Long after cigarettes have been snuffed out in other public facilities, administrators in California's psychiatric hospitals are still debating how to keep work sites smoke-free when many of the people they care for are heavy smokers.

Their quandary is complicated by emerging evidence that smoking may help calm patients with major mental disorders such as schizophrenia. In schizophrenics, nicotine appears to reduce anxiety and the adverse effects of antipsychotic medication while increasing concentration, studies report. But for doctors, tolerance of smoking is clearly a double-edged sword. Although offering temporary relief, the habit may end up killing patients. Hospital administrators, meanwhile, must respond to employee demands for a workplace free of secondhand smoke. California banned smoking in nearly all businesses and public places beginning in 1995. Many psychiatric hospitals have struck a compromise, allowing patients to smoke on outdoor patios during supervised breaks. A few have created well-ventilated smoking rooms that are closely monitored by staff. But a growing number are considering, or have already imposed, outright bans on lighting up. That has brought protests from advocates for the mentally ill, who say such a measure is too harsh for critically ill patients. "When people are agitated and disoriented and they go the hospital, that is no time to take away their smoking privileges," said Karyn Bates, an advocate and former patient from Ventura. The latest battleground is in Ventura County, where administrators at the county hospital were considering a complete ban — even in the outdoor courtyard where psychiatric patients now gather hourly for a cigarette break. Los Angeles County's mental health department tried a smoking ban, but dropped it after patient advocates filed a discrimination lawsuit. St. Helena Psychiatric Hospital in Napa County also imposed a ban, but changed direction after four years. Julia Graham, supervisor of the inpatient unit at Napa, said staff members pushed for a resumption of smoking privileges after seeing the effect the ban had on patients. Many are admitted involuntarily and cannot leave for at least three days, she said. Denied cigarettes, some attempted to go AWOL and others became combative, she said. The biggest problem, though, was that patients were so irritated by the ban that they could think of little else, she said. That was true even when they were offered patches to relieve nicotine withdrawal, she said. "If all they can talk about is [that] they want a cigarette and why can't they have a cigarette, they are not focusing on the problems that brought them into the hospital," Graham said. "It was a hard decision, because smoking is harmful to your health. We all recognize that. We just felt this crisis time was the wrong time to intervene." But bans have apparently worked in other locations. Humboldt County imposed a no-smoking rule several years ago with few problems, said Dr. Michael Ferguson, former director of that county's mental health division. "There were some patients glad to leave so they could resume their addictive behavior," Ferguson said. "But it did not raise significant complaints. Once it was clear that's the way it is, it was a relatively minor issue." In Ventura County, officials agreed to back off from a ban for now, after mental health advocates protested. Next month, though, Ventura County Medical Center will begin offering a voluntary smoking-cessation program for psychiatric patients. Patients will be offered counseling and nicotine patches when admitted, said operations manager Curtis Ohashi. They can also take stress-reduction classes to find ways other than grabbing a cigarette to deal with anxiety. Ohashi and others know they face an uphill battle. Studies estimate that nearly half of those with mental illness are smokers. Doctors have long noticed that schizophrenics, in particular, are attracted to smoking. Nearly 90% of them take up the habit, studies report. Now there is some evidence that smoking could be a form of self-medication. A study conducted at Thomas Jefferson University in Philadelphia found that schizophrenics who smoke could pay attention and control impulses better than those who did not. Other studies have come to similar conclusions, although scientists caution that more research is needed. Some attention is being paid to the issue at medical schools around the nation. On a recent day at Ventura's hospital, two dozen patients headed to an outdoor courtyard as soon as the break was announced over a PA system. There, surrounded by 22-foot-high block walls, they stood single file in lines to be handed a cigarette by a staff member. "Lighter's over here!" shouted another staff member, holding the flame as patients then lined up to get their smokes lighted. One man paced the courtyard, ignoring everyone as he took deep drags. Others sat on a shaded picnic table and chatted. Longtime mental health practitioners say the tight control over tobacco today contrasts sharply with the psych wards of even two decades ago. Back then, patients chain-smoked in large dayrooms, said Hedda Markham, a psychologist who worked at Camarillo State Hospital before it closed. Camarillo even had a cigarette lighter built into the wall, she said. Dr. Ronald Shaner, medical director of the Los Angeles County Department of Mental Health, recalls that smoking was perfectly acceptable in the 1970s and early '80s. "There was a time when cigarette companies gave free cartons of cigarettes to hospital wards," Shaner said. "It was just compliments of the company. We have, for obvious reasons, come a long way."

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