Recruitment of staff.

We sampled staff purposively, to include diverse professions: nurses, health care assistants, social workers, occupational therapists, resident psychiatrists, pharmacists, clinical team leaders, cultural advisors, and consumer advisors.

Recruitment of service users.

As per our ethics protocol, we were provided with a list of inpatients from each study site assessed by their lead clinician as competent to consent and well enough to participate, and who were potentially interested in being involved. GJ met with these potential participants and interviewed those who agreed and provided written consent to participate.

Interview schedule.

While our semi-structured interview schedule explored multiple aspects of three key topics, this MS reports on responses to the following stem question: ‘how do you feel about the rules around smoking on the ward?’ We probed responses using prompts, such as ‘what do you like/dislike about them?’ and ‘why do you say that?’ While these questions generated rich data on staff members’ and service users’ perspectives on smoking, many salient comments emerged in response to questions exploring how and where staff and service users spent their time, their use of outdoor spaces, and their perceptions of safety on the ward.

Interviews.

All interviews were conducted by GJ, a social scientist and experienced qualitative researcher. Most interviews were conducted face to face on the ward, but ten were conducted by phone. Interviews lasted 30–90 minutes and were transcribed verbatim.

Difference between policy and practice.

Of the three wards where smoking occurred, staff and service users acknowledged that policy and practice varied:

It’s meant to be totally smoke-free. The whole hospital is smoke-free, allegedly, but it’s not. (staff B9)

You know, the hospital [is] supposed to be a smoke-free environment, I mean it isn’t. (service user C6)

‘Going smoke-free causes violence and aggression’.

Staff from the three wards that had not implemented the smoke-free policy believed that violence and aggression would result from denying service users’ requests to smoke and saw this belief as the major barrier to going smoke-free:

So, I know that it [smoke-free] was tried a few years ago, before my time, and the assaults went berserk. (staff B9)

Staff also felt too threatened and intimidated to implement or enforce smoke-free policy:

[The smoke-free policy is] something that I would not enforce. I’m not going to get smacked over because someone wants to go and have a cigarette. It’s not worth it. You’ve got to pick your battles. (staff B4)

Similarly, service users appeared intimidated as they recalled experiences that linked the smoke-free policy with aggression:

Well, one guy went off his nut the day before yesterday and started screaming at one of the elderly women because he wanted to go out for a smoke, and they wouldn’t open the door until a certain time. So, he lost it, and threatened her. (service user A3)

Some staff claimed evidence from ward incidents supported their claim that smoking cessation was associated with increased violence:

We have a lot of aggression and violence, a lot of that is actually caused by … [they] are not allowed to smoke … so staff assaults are quite high and there’s some stats. (staff C1)

Managing nicotine withdrawal was therefore viewed as an important part of preventing violence on the ward, which staff did in various ways. Escorting service users outside to smoke was one option for managing the agitation caused by smoking withdrawal, even on the smoke-free ward:

You’d probably just say … someone on the floor can go out [to the hospital grounds] with them for five minutes. They can have a cigarette and they can come back in. (staff D5)

NRT was the most common option for managing agitation due to nicotine withdrawal:

You can usually de-escalate someone if they’re having smoking withdrawal, and we’ve got the NRT [nicotine replacement therapy], and if we’ve identified that as the cause of their irritability. (staff D5)

However, some staff felt NRT had limited effectiveness in reducing the effects of nicotine withdrawal:

They are offered the NRT … But, it’s not good enough. It’s not satisfying for them [compared to smoking] and—yeah. (staff D8)

One staff member cited research evidence that vaping reduces violence:

[We allow vaping] in the courtyard. Both here and HNU [high needs unit]. We are the first DHB in NZ to do it. Australia does it, Canada does it, and UK do it. Research evidence has shown that in psychiatric inpatient units where vaping has been allowed, it’s been associated with a 6–8 percent reduction in violence and aggression rates. (staff C7)

‘Smoking has sedative effects and alleviates stress’.

Unsurprisingly, given the significance of the staff and service users’ views on the link between nicotine withdrawal and increased violence on the ward, many staff and service users believed that smoking had calming effects, alleviating anxiety and stress:

For some of our clients it’s the only way to cope and keep calm. (staff A9)

I would love to give half our patients a cigarette because it’s a PRN [pro re nata – medication when necessary] in itself … Like a de-escalator in itself … instead of antipsychotic … or a benzo. (staff D2)

One staff member told us that the deliberate supply of nicotine was a useful calming tool:

Actually, what they even used to do, which would shock the anti-smoking people, when I was first went there, there was a packet of tobacco and if people were desperate, the nurses could give somebody one, and that really does calm somebody down. (staff C11)

Service users noted how stress often drove them to smoke in general, and some felt that the stress of being in the acute mental health ward exacerbated their smoking. Being on the ward also contributed to some service users relapsing to smoking as part of socialisation or as self-medication:

I get a bit tense … I bought a cigarette. I’m not addicted but I know these other guys always want to go out for smoke. (service user D8)

I gave up smoking, but I’ve started again … I do it when I’m stressed. (service user A7)

A staff member also commented on smoking uptake among staff as a stress management tool:

Because there’s a lot of staff nurses that smoke … stress. Because I had actually stopped smoking for two years, and then I came to work here. (staff A1)

‘Smoking is all they/we have’.

Both staff and service users talked at times about smoking being ‘all they [service users] have.’ Staff expressed sympathy that service users had very little and, while it was not clear if they were talking about possessions, people to care for them, or meaningful and pleasurable activities, smoking was conceptualised as one of the few mechanisms of autonomy that service users have on the acute ward:

I think they should be allowed to smoke. I think sometimes that’s all they’ve got left. (staff D7)

Service users echoed this sentiment:

They let them smoke outside. You’ve got to have something in here, you know? (service user A4)

For most service users, a serious lack of meaningful activity on the acute mental health ward underpinned claims that smoking was all there was. Smoking functioned to alleviate boredom:

The reason they [other service users] smoke now is because it’s boring and that’s all there is to do, so that’s why they smoke. (service user A6)

Boredom also drove some service users to smoke more:

My smoking had increased because of boredom. (service user A9)

Some cited the lack of activities and boredom as factors that led to smoking relapse:

[Smoking] That’s literally all you’ve got to do here. And so, I started smoking again when I was brought in here … I want something to do so people don’t have to smoke. (service user A5)

‘An acute crisis is not the time to address smoking’.

Some staff thought smoking cessation did not align easily with acute crises and could add to the stress service users experienced:

Smoking is the hardest thing to give up as far as we know. So why would you make someone who is acutely unwell, give up smoking? (staff D5)

They are agitated, they’re unwell. A lot of them self-medicate with tobacco, as something to relax them. Yeah. That may not be the best time to make them stop. (staff A6)

Many staff deemed encouraging smoking cessation as a low priority in the hierarchy of issues that needed to be addressed on the ward:

You have bigger fish to fry than quitting smoking. You know that’s not an issue that we should be trying to tackle, we’ve got enough issues to deal with. (staff D2)

It’s good to give them the advice, but really, that’s the least of their worries. (staff C11)

‘Smoke-free is difficult to police and takes up staff time’.

Staff also talked about the difficulty of ‘policing’ the smoke-free policy, with service users often smoking covertly in the bathrooms or their bedrooms. Attempts to prevent clandestine smoking, such as removing tobacco and lighters and storing these in the nurses’ station, had limited success as service users found novel ways to circumvent these measures:

The number of lighters! When I’m on nights, and somebody’s smoking in their bedroom, which is also against the rules, and I take a lighter off them, and find them the next hour still smoking. I take another lighter, and another lighter, and their cigarettes, and yet they still manage to go to wake somebody else up and get their lighters and cigarettes off them. (staff A3)

Some staff noted that smoke-free policies caused covert smoking:

When it was smoke-free, people just smoked in their rooms … instead of having someone smoke safely in the courtyard … I think there was a curtain lit one day, because he was smoking out the window. (staff C2)

Some staff also reported how much of their time was spent disregarding the smoke-free policy by escorting service users outside of the ward to the wider hospital grounds to smoke. For service users who were not able to leave the ward unaccompanied, smoking outside was only possible with a willing nurse escort. Many staff had grave concerns about the risk of service users absconding and/or harming themselves if they left the hospital grounds alone:

… [O]bviously they should be going out of the hospital [to smoke], but if an unwell patient [was] walking to the train station, you know what I mean? So, a lot of them smoke in front [of the building], which has, you know, you’re not allowed, but staff would almost draw a blind eye because you know, it’s either that or that and run away. (staff D1)

Some staff also lamented high staff turnover, staff shortages, and inadequately trained staff as other factors making smoke-free policy implementation a challenge:

We’re really low on staff and we’ve such high turnover, a lot of our extra learning opportunities [professional development and training] are getting taken away because we don’t have enough people on the ward to do … the education. (staff D2)

‘Smoking confrontations are challenging’.

Many staff found confiscating tobacco or cigarettes difficult, and potentially likely to result in an unpleasant confrontation, while others suggested enforcing smoke-free policies was a threat to the therapeutic alliance:

But that is a real challenge … we do take the cigarettes off them, but you have to be so careful with how you approach that … You might have got on really well with them half an hour ago but right now, they will have a strong reaction to you if you are questioning them about if they’ve been smoking in their room … I support the idea of non-smoking, but … (staff D3)

Another staff member reflected on their previous work experience in an Australian acute mental health ward, where security guards enforced the rules rather than nurses, and suggested this approach protected the therapeutic alliance (anecdotally, we know of at least one ward in NZ that has taken this approach).

Service users who smoked recalled confrontations with other service users who coerced or bullied them to relinquish their tobacco, even on the smoke-free ward:

He’s stolen about, I don’t know, 50 bucks [dollars] worth of cigarettes off me, in the space of two weeks. (service user D8)

‘Smoking facilitates social connections’.

Service users who smoked also found smoking provided some social benefits; they told us how they chatted and formed social connections when smoking:

The only time you get together is when you’re smoking outside. (service user A9)

Smoking in the courtyard supported socialising with visiting family members:

So, they [visiting family] can have a smoke, you see. [Especially] the youngest daughter. (service user B7)

‘The policy infringes my rights’.

Some smoking service users framed the issue of smoking as a human rights issue:

I’m upset ’cause I can’t even go outside if say … I mean, I still have the rights of people to have a smoke. (service user D2)

Not being able to smoke in combination with the locked doors contributed to servicer users’ sense of imprisonment:

And being held like we’re prisoners … I reckon it’s against people’s rights in a way… if no one can actually sit out and have a smoke somewhere… I’ve been only inside in this building; we’re not allowed to smoke outside; we’re not allowed to go anywhere. (service user D1)

‘Matches and lighters are a safety hazard’.

Staff in all four wards tried to control access to lighters and matches because of concerns about safety due to fires; however, these efforts were not always successful:

There’s been several small fires, usually lit by clients deliberately … after we’d had one fire on the open side, in which a patient managed to AWOL [abscond], and the police had to go and collect him from his house, after that, we collected all the lighters in that night, and for the next few nights … But the difficulty of getting lighters off patients actually caused several assaults. And then they hadn’t just got one lighter. (staff A3)

Fires also set off the fire alarms, which are very loud, and necessitate evacuation with the risk that some services users may not return to the unit.

‘Second-hand smoking is harmful to others’.

Staff did not talk specifically about the adverse physical health effects of smoking for those who smoked, but raised concerns about exposure to second-hand smoke. Staff on two wards, A and B, complained about smoke drifting into their offices or the building generally:

That’s that second-hand smoke thing within five metres of the doors. I’d prefer that we didn’t have any smoking in the building, or adjacent to windows and doors. (staff B13)

‘Smoking monopolises the unit courtyard’.

Service users’ reasons for opposing smoking differed from those identified by staff. Three wards allowed service users to smoke in the courtyards; however, the predominantly non-smoking service users complained that smokers dominated and ruined the courtyards:

The courtyard was good, but you had to avoid the smokers, and I’m not a smoker… it’s just a bit, you know, when you had to pick a chair where there weren’t smokers around you where you were sitting so you didn’t get the passive smoking. (service user A10)

Service users described the mess caused by butts and ash on the ground, and the circulating smoke, as ‘gross,’ and suggested various solutions:

Yeah, the smoko area is … [disgusted facial expression] people need to clean up after themselves, there needs to be more strict rules, people coming out and saying, ’Oh clean up, clean up … you’re not children, you’re not three-year olds.’ (service user A9)

Others complained about the mess of covert smoking in other parts of the wards, such as the shared bathrooms:

The patients don’t look after them … they smoke in them after the doors have closed … They’re just real gross. (service user B4)

Smoke drift’s polluting effects extended beyond the courtyards and into other areas of the unit, even in Ward B, which had external facing courtyards. Allowing smoking in the courtyards led non-smoking service users to confine themselves to other areas of the ward:

I’m a non-smoker, I gave up smoking. I pretty much [spent] a whole lot of time on my own because most people were outside in the courtyard smoking or hanging around in smoking area. I have other health issues, so I don’t really want to be hanging around in that, with that smell. It gets in my room. (service user A6)

Another service user complained that the smoking in the courtyard was a problem for visiting family members:

There’s nowhere for people to bring their family to visit … there’s two picnic tables and they’re usually full of smokers and there’s actually nowhere to go with your visitors. (service user A2)

Although wards have family rooms for visitors to use, these are often small and uninviting, and family members often want to use the outdoor courtyard space for visits.

Solutions offered by service users to the problem of smoking included having designated smoking areas for smokers and smoke-free outdoor areas for non-smoking service users and visiting family:

You know, if you got rid of the courtyard and made just a little smoking area … you could actually have your family there. (service user A2)

I’d like smokers to actually be designated somewhere that’s inconvenient to them, not inconvenient to people who don’t smoke. Because I can’t go outside because they smoke. So, I have to be stuck inside. (service user A6)

Because of differences in the size and layout of the wards, some of these suggestions would require re-design of existing courtyards (Case A), re-purposing of existing courtyards (Case B where there were multiple courtyards), or the addition of another courtyard (Case C).

Smoking rules are in our best interest.

A minority of service users acknowledged the rules around smoking as in their best interests, not because of smoking’s health effects, but because it disturbed sleep and disrupted safety on the ward:

I’m not addicted but I know these other guys always want to go out for smoke before bed. But the reason you don’t is ’cause the nicotine keeps you awake. (service user D8)

Because the light and an aerosol can amount to a weapon … like a flame torch … Which you can remove a service user’s face. That’s why lighters are separated from service users at night mainly. (service user D3)

‘Differences in the enforcement of the smoke-free rules cause tension’.

For staff, variable enforcement of the smoke-free rules caused tensions between them and services users:

So actually, you’ve got certain staff like me who turn my blind eye to it. Yeah, then you’ve got other staff who … will go out and then say to them you need to put that cigarette out and then it causes … [significant problems]. (staff C7)

Staff also noted that enforcement differences caused tensions between staff:

You’d have a client that is allowed to smoke all day long and then a changeover of shift. The [next] nurse that comes on [says], ‘You know this is a no-smoking area, blah, blah, blah’… before you know it there’s a bit of a tiff between … the staff member and the client. And then the staff member feels like that the staff member on the earlier shift had set them up for, for all of this. (staff C10)

Several staff also reported how making exceptions in some circumstances had caused on-going problems, as one staff member explained:

[Going smoke-free] did actually last for about three months, I think. And then of course we had this patient that wasn’t allowed any leave at all and was going to be here for quite a long time because they were waiting [for] a rehab bed for him. So, he was getting unofficial permission to smoke, and so everybody else insisted on smoking. So now they all smoke in the courtyard. They have tried to reintroduce the policy, but of course because a lot of our clients are returners, they say, ‘Well last time I was in, I was allowed to.’ (staff A3)

However, one staff member conceded that opposition to a smoke-free ward diminished with time:

When the whole ward was completely smoke-free, and it was enforced, we had issues at the start, but then once people realise you’re not getting a cigarette, it becomes less of an issue. But it was tough at the start. We had people attacking us then. But once they realised the only way you’re going to get a cigarette is if you work with the team and you can get leave, then they changed their behaviours. (staff A7)

‘Differences in enforcement are confusing or unfair’.

For many service users wanting to smoke, inconsistent application of the rules was itself was a source of frustration, resentment, and perceived injustice:

We are not allowed lighters here [high secure ward] but you’re allowed lighters in the other ward. (service user D3)

Some service users reflected on previous admissions and associated differences in smoke-free policies to changes in locked door policies:

So, this is the first time that [the door]’s actually been locked and all my other previous admissions I have been able to just walk out the ward and, because there is no smoking policy … everybody who was smoking had to go out the front of the hospital. But what was happening was people were doing runners and other people were going off to kill themselves, so. They are now having it that the courtyard, which is a big gigantic ugly concrete structure, is for smoking so that patients don’t just leave the ward whenever they want now. (service user A2)

Targeted myth-busting education.

Educating staff about the benefits of smoking cessation for people with mental illness should include myth-busting targeted at some of the beliefs shared by our participants.

Staff should be educated about the health, social, and financial costs of smoking for those with serious mental illness, and beliefs on the supposed mental health benefits of smoking should be challenged. Staff should be taught to differentiate between symptoms of nicotine withdrawal and mental illness, understand potential interactions between nicotine and other medications, and provide education and advice to service users who are stopping smoking, including on continued smoking cessation upon discharge. Smoking cessation experts could either train staff or an expert could be embedded in the services to manage the overall smoking cessation programme [17, 27, 40]. While generic policies on smoking cessation exist, this study supports the importance of bespoke packages for mental health services.

Assertive smoking cessation support.

Treatments for tobacco dependence are available, well-tolerated, and cost-effective [e.g., 60]. The most successful programs combine pharmacotherapy and behavioural intervention strategies (e.g. physical activity, relaxation, deep breathing) [61]. Tailored treatment programs have been shown to increase attempts to quit and lower levels of nicotine dependence at six months after discharge [62, 63]. Evidence-based treatments available and licensed in NZ include NRT, bupropion, and varenicline.

NRT is used widely in mental health settings, but it would be useful to audit this usage setting against best practice guidelines. Varenicline and bupropion are not routinely prescribed in inpatient wards. After the FDA announced in 2017 that the black box warning for serious neuropsychiatric adverse reactions from the varenicline data sheet in 2017 would be removed, the NZ regulator, Medsafe, issued a prescriber update advising ongoing caution regarding neuropsychiatric adverse reactions [64]. Clinicians still tend to avoid prescribing these drugs during a mental health crisis when people may also have diminished capacity to provide consent. Arguably, given the evidence from the EAGLES trial supporting the safety and efficacy of varenicline and bupropion for those with mental illness, this approach could be reconsidered [65, 66], and these treatments should certainly be offered more assertively to service users in the community.

Some research into smoking cessation support suggests that Cognitive Behavioural Therapy or counselling support in conjunction with pharmacotherapy on the ward may also better support smoking cessation [67].

One recent suggestion has been to allow ‘vaping’ – use of Electronic Nicotine Delivery Systems (ENDS) in outdoor spaces on the ward. At the time of data collection, the four ward case studies did not allow ENDS use [68]. Research examining ENDS has increased exponentially in recent years but the effectiveness of using e-cigarettes for quitting smoking in the general population remains disputed [69]. While far fewer studies have been conducted with people with serious mental illness, emerging research suggests that ENDS may be a promising intervention to help people from this vulnerable group to switch from smoking [70–72].

A recent open label study examining the effects of ENDs in 40 adult smokers with schizophrenia found that after 12 weeks, 40% had stopped relying on and using traditional cigarettes and the median number of daily cigarettes dropped from 25 to six [72]. After six months, 35% of the participants had stopped smoking traditional cigarettes and continued with vaping and 57.5% already reduced their traditional cigarette use by over half. Participants’ quality of life and health also improved, with reductions in blood pressure, weight, and heart rate, and improvements in wellbeing.

In New Zealand, ENDS is not a subsidized pharmaceutical like NRT, thus, the initial cost of purchasing an ENDS device and e-liquids may present a barrier; though, once people switch from smoking, ENDS are typically cheaper to use than smoking.

Physical design.

The acute mental health care setting should provide a therapeutic environment that promotes recovery with opportunities for connection, hope and optimism, identity, meaningful activity, and empowerment, along with safety and security [41]. In practice, these units often fall short on alignment of the model of care and ward design with recovery principles. The NZ government has recently committed to a significant funding investment in the rebuild and refurbishment of adult acute mental health facilities in NZ to address these concerns. This investment creates an opportunity to address concerns participants raised about smoking. For example, if courtyards are well-designed, attractive, and smoke-free, they will be therapeutic and encourage use by all, fostering connection and facilitating meaningful activities.

The courtyard of an acute mental health facility is the only outdoor space accessible to all service users and offers therapeutic value via exposure to nature and social interactions. The use of the courtyard as a ‘smoking room’ has a serious detrimental effect on its usefulness by removing a calming and healthful environment that offers respite from the institutional interiors.

Evidence from the newly-built ward in this study, which has been most successful in the implementation of smoke-free policy, suggests that modern state-of-the-art architectural design combined with a service-user-oriented model of care may have considerable influence on culture and practice.

Resourcing and support.

For these strategies to work effectively, staff need the time and resources to provide smoking cessation services. Implementation of smoke-free wards could use a preparation period where staff receive training ahead of smoke-free policy introduction.

NZ acute mental health services have been experiencing year-on-year increases in demand, and services are under-resourced and understaffed, with many of our staff participants describing feeling burnt out [73]. Services may require additional support to persevere through the transition phase of embedding a smoke-free policy.

Maintaining smoking cessation in the community represents a considerable challenge; studies show that relapse rates are high after discharge [27–29]. These findings indicate that additional post discharge smoking cessation support for mental health service users is critical and overdue. Community mental health services and primary care play integral roles and the smoke-free goal should not be abandoned at the hospital gates.