A smoking ban for mental health workers at the work place by @nurse_w_glasses

Nurse with glassesTo 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.

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.

Nurse with glasses is a mental health nurse on a mission. She is the creator of the ’20 commandments for mental health workers’ which, thanks to the internet adorns staff rooms and nursing stations across the world. You can visit her blog at:

http://20commandments.blogspot.co.uk/2012/04/20-commandments-for-mental-health.html

Care to Share Magazine volume 1 issue 1.

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21 thoughts on “A smoking ban for mental health workers at the work place by @nurse_w_glasses

  1. Hi Nurse With Glasses. Thankyou for this article which I’m sure will rattle a few cages – including mine, if I’m honest. Yes – I’m another of those awful smokers, I’m afraid.

    I have a few reservations about a smoking ban, not least related to the appropriate purpose of mental health care and whether or not it’s OK to impose a particular risk-aversion on a particular group of staff and not on others. This is especially interesting when the risk relates to something that is both legal and addictive.

    I also need to think through the idea of what amounts to enforced health promotion by proxy:

    We want people with mental illness to stop smoking. But it would be wrong to impose this upon them so we’ll place sanctions upon those who care for them instead.

    Having said all that I can see your point and I appreciate that it’s a thorny issue to address. As we both know thorny issues don’t get resolved by ignoring them so I’m grateful for the opportunity to discuss it here.

    Cheers,

    Stuart

  2. I think this is a really interesting blog post, covering some key issues about normalisation and visibility of health behaviours. I think the “decrease-smoking course” sounds really useful, like a step in the right direction. Has it been evaluated more formally? I also wonder if it can be rolled out (and evaluated) more widely, like in the UK for example?

    Best wishes,

    Emma

  3. In the UK we have had a smoking ban in all hospitals for some years. Staff were initially resistant because among other things often inviting a patient for a cigarette was a good and effective way to talk with a patient in an informal and relaxed way. It was also an effective means of bridging the us/them divide becuase you become ‘in that therapeutic space’ just two people kicking back enjoying a smoke. Anyone who does smoke will know its one of the best ways to strike up a conversation with a stranger. Now i have heard over and over that as nurses we are ‘role models’ and our role is to promote health. I see my role as a nurse as being one which promotes health in an imperfect world and acknowledges that we all have the ‘right’ to make bad decisions for ourselves. I prefer realism to idealism and i am not a walking talking ideal and if i promoted myself as such you can be sure that patients would catch me out for the hypocrisy it would be. Besides nipping out of the grounds to smoke on my break ( which is what all us smokers did when i worked on inpatients) only hid what we were doing….and badly….everyone can smell a smoker. I’m not advocating staff should smoke, in fact i prefer it now they don’t because it makes for a healthier environment particularly for non smoking patients. But there is another side and there are an array of articles out there which discuss it.

    As an aside i recently began using an electronic cigarette. It was probably one of the most effective means of reducing my smoking habit to single figures and i was on my way to quitting until…..i was informed that i could not use it indoors because ‘as per policy’ it was considered to be a fire hazard ( it required charging via usb!) and promotes smoking due to its design ( it looks like a pen and is a vaporiser) so……i was told to go outside to use it…….with ‘the smokers’ *sigh*.

    It is the world which has gone mad and mental illness seems to be a manifestation of that madness.

    • I think what NWG is suggesting goes way beyond hospital buildings. Seems to me she includes all mh workers in all workplaces for the duration of their shift (irrespective of breaks). That seems to be much further-reaching than the current UK restrictions.

  4. Well if so i passionately disagree and resent any intrusion on how i use my personal time by others. As an aside if we are role models whats the position on obesity in the work place. Should all overweight staff members be placed on a restricted diet and banned from eating ‘junk’ at work. Lets remember that obesity is also a huge health risk for the mentally ill particularly with patients prescribed Olanzapine or diagnosed with diabetes. Where is the line drawn on forcing individuals to behave in a way that others deem healthy?

    • I agree. Providing the staff do not smoke in view of patients and try their best to mask the smell, they should be able to do what they want on their breaks. An obese person wouldn’t be stopped from nipping to McDonald’s. This being said, I do agree with some of what this post is saying. I DO NOT think it should be banned but it should be done descretely.

  5. I am a smoker but I do agree with what most of what NWG has said. I do think people are too quick to attack smokers, though providing they do it in a considerate way, of course. I do wonder whether the same would be said to healthcare professionals who were obese through eating too much (no other medical reasons). Also very unhealthy and costly to the NHS but rarely spoken about like smoking through fear of offending.

    • There are many lawful (but unhealthy) choices that people make. If we ban mh workers as an attempt to stop mh service users smoking are we really guilty of mh discrimination by proxy?

      If we’re not imposing a ban on mh patients do we really think that banning mh workers will actually stop service users smoking?

      If it was successful how would we justify such paternalism?

  6. To break the smoking culture in psychiatry and enable patients to adapt healthier life styles easier we need management to set strict measures for mental healthworkers. I often hear that patients who smoke are being taken out more for walks by smoking nurses than the patients who dont smoke.
    Or that a patient wants to quit get discouraged by nurses are standing outside with a smoke
    We should try everything to improve life stats of our patients. To break the smoke culture is a first and very important step. Management could help staff by providing free nicotine gum / patches.
    And every mental health institution should offer quit / reduce smoking courses for patients and staff.
    I often hear that cigs are good for bonding. I dont need cigs for that, there are much healthier ways. My patients all know I’m out of breath 3 days when i have been in a smokey environtment. So they dont smoke an hour before I arrive and they dont mind. I seem to be worth the effort. They say they save quite a bit of money every year because they smoke less since they have me as a casemanager 🙂

    • I think a lot of ot depends on the smoker and how considerate they are. I would never smoke indoors anyway (even if I lived alone) but certainly wouldn’t around non-smokers. I also don’t smoke as I walk in public so my smoke doesn’t blow into stranger’s faces. I believe all smokers should so the same. We can’t expect non-smokers to respect our choice to smoke if we don’t respect their choice not to subject their bodies to the horrible poisons.

  7. ah well i will happily allow patients to smoke in my company when i visit them at home despite not smoking with them. As their case manager i am there to advocate and support health not dictate it…and this has been the case even in those periods where i have given up smoking myself. What i promote most is the ability to make informed choices. People are more receptive if they feel they are not being railroaded to conform to others expectations.

  8. I find it appalling that staff are so concerned with their own addictions that they can use psychiatric patients as proxy enablers. Using every excuse imaginable, with scant regard for their patients health.
    Many patients didn’t start out smoking when entering treatment, but succumbed to peer pressure reinforced by those supposedly caring for them.
    Of course patients should be encouraged to stop smoking. Its not just physical health that’s damaged by smoking. Psychological health is equally impared. Anxieties, stress, low self esteem are always made worse by constantly self medicating with smoking. Hopelessness is reaffirmed, smoking may easily be a form of acceptable self harming and in many studies has been proven to be a pre curser of a progression of seemingly random, but often planned regressions.
    Stop the abuse now!!!!

    • I’d support a general smoking ban. Just as the law changed & opium was made illegal in the late 19th century I’d support making smoking illegal tomorrow.

      But I don’t accept the inequity of a lawful practice being denied to me because of proxy mental health paternalism.

      I find it appaling that anyone would ty to silence objections to this proxy discrimination by appealing to emotional blackmail.

      (Paraphrasing but only partly tongue in cheek).

    • [quote]Many patients didn’t start out smoking when entering treatment, but succumbed to peer pressure reinforced by those supposedly caring for them.[/quote]

      where is your proof of this because i would question the truth of this statement Stephen Jones?

      You tone is rather sanctimonious . There are so many things in this world to be appalled by, staff smoking and ‘failing’ to be perfect role models of health is not the worst thing is it? I don’t think i have met a perfect human being yet. Careful where you throw your stones…life is one big glass house.

  9. I cannot produce any studies, but I can speak of my own experience.
    I had undiagnosed bipolar for over 30 years before having access to psychiatric medications. During most of that period I was a smoker. I found smoking calmed my anxiety and distracted me from my manic thoughts – it was all I had to rely on.
    It may have been coincidence, but within months of my quitting smoking, the intensity of my symptoms increased dramatically, eventually taking me to extended inpatient stays and attempts to control my moods with a variety of medications; it took about seven years to harness my bipolar through drug and cognitive therapy, even after being forced into a disability retirement (and thus distanced from the most stressful situations.)
    I am against a smoking ban for any human being in a stressful psychiatric treatment setting. Until our meds are so good that they can replace the immediate beneficial effects of a satisfying drag on a cigarette, there simply is no replacement.

    • Thanks for that Paul. I keep meaning to write a long comment on this article (NWG & I had quite a conversation about it, as it happens 😉 ).

      Unfortunately work pressures have taken all my time for the last few days but hopefully by next weekend I’ll have a free hour to formulate a response.

  10. I stopped smoking exactly a year ago following a short period in hospital – having a neuromuscular condition coupled with being a wheelchair user meant it was kinda silly to be smoking for as long as I did – but my life is a complicated journey and addiction to nicotine is evil and getting off the ciggies I reckon is down to a real longing to stop – and a big bit of luck – it also helps if you can’t smoke for two weeks and take it from there. But it’s a dangerous game to command people to stop smoking – if only life were that simple. But I liked the argument from the lady in the car with glasses on. Sorry, @nurse_w_glasses ‘ moniker (or is that a ‘twoniker’ reminds me of the name of a song from an old Scottish punk band I used to like.

  11. Interesting proposal, while well intentioned I doubt implementation would be feasible or successful. I live & work in the U.S. so health care is obviously a bit different here & thus some of my comments may be irrelevant.

    First & foremost, most restrictions on habituating substances aren’t just terribly effective because of the nature of these substances. People always seem to find a way to get their fix. Albeit sometimes in less harmful ways (ecigs for example). Many hospitals in the US have smoke free campuses, but there’s always a few spots where people will smoke. There is (thankfully) no smoking indoors, which is definitely a positive.

    Patients at the particular facility where I work aren’t allowed to smoke, but nicotine patches & gum are available. I’m sure this is a function of the non smoking campus policy, & seems somewhat effective. It’s probably important to note that this is not a long term care facility, though sometimes patients do end up here for some time.

    In the US hospitals are owned by a littanty of different corporations, state & local governments, & non profit organizations, so getting any universal policy would be all but impossible. This may be different in countries with national health care systems.

    Also I feel there would be some backlash given the hypocrisy/inconsistency regarding personal health decisions by singling out smokers. There are vending machines everywhere filled with all sorts of unhealthy items (one near my floor even has a picture of a stressed looking guy & the phrase “FEED THE NEED” smh) & plenty of less than healthful choices in the cafeteria. Given our obesity & heart disease epidemic these are of similar negative consequence.

    In the realm of the possible I’m all for limiting smoke breaks & not giving preferential treatment to patients who smoke. And it most certainly should be encouraged.

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