Smoking and mental health - NCSCT

Population strategies to prevent smoking in mental disorders 6
6.4 Factors perpetuating smoking in mental health settings
6.4.1 A smoking culture
Despite the scope of the problems caused or exacerbated by tobacco smoking in
mental health settings, smoking among patients in these settings has typically
been neglected, particularly by clinicians. 88,89 Consequently, although a societal
change towards the ‘de-normalisation’ of smoking and prevention of passive
smoke exposure in public and work places has occurred in the UK over recent
years, smoking is still widely, if covertly, condoned in mental health settings.
Indeed, the complexity of social and systemic aspects involved in the
perpetuation of smoking in these settings is well recognised, and has been
described as a ‘culture of smoking’, created and perpetuated by the coming
together of ‘various players, with various roles and rules for behaviour,
interaction and communication, informed by beliefs and attitudes, set in the
context of established rites, structures, artefacts and ideologies that together serve
to perpetuate the culture’. 89 These conditions apply in relation to smoking in
mental health settings. 90 Ethnographic and other work has demonstrated that
smoking is a primary activity for mental health inpatients, forms a central part of
the daily experience of both patients and staff, and has done so historically. 89
Smoking as a ‘multifaceted tool’ had become entrenched in the more complex set
of social rules that apply in mental health settings and is used for purposes, such
as the relief of boredom and stress associated with a ward environment,
facilitating social interaction and the development of rapport between patients
and staff, and controlling patient behaviour using cigarettes as a means of reward
and punishment. Cigarettes have been described as the ‘currency by which
economic, social and political exchange took place’, with patients and staff
describing a complex enculturation process that involved strong reinforcement to
smoke and rendered an escape from the culture in the studied settings extremely
difficult. 89,91 Some important determinants that contribute to the perpetuation
of the smoking culture are discussed in the following sections.
6.4.2 Staff beliefs and attitudes
The potential importance of the role of clinicians and other healthcare staff in
promoting healthy behaviour in general and smoking cessation in particular is
well recognised, 92 and staff beliefs and attitudes to smoking are important
determinants and perpetuators of a smoking culture. The role of mental health
nurses has been described to encompass that of a ‘custodian, carer, cigarette
source, counsellor, educator, behaviour modifier and gaoler’ 91 and, although staff
in mental health settings generally recognise the importance of health promotion
for people with mental disorders, they also often report that they perceive
smoking to be a personal right and expression of self-determination that they are
© Royal College of Physicians 2013 121