4. Discussion and conclusion
4.1. Discussion
This is the first Canadian study to examine community-based mental healthcare providers’ attitudes and practices related to their engagement in smoking cessation intervention with clients. We found that the rate of tobacco use among providers was higher than that of the provincial general population rate (22% vs. 16%) [26]. Previous work in this area has highlighted high rates of smoking in psychiatric settings. For example, a Dutch study examining environmental tobacco smoke found that 31% of treatment staff in psychiatric settings smoked cigarettes [27]. Similarly, an Israeli study found that 37.3% of staff at an inpatient psychiatric hospital smoked cigarettes [28]. Previous research has also noted a higher rate of tobacco use among psychiatric unit staff than in the general population [29]. Although in the current study the providers’ smoking status was associated with assessing clients’ smoking at intake, it was not associated with engaging in discussions with clients about their tobacco use. This suggests that a provider's personal smoking behaviour may be a barrier to engaging in some smoking cessation practices. Further, the high rate of tobacco use among this group of healthcare providers, and the health risks posed, are concerns that warrant attention.
An important limitation of this study is the less than optimal response rate. Other researchers have reported response rates in the range of 40% [22] and [30]. The low response rate in the current study may in part be due to a lack of openness to research within this community as evidence-based practice is a relatively new phenomenon in the field of mental health field. We also contend that recruitment outside of traditional psychiatric inpatient settings may be even more difficult due to the varied locations of community mental health institutions and the diverse cultural and professional dynamics and infrastructure. In general, we found that the providers lacked interest in the survey. This in itself is an important finding in that the topic of tobacco use was generally not seen to be relevant to the providers’ mental health practice. Although the characteristics of those surveyed did not appear to differ in important ways from the target population, this cannot be confirmed. The fact that providers who smoked responded to the survey suggests that smoking, and attitudes associated with the behaviour, did not hinder participation. In addition, the use of cross-sectional data limited the ability to causally connect the predictor variables with the outcomes.
Smoking cessation counselling is an effective intervention to assist clients to stop smoking [31]. In general, we found that the providers we surveyed did not systemically engage in smoking cessation practices that are considered to be fundamental to a comprehensive tobacco control program. We found that the providers had moderate levels of confidence in their ability to engage in smoking cessation counselling and that those with less confidence were less likely to assess smoking status and to discuss smoking cessation with their clients. Confidence is amenable to change and interventions that bolster the self-efficacy of providers may go a long way to improve practices [32], [33] and [34].
This study is unique in that it included professionals and paraprofessionals. Health professionals were more likely to engage in smoking cessation interventions. However, these differences were not significant once confidence and attitudinal factors were controlled. Paraprofessionals constitute a considerable component of the mental health workforce and clients do not necessarily make distinctions among the staff's different roles [35]. In particular, substantial attention is now being paid to those who assume peer- and lay-support roles [36] and [37]. Work is required to engage all individuals employed in the mental healthcare sector and to educate, encourage, and support them to incorporate smoking cessation interventions, including nicotine replacement in their practices.
It is interesting to note that those more years of experience in the health setting were more likely to engage in smoking cessation practices. Perhaps these individuals are cognizant of the long-term effects of smoking for their clients. This suggests that newly employed practitioners should be specifically targeted for tobacco control education initiatives.
Attitudes related to the providers’ and clients’ roles in smoking cessation were associated with engaging in smoking cessation practices. Providers who perceived that they did not have the time or resources to engage in cessation activities and did not think it was part of their role were less likely to engage in smoking cessation activities. Similarly, providers who indicated that clients could stop on their own, or