Revista Colombiana de Psiquiatría ISSN: 0034-7450 [email protected] Asociación Colombiana de Psiquiatría Colombia

Castro J., Héctor E. Bans and their Potential Implications for Mental Healthcare. A Review of the Evidence Revista Colombiana de Psiquiatría, vol. 41, núm. 2, junio, 2012, pp. 384-394 Asociación Colombiana de Psiquiatría Bogotá, D.C., Colombia

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How to cite Complete issue Scientific Information System More information about this article Network of Scientific Journals from Latin America, the Caribbean, Spain and Portugal Journal's homepage in redalyc.org Non-profit academic project, developed under the open access initiative Smoking Bans and their Potential Implications for Mental Healthcare. A Review of the Evidence

Héctor E. Castro J.1

Abstract

Different publications have described a close relation between consumption and major psychiatric disorders. A great number of countries have enacted smoking bans in public or working places since the early 2000s; nonetheless, concerns remain over the exemption in some psychiatric settings regarding smoking bans. Admission of smokers to smoke-free units may lead to behavior deterioration, but some recent evidence refutes this argument. Methods: Literature review. Results: One of the earliest smoking bans was a 1.575 Mexican ecclesiastical council ban aimed at smoking prevention in churches. Several recent studies have documented health and economic benefits related to smoking bans. Over 83 countries now have introduced different sorts of regulations. There was no increase in aggression, seclusion or discharge against medical advice, neither increased use of PRN (as needed) medication following the ban. As part of the ban imposition, Nicotine Replacement Therapy- NRT was used by patients. Consistency, coordination and full staff support for the ban were seen as key success factors. Many patients continued smoking after discharge. Conclusions: Evidence shows that smoking has no place in psychiatric hospitals or facilities. The introduction of smoking bans in psychiatric settings is possible, but these bans must be conceived only as part of a much larger strategy, necessary to diminish smoking high rates among mental health populations.

Key words: Second hand smoking, ban, mental health, regulation, globalization, .

Título: Prohibición de fumar y sus implicaciones potenciales en cuidados de salud mental. Revisión de la evidencia

Resumen

Diferentes publicaciones describen una amplia relación entre el consumo de tabaco y desórdenes siquiátricos mayores. Desde comienzos del 2000, gran número de países han prohibido fumar en espacios públicos o de trabajo. No obstante, persisten dudas respecto a la excepción en algunos ambientes siquiátricos. Se cree que la admisión de fumadores en

1 MD, MSc, DrPH (c). Doctor in Medicine and Surgery, Universidad del Rosario, Bogotá, Colombia. MSc Occupational Health, Universidad del Valle, Cali, Colombia. MSc Health Policy, Planning and Financing, London. School of Hygiene and Tropical Medicine/London School of Economics and Political Science, Doctor in Public Health & Policy (candidate) London School of Hygiene and Tropical Medicine. Assistant Professor Departament of Clincal Epidemiology at Pontificia Universidad Javeriana. Bogotá, Colombia.

384 Rev. Colomb. Psiquiat., vol. 41 / No. 2 / 2012 Castro H. Smoking Bans and their Potential Implications for Mental Healthcare. A Review of the Evidence

or smokeless tobacco products like sychotic medication in patients with unidades libres de humo puede implicar el including Public Health trends. The chewing presentations (4). schizophrenia, acting as a form of deterioro del comportamiento; sin embargo, recent Swine flu pandemic could be evidencia reciente refuta este argumento. Different research studies have self- medication. Withdrawal from pictured as a classical example of Métodos: Revisión de literatura. Resultados: assessed the effectiveness of tobacco smoking has been associated in Una de las primeras prohibiciones fue esta- how a virus can find its way across control campaigns, showing with major depression with relapse of blecida por un concejo eclesiástico mexicano borders in a few days and how vac- different levels of agreement that symptoms following cessation (19). de 1575, en procura de que no se fumara cination and education can have a fiscal policies and mass media in- Nevertheless it is well known that en las iglesias. Varios estudios recientes positive impact on preventing the documentan los beneficios económicos y tervention may play important roles sociocultural and economic factors disease. para la salud derivados de la prohibición de in achieving prevalence reduction of could influence smoking behavior fumar. Más de 83 países han implementado Major health problems asso- smoking in target populations; it has with or without the presence of men- diferentes tipos de reglamentaciones. Esto ciated with tobacco smoking were been discussed by some authors that tal illness (20,21). no hizo que se incrementaran la agresión, established more than 40 years ago, all these interventions may delay but A great number of countries la segregación ni los pacientes dados de alta despite diverse stra- en contra de la opinión médica; luego de la not prevent recruitment to smoking have enacted bans on smoking in tegies deaths from smoking continue prohibición tampoco se registró aumento on young audiences (5) public or work places since the early en la medicación PRN (según necesidad). to rise globally (2). Every year around 2000s, but authors like O´Gara et four million people die in the world Como parte de la prohibición, se usó en los Tobacco smoking and mental al (22) have addressed the issue of pacientes la terapia NRT, terapia de rempla- from smoking related diseases, and illness smoke- free legislation and encou- zo de nicotina. La coherencia, coordinación this figure is expected to reach 25 y apoyo de todo el equipo fueron factores raged mental units should be free million by the year 2025 (3). Not claves de éxito. Muchos pacientes conti- Tobacco smoking is recognized of smoking; nonetheless concern re- nuaron fumando luego de haber sido dados surprisingly this form of addiction to as a form of substance abuse that mains that some psychiatric settings de alta. Conclusiones: La evidencia muestra nicotine is currently one of the major causes far more deaths than all other will be exempt from smoking bans. que fumar en hospitales o instalaciones concerns in global public health. To- psychoactive substances. Research Admission of smokers to smoke- free psiquiátricas no debe tener lugar. Es posible bacco addiction is usually acquired implementar esta prohibición en ambientes has indicated that nicotine now clas- units may lead to behavioral dete- at young ages. de hospitalización psiquiátrica, pero debe sified as a psychoactive substan- rioration, but some recent evidence concebirse como parte de una estrategia más Governments have responded ce (6) regulates the dopaminergic refutes this argument. amplia, necesaria para disminuir los índices to the growing health epidemic of transmission in the mesolimbic and de fumadores en la población con problemas de smoking through different mecha- nigrostriatal systems through nico- salud mental. The role of smoking bans in nisms of regulation: bans on tobacco tinic receptors (7). prevention advertising and promotion, restric- Palabras clave: Fumador pasivo, prohibi- A higher association between ción, salud mental, reglamentación, globa- tions on smoking (schools, public tobacco consumption and major psy- Smoking bans can be defined lización, fumar tabaco. and work places), restriction on chiatric disorders has been described as public policies (criminal laws sales to minors, control of cigarette by different publications especially and occupational safety and health vending machines, increases in to- in High Income Countries- HIC (8- regulations), which prohibit tobacco Tobacco smoking and global bacco taxation, measures to curb or 12). Smoking tobacco is a common smoking in workplaces and/or other public health control smuggling, implementation finding among patients with schi- public spaces. The main recent es- of programs and zophrenia and affective disorders tablished goal for smoke-free laws Globalization is defined as the health education campaigns as well (13-15). is to protect passive smokers from “complex set of processes which in- as requiring the placement of health Some authors (16-18), have ar- the effects of second-hand smoke; crease interconnectedness and inter warnings on tobacco products. Very gued that nicotine could control according to scientific evidence pas- dependencies between countries little has been done or published on psychotic symptoms, and reduce sive smokers are at risk of the same and people” (1), and can be noticed regards to the non- classical presen- extrapyramidal side effects of antip- problems as direct smokers, inclu- almost everywhere in modern world tations of tobacco (as water pipes)

Rev. Colomb. Psiquiat., vol. 41 / No. 2 / 2012 Rev. Colomb. Psiquiat., vol. 41 / No. 2 / 2012 385 386 Smoking Bans and their Potential Implications for Mental Healthcare. A Review of the Evidence Castro H. ding lung cancer, cardiovascular This article reviews the publis- the quality of primary studies the vent smokers from tobacco (29). By disease, and lung ailments such as hed evidence on the impact of globa- quality criteria tool referred by NICE June 2009, 89% of European Union emphysema, bronchitis, and asth- lization, both in smoking promotion was used (NICE, 2006, pp. 65-110). member states and some other High ma (23). Lifelong non-smokers with and smoking banning; and also on Income Countries (HIC) have man- partners who smoke in the home recent findings on how the imple- Results dated text-only health warnings on have a 20–30% greater risk of lung mentation of smoke- free mental tobacco products over graphic and cancer than non-smokers who live facilities may or may not have an Tobacco smoking regulation and text warnings. with non-smokers. Non-smokers impact on the clinical outcomes of globalization exposed to cigarette smoke in the psychiatric patients. The bans workplace have an increased lung Smoking bans implementation cancer risk of between 16% and Methods in more than 83 countries around One of the earliest smoking bans 19% (24-26). the globe in the last decade based was a 1.575 Mexican ecclesiastical Laws implementing bans on in- A systematic search of medical, mainly on the willingness to protect council ban that forbade the use door smoking have been introduced nursing, psychological, social science passive smokers is another example of tobacco in any church in the by many countries in various forms and ‘grey’ literature in 12 databases of policy change in a globalized era. country. Ancient bans date from over the years, with some legislators and 3 websites (EMBASE, Classic Aggressive promotion of cigarette the Popes Urban VII and VIII in citing scientific evidence that shows EMBASE, Social Policy & Practice, consumption from manufacturing 1.590 and 1.624 respectively. The tobacco smoking is harmful to the Pubmed, Medline, Cochrane Library, companies and globalization has earliest citywide European smoking smokers themselves and to those CAB Abstracts, Global Health, Psy- created a global upward trend for bans were enacted shortly after in inhaling second-hand smoke. Such cEXTRA, PsycINFO, ADOLEC, Web consumption in many countries. Bavaria and certain parts of Austria laws may lower health care costs science, CINAHL plus, IBSS and To reverse this different approaches in the late 1600s, Berlin in 1.723 (27), improve work productivity, and SCIRUS), sought published sources have been attempted, this enfor- and Greece in 1.856. Most of these lower the overall cost of labor in a from their date of inception up to No- cement measures have shifted the prohibitions were valid only within community. vember 2011 on the evidence of the market focus of smoking products´ state buildings and were grounded Previous rationales for smoking association between mental illness manufacturers from developed to on the need to prevent accidents or restrictions were aimed to reduce risk and tobacco consumption, also on developing countries. Among the fires in public or holly places, and of fire in public areas; cleanliness in the history of smoking banning, and global drivers for smoking described most of them were defeated in later places where certain products are on the potential final impact of pro- by the evidence could be included: wars or revolutions. manufactured (e.g. food, pharma- hibition in mental clinical outcomes. high susceptibility among general The first modern, health based ceuticals, semiconductors, precision The systematic comprehensive population, second hand smoke, nationwide tobacco ban was impo- instruments and machinery are); search was performed for primary pro- tobacco campaigns through ad- sed by the Nazi party in Germany alongside taxes, cessation support, studies in any language and setting vertising and governmental delay to (universities, post offices, military and education, policy (high, middle or low income coun- regulate specially in Low and Middle hospitals and Nazi party offices), is currently viewed as an important tries). OVID SP was the primarily Income Countries (LMICs) (29). under the auspices of Karl Astel’s element in lowering smoking rates browser used, as well as additional International regulation of to- Institute for Tobacco Hazards Re- and promoting public health. When independent websites; search strate- bacco in recent times complies more search, created in 1941 (30) major correctly and strictly implemented it gy included terms: (tobacco products with standards agreed by health anti-tobacco campaigns were widely is seen as one important policy goal OR smok* OR cigar*) AND (prohib community than those set by the broadcasted by the Nazis until the to change human behavior away adj3 ban* OR restric*) AND ((psychi* , but the latter still demise of the regime in 1945 (31). from unhealthy consumption and OR mental) OR (illness or disord*)) continues to oppose regulation, in- For a while Tobacco industries towards a healthier lifestyle (28). AND (effect* OR Impact). To assess cluding warnings, which might pre- avoided smoking bans by promoting

Rev. Colomb. Psiquiat., vol. 41 / No. 2 / 2012 387 388 Rev. Colomb. Psiquiat., vol. 41 / No. 2 / 2012 Smoking Bans and their Potential Implications for Mental Healthcare. A Review of the Evidence Castro H. a courtesy (“tolerance”) policy bet- 2000s, but also middle and low in- Figure 1. Map of smoking bans by country ween smokers and non- smokers. In come countries were caught by this the US, states were encouraged to trend, hence smoking bans have pass laws providing separate smo- been enforced in the last 3 or 4 years king sections (32). The city of San in: Argentina, Australia, Bahrain, Luis Obispo, California, became the Bangladesh, Bhutan, Brazil, Chile, first city in the world to ban indoor China, Colombia , India, Israel, Italy, smoking at all public places (bars Puerto Rico, Thailand, United Arab and restaurants included) (33). In Emirates, Uruguay, Vatican city US, the success of this ban enacted among others. Even the United Na- by the state of California in 1998 tions Organization- UN has its own encouraged neighboring states. smoking and non-smoking policies. In May 2003 after almost four Kofi Annan introduced in 2003 a total years of negotiation by member sta- ban on smoking at UN Headquarters tes of the World Health Organization (35). Some specialized agencies of (WHO) the final text of the Framework the UN, such as the United Nations Convention on Tobacco Control was Children’s Fund- UNICEF and the agreed. On March, 2004, the Repu- WHO have their own strict smoking Source (Canadian council for tobacco control- as of Jan 1, 2010) No restrictions or no data blic of Ireland implemented a ban on bans which apply to their offices Patchy and incomplete bans, low enforcement smoking in the workplace, the first worldwide. See figure 1 for a global No national ban, some localities have comprehensive indoor bans country to do so. In Norway similar map of smoking bans. Strong national ban in public areas except entertainment and restaurants, or weak legislation was put into force on July Although these major policy enforcement in indoor entertainment areas Strong national ban in public areas except entertainment and restaurants, some localities 1 that same year. changes have occurred, some coun- have comprehensive indoor bans became subject to a ban on smoking tries still have no legislation against Strong national ban in all public indoor areas with some exceptions in enclosed public places in 2007, smoking whatsoever and some others Strong national ban in all public indoor areas. Note: Countries with all sub national en- tities having a ban equates to a nationwide ban here, such as for Canada and Australia nonetheless became the with high tobacco consumption have last region of the UK to have the bans that are unheard of or un- legislation come into effect. In 2007, enforced. These countries include significant improvements in bar after the smoking ban in England, Chandigarh became the first city in Cameroon, Central African Republic, workers’ lung function and inflam- compared with July 2006 (39). Smo- India to become ‘smoke-free’. Smo- Chad, and many other countries in matory markers attributed to a king bans may make it easier for king was banned in public indoor Central and Western Africa, where smoking ban in New York City was smokers to quit, according to a venues in Victoria, Australia on July people can smoke wherever they found to have prevented 3,813 hos- survey 22% of UK smokers may 1, 2007, as of April 2009 there were want. Saudi Arabia has no gover- pital admissions for heart attacks quit in response to a smoking ban 37 states of the US with some form nment ban on smoking anywhere. in 2004, and saved $56 million in in enclosed public places (40). Even of smoking ban (34). Some areas Several recent studies have health-care costs for the year (38). restaurant smoking bans may help in California began making entire documented health and economic Some other relevant data reports to diminish young people from beco- cities smoke-free, except private benefits related to smoking bans. informed that in Ireland, cigarette ming habitual smokers, a study of residential homes. (e.g. hospital admissions for heart sales fell by 16% in the six months Massachusetts youths, states that An important number of HIC attacks dropped by 27% (36), 40% following the ban’s introduction. those in towns with bans were 35 have enacted bans on smoking in reduction in heart attacks following In the UK, cigarette sales fell by percent less likely to be habitual public or work places since the early the imposition of a smoking ban (37), 11% on July 2007, the first month smokers (41,42).

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