Total smoking bans in psychiatric inpatient services: a survey of perceived benefits, barriers and support among staff

Comfort levels in discussing tobacco smoking among hospital staff in a children's hospital

INTRODUCTION

Hospital staff discussing smoking with children and their families can impact tobacco control, which is crucial in reducing the harmful effects of tobacco smoke exposure. Our study aims to assess staff comfort level in discussing smoking with patients or their families, and coworkers, after the implementation of a hospital-wide tobacco control policy.

METHODS

This cross-sectional study included 2340 staff members who completed an anonymous online survey in a large urban children's hospital in 2019. The main outcomes of interest were the comfort level in discussing smoking with patients or their families, and co-workers. We used multivariable logistic regression to identify whether the comfort level varied by sex, age, job type, and smoking status.

RESULTS

Most of the respondents (83.8%) were female, 41.2% were aged 18-35 years, 57.6% worked as clinical staff, and 15.5% were ever smokers. Compared to males, females were less likely to feel very comfortable in asking patients or their families about their smoking tobacco (adjusted odds ratio, AOR=0.72; 95% CI: 0.56-0.92) or talking to co-workers about the health risks associated with their smoking (AOR=0.71; 95% CI: 0.54-0.93). Staff who were non-smokers were less likely to feel very comfortable in talking to co-workers about the health risks associated with their smoking (AOR=0.60; 95% CI: 0.45-0.78). The odds of feeling very comfortable in discussing smoking were consistently lower among those aged 18-35 years than their older counterparts. Clinical staff were more likely than non-clinical staff to feel very comfortable in discussing with patients and their parents about smoking, but there was no difference when talking to co-workers.

CONCLUSIONS

We found differences in staff comfort level in discussing smoking with patients or their families, and coworkers, by sex, age, job type, and smoking status. These results can guide training and identify potential barriers and improve tailored tobacco control training programs and policies for hospital staff.

A selective literature review exploring the role of the nicotinic system in schizophrenia

Nicotine use is more prevalent in patients with psychiatric disorders, especially those diagnosed with psychotic illnesses. Previously, this higher prevalence has been partially attributed to the potential ameliorative effects of nicotine on symptom severity and cognitive impairment. Some healthcare professionals and patients perceive there is a beneficial effect of nicotine on mental health. Emerging data show that the harm associated with nicotine in the population of patients with mental health conditions outweighs any potential benefit. This paper will review the evidence surrounding the nicotinic system and schizophrenia, with a focus on any causality between nicotine and psychosis.

Nurses’ Perspectives on Smoking Policies, Safety and Cessation Support in Psychiatric Wards: A Cross-Sectional Survey

A high prevalence of smoking and low rates of smoking cessation interventions can be observed in psychiatric wards. A questionnaire-based, cross-sectional study was performed in five hospitals among 107 psychiatric ward nurses. The aim was to investigate nurses’ views on patients’ smoking practices and their influence on the safety of both the patients and medical personnel. In addition, we asked about the availability of smoking cessation support. Most of the respondents noticed the negative impacts of smoking on patients and medical personnel. Nearly a third of our respondents (29.0%) recalled smoking-related accidents in their facilities. In 45.2% of these accidents, a patient set someone else on fire. Around one fifth of nurses had rather permissive attitudes towards tobacco use in hospital wards. Significant associations were identified between respondents’ smoking status and their opinions on amending smoking policies and on unsupervised smoking. Regarding professional help available to smoking patients, 88.8% of participants reported that interventions to address smoking were available in their wards. Psychiatric hospitalisation can be an opportunity to offer tobacco treatment to patients with mental health conditions. To make use of this opportunity, smoke-free policies need to be put in place and hospital personnel, particularly nurses, should be trained and equipped with the knowledge and skills needed to assist in the smoking care of psychiatric ward patients.

Support and attitudes of Qatar mental health professionals to a proposed mental health inpatient smoking ban: Results of a cross-sectional survey

WHAT IS KNOWN ON THE SUBJECT?: Smoking is more common among people with serious mental illness, and it contributes to a reduced life expectancy. Several Western countries have successfully introduced smoke-free policies in inpatient mental health units. There is virtually no information about attitudes to smoking bans in mental health units from countries in the Middle East and North Africa region. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: We surveyed mental health professionals working in Qatar's main mental health service to determine support for and attitudes towards a proposed total smoking ban in psychiatric wards. Most staff who completed the survey supported an inpatient smoking ban. However, further analysis, both quantitative and qualitative, showed markedly ambivalent attitudes, that is staff simultaneously held attitudes that supported and opposed a smoking ban. Professionals who did not support a ban were more likely to have not received smoking cessation training in the last 5 years, to be a psychiatrist rather than a nurse or allied mental health professional, to be current smokers and to be a Middle Eastern and North African national. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Further staff training is necessary to achieve more consistent attitudes that support a total smoking ban and increase the likelihood of successful implementation. The attitudes in this study showed similarities and differences to those reported for mental health professionals in Western countries. This highlights that local research is necessary to help shape training and successfully implement smoke-free policies. ABSTRACT: Introduction Despite the fact that patients with serious mental illness (SMI) have high rates of smoking and an increased standardized mortality, there is virtually no information about attitudes to smoking bans in mental health units from countries in the Middle East and North Africa region. Aim To assess support for, and attitudes towards, a proposed total smoking ban in psychiatric wards among mental health clinicians in Qatar. Method Cross-sectional survey of mental health professionals working in Qatar's primary mental health service. Results The response rate was 68% (353/520). Support for a ban was assessed with a single-item question; 73% of respondents supported a ban with opposition significantly (p < .05) associated with being a current smoker, a Middle Eastern and North African (MENA) national, a psychiatrist versus a mental health nurse or allied health professional and not receiving smoking cessation training in the last 5 years. A 21-item questionnaire assessed attitudes to a total smoking ban. It showed marked ambivalence with multiple linear regression identifying MENA nationality, male gender and current smoking status as independent variables influencing attitudes. The most strongly held attitude supporting a ban was concern about passive smoking and against a ban was concern it may increase patient agitation. Qualitative data confirmed ambivalent views. Discussion The results show similarities and differences to research from other countries suggesting that cultural factors influence some attitudes to smoke-free policies. Implications for Practice Staff support and smoking cessation education are necessary to achieve more consistent staff attitudes to support smoke-free policies.

Staff attitudes to completely smoke-free policies and smoking cessation practices in a mental health setting

BACKGROUND

Mental health trusts in England were expected to become completely smoke-free and embed smoking cessation practices by 2018. Such policies are fraught with concerns and have received mixed support from mental health staff. Understanding staff attitudes to these practices prior to enforcement of the policy could help design an effective implementation strategy.

METHODS

A cross-sectional survey was conducted with clinical and non-clinical staff in a Mental Health Trust to understand smoking cessation practices and attitudes to the implementation of a completely smoke-free policy.

RESULTS

There were 631 responses. Most participants disagreed with the policy on wards (59.6%) and throughout all mental health settings (57.4%). Clinicians expressed significantly lower organizational policy support (P = 0.001) than non-clinicians (P = 0.001). Psychiatrists were more supportive of the organizational items than nurses and allied health professionals. Clinicians' attitudes towards smoking cessation practices were less positive for those who were current smokers (P < 0.001), but more positive for clinicians who had received or were interested in attending smoking cessation training (P < 0.001).

CONCLUSIONS

Partial and completely smoke-free policies remain unsupported by staff in mental health settings. Smoking cessation training appears to reinforce rather than alter attitudes towards smoking cessation.

Hospital staff perspectives on the provision of smoking cessation care: a qualitative description study

OBJECTIVE

To explore the perspectives of hospital staff regarding the provision of smoking cessation care.

STUDY DESIGN

A qualitative description study using focus group discussions.

STUDY SETTING

Data were collected across metropolitan regional and rural hospitals in Victoria, Australia, between November and December 2019.

PARTICIPANTS

Clinical and non-clinical hospital staff.

RESULTS

Five focus groups were conducted across four hospitals. Staff (n=38) across metropolitan regional and rural hospitals shared similar views with regards to barriers and facilitators of smoking cessation care. Four themes were present: (1) Clinical Setting wherein views about opportunity and capacity to embed smoking cessation care, relevant policies and procedures and guidelines were discussed; (2) Knowledge consisted of the need for training on the provision of pharmacotherapy and behavioural interventions, and awareness of resources; (3) Consistency represented the need for a consistently applied approach to smoking cessation care by all staff and included issues of staff smoking; and (4) Appropriateness consisted of questions around how smoking cessation care can be safely delivered in the context of challenging patient groups and different settings.

CONCLUSIONS

Staff across metropolitan regional and rural hospitals experience similar views and identified shared barriers in implementing smoking cessation care. Responding to staff concerns and providing support to address smoking with patients will help to foster a consistent approach to cessation care. Clear practice guidelines for multidisciplinary clinical roles need to underpin staff training in communication skills, include priorities around smoking cessation care, and provide the authorising environment in which clinical staff actively provide smoking cessation care.

The right to smoke and the right to smoke-free surroundings: international comparison of smoke-free psychiatric clinic implementation experiences

BACKGROUND

In Scandinavia, people with a severe mental disorder have a reduced life expectancy of 15-20 years compared with the general public. Smoking is a major contributor, and smoke-free policies are increasingly adopted in psychiatric clinics around the world. We compared potential facilitators and barriers among staff and management, for the implementation of smoke-free psychiatric clinics.

AIMS

To investigate the attitudes and experiences regarding smoke-free policies among managers and staff involved in the implementation processes of smoke-free psychiatric clinics at hospitals in Malmö (Sweden) and Barcelona (Spain).

METHOD

We used a qualitative methodology, with 15 semi-structured interviews. The interviews were conducted with each participant individually, and were subsequently transcribed. The data were analysed with systematic text condensation.

RESULTS

There were notable differences in how the smoke-free policies were carried out and experienced, and attitudes regarding the policy changes differed in the two settings. Key differences were the views on the right to smoke in compulsory care and to stay in smoke-free surroundings supported by smoking cessation intervention; the prioritisation of staff facilitation of smoking breaks; and views on smoking and smoke-free psychiatry. In contrast, participants agreed on the importance of staff education and management support. A smoking ban by law and belonging to a network of smoke-free hospitals were also relevant.

CONCLUSIONS

Staff education, and support from staff and management for the patients' right to stay in smoke-free surroundings, facilitated successful implementation of smoke-free policies in the psychiatric clinics, whereas supporting the right to smoke was a barrier.

Supporting mental health service users to stop smoking: findings from a process evaluation of the implementation of smokefree policies into two mental health trusts

BACKGROUND

Life expectancy is 10-20 years lower among people with a severe mental health disorder. Most of these early deaths are due to chronic conditions, including cardiovascular and respiratory diseases. Smoking is a major risk factor for these conditions and introducing smokefree policies has been recommended to mental health service providers in England by the National Institute for Health and Care Excellence (NICE), in their Public Health Guideline 48: Smoking: acute, maternity and mental health services. This paper reports a process evaluation of introducing these policy recommendations, which were updated in 2013.

METHOD

Process data were collected through semi-structured interviews with staff (n = 51), members of partnering organisations (n = 5), service users (n = 7) and carers (n = 2) between November 2016 - April 2017. Normalization Process Theory (NPT) was used to design the data collection tools and analyse the data. A framework approach was taken with the analysis, using the four concepts of NPT: coherence, cognitive participation, collective action and reflexive monitoring.

RESULTS

The policy made sense to some staff, patients and carers (coherence) who 'bought-into' the idea (cognitive participation) but other participants disagreed. Although smokefree policies were operationalised (collective action), sometimes they were opposed. Progress was made, especially in some units, but continued to be resisted in others. Informal appraisal of progress (reflexive monitoring) presented a varied picture.

CONCLUSION

Some progress has been made in terms of changing an entrenched, smoking culture into one that is smokefree on Trust sites across the region. Perseverance and resourcing over the long-term is required to establish a non-smoking culture in on-site provision of mental health services.

Preventive care for physical activity and fruit and vegetable consumption: a survey of family carer expectations of health service delivery for people with a mental health condition

Background

Chronic disease is a leading cause of death globally, where inadequate fruit and vegetable consumption and inadequate physical activity are consistently implicated as key contributing risk factors for such diseases. People with a mental health condition are reported to experience a higher prevalence of such risks and experience an increased morbidity and mortality from resultant chronic disease. Despite guidelines identifying a need for services accessed by people with a mental health condition to provide care to address such health risk behaviours, sub-optimal care is frequently reported suggesting a need for innovative strategies to increase the provision of physical health care. An exploratory study was conducted to examine: 1) family carers’ expectations of care provision regarding fruit and vegetable consumption and physical activity by health and community services for people with a mental health condition; 2) carer’s own health risk behaviour status and perceptions of the influence of the health risk behaviours on mental health; and 3) possible associations of socio-demographic, clinical and attitudinal factors with carer expectations of care provision for fruit and vegetable consumption and physical activity.

Methods

Family carers (n = 144) of a person with a mental health condition completed a cross-sectional survey. Participants were members of a mental health carer support organisation operating in New South Wales, Australia.

Results

A high proportion of participants considered care for fruit and vegetable consumption and physical activity respectively should be provided by: mental health hospitals (78.5, 82.7%); community mental health services (76.7, 85.9%); general practice (81.1, 79.2%); and non-government organisations (56.2, 65.4%). Most participants perceived adequate fruit and vegetable consumption (55.9%), and physical activity (71.3%) would have a very positive impact on mental health. Carers who perceived adequate fruit and vegetable consumption and physical activity would have a positive impact on mental health were more likely to expect care for such behaviours from some services.

Conclusions

The majority of participants expected care for fruit and vegetable consumption and physical activity be provided by all services catering for people with a mental health condition, reinforcing the appropriateness for such services to provide physical health care for clients in a systematic manner.

Non-compliance and associated factors against smoke-free legislation among health care staffs in governmental hospitals in Addis Ababa, Ethiopia: an observational cross-sectional study

Background

In 2014, the Ethiopian government passed a new smoking legislation that banned smoking in public and workplaces including health care facilities. However, data’s on level of non-compliance and associated factors with non-compliance towards smoke-free legislation in hospital settings of the country has not been studied yet.

Methods

Hospital-based Cross-sectional study design triangulated with observational study was conducted in five hospitals. Data were collected through direct observation and interviews using checklist, structured and pre-tested questionnaires for observational study and survey of hospital employee respectively. Nine data collectors and one supervisor were involved in data collection. Three hundred fifty (350) health care staffs were interviewed. Fifteen (15) buildings were purposively observed for observational non-compliance in the selected hospitals. Data were entered by Epi Info and analyzed using SPSS version 21 software. Logistic regression was used to compute the crude and adjusted odds ratios for the factors affecting employee non-compliance with the legislation. A p-value of < 0.05 at 95% CI was considered to be statistically significant.

Results

Anti-smoking signs were absent from a high proportion of hospital areas (97% overall) although visible cigarette butts were generally not observed in most areas of the hospitals. Non-compliance level among health care staffs was 50(10.3%).Associated factors affecting to the non-compliance level of the staff were: being male (AOR = 5.89, p value = 0.001), having poor knowledge (AOR = 2.71, p-value = 0.022) and having Unfavorable attitudes (AOR = 6.15, p-value = 0.000).

Conclusions

Non-compliance level was high and needs careful implementation for 100% smoke-free legislation in addressing knowledge and attitudes of health care staffs.

Moving Beyond the Behavior-Change Framework for Smoking Cessation: Lessons for a Critical Ontology From the Case of Inpatient Psychiatric Units

BACKGROUND: Leading scholars have called on nursing schools to pay more attention to smoking cessation in the education of nursing students. AIM: This article argues that attention to this subject should include a rethinking of the behavior-change framework that forms the methodological basis of this field. METHOD: Drawing on classic and contemporary work in sociology, anthropology, and critical public health, this article explores the specific example of smoking in long-term inpatient units to illustrate the limitations of a behavior-based ontology and suggest an alternative conceptual vocabulary. RESULTS: An alternative approach posits smoking as a social practice. It sheds light on situational factors that incentivize smoking and might be contributing to patient resistance to cessation. CONCLUSIONS: A different conceptual framing of smoking can point to interventions beyond the level of individuals, focusing instead on the broader interface between people and situations, where decisions and desires meet institutional and organizational dynamics and structures of opportunity and access.

An Exploration of the Perspectives of Associate Nurse Unit Managers Regarding the Implementation of Smoke-free Policies in Adult Mental Health Inpatient Units

CONTEXT

In Adult Mental Health Inpatient Units, it is not unexpected that leadership of Associate Nurse Unit Managers contributes to successful implementation of smoke-free policies.

AIM

In light of challenges facing mental health nursing, and limited research describing their leadership and the role it plays in addressing smoke-free policy implementation, the aim of this study is to explore Associate Nurse Unit Managers perspectives' regarding the implementation of smoke-free policies, which were introduced on 1 July, 2015.

DESIGN, SETTING, PARTICIPANTS

Individual in-depth semi-structured interviews were undertaken six months post the implementation of smoke-free policies. In this qualitative descriptive study, six Associate Nurse Unit Managers working in a Victorian public Adult Mental Health Inpatient Unit, were asked eight questions which targeted leadership and the implementation and enforcement of smoke-free policies. Associate Nurse Unit Managers provide leadership and role modeling for staff and they are responsible for setting the standards that govern the behavior of nurses within their team. All participants interviewed believed that they were leaders in the workplace.

MAIN OUTCOMES

Education and consistency were identified as crucial for smoke-free policies to be successful. Participants acknowledged that the availability of therapeutic interventions, staff resources and the accessibility of nicotine replacement therapy were crucial to assist consumers to remain smoke-free while on the unit.

CONCLUSION

The findings from this research may help to improve the understanding of the practical challenges that Associate Nurse Unit Manager's face in the implementation of smoke-free policies with implications for policies, nursing practice, education and research.

Supporting change in chronic disease risk behaviours for people with a mental illness: a qualitative study of the experiences of family carers

Background

People with a mental illness experience greater chronic disease morbidity and mortality, and associated reduced life expectancy, compared to those without such an illness. A higher prevalence of chronic disease risk behaviours (inadequate nutrition, inadequate physical activity, tobacco smoking, and harmful alcohol consumption) is experienced by this population. Family carers have the potential to support change in such behaviours among those they care for with a mental illness. This study aimed to explore family carers’: 1) experiences in addressing the chronic disease risk behaviours of their family members; 2) existing barriers to addressing such behaviours; and 3) perceptions of potential strategies to assist them to provide risk behaviour change support.

Methods

A qualitative study of four focus groups (n = 31), using a semi-structured interview schedule, was conducted with carers of people with a mental illness in New South Wales, Australia from January 2015 to February 2016. An inductive thematic analysis was employed to explore the experience of carers in addressing the chronic disease risk behaviours.

Results

Two main themes were identified in family carers’ report of their experiences: firstly, that health behaviours were salient concerns for carers and that they were engaged in providing support, and secondly that they perceived a bidirectional relationship between health behaviours and mental well-being. Key barriers to addressing behaviours were: a need to attend to carers’ own well-being; defensiveness on behalf of the family member; and not residing with their family member; with other behaviour-specific barriers also identified. Discussion around strategies which would assist carers in providing support for health risk behaviours identified a need for improved communication and collaboration between carers and health services accessed by their family members.

Conclusions

Additional support from general and mental health services accessed by family members is desired to assist carers to address the barriers to providing behaviour change support. Carers have the potential to support and extend health service interventions aimed at improving the chronic disease risk behaviours of people with a mental illness but may require additional information, and collaboration from services. Further research is needed to explore these constructs in a large representative sample.

Violence in mental health settings: A systematic review

The introduction of smoke-free policies is increasingly common in mental health settings, to improve health. However, a barrier to implementing smoke-free polices is staff concern that violence will increase. We conducted a systematic review comparing the rates of violence before and after the introduction of smoke-free policies in mental health settings. Two authors searched major electronic databases. We included studies reporting the prevalence of violence (verbal and/or physical or combined) before and after the introduction of a smoke-free policy in a mental health, forensic, or addiction setting. We included 11 studies in the review. A narrative synthesis was used to describe the key results of each study. Six studies measured physical violence specifically; four reported a decrease or no change and two reported a short-term increase. Five of these six studies also measured verbal violence; two found an increase, with one of the studies reporting that this increase was temporary. Three reported a decrease in verbal violence. A further five studies evaluated the rate of combined verbal and physical violence; four reported a decrease or no change and the other an increase. We conclude that the introduction of smoke-free policies generally does not lead to an increase in violence. There is a need for more robust studies to support this finding. However, the conclusions from this review may be a step in reducing staff concerns.

Exploring the Potential for Family Carers to Support People With Mental Illness to Stop Smoking

Cigarette smoking poses significant health burdens for people with mental illness. They die sooner than they should, and smoking is a major contributor to their high rates of morbid chronic physical health conditions and early mortality, compared to the general population. Family carers provide important support to people with mental illness. However, family carers' perspectives of smoking by their family members with mental illness are largely absent from the research literature and from practice, despite smoking rates remaining high and quit rates remaining low for this population. We know little about how family carers are or could be involved in supporting people with mental illness who smoke to stop smoking. This paper aims to provide a discussion of the opportunities for family carers to support their family member's smoking cessation and a discussion of our preliminary research on this topic. From the available literature, it appears that family carers are well placed to support smoking cessation for this population; however, they struggled physically, philosophically, and emotionally with perceived responsibilities involving their family member's smoking and the caring role. They felt isolated and asserted that there was limited support from service providers to assist them. We concluded that family carers are important agents within the person's immediate environment who could help them to improve their smoking cessation success. This suggests also that mental health services and other health service providers could benefit from including family carers in their efforts to support smoking cessation for people with mental illness who smoke.

Smoking Cessation Care for People with a Mental Illness: Family Carer Expectations of Health and Community Services

Introduction: Smoking prevalence remains high among people with a mental illness, contributing to higher levels of morbidity and mortality. Health and community services are an opportune setting for the provision of smoking cessation care. Although family carers are acknowledged to play a critical role in supporting the care and assistance provided by such services to people with a mental illness, their expectations regarding the delivery of smoking cessation care have not been examined.

Aims: To explore family carer expectations of smoking cessation care provision by four types of health services, to clients with a mental illness, and factors associated with expectations.

Methods: A cross-sectional survey was conducted with carers of a person with a mental illness residing in New South Wales, Australia. Carers were surveyed regarding their expectations of smoking cessation care provision from four types of health services. Possible associations between carer expectation of smoking cessation care provision and socio-demographic and attitudinal variables were explored.

Results: Of 144 carers, the majority of carers considered that smoking cessation care should be provided by: mental health hospitals (71.4%), community mental health services (78.0%), general practice (82.7%), and non-government organisations (56.6%). The factor most consistently related to expectation of care was a belief that smoking cessation could positively impact mental health.

Conclusions: The majority of carers expected smoking cessation treatment to be provided by all services catering for people with a mental illness, reinforcing the appropriateness for such services to provide smoking cessation care for clients in an effective and systematic manner.

Type of unit and population served matters when implementing a smoke-free policy in mental health settings: Perceptions of unit managers across England

BACKGROUND

Globally, smoking remains a significant issue for mental health populations. Many mental health trusts in England are facing challenges of implementing the National Institute for Health and Care Excellence guidance according to which all mental health settings, no matter the type, should be entirely smoke-free and provide comprehensive smoking cessation support.

AIM

The aim of this paper was to determine if unit type and unit manager smoking status influence mental health smoke-free policy implementation.

METHOD

This paper reports on the secondary analysis of data from a cross-sectional survey of 147 mental health inpatient settings in England, in 2010. The original study's main aim was to understand unit managers' perceived reasons for success or failure of smoke-free policy.

RESULTS

Unit managers (n = 131) held a positive stance towards supporting smoke-free policy and most perceived that the policy was successful. Non-smoker unit managers were more likely to adopt complete bans than smoker unit managers, whereas smoker unit managers were more likely than non-smoker unit managers to think that stopping smoking aggravated patients' mental illness. Smoking rates for staff and patients remain high, as perceived by unit managers, regardless of unit type. Proportion of units offering nicotine replacement therapy and peer support to patients was significantly higher in locked units compared to semi-locked or residential rehabilitation. Applied strategies significantly vary by type of unit, whereas unit managers' knowledge, attitude and practices vary by their smoking status.

DISCUSSION

There are nuanced differences in how smoke-free policy is enacted which vary by unit type. These variations recognise the differing contexts of care provision in different types of units serving different patient groups. Addressing staff smoking rates, promoting consistency of staff response to patients' smoking and providing staff education and support continue to be key strategies to successful smoke-free policy.

CONCLUSIONS

Our results demonstrate the importance of taking into account the type of unit and acuity of patients when enacting smoke-free policy and addressing staff smoking.

Smoking bans in mental health hospitals in Japan: barriers to implementation

BACKGROUND

A number of studies have reported that smoking rates are higher and smoking cessation rates are lower in patients with mental disorders than in the general population. Despite the harmful effects of smoking, implementing total smoking bans in mental health hospitals is difficult. We investigate the status of smoking bans and the barriers to the implementation of total smoking bans in Japanese mental health hospitals.

METHODS

A questionnaire survey was administered to the directors of 1242 Japanese mental health hospitals in March 2013.

RESULTS

Forty-nine percent (n = 612) of the hospital directors responded. Of these, 24 % implemented total smoking bans and 14 % limited the bans to hospital buildings. In 66 and 68 % of the remaining hospitals, smoking rooms were located in open and closed wards, respectively, and completely separate from nonsmoking areas. Hospitals that had not implemented total smoking bans were concerned that introducing a total ban would exacerbate patients' psychiatric symptoms (46 %) or increase the incidence of surreptitious smoking (65 %). However, of the hospitals that had implemented total smoking bans, only 2 and 30 % identified "aggravation of psychiatric symptoms" and "increased surreptitious smoking" as disadvantages, respectively. The other concerns regarding the implementation of total smoking bans were staff opposition (21 %) and incidence of smoking around hospital grounds (46 %). These concerns were overcome by educating staff about smoking and cleaning the area around the hospital.

CONCLUSIONS

There are some barriers to implementing total smoking bans in Japanese mental health hospitals. However, our study indicates that implementation of total smoking bans in mental health hospitals was minimally problematic and that barriers to the implementation of smoking bans could be overcome. As the current number of hospitals that have implemented total smoking bans is low in Japan, more hospitals should introduce total smoking bans.

Implementation of a smoke-free policy in an inpatient psychiatric facility: Patient-reported adherence, support, and receipt of nicotine-dependence treatment

The implementation of smoke-free policies in inpatient psychiatric facilities, including patient adherence, mental health nursing staff support, and provision of nicotine-dependence treatment to patients, has been reported to be poor. The extent to which the quality of smoke-free policy implementation is associated with patient views of a policy is unknown. We conducted a cross-sectional survey of 181 patients (53.6%, n = 97 smokers; and 46.4%, n = 84 non-smokers) in an Australian inpatient psychiatric facility with a total smoke-free policy. Smokers' adherence to the policy was poor (83.5% smoked). Only half (53.6%) perceived staff to be supportive of the policy. Most smokers used nicotine-replacement therapy (75.3%); although few received optimal nicotine-dependence treatment (19.6%). Overall, 45.9% of patients viewed the smoke-free policy in the unit as positive (29.9% smokers; 64.3% non-smokers). For smokers, adhering to the ban, perceiving staff to be supportive, and reporting that the nicotine-replacement therapy reduced cravings to smoke were associated with a more positive view towards the smoke-free policy. These findings support the importance of patient adherence, mental health nursing staff support, and adequate provision of nicotine-dependence treatment in strengthening smoke-free policy implementation in inpatient psychiatric settings.

Health care professionals implementing a smoke-free policy at inpatient psychiatric units

Smoke-free grounds policies (SFGPs) were introduced to inpatient psychiatric hospital settings to improve health among patients, staff, and visitors. We conducted an ethnographic study in Northern British Columbia, Canada, to describe how the implementation of SFGPs is affected by institutional cultures. Data reported here included participant observation, document review, informal discussions (n = 11), and interviews with health care professionals (HCPs; n = 19) and staff (n = 2) at two hospitals. We used iterative and inductive processes to derive thematic findings. Findings related to HCPs illustrate how local contexts and cultural factors affect SFGP implementation. These factors included individual beliefs and attitudes, the influence of group norms, leadership and consensus building, and locale-specific norms. Strong, consultative leadership, in which leaders solicited input from and long-term support of people most directly responsible for policy implementation, was key to success.

Observation of the extent of smoking in a mental health inpatient facility with a smoke-free policy

BACKGROUND

People with a mental illness experience a higher burden of smoking-related disease. Smoke-free policies in mental health facilities provide an opportunity to reduce smoking-related harms for patients and staff alike. Limited evidence regarding the effect of such policies on preventing smoking in mental health facilities has been reported. The aims of this study are to describe the extent of smoking and the provision of nicotine replacement therapy (NRT) to patients in a mental health facility with a smoke-free policy.

METHODS

Cross-sectional studies of smoking (cigarette butt count and observed smoking) and nicotine dependence treatment (patient record audit) were undertaken over 9 consecutive weekdays in one mental health facility in Australia. A smoke-free policy incorporating a total smoking ban and guidelines for treating nicotine dependence among patients was implemented in the facility 4 years prior to the study.

RESULTS

Two thousand one hundred and thirty seven cigarette butts were collected and 152 occasions of people smoking were observed. Staff members were observed to enforce the policy on 66% of occasions. Use of NRT was recorded for 53% of patients who were smokers.

CONCLUSION

Implementation of the smoke-free policy was less than optimal and as a consequence ineffective in eliminating smoking and in optimising the provision of NRT. Additional strategies to improve the provision of nicotine dependence treatment to patients and the monitoring of adherence are needed to ensure the intended benefits of smoke-free policies are realised.

Employee attitudes about moving toward a smoke-free campus at a Veterans Affairs hospital

BACKGROUND

Although Veterans Affairs (VA) hospitals have been smoke-free inside of buildings since 1991, smoke-free campuses have not been initiated. The purpose of this article is to describe staff attitudes regarding making the VA hospital a smoke-free campus except for the mandated smoking shelters.

METHODS

In 2008, a cross-sectional, anonymous survey was conducted with a convenience sample of employees at a Midwestern VA (N = 397).

RESULTS

Descriptive statistics showed that the vast number of employees were in support of a smoke-free campus (76%), relocating the smoking shelters (62%), and offering employees assistance to quit smoking (71%). Multivariate analyses showed that those who were nonsmokers, older, women, and higher educated were the greatest supporters of policies to support a smoke-free environment (p < .05). Write-in comments were generally favorable but also revealed employee resistance related to freedom, personal choice, and potential loss in productivity as smokers go further away from the building to smoke.

CONCLUSIONS

VA hospitals have unique challenges in implementing smoke-free campus policies.

Online comments on smoking bans in psychiatric hospitals units

OBJECTIVE

Individuals with mental health concerns are disproportionately affected by and suffer the negative consequences of tobacco use disorder, perhaps because smoking has historically been part of psychiatry's culture. In the early 1990s, psychiatric inpatient facilities were exempted from U.S. hospital smoking bans, in response to public outcry with national media attention. Almost 2 decades later, the current study characterizes online conversation about psychiatric hospital smoking bans. Previous commenting studies have demonstrated commenting's negativity, documenting the "nasty effect" wherein negative comments color perceptions of neutral articles. Thus, we focused particular attention on cited barriers to implementing health-positive smoke-free policies.

METHODS

We collected online comments (N = 261) responding to popular media articles on smoking bans in inpatient psychiatry between 2013 and 2014 and conducted an inductive and exploratory qualitative content analysis.

RESULTS

Verifying previous studies documenting the prevalence of negative commenting, of the comments explicitly supporting or refuting psychiatry smoking bans, there were over twice as many con comments (n = 44) than pro (n = 18). Many commenters argued for access to outdoor smoking areas and warned of patient agitation and risk posed to care workers. Identified content themes included psychiatric medication and negative side effects, broken mental health systems and institutions, denigration of the health risks of tobacco in the context of mental illness, typical pro-smoking arguments about "smokers' rights" and alternatives (including e-cigarettes), addiction, and stigma.

CONCLUSIONS

The current findings provide a platform to begin to understand how people talk about mental health issues and smoking. Our analysis also raised complex issues concerning forces that impact U.S. patients with serious mental illness but over which they have little control, including medication, the U.S. health system, stigma, perceptions that life with chronic serious mental illness is not worth living, and psychological and physical pain of coping with mental illness. In consideration of identified barriers raised in opposition to smoking bans in inpatient psychiatry, efforts should emphasize patient stakeholder involvement; patient, visitor, and staff protection from smoke exposure; the effectiveness of nicotine replacement for managing withdrawal; and the lack of evidence that cigarettes are therapeutic.

Psychologists and Smoking Cessation Intervention: Unrealised Potential

Smoking cessation interventions during routine clinical encounters by health professionals have the potential to reach smokers and facilitate cessation. Although psychologists might appear to be ideal providers of such interventions, international research suggests that their provision is limited. This paper reports the results of a survey conducted in NSW, Australia, of psychologists’ (n = 72) smoking intervention practices, attitudes, and barriers to providing such care. Less than half of the respondents reported assessing smoking status for ‘all or nearly all’ of their clients. Across a range of smoking cessation intervention types, the most frequent response given indicated provision to ‘none or almost none’ of clients who smoked. Only 13% of respondents indicated even ‘advising cessation’ to ‘all or nearly all’ of their smoking clients. Barriers included concern about negative influence on the therapeutic relationship, inadequacy of training and lack of confidence to intervene. Respondents were less likely to provide intervention for smoking than for cannabis, methamphetamine ‘ice’, and alcohol. The study suggests that the potential of Australian psychologists to assist smokers to quit is not being realised, and that there is a need to address the barriers to care provision.

Achieving smoke-free mental health services: lessons from the past decade of implementation research

The culture of smoking by patients and staff within mental health systems of care has a long and entrenched history. Cigarettes have been used as currency between patients and as a patient management tool by staff. These settings have traditionally been exempt from smoke-free policy because of complex held views about the capacity of people with mental disorder to tolerate such policy whilst they are acutely unwell, with stakeholders' continuing fierce debate about rights, choice and duty of care. This culture has played a significant role in perpetuating physical, social and economic smoking associated impacts experienced by people with mental disorder who receive care within mental health care settings. The past decade has seen a clear policy shift towards smoke-free mental health settings in several countries. While many services have been successful in implementing this change, many issues remain to be resolved for genuine smoke-free policy in mental health settings to be realized. This literature review draws on evidence from the international published research, including national audits of smoke-free policy implementation in mental health units in Australia and England, in order to synthesise what we know works, why it works, and the remaining barriers to smoke-free policy and how appropriate interventions are provided to people with mental disorder.

Spaces for smoking in a psychiatric hospital: social capital, resistance to control, and significance for 'therapeutic landscapes'

This paper reports on research framed by theories of therapeutic landscapes and the ways that the social, physical and symbolic dimensions of landscapes relate to wellbeing and healing. We focus especially on the question of how attributes of therapeutic landscapes are constructed in different ways according to the variable perspectives of individuals and groups. Through an ethnographic case study in a psychiatric hospital in the North of England we explore the perceived significance for wellbeing of 'smoking spaces' (where tobacco smoking is practiced in ways that may, or may not be officially sanctioned). We interpret our findings in light of literature on how smoking spaces are linked to the socio-geographical power relations that determine how smoking is organised within the hospital and how this is understood by different groups using the hospital building. We draw on qualitative research findings from discussion groups, observations, and interviews with patients, carers and staff. These focused on their views about the building design and setting of the new psychiatric hospital in relation to their wellbeing, and issues relating to smoking spaces emerged as important for many participants. Creating and managing smoking spaces as a public health measure in psychiatric hospitals is shown to be a controversial issue involving conflicting aims for health and wellbeing of patients and staff. Our findings indicate that although from a physical health perspective, smoking is detrimental, the spaces in which patients and staff smoke have social and psychological significance, providing a forum for the creation of social capital and resistance to institutional control. While the findings relate to one case study setting, the paper illustrates issues of wider relevance and contributes to an international literature concerning the tensions between perceived psychological and psychosocial benefits of smoking vs. physical harm that smoking is likely to cause. We consider the implications for hospital design and the model of care.

Implementation of a smoke-free policy in a high secure mental health inpatient facility: staff survey to describe experience and attitudes

BACKGROUND

In 2008, a new forensic hospital was opened as a totally smoke-free facility. This study describes the attitudes and experience of mental health professionals working in the high secure mental health facility three years after it was opened. It is part of a larger evaluation describing the experience of current and discharged hospital patients.

METHODS

Quantitative data was collected using a survey of hospital staff (N = 111) with a 50% response rate. The survey collected demographic and smoking data to describe staff responses to statements relating to hospital smoking policy, patient care and staff support.

RESULTS

Among staff surveyed, 13% were current smokers and 41% were ex-smokers (10% quit after commencing employment in the smoke-free hospital). Most (88%) preferred to work in a smoke-free environment, although this was significantly lower in smokers compared to non-smokers (39% vs. 95%). While most staff felt that the smoke-free environment had a positive impact on the health of patients (86%) and on themselves (79%), smokers were significantly less likely to agree. Just over half (57%) of staff surveyed agreed that patient care was easier in a totally smoke-free environment, although less smokers agreed compared to non-smokers. Staff who smoked were also significantly less likely to indicate they had sufficient support working in a smoke-free environment, compared to non-smokers (15% vs. 38%).

CONCLUSIONS

The staff surveyed supported the smoke-free workplace policy; most agreed that patient care was easier and that the policy did not lead to an increase in patient aggression. Implementation of a total smoking ban can result in positive health outcomes for patients and staff, and may influence some staff to quit. Staff who smoke have a less positive experience of the policy and require additional support.

A protocol for a smoke-free mental health facility

It is not uncommon for staff of mental health facilities to have diverging opinions regarding the tobacco use of their patients. Surveys have shown that a significant proportion of staff believe that the smoke free policies are harsh and difficult to implement in health facilities where patient compliance is a matter of serious concern (Lawn, 2004, Wye et al., 2010). Intra-staff disputes and arguments with patients as to how to implement these policies, if at all, occur frequently. This protocol was developed at the request of staff at a mental health facility for HIV AIDS patients afflicted with dementia. Staff were concerned about imminent smoke-free regulations that would impact on their unit.

'Do more, smoke less!' Harm reduction in action for smokers with mental health/substance use problems who cannot or will not quit

Although smoking rates among mental health/substance abusing populations are very high, the focus of treatment and research has tended to be on substances other than tobacco. A range of harm-reduction strategies is needed, including long-term nicotine maintenance, smokeless tobacco and 'clean' nicotine products. For those who cannot or will not quit, assistance in reducing smoking should be given. Interventions for smoking among people with mental health/substance use problems may best be delivered by addressing multiple health-risk behaviours, especially physical activity, around the same time.