May 22, 2013

Smoking Bans in Psychiatric Hospitals

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Massimiliano Grassi, MSc, and Silvia Daccò, MSc

Villa San Benedetto Hospital, Hermanas Hospitalarias, FoRiPsi, Albese con Cassano (Co), Italy


Smoking is harmful, no doubt about it. And not only because of nicotine, at least not primarily, but also for the hundreds of other substances that have well-known harmful consequences on health, such as cardiovascular and lung diseases. If smoking is a widespread damaging habit in the general population, it is far more widespread in certain psychiatric populations. Studies report that the prevalence of daily smoking is about 50% in patients with major depressive disorder, 60% to 70% in patients with bipolar disorder, and 70% to 90% in patients with schizophrenia.1 Several possible explanations for the high rates of cigarette smoking in people with psychiatric disorders have been proposed, such as common risk factors2 and smoking as “self-medication” for either symptoms3 or cognitive deficits.4 No definite answer is available yet.

Smoking is forbidden in most health facilities, but this is often not true in psychiatric hospitals. Not only do psychiatric inpatients have designated smoking areas, but cigarettes have even been used as rewards for positive behaviors, eg, compliance with treatment. However, things have been changing in the past several years. In Louisiana, USA, for example, a recent law extended the smoking ban to include psychiatric facilities. Should smoking be forbidden in psychiatric hospitals?

Clinical experience is varied. Some clinicians believe cigarettes can limit psychomotor agitation in patients with schizophrenia. On the contrary, others report concern about patients getting agitated while they are awaiting the next smoke break. Furthermore, nicotine reduces the pharmacologic efficacy of some psychotropic agents, worsening psychiatric symptoms and risking the occurrence of relapses and new hospitalizations.

Patients who smoke usually state that they are unable to stop. Smoking is considered one of their few remaining pleasures, a little grant of freedom alleviating the discomfort of hospitalization. For patients, smoking is pleasing not only due to the actual smoking of the cigarette but also because of the associated rituals and as an aid to ease socializing.

Hospitals where smoking was forbidden have experienced a decreased hospital admission when patients have a choice to go to a facility where smoking is allowed, and those who are patients in nonsmoking facilities sometimes sneak in cigarettes. The efforts of patients to circumvent the ban also include pressuring fellow patients for cigarettes and even bribing them through unsuitable behaviors such as sex acts.

So, what is the right choice? Both pros and cons arise from a smoking ban in psychiatric hospitals. Of course, less smoking will result in health improvement and reduction of consequent, often fatal, diseases. However, patients will lack the positive effects on symptoms and cognition that may be the basis of their smoking habit.

An option to make the ban on smoking easier to accept is to supply alternative strategies to compensate for the lost effects of smoking. As a matter of fact, some hospitals have adopted cessation programs or offered nicotine patches with promising success. Complementary behavioral strategies may improve patients’ social skills and promote alternative and more functional rituals.5

Financial disclosure:Mr Grassi and Ms Daccò had no relevant personal financial relationships to report.


1. George TP, Krystal JH. Comorbidity of psychiatric and substance abuse disorders. Curr Opin Psychiatry. 2000. 13(3):327–331. Accessed April 17, 2013.

2. Fergusson DM, Goodwin RD, Horwood LJ. Major depression and cigarette smoking: results of a 21-year longitudinal study. Psychol Med. 2003;33(8):1357–1367. PubMed

3. Andreasen JT, Redrobe JP. Antidepressant-like effects of nicotine and mecamylamine in the mouse forced swim and tail suspension tests: role of strain, test and sex. Behav Pharmacol. 2009;20(3):286–295. PubMed

4. Caldirola D, Daccò S, Grassi M, et al. Effects of cigarette smoking on neuropsychological performance in mood disorders: a comparison between smoking and nonsmoking inpatients. J Clin Psychiatry. 2013;74(2):e130–e136. Abstract

5. Jochelson K. Smoke-free legislation and mental health units: the challenges ahead. Br J Psychiatry. 2006;189:479–480. PubMed

Category: Medical Conditions , Mental Illness
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34 thoughts on “Smoking Bans in Psychiatric Hospitals

  1. I’m a (UK resident) smoker and happily have never been a patient in a psychiatric ward.
    The arguments for NON-smoking are well known and rehearsed. But patients (particularly those suffering from Schizophrenia) in psychiatric wards are special cases. I believe that — with safeguards for staff against the inhalation of smoke, ie special smoking areas — patients in psychiatric wards should be allowed to smoke. The benefits, to the individual patients AND to staff, outweigh the disadvantages.
  2. Smoking should be banned in all hospitals. Permitting exposure to a known potentially lethal health hazard is denial of reality at a minimum, as well as placing other patients and staff at risk from second hand smoke. It has no place in a hospital.
    N.B. I have had the equivalent of a pack a day exposure to cigarette smoke from staff and patients who smoked during my years of training on psychiatric wards and early years of practice. Agitation is not a good reason to allow smoking. We deal with agitation, and the patient with nicotine addiction will have impetus to address it, and to practice frustration tolerance as well.
  3. I experienced the transition of Smoking to Non-Smoking in two different Psychiatric facilities. I remember that the week before and the day before the Ban was to start, almost every worker expected chaos and disruption, and patients going really unmanageable. Nothing happened. The transition was as smooth as the Y2K was.
    As a psychiatrist I do not prescribed medication only. I teach my patients healthy living. Meaning to live a clean, hygienic life. That includes avoiding use of any addictive substance. If a patient smokes, it will be easier for him to get a beer. It will also be easier for the person to go back to old behaviors such as use of Marijuana, Cocaine, etc.
  4. If smoking is not permitted and a newly admitted
    patient has withdrawal, will this confuse diagnosis
    and treatment. There will be the psychiatric problem
    to treat along with a new problem of smoking withdrawal.
  5. Icompletely agree with your opinion. I think if you dont understand addiction, esp nicotine, you probably dont need to be working with this population. These patients are already stressed , why confound the agitation with nicotine withdrawl? Will the hospital provide an additional 21 days at no cost to patient for nicotine withdarawl ?
  6. At some point the smoking should be treated, as should all illness, especially with all the proof of how deadlly smoking is. Rediculous to be concerned about metabolic syndrome and not about smoking. Nicotine replacement can prevent withdrawal symptoms
  7. At CMHI at Ft Logan we reviewed this issue in 2007 and went no smoking in 2008. Evidence indicated that if smoking was prohibited there would be fewer assaults generated around smoking. That has been the case.
  8. If someone is already hospitalized for a behavior stemming psychiatric order to withdraw that piece of comfort would be cruel. If it is true that nicotine is addiction is comparable to cocaine addiction then a mere patch is not going to be comparable. Give them an area!
  9. they are seeking psychiatric help, not a smoking cessation program. they shouldn’t be forced to go through withdrawal, physical or psychological, when they are going through a crisis.
  10. It’s mentioned that smoking interacts with many medications (true)- so stabilizing a patient on a short acute admission to a non smoking hospital and then seeing them light up as they hit the exit door has obvious implications.
  11. Cigarette smoking reduces the effectiveness of clozapine. Seven to 12 cigarettes a day reduces clozapine plasma levels by 28 – 72%. To regain antipsychotic effect dosage should be increased by 50%(mid-point), an algorithm accepted internationally. Since maximum dose is ~450mgms, it would be risky and generally unwise to suggest that 900mgms is a good idea.
  12. Schizophrenic patients smoke more cigarettes than usual when they are hospitalized and we have to protect nonsmokers. Need for a seperate place in the ward for smoking. The system Works well in Turkey
  13. Nicotine is an inducer and limits and interferes with psychotropic medications, also taking in consideration cardiovascular, pulmonary and cancer risk, it should be equally treated as an adjunct risk. We have to educate our patients regarding the risks of nicotine abuse, and provide them with the different tx options to quit.
  14. As a grateful ex-smoker, I understand the nature of this addiction all too well. Nevertheless, it seems that in this report, places that cut out smoking did not experience enormous problems. A smoke free environment always feels better and
    that should be the goal. Perhaps not cold turkey but gradually limited where smoking can occur and reducing the number of cigarettes patients can have in a day, implementation of smoking cessation strategies that patients can elect – all with the goal of creating a healthy healing environment.
  15. I’ve been working with psychiatric patients for close to 50 years, starting as orderly in a psych. hospital while in med. school and I have retired as Chief of Dept. in one. Most ptnts. smoke. It helps them with most EPS, especially akathisia; it also helps them with their concentration. Smoking also fulfils a social role in interpersonal interactions and even is a tool in token-economy.I did smoke for a while and I confess that it helped with my rapport with patients, especially the aggitated ones in ER. So, let them smoke, since a lot of them don’t have much more to look forward to enjoy. The downside of the medications we give them is not that much less harmful.
  16. why add addiction to nicotine to an already mentally compromised individual? why make this individual a “dual diagnosis ” patient?
  17. I agree with Eliahu. I don’t smoke at all. But I believe smoking helps my psych pts psychologically. I know the harm of smoking.However, there are still a lot of smokers in the society. Psych pts should be the last ones to prohibited.
  18. At IP psych hospitals, having been a hospitalist for mentally ill for over 20 years, the majority of patients are under the (SPMI) Diagnosis categories that require meds for life. In addition, a great majority of these patients have smoked for many years and will continue to do so for many years after DC. So if you look at the short lenghts of stay these days 3-5-7 days and taking into account that OP services are very diverse and non really geared to smoking vs non-smoking risks and education for the SPMI, it is truly unrealistic that these individuals will truly stop smoking while in theirshort tay these days IP. Furthermore, these SPMI will migrate from hospital to hospital as needed due to involuntary commitments in which they are taken to “x/Y/Z” receiving facilities so there is no standard for smoking at each facility as some do permit smoking and others do not. I believe in educating the patients on healthy life-styles and it is up to each individual person to adapt to it. I truly detest policy making for the benefit of an institution and not looking at the reality of our patients today. This issue is similar to an IP medical unit w/ respect to diets. Patients are placed on different dets according to disease management which is a most correct process but we forget to look at the fact that when they are DC from an IP medical facility they have no access to money or resources to get their diets. In summary, unless we turn ourselves to education and true behavior modification of these individuals we will be another policy making that will not suceed. After all, there is too much writng and little of resources to patient care.
  19. One can debate the theory until the cows come home. The evidence to date is overwhelmingly that the patients on units that change to non smoking with nicotiene replacement experience fewer instances of emotional distress sufficient to behavioral dyscontrol.
  20. It is heartwarming to read all these comments by well meaning dedicated professionals. I have also treated these patients for 50 years, and still do. I worked at all types facilities and had to deal with smoking. All the arguments have true merit and we have sometimes to make decisions
    that impinge on our pts freedom to choose. They all want to smoke, I’ll never forget my then older colleague who had severe COPD and could not stop smoking. I still remember her with an oxygen pipe in left hand and a cigarette in her right. And that is how she died ! My brother is a SPMI, in his 70s, hospitals since 20 s, not much pleasure in life. Currently in a nice home for elderly
    and disabled – he was forbidden to smoke after an MI. He stopped for a year. He is back to “just a few”. I can understand and accept that he does not want to quit. It is his choice…………….
  21. We have been a smoke free psychiatric facility for several years. People do quite well with nicotine replacement. There is nowhere on hospital grounds for anyone (med/surg patients, staff, etc.) to smoke and everyone has survived the ban.
  22. and staff should not be forced to have tobacco exposures. Just who should supervise patients while they are smoking? Should we close beds to create a new room? Who will pay the costs to build and ventilate it? Who lights the cigarettes? Patients certainly are not allowed to have matches.
  23. They might be encouraged to spend more on food and less on cigarettes. It’s not reasonable to predict failure of hospital bans when so many facilities have been successful.
  24. We run a ten bed unit of acute psychiatry. We stopped giving smoke to patients for two years. We find it very helpful for the patients. They get a chance to reduce or stop smoking after the hospitalization. They used to nag for smoke earlier as they do now but nagging is less if they know that it is not being done. Earlier it was like viral if one patient smokes the other will also ask for. The other advantage is of preventing fire.
  25. Smoking is banned in Canadian hospitals. Patients being held in psyche wards are allowed to smoke outside the building but the cost of supervising these patients is too great so they are let out without supervision even though they are deemed to be a danger to themselves or others. Patients let out to smoke often engage in behaviour that is harmful to themselves.
  26. I am working in a psychiatry emergency department in Romania. I am not a smoker and I had some programms to educate general population not to smoke, but in few year of experience in emergency ward I had some occasions in which I was able to avoid some serious problems (violent acts, drugs nonaderence, hospitalization denial and so on) by simply let a patient to smoke. In a poor healthcare sistem where you dont have enough drugs ( I have 24 H on calls whithout any benzodiazepines on ward), dont have enough staff, if I can deescalade a emergency situation like I just mentioned (and probably others) I will go for it
  27. I believe smoking should be allowed. My husband has bipolar 1 with extreme manic episodes. He has refused to go to mental health units simply because he can’t smoke. He ends up being committed against his will, but not until his behavior has caused damage in our lives and sometimes jail for disorderly conduct. When he’s committed he is extremely anxious because he knows he can’t smoke and wants me to smuggle him in cigarettes. I was actually planning to see if some changes could be made regarding allowing people to smoke so people like my husband will willingly commit themselves. A further note, as soon as he is released he smokes but when he is stabilized he quits smoking on his own within a few weeks to a couple months.
  28. As one comment says-we can debate till cows come home. Many pros and cons seems that no one knows what to do about this so it is left to individual MDs in charge…………

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