Our analysis revealed five discursive frames that influenced talk about tobacco. Although other discourses were present in some interviews, the research team was struck by the prevailing presence of these five frames.
Managing a smoke free environment
As a result of the recent policy restricting where clients could smoke, some providers had assumed new responsibilities. The tasks associated with managing a smoke free environment were framed as placing providers in an authoritarian role. This discourse was most common among the paraprofessionals working in the resource centres and the housing facilities who had acquired the added responsibility of implementing the "new rules."
Investing time in monitoring the smoke-free environment was commonly discussed by resource centre staff. The power of this discourse was evident as they described being involved in crowd control, or "moving people along" when clients were smoking in front of the building. Patrolling was a regular activity because clients resisted the "rules."
We are constantly going outside and telling people to please smoke in the back. People know that's the rule but they do it anyway. And if you go ask them to leave, they will leave but they won't really stop. [Paraprofessional, Non-Smoker, Resource Centre]
The management of the smoke-free environment also encompassed "maintaining the calm" beyond the physical space of the smoke-free setting. Paraprofessionals across settings saw themselves as responsible for minimizing the policy's impact on the local surroundings, referred to by some as the "good neighbour policy." Given that clients were no longer "allowed" to smoke in front of the resource centre, some had moved their tobacco use in front of nearby businesses. As a result, some providers described being further burdened with making amends when there was discord with neighbours.
So now we have an overflow and the businesses are shooing our members away from their front steps...it's just that they are losing business as a result of the smoking...We are trying to use a lot of tact, and diplomacy and encouragement to be respectful to the businesses and to the members. [Paraprofessional, Non-Smoker, Resource Centre]
Another paraprofessional conveyed her discomfort with being caught in the middle of managing conflicts: "We get yelled at by the neighbours and clients." Such discordance affected the work environment and hampered staff members' abilities to engage with other clients.
For some paraprofessionals there were expressions of resignation, having to "enforce rules imposed by the city." The so-called "edict" had been made elsewhere which placed providers in an awkward position vis-a-vis their clients, a position of power and powerlessness. The terminology in this discourse reinforced that this expanded role was a source of tension and "conflict" within the staff-client relationship. According to one paraprofessional administrator, "It's just a perception that the smoking ban, especially for the chronic smokers, has been kind of forced down everyone's throat. So now we have been asked to police it." This "tedious" responsibility required repeating the same message wherein paraprofessionals had become the target of blame.
The most challenging for me is having to ask the same people over and over and reminding them of the rules, to step away from the building. They don't even have to say a word, but just the way they are looking at me is kind of like I have come up with the rule. [Paraprofessional, Current Smoker, Resource Centre]
As self-declared managers of the smoke-free environment, some staff positioned themselves as embroiled in uncomfortable power dynamics. When clients ignored the "rules" by smoking within smoke-free zones, paraprofessionals were obliged to exert control and impose "penalties." At the resource centres, this could mean banning clients for two days, a serious consequence for clients who relied heavily on the services, "that means that they don't get the service, they don't get lunch."
Resistance was a common element in this discourse and took the form of not always enforcing the "rules." For some, priority was given to the clients' well-being and rules were bent accordingly, claiming this was more in keeping with the perceived role of a service provider. Circumventing rules was a way to avoid conflict in the client-provider relationship.
I would lie if I said that we strictly enforce the 3-meters-from-a-door deal. I'm not going to make somebody who is having a bad day go stand in the cold rain. If they're going to stand under the awning out the back door, it's fine because the door is always closed, the smoke doesn't come in anyways. [Paraprofessional, Current Smoker, Resource Centre]
Similarly in one residential facility, staff would not "rat out" the clients for smoking in undesignated areas; no staff member wanted a client to be fined $2000, all the while recognizing the futility knowing that the Health Authority would end up "paying for it."
On the mental health teams, the discourse was much more subdued. The smoke-free environment was a better fit among the multidisciplinary teams than it was at the resource centres and residential settings where more providers were smokers. Nonetheless, there were hints of resistance with suggestions of inconsistent action. As one professional noted, "Sometimes those regulations are transgressed by clients and some staff will approach the person and correct them, and some won't." Given that monitoring the smoke-free environment was a new "duty," there were now "watchdogs" on the teams. On rare occasions, "relocating" clients was necessary; that became the responsibility of "someone else," typically a senior staff member which provided some professionals a safe distance from dealing directly with the issue.
There have been some conflicts with clients smoking right outside our facility, despite the signs. There was almost an altercation when a staff asked a client to stop smoking right in front and go down the stairs. [Professional, Non-Smoker, Mental Health Team]
Interestingly, the professionals on the mental health teams maintained that they were critical of punitive measures. This stance was perhaps easy to take given that they did not need to take such measures.
Tobacco is therapeutic
The discourse that smoking "helped" clients was present in interviews across all settings. At the root of this discourse was the claim that tobacco use was not only beneficial, but that quitting smoking was difficult and potentially harmful for clients. Tobacco use was described as providing relief from symptoms associated with mental illness. There was a common conviction that tobacco use countered some side effects of "anti-psychotic" medications, therefore "It helps them with their medications to be able to have their cigarette." Knowledge derived from work experience pervaded this discourse.
We know that somehow tobacco use helps schizophrenia or psychiatric clients to cope with their symptoms. And the years of observation of the clients in the hospital or during any activities here in this setting, obviously it has a calming effect, or at least they are severely hooked on that. [Professional, Former Smoker, Mental Health Team]
Others considered cigarettes to be a "quick fix" and "instant pleasure." The language focused on the positive effects of smoking in keeping with self-medication terminology. Tobacco was lauded for providing the clients' "only joy in life." The comparison of tobacco to other substances served to minimize the harmful effects of tobacco. One paraprofessional challenged, "I question the effects of smoking compared to the effects of prescription medications that they are taking, compared to the coffee that they are drinking, everything else in their lives."
As further support, the providers emphasized the dangers of quitting smoking, placing clients at risk. One professional elaborated, "At one point, there was a client who attempted to end his smoking but he became so stressed and it started to impact his mental health." Tobacco cessation was framed as removing "their comfort" which reinforced that smoking was beneficial and served a purpose.
For some, smoking is a core part of their stress coping. And for some I think it is really important to continue smoking because that is all they have...For some, taking away their cigarettes is the worst possible thing you could do to them. [Professional, Former Smoker, Mental Health Team]
The strategy of minimizing the therapeutic value of other forms of nicotine infused this discourse. Nicotine replacement therapies did not "work," and they were costly and problematic. "And a lot of people can't wear the patch for allergies, can't chew gum because of dental work." Another provider concluded that social support was absent when using these forms of nicotine, cautioning that clients could become "isolated", "There is nothing social about NRT, you get together and have a coffee and cigarette. You don't get together to chew gum." In contrast, the social role of cigarettes was presented as beneficial for clients. "Even outside of the actual addiction to the nicotine, it's also the addiction to the smoking to having the relationships that they do. People get into patterns of smoking out there with particular people, having particular types of conversations."
Smoking with clients outdoors functioned as a therapeutic tool; some providers who smoked positioned this action favourably. "Often it's a way to just get someone to calm down too. 'C'mon, let's just go out there and relax and have a smoke.'" The shared activity was described as a conduit for relationship building, suggesting a privileged relationship that was also power-laden in that it maintained the status quo.
I've seen it as being beneficial in a sense since you have that time where you sit down, even though it's just for a cigarette, you have that one-on-one interaction. So in that sense, I've developed a lot of trust from going out there and just having a casual conversation that I wouldn't have had within the building surrounded by people. [Paraprofessional, Current Smoker, Resource Centre]
One staff member had quit smoking 6 months earlier and spoke with nostalgia about the strength and value of the client-staff connection through smoking and how the intimacy that existed was now "lost." Not only did she feel more "in touch" with what was going on with clients, smoking with clients also functioned as an opportunity for information sharing.
A lot of the work I was doing came from...sitting down with people and smoking and talking about stuff...they would kind of relax a little bit and we'd get talking....I miss that connecting with people on that level. [Paraprofessional, Former Smoker, Resource Centre]
Nonetheless, a sense of discomfort was articulated by some providers. One provider "struggled" with his role in this shared activity "we are trying to assist people to quit smoking, but we smoke with them."
Descriptions of accommodating client requests for cigarettes and rolling paper was part of the therapeutic discourse. "I'll give them the end of a cigarette, but I won't take it back. I just don't, you never know what they might have picked up or germs or things like that." The availability of rolling paper at the resource centres was framed as meeting a need and providing a healthy alternative that counterbalanced the health risks associated with clients' practice of "picking up butts."
Tobacco use is an Individual Choice
The discourse that framed tobacco use as an individual choice focused on the autonomy of clients and how in relation to tobacco use, they "have the right to choose." By engaging with clients in a manner described as "respectful," clients were presented as in charge and responsible for deciding about their tobacco use in discussions that took place within the context of following the client's lead.
At the outset, this discourse revealed a distancing strategy. Providers described a reluctance to formally initiate the topic of smoking with clients. Some explained how they did not assess client smoking when they first met because it would seem "judgmental." They reasoned that assessing tobacco use at the initial assessment had not been a part of their training. Other goals took precedence for both clients and, subsequently staff.
When I first work with people I ask them what their goals are, what things they would like to achieve in addition to seeing us for mental health symptom management... I usually take it as a cue from them when they feel as if they are ready to engage in discussion about smoking cessation, but for sure, it is not high on my priority list. And I certainly don't see it very high on some of my client's priority list either. [Professional, Non Smoker, Mental Health Team]
Defending a position of "not pushing" or even omitting the smoking cessation agenda altogether was common. Ultimately, clients were placed in a position of power, being in charge when it came to addressing tobacco use.
I find a lot of the clients, if it is brought up, it's just brushed off or not discussed in depth. And so if I mention it or bring up smoking, then they're just "Oh yeah, that's not an issue," then I'll drop the issue as well. [Professional, Non-Smoker, Mental Health Team]
Silence regarding client tobacco use was framed within the context of being respectful, "If they are not open to having the conversation, then I don't usually pursue it." Viewed from another angle, this discourse served to justify providers' inactive engagement. Although labelled as showing "respect," this meant no further action on the part of the provider. The language used was moralistic and prescriptive. One professional concluded, "I see it as people's choice, especially in the community people are able to make their own choices and be responsible for themselves, be autonomous for their own care."
Treading lightly was a tactic employed to avoid discord while supporting clients' right to smoke. Some providers expressed uncertainty, discomfort and a sense of "struggle" when it came to addressing tobacco use with their clients. As one psychiatrist noted, "I admit that I don't address it enough...I still have the hesitancy about how to work it in there and how to not make it something that is just another burden to patients." In fact, staff-driven attempts at initiating a discussion about smoking cessation were described as "hassling" clients about "one more thing."
If they haven't really expressed any idea about quitting, how to bring it up in a way that won't turn them off? Because that's what I feel that right away they retreat from that approach. If it starts to put them off, right away you are going to lose them. [Paraprofessional, Non-Smoker, Mental Health Team]
Consequently, honouring clients' lack of interest regarding the topic of smoking cessation allowed the client to exercise their unchallenged choice to continue to smoke.
The responsibility and "choice" of remaining a smoker was placed into the hands of clients. Clients were described as "reluctant to quit," and lacking "motivation." Speaking knowingly about the power of clients' nicotine addiction further removed the onus of personally engaging with clients and served as a distancing device, "They would rather have a cigarette than food. These people are addicted to tobacco. This is a very strong addiction - they cannot control themselves with nicotine." However, offering clients "information" such as brochures about smoking cessation programs was considered a non intrusive gesture that allowed clients to "make a choice about it."
In contrast, client-led invitations to engage in the topic of smoking were met with enthusiasm. These opportunities occurred when the client-provider relationship was well established. "When somebody talks about smoking, I leap on it and I say, 'The Daytox, they have an excellent program.' And I'm excited and I really, really encourage people once they articulate it." Such interactions were presented as the moment for planting a favourable seed that might influence a client's choice about tobacco use in the future, conveying a glimmer of hope.
It's Someone Else's Role
In this discourse, providers dismissed the role of directly supporting client tobacco cessation. Rather, they framed this role as belonging to an "expert." Relying on available resources such as support groups or other professionals with expertise area figured prominently in their explanations.
Both paraprofessionals and professionals viewed the scope of their role in smoking cessation to be limited. A staff member from one housing facility stated, "it's not necessarily our role to dictate to people what they should be doing with their lives." There was often a shift of focus when providers looked to others to assume the role. Some professionals saw this as a specialized skill set beyond their domain while some paraprofessionals viewed the professionals as the experts.
Perhaps an in-house therapist/counsellor can be accessed. I don't think it's that much a physician needs to be involved in. Identify the problem and encourage them to quit, yes, but in actually providing cessation counselling and that type of stuff, I don't think so. [Professional, Non-Smoker, Mental Health Team]
I am not the one who can control her [client] smoking, her attitude or her routine, but the nurse and the psychiatrist can do that, I'm just their worker. I just tell them that smoking is harmful to your health. [Paraprofessional, Non-Smoker, Mental Health Team]
Typically, this discourse involved accentuating a lack of training and knowledge regarding tobacco use. As one paraprofessional surmised, "I am comfortable addressing and looking at readiness in terms of quitting smoking but personally, I don't know that much about implementing smoking cessation goals." At times, the role of engaging with clients in tobacco cessation was presented as unattainable.
It's an addiction, so you need a lot of resources to help out with it. It would never be something that I could do. It's not like something else where I could help them, like by referring them to a job. [Professional, Non-Smoker, Mental Health Team]
Multiple-roles and conflicting priorities were offered as reasons for not being able to assume this role. This strategy maintained the comfortable power and position of the health care provider yet ceded specialized knowledge and power to others. For one professional, taking on the issue of tobacco use was portrayed as adding to the "workload" in an already "overwhelming" multidisciplinary team environment. Another professional expanded, "It's another thing to consider because at the same time we are dealing with diabetes because that is a huge concern for our clients. We are taking on that whole metabolic monitoring and now the smoking as well." Being a smoker was sometimes used as a rationale for dismissing the role entirely.
As I am right now in the middle of trying to stop, I just don't find that it makes sense for me to say things about smoking when I am a smoker, inside I would feel guilty. And so say to them it's not good to smoke and this is what you should do. [Paraprofessional, Current Smoker, Resource Centre]
To ease the tension of not engaging in this role, distributing educational brochures about tobacco use and cessation programs filled a useful function - providers had satisfied their responsibilities. This also strengthened the message that others had tobacco cessation expertise, reinforcing that this responsibility belonged elsewhere. In the same way, referring a client elsewhere for tobacco cessation support was presented as being professionally responsible; this specialized role belonged to someone else. It was, however, safe territory to promote the advantages associated with joining these programs, "So if I know they smoke, I will talk to them about this program, this free patch and free nicotine and I encourage them to join."
Tobacco Control as Health Promotion
In the discourse of health promotion, tobacco was powerfully described as "unhealthy," a "drug" that was "highly addictive" and linked with cancer and cardiovascular complications. Many providers recalled clients and their own family members who had died from tobacco-related causes. This health-focused discourse translated into promoting tobacco cessation, and harm reduction approaches, therefore challenging the assumptions of the previous four discourses. Formal interventions belonged to professionals who had the expertise while paraprofessionals engaged in an informal discourse, encouraging and reinforcing the message, which often highlighted a personal style.
Cessation interventions by professionals were characterized by a specialized skill set involving counselling (e.g. motivational interviewing) and pharmacological interventions. Some descriptions focused on the human element of engaging, others on the bio-physical aspects of treating the addiction; both conveyed that there was an expert and voice of authority.
And if they are motivated about it, I can engage them in a process of discussion and interest. I have some sense of the tools available and so on. It's very satisfying. You know when I was in general practice and I would help people quit smoking, years later when I would see those people... they would say 'You're the one who helped me quit!' [Professional, Former Smoker, Mental Health Team]
Weighing competing risk factors and tailoring approaches accordingly were key elements of interventions. The health promotion discourse revealed that certain clients received more attention about smoking cessation than did others, specifically, those with other medical conditions. One professional prioritized his client's "bad airways," "I have a young guy...He also has terribly severe asthma and he's really pre-contemplative about changing his smoking. But I've spent a lot of time trying to move him along to that stage of change."
The content and the delivery of the health promotion message varied according to their clients' socioeconomic status and the perceived level of function. The expert provider was in a position to know how the message would be interpreted.
A lot of our clients, they are really poor. They have no stimulation in their life. And I see cigarettes as really important to them...For some, it's taking a core part of their identity away, their best friend away. So for those, I will have a different approach, or a softer approach. [Professional, Former Smoker, Mental Health Team]
The timing of targeted interventions was important. This meant that the client had to be "stable" and it had the tone of the expert taking charge when timing was "appropriate" when the client was "activated in their recovery process, as exemplified by one professional "I address it more as 'Oh, you are really doing well, you are more stable, you are making your appointments, you are taking your meds, your symptoms aren't bothersome now, why don't we look at dealing with the smoking issue?’” Knowing when it was the "right time" was portrayed as a skill, with the emphasis placed on holistic well-being. According to one professional, "To me it seems like an art, experiential, knowing when to push and when to back off, how to rate it among people's other issues, looking at the whole picture."
Intervening to reverse tobacco reduction or cessation was described as the necessary harm reduction measure when the timing was not right for a client's "mental health." In this situation, the expert voice of authority ruled, "I advised her to forget it now because she is not stable."
Some providers described how they looked for and worked with "outward signs" when clients were "coughing like mad." Such moments were considered to be a "good time" to raise the topic of tobacco use: "I'm a nurse, so if someone is coughing a lot, I will say 'So how much are you smoking and do ever think of cutting back?'" Another provider recalled transforming a situation of being "on the spot" during a shopping assessment into an opportunity to engage in tobacco cessation discussion.
It is awkward because they say, "Do you mind if I have a cigarette?" and I kind of do... I asked him if he had smoked for a long time, would he be interested in [quitting] smoking. He said "Maybe one day." At the end, I gave him the information about the ButtOut group. It was an opening. [Professional, Non-Smoker, Mental Health Team]
There was a call for immediate intervention when client smoking posed a serious safety concern as was the case for one professional whose client, a woman with alcohol dementia, had caused a fire in her apartment. "I'm really working very hard to get her to stop smoking because not only is she at risk, but so are the people in her building." This was further described as "beyond an individual's right to do something that is unhealthy" and more about protecting others from "physical harm."
An informal harm reduction approach was a part of the health promotion discourse. One paraprofessional claimed to not "have any information" for her clients, but reminded them of the health and financial benefits of cutting back. Another provider explained, "I encourage more of a harm reduction approach. I see a lot of people do the cold turkey thing and come back to it and I expect there's guilt." Those who had been personally touched by the tobacco-related loss of a family member dedicated themselves to fully engaging in this discourse.
I myself am not a smoker but I do know it's addictive, I do know people go through a pack a day, so I just try to start conversations, "Oh, how much do you smoke? Oh, a pack a day. Okay, what are you hoping to do, like next month? Are you hoping to reduce? What's another thing that you could substitute it with? [Paraprofessional, Non-Smoker, Resource Centre]
Attentive communication was emphasized in the health promotion discourse. "So I have to listen to what their plan is and reflect it back. And hopefully they have time to think, 'Oh, is it a reasonable plan?'" Although continual efforts to engage clients were labelled "frustrating" the potential for tobacco reduction or cessation was held up as an option: "They say, 'I cannot quit smoking, I am addicted. I've smoked for fifty years or twenty years, for many years.' And I say, 'Can't you just cut back a little bit?'" Trying to "grasp at something" was a device used to keep the tobacco discussion open with one client who was grieving the loss of her son "She has one remaining son. That son has now had a son and I say "Don't you want to be around to see that grandson?"
Personalised approaches were adopted when exploring client motivation to quit smoking. One paraprofessional spoke with confidence about investigating client motivation by "testing readiness" in a way that resembled a formal approach.
You recognize patterns and human behaviour and if it's not a level of motivation, something that I would grade over a 7, I wouldn't invest a lot of time supporting that. So I am looking and testing levels of motivation whether it's through body gestures, eye contact, things that they are saying, if they've done their research on their options. [Paraprofessional, Current Smoker, Resource Centre]
Another paraprofessional, a smoker, was adamant that he would "never stop" talking to his clients about smoking cessation, albeit his words were flavoured with wishful thinking. "I hope that one day when they are on about it, I happen to say the right word, the right combination of words and just catch them at that right moment where it's going to work."
There was tension beneath the language of this discourse. Approaching the topic of tobacco use was a "sensitive" matter that called for self reflection. One professional wrestled, "You have to ask, is this respectful, am I preaching to them, am I judging them? So it's a really delicate balance to play with smoking." Nevertheless, there was relief with the recognition that some clients had been successful in their efforts to quit smoking.
We used to be afraid to bring it up, because that would destabilize people, they can't handle it, but now we know it can be hard but with the right support, people can actually reduce or quit their smoking. So that is a tremendous shift in attitudes. [Professional, Non-Smoker, Mental Health Team]