An ideal opportunity for cessation.

There was a general consensus amongst participants that residential rehabilitation was a good time and place to begin the process of smoking cessation, as residents were already in the appropriate mind set for change, and that promoting a healthier lifestyle was important.

Rehab is designed so that people can think about every aspect of their life, and smoking’s one of them. You’ve got them there for six months, you might as well take advantage of the opportunity, it’s a captive audience…Make them a gang of people that supports each other not to smoke. (male, smoker)

When you’re in somewhere like that you can feel yourself changing, people are embracing change, you know. It’d be a good time to do that, get rid of both while you can (male, smoker)

Five participants felt that the group setting was ideal and could benefit non-smokers too by focusing on wellbeing and diet as well as smoking. Three thought that smoking cessation was not the role of the treatment service and would be better offered as aftercare or as part of an ongoing treatment plan. There was also some concern that focusing on smoking cessation might jeopardise recovery from alcohol misuse.

I think these things take time, and you should deal with one thing before the other. But after a length of time, if they were to put it to me, say “hey, well done, you’ve done well with drinking, how about having a look at smoking cessation? We’ll be doing it here, you know the groups and what we’ve gone through”, stuff like that, because I’m around people that I …trust, and trust is a massive thing, I would probably say yeah, why not. (male, smoker)

Facilitators for smoking cessation.

Several factors that promoted smoking cessation in the context of residential rehabilitation were identified. Four participants cited the financial cost of smoking as the primary reason they had or intended to quit or had switched to vaping or rolling tobacco:

Obviously cost has quite a bit to do with it, and a lot of people around me when I was at (community drug and alcohol service) were on rollies, so I had one or two and I actually found that I preferred them. It’s nice that the cost is phenomenally cheaper to buying packets of cigarettes. (male, smoker)

Interestingly, the cost of cigarettes also contributed to some resentment. Services give residents a shared household budget and some participants observed that smokers would spend an unequal amount on tobacco, leaving less to buy the weekly food.

They used to do community shops and two or three shops a week, so as a community we’d all get together. If you can imagine there’s 20-odd people, some of that shop money was about buying cigarettes and papers. (male, former smoker)

Despite universal awareness of the health consequences of smoking, five participants were current smokers and none mentioned health as a reason for quitting. Two had witnessed family or friends suffer from smoking related illnesses, and one former smoker had undergone surgery to remove a growth, which he thought was smoking related:

I had a lump in my neck… the day I went into the hospital and the day before I went to hospital I smoked, and I came out of hospital and I’ve not had a cigarette since. (male, former smoker)

Challenges to smoking cessation in residential rehabilitation.

Whilst participants were generally positive about the prospect of smoking cessation in residential rehabilitation, some recognised that specific issues related to treatment services such as the shortage of staff time and resources and the attitudes of staff that smoking was of secondary importance would potentially act as barriers to cessation:

It’s such a secondary thing to what they’re saying… it goes alcohol, then big list of drugs, with smoking at the bottom. So it’s almost an afterthought really. (male, smoker)

Other factors that could potentially hinder smoking cessation efforts in residential rehabilitation were highlighted. These included the perceived social and psychological benefits of smoking, the normalisation of smoking, policy and regulation, as well as perceptions and prioritisation of risk.

Smoking as a social and psychological lubricant.

Seven participants mentioned the social and psychological benefits of smoking, saying that it helped them cope with feeling socially anxious, especially when entering treatment. Some had started smoking as a way to fit in with others, to alleviate the boredom and the stresses of giving up alcohol.

I didn’t smoke at all, when I came here. When I was drinking heavily. So literally the day I got here I started smoking again. It was something to do. And I suppose, it’s talking to people socially when you come in. And it’s stopping drinking as well. (male, smoker)

Five participants also cited that staff smoking with residents was a way to connect and engage with them; smoking acted as social lubricant.

There’s nowhere to hide when you’re standing next to someone having a fag, it’s more honest, more relaxed. It’s the same as having a drink with someone really; it’s a social lubricant, just in a different way…you’re both indulging in the same semi-illicit activity, so it’s easy to build up that bond of trust. (male, smoker)

One participant reported that smoking had helped him get through difficult situations relating to his alcohol use and his poor mental health because it provided an escape.

In times of stress when you’re in there and you’ve got this feeling of, I need a drink, or you can visualise a bottle in front of you, you just think, I know, I’ll go downstairs, I’ll go outside and I’ll have a fag, that will calm me down. And it does actually calm you down. That’s how I feel, that’s how a smoker feels, it calms you down. It takes you away from … what you’re trying to deal with there (male, smoker)

Another described his relationship with cigarettes and alcohol as a ‘love affair’, saying that despite the known harms of both he continued to use them because of an emotional attachment. Holding on to the secondary addiction (tobacco) made giving up alcohol feel like an achievable challenge. Tobacco was seen as the less immediate risk and less damaging, at least in the short term:

It’s an emotional wrench, taking alcohol away from someone, it certainly was for me. I was taking away something I loved, I mean my life was in a complete mess but I loved alcohol, but I knew it had to go. Taking away smoking at the same time…I would have thought twice about going into residential treatment. (male, smoker)

The culture of smoking in treatment services.

Social norms and behaviours play a large part in smoking habits. When placed in a group setting, such as residential treatment, these norms become amplified, and the desire to fit in to a new setting can be perceived as essential to successful treatment outcomes. Participants widely regarded smoking in residential services as the norm.

Over two thirds of any group…were smoking… and I’d say possibly half the staff smoked. It’s kind of like a social gathering. There was no positive role modelling in regards to smoking, it was just the norm. (male, former smoker)

Three non smokers felt excluded because they did not smoke, even if they chose to join smokers in the smoking area. One was frustrated at the way tobacco was normalised within the treatment service:

I’m unusual because I haven’t got a fag in my hand. I wish I did sometimes so that I could be part of the social group. (male, non-smoker)

Addiction’s addiction, and if you minimise one against the other it kind of makes it alright, “you can’t use substances here, you can’t drink, but you can smoke all you want”. (male, former smoker).

Non-smokers who did not wish to sit in the smoking area felt socially penalised for not smoking.

They were getting preferential treatment, the smokers, in that they (staff) were engaging with them more (female, non-smoker)

The normalisation of smoking, as well as the fact that many staff were smokers, was seen to contribute to the continued and even increased tobacco use reported by some participants. Such entrenched normative behaviour would likely hinder any cessation interventions implemented.

Relationship between tobacco and other substances.

Smoking tobacco was viewed by participants as a very different issue to alcohol or illicit drug use, due to the perceived lack of intoxicating effect and its legal status. Three participants who claimed not to smoke still used tobacco in joints, illustrating that cannabis smoking and tobacco smoking were seen as different. Three also reported that tobacco use had increased with cannabis use. Many reported that they smoked more when drinking, one saying he could not have a drink without a cigarette. Even occasional or self-defined social smokers reported being more likely to smoke when having an alcoholic drink. All of these factors are reasons why people continue to smoke, and are resistant to stopping, and demonstrate the importance of addressing smoking in conjunction with use of other substances.

Perceptions and prioritisation of risks.

All participants acknowledged the health risks of smoking, but their perceptions and prioritisation of these risks varied. Notably, two of the younger participants did not feel that smoking was an immediate risk, believing that as long as they stopped at some point in the future, they could avoid damage to their health [26]:

I know it’s just another addiction, but for me, smoking wouldn’t kill me as quickly as the amount I was drinking was going to. (male, smoker)

The sense that other substances presented a more immediate risk and therefore should be prioritised was highlighted by eight of the participants:

When you’re dealing with people who are injecting heroin and crack into their groin four or five, six times a day, then you tend to gloss over the cigarettes, ‘cause you know it’s not going to kill them immediately, is it? (male, smoker)

Policy with treatment services.

Within the treatment services, policy changes had shifted smoking from inside, in communal living areas, to outside. Both services included in this study still allowed smoking in a designated area in the garden of the property. Whilst smoking policies were widely regarded as positive by non-smokers, there was concern that any further attempts to control tobacco use (such as banning it on the premises) would lead to conflict and tension. Even the non-smokers felt that enforcing a non-smoking policy was unfair and would be seen as a punishment.

I think people would go mad. Actually, literally. You know, they’ve got one little vice and maybe after they’ve cleared up the first one, once they’ve come out you can tackle it then, but I just don’t think two in one go is very wise and for health reasons, you know, mentally and physically it’s not good. (female, non-smoker)

There were also concerns that any increased regulations would escalate behaviours such as illicit smoking in bedrooms or other residential spaces, which would increase the risk of fire. Additional worries that other substances might be smoked instead, and that smokers may become more irritable if denied access to cigarettes were also expressed:

I think they’d get a lot more people trying to smoke in their rooms, or you’d get a lot more illegal things being smoked because they can’t go to the shop and buy cigarettes. (female, non-smoker)

I have known groups that have scrapped the smoking break, and they don’t tend to work as well. You tend to get a bit of animosity between people. The people who smoke, you can see them getting agitated when they’re not quite sure when the break’s coming. (female, non-smoker)

In summary, the findings of this study included barriers and facilitators for implementing smoking cessation in this type of setting. Some of the challenges were posed by distorted perception of risk, staff attitudes and availability, established smoking culture in substance use treatment services, issues involving group living and the social aspects of smoking. Facilitators included the motivation to change and the social benefits of communal living, staff understanding and the rising costs of tobacco as a motivation to change smoking habits.