Patsi Davies and Sharon Lawn: Mental illness and tobacco use need not go hand in hand

BP has increased its profit, in part because the anxious citizens of Christchurch have been buying more cigarettes.

We learnt this from a report in the Herald. Such statements perpetuate the myth that cigarettes reduce anxiety and they also normalise the availability of cigarettes.

Normalisation, a concept originating from Danish mental health law, refers here to the taken-for-granted acceptance of the availability and use of tobacco throughout society.

When questioned, people offer reasons why the use must continue, or there is loud silence about the effects of smoking for a population group. Take, for example, smoking by people with a mental illness.

Smoking harms smokers and people exposed to the second-hand smoke. We know that the number of smokers has been declining yet our efforts to reduce smoking have not had an equal impact throughout our communities.

For many decades, smoking has served a number of functions within mental health service systems. Health professionals have relied heavily on cigarettes to manage patients behaviourally and clinically. This has been at the expense of recognising the pivotal role of smoking in reinforcing poverty and stifling recovery from mental illness.

Why? Because we know that people's mental health improves when they quit smoking and that most smokers want to quit.

We also know that the chemicals in cigarettes interact with many psychiatric medications. This mirrors relief from the side effects of those medications but paradoxically requires people to need higher doses of those same medications if they are smokers.

The perceived short-term stress relief they experience from smoking is just that: short term and largely because of the action of this very clever addictive substance that keeps them locked in its vicious cycle.

Tobacco companies know this, which is why they now market vigorously and increasingly to the poor, the homeless and to new markets in Third World countries. It is also likely why their response to plain packaging moves in Australia has been so immediate and potent: a threat to halve the price of cigarettes.

People with mental illness are also entitled to the same level of service offered to people who use the general health services. Historically, this has not been the case. For example, when general hospitals first implemented smokefree policies, the mental health services were exempt.

Policymakers and health workers said, first, that smoking was the "only pleasure available for these people" and, secondly, that a smokefree mental health in-patient environment was a breach of human rights.

The first argument implies that patients are choosing to smoke and we are letting them do so.

What it really shows is that we, as workers in health, are absolving ourselves of responsibility, not offering a stimulating care environment and worse, we are failing to assist people who need our support the most. The second argument shows a misunderstanding of human rights. Smoking is not a human right.

How on earth did it get to the point where smoking is "their only pleasure"? Is this good enough given we say that we are supporting people in their recovery, and what can we all do about it? Further arguments are put about choice.

Justifications include that we have taken away their liberty through detaining them to provide treatment, that it is not their choice to be in hospital and that, if they are unable to leave hospital grounds because of detention, we need to provide designated areas for people to smoke while in hospital.

On the list of what involves choice and what is not negotiable how did smoking get on the okay side of the list? Health providers are clear that alcohol and illicit drug use are not on the choice side of the equation. Let us not fool ourselves about the harms of smoking for these populations who have two to three times the mortality and morbidity from all the major health problems compared to others in our community.

We need to be clear about the values we bring to our decisions about what we put on one side of the choice list and what we put on the other side. Did we put smoking and support for non-smoking in the too hard basket? Mental health improves when people quit, yet we continue to ignore this.

Normalisation has many tentacles. Recently it was argued that mental health patients return to smoking as soon as they leave hospital, so why should they be denied cigarettes in hospital.

This is a flawed argument. Across multiple areas of health care, people receive hospital care and then run the risk of returning to behaviours that fly in the face of the good treatment they receive. People with addictions often return to misuse of those substances, yet this is not proffered as a reason to let them use while in hospital.

This issue is not about choice. Instead, it shows a fragmented system that lacks processes of continued support for people once they leave hospital. Some services have become smokefree, however the co-ordination between hospital and community services is essential to help people stay tobacco free.

The insidious nature of normalisation probably explains why an equitable approach to mental health and smoking was not traversed in the Government's final response to the Maori affairs committee inquiry into the tobacco industry and the consequences of tobacco use for Maori.

* Patsi Davies lectures in Tobacco Control at AUT and Dr Sharon Lawn is an associate professor in the Human Behaviour & Health Research Unit at Flinders University in South Australia.