The working group defined two initial steps. First, a guide to good practice principles was edited.10 The group translated and adapted a guide from the Irish Health Promoting Hospitals Network11 for the Catalan context. This document established the major principles for achieving good tobacco control in mental health hospital units. Second, the level of tobacco control in mental health-care services in Catalonia was explored.12 Based on the principles delineated in the guide, an electronic questionnaire was designed to explore four dimensions: smoking intervention and resources, staff training and commitment, management of smoking areas, and communication of smoke-free policies. The questionnaire was sent to, and completed by, the line manager of each unit. Responses to this questionnaire indicated that the main areas of concern were related to smoking intervention (offering intervention, the availability of smoking-cessation drugs, and follow-up after discharge) and staff training on smoking cessation. As an example, only 41% of the 186 units surveyed (96.6% of all the units in Catalonia) offered smoking cessation treatment to their patients, and only 53% responded that their professionals had knowledge or training in tobacco cessation treatment.

Based on the results of the questionnaire, the working group set objectives related to staff training. The complexity of new procedures or interventions affects their rate of diffusion. Thus, adopting new interventions requires the potential adopter to develop new skills and conceptualizations (the complexity of the proposed change, in Roger's theory).8

This training goal was achieved via three strategies. First, one-day training sessions in the headquarters of the Network were designed for all professionals working in mental health units in hospitals. The members of the working group acted as peer educators. Second, mental health staff teams were trained in their own hospitals though a “Training the Trainers” program launched by the Network. Some members of the working group were accredited to deliver a standard course in their own hospitals. The program offered personalisable presentation slides, pocket intervention guides, and credits for participants. Third, the working group wrote a comprehensive evidence-based clinical intervention guide for smoking cessation for patients with mental disorders13 as well as a guide for conducting this intervention throughout inpatient stay and beyond.14

Until January 2011, Spanish tobacco-control law 28/2005 banned smoking inside hospitals. The new law (Law 42/2010, which came into force in January 2011) extended the ban to outdoor hospital campuses and to short-stay psychiatric units, both indoors and outdoors (these units included acute-patients units, sub-acute and medium-stay patients units, detoxification and dual disorders units). Only in long-stay patients units smoking were still allowed indoors and outdoors. After publishing arguments in favour of smoke-free outdoor spaces15 the Network advised several members of the Spanish Parliament of the necessity and feasibility of implementing these changes.

In the mental health-care settings of many countries, the debate about implementing total smoking bans has been long and hard; there was previously no scientific evidence about the potential health effects of implementing smoking bans, from the most permissive to the strictest. The Network therefore evaluated the levels of second-hand smoke (SHS) in all adult inpatient units in Catalonia16 through the measurement of air concentrations of particulate matter <2.5μm (PM2.5). The study included all type of mental health inpatient units (short- medium- and long-stay psychiatric units) and was conducted between November 2010 and March 2011, when Spain was transitioning from implementation of one national smoking regulation to a newer one (Law 42/2010, enforced starting in January 2011). The results of this study showed that only units with total smoking bans had SHS levels below the WHO-recommended levels for long-term exposure (10μg/m3), and units with indoor or outdoor smoking areas had levels of SHS between two and five times the recommended threshold.16 However, professionals in these units were not aware of the levels of SHS and of the potential harmful health effects.3 The Network's analysis was sent to the managers of each unit in order to foster a more realistic perception of the SHS levels in their wards. In general, greater perception of the advantages of an innovation leads to quicker adoption (the perceived benefit of change in Rogers’ theory).8

Implementation of the new Spanish regulation prompted mental health units to design intervention programs for smoking cessation and to have smoking-cessation drugs available. Nicotine-replacement therapy was not usually included in the hospitals’ portfolio services for these units; in 2009, only 48% of the acute units in Catalonia had nicotine-replacement therapy available12 versus 81% in 2013.

Communication of the activities carried out by the working group is important because the new procedures must be visible to potential adopters. An essential aim of this communication is to raise awareness in the mental health community. New ideas, procedures, and interventions are not rapidly adopted if they are not compatible with the current values, beliefs, and practices of the majority (compatibility with existing beliefs and practices in Rogers’ theory).8

Our dissemination strategy has been based on a variety of activities, for example: 1) clinical sessions at the hospitals that are conducted by members of the working group in those units and demonstration of the materials produced by the working group; 2) presentation of the results of studies and other activities in national congresses of psychology, psychiatry, nursing, addiction, and public health, on the group's web page, and, more recently, via Twitter; and 3) organization of conferences supported by the Catalan Government. Three one-day conferences have been organized over six years. The aims of the conferences were to challenge prevailing misconceptions, to present guides formulated by the working group, and to show examples of good practices in hospitals, since facilitating the visibility of the results of new procedures leads to higher probabilities of adoption (observable results of the adoption of the change by others in Rogers’ theory).8

The goals achieved during hospitalization were usually lost after the patients were discharged. The Network's efforts have been limited to the hospital setting; the outpatient setting is beyond the scope of the Network. Appropriate follow-up has been demonstrated to be a key factor in maintaining tobacco abstinence after discharge. Thus, the Network and the Catalan Government designed a new program to ensure effective follow-up: all inpatients motivated to maintain their abstinence after discharge are offered intensive cognitive-behavioral therapy with one year follow up and free smoking-cessation drugs during outpatient treatment. This strategy implies high levels of coordination and consistency among settings, as well as brief waiting periods between discharge and the first outpatient visit. The program has been progressively implemented, initially on a small scale (trialability in Rogers’ theory).8 Acute patients units, Detoxification units and Dual Disorders units participated in the program. Preliminary results on 197 patients from 11 hospitals, all highly motivated to maintain the smoking cessation post-discharge, resulted in 41% abstinence at first month, 24% at three months, 15% at six months and 7% at 12 months after discharge (Ballbè M, Antón L, Fernández E. El Programa PDT-sm. Barcelona: Annual meeting of the Catalan Network of Smoke-free Hospitals. Personal communication, November 23rd; 2015).

In the context of an integrative service model, the challenge of this program is to enhance collaboration and coordination of the hospital with other levels of the National Health Service that provide outpatient treatment.