Thousands of people who are hospitalized with mental illness in the Philadelphia region will soon experience what has long been the reality for everyone else: living smoke-free.
All psychiatric hospitals that have contracts with the city must ban all forms of tobacco, inside and outdoors, among patients and staff, on Dec. 14. All but one is including visitors in the policy, as well.
The conventional wisdom is that banning smoking could make matters worse by, among other things, aggravating behavioral problems.
A raft of research suggests the opposite. Treatment for schizophrenia and depression is more effective in the absence of tobacco, evidence suggests. Other studies have found that smoking cessation is no more disruptive for the mentally ill than for others, although quit rates are lower than for the general population.
Studies have found that people with mental illness die on average 25 years earlier than others, and the biggest contributors are tobacco-related heart and respiratory conditions. This makes the new policy a moral imperative, said Rose Julius, a psychiatrist and addiction specialist who is overseeing the change for Community Behavioral Health, the nonprofit that handles Medicaid payments for behavioral health in the city.
"Our populations smoke at a higher rate than the general population, they smoke more heavily, they smoke for a longer period of time," she said. "They consume roughly 50 percent of all the cigarettes consumed in the U.S."
About 10,000 city residents a year spend an average of 10 days apiece in the 14 acute psychiatric inpatient units that are affected by the ban, including two located in the suburbs and three that had already made the change on their own. Some have their own campuses; many are individual units within smoke-free hospitals. Together, they represent the majority of psychiatric facilities in Southeastern Pennsylvania.
The city coverage applies only people on Medicaid. The impact will be broader, however, because those hospitals take patients from all over the region, with all forms of insurance. Within the next couple of years, smoking also will be banned at dozens of inpatient drug and alcohol treatment centers.
The policy change was encouraged by an ongoing city health department campaign - SmokeFree Philly - that also played a role in the Philadelphia Housing Authority's decision over the summer to ban smoking in all its units.
Community Behavioral Health has been working on the issue with providers for two years, and is paying for a range of cessation treatments. Philadelphia is believed to be the largest city to write smoke-free language into its contracts with private psychiatric providers.
Many state hospital systems, which do not have to fear competition for clients, have banned smoking, including Delaware in 2007 and New Jersey in 2009. Pennsylvania state hospitals set their own policies and none are smoke-free, a spokeswoman for the state Department of Human Services said.
In an enduring image from One Flew Over the Cuckoo's Nest, Nurse Ratched confiscates McMurphy's cigarettes and rations them out in a battle for control of the ward. Both the mental institution and Jack Nicholson's character are gross exaggerations; his smoking habits less so.
Much has changed since the movie was released in 1975 - smoking in locked units these days is confined to designated areas, or requires a staff escort to the front door. But psychiatric hospitals' action on smoking has lagged behind that of airlines, hotel chains, and even many city parks, not to mention medical hospitals.
"There are two major reasons why this has been an ignored problem. One is that a lot of health professionals thought that this was the only pleasure that these patients had," said Steven Schroeder, a physician and director of the Smoking Cessation Leadership Center at the University of California, San Francisco. The other was that smoking is "so much a part of the culture that people thought if you disrupted that, people would get angry" and their treatment would suffer.
Mark A. Davis, a 59-year-old mental health activist from South Philadelphia with bipolar disorder, remembers the days when some institutions had lighters on the wall. Over nearly 30 years as a smoker, he intentionally chose hospitals that allowed smoking.
Ironically, he had checked into one of those - the Belmont Center - when a staffer's routine question about setting goals prompted him to blurt out, "reduce my smoking." His final cigarette was on Feb. 10, 2001, during the last of his 15 hospitalizations.
In a recent interview, Davis worried that a blanket no-smoking policy might cause some people with heavy habits to avoid the hospital.
Schroeder agreed that this was a potential worry, although he pointed out that psychiatric patients who are sensitive to smoke might be staying out now.
Mentally ill smokers who are committed involuntarily are likely to have the hardest time, he said, because they don't believe that they have a problem at all. So-called 302s, a reference to a section of state law, make up 35 percent of the hospitalizations covered by Philadelphia's new policy.
On the picturesque Northeast Philadelphia campus of Friends Hospital, the oldest private psychiatric facility in the country, chief executive officer John Repique has been holding monthly workshops to ready patients and staff for the transition. A Tobacco-Free Living, Health, Wellness and Recovery Fair is scheduled for Wednesday - the day before the Great American Smokeout.
Like patients, staff at psychiatric facilities smoke at higher than average rates. Repique said some of his 700 employees resisted the coming change at first but have since become "engaged."
Currently, patients must be accompanied by staff for smoking breaks in covered courtyards. The five or six breaks a day will gradually be reduced over the next month to two or three times a week and then zero.
"I am anxious as a hospital administrator," Repique said, noting that the first few smoke-free days at his 192-bed inpatient units will be tough. One thing they will not be is a surprise: "Everybody talks about it."
Each facility is planning its own transition, with guidance from the University of Pennsylvania's Comprehensive Smoking Treatment Program. More than 200 staff members have been trained, some in one-on-one sessions.
Frank T. Leone, a medical school professor who directs the program, said the city's collaborative approach to the process was unusual for a government agency, as is the reimbursement that the psychiatric hospitals will receive. CVS kicked in a $25,000 grant; the rest of the cost, which has not been finalized, will come largely from Medicaid.
Among the challenges, Leone said, is overcoming misconceptions that medications used to treat tobacco dependence make psychiatric symptoms worse. Anecdotal reports that Chantix, for example, was linked to depression persist despite controlled studies that later showed no association, he said.
The real issue, he said, is change. "Cigarettes make the patients more comfortable and make providers more comfortable," he said. "That is the way they have always done it."