I Smoked All of England’s Cigarettes: Mental Illness and Smoking

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?”

Whoops.
There’s a lot in the press right now about smoking and mental health.  This article in the Independent outlines somewhat baffling advice from the British Lung Foundation...

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.

18 Responses

  1. Ah, excellent write. The ‘what time is a good time to give up’ bit really resonated with me. I’ve spent the last 5 years looking for a good time to quit and I’ve managed it for 2 or 3 weeks at the most before something fucked it up. Also re: MH service resources, yes: where is the funding going to come from? How do they plan to deliver a quality service to those who may be identified/diagnosed by being referred due to smoking? Consistent service quality is already a distant fantasy for a mighty chunk of the currently diagnosed.

    Finally, re: your brief account of smoking in a secure unit – I am currently writing my final extended essay on learning/intellectual disabilities, particularly recent discourse re: person centred care and choice & control and it has just now struck me how wrong it is that this is not also emphasised for those with psychiatric/mood disorders in secure/forensic units. Clinically, I understand the justification for the treatment you have described above, but fucking HELL it’s more than a little short sighted/cruel/damaging/distressing…

  2. Good post. Vive les incurables! So many silly things and assumptions in the BLF’s statement. I object to the assumption that all people are curable. For what? To function in this deranged society? Give me a happy, loving life, productive and fulfilling work, social neighbours I’m glad to meet, and I swear I shall be cured of smoking and madness. Otherwise, existing in the twilight years of Late-Capitalism, forgive me if I spark up. Dx

  3. Brilliant, and oh! The picture! The pink hair!! I want pink hair so bad!!! Very sweet all around.

  4. Seaneen~

    My 25 yr. old daughter, Katie, recently had the same reaction to Champix and ended up in the hospital after attempting to commit suicide. She’s smoking again and pretty stable now.

  5. Apparently rich people and poor people are just as likely to start smoking, but rich people are more likely to give up. Smoking is a reward to the self. Richer people can see and afford alternative rewards that stand in the future. Poorer people do not have that privilege equally.

    I was hospitalized during a psychotic episode. I am an ex-smoker and fortunately I managed to stay non-smoking. For a while I was only allowed outdoors during other people’s hourly smoking breaks. The smoking I saw was pretty intense. Smoking might be a maladaptive response, but I wonder if nicotine is actually beneficial for some people.

    I

  6. Love the pose! And the post🙂

  7. […] Er, wow! But is it really that simple? Premier mental health blogger Seaneen Molloy has pointed out potential flaws in the Lung Foundation’s thesis. She writes that ‘causation does not equal correlation.  A lot of people who have mental […]

  8. Very well expressed Seaneen!

  9. I can’t believe that the British Lung Foundation would make such a recommendation. But then again, I think the health authorities just want everyone to quit smoking regardless. If you smoke, you are now suspected of being mentally ill. That’s another form of pressure and social stigma.

  10. Thanks Seaneen for the argument. Kristie, you think that’s weird, let’s hear this, in Vietnam, women are generally not smoker, and the interpretation about is: “a woman who smokes must be/is a prostitute.” Because only prostitutes defy societal norms and hold a cigarette in public,🙂

  11. I dont know dear.. Big part of me believes that if you came off smoking, you wouldnt have to deal with manic episodes and many of the reasons you are smoking is because you are taking an antipsychotic and smoking acts against that to make you feel normal. Too bad you couldn’t quit smoking and (if you drink it) coffee and quit antipsychotics all at once too.

  12. I keep asking my doc for help quitting smoking but she says I’ve “got other things to focus on first”
    I smoke because of panic/anxiety yet nicotine increases the likelihood of panic attacks. However, I’m legit scared of quitting as each time I’ve tried I’ve been nervous as fuck.

  13. My GP is forever trying to get me to attend the smoking cessation clinic his surgery runs. He just can’t seem to accept that i’ve never smoked. I think in his mind mental = smoker.

  14. […] Secret Diary of a Manic Depressive blog by Seaneen, has lots of pieces on the day to day realities of managing bipolar disorder – some recent examples are When you find the changing seasons affect you without reason, Saw GP today & I Smoked All of England’s Cigarettes: Mental Illness and Smoking […]

  15. […] { jQuery('.relatedpages').html(d); } }); Health care blog – Articles videos and news on healthcareThe Secret Life of a Manic Depressivevar base_url_sociable = […]

  16. […] Small hospitals have… on I Smoked All of England’… […]

  17. Is that a photo of you?! So pretty!!!
    I’m so glad I found your blog🙂

  18. Oh, yep the “you want your cigarette” (which at one point was *allowed* at quarter past every hour between 10am and 5pm while on at arms length from 2 nurses on bed-rest) power kick some staff in some psych wards get out of it is awful…at that time, the nurses could, and would smoke beside the bed when they deemed me to have been “challenging” / “difficult” / “displaying SH behaviours”.

    Like you, Im not stupid and am aware that smoking is not *healthy*, it has been however a very short-term sanity saver and as you say, psych patients who are in-patients often have zero autonomy over their own bodies as it is (I never chose parkinsonism, and never needed antipsychotics but that was the choice of the Psychiatrist) so to remove that one choice/comfort/ 5 minutes of “me time” from psychiatric in patients is something I cannot support.

    This post is brilliant, thank you for sharing.

    x

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