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In the shadow of a new smoke free policy: A discourse analysis of health care providers' engagement in… Johnson, Joy L; Moffat, Barbara M; Malchy, Leslie A Jul 28, 2010

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RESEARCH Open AccessIn the shadow of a new smoke free policy:A discourse analysis of health care providers’engagement in tobacco control in communitymental healthJoy L Johnson*†, Barbara M Moffat†, Leslie A Malchy†AbstractBackground: The prevalence of tobacco use among individuals with mental illness remains a serious public healthconcern. Tobacco control has received little attention in community mental health despite the fact that manyindividuals 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 careproviders, both professionals and paraprofessionals, in relation to their roles in tobacco control in the communitymental health system. Tobacco control is best conceptualised as a suite of policies and practices directed atsupporting smoke free premises, smoking cessation counselling and limiting access to tobacco products. The studytook place following the establishment of a new policy that restricted tobacco smoking inside all mental healthfacilities and on their grounds. Ninety one health care providers participated in open-ended interviews in whichthey described their role in tobacco control. The interview data were analyzed discursively by asking questionssuch 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 anindividual choice located the decision to smoke with individual clients thereby negating a role in tobacco controlfor 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 areused to support the health of clients.Conclusions: This study provides insights into the complex factors that shape tobacco control practices in themental 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 healthcare providers are both imposing and resisting the smoke free policy.BackgroundThe prevalence of tobacco use among individuals withmental illness remains a serious public health concern.Compared to the general population, individuals withmental illness smoke more cigarettes and have greateradverse health outcomes associated with their tobaccouse [1]. Tobacco use is also responsible for contributingto economic and social harms for people living withmental illness [2].The mental health system has not yet developed anappropriate response to tobacco use. Historically, in themental health field, the role of engaging in smoking ces-sation intervention has fallen largely to physicians. How-ever, the uptake of these interventions has been limited.* Correspondence: joy.johnson@ubc.ca† Contributed equallyNursing and Health Behaviour Research Unit, School of Nursing, University ofBritish Columbia, Vancouver, CanadaJohnson et al. International Journal of Mental Health Systems 2010, 4:23http://www.ijmhs.com/content/4/1/23© 2010 Johnson et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the CreativeCommons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, andreproduction in any medium, provided the original work is properly cited.In one study, psychiatrists offered cessation counsellingduring only 12.4% of patients’ office visits [3]. The activeengagement of health professionals in tobacco cessationinterventions for the general adult population seekingmedical help is growing and includes brief interventionsdelivered by counsellors working in substance abusetreatment [4-6]. Yet a similar role for professionalsworking within community mental health settings is lesscommon [7]. Although one study examined six and 12-month outcomes of a community-based smoking cessa-tion intervention for 79 individuals with severe mentalillness, the sessions were facilitated by highly qualifiedspecialists [8] suggesting an expert role without consid-ering similar core skills for a wider group of mentalhealth providers. Of note, these authors reported successrates comparable to group-based treatment with “men-tally healthy smokers.”Overall, the mental health system has been slow toimplement tobacco cessation interventions [9]. There is,however, strong evidence that many individuals livingwith mental illness want to reduce or stop smoking alto-gether [10,11]. Although smoking cessation rates arelower among persons with mental illness than the gen-eral population, results are nonetheless substantial [12].Tobacco control is best conceptualised as a suite ofpolicies and practices directed at supporting smoke freepremises, smoking cessation counselling and limitingaccess to tobacco products. The reasons for the limiteduptake of the tobacco control role within the commu-nity mental health system are complex [2]. Many mentalhealth care providers working in the community lackconfidence in their ability to provide smoking cessationcounselling; some are ambivalent and may not seethemselves as credible role models given their owntobacco dependence [13]. Tailored interventions andclose monitoring of clients by health care professionalsare often required due to the presence of heavy nicotinedependence in this population combined with the use ofpsychiatric medications. There are particular issues thatrequire attention when encouraging those with mentalillness to quit smoking. People with schizophrenia havebeen noted to smoke cigarettes to alleviate medication-related side effects such as sedation and neuroleptic-induced Parkinsonism [14]. Tobacco use also affects themetabolism of certain antipsychotic medications (e.g.clozapine and olanzapine) by reducing the serum con-centrations by as much as 40% [14,15].Over the last few decades, the mental health care sys-tem has undergone significant changes in the delivery ofcare. A body of literature examines the roles and per-ceptions of mental health care professionals within thecontext of deinstitutionalization [6,16,17]. Research find-ings point to the overlap in professional roles amongproviders as well as the gaps in the delivery of services.Some of this research focuses specifically on therequired roles of individual professional groups [6] whileother studies explore the growing trend of teamapproaches in community mental health, collaborativedelivery of care and shared leadership [17,18]. Lessattention, however, has been paid to the role of non-medical providers working in mental health settings[19]. Mitchell’s study reveals how some non-medicalproviders’ wish to expand their role within the system.Of note, no literature was found that explored thepotential for a shared role in the area of tobacco controlamong mental health care providers which points to theneed for further investigation.Some qualitative studies have shed light on the smok-ing behaviours of community-based clients with mentalillness, ways to incorporate evidence based tobacco ces-sation interventions to the unique challenges of peopleliving with mental illness and the barriers and opportu-nities to the changing culture of mental health settings[20-22]. A qualitative approach is well suited to furtherexploring how health care providers working in commu-nity mental health construct their roles in the domain ofclient tobacco control.In this paper, we explore the perceptions of healthcare providers, both professionals and paraprofessionals,in relation to their roles in tobacco control in the com-munity mental health system. These perceptions areinformed by powerful discourses that structure the waythe providers think and act. Our particular interest wasan examination of the discourses that underlie role per-ceptions related to smoking cessation intervention. Ourapproach was based on the assumption that if practicesare to be changed, they must first be understood. Dis-course analysis has been used to study practices in awide range of community-based and hospital settings[23,24]. In the field of mental health, Mitchell utilizeddiscourse analysis to examine how mental health careproviders in non-medical primary health and social careservices viewed their roles [25]. Findings revealed thatroles were constructed in opposition to the putative, orassumed role positions of specialist mental health ser-vices which the author suggests may contribute to someproviders’ reluctance to engage with certain agendaspromoted by mental health services. A lack of attentionhas been given to how discourses can play a pivotal rolein supporting tobacco control efforts in the translationof health knowledge, which was the impetus for thisstudy.MethodsAs part of a larger action research project, we conducteda qualitative study focused on understanding the waysthat community mental health care providers situatetheir work related to engaging in smoking cessationJohnson et al. International Journal of Mental Health Systems 2010, 4:23http://www.ijmhs.com/content/4/1/23Page 2 of 12support. We sought to understand the discourses thatinformed how they described their practices. The objec-tives of the larger project focused on designing andimplementing tobacco reduction interventions foruptake by persons working within community mentalhealth systems. For this larger project we targeted sixsites. Key staff at each site were identified to collaboratewith the project researchers. Using appreciative inquiry[26] that builds on the strengths and priorities of eachsite, we developed site-specific strategies which wouldfurther a tobacco control agenda. As a first step in thisstudy, we conducted interviews with the care providersin the target settings.Our research approach drew on the methods of dis-course analysis. Discourses can be thought of as the setsof common assumptions, values, attitudes, and “rules”that structure the ways in which we think and act [25].Cheek [27] describes discourses “as the scaffolds of dis-cursive frameworks which order reality in a certain way”(p.1142). These frameworks are often invisible or takenfor granted but can be “read” in the ways in which wetalk and act. Discourses both enable and constrain theproduction of knowledge; they allow for certain ways ofthinking about reality while excluding others [27]. Inthis study, we were interested in understanding the dis-courses that shaped discussion about tobacco controlpolicy and related practices within the community men-tal health system. Our approach was informed by a Fou-cauldian perspective in that we sought to understandhow discourses operate in ways that privilege certainpositions and marginalize or even exclude others. Acentral concern of Foucault’s work is how discourses areshaped and become forms of power that enable particu-lar understandings.This study took place as a new policy was being intro-duced that restricted tobacco smoking inside commu-nity-based mental health facilities and on their grounds.This policy had been implemented without wide consul-tation and the health care providers we interviewedwere in the midst of adapting to or at times resistingthe policy. In addition, those we interviewed had a vari-ety of roles and education; some providers were in para-professional roles while others were in professional rolessuch as nursing, medicine, or occupational therapy. Wechose to pool the data paying careful attention to theways in which power and privilege influences discursiveframes.Data collection occurred in six study locations withinthe health services district of a large urban setting inwestern Canada: two community mental health teams,two community resource centres and two mental healthhousing units. Services at the mental health teams coverassessment and diagnosis, case and medication manage-ment, counselling, and psychosocial rehabilitation. Thecommunity resource centres provide drop in services toa range of clientele, some of whom are at high risk forother health issues (i.e., homelessness, substance use).These centres are managed by contracted non profitorganizations; outreach and social support workers offerservices such as crisis intervention, meals, education andleisure programming, advocacy services, life skills, andoutreach services. The services offered at housing unitsvary according to the residents’ needs; social service andcommunity support outreach workers provide medica-tion management, case management, support groups,and meal programs.Data was collected over a period of four months(January-April 2009). Ethical approval was obtainedfrom the relevant ethical review boards. Three researchinterviewers administered a needs assessment thatincluded quantitative and qualitative data collection.The quantitative component at the beginning of theinterview assessed knowledge, beliefs, and practicesrelated to tobacco control and the results will bereported elsewhere. This paper focuses on the qualita-tive portion of the interview in which the participantswere asked to expand on three broad open-ended ques-tions related to: 1) the main issues surrounding smokingin their workplace, 2) their challenges with addressingtobacco use in the workplace and, 3) the types of sup-port, policies or resources that they would find mostuseful in supporting client smoking reduction or cessa-tion attempts. Initially the interviews were not recordedand detailed notes were kept. However, when theresearch team realized that the participants had a greatdeal to share, the decision was made to record the quali-tative portion of the interviews. Ethical approval forrecording interviews had already been obtained for thelarger study. Research staff assured participants thatinterviews were confidential and that data would bereviewed only by the research team. In total, 79 of the91 interviews were digitally recorded. Detailed notescaptured verbatim content from interviews that werenot recorded. The recorded interviews and the noteswere transcribed and analyzed by the research team.The interview data were analyzed discursively by ask-ing questions such as: what assumptions underlie whatis being said about tobacco? We were particularly inter-ested in why providers said certain things about addres-sing tobacco, why they did not say other things and whythey selected certain words. To that end, the texts were“interrogated to uncover the unspoken and unstatedassumptions implicit within them that have shaped thevery form of the text in the first place” [27] (p. 1145).Recognizing that any text will only ever convey orproduce a partial perspective of reality, we were con-cerned with over interpreting what was said. To preventimposing excessive meaning, the team met regularly toJohnson et al. International Journal of Mental Health Systems 2010, 4:23http://www.ijmhs.com/content/4/1/23Page 3 of 12discuss the development of the discourse analysis. Inaddition, we embraced the understanding that discourseanalysis refers to situated reality. Therefore we consid-ered texts as constructed by and in turn constructingunderstandings of reality rather than describing a or thereality [27]. In other words, the ways in which providerstalk about their practice reinforces and shapes how theyprovide care.As noted, the sample included professionals [n = 42]and paraprofessionals [n = 49]. Over half (63%) of thetotal sample was female. The average time spent work-ing in the mental health system was 10.3 years and theaverage time in the current workplace was 4.8 years. Ofthe 91 participants, 52 were non smokers, 18 were for-mer smokers, 6 were occasional smokers and 15 identi-fied as current smokers. Just under half (45%) of theparticipants had previously attended some form of train-ing related to tobacco. The sample included frontlinestaff who worked full time and part time with an adultcare population, but not those who worked on a casualbasis.ResultsOur analysis revealed five discursive frames that influ-enced talk about tobacco. Although other discourseswere present in some interviews, the research team wasstruck by the prevailing presence of these five frames.Managing a smoke free environmentAs a result of the recent policy restricting where clientscould smoke, some providers had assumed new respon-sibilities. The tasks associated with managing a smokefree environment were framed as placing providers inan authoritarian role. This discourse was most commonamong the paraprofessionals working in the resourcecentres and the housing facilities who had acquired theadded responsibility of implementing the “new rules.”Investing time in monitoring the smoke-free environ-ment was commonly discussed by resource centre staff.The power of this discourse was evident as theydescribed being involved in crowd control, or “movingpeople along” when clients were smoking in front of thebuilding. Patrolling was a regular activity because clientsresisted the “rules.”We are constantly going outside and telling people toplease smoke in the back. People know that’s the rulebut they do it anyway. And if you go ask them toleave, they will leave but they won’t really stop.[Paraprofessional, Non-Smoker, Resource Centre]The management of the smoke-free environment alsoencompassed “maintaining the calm” beyond the physi-cal space of the smoke-free setting. Paraprofessionalsacross settings saw themselves as responsible for mini-mizing the policy’s impact on the local surroundings,referred to by some as the “good neighbour policy.”Given that clients were no longer “allowed” to smoke infront of the resource centre, some had moved theirtobacco use in front of nearby businesses. As a result,some providers described being further burdened withmaking amends when there was discord with neigh-bours.So now we have an overflow and the businesses areshooing our members away from their front steps...it’sjust that they are losing business as a result of thesmoking...We are trying to use a lot of tact, anddiplomacy and encouragement to be respectful to thebusinesses and to the members. [Paraprofessional,Non-Smoker, Resource Centre]Another paraprofessional conveyed her discomfortwith being caught in the middle of managing conflicts:“We get yelled at by the neighbours and clients.” Suchdiscordance affected the work environment and ham-pered staff members’ abilities to engage with otherclients.For some paraprofessionals there were expressions ofresignation, having to “enforce rules imposed by the city.”The so-called “edict” had been made elsewhere whichplaced providers in an awkward position vis-a-vis theirclients, a position of power and powerlessness. The ter-minology in this discourse reinforced that this expandedrole was a source of tension and “conflict” within thestaff-client relationship. According to one paraprofes-sional administrator, “It’s just a perception that thesmoking ban, especially for the chronic smokers, has beenkind of forced down everyone’s throat. So now we havebeen asked to police it.” This “tedious“ responsibilityrequired repeating the same message wherein parapro-fessionals had become the target of blame.The most challenging for me is having to ask thesame people over and over and reminding them ofthe rules, to step away from the building. They don’teven have to say a word, but just the way they arelooking at me is kind of like I have come up with therule. [Paraprofessional, Current Smoker, ResourceCentre]As self-declared managers of the smoke-free environ-ment, some staff positioned themselves as embroiled inuncomfortable power dynamics. When clients ignoredthe “rules” by smoking within smoke-free zones, para-professionals were obliged to exert control and impose“penalties.” At the resource centres, this could meanbanning clients for two days, a serious consequence forJohnson et al. International Journal of Mental Health Systems 2010, 4:23http://www.ijmhs.com/content/4/1/23Page 4 of 12clients who relied heavily on the services, “that meansthat they don’t get the service, they don’t get lunch.”Resistance was a common element in this discourseand took the form of not always enforcing the “rules.”For some, priority was given to the clients’ well-beingand rules were bent accordingly, claiming this was morein keeping with the perceived role of a service provider.Circumventing rules was a way to avoid conflict in theclient-provider relationship.I would lie if I said that we strictly enforce the 3-meters-from-a-door deal. I’m not going to makesomebody who is having a bad day go stand in thecold rain. If they’re going to stand under the awningout the back door, it’s fine because the door is alwaysclosed, the smoke doesn’t come in anyways. [Parapro-fessional, Current Smoker, Resource Centre]Similarly in one residential facility, staff would not “ratout“ the clients for smoking in undesignated areas; nostaff member wanted a client to be fined $2000, all thewhile recognizing the futility knowing that the HealthAuthority would end up “paying for it.”On the mental health teams, the discourse was muchmore subdued. The smoke-free environment was a bet-ter fit among the multidisciplinary teams than it was atthe resource centres and residential settings where moreproviders were smokers. Nonetheless, there were hintsof resistance with suggestions of inconsistent action. Asone professional noted, “Sometimes those regulations aretransgressed by clients and some staff will approach theperson and correct them, and some won’t.” Given thatmonitoring the smoke-free environment was a new“duty,” there were now “watchdogs“ on the teams. Onrare occasions, “relocating“ clients was necessary; thatbecame the responsibility of “someone else,” typically asenior staff member which provided some professionalsa safe distance from dealing directly with the issue.There have been some conflicts with clients smokingright outside our facility, despite the signs. There wasalmost an altercation when a staff asked a client tostop smoking right in front and go down the stairs.[Professional, Non-Smoker, Mental Health Team]Interestingly, the professionals on the mental healthteams maintained that they were critical of punitivemeasures. This stance was perhaps easy to take giventhat they did not need to take such measures.Tobacco is therapeuticThe discourse that smoking “helped“ clients was presentin interviews across all settings. At the root of this dis-course was the claim that tobacco use was not onlybeneficial, but that quitting smoking was difficult andpotentially harmful for clients. Tobacco use wasdescribed as providing relief from symptoms associatedwith mental illness. There was a common convictionthat tobacco use countered some side effects of “anti-psychotic” medications, therefore “It helps them withtheir medications to be able to have their cigarette.”Knowledge derived from work experience pervaded thisdiscourse.We know that somehow tobacco use helps schizophre-nia or psychiatric clients to cope with their symp-toms. And the years of observation of the clients inthe hospital or during any activities here in this set-ting, obviously it has a calming effect, or at least theyare severely hooked on that. [Professional, FormerSmoker, Mental Health Team]Others considered cigarettes to be a “quick fix“ and“instant pleasure.” The language focused on the positiveeffects of smoking in keeping with self-medication ter-minology. Tobacco was lauded for providing the clients’“only joy in life.” The comparison of tobacco to othersubstances served to minimize the harmful effects oftobacco. One paraprofessional challenged, “I questionthe effects of smoking compared to the effects of prescrip-tion medications that they are taking, compared to thecoffee that they are drinking, everything else in theirlives.”As further support, the providers emphasized the dan-gers of quitting smoking, placing clients at risk. Oneprofessional elaborated, “At one point, there was a clientwho attempted to end his smoking but he became sostressed and it started to impact his mental health.”Tobacco cessation was framed as removing “their com-fort“ which reinforced that smoking was beneficial andserved a purpose.For some, smoking is a core part of their stress cop-ing. And for some I think it is really important tocontinue smoking because that is all they have...Forsome, taking away their cigarettes is the worst possi-ble thing you could do to them. [Professional, FormerSmoker, Mental Health Team]The strategy of minimizing the therapeutic value ofother forms of nicotine infused this discourse. Nicotinereplacement therapies did not “work,” and they werecostly and problematic. “And a lot of people can’t wearthe patch for allergies, can’t chew gum because of dentalwork.” Another provider concluded that social supportwas absent when using these forms of nicotine, caution-ing that clients could become “isolated”, “There is noth-ing social about NRT, you get together and have a coffeeJohnson et al. International Journal of Mental Health Systems 2010, 4:23http://www.ijmhs.com/content/4/1/23Page 5 of 12and cigarette. You don’t get together to chew gum.” Incontrast, the social role of cigarettes was presented asbeneficial for clients. “Even outside of the actual addic-tion to the nicotine, it’s also the addiction to the smokingto having the relationships that they do. People get intopatterns of smoking out there with particular people,having particular types of conversations.”Smoking with clients outdoors functioned as a thera-peutic tool; some providers who smoked positioned thisaction favourably. “Often it’s a way to just get someoneto calm down too. ‘C’mon, let’s just go out there andrelax and have a smoke.’” The shared activity wasdescribed as a conduit for relationship building, suggest-ing a privileged relationship that was also power-ladenin that it maintained the status quo.I’ve seen it as being beneficial in a sense since youhave that time where you sit down, even though it’sjust for a cigarette, you have that one-on-one interac-tion. So in that sense, I’ve developed a lot of trustfrom going out there and just having a casual conver-sation that I wouldn’t have had within the buildingsurrounded by people. [Paraprofessional, CurrentSmoker, Resource Centre]One staff member had quit smoking 6 months earlierand spoke with nostalgia about the strength and valueof the client-staff connection through smoking and howthe intimacy that existed was now “lost.” Not only didshe feel more “in touch“ with what was going on withclients, smoking with clients also functioned as anopportunity for information sharing.A lot of the work I was doing came from...sittingdown with people and smoking and talking aboutstuff...they would kind of relax a little bit and we’dget talking....I miss that connecting with people onthat level. [Paraprofessional, Former Smoker,Resource Centre]Nonetheless, a sense of discomfort was articulated bysome providers. One provider “struggled“ with his rolein this shared activity “we are trying to assist people toquit smoking, but we smoke with them.”Descriptions of accommodating client requests forcigarettes and rolling paper was part of the therapeu-tic discourse. “I’ll give them the end of a cigarette, butI won’t take it back. I just don’t, you never know whatthey might have picked up or germs or things likethat.” The availability of rolling paper at the resourcecentres was framed as meeting a need and providinga healthy alternative that counterbalanced the healthrisks associated with clients’ practice of “picking upbutts.”Tobacco use is an Individual ChoiceThe discourse that framed tobacco use as an individualchoice focused on the autonomy of clients and how inrelation to tobacco use, they “have the right to choose.”By engaging with clients in a manner described as“respectful,” clients were presented as in charge andresponsible for deciding about their tobacco use in dis-cussions that took place within the context of followingthe client’s lead.At the outset, this discourse revealed a distancingstrategy. Providers described a reluctance to formallyinitiate the topic of smoking with clients. Someexplained how they did not assess client smoking whenthey first met because it would seem “judgmental.” Theyreasoned that assessing tobacco use at the initial assess-ment had not been a part of their training. Other goalstook precedence for both clients and, subsequently staff.When I first work with people I ask them what theirgoals are, what things they would like to achieve inaddition to seeing us for mental health symptommanagement... I usually take it as a cue from themwhen they feel as if they are ready to engage in dis-cussion about smoking cessation, but for sure, it isnot high on my priority list. And I certainly don’t seeit very high on some of my client’s priority list either.[Professional, Non Smoker, Mental Health Team]Defending a position of “not pushing“ or even omittingthe smoking cessation agenda altogether was common.Ultimately, clients were placed in a position of power,being in charge when it came to addressing tobacco use.I find a lot of the clients, if it is brought up, it’s justbrushed off or not discussed in depth. And so if Imention it or bring up smoking, then they’re just “Ohyeah, that’s not an issue,” then I’ll drop the issue aswell. [Professional, Non-Smoker, Mental HealthTeam]Silence regarding client tobacco use was framed withinthe context of being respectful, “If they are not open tohaving the conversation, then I don’t usually pursue it.”Viewed from another angle, this discourse served to jus-tify providers’ inactive engagement. Although labelled asshowing “respect,” this meant no further action on thepart of the provider. The language used was moralisticand prescriptive. One professional concluded, “I see it aspeople’s choice, especially in the community people areable to make their own choices and be responsible forthemselves, be autonomous for their own care.”Treading lightly was a tactic employed to avoid dis-cord while supporting clients’ right to smoke. Some pro-viders expressed uncertainty, discomfort and a sense ofJohnson et al. International Journal of Mental Health Systems 2010, 4:23http://www.ijmhs.com/content/4/1/23Page 6 of 12“struggle“ when it came to addressing tobacco use withtheir clients. As one psychiatrist noted, “I admit that Idon’t address it enough...I still have the hesitancy abouthow to work it in there and how to not make it some-thing that is just another burden to patients.” In fact,staff-driven attempts at initiating a discussion aboutsmoking cessation were described as “hassling“ clientsabout “one more thing.”If they haven’t really expressed any idea about quit-ting, how to bring it up in a way that won’t turnthem off? Because that’s what I feel that right awaythey retreat from that approach. If it starts to putthem off, right away you are going to lose them.[Paraprofessional, Non-Smoker, Mental HealthTeam]Consequently, honouring clients’ lack of interestregarding the topic of smoking cessation allowed the cli-ent to exercise their unchallenged choice to continue tosmoke.The responsibility and “choice“ of remaining a smokerwas placed into the hands of clients. Clients weredescribed as “reluctant to quit,” and lacking “motiva-tion.” Speaking knowingly about the power of clients’nicotine addiction further removed the onus of person-ally engaging with clients and served as a distancingdevice, “They would rather have a cigarette than food.These people are addicted to tobacco. This is a verystrong addiction - they cannot control themselves withnicotine.” However, offering clients “information“ suchas brochures about smoking cessation programs wasconsidered a non intrusive gesture that allowed clientsto “make a choice about it.”In contrast, client-led invitations to engage in thetopic of smoking were met with enthusiasm. Theseopportunities occurred when the client-provider rela-tionship was well established. “When somebody talksabout smoking, I leap on it and I say, ‘The Daytox, theyhave an excellent program.’ And I’m excited and I really,really encourage people once they articulate it.” Suchinteractions were presented as the moment for plantinga favourable seed that might influence a client’s choiceabout tobacco use in the future, conveying a glimmer ofhope.It’s Someone Else’s RoleIn this discourse, providers dismissed the role of directlysupporting client tobacco cessation. Rather, they framedthis role as belonging to an “expert.” Relying on availableresources such as support groups or other professionalswith expertise area figured prominently in theirexplanations.Both paraprofessionals and professionals viewed thescope of their role in smoking cessation to be limited. Astaff member from one housing facility stated, “it’s notnecessarily our role to dictate to people what they shouldbe doing with their lives.” There was often a shift offocus when providers looked to others to assume therole. Some professionals saw this as a specialized skillset beyond their domain while some paraprofessionalsviewed the professionals as the experts.Perhaps an in-house therapist/counsellor can beaccessed. I don’t think it’s that much a physicianneeds to be involved in. Identify the problem andencourage them to quit, yes, but in actually providingcessation counselling and that type of stuff, I don’tthink so. [Professional, Non-Smoker, Mental HealthTeam]I am not the one who can control her [client] smok-ing, her attitude or her routine, but the nurse andthe psychiatrist can do that, I’m just their worker. Ijust tell them that smoking is harmful to your health.[Paraprofessional, Non-Smoker, Mental HealthTeam]Typically, this discourse involved accentuating a lackof training and knowledge regarding tobacco use. Asone paraprofessional surmised, “I am comfortableaddressing and looking at readiness in terms of quittingsmoking but personally, I don’t know that much aboutimplementing smoking cessation goals.” At times, therole of engaging with clients in tobacco cessation waspresented as unattainable.It’s an addiction, so you need a lot of resources tohelp out with it. It would never be something that Icould do. It’s not like something else where I couldhelp them, like by referring them to a job. [Profes-sional, Non-Smoker, Mental Health Team]Multiple-roles and conflicting priorities were offeredas reasons for not being able to assume this role. Thisstrategy maintained the comfortable power and positionof the health care provider yet ceded specialized knowl-edge and power to others. For one professional, takingon the issue of tobacco use was portrayed as adding tothe “workload“ in an already “overwhelming“ multidisci-plinary team environment. Another professionalexpanded, “It’s another thing to consider because at thesame time we are dealing with diabetes because that isa huge concern for our clients. We are taking on thatwhole metabolic monitoring and now the smoking aswell.” Being a smoker was sometimes used as a rationalefor dismissing the role entirely.Johnson et al. International Journal of Mental Health Systems 2010, 4:23http://www.ijmhs.com/content/4/1/23Page 7 of 12As I am right now in the middle of trying to stop, Ijust don’t find that it makes sense for me to saythings about smoking when I am a smoker, inside Iwould feel guilty. And so say to them it’s not good tosmoke and this is what you should do. [Paraprofes-sional, Current Smoker, Resource Centre]To ease the tension of not engaging in this role, distri-buting educational brochures about tobacco use andcessation programs filled a useful function - providershad satisfied their responsibilities. This also strength-ened the message that others had tobacco cessationexpertise, reinforcing that this responsibility belongedelsewhere. In the same way, referring a client elsewherefor tobacco cessation support was presented as beingprofessionally responsible; this specialized role belongedto someone else. It was, however, safe territory to pro-mote the advantages associated with joining these pro-grams, “So if I know they smoke, I will talk to themabout this program, this free patch and free nicotine andI encourage them to join.”Tobacco Control as Health PromotionIn the discourse of health promotion, tobacco waspowerfully described as “unhealthy,” a “drug“ that was“highly addictive“ and linked with cancer and cardiovas-cular complications. Many providers recalled clients andtheir own family members who had died from tobacco-related causes. This health-focused discourse translatedinto promoting tobacco cessation, and harm reductionapproaches, therefore challenging the assumptions ofthe previous four discourses. Formal interventionsbelonged to professionals who had the expertise whileparaprofessionals engaged in an informal discourse,encouraging and reinforcing the message, which oftenhighlighted a personal style.Cessation interventions by professionals were charac-terized by a specialized skill set involving counselling(e.g. motivational interviewing) and pharmacologicalinterventions. Some descriptions focused on the humanelement of engaging, others on the bio-physical aspectsof treating the addiction; both conveyed that there wasan expert and voice of authority.And if they are motivated about it, I can engagethem in a process of discussion and interest. I havesome sense of the tools available and so on. It’s verysatisfying. You know when I was in general practiceand I would help people quit smoking, years laterwhen I would see those people... they would say‘You’re the one who helped me quit!’ [Professional,Former Smoker, Mental Health Team]Weighing competing risk factors and tailoringapproaches accordingly were key elements of interven-tions. The health promotion discourse revealed that cer-tain clients received more attention about smokingcessation than did others, specifically, those with othermedical conditions. One professional prioritized his cli-ent’s “bad airways,” “I have a young guy...He also has ter-ribly severe asthma and he’s really pre-contemplativeabout changing his smoking. But I’ve spent a lot of timetrying to move him along to that stage of change.”The content and the delivery of the health promotionmessage varied according to their clients’ socioeconomicstatus and the perceived level of function. The expertprovider was in a position to know how the messagewould be interpreted.A lot of our clients, they are really poor. They haveno stimulation in their life. And I see cigarettes asreally important to them...For some, it’s taking a corepart of their identity away, their best friend away. Sofor those, I will have a different approach, or a softerapproach. [Professional, Former Smoker, MentalHealth Team]The timing of targeted interventions was important.This meant that the client had to be “stable“ and it hadthe tone of the expert taking charge when timing was“appropriate” when the client was “activated in theirrecovery process, as exemplified by one professional “Iaddress it more as ‘Oh, you are really doing well, youare more stable, you are making your appointments, youare taking your meds, your symptoms aren’t bothersomenow, why don’t we look at dealing with the smokingissue?’” Knowing when it was the “right time” was por-trayed as a skill, with the emphasis placed on holisticwell-being. According to one professional, “To me itseems like an art, experiential, knowing when to pushand when to back off, how to rate it among people’sother issues, looking at the whole picture.”Intervening to reverse tobacco reduction or cessationwas described as the necessary harm reduction measurewhen the timing was not right for a client’s “mentalhealth.” In this situation, the expert voice of authorityruled, “I advised her to forget it now because she is notstable.”Some providers described how they looked for andworked with “outward signs“ when clients were “cough-ing like mad.” Such moments were considered to be a“good time“ to raise the topic of tobacco use: “I’m anurse, so if someone is coughing a lot, I will say ‘So howmuch are you smoking and do ever think of cuttingback?’” Another provider recalled transforming aJohnson et al. International Journal of Mental Health Systems 2010, 4:23http://www.ijmhs.com/content/4/1/23Page 8 of 12situation of being “on the spot“ during a shoppingassessment into an opportunity to engage in tobaccocessation discussion.It is awkward because they say, “Do you mind if Ihave a cigarette?” and I kind of do... I asked him ifhe had smoked for a long time, would he be inter-ested in [quitting] smoking. He said “Maybe oneday.” At the end, I gave him the information aboutthe ButtOut group. It was an opening. [Professional,Non-Smoker, Mental Health Team]There was a call for immediate intervention when cli-ent smoking posed a serious safety concern as was thecase for one professional whose client, a woman withalcohol dementia, had caused a fire in her apartment.“I’m really working very hard to get her to stop smokingbecause not only is she at risk, but so are the people inher building.” This was further described as “beyond anindividual’s right to do something that is unhealthy“ andmore about protecting others from “physical harm.”An informal harm reduction approach was a part ofthe health promotion discourse. One paraprofessionalclaimed to not “have any information“ for her clients,but reminded them of the health and financial benefitsof cutting back. Another provider explained, “I encou-rage more of a harm reduction approach. I see a lot ofpeople do the cold turkey thing and come back to it andI expect there’s guilt.” Those who had been personallytouched by the tobacco-related loss of a family memberdedicated themselves to fully engaging in this discourse.I myself am not a smoker but I do know it’s addic-tive, I do know people go through a pack a day, so Ijust try to start conversations, “Oh, how much do yousmoke? Oh, a pack a day. Okay, what are you hopingto do, like next month? Are you hoping to reduce?What’s another thing that you could substitute itwith? [Paraprofessional, Non-Smoker, ResourceCentre]Attentive communication was emphasized in thehealth promotion discourse. “So I have to listen to whattheir plan is and reflect it back. And hopefully they havetime to think, ‘Oh, is it a reasonable plan?’” Althoughcontinual efforts to engage clients were labelled “frus-trating“ the potential for tobacco reduction or cessationwas held up as an option: “They say, ‘I cannot quitsmoking, I am addicted. I’ve smoked for fifty years ortwenty years, for many years.’ And I say, ‘Can’t you justcut back a little bit?’” Trying to “grasp at something“was a device used to keep the tobacco discussion openwith one client who was grieving the loss of her son“She has one remaining son. That son has now had ason and I say “Don’t you want to be around to see thatgrandson?”Personalised approaches were adopted when exploringclient motivation to quit smoking. One paraprofessionalspoke with confidence about investigating client motiva-tion by “testing readiness“ in a way that resembled a for-mal approach.You recognize patterns and human behaviour and ifit’s not a level of motivation, something that I wouldgrade over a 7, I wouldn’t invest a lot of time sup-porting that. So I am looking and testing levels ofmotivation whether it’s through body gestures, eyecontact, things that they are saying, if they’ve donetheir research on their options. [Paraprofessional,Current Smoker, Resource Centre]Another paraprofessional, a smoker, was adamant thathe would “never stop“ talking to his clients about smok-ing cessation, albeit his words were flavoured with wish-ful thinking. “I hope that one day when they are onabout it, I happen to say the right word, the right combi-nation of words and just catch them at that rightmoment where it’s going to work.”There was tension beneath the language of this dis-course. Approaching the topic of tobacco use was a“sensitive” matter that called for self reflection. One pro-fessional wrestled, “You have to ask, is this respectful,am I preaching to them, am I judging them? So it’s areally delicate balance to play with smoking.” Neverthe-less, there was relief with the recognition that some cli-ents had been successful in their efforts to quit smoking.We used to be afraid to bring it up, because thatwould destabilize people, they can’t handle it, butnow we know it can be hard but with the right sup-port, people can actually reduce or quit their smok-ing. So that is a tremendous shift in attitudes.[Professional, Non-Smoker, Mental Health Team]DiscussionThis study is not without limitations. We acknowledgethat we do not capture all of the discourses related totobacco control in community mental health settings.Nor do we claim that the discourses reported are takenup by mental health providers in other settings. Theanalysis does however provide useful insights into therelationship between organizational structures and pro-vider practices.Although there was a discourse that clearly dominatedeach one of the provider interviews, the providers ofteninvoked multiple discourses during the course of theinterview. Typically, the dominant discourse appearedJohnson et al. International Journal of Mental Health Systems 2010, 4:23http://www.ijmhs.com/content/4/1/23Page 9 of 12alongside a secondary and at times tertiary discoursethat backed up the main discourse. For example, a cen-tral discourse of tobacco as “therapeutic” was oftenaccompanied by the minor discourse of “individualchoice” with some minimal reference to the discourse of“managing a smoke free environment” in the back-ground. This movement between discursive frames mayhave been a reflection of the transition and state of fluxwithin the mental health care system with the introduc-tion of the new smoking policy.The presentation of the discourses is not intended toportray community mental health care providers in anegative light; rather, our aim is to highlight theassumptions of those working within a climate of recentorganizational change. The providers in this study wereindeed concerned about their clients’ well being, albeit,how this was manifested in terms of tobacco controlpractices varied widely. Importantly, the findings high-light the challenging context within which many com-munity mental health care providers are working andwithin which smoke free policy is being attempted andtherefore point to direction for future action. For exam-ple, the discourses of tobacco use as “therapeutic” and“an individual choice” point directly at systemic obsta-cles to changing practice and the “historical situated-ness” of tobacco in the mental health system. Of note,these two discourses mirror the findings in the Lawn etal. 2002 qualitative study of community-living clientswho described smoking as a way of finding companion-ship and sense of identity while cigarettes themselveswere a symbol of control [20]. There are undoubtedlyongoing opportunities to challenge and shift some pro-viders’ beliefs about “the power” of tobacco for their cli-ents, for example the common interpretation thattobacco use serves as a tool for “intimacy” within theclient-provider relationship [20]. Approaches to practicechange need to take into account these embedded per-spectives. As Waring and Currie [28] point out, practicechange is rarely best accomplished through a “top-down” approach; in their words, “to ‘harvest’ best prac-tice through learning requires an approach that allowsfor customization and localization” (p. 775).The discourse of “managing the smoke-free environ-ment” is particularly interesting as it exemplifies thecomplex and interdependent relationship between struc-ture and agency. It is tempting to conceptualize policiesas objective and external to health care providers, yet itis the actions of the providers that make these policies“come alive” and enforce their use. The providers in thisstudy embodied the new tobacco policy in their actionseven though many wanted to resist it. Indeed, ratherthan questioning the policy, or determining how itcould best be implemented, many took up the role ofenforcing it, thus socially and discursively constructingthe tobacco policy. From a Foucauldian perspective, thisdiscourse provided the mechanism to ensure that provi-ders maintained their own power within the system.Many of the providers reinforced the rules because theywere at a loss as to what else they could do. As Daviesand Nutley remind us, organizational change cannoteasily be wrought by simple exhortation [29]. Successfulstrategies need to take into account the needs, fears, andmotivations of staff at all levels. Furthermore, anyattempt to influence key practices must be part of amuch wider approach that addresses concerns related toresources, power and control.The issues of power are also interesting to consider inrelation to the discourse of tobacco use as “individualchoice.” The meaning and value of cigarettes for clientshas been well documented and is increasingly recog-nised [20]. Although the respect of clients’ choices islaudable, at the same time it denies the contextual fac-tors at play that reinforce tobacco use among those withmental illness. In fact, this position appears to cedemore power, privilege and authority to clients than iswarranted, thus absolving the provider of any responsi-bility for addressing issues of tobacco use. Similarly, theclaim that tobacco is therapeutic because it is the cli-ent’s “only joy” frees the provider from considering waysto assist clients with finding pleasure through othermeans. Why is it that clients are not provided opportu-nities for other sources of pleasure? What structuralchanges are required to help clients meet their needs?While we need to be respectful of clients’ choices, it isalso important for us to consider how their choices maybe constrained by social and structural factors. Polandand colleagues suggest that tobacco control programmeshave not sufficiently addressed the issue of power rela-tions and the central importance of context with respectto smoking. If the discourse can be shifted whereintobacco use is seen as a socially embedded practice, pro-viders may be prompted to consider the ways their ownpower and social locations influence relations with thosewho use tobacco [30].The discourse of “it’s someone else’s role” may in partbe a lingering symptom of the “historical divide”between addiction and mental health services. Unfortu-nately, the “hands-off” approach implied by this dis-course resulted in a gap in services for clients whoneeded support within the context of the new “smokefree” policy. Goldberg points to the evolution of inte-grated treatments in which some clinicians (psychiatristsand psychiatric nurses) now recognize their role in med-ication and symptom monitoring, therefore supportingclients who adopt a smoke free lifestyle [31]. Similarly,our study findings reflect a system that is evolving, oneJohnson et al. International Journal of Mental Health Systems 2010, 4:23http://www.ijmhs.com/content/4/1/23Page 10 of 12in which some community mental health providers arebeginning to rethink their ethical obligations, roles andresponsibilities.The health promotion discourse was taken up predo-minantly by members of the mental health teams wherethere was strong support for tobacco control. Nonethe-less, this discourse was also present in the other settingsdespite the fact that those providers were heavilyengaged in controlling the location of tobacco use.Some professionals and paraprofessionals made use ofopenings regarding tobacco reduction or cessation in allsettings. Goldberg proposes a shift has already occurredwithin the mental health system where past missedopportunities are now replaced by supporting and moti-vating clients in the process of change towards a heal-thier lifestyle [31]. Certainly the findings of the healthpromotion discourse convey optimism within a contextof change in which providers’ use of “openings” andmotivational interviewing can contribute toward asmoke-free lifestyle for clients [32].Our findings add to the limited literature examiningthe role of community mental health providers in thedomain of tobacco control and clarify direction for con-tinued efforts. Despite some brief training for staff atthe introduction of the smoke free policy, knowledgeand skills’ deficits regarding the implementation oftobacco control measures were widespread. As a result,some providers were unprepared for the policy and didnot have the tools to advocate for practice or policychanges. Staff training and ongoing educational needsmust be incorporated, paying attention to realisticexpectations of the work environment as well as theoverall culture, dynamics and uniqueness of each set-ting. Other research supports the benefits of staff train-ing in terms of smoking cessation practices andpreparedness [7].The study findings suggest that providers’ own smok-ing status can affect the ways in which they engage intobacco related interactions with clients, consistent withother research [4]. Offering cessation support to inter-ested staff members could contribute to a culture ofchange within the mental health system by promoting“wellness” focused dialogue between providers and cli-ents regarding tobacco use [22]. In addition, educationalsupport to non smoking staff would strengthen theirabilities to advocate for smoke free environments. In thespirit of collaboration and appreciative inquiry, we mustcontinue to ask what providers want and need to fulfiltheir roles [26].Despite efforts to provide smoking cessation supportto people with mental illness, a gap remains betweenscience and service [33]. In the current study, despitekey policy changes towards a smoke free environment,there was no systematic uptake of other practicechanges. While implementing smoke free policies is animportant and timely intervention in itself, the lack ofmanaged change process can unintentionally reinforcenegative attitudes about tobacco control initiatives.The misinformation about tobacco use and mental ill-ness was most pronounced in the discourse of tobaccouse as “therapeutic.” Similarly, Ziedonis et al. haveemphasized the importance of challenging misconcep-tions about the putative therapeutic benefits of tobaccouse which contributes to reluctance on the part of someproviders to support reduction or cessation efforts [2].Ferron et al. point to the controversy surrounding this“self-medication hypothesis,” noting that study resultshave been mixed [14]. Accurate information focused onthe safety and efficacy of nicotine replacement therapyand other smoking cessation medications translates intohealth messaging that can be useful and ethically sound.The concern that quitting smoking is too stressful forindividuals with mental illness is not supported byempirical evidence and can therefore be viewed as anopportunity to dispel a long standing myth within thissystem [8]. Smoking cessation interventions can beeffective for some people with schizophrenia and relateddisorders [14]. The introduction and resourcing ofempirically sound health promotion efforts would con-tribute to shifting tobacco control discourses within thecommunity mental health system. As Ziedonis and col-leagues suggest, addressing tobacco use in the contextof mental illness requires both program and systemlevel change [34].ConclusionsPractice change cannot take place in a vacuum. Rather itmust be based on a solid understanding of the contex-tual factors that shape knowledge, attitudes and prac-tices. This study provides insights into the complexdiscourses that shape tobacco control practices in themental health field and reinforces the need to see prac-tice change as a matter of that extends beyond theindividual.AcknowledgementsThe research was made possible by funds received from Canadian Institutesof Health Research (Grant # KAL - 86799).Authors’ contributionsJLL designed the larger study, conceptualized and participated in dataanalysis, and participated in writing the manuscript. BMM collected andanalyzed data, and participated in writing of the manuscript. LAM managedthe larger study, collected data and participated in writing of themanuscript. All authors read and approved the final manuscript.Competing interestsThe authors declare that they have no competing interests.Received: 23 June 2010 Accepted: 28 July 2010 Published: 28 July 2010Johnson et al. 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International Journal ofMental Health Systems 2010 4:23.Submit your next manuscript to BioMed Centraland take full advantage of: • Convenient online submission• Thorough peer review• No space constraints or color figure charges• Immediate publication on acceptance• Inclusion in PubMed, CAS, Scopus and Google Scholar• Research which is freely available for redistributionSubmit your manuscript at www.biomedcentral.com/submitJohnson et al. International Journal of Mental Health Systems 2010, 4:23http://www.ijmhs.com/content/4/1/23Page 12 of 12


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