S-625 - Senator Vitale's Bill to Allow Tobacco-Free State Psychiatric Hospitals

Following is the entire testimony of Mr. Kevin Mrtone and Mr. Jacob Bucher.

Testimony of Kevin Martone, Assistant Commissioner Department of Human Services, Division of Mental Health Services
Senate Human Services Committee
S-625 Smoking Cessation
January 24, 2008

Good afternoon Chairman Vitale, and members of the Committee. Thank you for the opportunity to discuss the Division of Mental Health Services support for S-625. In addition to managing New Jersey ’s community-based mental health system, the Division operates 5 psychiatric hospitals whose mission is to provide for the psychiatric and physical well-being of people with serious mental illness. This bill is consistent with our reform activities.

Smoking kills. Gone are the days when “Just let them smoke” is an acceptable response. On average, people with mental illness die 25 years sooner than you and I; 25 years! Considering that 75% are addicted to nicotine, smoking is known as a large driver of premature death in this population. Given what we know, we as a State should not contribute to this process while patients are under our care.

As a Board member of the National Association of State Mental Health Program Directors (known as NASMHPD), I also bring some national perspective on this topic. In October, 2006, NASMHPD issued a position paper and technical report on smoking in state operated psychiatric facilities. The report states, “Science as well as experiences in mental health facilities have also shown that tobacco smoking leads to negative outcomes for mental health treatment, the treatment milieu, overall wellness and, ultimately, recovery.”

The report revealed the positive effects for patients and employees of going tobacco-free and identified national trends. In fact, nearly 45% of state psychiatric hospitals across the country are now smoke fee on their campuses for patients and employees. This trend is increasing; in addition to states that have already implemented this, at least nine other states right now plan to have tobacco-free campuses this year. Delaware State Hospital just went tobacco-free in November. Many local New Jersey hospitals have gone smoke free on their campuses as well, most of which have inpatient psychiatric units. Seventeen inpatient units throughout the state, all of which send patients to the state hospitals, are smoke-free.

Smoking is an addiction and addiction is NOT a choice. We must consciously separate our beliefs that smoking is more socially acceptable than other drugs from the fact that nicotine addiction is more lethal than many other drugs that we currently prohibit.

While the Division currently faces significant challenges in one of its state facilities, the New Jersey state hospital system as a whole continues to move aggressively forward to raise the standard of its treatment so that it is consistent with best practices.

An overwhelmingly large number of patients in our state hospitals have an additional diagnosis of treatable substance abuse disorder, ranging from heroin to alcohol and nicotine. It is incumbent upon us, as a provider of healthcare, to simultaneously treat the illness, no matter if it’s schizophrenia, nicotine dependence or high blood pressure. To not do so is negligent. Typically, a patient is only admitted to a state hospital after a stay at a local inpatient psychiatric unit. Ironically, there, they have already been prevented from smoking. However, upon admission to the state hospital, access to cigarettes is granted and we have thereby facilitated a quick return to their addiction.

Smoking in state hospitals is a risk management issue. The belief has been that cigarettes are used by staff coercively to keep patients calm, and this inability to use cigarettes as a reward will serve only to increase incidents. The research shows otherwise. State hospitals across the country have demonstrated that smoking bans on campus result in decreased patient to patient and patient to staff assaults, decreased use of seclusion and restraints and increased therapeutic interactions.

Currently, many patients become anxious throughout the day waiting for their cigarette breaks. Further, heavy smokers admitted directly from emergency rooms actually go through greater withdrawal upon admission when they are immediately reduced to roughly 5 cigarettes per day. The resulting withdrawal symptoms are often antecedents to incidents. Whereas complete abstinence supplemented by nicotine replacement therapy results in supervised withdrawal, which is more humane.

Last year, a patient assaulted a medically fragile patient for a cigarette. That patient later died due to medical complications. Just last week, a patient ignited a fire in his room. Luckily, the staff responded appropriately and there were no injuries.

Smoking is not a Right . Multiple court decisions both nationally and in New Jersey have affirmed that smoking is not a fundamental right. The patient rights argument should also consider non-smokers exposed to secondhand smoke. In face, a patient filed a lawsuit against the State last year for permitting smoking at one of our hospitals.

Lastly, psychiatric hospitals are not homes. They are treatment facilities intended to discharge patients back into the community as they no longer meet commitment standards.

Smoking in state hospitals costs the taxpayer . Patients who smoke often need higher doses of medication to maintain the appropriate balance of medication in their system. Psychiatric medication is very expensive, and as a result, the state bears the cost of increased medication, as well as for medications and other services needed to treat patients’ smoking-related health problems. Research shows that employees who smoke use more sick time which directly impacts overtime costs. Working to improve the wellness of staff may result in a secondary gain of improved attendance and reductions in overtime.

Smoking is expensive . Many consumers experience extreme poverty. The monthly SSI reimbursement is $637. A pack of cigarettes costs $6.51. A pack a day costs roughly $195 a month, or 30% of monthly income. Many smoke more. Granted, many consumers will return to smoking when they return to the community, but we can provide them with the opportunity to quit while under our care.

Employees : The Division has spoken with each of the unions that work in the state hospitals. All agree that there is no doubt concerning the health benefit to employees and patients. Each union expressed concerns about the transition period and what type of disciplinary action an employee would face if they violated the no smoking policy.

We want as much buy-in as possible. Yes, it will be an adjustment. However, this is being done successfully all over the country in state hospitals and right here in New Jersey.

We know that most employees do not smoke. On average, 30% of employees in psychiatric facilities smoke; meaning 70% do not (NASMHPD). Many who do smoke want to quit and we intend to assist them in that process. Nonsmoking staff will avoid exposure to secondhand smoking in a smoke free campus. Going forward, all new employees will be hired with the understanding that the hospital is a smoke free campus.

What have we done ? New Jersey ’s state hospitals have been preparing to go smoke free on campus for over a year now, utilizing best practice guidelines and consultation from nationally recognized experts.

Important to note is that the Division itself developed and funded, in partnership with UBHC, a manual considered a best practice tool nationally to smoking cessation. Both the manual, as well as a consumer-operated support program are currently being used in our state hospitals and are referenced in a national best-practices toolkit, Tobacco Free Living in Psychiatric Settings.

Greystone has been planning for over a year to open its new facility smoke free. Among its activities, the hospital has been prescribing smoking cessation treatments; running Healthy Living Groups; has conducted patient and staff surveys; already successfully created smoke free units; posted educational information throughout hospital; provided information for family members; distributed educational materials; conducted and implemented a training curriculum for staff; and developed a newsletter.

Physicians have received training in the use of nicotine replacement therapy and tobacco cessation treatment. No patient will be exposed to sudden withdrawal.

Janet Monroe, the CEO of the hospital, is here to answer any questions about the hospital’s activities and readiness. Patients are expected to move into Greystone in late February/early March. The remaining hospitals would phase this in over the course of the year, based upon readiness, and consistent with this bill.

In closing, S-625 is consistent with our overall efforts to facilitate the wellness and recovery of people with mental illness while under our care.

Thank you.

Collaborative Support Programs of New Jersey
(CSP-NJ) supports S 625 Smoking Cessation

I am Jacob Bucher , the Executive Director of CSP-NJ, a consumer run mental health agency. I thank you for the opportunity to share our position on the smoking ban at the state psychiatric hospitals. As a person living with a mental illness who has received services from in and out patient psychiatric settings, and who also is a former heavy long term smoker, I will share my personal perspective as well as the perspective of our agency that strives to promote wellness oriented services.

The Problem
Adult consumers living with mental illness die *25 years younger than other Americans. This means that men living with mental illness will likely to die by age 53, compared with a man of the same age (who can be expected to live until age 78). Examination of the causes of death show that about 15-20 years of the disparity can be attributed to chronic diseases, such as heart and circulatory disorders, diabetes, or other long-term diseases*. People who live a bit longer than 53 (like me) live with chronic physical health problems. Most consumers (we consume over 50% of cigarettes in this country) are smokers and smoking significantly contributes to dying younger and living with chronic physical health problems that severely impacts quality of life and is quite costly to society.

It is ironic that these statistics are based on people who ar e receiving services from the mental health system*.The mental health system has been negligent of this problem. Further the mental health system is where many of my peers learn to smoke as it is the only thing they are told to do to ‘calm down’ or worse smoking has been a used as a reward system or way to control people. The mental health system needs to take urgent action to address this glaring, unacceptable disparity.

CSP-NJ applauds the Division of Mental Health Services (DMHS) for having the insight and courage to take this on health disparity issue proactively to promote the wellness for NJ citizens receiving care at state psychiatric facilities.

Yes, DMHS urgently needs to do a lot to improve state hospital conditions and offer treatments and a therapeutic environment that promotes wellness and recovery (this has been known for many years, not just recently). This legislation banning smoking is a step in the right direction.

I am living proof of this alarming statistic. I am an individual living with a mental illness who was a heavy smoker under the care of the mental health system and encounter significant health problems. I smoked for over 50 years and during my hospital stays and life in boarding homes smoking was a reward and main point of social contact for people like myself who are isolated, lonely and stigmatized

. I did realize then that smoking was a life safety problem for these large facilities and there were fires that killed people as well due to smoking. I watched and worried about that but that was not enough to stop my smoking addiction. The true physical toll knocked me out in March of 2005 when I suffered a stroke. Before then and now I live with serious physical health problems due to this smoking addiction. Smoking is clearly an addiction and needs to be addressed in state psychiatric facilities as such. I was fortunate that when going through my physical rehabilitation they offered me nicotine replacement to help me fully Quit the Habit! (I am smoke free almost 3 years).

Many advocates (and we are advocates) say “smoking is a right”—but we at CSPNJ believe “ good health is the right we need to preserve”.

State psychiatric facilities are an appropriate place that should offer an environment and services that preserve good health for citizens in need.

Solutions

• We are CSPNJ firmly believe that a hospital environment is the best place for a person to deal with an addition such as smoking. We hope people won’t be expected to go cold turkey when they enter a psychiatric facility. The rehabilitation center (which is smoke free) offered me nicotine replacement and psychiatric facilities should be expected to follow this protocol as well.

• We urge DMHS to offer people the resources, education and opportunity to develop skills and support so they can kick the habit in the hospital and when they return to the community. In addition many consumers are extremely poor and this addiction will surely contribute to remaining in poverty. Efforts to promote smoking cessation can positively help people physically and economically as well.

• DMHS should make every effort to work collaboratively with tobacco dependence experts to design services, resources and education for patients and staff so their right to good health can be preserved for patients and state hospital staff.

• Resources need to be available at the hospitals as well as for state funded community mental health services to help people manage overcoming this addiction when a person is discharged from a state facility.

• There are nationally recognized tobacco dependence experts in NJ who specifically target the needs of people living with mental illness. Their expertise and collaboration with state and the community provider system will help NJ make a significant impact on addressing this health disparity.

For information on mortality and morbidity refer to

*Parks, J., Svendsen, D., Singer, P., Foti , M.E. , & Mauer, B. (2006, October). Morbidity and mortality in people with serious mental illness [Technical Report]. Retrieved June 12, 2007 from http://www.nasmhpd.org/general_files/publications/
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