Smoking Bans in Psychiatric Units: An Issue of Medical Ethics.

Abstract

Smoking and smoking-related illnesses are overrepresented among people with mental illness, contributing substantially to the reduced life expectancy observed in this group (1). Creating totally smoke-free inpatient psychiatric facilities is a goal that hospitals and policy makers are increasingly supporting, with a goal of improving health outcomes of both patients and staff (2). The unique situation of many psychiatric patients in being unable to leave hospital grounds, however, means smoking bans remain a contentious issue in these settings (3, 4). Debates around patient choice, harm avoidance and the health service's moral imperative to promote well-being persist, leading to wide variations in the application of smoking bans across facilities (3, 5–7). While most psychiatric units do not allow smoking indoors, many only have partial smoke-free policies in place. This enables psychiatric patients to smoke outdoors on hospital grounds, often despite total smoking bans (indoor and outdoor) being in place for all other patients (8, 9). This article evaluates the debate using a framework of the four basic principles of medical ethics—autonomy, justice, beneficence, and non-maleficence (Table 1). Within the context of each principle, arguments for and against total smoking bans in psychiatric facilities are evaluated, and evidence to support the most ethical way forward is discussed. Table 1 The basic principles of medical ethics, applied to the major arguments for and against inpatient psychiatric unit smoking bans.