Table 4.

Themes and subthemes identified in qualitative synthesis.

Theme	Subtheme	Study references	Illustrative quotes
Beliefs about patients quitting smoking	Negative perceptions of patients' motivation/ability to quit	35, 37, 32, 31, 36, 39, 38	‘Some directors and staff members 9 and only 1 client cited that clients do not want to quit… ‘But the reality is most of our adult smokers could care less. I mean they're not interested in quitting smoking’ 38
			‘Providers and consumers both voiced negative expectations regarding the ability of persons with mental illnesses to quit smoking, but providers made these comments more frequently’ 36
	Concerns about the negative consequences of quitting	37, 32	‘Some wondered whether attempting to provide SC treatment in SRTPs could jeopardize patients' sobriety’ 37
			‘Helping service users to quit smoking was ‘too hard’…, and there was a fear of patients becoming violent’ 32
Barriers to the provision of smoking cessation treatment	Lack of opportunity to provide treatment	35, 37, 32, 36, 39, 38	‘Providers cited a lack of clinical resources such as smoking cessation groups and financial resources [both patient and system] to pay for the treatment’ 36
			‘Time restraints mean other issues increase in priorities’ 35
	Lack of capability to provide treatment	32, 36, 39, 37	‘The participants' skills and knowledge relating to smoking and nicotine dependence treatment seemed lacking’ 39
			‘One respondent suggested that there was a ‘total lack of knowledge’ about the importance of, or the need for, service users to stop smoking’ 32
	Health professionals' behaviour	37, 32, 31, 36, 38	‘In the locked settings, clients and staff spent much time in direct contact, often in the smoking area with the majority of clients and staff smoking, with staff acting as social role models for clients at such times’ 31
			‘Far from encouraging cessation, some staff enabled smoking by “offering cigarettes” with ‘nurses who purchase cigarettes [for the service users], even out of their own money at times’ 32
Attitudes to the provision of smoking cessation treatment	It is important	35, 37, 32, 36, 39, 38	‘Providers identified tobacco cessation for persons with mental illnesses as a promising or emerging evidence‐based practice and strongly supported integrating tobacco cessation services in mental health settings as a clinical priority’ 36
	It is not a priority	35, 37, 32, 36, 39, 38	‘Another difference reported [between smoking and other drug use] was that smoking was not a focus or a high priority in drug treatment’ 38
			‘An ‘unwillingness to place nicotine addiction high enough to warrant the same attention as other addictions’ led to a ‘low need to quit’ 32
	It is not part of own role	35, 37, 32, 38	‘Several participants said that SC counseling was not in their job description and was outside their scope of work’ 37
			‘The capacity to provide cessation support was perceived to be limited by exclusion of the requirement to possess the skill or deliver support in employee job descriptions’ 32
	Negative beliefs about providing treatment	37, 32, 36, 38	‘Participants stated concerns that “trying to force patients to quit” might make them leave the programme’ 37
			‘As one provider put it, “the problem is that there isn't actually evidence that it [cessation strategies] works”’ 36
	It is dependent upon the patient	35, 37, 39, 38	‘Most participants expressed discomfort with advising uninterested patients to quit, indicating interventions were typically presented to only patients who explicitly asked for help. One participant described the process as, “If they say they don't want to stop smoking, they get told about the dangers and that's it”’ 37
Acceptance of patients' smoking	Culture of smoking	37, 32, 31	‘A number of staff beliefs and practices supported a “culture of smoking”, with “smoking as the norm”’ 32
	It is a patients' right/personal choice	35, 37, 32	‘I believe people should have a choice if they smoke or not’ 39
	Smoking is a ‘core need’	31, 36, 39	‘Several providers commented that “they [mental health consumers] don't care how much they spend on cigarettes. Their cigarettes are so important to them, it doesn't matter”’ 36
			‘Clients and staff focused much attention on ensuring the supply of cigarettes as a core need for clients’ 31
Smoking as a useful tool	For patients	32, 31, 36, 39, 38	‘Respondents generally viewed smoking as an important coping mechanism for patients—providing a way to deal with stress’ 39
			‘In the locked ward I don't think there's much in the way of one‐to‐one therapeutic activity that happens. It's a kind of, “Let's wait for the medication to work”. There's just nothing to do. The only normal thing to do at the time is to smoke’ 31
	For staff	37, 32, 31, 36	‘Some respondents believed that smoking enabled positive social experiences, which helped staff develop rapport with service users’ 32
			‘Moreover, in some settings, such as psychiatric hospitals, consumers earned smoking privileges as a behavioural reward’ 36