Recent studies in adolescents have found a weak association between lower self-esteem and smoking. However, this association has not been investigated in a psychiatric setting. In 223 inpatient adolescents [140 girls (16.5 years) and 83 boys (16.4 years)], self-esteem was measured with Coopersmith's self-esteem inventory (SEI), and smoking dependence with the Fagerström Test for Nicotine Dependence (FTND). DSM-IV categories included major depression (n=35), anxiety disorders (n=35), psychotic disorders (n=31), eating disorders (n=9), and conduct disorders (n=113). There were 101 smokers and 122 nonsmokers. Self-esteem scores were lower in smokers than in nonsmokers (p=0.039). Self-esteem scores were very significantly lower in smokers showing moderate or high nicotine dependence (i.e., FTND score>or=4) when compared with nonsmokers (p=0.002). Smoking with moderate or high nicotine dependence was associated with lower self-esteem in both girls and boys, whereas smoking with no or low nicotine dependence was associated with lower self-esteem only in girls. Smoking was associated with lower self-esteem in all diagnostic categories, except in eating disorders. Interventions targeted on self-esteem might be used to prevent smoking in adolescents with mental disorders.