Abstract
Tobacco smoking is common among people with moderate/severe forms of mental illness, and it is a major contributor to their generally poorer physical health. Tobacco control policies and cessation programmes have not achieved the same reductions in prevalence for people with mental illness as for general populations. Relatedly, smoking-related inequalities have persisted in high-income countries such as New Zealand.
A substantial body of research has shown that social networks and social integration have a significant influence on individuals’ health. Having adequate social connections is protective of health and is associated with lower rates of smoking and better quitting outcomes. There are strong social influences on smoking for this population, yet there are few in-depth social network analyses and these have usually featured people receiving a cessation programme. This study provides an in-depth, mixed-methods analysis of smoking in the social networks of smokers with mental illness, along with a grounded theory analysis of their views about their smoking in relation to their social network and social context. Fifteen people who smoked and accessed community-based mental health and addictions services took part in an in-depth interview.
The aim of this study was:
To investigate how the social networks and contexts of New Zealand smokers with mental illness influenced their views and behaviours in relation to smoking and quitting.
The following research questions guided this study:
1. What are the key features of the social networks of a sample of New Zealand smokers with moderate/severe mental illness?
2. How common is smoking within these social networks, and how is it patterned according to relationship type and perceived closeness?
3. What role does smoking play within the lives of smokers with moderate/severe mental illness, and what are their experiences and attitudes towards smoking and quitting?
4. How do personal social networks and broader social context influence the smoking-related attitudes and behaviour of smokers with moderate/severe mental illness?
Network analysis found that network sizes varied considerably across participants (range 5-40+), and to an extent, network sizes overstated the extent of social connection. On average, networks comprised 43% friends, 39% family, 10% support professionals, and 7% other relationships (e.g. landlord). Across the 15 networks, average smoking prevalence was 36%, and nine out of 15 participants had network smoking prevalences ≥30% (twice the national adult smoking prevalence). Smokers in the networks tended to be friends and were given high closeness ratings.
The in-depth interviews revealed smoking was a central activity to many participants. Efforts to cut down consumption (or intentions to) were common. The financial hardship of continuing to smoke was highly relevant to cutting down and people’s desire to quit. Smoking was used to manage and cope with the demands of daily life, boredom, acute stressors, traumatic memories, and mental illness symptoms. Smoking was also used to break down social barriers, and form and strengthen social connections. The act of smoking could be a support of its own and it was sometimes described as a “friend”. Many participants wished to prevent or minimise harm to themselves and others, and some presented themselves as “considerate smokers”. Most participants experienced smoking-related stigma, and in turn, some of these participants developed a highly defensive stance towards anti-smoking messaging and interventions. The over-arching concept of “smoking enclaves” was developed to encapsulate the concentration of smoking in networks and groups that smokers with mental illness were members of, and the complex of beliefs and behaviours, physical environments, and peripheral social position that were important to their continued smoking.
This research highlights the concentration of smoking in this population. The concept of smoking enclaves may advance our understanding of the high rates of smoking often observed in this population, and the maintenance of smoking-related inequalities. This study provides an in-depth analysis of smoking-related stigma in this population and the potential consequence of defensive responses to public health intervention.
The challenge for government, public health, and health/social care services is to administer policies and cessation support to reduce smoking harm for all population groups while also addressing economic and social inequalities. Policy and intervention solutions are needed for this population that are tailored, accessible, and which do not exacerbate social exclusion, stigma, and resistance. Greater incorporation of social network theory and research is indicated.