Exploring Smoking Ban Adherence among Patients and Prevention and Control Programs at Amanuel Mental Specialized Hospital, Addis Ababa Ethiopia

Special Article – Tobacco and Smoking Cessation

J Fam Med. 2017; 4(6): 1129.

Exploring Smoking Ban Adherence among Patients and Prevention and Control Programs at Amanuel Mental Specialized Hospital, Addis Ababa Ethiopia

Abebaw D¹*, Shumet S1,2 and Getnet M¹

¹Department of Epidemiology, Jimma University, Ethiopia

²Department of Psychiatry, University of Gondar, Ethiopia

*Corresponding author: Dessie Abebaw, Department of Epidemiology, Jimma University, Ethiopia

Received: August 29, 2017; Accepted: September 25, 2017; Published: October 02, 2017


Background: The implementation of smoke-free policies in mental health settings represents a significant challenge. Timely smoke free environment initiation is the main factor for successful smoking ban program. However studies to understand patients, health care givers and staffs perspective on smoking ban initiation has been limited in Ethiopia. The main aim of this study was exploring smoking ban adherences among patients and prevention and control programs at mental health care institutes.

Methods: The in-depth interview was considered to be appropriate for investigating patients, care givers and hospital staffs attitude, practice and hospital smoking ban program related factors. A total of 22 patients who were smokers, 12 patient families and 14 staffs were participated in the study. A thematic content analysis of the interviews was performed using the Open Code software version 3.6.

Result: We found that having different sources of cigarette access, less group therapy or psychological treatment and cigarette contraband were the main reasons for less initiation of smoking ban adherence. On the other hand, Staffs were more motivated for initiation of smoking ban program.

Conclusion: Challenges of contrabands, low psychological treatment, having different source of cigarette and poor occupational therapy were factors that most influenced timely smoke free environment initiation.

Keywords: Adherence; Mental specialized hospital; Total smoking ban


Patients, who smoke at heavier rates than in the general population and most patients, start smoking in their teens, before the illness begins. This excessive smoking is frequently attributed to the high mortality and morbidity rates among this particular group of people. Around the world, at the present time, it is estimated that tobacco kills over 4.9 million people per year around the world [1-5].

Smoking is one of the known causes of chronic health conditions. Chronic health conditions, like cancer, diabetes, or heart disease, in turn are primary drivers of health care spending, disability, and death [6]. Though many countries decide smoking ban in their working and public environment, there was a great debate between public health professionals and policy makers in one group and tobacco industries and organizations supported by tobacco industries in another group [7].

In psychiatry hospital Tobacco smoking remains a neglected issue despite high rates of associated morbidity and mortality. Mental health facilities are highly neglected to control smoking as compared to general population and other facilities [8,9]. Smoking also appears to play a central role on social interaction on patient wards. Like many policies, smoke-free policy implementation is a process, not an event. Evidence of problems does not mean the policy is inappropriate or a failure. Addressing the damage caused by tobacco for people with mental disorder requires a multipronged approach across the continuum of care [1,10].

Programs which support smoke cessation at psychiatry health facilities during patient stay have both an efficacious and cost effective [11,12]. In terms of lives saved, quality of life, and cost efficacy, treating smoking is considered to be the most important activity a clinician can undertake [13-15].

It takes courage, leadership and planning to successfully implement a smoke-free policy in mental health settings. Management and clinicians should work closely together to develop and coordinate the implementation strategy, ensuring that resources are effectively used and deadlines are met. Key success factors are effective management at both central and local levels, as well as consultation with service users, careers and staff to gain support for the policy and obtain suggestions for improvement. Other important factors are advance planning, recruitment of experienced staff, effective communication and extensive training of staff in smoking cessation support [2,12].

Although in psychiatry hospitals total smoking ban was not strictly enforced and was overall acceptable to both patients and staff, total ban increased the proportion of smokers who tried to quit smoking during their hospital stay [8,11,16,17]. This is also supported in other facilities like in universities above 45% of the students are agreed for total smoking ban in the university [16]. Psychiatric institutions that implement general smoking policies must be aware that they need to overcome the problems of compliance and inadequate smoking rooms, otherwise the problem of environmental tobacco smoking exposure is not adequately solved [1,12,16].

Mental healthcare staffs are more than twice as likely to be smokers as their colleagues in general healthcare. Mental healthcare staffs are also known to be significantly less positive towards smokingrelated policies and treatments than their counterparts in other areas of healthcare. A recent UK survey reported that roughly 1 in 10 staff in general healthcare settings disagreed with a smoking-ban in their wards or clinics; however, 1 in 3 psychiatric staff were against such a ban in their settings [18,19].

In Ireland, Scotland and UK smoke-free legislation has been introduced which bans smoking in enclosed public areas or workplaces. In Scotland and Ireland, mental health units are exempt from implementing smoke-free legislation. Guidance for voluntary smoke-free implementation in mental health units is available for Scotland and for Ireland [19,20].

These fears are understandable but research evidence does not support them. A review of 22 studies of total and partial smoking bans in mental health settings found no adverse effects in terms of unrest or refusal to comply reviewed 26 international studies of smokingbans in mental health units, finding no increase in aggression, use of seclusion, discharge against medical advice or use of medication on an ‘as required’ basis [12].

Staff attitudes can become more positive, who found that initially only 7% of staff favored a smoking ban before its introduction, rising to 90% post-implementation. In a Canadian study, successful smokefree implementation was found to depend on staff preventing patients from gaining access to tobacco [8,15].

In Ethiopia mental health hospital, majority of the patients were smokers, the newly admitted mentally ill patients are exposed to smoke cigarette thought, and previously they were not smokers. The Ethiopian government declare smoking ban in public and working areas by 2014 and Amanuel mental specialized hospital were the first working environment to implement this regulation. The hospital develops its regulations to have successful smoking ban program. Inconsistent adherence to the smoking ban and prevention program might lead to ignoring smoking ban activities and , making it difficult to achieve high success rate. Therefore this study helps to understand what factors influence the willingness or the ability of patients to adhere to smoking ban and prevention programs, to utilize this understanding to change the affected individual’s behavior to improve adherence rates and, to modify the existing programs. On the top of this, the study would motivate the health authorities and policy makers to have close contact with health institutions to decrease cigarette smoking activities and mobilizing affected individuals in order to adhere the smoking ban program.


Study setting

Institution based study was conducted in Amanuel Mental Specialized Hospital in Addis Ababa. It is one of the oldest hospitals established in 1930 E.C during the Ethio-Italian war and it is the only mental Hospital in Ethiopia. In the Hospital the health service had been given up in 1940 by low level psychiatric professionals. Starting from 1946-1970 the treatment was given by doctors came from Russia, Bulgaria, and Cuba.

It is located in western part of Addis Ababa in Addis Ketema Subcity, kebele 08. The hospital is working on increasing the efficiency &effectiveness of mental health care excellences by giving core mental clinical services, conducting research and trainings and other administrative services. More than 41 % of the hospital patients were cigarette smokers.

Study design

Methodologically, this qualitative study was framed within phenomenology in its natural setting to explore smoker mental patients adherence to total smoking ban and prevention programs in Amanuel mental specialized hospital. This phenomenology study describes the meaning for several individuals of their lived experiences of a concept. The researcher focus on describing what all participants have in common as they experience a phenomenon.

Study participants and procedures

Adult male and female mentally ill patients admitted in the hospital who were smokers, hospital workers including health professionals’ guards and senior managements and patient families were the study participants. Patients who were smokers before three months in which the hospital declared total smoking ban and have an insight to respond were eligible to participate whereas , patient family who were stayed at least three weeks in the hospital were eligible to participant in the study. Saturation of data occurred with a sample of 22 patients who were smokers, 12 patient families and 14 staffs. Participants were selected purposively. Before interview the purpose and importance of this study was explained for each participant, and if they agreed to participate, they signed an informed consent form prepared in Amharic which is the local and national language of Ethiopia, and participants’ involvement was assured on voluntary bases. Participants who were unwilling to participate and want to abstain at any step of in-depth interview were informed to do so without any restriction.

The in-depth interview

In-depth interviews were conducted by one interviewer who is trained in qualitative interviewing techniques using Semi-structured guide with one note takers. The guide was prepared in English and translates in to Amharic which is the local language. Interviews were undertaken by audiotape, by note taking and again by observation of the participants during the interviewing. The interviewer was, guided by the participant’s responses in deciding when and how to probe the emergent themes. The interviews lasted averagely 50-60 minutes and the audio tape record was done with the consent of the interviewees. The interviews were continued until all categories are addressed and point of saturation reached.

Data analysis

Tape recorded in-depth interview were firstly transcribed in Amharic character and then translated in to English by two trained staffs in Amanuel mental specialized hospital. Codes were developed based on original terms used by participants. The translated data was read repeatedly in order to have clear understanding of the idea and to categories for appropriate themes. The transcript and notes were analyzed using open code version 3.6 then the data were cleaned, saved in plain text file. A descriptive phase of identifying meaning units and assigning codes which were then compared and reorganized into tentative categories.

Ethical consideration

Ethical approval was obtained from ethical review committee in Amanuel Mental Specialized hospital. To insure the ethical issues not to be violated, written consent was taken from each interviewee. In similar ways, the recordings and notes has been kept in a safe and protected place to assure privacy.


Characteristics of the study participants

A total of 22 (6 females and 16 males) patients who were smokers, 12 patient families (4 females and 8 males) and 14 staffs (5 females and 9 males) a total of 48 participants were participated in the study. Majority of patient families were stayed above 25 days in the hospital. Three main themes which emerged from the content analysis are reported in detail below.

Theme one: patient related factors

Patients’ attitude towards smoking ban: Temporarily the Ethiopian government declared smoking in public areas, health institution and other working areas is totally forbidden. Following this, Amanuel mental specialized hospital applies the rule immediately. All participants accept total smoking ban program but, practically less than half of the participants were never smoke cigarette and advice others not to smoke after the hospital declared total smoking ban.

One patient who stayed for 35 days in the hospital explains his feeling about the hospital smoking ban program and his commitment as follow.

“…..Really it is wonderful; I can say it was late. From the beginning any patient admitted to hospital should obey the rules and regulations of the hospital and the order of the doctor. So after smoking ban I never smoke and I strongly fight those who smoke cigarette in my case team”.

A 45 years old patient who was smoker for 15 years explains his opinion that total smoking ban is not difficult as everybody thinks.

“I was chronically dependent on tobacco, but its effect on my health becomes worse and worse. That is why I am admitted here. I decide to stop smoking as soon as I hear the hospital has declared total smoking ban. Then I tried to stop smoking and still I don’t smoke as well I don’t face any problem starting from the beginning of smoking ban so that it was not difficult as they think; it is possible to stop smoking.”

On the other hand ,majority of the participants are smoking at least once a week because of different reasons, like peer pressure, availability of cigarettes in the hospital that inters via patient family, visitors, patient themselves and the absence of organized rehabilitation center (Table 1).