly, a professor of psychiatry at Western University, was quoted as saying that "when we stop patients from smoking, we aren't using the least restrictive alternative. In fact, we precipitate them into nicotine withdrawal, which is an extremely distressing condition." Smoking bans, he said, contradict involuntary admission principles and inflict unnecessary suffering on inpatients.

Beamer Smith of the Ontario Association of Patient Councils stated in that article that a smoking ban "feels like punishment; yet hospitals of this type should deal in compassion." David Simpson, program manager for Ontario's Psychiatric Patient Advocate Office said that "We hear from patients that a lot of behavioural issues start because they've been denied a smoke. Some have smoked for decades and suddenly, because they need mental health treatment, that's the end of it. They engage in acting-out behaviour and may end up in seclusion or restraints, which creates health and safety risks for patients and staff."

Dr Zahn states in her blog that this is not the case. She said "there is no increase in aggression or violent incidents when smoke-free policies are implemented." but provides no research evidence to support that. She also states that "facilities that have implemented tobacco-free policies have noted some significant benefits. Improvements in patient health outcomes......."

But here is the thing. Patients in hospital are often receiving drug therapy and having the proper dose of medications that are optimally effective with minimal side effects determined. They are not allowed to smoke and then they are discharged and resume smoking at the same level as before hospitalization. As Dr O'Reilly pointed out, "the resumption of smoking can interfere with the effectiveness of their antipsychotic medication dose."

Dr Zahn failed to mention if inpatients are receiving smoke cessation programs or nicotine replacement while in hospital, as those would be beneficial for many. Unfortunately, nicotine patches and gum are not always beneficial and are often not even wanted by smokers. As Dr O'Reilly said, "Many severely ill patients live impoverished lives and say they get pleasure from coffee and cigarettes. While we should try to improve their lives more globally, that's something to do when they're out of hospital; but when they're in hospital, to take away, in some cases, both things that they like, I think that's mean."

And that is why I agree with Ms DiManno who ended her column with "It's the maniacs -- and their bureaucratic enablers -- who've taken over the asylum."

It is time for a change in management at CAMH.

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