Intended for healthcare professionals

Rapid response to:


Exempting mental health units from smoke-free laws

BMJ 2006; 333 doi: (Published 24 August 2006) Cite this as: BMJ 2006;333:407

Rapid Response:

Smoking subculture in psychiatric patients


Campion, McNeill & Chencinski raise their concerns about further worsening of health inequalities for people with mental health problems if smoke-free laws are exempted in mental health units (1). However, the relationship between smoking ban and health equality is not a straight forward one and there are a number of issues which need to be considered.

Heavy smoking is related to a perception of powerlessness and futility in the daily lives (2) and these are common experiences among individuals with mental health problems. Tobacco is viewed as a “chemical comforter” helping them to cope and maybe one of the ways to reduce the possible distress from the symptoms. Hospitalisation is already reinforcing the sense of powerlessness, especially for those detained under the Mental Health Act. Smoking ban in in-patient units, particularly in acute wards, is likely to exaggerate this feeling. There is a possibility that patients refuse to come to hospital informally because of the smoking ban, even in-patient treatment is the best option for them. As a result of this, patients may need to be detained under the Mental Health Act.

Psychiatric treatment has changed dramatically in the past decades, with an increased emphasis on treatment in the community and the view of service users. One of the reasons for this shift is to allow individuals with mental health problems to be managed in a less restrictive environment. This has shown to improve patients’ satisfaction (3). Without doubt, in-patient psychiatric treatment is still needed for more disturbed patients. Even so, these patients should be managed in an environment with minimal restriction if possible. Complete smoking ban in psychiatric units instead of providing alternative ways (e.g. well-ventilated smoking room) can be viewed as coercion (4) and possibly counter-therapeutic.

Even complete smoking ban in psychiatric units is endorsed, the attitude of staff in psychiatric unit is the key for successful implementation. A recent survey conducted in the UK has reported that nearly one in three psychiatric staff was against smoking ban in psychiatric settings (5). Nurses who felt mandated to enforce smoking bans believed this activity disrupted their relationships with patients and viewed tobacco control as a burden, even they clearly demonstrated knowledge of health consequences related to tobacco use (6).

Present evidence also suggests that most of the patients resumed smoking after they were discharged from smoke-free psychiatric unit (7). One of the aims of smoke-free units is to encourage cessation. In order to achieve this goal, a more structured longer term intervention should be available. The NICE recommends brief intervention for smokers (8) in a recently published public health intervention guidance but it is still too early to know how well the guideline is followed, especially among individuals with mental health problems.

Personally I do not smoke and I am more than happy to work in a smoke-free environment. However, with the current situation, complete smoking ban is likely to cause more problems rather than helping our patients to give up this addiction. Most researches focus on the pharmacological aspects of smoking in those with mental health problems. Ethnographic study exploring the meaning of this smoking subculture in individuals with psychiatric disorders may help to identify more suitable interventions for this group.


(1) Campion J, McNeill A, Checinski K. Exempting mental health units from smoke-free laws. BMJ 2006; 333: 407-408.

(2) Helman C. Culture, Health and Illness. London: Butterworth Heinemann, 2000.

(3) Johnson S, Nolan F, Pilling S, Sandor A, Hoult J, McKenzie N, White I, Thompson M, Bebbington P. Randomised controlled trial of acute mental health care by a crisis resolution team: the north Islington crisis study. BMJ 2005; 331: 559.

(4) House of Commons health select committee. Smoking in public places. First report of session 2005-6. London: House of Commons, December 2005.

(5) McNally L, Oyefeso A, Annan J, Perryman K, Bloor R, Freeman S, Wain B, Andrews H, Grimmer M, Crisp A, Oyebode D, Ghodse A. A survey of staff attitudes to smoking-related policy and intervention in psychiatric and general health care settings. Journal of Public Health 2006; 28: 192-196.

(6) Schultz A, Bottorff J, Johnson J. An ethnographic study of tobacco control in hospital settings. Tobacco Control 2006; 15: 317-322.

(7) Jonas J, Eagle J. Smoking patterns among patients discharged from a smoke-free in-patient unit. Hospital and Community Psychiatry 1991; 42: 636-637.

(8) National Institute for Health and Clinical Excellence (NICE). Brief interventions and referral for smoking cessation in primary care and other settings. London: NICE, 2006.

Competing interests:
None declared

Competing interests: No competing interests

01 September 2006
Daniel Tai-yin Tsoi
Clinical Lecturer in Psychiatry
Academic Clinical Psychiatry, Longley Centre, Norwood Grange Drive, Sheffield S5 7JT