In the shadow of a new smoke free policy: A discourse analysis of health care providers' engagement in tobacco control in community mental health
Open accessAbstract
BACKGROUND: The prevalence of tobacco use among individuals with mental illness remains a serious public health concern. Tobacco control has received little attention in community mental health despite the fact that many individuals 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 care providers, both professionals and paraprofessionals, in relation to their roles in tobacco control in the community mental health system. Tobacco control is best conceptualised as a suite of policies and practices directed at supporting smoke free premises, smoking cessation counselling and limiting access to tobacco products. The study took place following the establishment of a new policy that restricted tobacco smoking inside all mental health facilities and on their grounds. Ninety one health care providers participated in open-ended interviews in which they described their role in tobacco control. The interview data were analyzed discursively by asking questions such 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 an individual choice located the decision to smoke with individual clients thereby negating a role in tobacco control for 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 are used to support the health of clients. CONCLUSIONS: This study provides insights into the complex factors that shape tobacco control practices in the mental 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 health care providers are both imposing and resisting the smoke free policy.
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Smokers might be less likely to stop if they believe their mental health will suffer.
“Smokers might be less likely to stop if they believe their mental health will suffer”
From Change in mental health after smoking cessation: systematic review and meta-analysis (2014) · cites this paper as [24]
In Results (‘Tobacco is therapeutic’), providers describe quitting as potentially harmful to clients’ mental health. The Discussion links such misconceptions to providers’ reluctance to support cessation. The paper does not establish that smokers who hold this belief are themselves less likely to stop. (LLM, conf=0.86)
Experimental — accuracy not yet measuredThere is a widely held belief among healthcare professionals that smoking cessation should only be attempted after mental health has improved.
“there is a widely held belief among healthcare professionals that smoking cessation should only be attempted after mental health has improved. 7 , 8”
From Service‐user experiences of an integrated psychological intervention for depression or anxiety and tobacco smoking in improving access to psychological therapies services: A qualitative investigation into mechanisms of change in quitting smoking. (2023) · cites this paper as [7]
The Results section (“Tobacco Control as Health Promotion”; page unavailable) describes providers who considered clients’ mental-health stability when deciding whether to address smoking, including one who advised a client to postpone quitting because she was not stable. This supports the belief described, but the paper studies community mental-health providers and does not establish that it is widely held among healthcare professionals generally. (LLM, conf=0.85)
Experimental — accuracy not yet measuredHealth professionals might be reluctant to intervene with some smokers because they believe that this might be detrimental to their mental health.
“health professionals might be reluctant to intervene with some smokers because they believe that this might be detrimental to their mental health.”
From Change in mental health after smoking cessation: systematic review and meta-analysis (2014) · cites this paper as [24]
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“This aligns with similar observations in other qualitative studies exploring HCPs’ attitudes toward physical health in mental health care, where HCP/CM struggle with either insisting on health measures or refraining based on the patient’s wishes [18,40,41].”
Meijer, E. (2025) · Discover Mental Health · doi:10.1007/s44192-025-00135-3 · Cited by 1 · see citing works
Ziedonis, D. M., & Kolodziej, M. E. (2012) · Journal of Dual Diagnosis · doi:10.1080/15504263.2012.672159 · Cited by 1 · see citing works
“…be more likely to be addicted to tobacco and less likely to quit than the general population, and agencies are looking for ways to better integrate tobacco addiction treatment into their current treatment plans for other addictions and mental illnesses (Johnson et al., 2010; Ratschen et al., 2009).”
Christiansen, B. A., Macmaster, D. R., Heiligenstein, E. L., Glysch, R. L., Riemer, D. M., Adsit, R. T., Hayden, K. A., Hollenback, C. P., & Fiore, M. C. (2016) · Journal of Health Care for the Poor and Underserved · doi:10.1353/hpu.2016.0069 · Cited by 1 · see citing works
Mental Illness and Tobacco Usage
Asharani, P. V., & Subramaniam, M. (2022) · Springer eBooks · doi:10.1007/978-3-030-92392-1_41 · Cited by 1 · see citing works
The Role of UAE Health Professionals in Maternal and Child Health Policy
Moonesar, I. A. (2015) · ScholarWorks (Walden University) · doi:10.13140/rg.2.1.3120.3288 · Cited by 1 · see citing works
The impact of smoke-free policies on inpatient psychiatric units : an ethnographic study
Grant, L. G. (2013) · cIRcle (University of British Columbia) · doi:10.14288/1.0073609
“Ethics Ethics approval was obtained from the University of British Columbia, the University of Northern British Columbia, and Northern Health before data collection commenced.”
BackgroundResultInfluentialQuitting smoking: Therapeutic in mental health treatment
Taylor, G. M. J., Greening, J., & Aveyard, P. N. (2014) · Pure (University of Bath)
Initiating Nicotine Cessation in a Community Mental Health Center
Keith, R. R. (2016) · ScholarWorks (Walden University)
Electronic cigarettes for smokers with schizophrenia spectrum disorders
Caponnetto, P. (2019) · Stirling Online Research Repository (University of Stirling)
Stein, K. F., Sawyer, K., Daryan, S., Allen, J. L., & Taylor, G. M. J. (2022) · medRxiv · doi:10.1101/2022.03.23.22272703
“There are many reasons for high smoking rates in this population, for example they are less likely to be prescribed smoking medicines (6), and it is widely believed that smoking cessation can worsen mental health (7, 8).”
BackgroundMental Illness and Tobacco Usage
Asharani, P. V., & Subramaniam, M. (2022) · Springer eBooks · doi:10.1007/978-3-030-67928-6_41-1
The Impact of Anxiety and Depression on Individuals with Smoking Habit
Utami, D. C. (2021) · Scientia Psychiatrica · doi:10.37275/scipsy.v4i4.96
“12,13 Numerous studies have consistently demonstrated a notable level of comorbidity between smoking and major depressive disorder (MDD).”
BackgroundEl-Falaky, M. S., Abdelaziz, H. M., Ahmed, A. M. M., & Abdelsamie, Y. (2025) · Language and Semiotic Studies · doi:10.1515/lass-2025-0020
“…and not any other negative mood, as Through the analysis of smoking behaviour, it is found that smokers lean to this practice as a therapeutic means (Johnson et al. 2010) to recover from mental illness, as those who su ff er psychological disturbance de fi ne smoking as a source of power and control.”
Bück, J., Sünkel, E. T., Machulska, A., Neubert, M., & Klucken, T. (2026) · JMIR Formative Research · doi:10.2196/97001
“Notably, these concerns are frequently shared by health care professionals [30-32], despite a substantial body of evidence demonstrating that smoking cessation is associated with pronounced improvements in mental health [33-35].”
Goulbourne, T. D., Leal, I. M., Britton, M., Chen, T. A., Bergey, A. E., Siddiqi, A. D., Williams, T., Casey, K., & Reitzel, L. R. (2026) · Healthcare · doi:10.3390/healthcare14203482
“Moreover, additional research has found that mental health providers also view smoking with patients as a tool to enhance the therapeutic relationships and manage behavior in inpatient settings [45,46].”
Influential
- Authors
- Johnson, J. L., Moffat, B. M., & Malchy, L. A.
- Affiliations
- University of British Columbia (CA)
- Corresponding author
- Johnson, Joy L.
- ORCID
- Johnson, Joy L.
- Venue
- International Journal of Mental Health Systems
- Published
- 2010
- Volume
- 4
- Issue
- 1
- Pages
- 23
- ISSN
- 1752-4458 (ISSN-L)
- PMC
- PMC2920253
- OpenAlex
- W2120688112
- Cited by
- 53
- References
- 39
- Citations by year
- 2026: 2 · 2025: 3 · 2024: 1 · 2023: 2 · 2022: 6 · 2021: 2 · 2020: 6 · 2019: 4 · 2018: 3 · 2017: 1 · 2016: 6 · 2015: 3 · 2014: 4 · 2013: 2 · 2012: 7
- FWCI
- 2.17
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- cc-by
- Locations
- International Journal of Mental Health Systems (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- cIRcle (University of British Columbia) (submittedVersion, cc-by)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion)
- Summit (Simon Fraser University) (submittedVersion, cc-by)
- Open Collections
- Funders
- Canadian Institutes of Health Research
- Topics
- Health Sciences › Medicine › Physiology › Smoking Behavior and Cessation
- Health Sciences › Medicine › Epidemiology › Substance Abuse Treatment and Outcomes
- Social Sciences › Business, Management and Accounting › Organizational Behavior and Human Resource Management › Global Public Health Policies and Epidemiology
- Keywords
- tobacco control, community mental health, smoke-free policies, healthcare workers, mental illness, smoking, smoking cessation counseling, tobacco access, provider perceptions, discursive frames, power and powerlessness, health promotion
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