The Impact of Smoking Regulations on the Daily Routine of Patients within an Irish Mental Health Setting

Abstract

A high prevalence of smoking has been reported among people receiving care within inpatient and forensic mental health services. An Irish inpatient mental health service introduced a “smoke free campus” policy in 2018. Six semi-structured interviews were completed with patients within this setting in 2019. Using thematic analysis, five themes were identified: Experience of stakeholder support, routine, experience of being an inpatient, the meaning of smoking, and the experience and perception of the smoking policy and governing bodies. The findings have implications for staff who work in mental health inpatient settings or who develop policies regarding smoking on hospital sites.

Keywords:

• Smoking
• smoke free campus
• mental health
• daily routine

Introduction

Smoking is a major threat to our population (Luck, 2020) and is the largest preventable cause of tobacco-related diseases for people living with mental illnesses (Campion et al., 2014). A disproportionate number of cigarette smokers are found within this group (Dickens et al., 2014; Williams & Ziedonis, 2004), perhaps as high as 70% of mental health patients in the UK (Royal College of Physicians & Royal college of Psychiatrists, 2013). Smoking has been referred to as a “dark” occupation (Twinley, 2017) among other occupations that are considered damaging, disruptive, or deviant (Hocking, 2020). It is important to consider the overall impact of limiting access to the occupation of smoking in mental health settings (MHSs) on the individual. “Dark” occupations share common features with other more mainstream, and potentially more socially accepted occupations (Hocking, 2020), such as holding meaning and reward for those who engage with it and therefore should be afforded equal consideration.

High rates of smoking within this group increase the risk of smoking-related diseases and complications such as cardiovascular disease, peripheral arterial disease, amputation, chronic obstructive pulmonary disease, type II diabetes, cancer, blindness and dementia (Campion et al., 2014). A reduced life expectancy of 10–20 years is associated with smoking-related diseases (Campion et al., 2014; Lawrence et al., 2013). Anti-smoking regulations within MHSs are seen as important to improve the health of smokers and nonsmokers alike, through better air quality (De Oliveira et al., 2018; Keizer et al., 2009; Ratschen et al., 2010). However, they are frequently only partially implemented (Huddlestone et al., 2018; Lawn & Pols, 2005), which further increases health inequalities for this group (Malone et al., 2018; Ziedonis et al., 2008).

Research exploring changes to smoking behavior after the implementation of a smoking ban suggests a statistically significant change (p < 0.05) to cigarette consumption rates following the ban (Stockings et al., 2014). Keizer et al. (2009) noted the patients’ experience of a smoking ban was influential to attitude and smoking behavior change. However, non-adherence and covert smoking persists within MHSs (Filia et al., 2015; Ratschen et al., 2010; Smith et al., 2013; Stockings et al., 2014). Non-adherence is more commonly noted in settings where the ban is partially implemented, i.e., not a complete smoking ban (Stockings et al., 2014). A hypothesis for this covert behavior is that partial smoking bans cause more disruption (Olivier et al., 2007). The attitude and behavior of peers and staff members have been found to have positive and negative influences on smoking (Malone et al., 2018; Smith et al., 2013) and the difficulty of implementing change to a long-standing behavior within this environment is evident.

Staff attitudes and beliefs relating to smoking can be highly influential (De Oliveira et al., 2018; Dickens et al., 2005; Keizer et al., 2009; Olivier et al., 2007; Ratschen et al., 2010). Staff members in MHSs can be averse to implementing a smoking ban particularly where historically, staff and patients used to smoke together (Dickens et al., 2005) and some wish to uphold these traditions (Skorpen et al., 2008). Dickens et al. (2005), reported that 77.8% of participants within a forensic setting (n = 102) believed that staff and patients should be permitted to smoke together. Staff members may be less likely to discourage patients from smoking if they view this as outside the scope of their professional responsibility (Dickens et al., 2005; Olivier et al., 2007), they do not want to deprive patients of a valued activity (Malone et al., 2018; Olivier et al., 2007) or they anticipate that there will be an increase in aggressive behavior amongst patients, based on past negative experiences (Malone et al., 2018). However, this latter claim was disputed in a systematic review that found smoking bans have not increased rates of patient aggression or discharges against medical advice (Stockings et al., 2014).

Staff members working in MHSs are faced with an ethical dilemma, as often they have a role to enable health-promoting occupations, and simultaneously to facilitate smoking breaks for patients (De Oliveira et al., 2018; Ratschen et al., 2010). Within occupational therapy literature, the complexity of supporting health promotion practices, acknowledging occupational narratives, whilst also maintaining moral and ethical codes to promote health and wellbeing is a contested issue (Greber, 2020). Some settings continue to use cigarettes as a “token economy” to control patient behavior (De Oliveira et al., 2018; Filia et al., 2015; Olivier et al., 2007), which directly enables and maintains cigarette smoking. It has been suggested that nursing staff are in a good position to plan and implement smoking cessation programs in line with the 24-hour care approach (De Oliveira et al., 2018). However, staff may fail to recognize the symptoms of nicotine withdrawal or differentiate these symptoms from that of the psychiatric diagnosis (Filia et al., 2015). There is a call for health care professionals to make meaningful efforts to support individuals during times of smoking cessation (Keizer et al., 2009). Knowledge of tobacco addiction and related challenges would aid in understanding this phenomenon (Farchaus Stein & Sharp, 2009; Malone et al., 2018), in addition to acknowledging the experience of addiction from an occupational perspective (Luck, 2020). Helbig and McKay (2003), suggest that addictions may be viewed through an occupational lens, considering the time use, daily organization and choices involved.

In general, there is evidence that smoking in some MHSs is part of the historical culture that is engrained and normalized within the environment (De Oliveira et al., 2018; Garg et al., 2009). Not only has this activity been accepted (Malone et al., 2018), it facilitates connecting with others through a shared experience (Skorpen et al., 2008), is an activity which is valued (Dickens et al., 2014) and is enjoyed and induces calming effects within a MHS (Ratschen et al., 2010). In a Norwegian study, Skorpen et al. (2008) described the designated smoking room within a MHS as the “patient’s sanctuary” (p.728). The same paper described the smoking room as being a patient-only area with a discussion of tactics used to discourage staff from entering the space (Skorpen et al., 2008). This designated environment is enjoyed by smokers and nonsmokers alike and they value this activity and space in the hospital (Skorpen et al., 2008). Based on the above findings, there is perhaps a deeper cultural significance of smoking in MHSs which health care professionals are failing to recognize when implementing smoking regulations within these environments.

From the service user perspective, the literature presents conflicting results on how smoking bans in MHSs are perceived. De Oliveira et al. (2018) in Brazil found that 46.8% of patients (n = 126) believed that they have a right to smoke within MHSs. Patients with four or more inpatient admissions were 82% less likely to agree with a smoking ban. Liberal attitudes to smoking were more likely in those who identified as a smoker (Dickens et al., 2005). Keizer et al. (2009), examined variations in smoking perceptions after the implementation of a partial smoking ban in a MHS in Switzerland. In this study, both the patients (n = 134) and staff (n = 85) reported a statistically significant reduction in the quantity of smoking in the setting (p = 0.00005), due to the smoking ban. Interestingly, the patients reported more negative opinions of the setting’s influence on their smoking than the staff participants. Similarly, low levels of acceptance of a complete smoking ban were documented in a UK-based study (Smith & O'Callaghan, 2008). Here, only 3% of the sample (n = 135) agreed to a complete smoking ban and 71.1% of patients supported general nonsmoking guidelines where designated smoking areas were provided. Forcefully implementing a smoking ban and thus removing the option to smoke in MHSs has been described as a violation of the patient’s rights (De Oliveira et al., 2018; Dickens et al., 2005; Filia et al., 2015; Hehir et al., 2012; Ratschen et al., 2010). It has been referred to as a negative and traumatic experience (Ratschen et al., 2010), as when service users exit hospital premises to smoke, they may feel vulnerable and unsafe.

In contrast to the previous discussion, De Oliveira et al. (2018) found that 57.1% of patients (n = 126) felt that enabling smoking is an omission of care. The majority stated that smoking in such settings suggests a lack of respect for nonsmokers. An Australian study (Hehir et al., 2012), reported that 81% of patients (n = 45) viewed a smoking ban as a great opportunity to quit. There is increasing evidence that patients welcome the discussion and support for smoking cessation (Malone et al., 2018; Olivier et al., 2007). Gaining a sense of achievement, welcoming the smoke-free environment and physical and financial benefits were associated with the implementation of a smoking ban (Hehir et al., 2012). Social support is seen as an important factor. Hehir et al. (2012), reported that 85% of the sample of forensic patients (n = 45) stated that it was easier to quit smoking within a group and Dickens et al. (2005), reported 79.4% of forensic in-patients reported that observing other patients smoking would increase the difficulty of quitting.

The experience of smoking in a MHS appears also to be related to activity participation and boredom as an inpatient. Keizer et al. (2009) found that 39% of their in-patient sample (n = 134) reported that they engaged in smoking due to boredom, lack of activities and waiting. Half of patients (n = 45) in a new smoke-free forensic MHS reported they were bored more frequently without the opportunity to engage in smoking (Hehir et al., 2012). Smoking is reported as an activity used to overcome feelings of idleness in MHSs (De Oliveira et al., 2018; Dickens et al., 2005; Malone et al., 2018). A lack of meaningful activity in the inpatient context contributes to feelings of boredom (De Oliveira et al., 2018; Dickens et al., 2014; Filia et al., 2015) and a sedentary lifestyle (Ratschen et al., 2010). Boredom was reported as a barrier to stopping or reducing smoking (Ratschen et al., 2010) and some nonsmokers were reported to take up smoking due to a lack of activity (Olivier et al., 2007). Dickens et al. (2014) and Ratschen et al. (2010) supported the idea that emphasizing activity and daily structural support may offset the risk of relapse.

The “Tobacco-free campus” campaign was adopted as an official policy in Ireland in 2012 (Health Service Executive, 2018). This policy is reflective of international best practice and has been implemented within some Irish hospitals. It is a smoke-free policy which prohibits staff, service users and visitors from smoking on all HSE campuses (Health Service Executive, 2018). While research has been conducted in MHSs in the UK, Australia and New Zealand (Malone et al., 2018; Stockings et al., 2014), there is limited research on this policy implementation within the Irish context. The literature demonstrates the multi-faceted experience of smoking within MHSs with relation to a culture of smoking, social and environmental influences, varied opinions of stakeholders and a lack of activity to replace this often-valued occupation. In promoting behavior change, health care professionals would benefit from understanding why individuals engage in this occupation and what impact (if any) a smoking ban poses to the daily structure and routine of service users. Occupations perceived as “risky” and “deviant” are often strongly associated with and connected to other occupations (Hocking, 2020) and have been noted to punctuate people’s daily routines (Luck & Beagan, 2015).

Aim & objectives

The aim of this small-scale research study was to gain an understanding of the lived experience of patients receiving care within an inpatient MHS in Ireland after the implementation of a tobacco free campus policy.

The study objectives were:

• To explore the experience of the tobacco free campus while receiving care within the setting.

• To explore the meaning of the occupation of smoking.

• To explore if the implementation of the tobacco free campus influenced or impacted their daily routine.

Methods

The aim of conducting a qualitative study with this population was to explore the participants’ experience of a phenomenon and interpret the findings through the lens of clinical application (Maxwell, 2013). Interpretive descriptive methodology was chosen as this methodology can be used to extract information applicable to the clinical environment (Hunt, 2009). It affords flexibility in examining and interpreting the experience, thus deciphering if this experience has clinical implications (Thorne, 2008). Interpretive description requires the researcher to become deeply involved with the material when compared to purely descriptive types of qualitative research (Lambert & Lambert, 2012) and is associated with a naturalistic and constructivist approach to investigation. Conducting the research within a MHS allowed for data gathering to take place in a highly contextualized manner, where participants were very close to the experience they were discussing.

Ethical considerations

Ethical considerations as outlined by King (2018) were consulted in the development and completion of participant interviews. The participants in this research study were receiving care in an inpatient MHS. A comprehensive risk assessment was completed prior to the study and written consent was gained from each participant. The participants were provided with an information leaflet prior to and on the day of the interview. Participants were not recruited if they were admitted involuntarily under the Mental Health Act 2001, the law governing involuntary admission to Mental Health inpatient care in the Irish context. Identity and demographic data were not recorded to protect privacy. A distress protocol was developed, and support staff were present on the ward during the interview process should support have been required.

Interview development

Despite some criticism of the over-dependence on interviewing in qualitative studies (Nunkoosing, 2005; Sandelowski, 2002; Silverman, 1985, Thorne, 2008), semi-structured interviews remain the leading source of data collection in the area of clinical qualitative research (Thorne, 2008). Exploring individual experiences and narratives helps to gain a deeper understanding of clinical issues we are exposed to in practice (Thorne, 2008). This research study utilized a semi-structured interview to gather the personal experience of in-patients about smoking regulations and how it may impact their day-to-day routine. The researcher designed the interview protocol with sensitivity to the environmental setting, rapport building, question formation, opening and closing statements and consideration for how to navigate difficult interview sessions (King et al., 2019). Opening questions brought the participant’s attention to the topic of the interview and their overall feelings (“What does smoking mean to you?” and “Can you describe your experiences of the smoking regulations here?”). Subsequent questions prompted the person to think through their day and how/if the regulations affected their routines, choices or options (“Do the smoking regulations impact your morning/evening/mealtime routines?” and “Do the regulations affect how you plan your day?”). Finally, questions prompted the person to think more deeply about the impact of the regulations on behavior, social connections and emotions (“Have the smoking regulations changed your experience of smoking and what it means to you”?).

The interview protocol was piloted with an individual familiar with the environment as recommended in the literature (Clarke & Braun, 2013). Given the vulnerability of the participants, the researcher took steps to remain neutral in the interviewing process and not to influence the interview (Thorne, 2008). The researcher explicitly described the aims of the research, methods of protecting the participant’s confidentiality and outlined what would happen to their results, including with whom they would be shared (King et al., 2019). Full ethical approval was sought and granted from NUI Galway College of Medicine, Nursing and Health Sciences Research Ethics Committee in January 2019.

Participants

Participants were recruited from an in-patient MHS in Ireland. Purposive sampling of this kind gathers rich data from people who have an experience with the phenomenon (Draper & Swift, 2011; Patton, 2015). A clinical staff member was identified as a gatekeeper but was not involved with the day-to-day care of the service users, thus reducing the risk of coercion. They distributed the research poster and information leaflet within the MHS. Participants self-referred to the study by contacting the gatekeeper. The use of a gatekeeper in this way was a requirement of the research ethics committee overseeing this study.

The inclusion criteria were; patients over the age of 18, smokers/nonsmokers/ex-smokers and patients with a status of voluntary admission to the MHS. In small qualitative projects, sample sizes of 6–10 are deemed suitable where 1:1 interview methods are applied (Clarke & Braun, 2013). Between 6 and 8 participants were sought for this study.

Data collection

The participants were interviewed individually on the ward, in a private space with the researcher. Identifying details, length of stay, or demographics were not recorded to maintain anonymity within the group. The expected length of the interviews in this study ranged between 20 and 35 minutes. Unfortunately, two participants’ interview sessions were cut short due to other commitments on the ward at the time of the researchers visit. The interviews were recorded using a Dictaphone and transcribed verbatim after each interview by the researcher to maintain contextual clarity (Serry & Liamputtong, 2013). Text-to-speech recognition software was utilized to further enhance accuracy and organized using NVivo (Version 12.2, NVivo, 2018). Utilizing software such as this has been recommended to improve the rigor and quality of qualitative research (AlYahmady & Al Abri, 2013), and enables structured organization of a large amount of data (Maher et al., 2018). Transcriptions were coded and pseudonyms were utilized (Participant 1–6).

Data analysis

Clarke and Braun (2013) thematic analysis was used to systematically interpret the findings of this research. Strengths of thematic analysis include the flexibility of the approach with clear steps that can provide guidance for analysis (Braun & Clarke, 2006, 2012; Clarke & Braun, 2013). Combining Interpretive Description as a methodological approach with thematic analysis seeks to extract and analyze data that may lead to useful insights applicable to clinical contexts (Thorne, 2008).

The researcher first identified codes for the data set and labeled the codes with a description. Colored tabs and sticky notes were used during the coding stages. Similar methods have been reported in qualitative research to facilitate meaningful engagement with the data (Maher et al., 2018). The researcher identified multiple codes that represented a similar experience, which then supported the development of sub-themes.The third stage of the analysis involved the identification of over-arching/main themes. Weekly meetings between the researcher and the second author enabled accurate identification and development of themes and sub-themes that added to research rigor (Maher et al., 2018). Figure 1 demonstrates the development of a main theme. Participants were provided with the opportunity to review the transcripts prior to analysis as recommended (Barusch et al., 2011). However, none of the research participants expressed an interest to do so.

Figure 1. Development of theme.

Results

This research explored the experiences of the smoking regulations and the potential impact on the daily routines of in-patients within a MHS. The experiences of both “smokers” and “nonsmokers” are included. However, the smoking status of the participants was not explicitly recorded. The terms “patient” and “service user” are used interchangeably throughout the results as the participants referred to both terms during the research. The following themes were identified within the data: (1) Experience of stakeholder support, (2) Routine, (3) Experience and perceptions of being an inpatient, (4) The meaning of smoking, and (5) Experience and perceptions of the smoking policy and governing bodies.

Theme 1: experience of stakeholder support

This theme identified varying aspects of physical, psychological, and pharmacological support offered by staff in the MHS. Additionally, an awareness of the difficulty with implementing the policy was reported. Participant 6 expressed their opinion of how the smoking regulations have not only impacted their smoking habit but the social implications of removing this occupation from the MHS:

Yeah, I built relationships with the other smokers…and then they came and took them all away from me…[p. 6].

A perception of social connectedness within the group was reported by four participants, with reference to a sense of community and support for fellow patients who smoke. One participant expressed their view that other individuals would support their desire to have access to a smoking area within the MHS.

There was some uncertainty about the smoking cessation supports available for those who were attempting to reduce or quit smoking within the MHS, with two participants stating they had no knowledge of this. Five out of six participants commented on the impact of the smoking regulations on the patient and staff dynamic within the MHS, including a nonsmoking patient. One participant actively avoided a staff member that was enforcing the policy. Participant 4 stated that they are treated with contempt from staff members and is displeased with the current smoking regulations:

…I think it impacts how staff talk to me…they look at me with disdain … [p. 4].

Contrastingly, two participants (both identified as smokers) described the pragmatic support that was offered from staff members in the transition toward smoking cessation:

…they have had a good effect on me…they give you patches and pipes and you learn to overcome your cravings…you learn to spend a few days without a cigarette…so it has it’s plusses. [p. 2].

Two participants commented on the difficulty faced by staff, suggesting an awareness of duty to implement health policies and a sense of empathy for staff in this position.

…they’re holding the staff back from helping so much more than they already do…staff in here are brilliant, they’re amazing…and they have to enforce these policies they don’t want, doesn’t make sense…you get so mad and then you realize they’re a person too…they’re just doing their job …and they have a tough job… [p. 5].

Theme 2: routine

The introduction of the smoking regulations had no direct impact on two non- smoking participants, one of whom was cognizant of the impact on their peers. Prior to admission, participant 4 stated that their day was punctuated with smoking breaks, which was habituated over some time. The same participant suggested a generational association with smoking and how it’s been a meaningful occupation for many years:

…(people) my age they often sit around with a bottle of beer and have done so since fifteen or sixteen or having a cigarette or whatever… [p. 4].

Two participants commented on their desire to reduce their overall cigarette consumption, but to maintain the punctuation to the daily routine that this occupation offers. Three participants agreed that the smoking regulations impacted self-directed daily planning in the MHS. Staff are placed in a difficult position where the implementation of the policy is expected in addition to facilitating outdoor leave, where patients may take the opportunity to smoke once off hospital property. This overarching control was felt strongly by one participant in particular who objected to the structured breaks. Minimal disruption to therapeutic groups or activities was reported. It was evident from two participants’ statements that they were experiencing boredom and an unfulfilled routine due to a lack of activity on the ward. For those struggling with the smoking regulations, this can only increase the difficulty of withdrawing from cigarettes:

…for weeks on end it was just one long day after another…it was very boring…very monotonous…very mind numbing nothing to stimulate you at all… [p. 2].

Theme 3: experience and perceptions of being an in-patient in mental health services

Although the focus of the interview was to explore the meaning of smoking and how the regulations potentially impact this occupation, participants discussed a more general view of their experience within this MHS. Two participants commented on the “social divide” within the group referring to the smoking or nonsmoking status of patients, with one participant commenting on the expectation of nonsmokers to socialize within smoking rooms.

I think we are all the same group of people…is there much of a difference? It’s a community…we shouldn’t be split up…strange to split up mental health…keep us as a community… [p. 4].

A loss of privacy and the perception of being monitored by staff were reported by two participants. Four out of six participants suggested a designated smoking area should be made available. Additionally, nonsmoking patients were passionately advocating on behalf of their smoking peers. Comments provided are indicative of support for fellow patients who are struggling with the smoking regulations and perhaps are not able to advocate for themselves:

… the smoking ban is causing so much pain and it’s avoidable…the policies are draconian… [p. 5].

Additionally, there was an overall sense that the smoking regulations are unnecessarily harsh, with the latter comments calling for accountability from policy developers, indicating a longing for policy developers to experience the severity of the smoking regulations for patients in MHSs. Interestingly, it is again the nonsmokers who speak more passionately about this topic than those who are directly impacted:

I have noticed the sign around about that say the entire campus is a non-smoking ban…that it sounded a bit radical… [p. 3].

Three participants described being punished for having a mental illness and a tobacco addiction.

…if you have cancer, you’re allowed smoke, but if you’re mentally ill you’re not…you shouldn’t be punished for being addicted to something… [p. 5].

Four participants believed that smoking addiction and mental illness should be treated separately. This contradicts the views of policy holders; in-patient settings offer an opportunity for tobacco reduction and control. This indicates that an in-depth understanding of the difficulties presented is necessary for successful policy implementation.

Theme 4: the meaning of smoking

Five participants commented on the various reasons for smoking; habitual, behavioral, sensory, emotional and utilizing cigarettes as a coping mechanism. This signifies the deeper associations of addiction that are potentially overlooked within this group.

Because when I actually smoke, my mind does get peace. So, it’s not like it doesn’t have a purpose, it does. [p. 4].

This discussion was a difficult topic especially for one participant who requested the interview to be discontinued due to fatigue. One participant commented on the negative perception they associated with smoking. Removing a valued coping mechanism results in negative consequences for those who heavily rely on this occupation:

You can feel a bit panicky about that…you can feel very worried that you’ll never get to smoke again while you’re in hospital…[p. 2].

The cultural significance of smoking was identified during the discussions. Not only regarding smoking in MHS’s, but also how Irish citizens have welcomed societal change and the desire to extend this acceptance to those who smoke.

It’s the same as drinking…it would be something that has been normalized in Ireland… [p. 5].

One participant fondly recalled smoking in the days gone by, reminiscing about the “old ward” and spoke of smoking in previous hospital environments with a sense of nostalgia. Another participant associated the maturation process with a progression to pipe smoking, which was typical of traditional Irish culture in previous generations.

Theme 5: experience and perceptions of the smoking policy and governing bodies

Participants offered a balanced argument identifying the positive benefits of the regulation, the challenges, the desire for additional information and the opportunity to discuss these concerns with policy makers. Four participants expressed positive views of the regulation, indicating that there are benefits for both the smokers and nonsmokers of the group. In contrast, three participants commented on the difficulty of implementing this policy in meeting the needs of all service users in the MHS.

It’s punitive…it’s very negative [p. 2].

Additionally, one participant suggested that mental health service users should be exempt from the smoking regulations. However, this may not resolve the current challenge of health providers in reducing the health inequalities faced by this group. Another participant stated the importance of consulting with staff members and service users before compiling a policy. Three participants expressed uncertainty regarding the regulation. This suggests that perhaps they have received little information regarding the complaints procedure and where to find more information.

I’ve asked who has written it, I have asked so many times! …and all I get back is “I don’t know, I don’t know, I don’t know” [p. 5].

One participant commented on how service users are required to exit the hospital property to smoke. This comment suggests that the regulations may place service users in a vulnerable position:

…and then they have to get permission to go outside the blue line and they mightn’t be well enough to leave… [p. 1].

One participant discussed their views of amending the policy, and what positive change this might bring:

And you just tweak the policy, you change five or six things (not identified by participant) and you make this place heaven for people trying to get better and that’s what it’s all about you know…it’s solvable, it’s easily solvable [p. 5].

Overall, there were both critical and constructive views of the regulations in this MHS. This topic resulted in passionate discussions, enabling service users an opportunity to express their views as some struggle to adapt to the new regulations. It is understood that smoking is ingrained in the daily routine, and removing the occupation of smoking creates a void, where service users are left unfulfilled and in search of something meaningful to replace it.

Discussion

This study aimed to explore the experiences of patients receiving care within a MHS after the implementation of a smoke free campus policy. Results produced rich insights into the meaning of the occupation of smoking, how removing this valued occupation impacted the routine and social interaction opportunities of the patients and identified a sense of comradery within the group. Smoking within the MHS was both a valued and contested issue. The study enabled an opportunity for the group to speak about their lived experience within the MHS and their perceptions of the smoking policy and governing bodies. Often prior to hospitalization, the participants’ days were punctuated with structured smoking breaks, also noted in Luck and Beagan (2015). The occupation of smoking presents similarities to other addictions in which it enables organization and structure to the day (Helbig & McKay, 2003; Kiepek & Magalhaes, 2011). Utilizing an occupational perspective can enhance the understanding of the complexity between addictions and occupation (Luck, 2020). One participant stated that smoking has been a habitual aspect of their day for many years, and they wish to continue engaging with this occupation. It has been noted that older adults are less likely to attempt smoking cessation (Jordan et al., 2017) and associate smoking with positive experiences (Kerr et al., 2006).

Quitting smoking is regarded a significant occupational transition (Luck & Beagan, 2015). Transitions may involve loss of roles, routines, relationships, social networks and ultimately a change in occupational identity (Luck & Beagan, 2015). Restricting smoking as an occupation in MHSs has a significant influence on the daily structure and routine for those within this transitionary phase. Supporting the transition from smoker to nonsmoker involves enabling the individual to explore new roles, to participate in other meaningful occupations and supporting self-discovery (Luck, 2020). Occupational therapy programmes such as Redesigning Daily Occupations (ReDO^®) could provide structure and peer group-support to those who are trying to change routines, analyze the roles and meaning of their life occupations and make changes for health (Erlandsson, 2013). Gutman (2006) suggests specific occupational therapy interventions for people experiencing addiction such as identifying trigger situations, real-world practice of alternative occupations and role-playing difficult social situations.

Two participants (smoker and nonsmoker) commented on their experience of boredom and having an unfulfilled routine while attending the MHS. Both participants complained of the lack of activity and the monotony of passing time in the MHS. A similar theme was identified in Molin et al. (2016). It has been noted in previous studies that a large percentage of time has been spent in passive leisure and restful occupations for patients within regional forensic settings (Farnworth et al., 2004; Stewart & Craik, 2007). A similar theme was found in a community based mental health study (Krupa et al., 2003). Establishing a routine with access to meaningful occupations rather than prescriptive activities is associated with reducing boredom and increasing satisfaction within such settings (Stewart & Craik, 2007). The occupational therapy department in MHSs has been identified by service users as a vital therapeutic space to do real-life activities in a non-clinical way. Using photographs, service users in Birken and Bryant’s study (2019) showed how simple spaces such as a garden, items such as paints or art materials, books, exercise equipment and the tea-kettle were ready to use and welcoming in the occupational therapy department – facilitating autonomy, personal choice, the development of coping skills and a sense of normality.

Two participants stated that they experienced a loss of privacy where staff were monitoring patients’ behaviors. Often concerns relating to privacy are reported in MHSs, as staff are required to complete documentation on the continuous observations of patients (Zakaria & Ramli, 2018). Two participants commented on the subtle divide between service users; the smokers and the nonsmokers, with others wishing to minimize this sense of separation within the patient group. There is evidence to suggest that individuals living with mental health difficulties experience social exclusion, often due to stigma and discrimination (Tew et al., 2012). Perhaps having limited social connections increases the desire to connect with others when in hospital. Social connectedness and closeness with others have been reported to foster a sense of self-expression and belonging while engaged in the occupation of smoking, which is considered meaningful for many (Luck & Beagan, 2015). By providing other kinds of meaningful social connections in hospital such as formal/informal groups involving meal preparation, reading, art or gardening, occupational therapists could facilitate this sense of separation from clinical environments that could aid recovery and enable peer support (Birken & Bryant, 2019).

Perhaps the longing for a sense of community and patient-only areas suggests a deeper meaning and resistance to change in the MHS. Fostering relationships with others who also experience mental health difficulties often leads to acceptance, understanding and reduced stigma that patients may not experience in other environments (Mead & MacNeil, 2006; Tew et al., 2012). The stigma experienced by this group is often internalized, resulting in, and enhanced by reduced social connections thus limiting recovery (Tew et al., 2012). There is a need to increase the social experiences of this population to enable the growth of personal relationships that will support their recovery (Tew et al., 2012). Peer support professionals offer emotional and instrumental support to patients within MHSs to support their recovery from mental distress (Johnson et al., 2014), and provide an opportunity for connecting with others (Schon, 2010). There is growing evidence for the effectiveness of providing a peer support service within MHSs with associated outcomes including increased engagement and improved relationships between patients and care providers and increased levels of empowerment and hopefulness for patients receiving input from a peer support professional (Chinman et al., 2014). A systematic review (Ford et al., 2013), found that peer-based smoking cessation interventions are effective when offered to socially disadvantaged groups as access to informal support is often limited. However, more research is required to determine the long-term effects of such interventions. This study also stated that delivering peer-based interventions enables the experience of social support to those wishing to reduce or stop smoking.

The perspectives of the participants confirm that there can be a culture of smoking in inpatient MHSs (Cormac & McNally, 2008; Filia et al., 2015). The significance of smoking within MHSs may be associated with occupational imbalance, deprivation or alienation that are common risk factors for addictions (Luck & Beagan, 2015). The occupation of smoking within MHSs enables shared experiences with others and promotes meaningful time use (Luck & Beagan, 2015). Smoking is also imbued with personal meaning (Rondina et al., 2007). The occupation of smoking may meet the needs of sensory seeking behavior (Rondina et al., 2007) and was considered a coping mechanism by the participants in this study. A similar finding was presented in Windle and Windle (2001), where smoking was considered a form of self-medication in those with low mood. One participant spoke fondly of their desire to transition to tobacco-pipe smoking as they grow older, suggesting not only a cultural but a generational aspect of this valued occupation. An understanding of cultural norms should be considered as part of the therapeutic process (Malkawi et al., 2020). A complimentary theme was stated in Parry et al. (2002), where older aged smokers experienced a drastic change in the social acceptance of smoking that they previously experienced in their younger years. Once considered a socially shared experience, the occupation of smoking was now associated with an increase in isolation and was no longer considered a shared social activity (Parry et al., 2002). An effective manualised intervention programme – Action Over Inertia (AOI) (Krupa et al., 2010), delivered by occupational therapists to those with mental illnesses, promotes an improvement in occupational balance and engagement for group participants (Edgelow & Krupa, 2011). A recent five-week pilot study adapted the original AOI intervention for use within a substance use recovery programme in the US (Jarrard et al., 2021). Weekly activities within this group intervention focused on developing healthy habits, identifying emotions and triggers, effective time use and making long term changes (Jarrard et al., 2021). Although this pilot study was not specifically supporting smoking addition recovery, this programme may compliment current inpatient smoking cessation programmes. Group programmes with an occupational focus may meet the need for social connection and support while transitioning from the role of smoker to non- smoker within this community.

Mixed opinions were presented in relation to the smoking regulations. One participant felt the MHS did not consult with staff or previous patients to gain wider perspectives of the needs of the group who were receiving care within the MHS. This highlights the need for patient involvement in the development of policies (Wyder et al., 2015). The need for service user involvement in health service research and development has been discussed (INVOLVE, 2014), with strong evidence for its applicability to MHSs (Ennis & Wykes, 2013). Service user involvement is particularly beneficial when enacted beyond a tokenistic offer (Oliver et al., 2008).

Finally, suggestions to facilitate the exemption of mental health patients from the smoking regulation were presented. These comments contradict the attempts made by the health authorities to minimize the health inequalities experienced by this group, as quoted in Healthy Ireland: A Framework for Improved Health and Wellbeing (2013–2025) and the HSE smoke free campus policy (2012). Supporting the health needs of a community or society has been a proposed role for occupational therapists given their understanding of health promotion and health determinants (Leclair, 2010). This statement was echoed by the World Federation of Occupational Therapists (World Federation of Occupational Therapists, 2016) stating the need to adopt a human rights perspective to promote the overall wellbeing of the community to reduce inequality. Griffiths and West (2015) reported that the state has a responsibility to promote the health of its citizens, particularly where the participation of people with mental health needs in health promoting initiatives is typically lower than the general population. However, it may be wise to consider the impact of removing a habituated and often valued occupation as part of the “whole person approach” as recently documented in a recent Irish government health policy “Sharing the vision: A mental health policy for everyone” (Gov.ie, 2020).

Limitations

Although the sample size was appropriate for an in-depth qualitative study (Clarke & Braun, 2013), it was considered relatively small in relation to the complete patient group within the setting. All six interviews were no longer than 35 minutes in length and this is considered a limitation of the study. Reasons for this included some participants having to attend to other commitments on the ward and one experienced fatigue during the interviewing process.

Polarized opinions often present within qualitative research (Thorne, 2008). Due to the small sample size, polarized opinions may be a potential limitation of the study. Due to the subjective nature of the data extracted during qualitative interviews, the researcher must not assume generalization of findings (Thorne, 2008). However, it may be hypothesized that as the current study was conducted within an approved, publicly funded MHS in Ireland, the findings may offer valuable insights to other such settings in Ireland. In addition, member checking of transcribed material was not completed, and this would have strengthened the rigor of the study. To avoid investigator bias, the second author reviewed the semi-structured interview questions prior to the interviews and regularly reviewed the transcriptions and interpretations of the data which adds to the credibility of the research (Maher et al., 2018).

Providing a clear description of the research setting and participant demographics adds to qualitative rigor (Maher et al., 2018). However, presenting such detail was not appropriate. To maintain confidentiality, participant demographic data or identifying details of the MHS were not collected due to the risk of compromising participant anonymity. This limits the opportunity to examine differences within the data set. Participation in this study was voluntary; however, there may be some potential for selection bias on the part of the gatekeeper who completed the recruitment process within the setting. As aforementioned, the gatekeeper was required to support ethical approval for the study.

Implications for practice

Results of this study may be of interest to anti-smoking policy developers in Ireland, particularly because the “Tobacco Free Ireland” initiative is subject to ongoing strategic planning as part of the National Implementation Plan (2018–2021). This research study hopes to offer insights to the awareness of smoking as an occupation for service users and the interruption to routine when this occupation is limited or restricted. Additionally, reducing boredom in MHSs by facilitating patient-inspired and meaningful activities that may be further enhanced by the addition of peer support programmes and may improve service users’ experience of their admission to a MHS. A longing for social connectedness and community within this patient group suggests the importance of patient social spaces or “a place to call their own” within MHSs. The “Sharing the vision” (Health Service Executive, 2020) policy was introduced in 2020 with an emphasis on processes and skills to support change within mental health settings in Ireland. Supporting the transition to an alternative, equally meaningful occupation is fundamental in health promotion and maintenance of well-being (Mee & Sumsion, 2001; Townsend, 1997; Wilcock, 1998). Supporting the occupational transition from smoker to nonsmoker is a potential area of further research within the field of occupational therapy. There is potential scope for occupational therapists to develop their role within current smoking cessation interventions such as “The Tobacco Cessation Support Programme” as delivered in Ireland (Health Service Executive, 2013). With extensive knowledge and awareness of coping, behavior change and occupational goal setting, occupational therapists may offer a valuable contribution to this established programme. Lastly, involving the patient’s voice in the development and implementation of service change ensures individual needs are considered and respected (Stewart & Craik, 2007).

Acknowledgments

The authors wish to thank the stakeholders within the mental health service that facilitated the research study. With particular thanks to the service users who dedicated their time to richly contribute to this study. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sector.

Data availability statement

Research ethics approval does not cover data sharing/storage in any repository other than NUI Galway to protect the identity of participants within the current study.