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Secondhand smoke in psychiatric units: patient and staff misperceptions
  1. Montse Ballbè1,2,3,4,5,
  2. Xisca Sureda1,3,5,
  3. Jose M Martínez-Sánchez1,3,6,
  4. Marcela Fu1,3,5,
  5. Esteve Saltó3,7,8,
  6. Antoni Gual4,
  7. Esteve Fernández1,2,3,5
  1. 1Tobacco Control Unit, Cancer Prevention and Control Program, Institut Català d'Oncologia, L'Hospitalet de Llobregat, Barcelona, Spain
  2. 2Catalan Network of Smoke-free Hospitals, L'Hospitalet de Llobregat, Barcelona, Spain
  3. 3Cancer Prevention and Control Group, Institut d'Investigació Biomèdica de Bellvitge—IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain
  4. 4Addictions Unit, Psychiatry Department, Institute of Neurosciences, Hospital Clínic de Barcelona—IDIBAPS, Barcelona, Spain
  5. 5Department of Clinical Sciences, Universitat de Barcelona, Barcelona, Spain
  6. 6Biostatiscs Unit, Department of Basic Sciences, Universitat Internacional de Catalunya, Sant Cugat del Vallès, Spain
  7. 7Health Plan Directorate, Ministry of Health, Generalitat de Catalunya, Barcelona, Spain
  8. 8Department of Public Health, Universitat de Barcelona, Barcelona, Spain
  1. Correspondence to Dr Esteve Fernández, Tobacco Control Unit, Institut Català d'Oncologia, Av. de la Granvia de l'Hospitalet, 199–203, L'Hospitalet de Llobregat, Barcelona 08908, Spain; efernandez{at}


Background Mental health units have usually been exempted from complete smoke-free policies. The aim of this study was to compare the self-reported level of exposure to secondhand smoke (SHS) of patients and staff in psychiatric units to objective measures, and examine preference for different types of smoking bans.

Methods Cross-sectional survey about ban preferences and self-reported exposure to SHS by means of a self-administered questionnaire administered to patients and staff from 65 inpatient psychiatric units in Catalonia (95.5% of all units). We measured air concentrations of particulate matter ≤2.5 μm (PM2.5 in µg/m3) as a marker of SHS in these units.

Results 600 patients and 575 professionals completed the questionnaire. 78.7% of them were objectively exposed to SHS (PM2.5>10 μm/m3) but 56.9% of patients and 33.6% of staff believed they were not exposed at all and 41.6% of patients and 28.4% of staff believed the environment was not at all unhealthy. Nurses had a higher smoking prevalence than psychiatrists (35.8% vs 17.2%; p<0.001), and nurses had a higher perception of being moderately highly exposed to SHS (40.3% vs 26.2%; p<0.001). PM2.5 levels were significantly different depending on the type of smoking ban implemented but unrelated to the perception of SHS levels by both patients and staff. Only 29.3% of staff and 14.1% of patients strongly supported total smoking bans.

Conclusions Patients and staff have substantial misperceptions about the extent of their exposure to SHS and low awareness about the harmful environment in which they stay/work. This might have an influence on the preference for less restrictive smoke-free bans. It is particularly noteworthy that less that one-third of mental health staff supported smoke-free units, suggesting an urgent need for further education about the harmful health effects of SHS.

  • Secondhand smoke
  • Health Services
  • Public policy
  • Priority/special populations

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The implementation of smoke-free policies in public places and workplaces in many countries has had beneficial consequences at a public health level, for example, in cardiovascular and respiratory diseases.1 ,2 While such bans have been progressively extended worldwide to healthcare centres and other public places, psychiatric units have usually been exempted.3–5

The absence of smoke-free bans or even partial bans in mental health units may send a message that smoking is an acceptable practice for psychiatric patients, whose smoking prevalence can reach up to 80%.6 People with severe mental illness die approximately 25–30 years earlier than the general population, mainly because of conditions provoked or worsened by smoking.7

Staff in mental health units are often reluctant to implement total bans in healthcare centre buildings or grounds.8 The main reasons for this concern relate to fears that total smoking bans will increase patients’ aggression, needs for restraint and discharge against medical advice.4 Nevertheless, there is compelling evidence showing that these consequences are unlikely to occur and that total bans result in much fewer disruptions than partial bans.9 ,10

Total bans in psychiatric units are the only types of smoking bans that safely protect against secondhand smoke (SHS), whereas partial bans may permit high levels of SHS with harmful health effects.11 However, staff and patients seem to prefer partial bans,12 ,13 which allow patients to smoke indoors and/or outdoors.

The aim of the study was to compare the self-reported level of exposure to SHS of patients and staff in psychiatric units to indoor and outdoor air concentrations of particulate matter ≤2.5 μm (PM2.5) as a marker of SHS, together with their preference for different types of smoking bans.


Study design and procedure

A cross-sectional study was conducted between November 2010 and March 2011. The target population was all the staff working and patients available during the time we visited each unit for the study. A complete list of public and private centres that offered public psychiatric services was obtained from the Health Department of the Catalan Government. The study included all mental health inpatient units (n=67) that treated adult patients in Catalonia (Catalonia is located in the north-eastern part of Spain and has 7.5 million inhabitants). All these units have a total of approximately 2300 beds, and more than 23 500 patients are admitted during a single year.14 Of these 67 units, 16 were acute-patient units, 31 were subacute and medium-stay and long-stay units, 12 were detoxification or dual disorders units (the latest treating addictive disorders concurrent with other mental health disorders), and in the other 8 facilities two different types of units were present (eg, one single ward with acute and subacute patients or detoxification and dual disorders units in one single ward). All except 2 of the 67 mental health inpatient units participated in the study. Two medium-stay and long-stay units declined to participate.

During the study period, Spain was in the transition of implementing new smoking regulations to replace existing smoking policies, which explains why the psychiatric units we studied had a variety of smoking policies. The previous law (Law 28/2005, which was enforced until December 2010) banned smoking in healthcare centres but excluded psychiatric units, where indoor and outdoor smoking areas were permitted. The new law (Law 42/2010, which was enforced starting in January 2011) extended the ban to outdoor hospital campuses, banned smoking areas (either indoor or outdoor) in short-stay psychiatric units and allowed smoking rooms in medium-stay and long-stay psychiatric units.15

Both an email with information about the study and follow-up telephone calls were used to contact the managers who were in charge of each unit and to arrange one single visit to conduct the survey and the measures of PM2.5 levels in the unit at the same time.

The Research and Ethics Committee of Bellvitge University Hospital approved the study protocol and the protocol was subsequently sent to and approved by the participant units, if required.

Questionnaire on SHS and smoking policies

All patients and staff available in each unit during the visit were invited to respond to a brief self-administered questionnaire containing demographic data (age, sex and profession in case of the staff), smoking status (never-smokers, former smokers and current smokers) and number of cigarettes smoked per day (on working days in case of staff, and during and before the admission in case of patients). The questionnaire included two questions about SHS in the unit: (1) if they perceived themselves to be exposed to SHS and (2) if they thought this could be harmful to their health. Finally, respondents were asked about their level of support for four different types of smoking ban: (1) Indoor and outdoor ban; (2) Indoor ban; (3) Indoor smoking rooms (ie, units that allow smoking in designated indoor smoking rooms that are used only for smoking) and (4) No ban (ie, units that allow smoking in one or more indoor common areas, mainly living rooms, that are shared by smokers and non-smokers).

The questions about SHS and the support for different types of smoking bans were evaluated using a five-point Likert scale (0=Not at all to 4=A lot/Strongly agree).

All patients and staff were asked to sign an informed consent and the questionnaire was anonymous and self-reported. The researcher offered help to clarify the filling of the questionnaire.

Patients who were legally incapacitated or with cognitive deficits and unable to understand the questionnaire and the informed consent were excluded from the study. Staff were consulted on patients’ eligibility.

SHS objective assessment

We measured the concentration of respirable suspended particles with an aerodynamic diameter ≤2.5 μm (PM2.5 in μg/m3) as an objective marker of SHS. The measurements were performed using a TSI Side Pak Personal Aerosol Monitor (model AM510; TSI Inc, Minnesota, USA). This portable, hand-size, discreet device does not disturb patients or staff, nor does it affect their normal behaviour. The device logged PM2.5 concentrations at 1 s intervals, was calibrated before the study using a K factor of 0.5216 and was zero-calibrated prior to each use with a high efficiency particulate air (HEPA) filter according to the manufacturer's specifications. The procedures have been described previously.11

We performed measurements in three common locations in each unit: the living room, the main corridor and the staff room. Every location was tested for a period of 15 min, and the median concentrations of PM2.5 in μg/m3 and interquartile ranges (IQR) were reported for all three measurements together for each unit (resulting in 45 min measurements at each unit). We also measured control measurements (outside the hospital campus) in order to register baseline PM2.5 levels.

The measurements were performed at the same time as the surveys were completed. Measurements on one dual disorders unit were excluded due to technical problems with the PM device during the field work which made the measurements unreliable.

Statistical analysis

For the analysis of the variable ‘number of cigarettes smoked’ we performed Wilcoxon tests for paired samples and Mann-Whitney U tests and Kruskal-Wallis tests for independent samples, due to the non-normal distribution of the variable. Given the clustered nature of the data (participants were recruited within mental health units) we used random-effects models to control the unobserved heterogeneity. In the analysis of number of cigarettes smoked per day we used generalised least squares multiple linear regression models with random effects to control the clustering between participants within mental health units.

For descriptive analyses, response categories for the Likert-type items were collapsed from five (‘Not at all’, ‘A little’, ‘Medium/Half’, ‘Quite a bit’, ‘A lot/Strongly agree’) to three (‘Not at all’, ‘A little/Medium/Half’ and ‘Quite a bit/A lot/Strongly agree’). To compare response rates, we fitted mixed-effects logistic regression models to control for clustering.

We compared PM2.5 concentrations according to the type of ban in the units and patients’ and staff’s self-reported level of SHS exposure using multiple linear regression models with random effects in order to adjust for clustering within units. We also conducted tests for linearity between the groups. We used log-transformed PM2.5 concentrations for all of these analyses due to the skewed distribution.

A p value <0.05 was considered significant. Data management and simple bivariate analyses were carried out using PASW Statistics V.18.0 (SPSS Inc, Chicago Illinois, USA). Multivariate regression models with random effects were fitted out using STATA V.10 (StataCorp, College Station, Texas, USA).


Among the 65 participant units, 600 patients (27.7% of the total patients admitted to the units at the time of our visit) and 575 professionals (80.1% of the total staff working in the units at the time of the study visit) completed the survey. The non-participation rate ranged between 30% and 50% for patients, and 0.5% to 10% for professionals. Among patients, 335 (58.3%) were male and 240 (41.7%) female, with a mean age of 43 years (SD=12.8, range 18–81). Among professionals, 168 (29.3%) were male and 405 (70.7%) female; the mean age was 37.7 years (SD=10.7, range 18–68); 99 (17.4%) were medical doctors, 346 (60.4%) were nurses and 127 (22.2%) were other professionals. In total, 52.1% of the medical doctors responded to the questionnaire, 97.8% of the nurses and 76.5% of the other professionals.

Cigarette smoking


Most of the patients interviewed (442; 74.4%) were smokers, with 43 (7.2%) of ex-smokers, and 109 (18.4%) never-smokers. Table 1 shows the number of cigarettes smoked per day depending on several variables. Patients smoked fewer cigarettes while inpatient when they had smoking breaks scheduled throughout the day than those in units without predefined smoking breaks (p<0.001). Patients smoked less in units without outdoor areas than those admitted in units with outdoor areas available (terraces or gardens), although the difference was not statistically significant (13.4% vs 17.4%, p=0.071).

Table 1

Number of cigarettes smoked per day by patients

Patients who smoked between 1 and 15 cigarettes per day before admission tended to increase their mean cigarette consumption while inpatient (from 8.9 to 11.4 cigarettes/day; p=0.012). Patients who smoked more than 15 cigarettes per day smoked less while inpatient: patients who smoked 16–20 cigarettes decreased from a mean of 19.8 to 16.3, patients who smoked 21–30 cigarettes decreased from a mean of 29.1 to 17.7 and patients who smoked ≥31 cigarettes per day reduced smoking from a mean of 45.7 to 21.0 (p<0.001) after their admission.


In total, 32.2% of the staff sample were current smokers (17.2% of medical doctors, 32.6% of nurses, 39.4% of assistant nurses; p<0.001). No differences were found according to the type of smoking ban implemented in the unit where the professional worked.

The mean number of cigarettes smoked per day by staff during working days was 11.0 (SD=5.5). We did not find differences in the number of cigarettes/day smoked according to sex, age, the existence of outdoor areas in the unit, nor type of smoking ban implemented in the unit.

Support for different types of smoking bans

As shown in table 2, we found significant differences in the degree of support among both patients and staff depending on their smoking status. Smokers were significantly less likely than non-smokers to support the most restrictive smoking bans and more likely to support the most permissive ones.

Table 2

Support (Quite a bit/A lot/Strongly agree) for different types of smoking bans by patients and staff


Patients first agreed with units having indoor smoking rooms (62.1% quite/a lot/strongly agree), second with indoor bans allowing smoking outside (49.2%), 18.1% agreed with not having any type of smoking ban and just 14.1% agreed with total smoking bans.


As shown in table 2, staff agreed with indoor bans where patients are allowed to smoke outside (59.7% agreed or strongly agreed) more than with other types of smoking bans, with lower support for indoor smoking rooms (36.3%), total bans (29.3%) and no bans (2.9%). No differences were found between types of professional staff.

Less than half of the staff (44.4%) working in units with total bans agreed or strongly agreed with this type of ban.

Perception of SHS level versus objectively assessed level of SHS

Figure 1 shows PM2.5 concentrations depending on the type of smoking ban implemented and according to the perceived SHS levels by the patients and the staff in the unit. The geometric mean of the PM2.5 concentrations at control locations was 10.88 μg/m3 (95% CI 10.26 to 11.52 μg/m3). PM2.5 concentration levels were significantly different depending on the smoking ban implemented in the unit and were unrelated to the perception of SHS levels by both patients and professionals.

Figure 1

Particulate matter ≤2.5 μm (PM2.5) concentrations (in μg/m3) according to different smoking bans implemented in the units and to the self-reported level of secondhand smoke exposure. ap Value adjusted for clustering within mental health units by means of generalised least squares, IQR multiple linear regression with random effects. bTest for linearity. 10 μg/m3 is the WHO-recommended threshold for PM2.5 concentration levels for long exposures (horizontal line). Boxes represent 25th and 75th centiles of the observations (interquartile range), with the middle bar representing the median, whiskers represent the minimum and maximum non-atipic values; circles represent outliers (values between 1.5 and 3 IQRs from the end of the box), and asterisks represent extreme values (values more than 3 IQRs from the end of the box).

As shown in table 3, in both patients and staff, smokers usually perceived themselves to be less exposed to SHS than non-smokers.

Table 3

Self-reported exposure to secondhand smoke by patients and staff in mental health units


Among patients, 78.8% (n=473) were exposed to PM2.5 in their unit over the WHO-recommended levels for long exposures (PM2.5 concentrations of 10 μg/m3 or over).

Among the sample of patients who were exposed to PM2.5 over the WHO-recommended limit, 56.9% of them reported not being exposed to SHS at all in the unit (mean PM2.5 concentration of 23.6 μg/m3 in their units). Moreover, 41.6% of these patients thought that the unit's environment was not at all harmful for their health, while 32.7% thought that it was quite a lot or very harmful.

As shown in table 3, female, younger and non-smoker patients perceived significantly higher exposure to SHS. Only 26.4% of the patients admitted to units without any smoking ban thought they were a lot or quite a lot exposed to SHS (PM2.5 concentration of 51.0 μg/m3 in those units).


Among staff, 78.8% (n=453) were exposed to PM2.5 in their unit over the WHO-recommended limit. Among these exposed professionals, 33.6% reported that they were not at all exposed and 28.4% thought the environment of their unit was not at all unhealthy. There were no differences in this perception between smokers and non-smokers. Some differences were found by profession: medical doctors were less likely than nurses to consider that they were highly exposed to SHS inside their unit (7.1% vs 36.7%; p<0.001). Consequently, 46.3% of the nurses and 26.8% of the doctors considered this environment strongly harmful for their health (p<0.001).

PM2.5 concentrations were five times the recommended WHO levels (PM2.5 concentrations of 51.0 μg/m3 in those units) in units where smoking was allowed indoors in common areas. However, only half of this staff considered themselves being quite or highly exposed. In units with indoor smoking rooms (twofold the WHO-recommended limit; PM2.5=24.2 μg/m3), 39.1% of the staff perceived themselves to be quite or highly exposed. Finally, in units allowing smoking only outdoors, 48.9% of staff reported they were not at all exposed to SHS, while mean PM2.5 concentrations for those units were 22.3 μg/m3 (twofold the recommended WHO limit).


This study provides the first data about psychiatric patients’ and staff's perception of self-exposure to SHS in their workplace/unit compared with objective measures in mental healthcare units that have implemented different types of smoke-free policies. We found a substantial gap between patients’ and staff's perceptions and objective measures. Patients and staff usually tended to underestimate their SHS exposure, mainly in units without any smoking ban implemented. Consequently, they are also not completely aware of the potential harmful health effects they may suffer when working or living in units with high to very high SHS levels.

In our study, the implementation of total smoke-free policies did not influence smoking cessation in staff. Although some studies have reported similar results,13 ,17 others have found smoke-free policies reduce staff's smoking prevalence.18 Possibly, this effect was not observed in our study because most of the units with total bans had only recently implemented them.

The smoking prevalence in our patient sample was 74%. A similar high smoking prevalence has been obtained in other studies.6 ,19 Similar to the results obtained by the Keizer and Eytan,20 patients smoked less while inpatient except for those with the lowest nicotine intake. On the other hand, smoking prevalence among staff participating in our study (32.2%) was higher than in the general population (29.5%)21 and, as found in other studies, smoking prevalence was even higher (35.8%) in non-medical staff.22

Nurses perceived the unit as very polluted more frequently than medical doctors. Consequently, they were more aware of the potential harmful health effects of the environment where they worked. In contrast, doctors significantly underestimated SHS levels and the potential harmful health effects of working in the unit. This could be due to the longer time nurses spend in the unit. Despite this, nurses had a higher smoking prevalence than medical doctors. Moreover, even though nurses were more aware of the potential adverse health effects, there was no difference in the preference for types of smoking bans between nurses and medical staff. This could be explained because nurses, who have to manage patients’ behaviour daily, might fear a negative impact on the mental health or behaviour of the patients when smoking is not allowed.10 ,23

Few studies have examined staff support for smoke-free policies in mental health settings. In our study only 29.3% of the staff were highly supportive of total bans regardless of their smoking status or profession, contrary to other studies.10 ,19 ,22 Half of the staff working in units with total smoke-free policies were highly supportive of these bans. Partial bans, allowing patients to smoke outdoors, were the most preferred type of ban as also found in other countries.13 ,24 ,25 Generally, it has been found that mental health staff express significantly less positive attitudes than general healthcare setting staff to smoke-free policies.12

Only units with indoor and outdoor smoking bans had PM2.5 levels below the standard recommended WHO limit for long exposures, and units with indoor smoking areas had twofold to fivefold the recommended levels of PM2.5 in non-smoking areas.11 Notably, 25 and 35 μg/m3 levels are associated with 9% and 15% increases in the risk of premature mortality, respectively.26 PM2.5 concentrations were significantly different depending on the type of smoking ban implemented, regardless of patient and staff perceptions of SHS levels. We would expect similar low PM2.5 levels for the units where the staff and patients declared to be not exposed to SHS at all. However, units where staff and patients declared they were not exposed to SHS at all had 2–6 times SHS levels over the WHO-recommended threshold. This difference was bigger for staff than for patients. Overall, we found a perception bias in patients and staff from units with all different types of smoking ban except for those with total smoke-free bans. This may be due to the normalisation effect of smoking in psychiatric units. In fact, support for total smoke-free bans usually increase after their implementation.27 ,28 Many mental health units have not yet implemented total smoke-free bans and have not begun the denormalisation process that may contribute to underestimate the SHS levels.

This study has some limitations. First, we asked staff to respond the questionnaire at the time we visited the unit (mainly in the mornings, when there is more staff); hence, staff usually working on other shifts (weekends, at night or in the afternoon) were not, or at least, less represented. In addition, psychiatrists were not as easily available in the wards as nurses, because they usually spend limited time in the wards making daily visits to inpatients and spend the rest of their working shift in other facilities, that is, attending outpatients, where we could not ask their participation. In the case of patients, the percentage of participation was lower compared with staff because we did not ask for collaboration to patients with the study's exclusion criteria, to patients who remained in their private rooms, were sleeping, or those who we did not have access (patients out of the unit with permissions or who were out throughout in the gardens). A second limitation is that current smoking status could not be objectively assessed. Moreover, recall bias could be present in the estimates of the number of cigarettes smoked before admission among patients. Third, the relatively high smoking prevalence in Spain may have an impact on the results, although other studies in other countries have shown similar results in the preference for partial bans. Finally, PM2.5 is not a specific marker of secondhand tobacco smoke. However, this method of measurement obtains results that are similar to those using air nicotine concentrations in the absence of other sources of combustion16 ,29 ,30 and has been widely used to assess SHS levels in indoor spaces.31 Moreover, PM2.5 control measurements showed low variability which strengthens the reliability of the indoor measurements.

The strengths of this study include its novelty, which has linked the perceived exposure of SHS in mental health settings to objective measures depending on the type of smoking ban implemented. Also of note, is the large sample of staff and patients, which also comes from a large sample of mental health units from a comprehensive area that covers more than seven million inhabitants (95.5% of all such existing units in the area).


In order to enhance awareness of the importance of implementing total smoke-free policies in psychiatric units, it would be useful to plan briefing sessions for staff, reporting data from measures of the SHS levels and the related potential health consequences for patients and themselves. Education addressing the benefits of total smoke-free bans has also been described as a key component in the sustainability of such bans.32 The misperception about the self-exposure to SHS and its potential harmful health effects would lead, to a certain extent, to a greater support for partial bans by patients and staff. Smoke-free environments along with smoking cessation interventions in psychiatric units are an important step targeting quality of life and life expectancy in this special population.

What this paper adds

  • There is a substantial misperception about the real exposure to secondhand tobacco smoke in mental healthcare settings, both by patients and by staff.

  • Medical doctors (vs nurses) and smokers (vs non-smokers) have a lower perception of being highly exposed to secondhand smoke (SHS) in mental health units.

  • Low awareness of staff about the harmful environment in which they work might have an influence on the preference for less restrictive smoke-free bans.

  • There is an urgent need for further education of mental health staff about the harmful health effects of SHS.


The authors wish to thank all of the psychiatric service managers, staff and patients who kindly collaborated in this study. We also thank Mr Joan Ballbè for his technical assistance during field work.



  • Contributors MB, XS, AG and EF designed the study protocol, which was revised by JMM-S and ES. MB and XS collected the data and, with JMM-S and MF, performed the statistical analyses. All authors contributed to the interpretation of the study findings. MB drafted the manuscript, and all authors revised it for relevant intellectual content. All authors approved the final version of the manuscript. EF is the guarantor.

  • Funding This work was supported by the Thematic Network of Cooperative Research on Cancer [RD12/0036/0053] 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.

  • Ethics approval Research and Ethics Committee of Bellvitge University Hospital.

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