Smoking and quitting: a qualitative study with community-living psychiatric clients

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Abstract

This paper reports the findings of a study investigating the smoking behaviours of a community-based psychiatric population. Using a qualitative, grounded theory approach, the four diagnostic categories of schizophrenia, bi-polar affective disorder, depression, and personality disorder were studied (24 interviews in total) in order to identify similarities and differences in smoking behaviours and perceptions of links between illness and cigarette smoking. A number of theoretical constructs emerged from the data, many of which confirm and enhance current understandings of issues, such as the role of cigarettes in managing the symptoms of illness. However, several themes not found in the existing literature also emerged. Smoking was found to play a significant existential role in the lives of participants: alleviating the effects of stigma, promoting positive and negative freedoms, and providing core needs as part of quality of life decisions. Perceptions of the nature and degree of interaction between psychiatric symptoms and the ‘need’ to smoke were also found to be significant. Variations in smoking between the different diagnostic groups were also found, in particular in the process of smoking itself, the nature of the nicotine dependence as predominantly physical or psychological, attitudes towards the quitting process and sense of control, and the degree of significance of existential factors. The research findings suggest that we may be able to add new methods to our current ways of intervening to assist people with a mental illness who want to quit smoking. Differences in perceptions and patterns of use suggest that intervention may be more effective if psychiatric diagnosis is also taken into consideration. Because the paper is descriptive and hypothesis generating, its findings need to be tested using a larger sample.

Section snippets

Background

Each year, approximately 25,500 Australians die from drug-related causes. Of these, 71% are directly related to tobacco smoking (Department of Health, Housing, and Community Services, 1992). This number represents 15.3% of all deaths from all causes in all age groups, 22% of deaths among 35–69-year olds (Australian Parliament, 1995), and 82% of drug-related deaths (Hill & White, 1995).

A common issue in research on addictive behaviour is “the lack of single, simple, and scientifically satisfying

Design

Semi-structured open-ended interviews were used for this grounded theory, qualitative study. Glaser and Strauss (1967) developed grounded theory as the theoretical framework for a study of staff managing dying patients. Their emphasis was on discovery through the ‘constant comparative analysis’ of data, that is, they believed that the collection and analysis of data go hand in hand. This process involves coding, comparison and clustering, labelling and categorising, further data collection and

Results

The participants’ age range was 25–63 years; 12 were men and 12 were women. Most participants started smoking in their teens, had smoked for more than 10 years (usually much longer), smoked high-tar cigarettes, smoked more than 20 cigarettes per day, and lived alone in public housing. All participants were unemployed at the time of interviews and follow-up contact. All received a government pension. Participants had a range of educational experience, however most had not completed high school.

Themes

The following six themes are an attempt to explain the core need, as perceived by the people interviewed for this study. The themes were: (1) Cigarettes as a symbol of control; (2) Why quit? Despair and hopelessness in the presence of mental illness; (3) Smoking as self-medicating illness; (4) Smoking for identity/cigarettes as a friend; (5) Reinforcement and acceptance of smoking; and (6) Quitting beliefs and attempts.

Direct quotes from participants have been used to illustrate the themes.

Discussion and conclusions

The most striking feature of these findings is the perceived centrality of smoking to participants’ overall well being, and the clarity of links made between their smoking and their mental illness. There is a growing literature emphasising links between nicotine withdrawal and illness relapse (Glassman, 1993; Glynn & Sussman, 1990; Greeman & McClellan, 1991; Hall et al., 1996; Stage, Glassman, & Covey, 1996). The most recent pharmacological research attempts unlock the riddle of interaction

Acknowledgements

The authors wish to thank Ms. Shaun Byrne for her role as Auditor, Dr. Judith Condon for her advice regarding the qualitative methodology, and Prof. Ross Kalucy for his encouragement. Our special thanks go to the clients of Southern Mental Health Services, Adelaide, who participated in this study and also to the reviewers who made several useful and critical comments about the paper.

The findings of this paper are part of a much larger study looking at the perceptions of smokers in the four

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