Smoking and mental health: must read transcript of a very interesting discussion
Saturday, June 6, 2015 at 11:07
Simon Clark

There was a fascinating, extremely well-balanced discussion on the Jeremy Vine Show on Radio 2 on Thursday.

It followed a report on the Today programme that highlighted Public Health England's new guidance on smoking in mental health units.

You can listen to the Jeremy Vine discussion here for a few more days or you can read the transcript below.

It's long but worth the effort. It features an interview with Mary, matron at the South London and Maudsley NHS Trust, who is determined her patients should stop smoking, plus insightful contributions from several mental health patients (past and present) who smoke.

Hats off to Jeremy Vine, by the way. He was studiously impartial and appeared genuinely interested in the issue:

Jeremy Vine, presenter:
So we learnt today that patients in mental health units are three times as likely to be smokers than the rest of the population. What’s even more interesting though is that while smoking has been generally in decline in England the smoking rate for mental health patients has barely shifted in the last 20 years. It's just not moving.

It's thought that 64% of those been treated in mental health units are addicted to tobacco. Those numbers come from a survey carried out the Government organisation Public Health England which wants to see all psych hospitals become smoke free zones but many psychiatric patients say cigarettes are a welcome distraction and they depend on nicotine to stay calm. Experts warn, they say hang on, smoking can actually increase depression and anxiety and even prevent their medication from working. Many of those who smoke while being treated in a mental health unit actually take up the habit in a hospital perhaps that’s because everyone else is doing it, relieves the boredom.

Maybe your smoking habit began when you spent time in a mental health unit. Can you tell us about that? How would you have felt if you would had been prevented from lighting up by a nurse who 10 years ago would have been only too happy to help you with a walk outside? Sima Kotecha, BBC reporter joins us, who has broken the story. So, it's very interesting, it's just not moving in the mental health population?

Sima Kotecha, BBC reporter:
Yes absolutely. So, in the general population, as you just said in your intro, we have seen smoking figures decline over 20 years. If we look at the same time period for those in mental health hospitals and mental health units, it hasn’t really changed. So why is that? Well, as you say there is a perception that smoking makes you feel more relaxed, it makes you feel more at ease, perhaps it eases the symptoms of anxiety and depression. Medical experts that I have spoken to say that’s absolutely not the case. In fact it's more likely to do the opposite.

Jeremy Vine:
And what was very interesting about your piece is that it seems people are starting to smoke when they arrive on the ward. So they get into a smoking culture. Is that right?

Sima Kotecha:
Absolutely yes. So the patients that I have spoken to say that they actually some of them started when they were admitted into hospital and it is absolutely that social culture, that time of the day when you can go out with the other patients, have a chinwag, escape from the misery that you are feeling because you are unwell, and also I have been told that some nurses maybe unconsciously encourage this type of behaviour by giving patients time out to go and have a cigarette, saying to them, 'Do you want to nip out and have a fag while it's sunny outside?', and the nurses I have spoken at Maudsley Hospital in South London, a psychiatric hospital, say there needs to be a cultural shift. Doctors and nurses need to be a lot more stern in terms of telling patients that smoking is going to be bad for you if you are suffering from a mental health illness.

Jeremy Vine:
But is it bad for you if you are suffering from a mental health illness? If your illness is causing you to be unhappy and smoking is making you happier, why not?

Sima Kotecha:
Exactly, you might have that viewpoint, but the Royal College of Physicians says that increasingly it believes that smoking can actually void out that medication that you are using and not make it be as strong because of the smoking. So what they are saying is, if you give up smoking the medication will work as a lesser prescription, if you like, and cost the NHS up to 40 million pounds less per annum.

Jeremy Vine:
Right, OK Sima, stay with us, we have just got on the phone Judy Mead who is from Bristol. Judy you were a patient in a mental health unit and did you smoke?

Judy Mead, former mental health patient and a smoker:
I did. I smoked, yes.

Jeremy Vine:
So you smoked in the unit? Did you start smoking in the unit?

Judy Mead:
I already smoked before I went into the unit. In those days you were allowed to smoke inside and outside.

Jeremy Vine:
So when was this, can I ask?

Judy Mead:
That was 1985 and 1987.

Jeremy Vine:
OK, and I know your mental health problems are behind you, thankfully, and that’s great.

Judy Mead:
Yes.

Jeremy Vine:
Did the nurses in the unit almost facilitate you as a smoker?

Judy Mead:
No, in the sense they would ration them so it would be easier to make, you know, a packet of ten last a couple of days or something like that.

Jeremy Vine:
And did you feel that cigarettes were helpful to you?

Judy Mead:
I did because it’s such a lonely and frightening experience being sectioned and being detained and being given electric shock treatment. Cigarettes were like a friend to me.

Jeremy Vine:
Sure, and I guess there is quite a smoking culture on mental health wards for that reason.

Judy Mead:
Yes, I imagine so.

Jeremy Vine:
Thank you very much, Judy. There is the case for, Sima?

Sima Kotecha:
Yes, and the smokers' lobby group Forest are not very happy about this. They actually have told us that Public Health England has absolutely no right to deny people a choice, that it would be discriminatory to stop smokers from smoking when it's something that is legal across the country.

Jeremy Vine:
So what are they trying to do about it, the authorities?

Sima Kotecha:
Well, they have published some new guidance which encourages mental health units across the country to go smoke free. At the moment 9% of mental health units across the country are smoke free. They want everyone to adhere to those rules and they are saying that if you do this you will actually improve the wellbeing of your patients and they say that you can do this by having non-smoking clinics on premises where patients can go and ask for help and advice and learn more about how they can actually give up this habit.

Jeremy Vine:
And you went on some wards I know when you were looking into this. Did you find patients prepared to go smoke free or maybe ones who have given up and thought it had helped them?

Sima Kotecha:
I spoke to one patient, yes. A former patient who suffered from clinical depression. He said that he wished that somebody had told him when he was in hospital how it could actually effect the medication he was taking and I spoke to the nurses on the ward. They were the ones that had very strict views about wanting to cut down on this and, if you like, very little, well, sympathy I guess for those who were saying that, 'You know, I really need a cigarette, it helps me to relax'.

Jeremy Vine:
Thank you very much, Sima Kotecha, BBC reporter. You can see why from that there is such a lag on the whole anti-smoking thing in the realm of mental health but do you think they should now crack down on it and stop people in psychiatric wards from smoking?

[Short break]

Jeremy Vine:
Smoking in mental health units. We heard from our reporter Sima Kotecha who has done the story talking about the fact that they are now getting around to thinking that this is not good for the patients. Mary Yates is a matron at the South London and Maudsley NHS Trust which runs four mental health units. I know that you are pretty anti-smoking, you are a health professional, so you would be.

Mary Yates, matron, South London and Maudsley NHS Trust:
Well it's not so much that I am anti-smoking but I am interested in considering tobacco dependence as a clinical issue and making sure that people with mental health problems have access to the treatment that they require to address that issue.

Jeremy Vine:
Sure, but tobacco smoking is a physical dependency and if somebody has a mental health problem that comes first, right? So if smoking is helping them be happy, let’s leave them smoking, surely?

Mary Yates:
Well I can understand why you might think that, Jeremy, but in fact all of the evidence that we have now is suggesting that smoking not only harms people’s physical health but is also detrimental to their mental health and well-being.

Jeremy Vine:
What is this evidence? I have never heard of this before.

Mary Yates:
Well it's quite compelling evidence now, which is suggesting that quitting smoking in fact really enhances people’s health and well-being.

Jeremy Vine:
The mental or physical health?

Mary Yates:
Their mental health.

Jeremy Vine:
Right.

Mary Yates:
People who have successfully quit, and we have lots of people now at South London Maudsley who have been supported to quit, and what we find is that their confidence improves, their self-esteem improves, their anxiety levels are decreased, they feel more able to tackle the other issues in their lives.

Jeremy Vine:
So it's bit like alcohol is it where people who have got depression or anxiety reach for a pint of beer, totally understandably? It's a brilliant short-term treatment for anxiety but long-term is dangerous, is that right?

Mary Yates:
It's lethal. In fact we want people to try and change their attitude to smoking and to see it as a silent killer. We want staff in our hospitals up and down the country to be really confident and capable to address this issue because it's gone unnoticed really up to now.

Jeremy Vine:
Sure, but if you have a mental health patient and they are in a state and they want to have a cigarette it's difficult to argue that long-term they will be happier if they give up the short-term anxiety relief of that fag. So help me out.

Mary Yates:
Definitely.

Jeremy Vine:
How do you make that case to them?

Mary Yates:
I am completely sympathetic to that because tobacco dependence, as you rightly say, that is quite a fierce addiction. What we are saying to people is we are not saying you have to ditch the nicotine. You can have as much nicotine as you want because people who are addicted to nicotine are really quite dependent on it.

Jeremy Vine:
So they can do vaping and patches?

Mary Yates:
They can have all of that.

Jeremy Vine:
Right.

Mary Yates:
And what we have promised to our patients is that within 30 minutes of their admission, if they are a smoker, we will make sure we have the nicotine replacement ready and waiting for them. So our cupboards are full of patches, inhalators, lozenges, whatever people want, so that ...

Jeremy Vine:
Do they get stressed when you say that?

Mary Yates:
For some people it has been a surprise because as you know smoking has been rife in our hospitals. You know it has been part of the routine, part of the culture for such a long time.

Jeremy Vine:
Do nurses smoke in your mental health ward?

Mary Yates:
There is a higher prevalence of smoking amongst health care professionals. Slightly higher than the national average. I mean we have done great work around smoking cessation in this country. We have now got prevalence of smoking below 20% for the UK population. It is a bit higher amongst health care professionals. The sad thing is that the prevalence of smoking amongst the mental health population is around about 70% and we have to do something about that. I mean it's crazy not to.

Jeremy Vine:
It seems part of the reason, Sima was saying that it’s a communal thing. It may not even be the physical addiction. It's to do with sharing something in this really difficult environment with other patients.

Mary Yates:
Yes, I completely understand that and, you know, smoking is a social behaviour, isn’t it, and it's a thing that people don’t generally do on their own. They do it together as a group. So we have to make a commitment to making sure that our hospitals are places where people are engaged in meaningful, therapeutic social activities but not activities that are going to race them fastly towards an early grave.

Jeremy Vine:
OK, we have got Vicky Gooding in Derby on the phone and Vicky, you were diagnosed with bipolar illness? Is that right?

Vicky Gooding: former mental health patient and a smoker
Yes that’s correct.

Jeremy Vine:
OK and did you smoke around that time or you smoked before and you stopped or what?

Vicky Gooding:
I started smoking when I was 21 when I first really started becoming very ill from bipolar disorder and then when I did go into psychiatric unit later on I continued to smoke. While I was in there I actually found smoking was a great help because while you are in the unit it's very extremely stressful situation because you are trying to deal with emotions and many other things and also being in an environment which is completely alien to you.

Jeremy Vine:
I totally, well, that’s the point I was making to our brilliant matron here, but Mary, if you go into her unit, you open the cupboard and she’s got patches in there and she has got probably some vaping canisters and she has got everything except cigarettes. So would you be happy with that, Vicky?

Vicky Gooding:
No, I wouldn’t be happy at all because when you have a mental illness, unlike physical, it completely changes your perception of the world. So to take away something that you really rely on that helps you to deal with stress will make your actual illness worse.

Jeremy Vine:
OK, so we have deadlock then, Mary? So what’s your next gambit when you are dealing with this, Vicky?

Mary Yates:
Well, obviously what my interest in is improving people’s health and well-being and I am very sympathetic to Vicky. I understand that the routine and the culture of smoking has prevailed and that it's a huge change for people but I am absolutely confident that if the right nicotine replacement and the right programme for supporting Vicky and others like her to understand the harmful effects of tobacco.

Jeremy Vine:
Right, but you see you are at the front desk of the psychiatric unit and you started a battle about smoking when there are a way bigger issues for Vicky? So don’t you just let this one go? Just say that, 'Vicky, smoke as much as you want.'

Mary Yates:
I am afraid that as a health care professional I can’t do that because my interest is in Vicky as a whole person and I think it is completely inappropriate for me as a health care professional not to consider her as somebody who needs to be afforded the most up-to-date evidence-based and cost effective treatment for the condition that she has.

Jeremy Vine:
OK, so Vicky, go on.

Vicky Gooding:
Can I ask a question then? The medication that I am taking at the moment causes far more damage to my liver than ever smoking will do because most of my medication is either old or not up to date to the standard of, say, cancer treatment. So at the moment the medication I take is causing damage to my liver and will continue to do so. So that is a far greater risk to my health than smoking will ever be.

Mary Yates:
Well, I have no doubt that there are lots of side effects to the medications that you are using, Vicky, but what I would say to you and to others like you that are taking lots of psychotropic medication, if you are able to cut down and if you are able to get the right support to quit your smoking you will potentially be able to reduce by 50% the medicines that you are currently taking.

Jeremy Vine:
Is that right? Well this is the other thing that in this report is surprising, that you can take less medication if you stop smoking. Is that right?

Mary Yates:
Potentially.

Jeremy Vine:
Right.

Vicky Gooding:
I haven’t read any research regarding that because I have been bipolar for a long time and recently I have actually gained an assistant to help me deal with my bipolar. Actually that has been so far the most effective thing in dealing with that on top of medication but I don’t believe stop smoking will make any difference at all. Yes, it will improve my lungs and my physical health, but mentally I haven’t found any benefit when I have tried to stop. I have actually found my mental health has got worse when I tried to stop smoking.

Jeremy Vine:
OK, thank you, Vicky. Thank you as well, Mary Yates, matron at South London and Maudsley NHS Trust. Did I get the names right? We have spent a lot of time on the name.

Mary Yates:
It’s a long one.

Jeremy Vine:
We are one of the first programmes to get it right. It's bit of a breakthrough at this end.

Mary Yates:
Thank you very much.

Jeremy Vine:
Thank you. It's nice to see you as well. Right, we are talking about smoking and mental health.

[Short break]

Jeremy Vine:
We were just talking about Mary Yates, the brilliant matron we had here, and Vicky, thank you for your call as well, who smokes and has bipolar, and just thinking, how did that conversation end up at the front desk because it was complete deadlock there. Vicky is going to smoke and Mary doesn’t want her to and I think she is going to take Vicky’s cigarettes. I think that’s going to happen. You are not going past the front desk now on a mental health ward with your cigarettes. Is that right?

Ellie Downs has emailed. Hi Ellie. She says:

My aunt Felicity was autistic and in institutions from, it's so sad, the age of eight to her death at 55, and my aunt was allowed to smoke in the hospital. She smoked when we visited. The visits could be disturbing but then when she smoked she was visibly more relaxed and happy and it was a gift for her parents. It was her only pleasure. Cigarettes.

Anonymous text in from Bath saying:

Some psychiatric wards are so appalling, out of date and frightening, the only thing you got is your cigarettes. Maybe they can use yoga or gardening but of course they have taken the gardens away where we used to relax and recuperate and they put up high fences. So it's like a prison. So bring back the gardens and then lose the cigarettes.

Paul Kelley says:

I work in a psychiatric unit in the North West where smoking is banned. Patients then smoke in the toilets on the ward which puts all of us at risk.

Getting lots on this. Vine@bbc.co.uk or tweet or Facebook or you could write a letter but it won’t get to us today.

Jean in Liverpool says:

My daughter has suffered with bipolar disorder since she was a teenager and she needs cigarettes to get through the day. She used to have disastrous and occasional violent times when she didn’t smoke.

Ella Maude says:

I am a mental health nurse. Patients on locked wards consider smoking one of their few remaining liberties after they are being sectioned. So taking away smoking on wards will cause riots.

Gosh this is so interesting and how you enforce it I have got no idea. Here is a last comment from Jacqueline who has emailed:

I am a smoker of 20 years, smoke about 10 cigarettes a day. I have also suffered from waves of extreme anxiety and depressive episodes. Now I have stopped smoking 10 days ago with the aid of a licensed inhaler from my pharmacy and I cannot put into words the turnaround in my state of mind and my immediate health. It is truly amazing.

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