Toronto’s Centre for Addiction and Mental Health (CAMH) – Canada’s largest addiction and mental health research and treatment facility – recently announced that come July 2010, three of its principle sites will be entirely smoke free. This announcement appears to be the next step from CAMH’s 2005 non-smoking policy, in which smoking was prohibited in all buildings and in the designated smoking rooms on inpatient units. Clients, staff and visitors were still able to smoke in designated areas on the grounds.
Justification for the new policy is based on the following argument:
“This is first and foremost part of CAMH’s commitment to transform care for our clients…we should not accept a lower quality of life for people with mental vs physical illness. This decision is equally motivated by health and safety – CAMH has a legal and ethical obligation to provide a safe, hazard-free treatment setting and workplace for our clients, staff, volunteers and visitors. In 2009 the primary cause of death in mental health and addictions populations was tobacco-related medical illness…”
Indeed, smoking rates are extremely high among persons living with various mental illnesses, particularly schizophrenia. There are many complex factors involved, which may explain the high smoking rates in this population. For example, the so-called “self medication” hypothesis suggests that tobacco use reduces or helps individuals tolerate unpleasant psychiatric symptoms, and nicotine may in fact enhance cognition and other forms of sensory gating. Other reports suggest that smoking helps to decrease the adverse side effects of medication (perhaps by reducing blood levels of antipsychotic medications metabolized by the hepatic CYP450 1A2 enzyme), and helps to increase the individual’s ability to cope with stress, anxiety, and depression. Moreover, some individuals living with severe mental illness perceive smoking to be effective as a social lubricant. These individuals also tend to be multiply disadvantaged: in addition to facing challenges with housing and accessing health and psycho-social services, individuals with severe mental illness face barriers to education and employment, and so it is unsurprising that individuals who are low socio-economic status and have lower education levels are more likely to smoke, have a more difficult time quitting (see, e.g., here), and have higher rates of psychiatric diagnoses.
The new CAMH policy appears to be following a recent global political trend called tobacco denormalization. The goal of tobacco denormalization programs is to promote the idea that tobacco use is not a mainstream activity within society. CAMH is but one of many psychiatric facilities world-wide that have implemented denormalization programs. Yet, as a recent Globe and Mail article covering the story noted, since CAMH “is the country’s largest mental-health centre, other institutions will undoubtedly be watching to see how the new policy unfolds.”
In fact, many tobacco denormalization programs tend to embrace the stigmatization of smokers as a public health tool. Stigma is achieved through a moralization of smoking. For instance, public education campaigns on the adverse health outcomes of smoking paints those who smoke as engaging in morally reprehensible behaviour. The philosopher Martha Nussbaum, for instance, has argued that humiliating or dehumanizing the victim is “central” for stigma to be enacted, and, following Goffman, the stigmatized person has to recognize this humiliation (spoiled identity) as a reality. Such an effort at manipulating the mores of society has clear implications for persons living with psychiatric illness. As UBC‘s Kirsten Bell and colleagues notice, “denormalization policies have the effect of sanctioning stigma implicitly directed towards a particular segment of the population: the segment with the least ability and/or willingness to quit” (p.797). Interestingly, denomalization programs are antithetical to public health efforts which are focused on eradicating stigma – particularly around eliminating negative public perceptions of people who use illicit drugs.
However advocates such as Bayer argue that the burden of stigmatizing denormalization policies imposed on vulnerable populations (e.g., individuals living with psychiatric illness) is justified by the (potential) benefits to that population. Since people living with psychiatric illness have the highest incidence of smoking-related adverse health outcomes, they also stand to benefit disproportionately from denormalizing efforts. Others argue that a restrictive ban on smoking is long over due in the mental health system, and the “culture of complacency” that has long been enmeshed in many psychiatric institution’s smoking policies is in need of a major paradigm shift.
Thus a major question that tobacco denormalization policies raise is whether the use of stigma as social control is ever ethically justifiable.
(Note: the issue of smoking denormalization was a topic of debate in Social Science & Medicine, vol. 7, issue 8, 2008).
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Neuroethics at the Core 
As far as the egregious use of stigma as a public health tool goes, nothing stands out more in my mind than the pervasive (and hopelessly ineffectual, and deeply damaging) shaming of fat people in the “war on obesity.” It’s about time that the “shame method” of behavior influencing came under serious data-accountable scrutiny – in every one of its myriad incarnations across various societal issues.
These totalitarian control freaks are the reason I don’t access health care for treatment for my schizophrenia. There’s nothing they like better than dictating what vulnerable people are allowed to do and the more vulnerable you are the more they bully.
I’ve got BPD and smoke a lot, my sense being that smoking is a substitute for substances that would be more damaging.
My avoidance and extreme fear of psychiatry was overcome about seven years ago due to my understanding that hospitalisation was unlikely in my case. My avoidance of therapists is due to my undermining nature. My avoidance of any kind of support group is due to smoking bans. A smoking ban is effectively a me ban.
A friend of mine who is bipolar and who sometimes is sectioned dreads the possibility of incarceration – seeing those circumstances as the worst possible time to be made to stop smoking.
Further, the special hospitals of England have now elected to stop smoking amongst those whose diagnosis starts with the word Criminal.
To apply a denormalisation campaign to people who so obviously have a distorted sense of normality is absurd.
The above article whiffs of the cruelty of eugenics.
Tinkering in another person’s private mental space, especially to fill it with negative messages, propaganda and lies in order reshape that person to conform to some desired norm — that’s the kind of quackery employed by authoritarian governments too lazy to come up with a compelling argument.
Resorting to things like propaganda, bullying, shaming, stigmatizing, nudging, nagging and especially raping another’s mind which is what denormalization does, reveals a lack of respect for other human beings.
Manipulating opinion using quackery rather than an open discussion of the issues is antithetical to a free society and a hallmark of tyranny.
Or is this a theoretical discussion of psychological warfare?
One way to gauge whether a behavior is ethically justified is to ask yourself how you would feel if you were the target, or some helpless person you love (perhaps a small child) were the target. That’s how my mother taught me empathy.
The denormalizers can claim that their intentions are benevolent, that they only want to save the life of the hapless smokers. But think about where the road paved with good intentions leads. If smokers are self-medicating one or more underlying conditions, how can the denormalizer be sure that removing the nicotine won’t kill the patient? One has to wonder how many of the suicides linked to verenicline are not a direct drug effect, but an indirect effect of removing the nicotine that kept the depressive symptoms under control.
There is a much better solution to the smoking problem than denormalization. It’s much easier to spell, too: “Truth.” Instead of giving smokers only two options, quit or die, tell them the truth about the relative hazard levels of alternative sources of nicotine. Several decades of research on Swedish smokers who switched to snus, a type of reduced-nitrosamine spit-free moist tobacco that is sold packaged in small discreet pouches, shows us that, when removed from the harmful elements in smoke, nicotine per se carries about the same level of risk as long-term use of caffeine.
Smokers who switched to snus have no higher rates of cancer or cardiovascular disease than smokers who stopped all use of tobacco or nicotine and they have an equivalent life expectency. The safety record of Swedish snus is being used by pharmaceutical companies that make NRTs as evidence that it would be safe for the US FDA to approve long-term use of their products. Given that products such as dissolvable tobacco orbs (on the market now for 10 years) and electronic cigarettes (on the market in the US for about 4 years) have even lower levels of nitrosamines, they should prove to be just as safe as switching to snus. Nothing is 100% safe, but these products are up to 99% less hazardous than smoking. They allow those with a real dependence on the beneficial effects of nicotine to become smoke-free without being required to sacrifice their cognitive and/or emotional health. The concept is called Tobacco Harm Reduction (THR). THR has the potential to save millions of lives in North America and billions of lives world-wide.
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