title: Type of unit and population served matters when implementing a smoke-free policy in mental health settings: Perceptions of unit managers across England.
abstract: BACKGROUND
  Globally, smoking remains a significant issue for mental health populations. Many mental health trusts in England are facing challenges of implementing the National Institute for Health and Care Excellence guidance according to which all mental health settings, no matter the type, should be entirely smoke-free and provide comprehensive smoking cessation support.
  
  
  OBJECTIVE
  The aim of this paper was to determine if unit type and unit manager smoking status influence mental health smoke-free policy implementation.
  
  
  METHODS
  This paper reports on the secondary analysis of data from a cross-sectional survey of 147 mental health inpatient settings in England, in 2010. The original study's main aim was to understand unit managers' perceived reasons for success or failure of smoke-free policy.
  
  
  RESULTS
  Unit managers (n = 131) held a positive stance towards supporting smoke-free policy and most perceived that the policy was successful. Non-smoker unit managers were more likely to adopt complete bans than smoker unit managers, whereas smoker unit managers were more likely than non-smoker unit managers to think that stopping smoking aggravated patients' mental illness. Smoking rates for staff and patients remain high, as perceived by unit managers, regardless of unit type. Proportion of units offering nicotine replacement therapy and peer support to patients was significantly higher in locked units compared to semi-locked or residential rehabilitation. Applied strategies significantly vary by type of unit, whereas unit managers' knowledge, attitude and practices vary by their smoking status.
  
  
  CONCLUSIONS
  There are nuanced differences in how smoke-free policy is enacted which vary by unit type. These variations recognise the differing contexts of care provision in different types of units serving different patient groups. Addressing staff smoking rates, promoting consistency of staff response to patients' smoking and providing staff education and support continue to be key strategies to successful smoke-free policy.
  
  
  CONCLUSIONS
  Our results demonstrate the importance of taking into account the type of unit and acuity of patients when enacting smoke-free policy and addressing staff smoking.
authors.affiliation: Flinders University, Australia.
authors.forename: Sara
authors.initials: S
authors.lastname: Zabeen
authors.affiliation: Flinders University, Australia.
authors.forename: George
authors.initials: G
authors.lastname: Tsourtos
authors.affiliation: South London and Maudsley NHS Foundation Trust, UK University College London and UCL Partners, UK.
authors.forename: Jonathan
authors.initials: J
authors.lastname: Campion
authors.affiliation: Flinders University, Australia sharon.lawn@flinders.edu.au.
authors.forename: Sharon
authors.initials: S
authors.lastname: Lawn
mesh_terms: D001291:Attitude of Health Personnel; D003430:Cross-Sectional Studies; D004739:England; D006778:Hospitals, Psychiatric / Q000145:classification / Q000458:organization & administration*; D006801:Humans; D007407:Interviews as Topic; D008503:Medical Staff / Q000523:psychology*; D008603:Mental Health; D062072:Patient Acuity; D010465:Perception; D057566:Self Report; D061845:Smoke-Free Policy / Q000331:legislation & jurisprudence*; D012907:Smoking / Q000523:psychology*
keywords: Mental health; implementation; patient acuity; smoke-free policy; smoking culture; staff perceptions; staff smoking