In the shadow of a new smoke free policy: A discourse analysis of health care providers' engagement in tobacco control in community mental health

Abstract

BackgroundThe prevalence of tobacco use among individuals with mental illness remains a serious public health concern. Tobacco control has received little attention in community mental health despite the fact that many individuals with mental illness are heavy smokers and experience undue tobacco-related health consequences.MethodsThis qualitative study used methods of discourse analysis to examine the perceptions of health care providers, both professionals and paraprofessionals, in relation to their roles in tobacco control in the community mental health system. Tobacco control is best conceptualised as a suite of policies and practices directed at supporting smoke free premises, smoking cessation counselling and limiting access to tobacco products. The study took place following the establishment of a new policy that restricted tobacco smoking inside all mental health facilities and on their grounds. Ninety one health care providers participated in open-ended interviews in which they described their role in tobacco control. The interview data were analyzed discursively by asking questions such as: what assumptions underlie what is being said about tobacco?ResultsFive separate yet overlapping discursive frames were identified in which providers described their roles. Managing a smoke free environment emphasised the need to police and monitor the smoke free environment. Tobacco is therapeutic was a discourse that underscored the putative value of smoking for clients. Tobacco use is an individual choice located the decision to smoke with individual clients thereby negating a role in tobacco control for providers. It's someone else's role was a discourse that placed responsibility for tobacco control with others. Finally, the discourse of tobacco control as health promotion located tobacco control in a range of activities that are used to support the health of clients.ConclusionsThis study provides insights into the complex factors that shape tobacco control practices in the mental health field and reinforces the need to see practice change as a matter that extends beyond the individual. The study findings highlight discourses structured by power and powerlessness in environments in which health care providers are both imposing and resisting the smoke free policy.

A mixed-method systematic review and meta-analysis of mental health professionals' attitudes toward smoking and smoking cessation among people with mental illnesses

“…This is in contrast to evidence that smoking cessation, if not actually benefitting mental health, does not impact mental health negatively in people with or without psychiatric disorders 20, even in life‐long, long‐term smokers 21, and that smokers with mental illnesses are just as likely to want to quit as smokers without 22. MHPs have also been reported to hold permissive attitudes towards smoking, such as the belief that smoking with patients can help build a therapeutic relationship 15, 23, 24 and that allowing patients to smoke ensures a smoother running of wards in in‐patient settings 19.…”

“…For instance, previous research has identified that some hold concerns that patients' mental health or abstinence will suffer 14, 15, 16, 17 and that smokers are unable 18 or unmotivated to quit 19. This is in contrast to evidence that smoking cessation, if not actually benefitting mental health, does not impact mental health negatively in people with or without psychiatric disorders 20, even in life‐long, long‐term smokers 21, and that smokers with mental illnesses are just as likely to want to quit as smokers without 22.…”

Implementing Tobacco Education and Cessation Services at a Large Community Mental Health Center: Lessons Learned

“…While the behavioral health system has come a long way, smoking bans still precipitate concerns about a breakdown of the therapeutic milieu in treatment settings (Johnson et al, 2010). Some behavioral health staff may view tobacco bans with ambivalence, believing that policy enforcement should be someone else's role.…”

“…Some behavioral health staff may view tobacco bans with ambivalence, believing that policy enforcement should be someone else's role. Engaging clinical, clerical, and housekeeping staff in the smoke-free policy should include sufficient and ongoing opportunities for input, personal support, and education on both cessation practices and reasoning for the ban (Johnson et al, 2010;.…”

“…Despite increasing efforts to address tobacco use in behavioral health facilities, a gap around tobacco treatment and policies persists (Stuyt, Order-Connors, & Ziedonis, 2003;Ziedonis, Parks, Zimmermann, & McCabe, 2007). Long-held beliefs about the therapeutic effects of tobacco endure among many behavioral health clinicians, stymieing efforts to debunk the remnants of a smoking culture that persist in the behavioral health field (Johnson, Moffat, & Malchy, 2010).…”