Table 2 Identified barriers and suggested interventions that have been informed by the literature, COM-B and TDF [16]
Barriers identified | COM-B | TDF | Intervention function | Possible intervention |
|---|---|---|---|---|
Poor comprehension of harm reduction approaches, smoke-free policy and its purpose. Unable to recall training content MHPs lack the confidence to address smoking with patients who do not initially indicate willingness to quit. | Psychological capability | Knowledge Memory, attention and decision Cognitive and interpersonal skills | Education Training Environmental restructuring Enablement | Brief, face-to-face or online smoking cessation training tailored specifically to MHPs roles [35]. Training which allows MHPs to practice the skills required to address smoking with patients (e.g. role play group training), thus improving capability as well as confidence and motivation [24] |
Inability to monitor patients’ smoking in community services. Lack of time and resources to provide smoking cessation interventions (only ask about smoking at initial assessment). | Physical opportunity | Environmental context and resources | Training Restriction Environmental restructuring Enablement | Improve access to specialist equipment, such as spirometers and CO monitors [26] [27]. Improve communications/referral process between mental healthcare (non-smoking specialists) services and stop smoking services (smoking specialists) [36]. |
Tobacco has become a prominent contraband item in the community and inpatient settings. Lack of support from colleagues to enforce smoke-free policy. | Social opportunity | Social influences | Restriction Environmental restructuring Modelling Enablement | Group training to encourage team work and shared learning across different care teams [24]. Videos of positive attitudes of fellow healthcare providers and colleagues. Increased vigilance to prevent anti-social behaviour (i.e. hiding tobacco in bushes and units) that is sensitive to mental healthcare contexts (e.g. ‘watchful eyes’ intervention [37] has been found to be effective in other contexts, but may not be appropriate in settings whereby patients experience paranoia). |
Intrinsic biases regarding mental health and smoking. | Automatic motivation | Reinforcement Emotion | Training Incentivisation Persuasion Coercion | Improve clinical reasoning and decision making skills, such as through reflective practice and active metacognitive review [23]. Use of emotive videos of patients who want to quit, but cannot due to their mental health. |
Smoke-free policy and training lacks relevance to non-inpatient services. Prioritise alcohol and other substances over tobacco. Only intervene with tobacco use in light of financial or physical health issue. Belief that addressing smoking with patients could provoke retaliation from some patients. | Reflective motivation | Professional role and identity Beliefs about capabilities Beliefs about consequences Intentions Goals | Education Persuasion Modelling Incentivisation Coercion Enablement | Tailoring training to clinical setting/role, and manuals to aid MHPs [23]. Incorporate smoking cessation into other treatments [34]. Improving awareness that ‘preventing’ is more beneficial compared with ‘treating’. Improved dissemination of findings that show violence has decreased in inpatient setting following smoke-free policy implementation [31]. |