Why is smoking so prevalent in mental health settings?

 In Mental Health, New Product, Pharmacy Information, Simplifying Product Supply

Smoking is a notoriously difficult habit to break, with many products on the market that will help you finally give up. However, smoking is much more of a problem in mental health inpatient units.

Mental health inpatient units have smoking rates of around 70% compared to 21% in the general population.

Not only that, but smokers with a mental illness smoke, on average, 20% more cigarettes per day than those without. More than half of patients diagnosed with nicotine dependence suffer from at least one mental illness. Smoking related diseases are, therefore, more common in these patients, which underlines the need for the issue to be tackled head on.

Giving up smoking is often more difficult for someone with mental illness as they often lack the confidence and historically have not been offered the specialist support required to quit. There are also a variety complications, due to different mental health conditions being affected by smoking and smoking cessation in different ways.


Smoking rates among adults with depression are twice as high as among adults without depression. Nicotine can act like an anti-depressant as it temporarily raises the levels of dopamine in the brain. However, it is known that smoking in the longer term decreases the overall release of dopamine and, therefore, exerts a depressant effect.

This can create a paradox, as a smoker with depression will notice the fast-acting antidepressant effects after smoking a cigarette, but not the more gradual and longer-term depressant effect that smoking will create. This simply serves to increase the appeal of smoking.

Numerous studies have found that smoking significantly increases the risk of major depression. The majority of patients who give up smoking (especially those who also suffer from anxiety) will experience a reduction in their symptoms. However, a small minority may experience more severe symptoms as a coping mechanism has been taken away. Therefore careful monitoring of this group is required.

Bipolar disorder

Although an association between smoking and bipolar disorder has not been firmly established, one study has found that among patients treated for bipolar disorder, smokers were more likely to have an earlier onset of the disorder, greater severity of symptoms, a history of suicide attempts, and co-morbid anxiety of substance use disorder. The association with suicide ideation was confirmed in a separate study.


The link between Attention Deficit Hyperactivity Disorder (ADHD) and smoking is well-established, with both children and adults significantly more likely to smoke and to go on to develop drug and alcohol disorders. There is also evidence that smoking while pregnant can increase the chances of the development of ADHD in children.

Studies suggest that people with ADHD use smoking to improve attention and cognitive performance. Studies have also shown that smoking can reduce symptoms of ADHD and in fact acts in a similar way to the medication used to treat it, which may explain ADHD sufferers using tobacco to self-medicate.


The prevalence rate of smoking amongst people with schizophrenia is estimated to be 58-88%, significantly higher than that of the general population.

One explanation for this is that sufferers smoke to manage some of the symptoms associated with the illness such as improving attention and short-term memory.

Patients with schizophrenia also tend to experience more severe withdrawal symptoms in the first week than other would-be quitters, making quitting even more difficult.

It is known that smoking lessens the side effects of antipsychotic drugs such as haloperidol. One study found that patients smoked more while medicated than when in a medication-free state.

Alzheimer’s disease and dementia

Recent research has shown that smoking is a risk factor for Alzheimer’s and vascular dementia by increasing the number of free radicals, which impair brain and body cell functions and undermine immunity. Nicotine use appears to worsen the effects of a brain protein called tau, responsible for the fibrous tangles that are an indicator of the disease.

While there is still some minor disagreement about the relationship between smoking and dementia, the belief that smoking had a proactive effect against Alzheimer’s disease through the stimulation of nicotinic receptors has now been discredited.

Post-traumatic stress disorder (PTSD)

There’s a clear bi-directional link between post-traumatic stress disorder (PTSD) and smoking. These smokers are also significantly more likely to be heavy smokers and to have significantly higher levels of nicotine craving and lower quit rates. It has been shown that those who successfully quit or who have reduced their levels of smoking have experienced a marked reduction in their PTSD symptoms.

Can smoking rates in mental health settings be reduced?

The rate of people suffering from mental health problems wanting to give up is about the same as the general population, even though the levels of smoking on mental health wards is much higher.

It is often considered that it is impossible for service users to stop smoking, however, research has shown otherwise. NICE recommends that inpatient mental health hospitals should have smoke-free policies and patients should be supported in their attempts to give up.

One of the key barriers to achieving this is ensuring staff are fully trained in this area. Surveys show that staff working in mental health generally do not support smoke-free policies, and also show a gap in their knowledge of the benefits of smoking cessation. Therefore, ensuring all staff have received training in smoking cessation is critical to enabling service users to successfully give up.

Often smoking is seen as a reward for good behaviour and taken away for bad behaviour, and stopping this mentality would be useful in encouraging smoking cessation.

There are a number of mental health inpatient units that are completely smoke-free, so it’s certainly possible. All of these agree that strong leadership and high-quality staff training are essential to the success of the scheme.

Help with establishing a smoke-free healthcare environment

Further guidance on smoking cessation in a health care setting is available in our Guide to Smoking Cessation, which can be ordered here.

Ashtons also offers an array of products that will aid patients with smoking cessation, and help them quit smoking for good. You can view our whole range of smoking cessation products on our Online Ordering Website.

If you require additional help with establishing a smoke-free healthcare environment, please call us on 0345 222 3550.

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