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1 Savant Journals Savant Journal of Medicine and Medical Sciences Vol 1(3) pp August, Copyright 2015 Savant Journals Original Research Paper Smoking Ban in Mental Health Facilities: Legal and Ethical Perspectives Yousef A. Qan'ir, M.Sc., RN Master Degree in Nursing, The Hashemite University, Zarqa, Jordan, P.O. Box , Zarqa 13115, Jordan. Accepted 29 th July, The smoking ban in mental health care facilities is controversy issue, which has different point of views regarding its legal and ethical positions. Smoking Ban is healthy practice that provide safe environment for patient with mental illness. Some opinions deem smoking as a right of patients with mental health problems, and reject smoking bans in mental health services under pretext of human rights. However, human rights are inconsistent philosophical concepts that cannot be articulated with distinct legislations. In general, this argumentative paper aim to prove the rationality of all ethical and legal aspects related to smoking ban policy in mental health services. To achieve this purpose a comprehensive search of several electronic databases was used in Pub Med, MEDLINE, in order to pinpoint smoking ban in psychiatric mental health settings. The following key words were used to search the electronic databases; smoking ban, smoking policy, mental health facilities. According to available scientific resources, Smoking ban in mental health services is ethically and legally considered. The claim that the ban breaches human rights is not proven. Human rights in relation to smoking are maintained if patients' health improved and is protected from harm of self and others. The effective assistant for smoking ban is using nicotine replacement therapy. In addition to that, smoking cessation program may be effective to encourage patients to quit. Briefly, Smoking ban can be implemented in mental health services effectively. Legal and ethical issues that may oppose smoking ban are not sufficient to reject it. Many evidences support implementing smoking ban policy for patients with mental health. Keywords: Mental Health, Smoking Ban, Smoking Policy, Legal and Ethical Aspects. INTRODUCTION Many countries have regulation and policies about smoking ban that prevent smoking in mental health care services. The smoking ban is a disputed issue, which has opponents and proponents, regarding its legal and ethical aspects. Smoking Ban is a healthy practice that provides a safe environment for patients with mental illness. Some opinions reject smoking bans in mental health services under pretext of human rights, but human rights are philosophical concepts that may be conflicting issues. This scholarly paper aims to prove the rationality of all ethical and legal aspects related to smoking ban policy in mental health services. The next themes reflect the main dimensions that will be articulated through this argument paper. 1. Right to self determination and privacy versus the right to health. 2. Right of staff to be protected from passive smoking in their workplace. 3. Right of health service user to exercise elective smoking. 4. Right of non smoking patients in psychiatric hospitals to inhale clear air. 5. Legality of smoking ban policy in mental health facilities. SMOKING AND MENTAL HEALTH In general, cigarette smoking is a common deleterious practice all over the world that has contributed to many health *Corresponding Author: Yousef A. Qan'ir. Master Degree in Nursing. The Hashemite University, Zarqa, Jordan P.O. Box , Zarqa 13115, Jordan. Yousefqaneer@hotmail.com

2 Y o u s e f A. Q a n ' i r S a v a n t. J. M e d. M e d. S c i. 036 problems, and is associated with high level of morbidity and mortality (1). Smoking is the second cause of death in the world that results in approximately five million deaths a year globally (2). Smoking habit has a considerable standing in public health issues in Jordan. For instance, one study in 2012, reported that 45% of Jordanian people had smoked in the past month, and 36% of Jordanian had smoked in the past 24 hours (3). Specifically, Smoking is a significant public health issue among people with mental illness (4). Cigarette-smoking prevalence in psychiatric population is two to three times higher than free mental illness population (5). Smokers with a mental disorders smoke more cigarettes per day than smokers in general (6). Smoking related morbidity and mortality from cancer, cardiovascular, and respiratory disease among patients with mental illness is considered (4). Accordingly, smoking problem among patient with mental illness has to be substantial in the management plan for this population. Concentrating on the effect of smoking permission or smoking ban may ease the process of adopting proper smoking policy. SMOKING POLICIES IN MENTAL HEALTH FACILITIES Many mental health care facilities issued policies that regulating smoking practice within their buildings. The objectives of these policies, concern about protecting their consumers' health, and improving the quality of mental care for them. In a like manner, smoking policies in mental health care centers resemble smoking policies in general health care facilities regarding their objectives. In other words, smoking policies for both psychiatric and general health care facilities is consistent with patient safety standards and quality of health care regardless the nature of health care that is provided in the health care facilities. The substantial objectives of these policies are to provide safe and healthy environment for clients, visitors, and employees. Both consumers and employees in mental health care hospitals have the right of smoke free environment. This right is usually protected by the law and local policies. Conversely, in Jordan, although we have a public low that prevents smoking in public area, but mental health care centers are not included under the authority of this law. Hence, it is important to reflect applicability and Legitimacy in mental health facilities in Jordan as a multifaceted issue. In general, the significant aspects that required more attention in this scholarly paper are legal and ethical dimensions. The religious dimension is also considered in Arabic and Islamic regions, specifically in Jordan. Here, contradictory opinions related to legal and ethical issues would be presented according to international practice. MEDICAL, LEGAL, AND ETHICAL ASPECTS OF SMOKING PAN POLICY Following this further, 91% of psychiatric nurse in England believed that mental health encounters particular challenges, because of high smoking prevalence among psychiatric patients. These challenges are associated with safety risks, and potential interactions with antipsychotic medications (7). Analysis of the national health services in England found that they are facing specific difficulties in implementing smoking ban policy (8). In consequence, all of health care providers, patients, and health care decision makers have to be concerned about the advantage and disadvantage of the smoking ban policy. The conflict in implementing smoking ban policy may need to be resolved by evidence-based decisions and regulations regarding the objectives and methods of implementing smoking ban policy. All parties that are concerned with implementing smoking ban policy have to enhance their position by evidences that justify the way of choosing a smoking policy. Smoking itself is a medical matter that requires a scientific approach to clarify objectives and goals of its policies. In mental health setting, there is specific respect to mental illness regarding stigma and disability. Ethical and legal issues, which are related to smoking policy, are important to decide if smoking policy is appropriate in a mental health setting or not. OPPOSITION POSITION TO SMOKING BAN POLICY Many psychiatric facilities still permit smoking within their unit. Policy makers in these facilities defend their decision according to the Joint Commission International (JCI) standards (9). JCI for accreditation of health care facilities banned smoking in hospitals, but exempted psychiatric unit from the ban (9). At the same time, many opponents of smoking ban policy argued that the ban violates human right of patients with mental illness. The ban opponents claim that smoking ban breach psychiatric patients' rights, and is extremely coercive (9). Ethically, some voices state that human rights should be seen as "a vehicle for making principles such as dignity, equality, respect, fairness and autonomy central to our lived experience as human beings" (10). Ethical considerations are enhanced by many advocates of human beings. The advocates treat patients with mental illness as a population that have to be protected and defended. Legally, many smoking permission advocates based their opinions on human rights law. Advocates believe that denying patients' right to smoke evinced no respect and dignity for patients with mental illness. Some advocates argued that the smoking ban is discriminatory of patients with mental illness and contrary to article 14 of the European Convention of Human Rights (11). The European Convention of Human Rights (ECHR) reported in 2010 (12) many articles regarding human rights. Two of these articles were used as legal subjects to defend the rights of patients with mental illness, in regard to rejecting smoking ban in psychiatric hospital. The first article is number 8 that titled right to respect for private and family life. Article 8 proposed that: 1. Everyone has the right to respect for his private and family life, his home and his correspondence. 2. There shall be no interference by a public authority with the exercise of this right except such as is in accordance with the law and is necessary in a democratic society in the interests of national security, public safety or the economic well being of the country, for the prevention of disorder or crime, for the protection of health or morals, or for the protection of the rights and freedoms of others. (12, p7) Article 14 that designated prohibition of discrimination term, pretenses that human being has right of being equal with others. Article 14 proposes that: The enjoyment of the rights and freedoms set forth in this Convention shall be secured without discrimination on any ground such as sex, race, color, language, religion, political or other opinion, national or social origin, association with a national (12, p8) minority, property, birth or other status. In regard to ECHR standards, many patients claimed that these regulations were unlawful, being in breach of their rights

3 Y o u s e f A. Q a n ' i r S a v a n t. J. M e d. M e d. S c i. 037 under article 8 and 14 (9). In the United Kingdom, Human rights emphasized by the Mental Health Act Commission (MHAC) to respect for home and private life under article 8 (13). Additionally, MHAC believed that smoking ban interferes with human rights of patients with mental illness, MHAC stated: We do not believe that patients who are deprived of their liberty through use of the Mental Health Act to detain them in hospital for psychiatric treatment should, as a consequence, be forced to abstain from smoking. Enforcing a smoking ban on patients whose detention in hospital is justified for the purposes of psychiatric treatment could be found to be an unjustifiable interference with their human rights. (14) Some opinions that oppose smoking ban policy refuse the flexibility in smoking ban policy. These opinions reject the idea of assigned smoking room. Because smoking room will expose employees and patient to multiple polluted air within enclosed area due to second hand smoking (15). Smoking persons have right to inhale clean air during smoking practice, even though they inhale smoke, what is called washing carbon dioxide (15). Smoking within enclose room will aggravate the risk of smoking and will lead to poor physical health (15). Many smoking permission defendants reported that Smoking permission does not breach standards of care; even it seems negligent (16). Other points of view declare that malpractice lawsuit must show that smoking permission action caused damage. It's hard to conclude that lenient smoking policies in psychiatric hospitals are the primary cause of long term smokers health problems (16). PROPONING POSITION TO SMOKING BAN POLICY Smoking ban proponents indicated that the ban intends to protect non-smokers from second hand smoke, and encourage smokers to quit (9). Proponents claim that non-smoker may be exposed to second hand smoking in psychiatric hospital, which raises the possibility of legal action by non-smokers (16). Unbelievers about smoking ban replayed by evidences of implementing ban policy outcomes. Specifically, Smoking ban policies have been successfully implemented in psychiatric hospitals and units (17). Legal action in USA and United Kingdom did not consider a basic right to smoke for patients with mental illness (9). In the United Kingdom, the administrative court rejected the concept of an absolute right to smoke wherever a person lived (11). The administrative court made a distinction between a private home and health care institution. For instance, patients in intensive care units in general hospital are not allowed to smoke in or outside the hospital. Hence, it is not sort of discrimination when prevent psychiatric patient to smoke. Some voices consider that as kind of equity between physical and psychiatric illnesses. The administrative court in United Kingdom built its legislation on evidences emphasized the risk of passive smoking and the dangers of smoking on health (11). The Court justifies that smoking ban policy protects the rights of resident patients to enjoy smoke free air, and assist patients who are trying to quit (11). Furthermore, the administrative court found smoking ban legislation is consistent with objectives of public health policies, that concern in reducing smoking, second hand smoke, smoking related disease, and smoking related death (1, 11). In New Zealand, the high court held that smoking ban policy promotes health of the patients and the community by avoiding the health hazards of smoking, for the same reason, the court rejected the idea of assigned smoking room (18). The high court in New Zealand rejected the allegation that smoking ban policy breaches human rights and exercise unlawful discrimination (18). The high court considered that smoking ban policy presents careful and respectful practice which not contrary with patients' rights (18). Additionally, the high court confirmed that smoking ban policy is applied equally to all patients and employees within the same institution (18). While general hospitals applied smoking ban policy, means that the ban is not restricted to patients with mental illness. DISCUSSION Smoking ban policy has multifaceted perspectives that articulated legal, ethical, religious, and health dimensions. The ban itself is a legal approach which aims to prevent smoking practice within mental health care services. In mental health settings, treating people with mental illness has a particular ethical consideration due to conceptions regarding mental problems. In Jordan, as a part of religious culture, Islamic doctrine has statutes that regulates life practice of Islamic patients. At this level, we will defend smoking ban policy in relation to legal, ethical, religious aspects regardless other dimensions that are significant in other argument sphere. ETHICAL PERSPECTIVE THAT SUPPORTS SMOKING BAN Opponents of smoking ban believe that libertarians are generally opposed to legal paternalism. Here, we can articulate the main feature of paternalism in smoking ban that has to be consistent with human being benefits. Paternalism is "interference with a person s liberty of action justified by reasons referring exclusively to the welfare, good, happiness, needs, interests, or values of the person being coerced" (19). According to the principle of paternalism, patients with mental health have no right to act what they want if that harms themselves or others. Psychiatric patients have all rights that are not contrary to health of their and others. This sound is corresponding with the ethical consideration of respecting others. Rights of patients to smoke need to be balanced against the right of non-smoking patients of safe environment (15). Hospital administrators and staff have ethical responsibility to prevent people being exposed to tobacco smoke within an enclosed environment. To prevent harm from smoking ban is the response for this request. A bit resilience in smoking ban policy may suggest permissive articles such as assigned smoke room or outdoor smoking. Harm reduction strategies involve advocating smokeless nicotine replacement products such as patches and gum as less harmful alternatives to cigarettes (20). Advocates of flexible smoking ban rely on view "Prevent harmful behavior completely, the next best option, if the behavior is likely to continue, is to ensure that the harm caused is kept to a minimum" (21). However, radical standpoints reject some suggestion. Because health care practice has solid principles that detect its regulation and behaviors. For instance Hackett stated: While respect for patient rights and respect for patient autonomy are fundamental guiding principles of ethical medical care, the ability to smoke within a treatment setting does not qualify as a fundamental right because granting permission to smoke does not meet the principle threshold of the physician s duty to provide (22, p109) competent medical care.

4 Y o u s e f A. Q a n ' i r S a v a n t. J. M e d. M e d. S c i. 038 In other word, there is no negotiation in providing optimal care for the patient when we have provided evidence about it. However, nicotine replacement and smoking cessation program are ethically acceptable regardless their effectiveness. Some believe that smoking ban violates patients' rights and may develop aggressive behaviors among patients with mental illness (1). Data from a national survey in the United Kingdom of smoking ban legislation indicated that it has been a great success after the ban was introduced (17). Limited evidences prove that applying smoking ban policy could lead to behavioral disturbances among patients with mental health (1). To manage aggressive behaviors among nicotine dependant smokers, providing smoking cessation aids may prevent developing aggression among patients with mental health (1). LEGAL PERSPECTIVE THAT SUPPORTS SMOKING BAN Actually, in some American states, civil commitment required finding that the patient with mental illness is not competent to make treatment decisions (16). In this situation, it is conflicting if incompetent patient, who is incapacitated to get a treatment decisions, is competent to make a decision about smoking. The question; is it legal to provide cigarettes to incompetent patients and abet them to self-injuries. The answer may reflect an opinion that patients with mental illness has to obey medical orders that aim to protect him regardless his wish. No doubt, malpractice and negligence allegations would not be possible at this level of practice. The opponents of the ban argued that patients could smoke in assigned room or outdoor. The high court in the United Kingdom rejects this kind of proposition. The high court builds its judgment that right of others to be protected from the effects of smoke pollution, such as observer staff (13). Furthermore, the court justifies its judgment on security corner, because an arrangement to smoke outdoor could not be feasible in psychiatric hospital environments all the time, and for all patients (13). For instance, suicidal attempt cases could need a highly secured place and observation. RECOMMENDATIONS According previous argument review, smoking ban is demonstrated as legal and ethical practice in mental health care setting. Some recommendations are listed below: 1. That psychiatric hospitals have to move toward imposing smoking bans as a priority for staff, patients and visitors in line with general hospitals. 2. In mental and psychiatric health facilities, develop clear guidelines that reflect strong regulations and commitment by staff with clear administrative support to achieve a smoke-free environment. 3. In psychiatric hospital, develop treatment protocols for patients, as well as comprehensive resource strategies and support for quitting. 4. Ensuring that psychiatric health care facilities adequately cover discussions about the smoking issue from a clinical, ethical and legal perspective. 5. Mental health facilities should work assertively with people with mental illness to discourage them from smoking and to support quit early. 6. Mental health services need to commission specialist help with smoking cessation such as CBT. 7. Staff in mental health services should understand nicotine withdrawal symptoms and how they can trigger mental distress, so that they can respond effectively. 8. Information should be available to staff, patients and visitors in psychiatric hospitals about smoking ban within the environment and help on how to quit. 9. An evaluation of compliance with smoking ban policies has to be submitted to the manager. SUMMARY Smoking ban in mental health services is ethically and legally considered. The claim that the ban breaches human right does not prove that human right is affected if patients' health improved and are protected from harm. Additionally, non smoker will be away from risk of second hand smoking in case the ban applied effectively. Assigning smoke room and allowing patients to smoke outdoor have many unjustified reasons. Smoking room will not protect smoking patient, but may increase the risk of second hand smoking due polluted air. Smoking outdoor also has struggles due to security concerns in psychiatric hospital and for patient safety. The effective assistant for smoking ban is using nicotine replacement therapy. Nicotine therapy may encourage patients to quit smoking and reduce symptoms of withdrawal. Furthermore, smoking cessation program may be effective to encourage patients to quit. CONCLUSION Smoking ban can be implemented in mental health services effectively. Legal and ethical issues that may oppose smoking ban are not sufficient to reject it. Many evidences support implementing smoking ban policy for patients with mental health. These evidences are well organized and can prove the validity of the smoking ban, according legal and ethical aspects. REFERENCES 1- Lawn S, Condon J. Psychiatric nurses ethical stance on cigarette smoking by patients: Determinants and dilemmas in their role in supporting cessation. International Journal of Mental Health Nursing (2006); 15: Kruger J, Trosclair A, Rosenthal A, Babb S, Rodes R. Physician advice on avoiding secondhand smoke exposure and referrals for smoking cessation services. Tobacco Induced Diseases (2012); 10: Abughosh S, Wuih H, Hawari F, Peters RJ, Yang M, Crutchley R, et al. Cigarette smoking among Jordanian adults. Journal of Ethnicity Substance Abuse (2012); 11(2): Annette K, Lela R, Shane P, Shanta R. Smoking Characteristics of Adults With Selected Lifetime Mental Illnesses: Results From the 2007 National Health Interview Survey. 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