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Smoke-free policies in psychiatric services: identification of unmet needs
  1. Montse Ballbè1,2,
  2. Gemma Nieva3,
  3. Sílvia Mondon2,
  4. Cristina Pinet4,
  5. Eugeni Bruguera3,
  6. Esteve Saltó5,6,
  7. Esteve Fernández1,7,
  8. Antoni Gual2,
  9. and the Smoking and Mental Health Group*
  1. 1Catalan Network of Smoke-free Hospitals, Tobacco Control Unit, Cancer Prevention and Control Program, Institut Català d'Oncologia, L'Hospitalet de Llobregat, Barcelona, Spain
  2. 2Alcohol Unit, Department of Neurosciences, Hospital Clínic de Barcelona, Barcelona, Spain
  3. 3Addictive Behaviours Unit, Department of Psychiatry, Hospital Universitari Vall d'Hebron, Barcelona, Spain
  4. 4Drug Dependence Unit, Department of Psychiatry, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
  5. 5Public Health Department, Ministry of Health, Generalitat de Catalunya, Barcelona, Spain
  6. 6Department of Public Health, Universitat de Barcelona, Barcelona, Spain
  7. 7Department of Clinical Sciences, Universitat de Barcelona, Barcelona, Spain
  1. Correspondence to Dr Esteve Fernández, Unitat de Control del Tabaquisme, Programa de Prevenció i Control del Càncer, Institut Català d'Oncologia, Av. Gran Via de l'Hospitalet de Llobregat, 199-203, 08908 L'Hospitalet de Llobregat, Barcelona, Spain; efernandez{at}


Introduction Smoke-free policies have been extended to enclosed workplaces in many countries; however, smoking continues to be commonly allowed on psychiatric premises. The aim of this study was to describe tobacco control strategies undertaken in psychiatric inpatient services and day centres in Spain.

Methods This cross-sectional survey included all psychiatric service centres that offered public services in Catalonia, Spain (n=192). Managers responded to a questionnaire of 24 items that covered four dimensions, including clinical intervention, staff training and commitment, smoking area management and communication of smoke-free policies.

Results A total of 186 managers (96.9%) completed the questionnaire. Results showed low tobacco control in psychiatric services: 41.0% usually intervened in patient tobacco use, 34.1% had interventional pharmacotherapy available and 38.9% had indoor smoking areas. Day centres showed the lowest implementation of tobacco control measures. Out of 186 managers, 47.3% stated that the staff had insufficient knowledge on smoking cessation interventions.

Conclusions The former Spanish partial law has not been sufficiently successful in promoting tobacco control in psychiatric services. There is room for improvement in tobacco control policies, specifically in smoking interventions, staff training and resource availability.

  • Smoking
  • psychiatry
  • hospitals
  • delivery of healthcare
  • policy
  • secondhand smoke
  • addiction
  • cessation
  • public policy
  • smoking-caused disease
  • prevalence
  • environmental tobacco smoke
  • cessation

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In individuals with mental disorders, smoking prevalence is twice that of the general population.1 ,2 This high prevalence is typically accompanied by high nicotine dependence, and it leads to elevated rates of morbidity and mortality. Individuals with severe mental illnesses die approximately 25–30 years earlier than expected for the general population, often by conditions usually caused or exacerbated by smoking.3 ,4

Interventions against tobacco use have proven to be feasible in mental health and addiction inpatient settings, where smoking prevalence may reach 70%–90%.5–7 Several studies have shown that a significant percentage of patients are, in fact, motivated to quit8 ,9 and that they can succeed in quitting smoking.3 ,10 However, individuals with mental illnesses or addictions have lower cessation rates compared with the general population.1 When applied consistently, total bans on smoking in psychiatric settings, though controversial, have been effective in protecting others from secondhand smoke.11 Moreover, despite the problems typically anticipated by the staff,12 total bans on smoking have not caused significant increases in the frequency or intensity of disruptive behaviours among psychiatric inpatients.13–15

In Spain, the former smoking regulation (Law 28/2005),16 which was in force until December 2010, banned smoking in indoor public places and workplaces, including hospitals. However, the law exempted psychiatric services, where indoor smoking rooms were permitted ‘if deemed necessary’. The new law (Law 42/2010, which came into force on 2 January 2011) has extended the ban to outdoor hospital campuses, and it also banned smoking areas (either indoor or outdoor) in short-stay psychiatric units. However, smoking rooms continue to be allowed in medium- and long-stay psychiatric units.17 In Catalonia (Spain), the Catalan Network of Smoke-free Hospitals, founded in 1999, recommends that its affiliates ban smoking without exemptions. To join the Network, hospitals must commit to a progressive implementation of tobacco control strategies with the support of the Network. The Catalan Network of Smoke-free Hospitals currently comprises 64 hospitals (90% of all public hospitals), including general hospitals with or without psychiatric services or psychiatric wards. The Network's mission is to promote progressive tobacco-free strategies in hospitals through several activities, as previously described.18 ,19

Very few studies have been conducted at the regional or national level to evaluate the implementation of smoking policies in psychiatric institutions.20 ,21 The aims of the present study were to examine tobacco control strategies undertaken in psychiatric inpatient institutions in Catalonia (Spain) and to examine unmet needs that resulted from the partial ban on smoking in Spain.


Setting and participants

A cross-sectional survey was conducted from December 2008 to March 2009. The survey target population was clinical managers directly in charge of psychiatric units. We included inpatient units and day centres used by psychiatric services in Catalonia (Spain). Specifically, these included Acute Services, Subacute Services, Medium- and Long-Stay Services, Detoxification Services, Dual Disorders Services (addictive disorders concurrent with other mental health disorders), Day Hospitals, Day Centres and Child and Adolescent Services. Nearly half (51.6%) of the in-hospital services were affiliated with the Catalan Network of Smoke-free Hospitals. Catalonia is one of 17 autonomous regions of Spain, located in the north-eastern part of the country. It has 7.5 million inhabitants, nearly 16% of the total Spanish population. Spain has a unique national health system, with decentralised management organised by the autonomous regions. The smoke-free policies and regulations are nationally applicable, without exception among autonomous regions.

Study instrument

The self-audit questionnaire developed by the European Network of Smoke-free Hospitals (ENSH)22 was adapted to fit mental health services. The questionnaire was adapted through review and consensus of the ‘Smoking and Mental Health’ working group of the Catalan Network of Smoke-free Hospitals. This working group comprised 29 health professionals from 18 different mental health centres and hospitals in Catalonia. The survey was based on the ENSH standards for good tobacco control management in hospital settings.22

First, the questionnaire collected structured information on the characteristics of each institution, in terms of: (1) types of patients admitted (ie, acute, subacute, day hospital, etc), (2) total number of admissions per year, (3) age of patients (child, adolescent or adult) and (4) financial funding (public or semiprivate). Second, the questionnaire explored the implementation of tobacco control policies in four dimensions: smoking intervention (six items), staff training and commitment (four items), management of smoking areas (eight items) and communication of smoke-free policies (six items); (table 1). The total score ranged from 0 to 96; high scores indicated high implementation of smoke-free policies.

Table 1

Percentage of services that responded ‘always’ or ‘often’ to survey items, according to the type of service or their affiliation to the Catalan Network of Smoke-free Hospitals

The survey also included seven items that asked about situations related to the violation of smoke-free policies in the service and about tobacco availability inside the healthcare facility. The responses to all questions were Likert-type (always, often, sometimes, rarely, never).


A complete list of public and private centres that offered public psychiatric services was obtained from the Health Department of the Catalan Government. The list included every hospital service and day centre that offered psychiatric services in Catalonia (n=192). An email was sent to all managers (directly in charge of the unit) explaining the overall goal of the survey, and it included a link to an internet-based questionnaire. Emails were sent in December 2008, and up to five reminders were sent afterwards, either by telephone or by emails. Survey responses were collected from December 2008 to March 2009.

Data analysis

Services were divided into six groups: Acute Services, Subacute Services and Medium- and Long-Stay Services, Detoxification Services and Dual Disorders Services, Day Hospitals, Day Centres and Child and Adolescent Services (under 18 years old).

For descriptive analyses, response categories for every item were collapsed from five (‘always’, ‘often’, ‘sometimes’, ‘rarely’, ‘never’) to three (‘always/often’, ‘sometimes’, ‘rarely/never’). All scores were based on an ordinal scale and they did not follow a normal distribution; therefore, we evaluated median scores. The Friedman test was used to compare ‘types of service’; the Wilcoxon test was used to compare ‘affiliations to the Catalan Network of Smoke-free Hospitals’. Median analyses and Wilcoxon tests included five response categories (maximum score was 4 for ‘always’ and minimum score was 0 for ‘never’). The four dimensions of the ENSH standards list (24 items = total maximum score: 96) included clinical intervention (maximum score: 24), staff training and commitment (maximum score: 16), management of smoking areas (maximum score: 32) and communication of the smoke-free policies (maximum score: 24). All analyses were carried out with the SPSS V.16.0 Statistical Package (SPSS Inc.). A p value <0.05 was considered significant.


Of the 192 managers in existing psychiatric services, 186 submitted completed surveys (96.9%). Taken together, these services admitted 23 462 patients in 2008. Of the 186 responders, 59 (31.72%) were at public institutions and 127 (68.28%) were at private institutions that were publicly funded and offered services within the National Health System. Most managers (87.1%; n=162) stated that they had a written policy on the provision for a smoke-free environment.

Table 1 shows the results from the survey, categorised by the type of service and the affiliation to the Catalan Network of Smoke-free Hospitals.

In the intervention dimension, 41.0% of services offered some assistance for managing patient nicotine dependence. Only 34.1% of services had pharmacotherapy available for this purpose. In contrast, 31.9% of services provided tobacco products to patients on a regular basis (including three Child and Adolescent Services), but only 7.6% of these admitted that they used cigarettes frequently (always or often) as a reward, incentive or therapeutic tool.

In the training and commitment dimension, we observed that managers generally promoted awareness-raising strategies that targeted the staff (77.1%); however, information briefings about how to implement smoke-free policies and the availability of training sessions for clinical interventions were relatively scarce (27.5% and 37.9%, respectively). Consistent with that result, 47.3% of managers reported that their staff did not have sufficient knowledge on clinical smoking interventions.

With respect to the areas dimension, 38.9% of services had indoor smoking areas and 23.7% reported that indoor smoking areas were commonly used by both smokers and non-smokers (including four child and adolescent day hospitals). Incidents related to the management of smoking were commonly registered in only 33.9% of the services assessed.

With regard to the communication dimension, 93.4% of services often or always communicated changes regarding smoke-free policies to staff and patients. Nevertheless, only 59.9% of services commonly asked for the opinion of the staff. Moreover, only 27.9% of services shared experiences about the implementation of these policies with other institutions.

We found significant differences in the medians of the four explored dimensions according to the type of service (p=0.011; table 2). Day centres showed the lowest scores in all dimensions (p=0.005) except in the ‘areas’ dimension. No statistical differences were found among the types of service in the ‘areas’ dimension; however, in terms of smoke-free areas, Detoxification and Dual Disorders Services exhibited the lowest medians.

Table 2

Median questionnaire scores according to dimension and type of psychiatric service

As indicated in table 3, services differed in their implementation of smoke-free policies, depending on their membership to the Catalan Network of Smoke-free Hospitals (p<0.01). Out of the 126 inpatient services surveyed, 64 belonged to the Network. We excluded day centres from these analyses because the Network included only hospital settings. Services that were members of the Network exhibited significantly higher scores than non-members in the dimensions of ‘intervention’ (p<0.01), ‘training and commitment’ (p<0.01) and ‘communication’ (p=0.005). Thus, compared with non-members, Network members exhibited a higher probability of offering support in managing patient smoking (50.8% vs 38.7%), providing pharmacotherapy (57.4% vs 32.8%), following up after discharge (55.7% vs 38.1%) and providing smoking cessation intervention for staff members (52.5% vs 33.3%). Also, Network members showed higher staff training levels in clinical tobacco interventions compared with non-members (79.0% vs 37.7%). There were no statistical differences between Network members and non-members regarding the ‘areas’ dimension.

Table 3

Median scores according to dimension and the affiliation to the Catalan Network of Smoke-free Hospitals


This study shows that smoking was managed at relatively low levels in the inpatient services and day centres explored, which represented nearly all the psychiatric services in a Spanish region with 7.5 million inhabitants. Health professionals did not routinely intervene in patient tobacco use (only 41% of services performed some kind of intervention).

Smoking cessation strategies are a critical component in the implementation of smoke-free policies.23 Clinical interventions may have been limited, in part, due to the unavailability of pharmacotherapy in many of the services evaluated. Nicotine replacement therapy has proven to be a simple intervention with clinically significant implications in inpatient psychiatric services.24 In Spain, however, the National Health System did not fund any pharmacological treatments approved for smoking cessation. This may have contributed to the low availability of these drugs in the services assessed. Furthermore, the lack of funding may indicate that these treatments are not perceived as a basic resource in these settings. It would also be interesting to follow-up smoking behaviour for longer periods after discharge.25

Of particular note was the low level of staff training. Only half of the services had sufficiently trained professionals for interventions in smoking. This percentage was the same as that found among Detoxification and Dual Disorders services, which typically placed little emphasis on smoking cessation,26 potentially because tobacco was considered a minor addiction.27 In Spain, current university curricula for medicine, psychology and nursing do not generally include specific training on smoking cessation.28

Low scores were observed in all four dimensions (intervention, training and commitment, areas and communication) for all types of services evaluated; but, generally, day centres showed the lowest scores. These services promoted psychosocial rehabilitation and personal healthcare. Patients admitted to these services were in a stable mental condition and typically remained in these units for long periods on a daily basis. Thus, this could be a critical opportunity for addressing tobacco use. However, our results showed that these centres have neglected to intervene in smoking, one of the most severe health problems of these patients. More effort should be made to improve training and intervention skills in these settings. Further research should clarify why tobacco control remains unaddressed in these centres.

The most concerning findings were that outdoor smoking areas existed in 45.5% of the services that treated patients under 18 years old, smoking was allowed in common indoor areas in 4-day hospitals and cigarettes were provided to patients on a regular basis in three services. Moreover, only 54.5% of all child and adolescent day hospitals offered some kind of smoking cessation intervention.

No significant differences were found in the management of smoke-free areas among the different types of services. The existence of indoor areas commonly used by smokers, non-smokers and staff indicated tolerance of an unhealthy environment. This practice must be corrected. Members of the Catalan Network of Smoke-free Hospitals (half of the services) showed significantly higher scores in intervention, training and commitment and communication. The Network provides resources specifically designed to assist hospitals control tobacco use, including training for professionals, a common tobacco cessation program for patients and professionals, free access to smoking cessation drugs, etc. In the mental health field, the Network published a guide in 2009 for best practices and recommendations,29 based on a similar Irish guide,30 to strengthen tobacco control activities in hospital mental health settings. Thus, psychiatric institutions would benefit from an affiliation to the Network.

The Spanish regulation on smoking has changed since 2 January 2011 in order to address the ineffectiveness of the previous legislation.17 The changes were primarily directed towards bars and restaurants, but the law was also modified for short-stay psychiatric services. Currently, Acute, Detoxification and Dual Disorders services must implement total smoking bans, both indoors and outdoors. To successfully apply the new law, these services must address the pitfalls identified in the current study. Future studies should re-evaluate the tobacco control strategies implemented in these services in response to this new law.

Few countries, states or territories have implemented total bans in smoking in psychiatric services31 and not all have shown an overall positive outcome.20 Even with complete implementation of a total ban, some concerns, similar to those found in this study, remain to be addressed. In particular, improvements are needed in the mode of intervention, availability of pharmacotherapy and education and training.32 ,33 A similar study conducted in Australia also reported a low percentage of institutions that provided patient smoking interventions and staff intervention training.21 Most studies were conducted in English-speaking countries.20 ,21 Moreover, the published studies on single hospitals did not account for cultural, structural, political and environmental circumstances but typically assumed contextual uniformity.32

A potential limitation of the present study was the self-reported nature of the data. Service managers may be biased towards ‘positive’ results or over-reporting the virtues of the tobacco control policies implemented. For example, future studies should ascertain the validity of the question regarding the use of cigarettes as a reward. Thus, our data represent the best-case scenario, despite the low scores obtained. Future research should consider a formal validation of the self-completed questionnaire with an external audit. Also, we did not include private inpatient services that did not serve the National Health Service; however, these were scarce in the area studied (only three institutions with <30 beds each), and this exclusion was likely to have a nearly negligible impact. On the other hand, the high participation rate (96.9%) was a strength of the study, which included a comprehensive area.

In conclusion, this study revealed unmet needs and areas that require improvement in tobacco control within the psychiatric health services.34 Approaches like those of the Catalan Network of Smoke-free Hospitals and changes in legislation could promote successful tobacco control in these settings. Patients with psychiatric illnesses deserve the same health protections as those with other types of illnesses.

What this paper adds

  • Very limited research has been conducted on the implementation of smoking policies in psychiatric services.

  • Results revealed unmet needs and areas that require improvement, mainly staff training, smoking interventions and the availability of pharmacotherapy.

  • Special efforts should be placed on day centres; our results showed that these settings had the lowest levels of tobacco control strategies, but they had the highest potential for success because patients had achieved a stable condition.


The authors wish to thank all the psychiatric service managers that kindly answered the questionnaire for this study.



  • * The group is also composed by: Dolors Agulló, Francesc Bleda, Margarita Cano, Margarita de Castro, Montserrat Contel, MaTeresa Delgado, Conxi Domínguez, Isabel Feria, Teresa Fernández, Francina Fonseca, Imma Grau, Rosa Hernández, Teodor Marcos, Isabel de María, Concepció Martí, Jordi Pagerols, Anna Pla, Antònia Raich, Maite Sanz, Teresa Sarmiento, Susana Subirà, Joan Viñas.

  • Funding This work was supported by the Thematic Network of Cooperative Research on Cancer (RD06/0020/0089) from the Instituto de Salud Carlos III, government of Spain, the Ministry of Universities and Research (2009SGR192) and the Directorate of Public Health, Ministry of Health (GFH 20051) from the government of Catalonia.

  • Competing interests None.

  • Provenance and peer review Not commissioned; externally peer reviewed.