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Mental health units should not be exempt from smoking ban

August 25, 2006

Exempting mental health units from the ban on smoking in public places would worsen health inequalities for people with mental health problems, warn doctors in this week's BMJ.

Smoking is the largest single cause of preventable illness and premature death in the United Kingdom, with 106,000 people dying of smoking related diseases in 2002, and more than 10,000 dying each year as a result of passive smoking.

The Health Act 2006 will make all enclosed public and work places in England and Wales smoke-free environments, but may exclude some mental health settings.

This would be a mistake, argue Jonathan Campion and colleagues, as the prevalence of smoking is high among people with mental health problems.

Nearly three quarters of people with schizophrenia, affective psychosis, and other mental health disorders who live in mental health settings are smokers, and they are more likely to be heavier and more dependent smokers than the general population, they write.

As a result, people with mental health problems are at a substantially greater risk of premature death from smoking related diseases than is seen in the general population. This is particularly important given that those with mental illness already experience high levels of social exclusion and health inequality, which are exacerbated by smoking.

Arguments for excluding mental health settings from the new smoke-free legislation are that they are places of residence and that some patients are detained under the Mental Health Act. However, health and safety legislation places a duty on NHS employers to protect staff and patients from exposure to environmental tobacco smoke.

Another argument is that preventing people smoking is an infringement of human rights, particularly for detained patients. But the Human Rights Act 1998 allows an individual choice only if that does not endanger others. Furthermore, this argument is not applied to other forms of drug misuse, and people are not allowed to drink alcohol or use illegal drugs in mental health units.

Research also shows that smoke-free policies have succeeded in mental health settings. Such bans have caused fewer problems than anticipated, and policies applied in a consistent way to all patients were more effective than selective bans.

The health select committee has proposed that psychiatric institutions in England and Wales should not be exempt from the Health Act 2006, say the authors. "We strongly endorse this proposal and suggest that all mental health settings should introduce complete smoke-free policies. These policies should be introduced in a flexible and pragmatic way, with support and treatment available for patients to stop smoking and manage withdrawal."

"Exemption from the Health Act will exclude mental health patients from mainstream health improvement strategies and exacerbate the inequality they already experience," they conclude.

BMJ-British Medical Journal