Smoking and the Forbidden Garden – a Dereliction of Sanity?

By @jonathan_rowson

Defending the rights of the mentally ill to do something that harms them is not a popular cause, but this much needs to be said: preventing psychiatric patients from smoking on hospital grounds is inhumane.

I am responding to the situation in a particular ward in a hospital in NHS Grampian region. At the time of writing my forty year old brother Mark is there, as he has been before. He is surrounded by other adult patients, many of whom are thought disordered, dysfunctional, and up to their eye balls in medication. Mark has given me permission to write publicly about his situation, but he is not well enough to grasp the full context. I am taking the liberty of making the following case on his behalf.

Many psychiatric patients are habitual smokers, but at the moment they are strictly not allowed to smoke anywhere on hospital grounds. Smoking has been banned in hospital buildings for about a decade, but in the hospital in question secure gardens adjacent to the locked wards and smoking shelters within the general grounds of hospitals were available to smoke. This arrangement seemed to work until the authorities decreed that the shelters should be knocked down and the secure gardens should be smoke free. Some psychiatric patients, staff and visitors now face the mild stigma and hassle of having to escape the hospital to smoke, but if you are sectioned under the mental health act it’s not so simple. The hospital ward is your de-facto home, and also your de-facto prison, so where do you go?

The ruling is unenforceable. In fact most staff feel they have no choice but to turn a blind eye. Patients are now smoking in their rooms or in the bathrooms; anywhere where the staff can have plausible deniability of not seeing them. Alas, the collateral damage of this necessary open secret is that none of the patients can now go to the outdoor area assigned to the ward. The small secured gardens are the most humanising place on the ward and a vital source of fresh air, but they lie unused due to the risk, not that patients will smoke, but that they will be seen to be smoking, and get staff into trouble as a result.

It’s madness. Really. But it’s an elective madness that impacts on those who have no such choice. There are important clinical details in some cases about the impact of smoking in conjunction with some psychiatric medications, but in many cases preventing those afflicted from smoking looks distinctly counter-productive and anti-therapeutic, reducing autonomy and increasing anxiety. NHS Grampian region has decided not to make an exception for such cases, presumably on the grounds that it sends a bad signal to suggest that the physical health of psychiatric patients is somehow less important that the health of other patients or staff.

They have a point. I have never smoked, and in response to the claim that smoking leads to hideous forms of cancer and avoidable deaths, a white flag of surrender is my weapon of choice. It’s all true. There is no defence to the claim that smoking is bad for your health and the health of others.

But while health is a preeminent good in life, it is not the only good, and it needn’t trump other goods when they have a stronger claim at any given time. When your mind is ravaged by psychosis and you find yourself in the phantom purgatory of a psychiatric ward, a cigarette is often your only friend. Smoking ends lives prematurely no doubt, but it also has life-giving properties; tempo, ritual, stimulation and a reason to talk and share. All of which provides consolation where there might otherwise be despair.

My brother is two years older than me and was diagnosed with schizophrenia when he was nineteen. After several rocky years, he had been stable on a particular psychiatric drug for a prolonged period, living more or less autonomously in supported accommodation, taking further education music courses, going to church, writing songs, playing his guitar, and looking tentatively to the future. Then about six months ago he noticed that his medication contained lactose. As a strict and gently obsessive vegan, he immediately came off the medication, rapidly became psychotic and dysfunctional, and has not yet recovered. My mother, 67, now lives in Troon, but she still travels across Scotland regularly to do something, anything, to bring Mark back from what feels like an outer circle of hell.

This issue is real for me because Mark is quite a heavy smoker, and it pains and angers me to think that after everything that he has endured over the last two decades, he is not allowed his small reprieves. If he has to be hospitalised, he should at least be able to escape the day time television, the trolley regimens and the relentless corridor pacing of fellow patients. In such a place it means the world to be able to walk out, sit amid some smatterings of green, and ignite your own moment of solace and freedom.

I don’t doubt the good intentions of those who insist on this current policy, but I do doubt the depth and fullness of their understanding. There is measurable health and immeasurable humanity, and in this case I feel the function of smoking for psychiatric patients has been lost. In failing to honour the reality of madness, there has been a dereliction of sanity.

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Comments (24)

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  1. WILL CASEY PURVIS says:

    REMEMBER THE BELL CURVE——-ONLY A FEW AT THE UPPER END

  2. Gillian says:

    I agree completely and there should be somewhere patients can go for a smoke. yes stopping smoking is good in theory (as a stop/start smoker myself) but when going through a challenging time a nicotine patch just doesn’t compare. Also importantly the staff are often unable or unwilling to accompany a patient for various reasons. My Dad has been in an Elderly Mental Health Unit in Fife and they do have a garden area in the middle of the ward (well designed as there is no escape!) so he is able to go in and out thus reducing his anxiety and aggression. NHS Grampian have enforced this non smoking ban and even staff are seen ‘loitering’ outwith hospital grounds, it really needs to be reconsidered in light of the reality of the challenges faced by people who do still enjoy a (albeit unhealthy) smoke.

  3. Tina says:

    Since the rule is unenforceable he should be able to go into the garden and light up and staff cannot be held accountable for his actions. After all, if he is sectioned he can hardly be thrown out of the hospital. It’s time that staff stood up for themselves and those patients unable to do likewise. Makes my blood boil.

  4. George. Bowie says:

    When I visited my local Hospital I had to run the gauntlet of people blocking the entrance smoking cigarettes exhaling on to me as I entered. The entrance ground littered with doubts. Many of the smokers were patients on drips, how can we ask our NHS to treat patients who don’t want to help themselves? Would the contributor also like to have alcohol drunk freely in hospital or non prescription drugs used?
    The only people benefitting, I see would be to the multinational Tobacco companies.

    1. Steve Branston says:

      Smoking isn’t illegal George, and for people in the situation being described here it can be an absolute crutch. Its not just the physical addiction, which is bad enough to get over if you are in complete control of your life. But, can you imagine a life where the only small thing you have any real control over is chosing when you can go outside and smoke a cigarette, and have a little time to yourself? Then imagine the impact of that being taken away from you. Its awful.

      I’m sure the NHS offers NRT for smokers in these situations, but heres the deal – it doesn’t work. The success rate is between 3-5%. (Far less than other bad life choices – standard treatment for obesity, hard drug addiction etc is considerably more successful). Bizarrely, most NHS trusts have also banned the one replacement which not only works, and would also allow that small degree of personal freedom which is so vital in these situations – ecigs.

      The mind boggles.

    2. DR says:

      You make a moral point, which unfortunately ignores reality. Yes, it would be better had these people not become addicted. As they are addicted, however, rapid/total removal of the addicting substance imposes severe physical and mental stress on top of other medical conditions. In terms of risk to individual patients, doctors accept that this stress can, and at times certainly does, pose a comparable risk of immediate harm than restricted smoking. (A drip does not cure addiction. It does not imply that the condition is a result of smoking. It does not suggest that someone would be able to leave hospital by stopping smoking.) The scene you encountered is the result of deliberate *policy*. The technology exists to sequester the activity indoors, eliminating passive smoking – but not providing the ‘benefit’ of ostracism and shaming! You do not mention if you walked to the hospital, or saw cars parked there? Did the car-park horrify you? It should have, as it is an indisputable fact that exhaust fumes cause more illness and death than current rates of smoking, but drivers still insist on exposing everyone in society, from birth to death, to their poisonous fumes. Within a few decades, the immoral, self-harming selfishness of driving will be equal to that of smoking. We know this: but today, everybody and their baby and their granny drives anyway. Still feel comfy chucking that ‘moral’ stone?

  5. Iain Miller says:

    Like Gillian, I agree completely but babies and bath water come to mind.

    Yet again. common sense (not to mention common decency) gets thrown out of the window in the name of P F#*%$ ‘n C!

    I rest my case …..

  6. David Fee says:

    This is a brilliant, compassionately argued piece. As an ex-smoker who generally agreed with smoking bans (even as a smoker) I couldn’t agree more with your suggestion for an exception to be made in this kind of scenario.

    I also agree with Tina in the comments above. It’s about time that staff in this kind of situation took a stand on behalf of their patients rather than kowtowing to “policy” out of fear of…of what…losing their jobs? Surely they’d have a good case if that ever materialised. This article would be of great value in the unlikely scenario that employment was threatened.

  7. Clive Scott says:

    What about the employer’s responsibilities to provide a safe working environment for employees and the rights of non-smokers for wholesome air? It would be ridiculous to permit the mentally enfeebled to flout regulations for the common good simply because of their illness. Smoking is a disgusting foul habit and addiction and every step possible should be taken to eliminate it from society.

    1. Anton says:

      Clive Scott: You say that “Smoking is a disgusting foul habit and addiction and every step possible should be taken to eliminate it from society.” Indeed. And so is alcohol. There are a staggering 137 alcohol-related admissions to hospital every single hour, compared to 61 for smoking, according to government figures. The cost works out at a staggering £1.43m every hour, and is enough to keep more than 260,000 police officers on the streets, or 278,000 nurses working in A&E.

      On the basis, then, that the facts show that alcohol is a disgusting and foul habit, and a far greater cost to the NHS than smoking, I assume you’d agree that “every step possible should be taken to eliminate it from society”, and that the Scottish Government should take immediate steps to shut down the whisky industry.

      A simple yes or no from you in answer to this question would suffice. I look forward to your reply.

    2. Don bradley says:

      Do you drive a car Clive ?
      29000 premature deaths per year from exhaust fumes ?
      ” we must make every effort to drive this from society ” ?
      I thought you’d agree !

    3. Tom says:

      I hope you never find yourself “mentally enfeebled”.

  8. mary docherty says:

    Ye can smoke in the jail !!!

  9. Dougie Blackwood says:

    The brainlessness of the jobsworth and box ticker is clear for all to see. The sensible thing is to have a smoking shelter, regardless of the harm they do to themselves and other smokers that sit with them. They are mostly well aware of the problems smoking brings; it’s clearly written on the packet.

    To deny an addict his only solace in times of severe trouble is inhumane in the extreme.

  10. Janie Munro says:

    Am I the only person to note that Mark was hospitalised after coming off his meds which contained lactose? Wouldn’t it be sensible to find him a lactose-free medication which would enable him to return home to the freedom to smoke as he wishes.

  11. Mary says:

    I have two G/Children. That never smoked or used Alcohol. They spent time in Stobehill mental Health . The amount of pressure they got from Alcoholics that where allowed out to buy there Alcohol and bring it back with Cigarettes. Was disgusting. Both are now heavy smokers and now drink. So there stint in this place. For having a break down. Ended up with them having Addictions.

  12. lesley says:

    There needs to be an exception here…Thanks for your article and understanding..my son had schizophrenia but took his life in 2006..I can still remember his incredible anxiety about being unable to smoke,about his only pleasure in a life of daily misery…For those critics commenting on the ‘mentally enfeebled’…I hope you never have to experience it…A tragedy for everyone in the family.I’m glad my boy is ‘ n’t suffering any more!

  13. Justin Kenrick says:

    A powerful compassionate call for us to remember our humanity, and act on it. Thank you.

  14. Maggie says:

    This is a compassionate AND sensible article. Others have made further comments which show deep understanding and empathy whether or not they have been affected by severe mental illness or smoke(d) themselves.
    And yes, of course there’s always more than one way to look at this issue.

    To let you know where I’m coming from, I was seen as something of an ‘anti-psychiatry’ maverick psychiatric nurse and loved my job. I was a smoker too. Smoking is bad – for everybody, including patients and staff. However, it was the case – and maybe it still is – that more psychiatric nurses smoke than general (adult) nurses do. Hmm!

    One area I think has not been commented upon and one that deserves to be considered in the ‘smoking is bad’ discourse relates to the inherent dangers from taking prescribed medication for years to treat psychotic illness – even worse -when it does not work many people will still be encouraged to take it.

    Besides acting directly on the brain the stuff causes liver damage and kidney failure and obesity (even drug companies have in the past, paid to provide ‘dietary’ assistance because of the known side-effect of excessive weight gain). In addition, the ‘common side-effects’ such as over salivation, impotence, drowsiness, lethargy, general malaise, all become minimised and dismissed as ‘necessary evils’ with patients needing even more medicines to counteract the side-effects. For many family members (and probably for many staff who have not received education in drug ‘therapies’), such effects become seen as ‘the illness’.

    People experiencing severe mental illness have more physical disease (including cancers) and have shorter life expectancy than the general population- they receive less help for physical conditions and prognosis is always poorer for them. How many people want to hear this?

    As I write this I’m wondering why fewer people seem to concern themselves about the people enduring mental illness, receiving medication that possibly does more damage than smoking will (because they may not live long enough to see the effects of smoking) and not only that, we need to keep in mind these psychiatric patients may being made more ill by those who are supposed to ‘care’ for them (medical iatrogenesis).

    As has been said or implied in other comments – those who want to take away, perhaps the only chemical assistance that gets patients through the day, need to walk, if only for a few minutes, in the shoes of those who have to live with such dreadful conditions.

  15. david says:

    is it only me that sees the irony of the phrase “..and a vital source of fresh air” in relation to the outside garden? not for non-smoking patients who are subjected to the noxious fumes being produced. WHat about their rights? As someone who works in mental health we really do no favours to patients by turning a blind eye, people with mental health issues have disproportionately worse physical health over the whole spectrum and smoking is one of the biggest contributors. Why minimize or rationalize mental health as a small issue its not,and just like we wouldnt really tolerate patients smoking on a lung ward, why do it on a mental health ward (where other patients might have serious lung disease already? any all it will take is some tabacco smoke to kick start a serious exacerbation

  16. Doreen Milne says:

    I agree wholeheartedly with your piece. I have seen the effect that being forced not to smoke has had on many clients I have worked with. It is detrimental to their ability to cope in many frightening and difficult situations. A shelter or designated area, away from more public areas would suffice and cause little or no disruption to nursing staff.
    On a personal note: Dementia runs through both sides of my family. I am a single, childless woman who smokes. I watched my gran’s memories and abilities slip from her, yet still she was able to continue smoking as she was supported and cared for by her family. The only time she was greatly distressed was when hospitalised and not allowed to smoke.
    I will not have that same family support and fear my choice to continue smoking will be arbitrarily removed from me.
    I would gladly waive any right to treatment for smoking-related illness if it meant I could continue to smoke.
    For me it is about choice and quality of life as opposed to quantity.

  17. IAB says:

    The obvious solution is to have a smoking and a non-smoking garden area and to find vegan medicines for those who need them

  18. C Rober says:

    Lifetime smoker , long time listener.

    Both my brother and sister dont smoke , both my parents did , Of their parents one half did , one half didn’t , barely any of the previous generations reached the old pension age , never mind the one expected for my generation.

    Surely these days that all that SELF injures should be banned? So goodbye booze , drugs , fags , takeaways , tv , the internet , anything with Simon Cowell behind it , and of course the car.

    I agree it is unfair for a GOVT to sanction , by the means of taxation , anything that is harmful , yet at the time of need , deny the addict treatment when the taxes are dwindling from them , in other words we’ve used your taxes , feck off , Goodbye , thank you for choosing your early death , and for giving us less pensioners to pay.

    We already see doctors refusing to treat long term smokers unless they quit , are drinkers also seeing the same treatment , what about the overweight , I suspect so.

    Surely there is therefore the case that Treatment should be offered , in the case of smoking areas , when these people are in hospital.After all even the murderer is allowed to smoke on public property , but god forbid the passive smoker is allowed to in private?

    IF no treatment works medically , patches are a joke , vapes seem to work though , then why not use medical grade vaping equipment ? , it really does exist.

    I do believe that smoking in cars with children should be banned , but how do you police it ,just like mobile phone use?

    The use of a persons addiction for freeing up hospital beds faster in this instance , ie the smoker/drinker wants out sooner than medically needed , could this be the underlying reason here?

    Its a fact that with smoking rooms , or gardens , that the patient uses less nicotine than if they were at home , speeding up recovery , to a point.

    Seeing as how there was comments on mental health , and the high incidence of nicotine use within those specific hospital treatment areas by patients

    This has been the findings for years , which got bastardised by an inept report , to mean high usage of Cannabis use as a psuedo link as well. Which has led to the long held , wrong belief , that the two are inexplicably linked….not instead nicotine and even alcohol , as perhaps like cannabis , as a form of self medication , rather than the causality itself.

    The current offerings from the SNHS is inadequate for smoking terminators , a help line , maybe some patches.Just the same as methadone treatment for heroin addicts.

    Perhaps a residential course , a smoking holiday is the answer , supervised medically and withdrawal done gradually , like some form of Bite the bullet@Butlins.

    I suspect that a govt would opt for a shock therapy implant , sensing nicotine like some form of pace maker , dug out of the experimental army warfare bins , but making instead our bladder involuntarily expel.

    But the smoker would just find some back Street dealer , like the current taxation leading to black market fags , but instead , while they buy their Turkish sawdust fags to supply them their fix , buying counterfeit adult nappies from the same dealer.

    Or should we therefore class all addiction as a mental illness , and section those that cannot , or will not help themselves?

    But where would we house them , certainly not in some state mental hospital , if indeed there are any left , you cant smoke there , so its back into the community.

    Community treatment , or shared community suffering , is the new goal for mental health treatment as the norm.But as we have long read in the papers , this can fail the community , when there is a breakdown , leading to death or injury of the innocent , just like passive smoking , but without the longer time limit.

    SO the nicotine addict , are all back in close contact once again , even more tempted than before around peers of the same ilk , standing outside the local pub once again.This state sanctioned purveyor of the last legal , yet socially acceptable drug , that has done more harm to Scotland than drugs and fags combined ever has.

    Standing outside the pub , the non smoker is asked when entering , “Any chance of a charge mate , my e-cig huz ran oot?”

    Now that is an fecking improvement!

    Cos its sooooo much harder than to get a box of matches , than get your e-cig charged.

    Then while your there getting matches , buy a pack of fags , “jist gies a bottle of Buckie anaw” , and furgit the pub ,with its glaring non smoker customers , and its prices , take the whole taxed polythene bag of antisocial goodies back hame.

    Its “let them eat cake legislation from the leftist Mearns minded in action” , as long as it wont affect the prices in the Golf club , and I can enjoy my cigar on the links , then who cares what goes on by the trackie bottom wearers from the council favelas.

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