• Subject Code : PUBH1080
  • Subject Name : Nursing

Studies in Population Health and Health Promotion


Significance of the topic.


Search strategy and justification of the use of literature.

Critical analysis of the literature.

Recommendations for practice.



Significance of The Topic

Smoking is an activity which leads to disability and disease condition in people. It nearly harms every organ of the person and thus makes them ill with the time. For every individual who was involved in smoking and died because of it, 30 people have to live along with a severe illness which is related to smoking. Smoking causes heart diseases, lung diseases, the chronic obstructive pulmonary disease which involves chronic bronchitis and emphysema, cancer, stroke and diabetes. In addition to all of this, it causes the risk of tuberculosis, immune system problem, eye diseases and so on (Centers for Disease Control and Prevention, 2020). With that, smokers generally have low well-being in comparison to the person who is a non-smoker. They also have a low level of mindfulness and thus experiences more negative effects (Barros, Kozasa, Formagini, Pereira & Ronzani, 2015). Smoking and the problems associated with it are overrepresented between the people who have mental illnesses as it has been observed that life expectancy of mentally-ill patients got reduced. Therefore, policies are being made to decrease smoking in the mental healthcare facility. Policies include the ban on smoking by the patient in the hospital setting. Debates are going around about this topic because smoking ban policies enhance the well-being of the patient but also disregard the choice of the person which leads to negative well-being (Woodward & Richmond, 2019). Therefore, in this research, the topic which is taken is the impact of smoking on health and no smoking policy impact on clients in adult in-patient unit in mental health.


Smoking is the process of exhaling or inhaling drugs or tobacco. Most often people use cigarettes for smoking and some individuals also make use of cigars, pipes and cigarillos (West, 2017). Exposure to substances like tobacco and drugs can cause risk of mortality and morbidity in people. Due to smoking, individuals also face depression and thus further develop other mental illnesses. Smoking has been known as the predisposing factor for developing signs and symptoms of depression (Milic et al., 2020). With that, people who are involved in smoking also have a lower quality of life than the people who have not smoked. They also have to experience anxiety and other mental disorders. Physical health of the people also gets affected because of this. Their functional and health status drops down and therefore causes chronic diseases to them (Milic et al., 2020). In addition to that, smoking causes underdeveloped fetus, miscarriages, cancer of the upper respiratory tract and coronary heart diseases. Smoking can also be the foundation of blindness. Fertility in men and women get reduced due to exposure to tobacco and it possesses danger of neonatal death and mental problem in a child. The child could also be born with respiratory diseases. It can further cause vascular dementia and Alzheimer's (West, 2017).

Smoking in the mental-ill patient is far more dangerous than any other individual. Mentally ill patients are found to be associated with more heaving smoking and have high rates of dependency on nicotine. With that, they have to bear with severe withdrawal symptoms. The patients of schizophrenia have an increased amount of psychiatric symptoms and higher rates of hospitalizations in comparison to non-smokers (Prochaska, Das & Young-Wolff, 2017). With that, patients also suffer from the problem of hallucination and delusions. Cigarette smoking moreover leads to alteration in blood levels of psychiatric patients. It also has been associated with suicidal behaviour in mentally-ill patients. In addition to that, smoking can worsen anxiety, substance use, depression and psychosis of patients (Prochaska et al., 2017). Therefore, smoking policies have been formulated for the welfare of the mentally-ill patients so they support and promote smoking cessation and abstinence which is temporary. The policies are also concerned about pathways which could help with the dependence on tobacco (Huddlestone, Sohal, Paul & Ratschen, 2018).

Search Strategy and Justification of The Use of Literature

To find the appropriate information it was necessary to find relevant literature articles that contain the information that is needed to perform the study. The database helps in finding those articles. Therefore, for the given study, articles were founded with the help of CINHAL and SCOPUS databases. They have articles regarding multiple topics such as nursing, healthcare, medicines, biomedicines and so on (Wright et al., 2015). The data was scanned by putting the search within the year 2010-2020 so that only recent study would come in search.

The search was performed in the databases to find relevant and authenticate articles for the study. Multiple processes are being used for search but for this study Boolean operators were utilized for finding the articles and literature. The keywords in addition to that were put into use that helped in easy identification of the relevant literature articles. There are multiple keywords used for the search. They were: Quit smoking, tobacco/cigarette, mental health inpatient unit, mental health, the barriers to quitting, disadvantages of smoking, no-smoking policy, mentally-ill patients, the impact of smoking, no smoke policy, mental health setting, acute setting and mental health ward.

Boolean operators were being used as an efficient strategy for locating the articles. Keywords were used in the combination so that literature could be retrieved from the database. The various combinations were:

Quit smoking AND mental health settings, tobacco/cigarettes AND disadvantage of smoking, no-smoking policy AND mentally-ill patients OR mental health ward, tobacco/cigarettes AND mental health and the patient unit, quit smoking AND mental health OR the barriers to quitting, the disadvantage of smoking AND mentally ill patient OR no smoke policy, acute setting and mental health wards AND no smoke policy OR impact of smoking, no-smoking policy AND mental health inpatient unit. 

So, after putting the keywords in multiple combinations, 26,000 articles were yielded and then after narrowing down to specific keywords only 1100 articles remained in the search section. Then after, from these remaining articles, 9 articles were chosen carefully for the study purpose which has the relevant data for the research that needs to be conducted.

Critical Analysis of The Literature

A critical analysis is done with the help of the Critical Appraisal Skills Programme (CASP) tool (Critical Appraisal Skills Programme, 2018).

Impact of Non-Smoking Policy in Mental Health Patients

In the study conducted by Stockings et al., (2015), it was found out the people with mental problems are most likely to have the habit of smoking and because of that, they suffer from smoking-associated mortality and morbidity. Their life expectancy also gets reduced from 12-15 years. The researchers also reported that high rates of hospitalization are reported among smoking mentally ill patients. Therefore, they considered that smoking cessation is one of the solutions to make the health of mentally ill individuals better than before (Stockings et al., 2015). In their study, they utilized cross-sectional study design which is appropriate to learn about the impact of non-smoking policy in the patients living in the psychiatric ward of the hospital in Australia. The recruitment procedure was also correct and the data collection strategy was appropriate. The findings suggest that 45.9% of people involved in the study have a positive outlook towards the policy and that patient wellbeing and the risk of danger is reduced due to the implementation of the policy. Therefore, this research was highly valuable in knowing about the impact of non-smoking policies (Stockings et al., 2015).

In the study conducted by Fila et al. (2015), it was found out that no-smoking policy in Australia’s mental health institutes and psychiatric institutes have been established within the recent 10 years. These policies range from promoting partial ban to complete ban on the use of cigarettes so lessen the impact on patients health which are related to smoking. For the study, researchers aimed to look at the experiences of people who have to relocate into mental health setting where there was smoke ban policy (Filia et al., 2015). So, for the research, they decided to ask patients their views with the help of the questionnaire before and after the policy implementation. The design and recruitment technique was correct and the data collection was performed by addressing the issue. The findings mentioned that not everyone acknowledges the policy but they smoke much less than before and that their ward is cleaner. Patients also acclaimed that they are experiencing negative emotions which are likely to be because of the withdrawal of nicotine. Therefore, the research was significant in finding views of mental health patients (Filia et al., 2015).

In the study conducted by Huddlestone et al., (2018), they found out that tobacco smoking has severe implications on the mental illnesses which in turn widen the gap of inequalities among the population. Therefore, they aimed to find out about policies implementation. The study design that is used by them was mixed method as it contains collection and analyzing the information about smoking and treatment pattern of the patient and the exploration of patient experiences after the policy put into practice. Therefore, the design was right for the study and the recruitment of the subjects from the mental health setting was also correct. The result shows that behaviour change was observed in patients after smoking cessation. Hence, the statement of finding was clear and the research was also significant about finding the impact of non-smoking policy on people (Huddlestone et al., 2018).

Barriers to Non-Smoking Policies and Their Implementation

In the study conducted by Spaducci et al., (2020), they have mentioned that smoke-free policies which are put in practice may heighten the response of mental health patients. These policies in turn increase the number of cases of physical violence in the mental healthcare setting. Therefore, the researchers aimed to address the management of physical violence so that it could be eliminated as the barrier of implementing no-smoke policy. Scientists looked into the period before the policy and after the policy and the number of violent cases reported. Thus, the research design was relevant to the study and the data collection method was also correct. The results highlighted that events of violence were reduced after the intervention. Therefore, it can be said that the findings were clear according to the research question and the study was significant in telling about preventing smoking-related violence (Spaducci et al., 2020).

In the study conducted by Ratier-Cruz et al., (2020), the researchers have talked about the policies that aimed to make mental health institutes completely smoke-free area with the help of practice of smoking cessation. However, these policies have caused concern among the health care staff in mental institutes as cases of violence and aggression could go high in diseased individuals. Therefore, the paper presented the staff attitude towards the policy. The study was conducted via cross-sectional study design which was appropriate for the research and results pointed that clinicians were very less positive about smoking cessation as they fear there will be increased aggression in patients and they believe that their time and support is a concern for the diseased individuals. Therefore, this study represented that behaviour and intentions could also be a barrier to implementation of no-smoking policy. This research is crucial because it tells about the views and ideas of clinicians in the mental health setting (Ratier-Cruz et al., 2020).

In the study conducted by Grant et al., (2014), the authors suggested that people with the smoking problem have a much higher prevalence of mental illnesses and the problem is multifaced. So, researchers aimed at finding the smoke free ground policies being affected by the institutional cultures. The study design and data collection methodology were appropriate as they utilized the documentation, fieldwork, interviews and observation processes in the psychiatric wards. The results showed that there are multiple factors which affect the implementation of policies. Those were attitude and beliefs, group norms influence, consensus and leadership building. They also suggested that these barriers could be removed if strong leadership is shown to support the people. Therefore, it can be said the findings are following the research aim and the study was relevant as it highlighted more barriers about the implementation of the no-smoking policies (Grant et al., 2014).

The Realistic Aspiration to Implement the No-Smoking Policy in Mental Health Institutes

In the study conducted by Krauth & Apollonio, (2015), the researchers mentioned that people are most likely to die because of tobacco addiction. Thus they aimed to find out about the policies in place to treat the addiction via cessation in the treatment facility with the help of clinical research. The results of the study suggested that reliance on research findings did not have much impact on the policy and cessation was also not implemented properly. Therefore, it can be said that the study was not of much relevance as their research hypothesis failed to tell about the realistic aspiration of implementing the policy in mental health institutes (Krauth & Apollonio, 2015).

In the study conducted by Hurley (2015), the authors outlined the smoking cessation and the concern of implying them in the hospital grounds. The paper did not have a proper design or methodology to discuss the issue as it takes a narrative approach and also the findings which are highlighted are from a personal point of view. The author talks about the non-smoking policy as the extreme step and that patients are not ready for this solution in mental health institutes. For that, he offers a solution that interventions should be introduced to decrease the rate of smoking in mental health patients. Therefore, the paper outlined a clear statement of finding that at this time non-smoking policy might be an extreme step and it is not realistic. Hence, the research is not highly valuable as it is focused on one own belief (Hurley, 2015).

In the research conducted by Zabeen et al. (2015), the researchers mentioned that smoking is one of the biggest concerns in patients with mental problems. The institutes are facing difficulties in the mental health institutes to set implement the policies of no-smoking. Therefore, the researcher aimed to find out about the status of nurse managers on the policy but looking at their smoking habits. Therefore, in the result, it was founded that nurses were in support of no-smoke policy and the non-smoker nurses were likely to adapt to the bans. The smoker nurse managers tend to complain about the enhancement of mental illness in the patients. Hence, it was founded that policies could be implemented if the staff response is there to provide support and education to make the policy implementation successful. Also, the study design and recruitment were appropriate and the findings were in sync with the research aim. Therefore, the study was significant (Zabeen et al., 2015).

Recommendations for Practice

The recommendation for the no-smoking policy implementation could be that support should be provided to the patients in the psychiatric or mental health setting before putting the policy into practice so that, they do not have to go through an extreme level of difficulties. By enhancing the use of interventions, violence and negative behaviour changes in patients can be controlled (Grant et al., 2014). With that support from clinical and nursing staff should also be taken care of. By their help, effort and teamwork, the policies could be implemented and the patient would not have to experience severe complications of the withdrawal (Stockings et al., 2015).

Conclusion on Smoking and No-Smoking Policy

In the conclusion, it can be said that smoking causes various problems in mental health patient. They may experience physical ailments and mental disorders like depression and anxiety. The research aimed to study the impact of smoking and no-smoking policy on mentally-ill patients. For that SCOPUS and CINHAL databases were used for the study. The nine papers were critically discussed by the use of CASP tool and it was found out that no-smoking policy has a positive impact on people but there are barriers present in their implementation such as people's attitude, aggression and violence. The no-smoking policy which is put in use needs more support from nurses and other members of the mental health facility to enhance the well-being of mental health patient.

References for Smoking and No-Smoking Policy

Barros, V. V., Kozasa, E. H., Formagini, T. D., Pereira, L. H., & Ronzani, T. M. (2015). Smokers show lower levels of psychological well-being and mindfulness than non-smokers. PloS One10(8), e0135377. https://doi.org/10.1371/journal.pone.0135377

Centers for Disease Control and Prevention. (2020). Smoking & tobacco use. Available at https://www.cdc.gov/tobacco/basic_information/health_effects/index.htm#:~:text=Smoking%20causes%20cancer%2C%20heart%20disease,immune%20system%2C%20including%20rheumatoid%20arthritis.

Critical Appraisal Skills Programme. (2018). Available at https://www.digiversal.info/portal/upload/2020/09/20200928225244PM-1160370965-3559784-375929767_MAS34256.pdf

Filia, S. L., Gurvich, C. T., Horvat, A., Shelton, C. L., Katona, L. J., Baker, A. L., Stafrace, S., Keppich-Arnold, S., & Kulkarni, J. (2015). Inpatient views and experiences before and after implementing a totally smoke-free policy in the acute psychiatry hospital setting. International Journal of Mental Health Nursing24(4), 350–359. https://doi.org/10.1111/inm.12123

Grant, L. G., Oliffe, J. L., Johnson, J. L., & Bottorff, J. L. (2014). Health care professionals implementing a smoke-free policy at inpatient psychiatric units. Qualitative Health Research24(12), 1732–1744. https://doi.org/10.1177/1049732314549026

Huddlestone, L., Sohal, H., Paul, C., & Ratschen, E. (2018). Complete smoke-free policies in mental health inpatient settings: Results from a mixed-methods evaluation before and after implementing national guidance. BMC Health Services Research18(1), 542. https://doi.org/10.1186/s12913-018-3320-6

Huddlestone, L., Sohal, H., Paul, C., & Ratschen, E. (2018). Complete smoke-free policies in mental health inpatient settings: Results from a mixed-methods evaluation before and after implementing national guidance. BMC Health Services Research18(1), 542. https://doi.org/10.1186/s12913-018-3320-6

Hurley, D. (2015). How does enforcement of smoke-free grounds in acute mental health settings sit with "recovery" focused practice? A personal view. Mental Health and Social Inclusion.

Krauth, D., & Apollonio, D. E. (2015). Overview of state policies requiring smoking cessation therapy in psychiatric hospitals and drug abuse treatment centers. Tobacco Induced Diseases13(1), 33.

Milic, M., Gazibara, T., Pekmezovic, T., Kisic Tepavcevic, D., Maric, G., Popovic, A., Stevanovic, J., Patil, K. H., & Levine, H. (2020). Tobacco smoking and health-related quality of life among university students: Mediating effect of depression. PloS One, 15(1), e0227042. https://doi.org/10.1371/journal.pone.0227042

Prochaska, J. J., Das, S., & Young-Wolff, K. C. (2017). Smoking, mental illness, and public health. Annual Review of Public Health38, 165–185. https://doi.org/10.1146/annurev-publhealth-031816-044618

Ratier-Cruz, A., Smith, J. G., Firn, M., & Rinaldi, M. (2020). Staff attitudes to completely smoke-free policies and smoking cessation practices in a mental health setting. Journal of Public Health (Oxford, England)42(2), 403–411. https://doi.org/10.1093/pubmed/fdaa033

Spaducci, G., McNeill, A., Hubbard, K., Stewart, D., Yates, M., & Robson, D. (2020). Smoking-related violence in a mental health setting following the implementation of a comprehensive smoke-free policy: A content analysis of incident reports. International Journal of Mental Health Nursing29(2), 202–211. https://doi.org/10.1111/inm.12659

Stockings, E. A., Bowman, J. A., Bartlem, K. M., McElwaine, K. M., Baker, A. L., Terry, M., Clancy, R., Knight, J., Wye, P. M., Colyvas, K., & Wiggers, J. H. (2015). Implementation of a smoke-free policy in an inpatient psychiatric facility: Patient-reported adherence, support, and receipt of nicotine-dependence treatment. International Journal of Mental Health Nursing24(4), 342–349. https://doi.org/10.1111/inm.12128

West R. (2017). Tobacco smoking: Health impact, prevalence, correlates and interventions. Psychology & Health32(8), 1018–1036. https://doi.org/10.1080/08870446.2017.1325890

Woodward, E. R., & Richmond, R. (2019). Smoking bans in psychiatric units: An issue of medical ethics. Frontiers in Psychiatry10, 134. https://doi.org/10.3389/fpsyt.2019.00134

Wright, K., Golder, S., & Lewis-Light, K. (2015). What value is the CINAHL database when searching for systematic reviews of qualitative studies?. Systematic Reviews4(1), 104.

Zabeen, S., Tsourtos, G., Campion, J., & Lawn, S. (2015). Type of unit and population served matters when implementing a smoke-free policy in mental health settings: Perceptions of unit managers across England. The International Journal of Social Psychiatry61(7), 700–710. https://doi.org/10.1177/0020764015575799

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