Smoking and mental health

It is difficult to overstate the possible physical health benefits of stopping smoking for mental health service users. Mental health service users in general are more at risk of a range of smoking-related illnesses such as cardiovascular and coronary heart disease, chronic bronchitis and emphysema (Joukamaa et al., Reference Joukamaa, Heliövaara, Knekt, Aromaa, Raitasalo and Lehtinen2001; Jochelson and Majrowski, Reference Jochelson and Majrowski2006). People who have a diagnosis of schizophrenia are many times more likely to die from respiratory diseases than those with other diagnoses and this can be attributed to the particularly high rates of heavy smoking in this population (Joukamaa et al., Reference Joukamaa, Heliövaara, Knekt, Aromaa, Raitasalo and Lehtinen2001). However, there is a confusing array of evidence about the relationship between smoking and mental health, supporting both the view that smoking may contribute to serious mental health problems and that it is symptomatic of or associated with them. The idea that smoking can be regarded as a form of ‘self-medication’ may be contentious, but the perception that this is so remains powerful. While the evidence is complex, smoking appears to reduce the effects of positive and negative symptoms and increase concentration levels, at least in the short term (McNeill, Reference McNeill2004; Mental Health Act Commission, 2005). However, there is also evidence that smoking might intensify some forms of mental disorder such as anxiety and panic disorders (Jochelson and Majrowski, Reference Jochelson and Majrowski2006), and at least one study of suicidality among adolescents appears to demonstrate that smoking may be a risk factor (Bronisch et al., Reference Bronisch, Höfler and Lieb2008). Interactions between smoking and medication add an important dimension to the issue. Higher doses of anti-psychotic drugs are required by people who smoke and some drugs appear to encourage smoking (McNeill, Reference McNeill2004; Jochelson and Majrowski, Reference Jochelson and Majrowski2006). Such evidence suggests that the effects of sudden and enforced tobacco withdrawal might be physiologically harmful for patients who smoke, particularly in terms of the possible effects on psychotic symptoms and/or the absorption of antipsychotic medication. Whatever the direction of the relationship – cause, effect and/or close association – it is clear that smoking is a fundamental health concern in mental health.

A number of theories to explain the higher prevalence of smoking among mental health service users have been suggested (McNeill, Reference McNeill2004). A particularly useful summary of the main issues as they relate to mental health service users who are detained under the Mental Health Act 1983 is provided by the Mental Health Commission (2005: 250–1). That nicotine in the form of smoking is regarded as a readily available form of self-medication by many service users is undoubtedly true. Once addicted, the difficulties involved in stopping smoking and dealing with negative side-effects mean that giving up smoking poses a greater challenge for people who experience mental health problems than those who do not (ibid.). According to their review of the evidence, the Mental Health Act Commission (2005) suggests that there are a number of reasons for this. The physiological effects of withdrawal might well be magnified by the experience of mental illness such that giving up is more difficult. People with mental illness may be less inclined to health promotion generally and therefore less likely to be able to take advantage of smoking cessation programmes; this might be especially true of people at what might be their ‘lowest point’, on admission to hospital. Furthermore, smoking cessation programmes do not generally take account of cannabis use which is widespread amongst some groups of mental health service users, particularly younger people. While stress reduction appears to be a major motivation, this again is a complex area, as smoking addiction creates a ‘new’ stress, that of craving nicotine.

Aside from the serious health implications of smoking for mental health service users, it is clear that smoking also fulfils a powerful symbolic role for smokers and non-smokers alike. Up until the ban, smoking was unwittingly encouraged in psychiatric units because the spaces and places that smokers congregated in meant that ‘“going for a cigarette” becomes a legitimate means of respite from the general ward environment that is not otherwise available’ (Mental Health Act Commission, 2005: 250). The symbolic meaning of smoking means that efforts to mitigate the effects of any ban can also have perverse and unforeseen consequences. The national ban on smoking that has been effective in the United States since 1992 also encompasses psychiatric units, but it incorporates exemptions through the use of ‘smoking passes’. This effectively recreates the use of cigarettes as reward tokens in a reward/punishment system. Ironically, as Prochaska et al. (Reference Prochaska, Gill and Hall2004) point out, this is the form of reinforcement that in older institutions meant hospital was the very place where some mental health service users were first introduced to cigarettes.

Smoking can therefore be used in struggles for control, both symbolic and real, particularly where people have been compulsorily detained. The smoking ban in the UK may prove anti-therapeutic because of the effects of confiscating cigarettes on patients' experience of the care regime (Mental Health Act Commission, 2005: 249). This might explain why the idea of a complete ban on smoking in mental health units appears to have very limited support from the users of such facilities, including non-smokers. Research carried out immediately prior to the implementation of the smoking ban on the attitudes of people who were currently in-patients in mental health facilities indicated that the majority (71.1 per cent) were in favour of retaining the current smoking policy (Smith and O'Callaghan, Reference Smith and O'Callaghan2008). Only 3 per cent of respondents in this study favoured a total ban on smoking, which the authors concluded might reflect the view that smoking policies should be less stringent in psychiatric units. Accounting for the symbolic importance of cigarettes should therefore be an important element in health promotion strategies which target mental health service users.

A further dimension, which is of central importance for understanding the relationship between mental health and smoking, is social deprivation. This is because of the strong association between mental health and socio-economic position, and the importance of social deprivation in accounting for differential rates of smoking. The rates of smoking among people from deprived socio-economic groups are consistently higher than those in other socio-economic groups (Layte and Whelan, Reference Layte and Whelan2008) and mental illness is also more prevalent in deprived populations (Rogers and Pilgrim, Reference Rogers and Pilgrim2003). Whilst it is not possible to argue that poverty causes mental illness, ‘it is safe to say that poverty contains causal influences which both create and exacerbate mental health problems’ (Pilgrim and Rogers, Reference Pilgrim and Rogers2005: 60). Perhaps most importantly for the arguments I am developing about smoking in this paper, there is evidence that it is the reduced likelihood of cessation among socio-economically deprived groups that is a key factor in the inequalities in smoking behaviour, as well as the increased likelihood of starting in the first place (Layte and Whelan, Reference Layte and Whelan2008). The reasons for the differentials in giving up smoking appear to be closely related to ‘the lived experience of socio-economic deprivation’ (ibid.: 10). If this is the case, it should not be surprising that cessation rates are also low among many mental health service users, for whom the lived experience of extreme forms of mental distress as well as deprivation are a fact of everyday life. Before examining the importance of low cessation rates, the paper sets the context for the discussion on human rights as it relates to smoking policies and mental health.

Human rights, health and the right to dignity and respect

The Department of Health has explicitly identified human rights as lying at the heart of healthcare in general. In its publication entitled Human Rights in Healthcare – A Framework for Local Action (DoH, 2007), it states that human rights should be seen as ‘a vehicle for making principles such as dignity, equality, respect, fairness and autonomy central to our lived experience as human beings’ (p. 13). Core principles such as dignity and respect are therefore seen as underpinning the rights that are explicitly stated in human rights legislation. Under the ‘Right to respect for private and family life’, the document lists the following as examples of relevant issues in healthcare settings: privacy on wards and in care homes; family visits; sexual and other relationships; participation in social and recreational activities; and independent living (p. 39). The emphasis is thereby on making human rights ‘real’ in the experience of people receiving health care.

A key moment in the emphasis on human rights for mental health service users was the embedding of a human rights-based approach in the activities of the Mental Health Act Commission. This project began in February 2005 and set out its objectives in the form of making the promotion of equality and human rights of people detained under the Mental Health Act (1983) a ‘core and central function’ of the organisation (Mental Health Act Commission, 2006: 1). In the context of this development, the direct link between the ban on smoking and the human rights of mental health service users was highlighted by the Mental Health Act Commission in its Eleventh Biennial Report (Mental Health Act Commission, 2005), again in response to the consultation on the implementation of the Health Act 2006 (Mental Health Act Commission, 2006), and then reiterated in its Twelfth Biennial Report in 2008:

The human rights emphasised by the Mental Health Act Commission in this context were the rights to respect for home and private life under Article 8. However, the application for judicial review of the smoking ban bought by patients of Rampton Hospital in 2008 under this article failed. The grounds given in the High Court judgement related firstly to health, including the rights of others to be protected from the effects of smoke pollution, and, secondly, security, in the sense that making arrangements for smoking by providing outdoor facilities would not be feasible in a high security environment such as Rampton (England and Wales High Court, 2008). The terms of this debate highlights what has been the central focus in relation to the smoking ban: the competing rights of smokers versus those of non-smokers and confusion about what can be defined as ‘home’. This paper shifts the debate away from these competing rights towards a focus on the nature of the smoking policies themselves, and the implications they have for the right to dignity and respect. This requires a focus on the complex nature of the relationship between health promotion and human rights.

The core argument of the health and human rights perspective as first advocated by Mann et al. (Reference Mann, Gostin, Gruskin, Brennan, Lazzarini and Fineberg1994) is that health promotion and protection and the promotion and protection of human rights are intrinsically linked and both are prerequisites for human well-being. The most relevant feature of the relationship between health and human rights emphasised for our purposes concerns recognition of the potential that public health campaigns have for burdening human rights and the desirability of ‘an approach to realizing health objectives that simultaneously promotes – or at least respects – rights and dignity’ (Mann et al., Reference Mann, Gostin, Gruskin, Brennan, Lazzarini and Fineberg1994: 17). The emphasis placed on the state's responsibility for recognising the differential effects of particular health problems for ‘a marginalised or stigmatized group’ (ibid.: 13) is also relevant to my argument because of the particular issues that smoking represents for many mental health service users, as already outlined.

A central argument of the present paper is that the current orientation of smoking policies and the nature of the strategies pursued encompass a moral agenda that potentially contradicts the core principles of dignity and respect in healthcare. This is because the cessation strategies that underpin smoking policies are strongly identified with moralistic forms of intervention that may have more to do with creating ‘better moral souls’ than making people healthier (Sweanor et al., Reference Sweanor, Alcabes and Drucker2007: 70). In contrast, harm reduction strategies may offer a more pragmatic solution for some of the most ‘high-risk’ groups of smokers, including mental health service users.

Harm reduction vs smoking cessation

The sheer scale of the health problem that smoking represents has understandably encouraged an attitude that any strategy that works should be adopted. However, approaches that increasingly involve ‘heavy-handed moral opprobrium’ (Bayer and Stuber, Reference Bayer and Stuber2006: 48) have implications, not only in terms of the human rights of those who smoke but also, just as significantly, the likely effectiveness of the strategies. This is particularly true in relation to those who are most at risk from the morbidity and mortality resulting from heavy smoking, including people from socially disadvantaged groups and consequently a large number of mental health service users. People in disadvantaged groups are likely to find it harder to give up in general (Layte and Whelan, Reference Layte and Whelan2008) and campaigns that stigmatise smokers are likely to prove especially ineffective with such groups (Farrimond and Joffe, Reference Farrimond and Joffe2006).

It is the difficulties in giving up for some groups that forms the main rationale behind harm reduction strategies:

Harm reduction strategies on smoking stress that cigarette tobacco is the vehicle for a less harmful substance, nicotine, and it is therefore nicotine addiction which is the primary cause of tobacco consumption (Britton and Edwards, Reference Britton and Edwards2008). In simple terms: ‘people smoke for the nicotine but die from the smoke’ (Sweanor et al., Reference Sweanor, Alcabes and Drucker2007: 74). Harm reduction strategies involve advocating smokeless nicotine replacement products such as patches and gum, or Swedish ‘snus’ as less harmful alternatives to cigarettes. Whilst such products do cause disease, they do so at significantly lower rates than cigarettes, and modern products of this kind are estimated to be as much as 90–99 per cent less deadly. However, harm reduction strategies are significantly hindered by an ‘irrational’ pattern of regulation of products in which the most harmful products – cigarettes – are freely available and barely regulated, whilst the less harmful smoke-free medicinal nicotine products are treated as drugs and as such are tightly regulated (Britton and Edwards, Reference Britton and Edwards2008). This regulatory anomaly means that medicinal nicotine is characterised by ‘low-addiction, low-dose, low-effectiveness’ (ibid.: 444).

Furthermore, the fact that cessation strategies demonise nicotine means that lower risk alternatives to cigarettes tend to be underutilised and users tend to use a lower dosage than required, thus increasing the likelihood of relapse into smoking. It is the binary choice between either smoking nicotine or not having it all which ensures the continued dominance of smoking as opposed to other forms of nicotine consumption (Sweanor et al., Reference Sweanor, Alcabes and Drucker2007: 72). From the perspective of risk analysis, this is irrational:

In any event, whatever the ‘true’ levels of harm that may be caused by smokeless nicotine products, they are without question significantly less harmful than smoking cigarettes (Britton and Edwards, Reference Britton and Edwards2008).

The simplification of the message in smoking policies about the risks involved in consuming tobacco to the single statement that ‘it isn't safe’ has been defended on the grounds that to present detailed information will cause confusion that might result in some people continuing or resuming smoking. This blanket approach has been criticised from a rights perspective on the grounds that, ‘the right to health information is not contingent upon how an individual makes use of that information’ (Kozlowski and Edwards, Reference Kozlowski and Edwards2005: ii6). For Kozlowski and Edwards (Reference Kozlowski and Edwards2005), the right to accurate health information about the risks involved in smoking and the use of smokeless nicotine products as a possible alternative to smoking is a human right based on the principles of autonomy and self-determination.

Whilst the practical issues relating to the strategies that are currently being deployed to reduce smoking in the general population are of concern, there is a more specific issue which has a special bearing on the experience of mental health service users who smoke, and that is the way smoking campaigns have mobilised stigma to achieve their objectives. It is to this issue the paper now turns.

Smoking, structural stigma and social disadvantage

The mobilisation of stigma in public health campaigns aimed at affecting collective behaviour has a long history, particularly in terms of their focus on the behaviour of people who are disadvantaged (Bayer and Stuber, Reference Bayer and Stuber2006). In this sense, the process of stigmatisation can be regarded as both ideological and moral, and is inextricably linked to structural disadvantage (Farrimond and Joffe, Reference Farrimond and Joffe2006). Poverty and smoking are strongly correlated, with smoking rates for both men and women from lower socio-economic groups more than twice those of their middle-class counterparts, and smoking among unemployed people even more prevalent (Farrimond and Joffe, Reference Farrimond and Joffe2006). This means that through smoking alone, it is the most socio-economically disadvantaged who are ‘bearing a vast burden of avoidable morbidity and mortality’ (Britton and Edwards, Reference Britton and Edwards2008: 441). The fact that there is also a close relationship between lower socio-economic status and certain diagnostic categories in mental health, particularly schizophrenia, may go some way towards explaining the extremely high smoking rates among mental health service users (Mental Health Act Commission, 2005).

Studies on stigma and smoking suggest that health promotion campaigns and smoking policies which use stigma as the main motivating factor for giving up may have a differential impact according to socio-economic status (Farrimond and Joffe, Reference Farrimond and Joffe2006). While people from higher socio-economic groups appear likely to change their behaviour in response to the increasingly stigmatised climate for smoking, people from lower socio-economic groups do not:

The literature on HIV/AIDS would also suggest that stigma is a highly ineffective process through which to influence health behaviour (Bayer and Stuber, Reference Bayer and Stuber2006). Those with experience in this field have been led to conclude that stigma is itself a major public health concern because of its deleterious effects on the effectiveness of health campaigns, particularly among the socially disadvantaged.

The ‘smoking discourse’ which is created through health promotion campaigns certainly appears to be important in terms of the attitudes of smokers towards their capacity to give up, and there is evidence for significant cultural differences in this respect. In a comparative study of representations of smoking in Greece and the UK, two countries with a very different level of restriction on smoking, Louka et al. (Reference Louka, Maguire, Evans and Worrell2006) found an apparent paradox. UK smokers experienced themselves as inhabiting a highly moralised climate with regard to smoking, in which smokers are regarded as ‘immoral’. Giving up was perceived by them as being extremely difficult and this perception was clearly linked to the notion of smoking as highly addictive, a discourse that is strongly represented in UK health promotion discourse. Greek smokers, in contrast, appeared to regard giving up as relatively unproblematic. While the translation of these perceptions into actual smoking behaviour is not explored, it is clear from such studies that the cultural narratives around smoking created by health campaigns have an important impact on the way smokers perceive their smoking behaviour. These perceptions of smoking behaviour may also in part explain some of the difficulties that some groups experience in giving up.

The emotion of shame is central to understanding the way stigma operates in relation to health behaviour such as smoking in groups where social disadvantage is a key factor. Shame is both a profoundly social but also an intensely private emotion (Sayer, Reference Sayer2005). It is an important mechanism in the production of social order through which norms, values and expectations about behaviour and how to live are internalised, particularly in relation to social class:

The more these norms and expectations are assumed to be valuable, the greater the risk of shame for the individual who cannot live up to them. Importantly for the argument presented in this paper, shame may remain unarticulated and beyond immediate awareness, ‘yet still capable of blighting one's life’ (ibid.: 954).

In socio-cultural terms, the metaphorical notion of pollution is a powerful element in mechanisms of stigmatisation and shame that can be considered common to both smoking and ‘madness’. Non-smokers associate smokers with ‘embodied dirt and decay’, with strong unpleasant smells and negative appearance, and conceive of passive smoking as a form of contamination (Farrimond and Joffe, Reference Farrimond and Joffe2006: 484). Sociologists have long observed that ‘odors do indeed bear social meaning’ (Largey and Watson, Reference Largey and Watson1972: 1027) and the meaning associated with the smell of smoking has undergone a transformation from its early association with almost therapeutic qualities to the present association with toxicity. The moral judgement of smokers is especially vigorous and emotional where the ‘contamination’ of children is concerned, and a particularly intense form of social disapproval and disgust is directed at those who smoke in restaurants or around food (Farrimond and Joffe, Reference Farrimond and Joffe2006). It is argued that ‘madness’ in the socio-cultural sense is also symbolically identified with waste and pollution, and such images have been constructed in powerful ways through media representations of people with a mental illness (Wilkinson, Reference Wilkinson, Symonds and Kelly1998).

Most significantly from the viewpoint of this paper, smokers are increasingly identified with the ‘Other’ and with specific ‘out-groups’ such as the old and disadvantaged. The ‘poor young single mother who smokes’ is identified by Farrimond and Joffe (Reference Farrimond and Joffe2006: 487) as an example in which the link between smokers and several stigmatised ‘out-groups’ (the poor, the young, single parents) appears to compound the strength of the negative response on the part of non-smokers. Mental health service users may also represent an ‘out-group’ for whom smoking may have important symbolic connotations, since: ‘The stigmatisation of “the unhealthy” is an active social process; risky behaviour is associated with and projected onto “Other” already stigmatised out-groups’ (Farrimond and Joffe, Reference Farrimond and Joffe2006: 482). The notion of ‘peril’ which underpins stigma (Farrimond and Joffe, Reference Farrimond and Joffe2006) can be understood in both symbolic and real terms in relation both to smoking and mental illness. The ‘smoking world’ (Louka et al., Reference Louka, Maguire, Evans and Worrell2006) inhabited by people with mental health problems is therefore increasingly characterised by exclusion, isolation and a further dimension to being ‘Other’. Just as mental health service users are multiply disadvantaged, they may also experience a multiplier effect of stigmatisation which in part arises from the unintended consequences of the health campaign against smoking.