Smoking Ban at Psychiatric Hospital Linked to Increase in Involuntary Admissions

Kate Johnson

September 30, 2010

September 30, 2010 (Toronto, Ontario) — The rate of involuntary admissions at Canada's largest psychiatric hospital jumped by 63% in the weeks following the implementation of a no-smoking policy at the institution, according to a study presented here at the Canadian Psychiatric Association 60th Annual Conference.

"When you tell people they have to stay they really feel like they're being imprisoned because of their smoking habit," said Paul Kurdyak, MD, head of Emergency Crisis Services at the Centre for Addiction and Mental Health (CAMH) in Toronto, Ontario, Canada, and lead investigator of the study.

"There's a time and a place for everything. For me the issue is that people are coming in crisis and it's a really tough time to ask them to stop smoking."

The study compared emergency department records for the 12 weeks preceding and following the no-smoking policy, which was implemented at CAMH in September 2005.

A study previously published by Dr. Kurdyak and colleagues documented a 15% decrease in overall visits to the emergency department after a provincewide smoking ban in public places (Can J Psychiatry. 2008;53:779-789).

The emergency department handles roughly 50,000 visits a year, 85% of them on a walk-in basis, he said.

Additional Burden for Individuals in Crisis

For the current study the researchers focused specifically on hospital admissions among patients who had psychotic diagnoses (schizophrenia, mood disorders, substance-related disorders) during the 24-week period spanning the ban.

"We focused on people with psychotic illnesses because they smoke a lot — more than any other patients — and they are put in this situation a lot in that they have a very high rate of hospitalization when they come to our emergency department," he said.

The data revealed an increase in involuntary admissions, from 34% before the no-smoking policy to 45% after (odds ratio, 1.63).

"When we offer these individuals help but say they can't smoke, then sometimes we need to detain them involuntarily — and it's a pretty unhappy moment for people who also happen to be in crisis. It certainly adds suffering — despite our efforts to provide nicotine replacement therapy."

Although it was not formally captured in the data, there were also a significant number of patients who did not meet criteria for involuntary admission but who were advised that they should be hospitalized but refused.

Need to Invest in Outpatient Smoking Cessation Strategies

"As someone whose responsibility it is to run a psychiatric emergency department, I am at odds with my organization, which is strongly behind this policy," said Dr. Kurdyak, who said he fully supports the notion of smoking cessation but questions the point of imposing it.

"I believe that smoking cessation is a huge investment for our patients, what I haven't seen is the investment in resources to help these individuals when they are stable outpatients."

One psychiatrist who attended the presentation agreed there should be more focus on long-term support for smoking cessation.

"When you're trying to stop an addictive process like smoking I think the person has to begin to see why it's of value to them," said Carl Ripley, MD, from the Royal Ottawa Mental Health Center in Ottawa, Ontario, Canada. "If they don't buy into that, if it's imposed by somebody else, then 5 minutes after they're out the door they're smoking again.

"I am certainly sensitive to what we are forcing on patients when we say you can't smoke in a psychiatric ward," said Jennifer Brasch, MD, medical director of Psychiatric Emergency Services at St. Joseph's Healthcare and Associate Professor in the Department of Psychiatry and Behavioural Neurosciences at McMaster University in Hamilton, Ontario, Canada.

"Don't quote me as saying I think psychiatric patients should smoke, because I don't, but I certainly recognize that taking away a familiar action and a brain-altering medication from someone who is already struggling with severe and persistent mental illness could be problematic."

Neither the presenter nor commentators have disclosed any relevant financial relationships.

Canadian Psychiatric Association (CPA) 60th Annual Conference: Abstract PS5e. Presented September 24, 2010.

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