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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