Position Paper on Smoking in Psychiatric Facilities

The MAP recognises the increased rates of smoking among adults with mental illness compared to the general population. International studies report rates of twice that of the general population (1). An audit carried out at Mount Carmel Hospital (MCH) in 2013 (2), showed that 46.1% of patients with severe and enduring mental illness smoked.

The MAP acknowledges that smoking-related diseases are among the most common causes of death among adults with mental illness (3). Smokers with mental health conditions, become disabled and die early from smoking-related conditions. Despite this, smoking cessation interventions are not routinely offered to patients (4).

The MAP acknowledges that smokers with mental illness may, in fact, want to stop smoking, and are able to do so. People with mental illness may face unique challenges in quitting smoking, even in terms of the effect of stopping smoking on medication efficacy, but may do so successfully with additional services such as more intensive counselling (5,6).

The MAP acknowledges that stopping smoking will not interfere with mental health recovery, and may, in fact, have mental health benefits (5,6). On the contrary smoking is associated with poor outcomes, and with acceleration of the metabolism of certain medications resulting in the need for higher doses. There is a large body of clinical research showing that people can quit smoking without worsening of psychiatric symptoms, if they are given the appropriate support (5). The evidence also suggests that stopping smoking is actually also associated with mental health benefits, including reduction in depression and anxiety, and lower rates of re-hospitalisation and suicide (7,8).

The MAP recognises the importance of the provision of smoking cessation assistance, and how this is an important part of mental health treatment.

TheMAP notes the current policies within psychiatric settings and the challenges faced with enforcing their implementation.

Points for consideration:

People with a mental illness, particularly a psychotic illness, show significantly elevated rates of cigarette smoking compared with the general population. Still, they deserve the same support to stop smoking and to avoid its burden of disease as other members of the general population. Smoking cessation measures may need to be tailored for this group in order to ensure that these efforts do not undermine their overall health and wellbeing.

As such, the MAP acknowledges that for some people with mental illness and those in institutional settings, smoking cessation is more complex and other factors need to be taken into account when encouraging quit attempts, and providing support to stop smoking.

Often, patients are admitted to hospital with complex psychosocial needs.
These have to be prioritised, and sometimes patients do not choose to stop smoking. The MAP acknowledges that the stress of quitting smoking, as anticipated by the patient, may interfere with the patient’s recovery if they subsequently choose to leave the ward or their program.


The MAP recognises that there is no safe level of cigarette smoking, and that as medical practitioners we have a responsibility to encourage all those who smoke to stop and to assist those who wish to do so.

While acknowledging the highly addictive properties of nicotine, and the difficulties associated with smoking cessation, the MAP calls on the relevant authorities to make available nicotine replacement treatment, and other smoking cessation aides to those admitted to hospital.

The MAP encourages Mental Health Malta to enforce a smoke-free environment and culture within the entire facility. We also believe that safe designated smoking areas need to be provided for patients who choose not to engage in smoking cessation programs.

Smoking by staff should be completely banned on hospital grounds, except for in designated areas. The MAP asserts that smoking should be prohibited in all public areas without exception. All staff and patients are entitled to a smoke-free environment.

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