The majority of patients who are smokers at Penetanguishene Mental Health Centre (PMHC) would disagree with PMHC's Smoke Free Task Force's assertion that the total smoking ban has been a "successful experience." As partisan advocates for our clients, we also disagree with this assessment, based on the numerous issues that they have brought to our attention. It appears that the facility's perception of "successful experience" may be from the facility's perspective alone and not from the patients'. Did the facility ask the patients for a report card on this issue? The Psychiatric Patient Advocate Office (PPAO) appreciates that smoking is a public health issue, especially in enclosed spaces. However, there are three issues with PMHC's smoking ban policy.

The first concern is that of choice. Patients at PMHC have not been given a choice. The facility has made the decision for them. While patients in general hospitals or any citizen out in the community have the option of smoking, PMHC patients don't. Some of the patients because of their legal status do not have privileges to get off their units. Those who have such privileges can do so and walk off the facility's grounds and smoke at their leisure. Such is the case for staff as well. Staff at PMHC is afforded the opportunity to go off-grounds during breaks and lunch to smoke, and return home at the end of the day to smoke at their leisure. While PMHC has designated smoking rooms with special ventilation and spacious grounds that would allow for smoking without exposure of others to second-hand smoke, these options have been denied to the patients.

The second concern is that of informed consent. We all agree about the addictive qualities of cigarette smoking. If an addiction is like any other medical condition, then patients must give their full informed consent before treatment is commenced. However, at PMHC patients were not given this choice. This treatment - smoking cessation - was forced upon them. Such a forced treatment also would have implications on new admissions to the facility. Any smoker who seeks to be admitted to the facility for a particular disorder, such as depression, would have to accept treatment for his/her addiction. These individuals still have a choice. They could find a facility that does not have an absolute ban on smoking. But how about forensic patients who are referred from the courts? What options do they have? None!

The third and final concern is that PMHC management has turned a blind eye to the consequences of the smoking ban. Clandestine smoking by staff and patients is rampant throughout the facility. It is a health and safety risk if patients are hiding matches, lighters and cigarettes as there is danger of a fire and potential harm to staff and other patients alike. The PPAO continues to investigate numerous complaints relating to the smoking ban, including: full-ward strip searches, allegedly some of which have included patients being restrained and their clothes forcibly removed when they would not consent to a strip search in the common area of the hospital, and the use of punitive measures such as loss of shower privileges if caught with "contraband" including cigarettes or matches. Other issues facing patients range from non-smokers' exposure to second- hand smoke as a result of clandestine smoking on the wards, to the gross markup on cigarettes through underground activity.

Despite the Task Force's claim that "effective and consistent communication was extremely important to the hospital's smoke-free initiative," patients were unfortunately not afforded an opportunity to participate in the decision-making process of a smoke-free policy.

In Ireland, the Irish government recently imposed a ban on smoking in the workplace with some exceptions, one being psychiatric hospitals. The government in this case appreciated that hospitals can be considered residences and exceptions are needed.

PMHC is proud of its policy and the "liberation" that it has brought to patients "who have been liberated from spending all their money on an addictive and harmful substance." Perhaps the patients need to be liberated from a facility that fails to listen to them, that makes best-interest decisions for them, that isn't sensitive to the patients' needs, that develops and implements restrictive and punitive policies and practices, that infringes on their legal and civil rights and that fails to remember that just because a person has a mental illness doesn't mean that they have no rights. Patients in this facility should be treated as any other patient in Ontario - they should have the same right to smoke out-of-doors if they choose to and if they choose to quit smoking then this should be an individual decision that is informed and of their making. Not one that is coerced and forced upon them like the decision made by the institutions of old.

While the PPAO supports the government's plans to ban smoking indoors and in closed spaces, we feel that decisions to smoke or stop smoking are decisions that should be left to the individual. The PPAO recommends that members of the Smoke Free Task Force revisit their decision and amend their policy to allow clients who wish to smoke the opportunity to exit the building to do so. Anything less will be a denial of individual rights and freedom.

About the Author

Cathy DiFonte and Julian Kusek, Patient Advocate, Psychiatric Patient Advocate Office, Penetanguishene