smoking mental illness
Pennsylvania has decided that unless you are willing to quit smoking for the duration of your treatment, you don't deserve mental health treatment from the state:
Tobacco products and vape devices have been banned at Pennsylvania's six state mental health hospitals, including Torrance State Hospital in Derry Township.
"Smoking is a contributing factor to the shortened life expectancy of individuals with a mental illness," Department of Human Services Secretary Teresa Miller said Monday in a statement announcing the ban. "This initiative will further support health, wellness and recovery within these communities."
The hospitals will be posted to advise patients, staff, visitors, contractors and tenants that the campuses and buildings are tobacco-free zones. The facilities will offer smoking cessation programs and support as needed, including nicotine patches and gum. Information about cessation support groups and programs will be posted online for employees.
We are, apparently, so concerned with moral theater that we are willing to act at the expense of mental health. State officials can argue that the goal of this new policy is to encourage healthy choices, but they will in effect be denying care to those who don't make the state's preferred decisions.

This health decision is not related to treatment of the condition for which they sought help - better mental health can be achieved without quitting. The policy is not even a result of mission creep. It is seeking a new mission at the expense of the existing one. Do we really need another government agency devoted to smoking cessation? Or do we need one devoted to the care of mentally ill citizens?

While society is loath to agree that very bad things can actually be good for you under specific circumstances, there is some science that suggests nicotine might actually help with schizophrenia and other ailments. Yet even the places that will allow nicotine by other means will often do so with an eye towards weaning people off of it.

There are exceptionally high rates of tobacco use among mentally ill people - this fact is often attributed to tobacco companies preying on them. But those high rates may be the result of mentally ill people self-medicating. Perhaps the ideal option would be to substitute tobacco use with more appropriate pharmaceuticals, but that must be secondary if the primary goal is improved mental health. It cannot be a precondition to treatment.

If tobacco use were strictly a matter of ingesting nicotine, we could deliver that through other mechanisms, such as the patch or gun. But the reasons that underlie tobacco use are often more encompassing than satisfying a physiological need. Even nicotine replacement therapy may not be sufficient for mentally ill patients if, for example, an element of their addiction is that their minds are soothed by the rituals of smoking. Access to treatment should not depend on the answer to these questions.

In a related development, the state of Vermont announced in 2013 that it would prohibit smoking at drug addiction treatment centers that receive state funding. The idea was that while people were being treated for heroin they would also kick the tobacco habit. That's not exactly what happened:
During the first few weeks of the year, less than half of the beds at the Maple Leaf Treatment Facility were full. It's one of four addiction treatment centers in the state, which normally has a long wait list. But a new statewide smoking policy is keeping some clients away.
"It was all consuming," said David Crounse. No smoking signs are now a common sight at the Maple Leaf Treatment Facility in Underhill. "It became the primary focus for our clients, became the primary focus for a lot of our staff," added Crounse, Assistant Director of Residential Services for the 24 hour facility.
They specialize in treatment, prevention, and counseling for addiction, including opiates and alcohol. But a new Vermont Department of Health smoking ban is causing some serious issues. "I completely agree that it's an addiction that needs to be treated. There's really good research that says folks can quit both at the same time, or all substances at the same time and do really well," said Catey Iacuzzi, Executive Director of Maple Leaf.
There is no doubt that some folks can quit both at the same time. By all means, encourage people to quit everything at once and see how that goes. If they succeed, that's an extraordinary win. But just because it can work that way doesn't mean that it will work that way - not with enough consistency to justify a blanket policy.

It is not the business of addiction treatment centers or mental health hospitals to separate patients into Saved and Damned on the basis of their tobacco cessation. Their job to help the most pressing issue - which in these cases do not center around tobacco use.

Smoking can do terrible things to a human body. It taxes the heart, destroys the lungs, and steamrolls the immune system. But it is not the only factor that can negatively affect a smoker's health. Other forms of addiction - including alcohol - can also cause physical harm, and can ruin your life to a greater degree than even tobacco. Untreated mental illness, of course, can also ruin your life-and can also result in physical harm.

Consider this graph. These smoking bans require that a substance with intense dependency, tobacco (blue), must be extinguished before any other treatment. It's as if they are demanding patients complete a weirdly difficult first-level boss on a Super Mario Bros game, before they can get to the advanced level bosses like street methadone, barbiturates, and amphetamines.

smoking bans
If someone were to get over alcoholism - or opiate or heroin addiction - using cigarettes as an aid, that person is likely to be, on the whole, better off. We should allow people to make that determination for themselves.

These are complex dynamics. Many of the advocates of these policies grasp the complexity of addiction when it comes to virtually anything else. They support needle exchanges and methadone because they understand a hierarchy of urgency and recognize that some evils are worse than others. But for some reason, when it comes to tobacco, all nuance goes out the window. People who know better decide to stop knowing better.

The war against smoking has become an endless loop of two questions: (1) Where are people smoking, and (2) Can we stop them from smoking there? At first, smoking bans were justified by the non-smokers who were inconvenienced or sickened. A lot of the most recent measures dispense with that justification entirely. It's difficult to argue that in entire airports, campuses hundreds of acres large, and entire hospitals that there is nowhere anyone can smoke without disturbing others.

Some object to this state of affairs while others praise it. Where it ought to hit a wall, however, is when we lay an unnecessary burden on those we are trying to help. It becomes apparent that it's not about them and their situation at all, but holding their welfare hostage to our own sense of virtue.

People receiving help for addiction or mental illness are not props in a morality play. If it's in their interest to tackle tobacco along with their other issues, then they should be encouraged to do so. But treatment cannot and should not be contingent on doing something people find extraordinarily difficult, even in optimal mental health.

Instead of seeing mental health treatment as another opportunity to modify undesired behavior, the state should focus on treating the urgent and important reasons why the patients are there.