Spaces for smoking in a psychiatric hospital: Social capital,resistance to control,and significance for ‘therapeutic landscapes’

This paper reports on research framed by theories of therapeutic landscapes and the ways that the social, physical and symbolic dimensions of landscapes relate to wellbeing and healing. We focus especially on the question of how attributes of therapeutic landscapes are constructed in different ways according to the variable perspectives of individuals and groups. Through an ethnographic case study in a psychiatric hospital in the North of England we explore the perceived significance for wellbeing of ‘smoking spaces’ (where tobacco smoking is practiced in ways that may, or may not be officially sanctioned). We interpret our findings in light of literature on how smoking spaces are linked to the socio-geographical power relations that determine how smoking is organised within the hospital and how this is understood by different groups using the hospital building. We draw on qualitative research findings from discussion groups, observations, and interviews with patients, carers and staff. These focused on their views about the building design and setting of the new psychiatric hospital in relation to their wellbeing, and issues relating to smoking spaces emerged as important for many participants. Creating and managing smoking spaces as a public health measure in psychiatric hospitals is shown to be a controversial issue involving conflicting aims for health and wellbeing of patients and staff. Our findings indicate that although from a physical health perspective, smoking is detrimental, the spaces in which patients and staff smoke have social and psychological significance, providing a forum for the creation of social capital and resistance to institutional control. While the findings relate to one case study setting, the paper illustrates issues of wider relevance and contributes to an international literature concerning the tensions between perceived psychological and psychosocial benefits of smoking vs. physical harm that smoking is likely to cause. We consider the implications for hospital design and the model of care.     

‘I’m searching for solutions’: why are obese individuals turning to the Internet for help and support with ‘being fat’?

Introduction This study explores what types of information obese individuals search for on the Internet, their motivations for seeking information and how they apply it in their daily lives. Method In‐depth telephone interviews with an Australian community sample of 142 individuals with a BMI ≥ 30 were conducted. Theoretical, purposive and strategic samplings were employed. Data were analysed using a constant comparative method. Results Of the 142 individuals who participated in the study, 111 (78%) searched for information about weight loss or obesity. Of these, about three quarters searched for weight loss solutions. The higher the individual’s weight, the more they appeared to search for weight loss solutions. Participants also searched for information about health risks associated with obesity (n = 28), how to prevent poor health outcomes (n = 30) and for peer support forums with other obese individuals (n = 25). Whilst participants visited a range of websites, including government‐sponsored sites, community groups and weight loss companies, they overwhelmingly acted upon the advice given on commercial diet websites. However, safe, non‐judgemental spaces such as the Fatosphere (online fat acceptance community) provided much needed solidarity and support. Conclusions The Internet provides a convenient source of support and information for obese individuals. However, many turn to the same unsuccessful solutions online (e.g. fad dieting) they turn to in the community. Government and community organisations could draw upon some lessons learned in other consumer‐driven online spaces (e.g. the Fatosphere) to provide supportive environments for obese individuals that resonate with their health and social experiences, and address their needs.     

Is there a relation between school smoking policies and youth cigarette smoking knowledge and behaviors?

To comply with workplace legislation, New Zealand schools are required to have policies regarding tobacco smoking. Many schools also have policies to prevent tobacco use by students, including education programmes, cessation support and punishment for students found smoking. This paper investigated the associations between school policies and the prevalence of students' cigarette smoking. Furthermore, we investigated the association between school policy and students' tobacco purchasing behavior, knowledge of health effects from tobacco use and likelihood of influencing others not to smoke. Data were obtained from a self-report survey administered to 2,658 New Zealand secondary school students and staff from 63 schools selected using a multi-stage sampling procedure. Components of school policy were not significantly associated with smoking outcomes, health knowledge or health behavior, and weakly related to a punishment emphasis and students advising others to not smoke. Similarly, weak associations were found between not advising others to not smoke and policies with a punishment emphasis as well as smoke-free environments. The results suggest that having a school tobacco policy was unrelated to the prevalence of tobacco use among students, tobacco purchasing behavior and knowledge of the negative health effects of tobacco.     

“<Emphasis Type="Italic">I’m not strong enough; I’m not good enough. I can’t do this,I’m failing</Emphasis>”: a qualitative study of low-socioeconomic status smokers’ experiences with accessing cessation support and the role for alternative technology-based support

Background

The social gradient in smoking rates persist with an overrepresentation of smoking and its associated harms concentrated within lower socioeconomic status (SES) populations. Low-SES smokers are motivated to quit but face multiple barriers when engaging a quit attempt. An understanding of the current treatment service model from the perspectives of treatment-seeking low-SES smokers is needed to inform the design of alternative smoking cessation support services tailored to the needs of low-SES populations. This qualitative study aimed to: i) explore low-SES smokers’ recent quitting experiences; ii) assess factors that impact treatment engagement; and iii) determine the acceptability and feasibility of alternative approaches to smoking cessation.

Method

Low-SES participants (n = 24) previously enrolled in a smoking cessation RCT participated in either a semi-structured focus group or in-depth telephone interview. Data was obtained and analysed using thematic analysis from October 2015 to June 2016. Analysis was deductive from the interview guide and supplemented inductively.

Results

Participants expressed feelings of guilt and shame around their smoking behaviour and experienced stigmatisation for their smoking. Guilt, shame, and stigmatisation negatively impacted treatment seeking behaviours with most avoiding current quit services. Costs of pharmacotherapy and treatment adherence were commonly cited barriers to treatment success. Electronic-cigarettes were perceived to be unsafe due to uncertainty on their legal status and regulatory restrictions. Technology-based text-messaging quit support was endorsed as a more favourable alternative compared to existing behavioural treatment services.

Conclusion

Stigmatisation was commonly endorsed and acted as an impediment to current treatment utilisation. Electronic-cigarettes may present a viable harm reduction alternative, but their likely uptake in socioeconomically disadvantaged groups in Australia is limited by smokers’ uncertainty about their regulation and legality. Mobile phone based cessation support may provide an alternative to telephone counselling and overcome the stigmatisation low-SES smokers face while trying to quit.

     

I’m so tired: biological and genetic mechanisms of cancer-related fatigue

Objective  

The goal of this paper is to discuss cancer-related fatigue (CRF) and address issues related to the investigation into potential biological and genetic causal mechanisms. The objectives are to: (1) describe CRF as a component of quality of life (QOL); (2) address measurement issues that have slowed progress toward an understanding of mechanisms underlying this symptom; (3) review biological pathways and genetic approaches that have promise for the exploration of causal mechanisms of CRF; and (4) offer directions for future research.     

Tobacco control and the inequitable socio-economic distribution of smoking: smokers’ discourses and implications for tobacco control

Warning: this article contains strong language.

This paper focuses on the ways in which social context structures smokers’ views of, and reactions to, tobacco control. This exploratory study examined the interactions between tobacco control and smokers’ social contexts and how this may be contributing to inequalities in smoking. We found in our sample that higher socio-economic status (SES) smokers are more likely to positively respond and adapt to tobacco control messages and policies, viewing them for their future health betterment. Lower SES smokers in our study, on the other hand, are in conflict with tobacco control and feel intransigent with regard to the effects that tobacco control is having on their smoking. A better understanding of how social context structures people's perceptions of tobacco control may help us to understand why social inequalities in smoking are deepening, and potentially what can be done better in tobacco control to decrease them.     

“It’s on everyone’s plate”: a qualitative study into physicians’ perceptions of responsibility for smoking cessation

Background

Little research has investigated in-depth how physicians perceive their role in smoking cessation care. This qualitative study sought to understand physicians’ perceptions of responsibility for smoking cessation.

Methods

Data were collected through individual semi-structured interviews and focus group interviews between June and November 2017 in The Netherlands. We interviewed 5 addiction specialists, 5 anesthesiologist, 4 cardiologists, 8 GPs, 5 internists, 5 neurologists, 2 pediatricians, 6 pulmonologists, 7 surgeons, and 8 youth healthcare physicians (N?=?55). Data analysis followed the framework approach.

Results

The analysis showed that three actors were perceived as responsible for smoking cessation: physicians, patients, and the government. Participants perceived physicians as responsible for facilitating smoking cessation -albeit to different extents-, patients as carrying the ultimate responsibility for quitting smoking, and the government as responsible for creating a society in which smoking uptake is more difficult and quitting smoking easier. Perceptions of smoking itself were found to be important for how participants viewed responsibility for smoking cessation. It remained unclear for many participants which healthcare provider is responsible for smoking cessation care.

Conclusions

The organization of smoking cessation care within health systems should be a focus of intervention, to better define physician roles and perceptions of responsibility. In addition, it seems important to target perceptions of smoking itself on the level of physicians and –as suggested by comments by several participants- the government.

     

‘I don’t think it’s risky,but…’: pregnant women’s risk perceptions of maternal drinking and smoking

In Switzerland, official recommendations relating to alcohol and tobacco use during pregnancy are based on a zero-tolerance policy. However, epidemiological research indicates that some pregnant women do not adhere to the abstinence principle, and this raises the issue of how pregnant women identify and respond to health risks. This article draws on a sociocultural study of 50 mainly white, partnered and educated pregnant women carried out in Switzerland between May 2008 and June 2009. The study used semi-structured interviews that examined how and in what ways pregnancy had changed women’s consumption of alcohol and tobacco and their perceptions of their riskiness. In this article we draw on these data to examine participants’ perceptions of the risks of smoking and drinking during pregnancy. We examine three main issues: women’s understandings of official recommendations, their contextualisation of risk in daily life and the moral issues which they saw surrounding smoking and drinking during pregnancy. We found that the women in our study perceived drinking and smoking during pregnancy as different types of risks with different meanings. The participants contextualised official recommendations about drinking during pregnancy and had their own views about its riskiness. In contrast all participants saw smoking as harmful and risky irrespective of the level of consumption. The pregnant women in our study saw smoking during pregnancy as a risk-taking behaviour and a failure to act in the best interest of the foetus. In contrast, under certain conditions, they saw moderate drinking of alcohol during pregnancy as acceptable and responsible behaviour.     

I’m Still Me: Inspiration and Instruction from Individuals with Brain Cancer

Individuals with brain cancer face many challenges, including threats to cognition, personality, and sensory and motor functioning. These can alter one’s sense of identity and result in despair. Chaplain-led spiritual interviews were conducted with 19 patients with brain cancer as part of a larger spiritual legacy intervention called “Hear My Voice.” The majority was female (58%), married (68%) and had aggressive/advanced tumors (63%). Participants were 22–68 years of age and expressed the following religious affiliations: Protestant (42%), Catholic (21%), Muslim (5%), and none (32%). Framework analysis was applied to reduce and understand the interview data. Primary codes were relationships with: God or the spiritual, others, and self. Brain cancer was reported to deepen and enrich patients’ commitment to these relationships. Struggle and grief were also revealed. Results suggest the continued vitality, growth and generativity of these participants and provide insight for chaplains and others on the medical team.     

What accounts for the relationship between social class and smoking cessation? Results of a path analysis

Despite the overall decline in cigarette smoking prevalence in the US, social class inequalities in smoking are likely to persist, or even to widen. One possible reason for the increasing gap in smoking prevalence across social class could be our lack of understanding of causal mechanisms: in other words, what accounts for the social gradient in smoking behavior? In this paper, we examine the mechanisms behind social gradients related to smoking cessation by use of path analysis techniques. The data come from a 3-year follow-up telephone survey of a cohort of US adults. The sample for the present analysis was drawn from the 481 respondents who reported being smokers and employed at baseline and who completed the follow-up interview. We examined two social class indicators, educational attainment and household income, in relation to smoking cessation. We tested the potential mediating effects of the following variables: differential use of resources for smoking cessation (e.g., booklet, pamphlet, quit line, nicotine replacement therapy and smoking cessation program), differential environments in terms of smoking at worksite and home, and differences in peer smoking. Our path analyses suggest that smokers from high social class are likely to use effective resources for smoking cessation and have restrictive home environment in terms of smoking, which leads to a relatively higher smoking cessation rate compared to those from low social class. The results of this study suggest that interventions should target resources for smoking cessation and home environments in terms of smoking to reduce socio-economic disparities in smoking cessation.     

The smoker’s paradox and the real risk of smoking

No satisfactory explanations have been offered for the smokers paradox, the greater short-term survival of smokers after a myocardial infarction nor for the large variations in the coronary risk rate for smoking ranging between 1 and 5.9. These discrepancies as well as the smokers paradox may be caused by different baseline characteristics of smokers and nonsmokers, whereas the usually quoted coronary risk of 2 is derived from studies based on the assumption of equal baseline characteristics. As neither this assumption nor the possibility of unequal starting conditions have been tested, we examined the main cardiovascular risk factors in smoking and nonsmoking boys as near as possible to baseline, at the age of fourteen. This age appeared to be best suited, because boys starting to smoke early are most likely to become regular and heavy smokers. Of 336 boys, 39 had smoked 8.3 ± 6.0 cigarettes/day for 15.5 ± 11.2 months. Compared to nonsmokers, boys who started to smoke early had lower LDL cholesterol and ₂-antiplasmin, greater handgrip strength, vital capacity and forced expiratory volume, better perfomance on bicycle ergometry and higher testosterone. The differences in total cholesterol, LDL cholesterol, vital capacity, handgrip strength, testosterone and ₂-antiplasmin persisted after adjustment for age, body mass, and testosterone. In addition, the differences in perfomance on bicycle ergometry and forced expiratory volume persisted after adjustment for age. These favourable baseline characteristics of those starting to smoke early can explain the smokers paradox. In addition, they suggest that the individual coronary risk in smokers is considerably higher than 2, because the assumption of equal baseline characteristics of smokers and nonsmokers cannot be upheld.This revised was published online in April 2005. In the previous version the article category was missing.     

Associations between mother’s level of education and offspring’s smoking and alcohol use in adulthood: a 28-year longitudinal follow-up study

Aims  The aim of this study was to examine the association between changes in mother’s education level during early childrearing years with offspring’s tobacco and alcohol (TA) use in adulthood. It was hypothesised that use of TA is lower among offspring whose mothers improve their level of education compared with offspring for whom mother’s education level does not increase. Subjects and methods  Information on TA use among 1,015 adults (from a national survey in 1998; response rate 72.7%) was linked with information on their mother’s education levels recorded in the National Education Register from 28 to 8 years earlier (mother’s education in 1970 and change in level of education from 1970 to 1990).Results   Multiple logistic regression revealed an inverse association between increase in maternal education level and risk of high alcohol use among female offspring. Higher level of mother’s education measured in 1970 was associated with lower risk of daily smoking and lower risk of moderate and high levels of alcohol use among male and female offspring.Conclusion   Low level of tobacco and alcohol consumption among adult offspring is influenced by mother’s level of education. Research on social inequalities in health behaviour should include more attention to the possible effects of mother’s social mobility during childrearing years.

Street smoking bans in Japan: a hope for smoke-free cities?

Objectives

This study analysed 112 municipalities enforcing municipal smoking restrictions on streets in Japan to examine anti-smoking measures implemented in urban settings from a health perspective and derive lessons for future tobacco control.

Methods

Municipal governments implementing ordinances which restrict smoking on streets were identified through grey literature review. Implementation period, characteristics, scope, and department responsible were examined.

Results

Since the first municipal regulation was introduced in 1997, many other municipalities have followed. Enforcement of fines started in 2002, which is now a common practice nationwide. Nevertheless, the health impact of exposure to secondhand smoke is not clearly articulated in the ordinances. Street smoking bans have been developed in connection with “beautification” and littering prevention for environmental purposes, and local health departments do not have responsibility for these ordinances.

Conclusions

There is potential to further prevent secondhand smoke exposure if such measures are expanded to indoor environments and integrated into broader policies. For policy-makers and advocates, the Japanese experience provides information on an additional tobacco control intervention as well as clues in the process of design, implementation and enforcement of such municipal measures. A more comprehensive and health-driven approach is required to effectively address the harm of secondhand smoke in Japan.     

What accounts for the association of education and smoking cessation?

BACKGROUND: Education has been identified as a potent sociodemographic predictor of smoking cessation and the Healthy People 2010 goals include the elimination of health disparities attributable to education. METHOD: The current study prospectively examined the association of education with smoking cessation as well variables that might account for that association among employed adults residing in the southeastern United States. RESULTS: A strong educational gradient in cessation was evident. Only 6% of smokers with less than a high school (HS) degree quit smoking during the 4-year study period, whereas 17% of smokers with a HS degree but no college degree and 28% of smokers with at least a college degree quit smoking. CONCLUSIONS: Education appeared to uniquely contribute to the prediction of smoking abstinence over and above the effects of demographic, environmental, tobacco dependence, transtheoretical model, and job-related variables. Obtaining a better understanding of how or why education influences smoking cessation could contribute to reducing the educational gradient in abstinence and warrants further research attention.     

Physician advice for smoking cessation in primary care: time for a paradigm shift?

General practitioners are often exhorted to routinely counsel patients who smoke about quitting in light of current evidence-based medicine (EBM) guidelines suggesting that such brief interventions provide an easy and effective way of increasing quit rates. Drawing on semi-structured interviews conducted with 25 smokers and 10 general practitioners (GPs) in British Columbia, Canada, this article explores smokers’ and GPs’ perspectives on smoking cessation interventions in primary care settings. Study findings indicate that both patients and GPs believe smoking is best broached when it is patient-initiated or raised in the context of smoking-related health issues, and there was a broader consensus that the role of doctors is to provide education and information rather than coercing smokers to quit. However, smokers wanted further recognition of the difficulties of quitting smoking and many questioned the competence of GPs to deal with addiction-related issues. Similar barriers to smoking cessation were raised by smokers and GPs – primarily inadequate time and resources. Based on these findings, we argue that the assumption that primary care consultations provide an important venue for encouraging smokers to quit deserves reconsideration based on the complexity of this issue, the circumstances in which most GPs practice, and the danger of alienating smokers. Questions are raised about whether current EBM guidelines are an adequate tool for guiding individual clinical interactions between GPs and smokers.     

Cigarette access and pupil smoking rates: a circular relationship?

Adolescents obtain cigarettes from both commercial and social sources. While the relationship between commercial access and adolescent smoking has been researched, no one has considered in detail whether rates of peer smoking affect cigarette availability. In two relatively deprived Scottish schools that differed in their pupil smoking rates, we assess pupil access to cigarettes. 896 13 and 15 year olds were surveyed, and 25 single-sex discussion groups held with a sub-sample of the 13 year olds. Smokers in both schools obtained cigarettes from shops, food vans and other pupils. However, pupils in the 'high' smoking school perceived greater access to both commercial and social sources, and had access to an active 'peer market'. These findings suggest that variations in cigarette access may contribute to school differences in pupil smoking rates, and that the relationship between access and adolescent smoking is circular, with greater availability increasing rates, and higher rates enhancing access.     

‘I think he is immune to all the smoke I gave him’: how women account for the harm of smoking during pregnancy

Despite women’s awareness of the risks of smoking in pregnancy to the developing foetus, a significant minority continue to smoke during pregnancy. In this article, we use a discourse analytic approach to analyse interviews with 12 Australian women who smoked during a recent pregnancy. We used these data to examine how women accounted for their smoking and identities in the light of the implicit but ever-present discourse that smoking in pregnancy harms babies. We found that the women in our study deployed two rhetorical devices in their talk, ‘stacking the facts’ and ‘smoking for health’, allowing them to situate their smoking within a discourse of risk or as a potential benefit to their health. Women ‘stacked the facts’ by citing personal observable evidence (such as birthweight) to draw conclusions about the risks of smoking in pregnancy to the baby. ‘Stacking the facts’ allowed women to show how they had evaded the risks and their babies were healthy. This device also allowed women to deny or cast doubt over the risks of smoking in pregnancy. Women’s accounts of ‘smoking for health’ involved positioning quitting as stressful and, as a result, more harmful than continuing to smoke a reduced amount. We found complex and counter-intuitive ways in which women dealt with the discourse that smoking in pregnancy harms babies and how these ways of accounting served to protect their identities. We argue that health promotion messages conveying the risks of smoking in pregnancy would benefit from contextualising these messages within women’s personal accounts (e.g. by ‘stacking the facts’ or ‘smoking for health’) and hence providing more ‘realistic’ health risk messages.