Intended for healthcare professionals

Rapid response to:

Smoking in psychiatry wards: freedom or discrimination?

BMJ 2015; doi: (Published 18 November 2015) Cite this as: BMJ 2015;:

Rapid Response:

Smoking in psychiatry wards: freedom or discrimination?

The debate on banning smoking in psychiatric hospitals is very interesting and a good opportunity to share professionals’ opinions and to raise fears.

We went through this debate five years ago, when the Spanish smoke-free legislation of 2010 put an end to the exemption that allowed patients to smoke both indoors and outdoors (1,2) which was later (2013) modified to include the ban on using electronic cigarettes in all hospital premises. In 2015, all acute and sub-acute psychiatric centres (including detoxification and dual disorder units) had to implement total smoke-free policies, including outdoor premises. Consequently, mental health services were driven to implement or improve intervention programmes for smoking cessation, training sessions for professionals and to ensure the availability of nicotine replacement therapy, as such tobacco control strategies were poorly implemented at that time (3). Arguments against the new law arose before its implementation, including similar fears to those which have appeared in the present debate. Just another example of how a similar smoking culture has been present in mental health care settings for many years in different countries.

Dr. Fitzpatrick based most of his arguments on patients’ right to choose about issues affecting themselves. He refers to the autonomy of patients, but this can be supported through many other ways. It is obvious patients are not allowed to choose everything while they are hospitalised. Do we provide them with “junk food” in the hospital? Do we let them bring a bottle of their favourite whisky brand to the hospitalisation ward? Therefore, why should things be different with tobacco? What if we know tobacco is the most harmful product they can consume? Smoking is not just a choice or an act of freedom, it is an addiction; in fact hospitalisation has been shown to be a trigger that increases smoking in patients smoking less than 15 cigarettes per day before admission (4).

Fitzpatrick’s “No” is also based on the premise that patients already know that smoking is harmful. The point is, are they aware of the full magnitude of the harm? Psychiatric patients will die, on average, 25 years earlier due to disorders caused or worsened by smoking. It is something that they probably do not know, neither do their families.

Allowing patients to smoke indoors or outdoors can also increase premature mortality among staff. In 2010-2011 we objectively assessed second-hand smoke in the psychiatric units of Catalonia (n=64) by means of fine particulate matter in the air (PM2.5 in μg/m3).5 The WHO has established a threshold of 10 μg/m3 from which premature mortality increase (6). We found a strong inverse trend with increasing levels of second-hand smoke being associated with decreasing smoking ban strictness: 8.81 μg/m3 inside units with total smoking bans; 13.80 μg/m3 in units allowing only to smoke outdoors (with some values up to 100 μg/m3); 24.29 μg/m3 in units with indoor smoking rooms; and 51.00 μg/m3 in units allowing patients to smoke in common indoor areas. The WHO report states that a level of 35 μg/m3 is related to a 15% increase in premature mortality.3 Moreover, levels in outdoor areas were 24.76 μg/m3 while patients were smoking there (maximum values of 465,16 μg/m3) and 286.50 μg/m3 in indoor smoking rooms. According to these results only total bans protect patients and staff from second-hand smoke. The other types of policies are incompatible with health and safety risk management policies in the workplace. The professional’s right to work in a healthy environment should be assured. On the other hand, we also observed that both professionals and patients were not aware of the actual levels of pollution in their units and consequently were not aware of the potential health problems associated for them (4).

In Catalonia total smoke-free policies are now naturally and widely accepted, and no problems have emerged either from patients or staff. Tobacco has been de-normalised in acute psychiatric wards. Nevertheless, we are still a long way off achieving the highest levels of tobacco control strategies in mental health settings (e.g., Spanish law still allows smoking indoors in medium- and long-stay patients’ residential units).

Currently, taking care of these patients means taking an overall care, that is, not only of their mental health but also of their physical health, including promoting a healthy lifestyle. If we do not treat these patients the same way patients of other non-psychiatric specialities are treated we will infringe their rights, we will infringe their right to stay in a healthy environment and the right to not to be treated different. We are in favour of total smoking bans in order to not discriminate these patients, treating them in a non-paternalistic way. That’s normality.

(1) Fernández E. Spain: going smoke-free. Tobacco Control 2006; 15:80-81.
(2) Fernández E, Nebot M. Spain: Beyond the 'Spanish model' to a total ban. Tobacco Control 2011; 20:6-7.
(3) Ballbè M, Nieva G, Mondon S, Pinet C, Bruguera E, Saltó E, Fernández E, Gual A, and the Smoking and Mental Health Group. Smoke-free policies in psychiatric services: identification of unmet needs. Tobacco Control 2012; 21(6):549-54
(4) Ballbè M, Sureda X, Martínez-Sánchez JM, Fu M, Saltó E, Gual A, Fernández E. Second-hand smoke in psychiatric units: patient and staff misperceptions. Tobacco Control 2015; 24:212-220
(5) Ballbè M, Sureda X, Martínez-Sánchez JM, Saltó E, Gual A, Fernández E. Second-hand smoke in mental healthcare Settings: time to implement total smoke-free bans? International Journal of Epidemiology 2013; 42(3):886-893
(6) World Health Organization (WHO). Air Quality Guidelines. Denmark: 2005.

Competing interests: No competing interests

18 November 2015
Montse Ballbè
Antoni Gual & Esteve Fernández
Tobacco Control Unit, Institut Català d'Oncologia / Addictions Unit, Hospital Clínic de Barcelona
Av. Granvia de l'Hospitalet, 199-203. 08908 L'Hospitalet de Llobregat (Barcelona), Spain