An exploration of mental health nursing students' experiences and attitudes towards using cigarettes to change client's behaviour

Accessible summary • This study explores the experiences of mental health nursing students in using cigarettes as a means of token economy. • The majority of the sample experienced the use of this particular intervention in various settings but also reported that other items apart from cigarettes were also used as part of a reward system. • Respondents generally did not like this practice, feeling that it did not work well, led to client staff conflict, was implemented in an ad hoc way and rarely recorded in a care plan. • An open debate on tobacco control and the use of cigarettes in behavioural change programmes is urgently required. Using cigarettes to change client behaviour is a common, yet little studied, practice in mental health care. A questionnaire survey was used to explore mental health nursing student's experiences and attitudes to this practice. The sample was four cohorts of mental health nursing students (n= 151). Of them, 84% had experienced the practice of using cigarettes to change client behaviour in acute wards (73%), rehabilitation wards (28%) and elderly care (14%). Cigarettes were used to change client behaviour in areas such as attending to personal hygiene (57%) or engaging in the ward routine (39%). However, items such as leave (60%) or drinks (tea and coffee) (38%) were also reportedly used. Of the respondents, 54% inferred that the practice did not work well with 46% stating it was not written up in care plans; 52% felt it was an ad hoc practice, 60% inferred that at times it was used as a punishment while 55% intimated that they felt bad withholding cigarettes. There are ethical and moral dilemmas around using lifestyle risk factors as rewards or using client's nicotine addiction as a means of controlling behaviour. The question of whether this intervention should ever be used, given its associated health risk, requires more critical debate in clinical practice.