I was supposed to stop at the age of 25. And never on my wedding day. How could I say, “Til death do us part?”
Smoking may be a sign of psychiatric illness, experts say. Doctors should routinely consider referring people who smoke to mental health services, in case they need treatment, they add.
The controversial recommendation from the British Lung Foundation, a charity, comes in response to a major report, Smoking and Mental Health, published this week by the Royal College of Physicians and the Royal College of Psychiatrists with the Faculty of Public Health. It says that almost one in three cigarettes smoked in Britain today is smoked by someone with a mental disorder. When people with drug and alcohol problems are included the proportion is even higher.
The reason is that smoking rates have more than halved over the past 50 years, but the decline has not happened equally in all parts of society.
“Smoking is increasingly becoming the domain of the most disadvantaged: the poor, homeless, imprisoned and those with mental disorder. This is a damning indictment of UK public health policy and clinical service provision,” the report says.
First of all, smoking is the domain of the poor because it’s (relatively) cheap compared to the vices of the rich; fancy dinners, gambling, harder drugs and alcohol. Smoking also doesn’t carry the self-righteous stigma that it does in the middle classes.
Secondly, causation does not equal correlation. A lot of people who have mental health issues smoke, ergo, people who smoke must have mental health issues?
I’m all for early intervention, but mental health services are already snapping beneath the weight of the draconian cuts levelled upon it. Referring people who might possibly have a mental health problem isn’t going to ease that burden. And people should choose if they want a mental health assessment. Obviously, there are cases when choice is limited (lack of insight, mental health act assessments) but general speaking, if a person is able to, they should be able to choose.
Thirdly, I think this recommendation fundamentally misunderstands the relationship between smoking and mental health. It’s true that a lot of people with mental health problems smoke- up to 90%- and providing them with support to quit? Awesome.
But it’s fraught with problems. I’ll use myself as a case study here.
I started smoking when I was 15 as a result of peer pressure. Around that age was also when my had my first onset of mental illness, so I smoked to calm down. My mum (who smokes heavily herself) condoned my smoking because, “It was better than you cutting lumps out of yourself”. Fair point, my mum, there. She’d sigh heavily (is there another way for a lifelong smoker to sigh?) and pass me a Berkeley when I was stressed. Eventually, I took the piss and would sneak into her bedroom when she was asleep and steal two.
This smoking was furtive-out-the-window-fuck-the-curtains-are-on-fire teenage frippery. I continued to smoke, but it wasn’t until I was 20 that I could smoke as many as my age. How did this start? I was hospitalised in an acute ward.
This was before the days of escorted smoking breaks. We just had a large, blue carpetted, nicotine walled room to huff and puff in. And so we did, because there was absolutely nothing else to do. Oh, there was a jigsaw with half the pieces missing and a television permanently tuned to ITV for the people too deep in psychosis or depression to move from the busted leather chairs, but those were the activities advertised in the brochure. Bugger all else.
Smoking was currency in hospital. If you gave someone a cigarette, you were MBFFLs (Mental Best Friends For Life). It was also an activity that was at once social and isolating. It was social because you were sat in a room with other people in contemplative quietness. And the quietness was important and holy in a, “therapeutic” environment soundtracked by screams, alarms and wails. In sisterly silence, you could, if you wanted to, turn and speak to someone without the oppressive presence of the television looming over you. More importantly, it was without the oppressive presence of nurses, who rarely strayed too far into the smoking room for fear of instantly developing lung cancer. (A lot of mental health nurses smoke, too, by the way. Not enough for me while I was on placement! I always honed in on the smokers and stuck to them).
The room was a pub, a living room, a garden.
Hospital is a difficult environment and, although I encourage health professionals to support people to stop smoking, it’s the worst place to do it. My trust went smokefree last month, and I’m quite glad I left my course beforehand. The lighter is a treasured object indeed- and it’s one of great power. Timed smoking breaks wrack tension up. I’ve been there myself as a student nurse- five minutes late and people begin to get agitated. Would this be removed if nobody smoked? Yes, in a perfect world. But in this environment, where you enter and go through the mortification process (I recommend Goffman), the freedom to smoke is an important one. It gives a sense of bodily agency and autonomy in an environment where such things are flagrantly disrespected. “For the greater good”, often, but people are still given medication, either willingly and unwillingly, by other people. Swallow a pill. Do you look at it first? Do you know what it does? What it’s for? Do you pause before you take it? Do you feel a little violated when it goes down your throat? Gag, maybe?
And in psychiatric units, bodily autonomy goes out the window. If you take medication, it might be the same medication you took in the Real World, but you can’t stay awake all night and watch TV (not allowed, too loud), or sleep in until the afternoon (not allowed, either). Whereas none of your personal rituals may be healthy, they are still yours, and you cling to them in an environment as unfamiliar as a hospital. Similar with self harm. It might not be a healthy coping mechanism, but it is your own. Hospitals are distressing places, and using the method that helps you cope gets you punished because it distresses others in turn. Go figure.
In the more unhappy wards, smoking can also be used as an instrument of power. I must say that I have never witnessed this myself (even working in a secure unit, where privileges such as leave are lost if you don’t behave), but I have heard of such things and I believe it is possible. You want your smoke break? Then you’d better be good.
When I was in hospital, I was given Haloperidol to slow my pinballing down. It did a fairly good job. But seven years later, I still take antipsychotics. I am on a way, way lower dose than I used to be, but there they are.
Antipsychotics are primarily, but not always, prescribed to people with psychosis. Psychosis can be a distressing experience and smoking can give a respite for that. There’s also anxiety, restlessness, loneliness. It’s a complete contradiction- nicotine is activating, not relaxing- but the ritual itself helps me calm down. Antipsychotics also have complex interactions with nicotine- typicals like Haloperidol more so.
So, you’re a mentalist and want to stop smoking. Applause, because I’d love to. Doctors absolutely should focus on smoking cessation with people who have mental health problems. The fact that so many people who have mental health problems smoke contributes to our pitifully short lifespan.
What do you do? Well, first of all, sometimes smoking is the least of your problems. I was actually told this, straight out, when I was hypomanic and thinking I’d be brilliant and go to the gym and become a sliver of gorgeous purity. I’d also come off all my medication. And I did the opposite and was smoking more than ever anyway. But I still wanted to.
“Don’t quit smoking- do you really need more stress right now?”
Fair point. And when you have a mental health problem- when is a good time? When you’re stable? How many people are stable? When you’re depressed? Depressed people smoke. Hypomanic? Not going to listen anyway. Psychotic? Good luck with that. Where is the window of opportunity to broach this subject?
As for the methods. Well, stop smoking groups with NRT or medication are generally fairly successful, which isn’t saying much as stop smoking methods are generally fairly pitiful in effectiveness. How easy do you think it is for someone who has a mental health problem- which could include lack of motivation, agoraphobia and social anxiety- to go to a group? Motivated enough to pick up their NRT prescription? Do many people who have mental health problems, especially those who take medication, have awesome memories? Awesome enough to remember that patch? And the magic-bullet pills. Speaking for myself, I took Champix and it made me impulsive and suicidal. I went from the kind of place where I was committed to stopping smoking to running around the flat fantasising about how to hang myself, and actively planning to. I was pulled off it, sharpish, and went back to smoking.
And here I am, with a fag hanging out of my mouth, tapping this to you. And there’s another reason; vanity. Yes, it makes my clothes stink, I cough, my teeth are fucked and my cat makes a scrunched up, disappointed face at me and runs from the smoke. But I’m a writer. And writers smoke. It means I can romanticise my sitting in my kitchen needing a wee and listening to awful 80s radio. I have a cigarette in my mouth and I’m on a laptop. I am following in the traditions of the greats. Yes. That must be it. Bollocks to this mental health stuff, then.