This is the first study assessing inpatients’ smoking behaviour in a non-smoking psychiatric unit in Greece. In our study, we monitored the smoking habits of patients admitted at a non-smoking psychiatric department and the patients were actively encouraged to reduce their CPD. We found that with this simple intervention, most of the smokers (83.5%) managed to reduce their cigarette consumption per day. The mean difference was 18.07 CPD (sd 19.9), and this was statistically significant (t = 11.7, p < 0.001). Patients with schizophrenia and mood disorders did not differ in their reduction of CPD. The only factor that predicted reduction in CPD was the female sex.

Greece has one of the highest smoking rate in the world and the highest rate (more than 40%) in the European Union with the second highest consumption of cigarettes per day (21.4) according to the Eurobarometer (Special Survey on Tobacco 332 (EB 72.3)) [3]. At the time of the study, Greece had a specific legislation about smoking prevention, but this was too old (1979) and there were too many violations, even in hospitals. At that time, there was discussion on the pros and cons of enforcing a smoking ban [4]. This difficulty in enforcing a cigarette smoking ban is even more pronounced in psychiatric units that until now have not been able to implement a total cigarette ban since there is concern that a smoking ban will lead to an increase of violent incidents [5]. The opening of a new psychiatric inpatient unit offered a unique opportunity to study the effect of a total smoking ban on the ward with patients who had never been hospitalized in this unit.

Smoking is common among patients admitted in psychiatric units worldwide [6]. This finding is closely associated with the diagnosis of schizophrenia. Several studies have shown that after correcting for possible confounders, such as demographic and socioeconomic status, alcohol and antipsychotic use, or institutionalization, higher rates of smoking are still found in schizophrenia across cultures and countries [1,6]. It is unknown why there is such widespread smoking in patients with schizophrenia. Some evidence seems to support that nicotine may help alleviate negative symptomatology, reduce side effects of antipsychotic medications and possibly ameliorate cognitive deficits [7,8]. Our study’s findings are in concordance with the scientific literature: Patients with schizophrenia smoke significantly more than the patients suffering from mood disorders (83/177 vs. 56/138, χ 2 = 4.8, p = 0.03).

Regarding sex differences’ effect on reducing smoking behaviour, literature findings are controversial. A Spanish population cohort study has reported that the average reduction in the number of cigarettes among subjects who reduced their tobacco consumption was similar in men and women (13 cigarettes/day) [9]. On the other hand, a Danish population study has shown that quitting smoking was positively associated with the male gender, older age, impaired lung function and being a moderate smoker (15–24 g/day) and negatively associated with inhaling the smoke [10]. Our study included only inpatients in a psychiatric unit. We found that female inpatients benefited more than males from our intervention. Our finding is in concordance with a Korean study in which females were less likely to be current smokers and more likely to be former smokers [11].

Though psychiatric inpatients smoke at high rates, interventions to reduce smoking and deal with nicotine addiction are scarce [2]. Nevertheless, there are studies that have underlined the need for cessation advice and appropriate follow-up care to psychiatric inpatient smokers [12,13]. The role of the nursing staff in helping psychiatric inpatients to avoid smoking is crucial [14,15]. It has been suggested that the reasons for these low rates of assessment and treatment may include the health professionals’ acceptance of smoking by psychiatric patients as a matter of individual rights and as a means of self-medication aimed at relieving symptoms or medication side effects. Staff generally anticipated more smoking-related problems than actually occurred. On the other hand, it has been observed that “There was no increase in aggression, use of seclusion, discharge against medical advice or increased use of as-needed medication following a smoking ban” [16]. It has been also shown that patients with schizophrenia under medication who quit smoking do not suffer deterioration in their mental health or quality of life [17]. It is also noteworthy that patients themselves and their relatives are interested in reducing the number of cigarettes that they smoke [14]. Our study showed that when the medical and nursing staff made consistent yet simple efforts in order to help patients, their smoking was substantially curtailed.

We have to report some limitations of the present study. Because of its naturalistic design, we did not include a control group (patients that were informed that smoking was not allowed but were not given any help or instructions by the nursing staff). This was not done because the therapeutic team did not want to give the message that some patients were receiving more attention and had been treated differently by the nursing staff during their hospitalization.