Mental health illnesses are associated with many biopsychosocial factors and stigma, compounding the difficulties in navigating life´s everyday challenges. Tobacco smoking has been and remains significantly more prevalent in psychiatric patients, especially those with severe mental illness, even though rates have dropped in the general population in many countries. Tobacco smoking contributes to the higher morbidity, mortality and lower quality of life of patients with mental illness and adds to frequent financial difficulties, conflicts and to personal and societal negative judgements of behaviour. Mental health services are frequently understaffed and underfunded and the culture of smoking is well rooted, making change all the more difficult. A team, two psychologists and one psychiatrist, initiated a smoking cessation / reduction programme about a decade ago with group intervention strategies in an outpatient setting in a psychiatric hospital and later included patients from the residential and forensic units, from primary care services and “difficult to treat” smokers, many of which with no formal psychiatric diagnosis, from general hospitals.
The key objective is to provide guidance but in a flexible tailored nonthreatening manner in a setting perceived as a safe space and taking into account the multiple functions and potential gains of group interventions, many of which not necessarily significant changes in smoking. The need to concomitantly address other addictions and behaviours beyond tobacco such as caffeine and alcohol intake and drugs, among which especially cannabis, and leisure and self-care activities, is evident. The inpatient units pose unique challenges, albeit with the advantage of having smoking cessation medication readily available, with a mixed rehabilitation and residential the first to receive the programme, prompting the need to explore other more interactive and facilitative strategies. Games, group dynamics, art activities, playing in general serve to bring down barriers introducing fun and offering the opportunity of being together as people. Similar strategies were employed in general psychiatric acute patient units including an inpatient unit for young people from 15 to 25 years old. Beyond these formal interventions, there are multiple informal interventions that spring spontaneously from the fact that the team and each member of the team is recognized as belonging to the “anti-tobacco brigade”. A walk in the hospital park is in itself a chance to meet with hospital staff who are smoking and with patients.
The COVID-19 pandemic brought with it significant change and admittedly tobacco treatment programmes are less of a priority in times of great crisis. The path to being together, closer to our patients, as people who treat people, has been disrupted and limited to phone calls, emails and social media which is an enormous downsizing. Group interventions are out of question at this time and individual counselling is quite unsatisfactory for patients who were used to the more cheerful and dynamic group interventions. The question of how many patients stop or reduce smoking is always difficult as so many variables and changes are at play.
Isabel Ganhao*, Miguel Trigo, Afonso Paixao