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

Background: The 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. Methods: This 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? Results: Five 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. Conclusions: This 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.Applied Science, Faculty ofNursing, School ofOther UBCReviewedFacult

Community mental healthcare providers' attitudes and practices related to smoking cessation interventions for people living with severe mental illness

Objective: This study aimed to describe mental healthcare providers’ attitudes about tobacco use, their personal smoking status, their confidence in offering smoking cessation support to clients living with severe mental illness, and the extent to which they incorporated smoking cessation interventions into their practice. The study also aimed to determine whether the providers’ attitudes, smoking status, and confidence were associated with offering smoking cessation support to clients. Methods: Self-administered questionnaires were distributed within community-based mental health agencies to those who provide care and support to adults living with severe mental illness. Outcomes measured included respondents’ smoking status, attitudes related to the provision of smoking cessation support, confidence in providing smoking cessation intervention, and smoking cessation practices. We conducted multivariate analyses using logistic regression analyses to examine the factors associated with the providers’ tobacco-related practices. Results: In total 282 of 871 care providers responded to the survey, 22% of whom were current smokers. The providers who held sympathetic attitudes about their role and their clients’ role in smoking cessation, who were never or former smokers, who were healthcare professionals rather than paraprofessionals, who had relatively more confidence, and who had more experience working in the mental health field were more likely to engage their clients in tobacco-related interventions. Conclusions: In this study the healthcare providers working in community-based mental health have a smoking prevalence rate that exceeds that of the region's general population and did not provide optimal smoking cessation support to their clients. Practice implications: Interventions that bolster the confidence of providers to engage is smoking cessation activities and that support a shift in attitudes about the role of tobacco use in mental health are required

Gender-specific profiles of tobacco use among non-institutionalized people with serious mental illness

Background: In many countries, smoking remains the leading preventable cause of death. In North America, reductions in population smoking levels are stabilising and, in recent years, those involved in tobacco control programming have turned their attention to particular segments of society that are at greatest risk for tobacco use. One such group is people with mental illness. A picture of tobacco use patterns among those with mental illness is beginning to emerge; however, there are several unanswered questions. In particular, most studies have been limited to particular in-patient groups. In addition, while it is recognised that men and women differ in relation to their reasons for smoking, levels of addiction to nicotine, and difficulties with cessation, these sex and gender differences have not been fully explored in psychiatric populations. Methods: Community residents with serious mental illness were surveyed to describe their patterns of tobacco use and to develop a gender-specific profile of their smoking status and its predictors. Results: Of 729 respondents, almost one half (46.8%) were current tobacco users with high nicotine dependence levels. They spent a majority of their income on tobacco, and reported using smoking to cope with their psychiatric symptoms. Current smokers, compared with non-smokers, were more likely to be: diagnosed with a schizophrenia spectrum disorder (rather than a mood disorder); male; relatively young; not a member of a racialised group (e.g., Aboriginal, Asian, South Asian, Black); poorly educated; separated or divorced; housed in a residential facility, shelter, or on the street; receiving social assistance; and reporting co-morbid substance use. There is evidence of a gender interaction with these factors; in the gender-specific multivariate logistic regression models, schizophrenia spectrum disorder versus mood disorder was not predictive of women's smoking, nor was education, marital status or cocaine use. Women, and not men, however, were more likely to be smokers if they were young and living in a residential facility. Conclusion: For men only, the presence of schizophrenia spectrum disorder is a risk factor for tobacco use. Other factors, of a social nature, contribute to the risk of smoking for both men and women with serious mental illness. The findings suggest that important social determinants of smoking are "gendered" in this population, thus tobacco control and smoking cessation programming should be gender sensitive.Applied Science, Faculty ofNursing, School ofOther UBCNon UBCReviewedFacult