Letter

To the Editor: The Connecticut Mental Health Center is a state-owned and state-operated facility with both inpatient and outpatient services, run jointly by the Connecticut Department of Mental Health and Addiction Services and Yale University. It serves individuals from the greater New Haven area who have severe and persistent mental illness, a substance use disorder, or both. Alarmed by the National Association of State Mental Health Program Directors report ( 1 ) documenting the shortened lifespan for patients with severe and persistent mental illness and encouraged by reports of other state facilities implementing smoke-free policies ( 2 ), the center's leadership undertook a rigorous and concerted effort to address smoking.

A staff survey was conducted to assess attitudes about smoking cessation programs in order to aid policy development. The anonymous survey was mailed to a random selection of one-third (N=227) of the 680 staff members in January 2007. Respondents were asked to note their level of agreement with four attitude statements using a 5-point Likert scale (1, strongly disagree, to 5, strongly agree). The first three statements concerned assistance to quit: "Inpatients [or outpatients or staff] who smoke should be offered assistance to quit." The fourth stated that the entire facility and grounds should be smoke free. Chi square and one-way analysis of variance tests were used to compare demographic characteristics of respondents in three smoking status groups. Ordinal regression analyses were conducted to examine whether smoking status was a significant predictor of responses to any of the four attitude statements. Age, race, sex, and job category were entered in all regression analyses as covariates.

Twenty-five of the 227 surveys were returned because the staff members were not currently employed by the center. A total of 175 of the remaining 202 potential respondents completed the survey (response rate of 87%). Most survey respondents were women (N=124, 71%) and Caucasian (N=117, 67%), and the mean±SD age of respondents was 42.5±11.8 years. Most respondents had never smoked (N=107, 61%); 14% (N=25) defined themselves as current smokers, and 25% (N=43) defined themselves as former smokers. The smoking status groups did not differ significantly by gender, race, or job category. Most respondents agreed that assistance to quit smoking should be offered to inpatients (N=154, 88%), outpatients (N=150, 86%), and staff members (N=142, 81%). Smoking status did not predict attitudes about whether smoking cessation assistance should be offered to patients and staff. Chi square analyses showed that respondents differed by smoking status in their agreement about whether the entire mental health center campus should become smoke free (p<.05). In addition, the overall regression model was significant ( χ ² =14.9, df=6, p<.05). When the analysis controlled for age, gender, ethnicity, and job category, smoking status continued to predict attitudes about a smoke-free center. In general, compared with former smokers and current smokers, a larger proportion of those who had never smoked agreed that the mental health center should be smoke free.

Prior research has demonstrated that mental health and addictions staff who smoke are less likely to counsel their clients regarding smoking cessation ( 3, 4 ). In our study we found that attitudes about whether the center should become smoke free differed by smoking status. To achieve the goal of improving the health of the individuals we serve and the staff who participate in that effort, we developed educational and incentive programs as key components of a multifaceted initiative to assist both staff and patients who smoked. The entire campus, including inpatient and ambulatory services, became a smoke-free environment on April 7, 2008, without incident.

This project was supported by grant P50-AA15632 from the National Institute of Alcohol Abuse and Alcoholism (principal investigator Dr. O'Malley), grant K12-DA-000167 from the National Institute on Drug Abuse (to Dr. Weinberger), and the Connecticut Department of Mental Health and Addiction Services. Tony P. George, M.D., F.R.C.P.C., served as a consultant on this project.

The authors report no competing interests.

The authors are affiliated with the Connecticut Mental Health Center and the Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut. The findings were presented as a poster at the National Association of State Mental Health Program Directors Research Institute Conference on State Mental Health Agency Services Research, Program Evaluation, and Policy, Alexandria, Virginia, February 11, 2008.