Posted by Susan Jones, Research Associate, Teesside University
Smoking rates and levels of dependency are high in people with psychiatric problems and, it has been argued, that smoking helps people with mental health disorders to cope with the struggles in their lives (Malone et al., 2018). On the other hand, the National Institute for Health and Care Excellence (NICE, 2013) argues that introducing a smokefree culture into NHS Trusts offers an opportunity for patients and staff to benefit in terms of physical and mental health and is achievable with appropriate support. Certainly this viewpoint was supported in our research:"I think for some of our patients because it’s actually a learning disabilities hospital but obviously a lot of them have mental health issues as well, it increased their confidence and self-esteem. A lot of our patients had poor self-esteem and they actually achieved something by stopping smoking, they achieved something that was extremely difficult and I think it made them think, if we can do that we can do other things as well."
Frontline Staff, Trust B
Normalisation of smokefree policies
In mental health, smoking is an established cultural norm both in the community and in healthcare settings. We found that it is seen as an acceptable, even beneficial, coping mechanism for people who suffer from mental health disorders.
Research evidence would argue the converse; that the physical and mental benefits are far greater than continuing to smoke (Harker & Cheeseman, 2016). People with psychiatric problems tend to be highly addicted and there is a definite need to push through the initial stages of withdrawal from nicotine, which can be harder due to greater dependency, and more complicated due to interactions with psychiatric medication. Nevertheless, the evidence shows that people still want to be physically healthier, free from the downsides of addiction and supported to achieve these goals (Harker & Cheeseman, 2016).
Promoting normalisation through collective action
Perseverance is required to change any norm; old habits and
perspectives die hard and continual reinforcement of new patterns are needed
for success (Jones et al., 2020). This applies at an individual level but also
at the organisational level.
Role of context
Our environment is so important in enabling or blocking behaviour; or even ‘nudging’ it in a certain direction (Ratschen et al, 2011). If a hospital is smokefree, then patients who don’t smoke will be able to maintain their status as non-smokers more easily. Alternatively, a smoking environment legitimises and encourages continued smoking.
Sustainability
Maintaining changed behaviours, like smoking, is known to be challenging; however there is an inherent contradiction in implementing smokefree policies on-site only. Patients and staff move between hospital and community and it is all too easy for this to be seen as abstaining while in hospital, rather than quitting for good.
- Inroads had been made in changing an entrenched, smoking culture into one that was smokefree on Trust sites. However, there remained variations across specialities and challenges to full implementation.
- Once there was sufficient ‘buy-in’ to a non-smoking culture it was anticipated that the issues relating to enforcement and perceived risk would diminish.
- Long-term perseverance is required to establish smokefree sites in participating mental health trusts, supported by robust, routine, data collection.
- Normalisation Process Theory and logic modelling are helpful in increasing understanding of the dynamic implementation process.
- Careful use of language is needed to encourage smokefree policies to be seen positively.
- When interpretation of the term ‘patient leave’ was left open for leave to be used for smoking, it led to inconsistent practice.
- Consistency of enforcement is key to success.
- There were many details that needed to be worked out following the introduction of the policies; suggesting a requirement for ongoing review and response in a timely manner.
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