Law Suits: CT Psychiatric Patients Challenge Smoking Ban

Lighting Up When Home Is A Hospital
Rights Issue Clouds Psychiatric Hospital’s Smoking Ban

By KATHLEEN MEGAN | The Hartford Courant
October 28, 2007

In Ken Kesey’s film “One Flew Over the Cuckoo’s Nest,” a climactic scene occurs when Cheswick explodes and demands that Nurse Ratched give him his cigarettes.

The cigarettes represent freedom. Controlling them seems so important because, for these patients, so much is out of their control.

The state of Connecticut is no Nurse Ratched, but in many ways, the state’s plan to ban smoking at Connecticut Valley Hospital because smoking is so unhealthful has summoned that same kind of passion.

“I think we should have a choice, and they are not giving us a choice. I was in the service; I fought for the freedoms of this country,” said Bill Johnston, who has been a patient at CVH for 26 years. “They shouldn’t come in and say you’re not having this.’

“I think we’re grown adults. Everyone is over 18,” said Johnston. “I think it’s a choice.”

Or Anthony Dyous, who has been at CVH for 24 years and believes “You cannot deprive me of my personal liberties: to play chess, to play baseball, to smoke a cigarette. … If you want to ban [smoking] on this campus then make it illegal all over the country. Don’t use it as a political ploy to make your point.”

For anyone with an understanding of all of the health hazards of smoking from cancer to cardiovascular illnesses banning smoking at CVH, as the state had planned to do, is a logical step.

This is especially so considering a recent study that showed that adults with serious mental illness treated in public systems die about 25 years earlier than most Americans, often from conditions related to smoking.

But smoking has a long and complicated history in psychiatric hospitals and is far more complex to address than in a non-psychiatric population.

And so, just before the state Department of Mental Health and Addiction Services was about to implement its tobacco ban at CVH on Oct. 1, Dyous, Johnston and several other patients filed a federal lawsuit claiming that this measure would violate their civil rights.

Since then the department has opted to hold off on implementing the ban until “there is greater clarity around the lawsuit,” Wayne Dailey, a spokesman said.

The state has asked for the dismissal of the suit, arguing, as Attorney General Richard Blumenthal said last week, that “the doctrine of equal protection does not apply when there is a recognized interest in protecting people from secondhand smoke” and when people are in a “limited space and cannot readily or voluntarily leave.”

Because smoking is allowed only in outside areas at CVH, smoking patients say others are not exposed to secondhand smoke.

Meanwhile, the issue is debated by professionals with long careers in the mental health field, roughly dividing them into those who see health as the primary issue and those who believe that the right to self-determination is even more important.

A Need For Nicotine?

Part of what makes a smoking ban at a psychiatric hospital so thorny an issue is the apparent therapeutic value of smoking for some psychiatric patients.

It has long been observed and more recently supported by scientific study that smoking actually does make many psychiatric patients feel better. Alex Cardorni, senior scientist at the Burlingame Research Center of Hartford Hospital’s Institute of Living says recent studies show that nicotine helps people with schizophrenia focus by filtering out environmental stimuli that can overwhelm them. Experts also say that for some patients, nicotine creates a sense of well-being and counteracts the sedative effects of powerful psychiatric medications.

Dyous, one of patients at CVH, can confirm this. When a psychiatric medication makes you feel like you want to “jump out of your skin … a cigarette is almost like a ‘must have.”

“It calms you down,” Dyous said. “It takes some of the discomfort away from certain side effects from medication.”

Perhaps the same effect could be obtained by nicotine patch, but as patients like Johnston will tell you, the smoking break itself along with the smokes is enjoyed. “It makes you focus and concentrates you,” said Dyous. “It relaxes you, so we can socialize with our buddies. If they couldn’t smoke, they wouldn’t socialize. The tobacco makes them come out of themselves and they talk to each other.’

Many experts believe that the high rate of smoking among psychiatric patients 75 percent of those with severe mental illness smoke compared with 22 percent in the general population has been a kind of self-medication.

Less seemly is the historical role of cigarettes as a tool in behavioral treatment. Over the years, hospitals have often doled out cigarettes and smoking breaks as rewards for good behavior and rescinded smoking privileges as punishment for bad. And often hospitals have offered little in the way of recreation or social opportunities other than smoking breaks..

Karen Kangas, a retired executive with the state mental health agency and a longtime advocate for people with mental illness, remembers that years ago, “We encouraged cigarettes and we also gave cigarettes out.”

Sometimes patients who didn’t smoke took it up, Kangas said, because it was the only way they were allowed outside. State officials said cigarettes are no longer used as reward or punishment in state psychiatric facilities.

Robert Glover, executive director of the National Association of State Mental Health Program Directors, which is leading an effort to make all public mental health hospitals tobacco-free, said it’s clear that the hospital system “has been part of the problem. We want to be part of the solution.”

In its position paper on the subject, the association of mental health program directors states that smoking “is a poor (and often only) substitute for practice in decision-making and relationship building and is inappropriate as a means to manage behavior within the treatment milieu.”

“And while smoking can be framed as the one ‘choice’ consumers get to make while inpatients, and a personal ‘choice’ for staff, it is critical to realize that addiction is not a choice. But quitting smoking is.”

Glover also said that while it has been feared that banning smoking would lead to more instances of troubling behavior among patients who might have to be restrained, the opposite has actually been true. The use of restraints and seclusion has gone down in hospitals where smoking has been banned, Glover said, because often the conflict was related to cigarettes and smoking breaks.

A Matter Of Rights

The other major complicating factor in banning smoking at a psychiatric hospital is the patient-rights issue. There are many mental health professionals who, while supporting all efforts to help patients voluntarily quit smoking, oppose a smoking ban on the grounds that for some hospital patients in this case those who have lived at CVH for many years the hospital is effectively their home.

“For me it’s not about smoking,” said Kangas, who has worked at CVH part-time. “It’s about self-determination.”

Kangas believes that if people in the community can choose to smoke in their homes, patients should be allowed to do so in theirs, as long as they can find a place to smoke probably outdoors without exposing nonsmokers to secondhand smoke.

At the Institute of Living, Dr. Hank Schwartz, psychiatrist-in-chief, drew the distinction between a hospital like the institute, where patients stay only an average of six days, and a place like Connecticut Valley Hospital, where patients may stay for years.

Schwartz said the institute is moving toward the elimination of smoking. However, at CVH, he said, “This essentially is their home. What’s more, they often live there involuntarily under civil commitment.”

Schwartz said he understands the desire not to “collude with a behavior that takes such a terrific toll on our patients.”

“But at the same time, there is the whole notion behind the recovery movement … that individuals are in the process of recovery for which they bear a responsibility and they must be enabled to exercise that autonomy. … Why do they have a lesser right to choose than the rest of us?”

Of course, he said, there are also the issues of secondhand smoke to be considered. Even outside the building, it can be a problem, he said.

Susan McKinley, who works at CVH and is a delegate for the u nion representing employees New England Health Care Employees U nion, District 1199 said many employees are very concerned about being exposed to secondhand smoke, even though the smoking is outdoors. She said the designated outside areas for smoking at the hospital are small and somewhat confined.

“We certainly have broad support for patients’ rights,” said McKinley, “but we’re not being bashful about pushing for a healthy lifestyle.”

James McGaughey, executive director of the state Office of Protection and Advocacy for Persons With Disabilities, said that while no one is in favor of smoking, it is very different to encourage patients to quit than to institute a ban. “It sort of speaks more to the power dynamics than it does to what we want to do,” said McGaughey. He said there must be “a more respectful way” than to “pass an across-the-board bar on it.”

At the National Alliance for the Mentally Ill, Ron Honberg, legal director, said the alliance strongly favors helping people to stop smoking, but opposes a ban, explaining that it’s unreasonable to “ask someone in the throes of a psychiatric episode when they are experiencing delusions and other horrifying symptoms to stop doing something that may give them some release.”

He said smoking cessation must be done slowly and carefully, because smoking affects the concentration of medication in the blood.

“Frankly,” he said, the alliance has “a lack of confidence that hospitals will do this right … It must be done very carefully and humanely.” Connecticut officials have said, however, that they do have smoking-cessation services in place, offering the patch and other nicotine replacement strategies.

Even within the alliance, there are many shades of opinions. At Connecticut’s chapter of the alliance, Kate Mattias, executive director, sees a ban on smoking as more “of a right to a healthy environment” than as a patients’ rights issue.

“I think the tactic on the part of CVH is to really begin to instill a picture of a health facility as opposed to a facility that sort of warehouses chronically ill individuals and sort of leaves them to their own devices, often including smoking.”

She believes that if implemented, recreational and social programs would provide a much more healthful alternative to smoking.

Glover said his organization is aware of the need to proceed carefully and slowly with smoking bans. “It’s not a sprint; it’s a marathon,” said Glover. “It will take cultural change.”

Kathleen Megan can be reached at kathy.megan@courant.com.