All providers of mental health services are in a unique position to provide tobacco cessation interventions due to expertise in behavior change and interpersonal counseling.
Who are Mental Health Professionals?
Mental health professionals include psychiatrists, psychologists, psychiatric nurses, social workers, licensed therapists, addiction counselors, and other licensed counselors.1
Screening for Tobacco Use and Dependence
Screening for tobacco use and dependence is one of the most important first steps for mental health professionals in the treatment of their patients’ tobacco dependence. Screening is simple, takes only a few minutes, and allows mental health professionals to better understand the overall health of their patients.
Unfortunately, many mental health professionals do not currently screen their patients for tobacco use and dependence.2 During outpatient physician visits, among patients who were identified as current tobacco users, only 20.9% received tobacco cessation counseling and 7.6% received tobacco cessation medication.3 Psychiatric inpatient hospitals have lower rates of smoking bans compared to US general hospitals.4
Only 4-7% of unaided quit attempts are successful, but this success rate can be significantly enhanced through the use of smoking cessation aids as more providers screen clients, discuss tobacco use and support for quitting with their clients.5
For more information on screening, go to the page on Screening, Brief Intervention, Referral, and Treatment (SBIRT).
Treating Tobacco Use and Dependence (TTUD)(9)
31.6% of individuals with mental illness smoke cigarettes compared with 13.7% of the general population.6 They make up roughly 35% of cigarette smokers and account for 38% of all U.S. adult cigarette consumption.7 They also tend to smoke more cigarettes per day. Therefore, mental health professionals should have resources available to provide smoking cessation interventions.8
Treating Tobacco Use and Dependence (TTUD9, a clinical practice guideline, was published to assist clinicians in implementing effective tobacco cessation interventions. This guideline recommends that all clinicians should have a systematic routine for identifying smokers.
There are five steps involved in providing a minimal intervention, called the "5 A's":
These are explained individually in detail on our Brief Interventions page. Despite the introduction of the TTUD9, studies have shown that these recommendations have not been widely implemented by psychologists.9
Resources: The Smoking Cessation Leadership Center, a national program office of the Robert Wood Johnson Foundation, provides some resources to help mental health professionals promote the use of smoking cessation interventions among colleagues.
Types of Interventions
For more information on the treatment of tobacco dependence in individuals who have mental illness, please visit our other page on co-occurring mental illness.
Brief interventions are short discussions with patients about their tobacco use and dependence in order to encourage them to quit smoking and equip them with necessary resources. They take around 5-15 minutes. In two studies comparing brief interventions to prolonged interventions, brief interventions were found to be more cost effective than prolonged interventions, but had lower smoking cessation rates than the individuals who underwent prolonged interventions.10,11 However, less than 25% of mental health counselors scheduled follow-ups to smoking cessation interventions with their patients.12 Following up with the individual after the brief intervention is important to enhance effectiveness (see Psychosocial Interventions page).
Similar to screening, only a minority of mental health professionals currently carry out brief interventions with their smoking patients.13 The recommended approach is the 5 A’s method, which is described in detail on our Brief Interventions page.
Prolonged interventions include multiple counseling and assessment sessions with a mental health professional and are usually combined with bupropion or nicotine replacement treatment (NRT).14 A meta-analysis of smoking cessation in individuals with severe mental illness (SMI) found that bupropion combined with group therapy is one of the most effective smoking cessation treatments for this subpopulation.14 Prolonged interventions are more effective than other interventions (i.e., brief interventions and self-help materials), but inherently require a longer time commitment from mental health professionals conducting the prolonged interventions.
For more information on different forms of psychosocial interventions, visit our Psychosocial Interventions page.
A meta-analysis done by the TTUD9 found:
Patients who had 31-90 minutes of contact in smoking cessation interventions were about 200% more likely to remain abstinent from smoking than patients who had no contact minutes, 9
Patients who only had 4-30 minutes of contact were 90% more likely to remain abstinent from smoking compared to the no contact patients.9
Patients who had undergone high intensity counseling (more than 10 minutes) were 130% more likely to remain abstinent from smoking than patients who had no contact,9
Patients who underwent low-intensity counseling (3-10 minutes) were about 60% more likely to remain abstinent from smoking than the no-contact patients.9
Patients who had undergone more than 8 person-to-person sessions of smoking cessation therapy were 130% more likely to remain abstinent than patients who had undergone 0-1 sessions of therapy.9
In another study of individuals with mental disorders, patients who attended 10 sessions of therapy were significantly more likely to quit smoking than those who attended at least one session but less than 10 sessions of therapy, at the 12-month follow-up point.15 Also, among the participants who attended all 10 sessions but did not quit smoking, the number of cigarettes smoked per day significantly decreased and their motivation for quitting smoking remained high at the 12 month follow-up point (84% of remaining smokers wanted to quit smoking).15
Barriers to Success
In a study of mental health counselors’ perceptions of smoking cessation, about 30% of the counselors reported not being trained in smoking cessation skills as a barrier to their involvement in patients’ tobacco dependence. Counselors who rated themselves as well prepared were significantly more likely to use the recommended 5 A’s approach than counselors who did not rate themselves as prepared.11
Mental Health Staff’s Personal Smoking Habits
Smoking is prevalent among mental health professionals. As a result, mental health professionals’ own smoking habits affect their attitudes towards the smoking habits of their patients.16,17
In a study with 871 mental health care providers, 282, or 22%, were current smokers. They also found that these providers do not provide optimal smoking cessation support to their clients. The providers who had never smoked or had quit smoking were more confident in addressing client smoking. Providers who had more experience working in the mental health field were also more likely to engage their clients in tobacco-related interventions.18
Myth: A smoking ban would not be beneficial to my patients or my mental health facility.
Research shows that smoking cessation interventions and policies benefit both individual patients and those working and interacting with them in mental health settings. Smoking bans are beneficial to the motivation and smoking habits of patients.18,20
Patients at a psychiatric hospital where a smoking ban was implemented (without additional smoking cessation interventions) felt significantly more likely to be successful in quitting smoking and felt that they would be better able to stay quit after their hospitalization.18 Furthermore, patients smoked significantly fewer cigarettes per day three months after their hospitalization than before hospitalization.18
One study found that while 67% of psychiatric staff (both clinical and non-clinical) support a smoking ban, 71% of staff responded that they did not feel a smoking ban would increase the quality of care given and 72% of staff felt that patients would continue to smoke despite the smoking ban.18,20
For more Myths on Smoking Cessation in the Mental Health Population visit our Common Myths about Smoking page.
Fax to Assist If you are employed by a HIPAA-covered facility, please consider joining our Fax to Assist Program.
Did you know that the Medicaid population is significantly more likely to use tobacco than the general population? Do you want to enhance your skills at reaching and intervening with Medicaid patients who use tobacco? MDQuit has an online training to teach you the strategies that can be utilized will all patients—regardless of their health insurance status. You can sign-up for this FREE self-paced online training by going to https://HABITSLabTraining.litmos.com/self-signup/ (link is external) and entering the training code, "medicaid".
1 Types of Mental Health Professionals. (2020, April). Retrieved July 28, 2020, from https://www.nami.org/About-Mental-Illness/Treatments/Types-of-Mental-Health-Professionals
2. CD;, S. (2010). Confronting a Neglected Epidemic: Tobacco Cessation for Persons With Mental Illnesses and Substance Abuse Problems. Retrieved June 18, 2020, from https://pubmed.ncbi.nlm.nih.gov/20001818/(link is external)
3. Ahmed, J. (2012, June). Tobacco Use Screening and Counseling During Physician Office Visits Among Adults - National Ambulatory Medical Care Survey and National Health Interview Survey, United States, 2005–2009. Retrieved June 18, 2020, from https://www.cdc.gov/mmwr/preview/mmwrhtml/su6102a7.htm(link is external)
4. G, O., & L, S. (2015, October). Smoking Ban Implementation in Psychiatric Inpatient Hospitals: Update and Opportunity for Performance Improvement. Retrieved June 18, 2020, from https://austinpublishinggroup.com/family-medicine/fulltext/jfm-v2-id1039...(link is external)
5. Fiore MC, Jaen CR, Baker TB, Bailey WC, Benowitz N, et al. 2008. Treating Tobacco Use and Dependency: 2008 Update Practice Guideline. Rockville, MD: US Dep. Health Hum. Serv. Public Health Serv. 179 pp.
6. Centers for Disease Control and Prevention. Current Cigarette Smoking Among Adults in the United States. Retrieved from https://www.cdc.gov/tobacco/data_statistics/fact_sheets/adult_data/cig_s(link is external)...(link is external). [accessed 2020 April 17].
7.. Centers for Disease Control and Prevention. National Center for Health Statistics. National Health Interview Survey, 2017. Analysis performed by the American Lung Association Epidemiology and Statistics Unit using SPSS software.
8.. D’Mello DA, Bandlamudi GR, Colenda CC. 2001. Nicotine replacement methods on a psychiatric unit. Am. J. Drug Alcohol Abuse 27:525–29
9. Tobacco Use and Dependence Guideline Panel. Treating Tobacco Use and Dependence: 2008 Update. Rockville (MD): US Department of Health and Human Services; 2008 May. Available from: https://www.ncbi.nlm.nih.gov/books/NBK63952/
10 Heather, N. (1989). Psychology and brief interventions. British Journal Of Addiction, 84(4), 357-370.
11 Sawa, M., Selvaraj, M., Brown, R., Parker, P., & Meehan, J. (2011). Brief interventions and referrals on smoking cessation. Mental Health Practice, 14(9), 30-33.
12 Sidani, J. E., Price, J. H., Dake, J. A., Jordan, T. R., & Price, J. A. (2011). Practices and Perceptions of Mental Health Counselors in Addressing Smoking Cessation. Journal Of Mental Health Counseling, 33(3), 264-282.
13 Solty, H., Crockford, D., White, W. D., & Currie, S. (2009). Cigarette Smoking, Nicotine Dependence, and Motivation for Smoking Cessation in Psychiatric Inpatients. (English). Canadian Journal Of Psychiatry, 54(1), 36-45.
14. Banham, L., & Gilbody, S. (2010). Smoking cessation in severe mental illness: what works?. Addiction, 105(7), 1176-1189.
15. Ashton, M., Miller, C. L., Bowden, J. A., & Bertossa, S. (2010). People with mental illness can tackle tobacco. Australian & New Zealand Journal Of Psychiatry, 44(11), 1021-1028.
16 Dwyer, T., Bradshaw, J., & Happell, B. (2009). Comparison of mental health nurses' attitudes towards smoking and smoking behaviour. International Journal Of Mental Health Nursing, 18(6), 424-433.
17. Johnson, J., Malchy, L., Ratner, P., Hossain, S., Procyshyn, R., Bottorff, J., . . . Schultz, A. (2009, April 23). Community mental healthcare providers' attitudes and practices related to smoking cessation interventions for people living with severe mental illness. Retrieved July 28, 2020, from https://www.sciencedirect.com/science/article/abs/pii/S0738399109000858
18 Shmueli, D., Fletcher, L., Hall, S. E., Hall, S. M., & Prochaska, J. J. (2008). Changes in psychiatric patients' thoughts about quitting smoking during a smoke-free hospitalization. Nicotine & Tobacco Research, 10(5), 875-881.
19 Benefits of Quitting. (2020, April 28). Retrieved July 28, 2020, from https://www.cdc.gov/tobacco/quit_smoking/how_to_quit/benefits/index.htm
20 Smokefree Policies Improve Health. (2018, January 17). Retrieved July 28, 2020, from https://www.cdc.gov/tobacco/data_statistics/fact_sheets/secondhand_smoke/protection/improve_health/index.htm
21 Lawn, S., & Campion, J. (2013). Achieving smoke-free mental health services: lessons from the past decade of implementation research. International journal of environmental research and public health, 10(9), 4224–4244. https://doi.org/10.3390/ijerph10094224
22 Wye, P., Bowman, J., Wiggers, J., Baker, A., Knight, J., Carr, V., & ... Clancy, R. (2010). Total smoking bans in psychiatric inpatient services: a survey of perceived benefits, barriers and support among staff. BMC Public Health, 10372-382.
23 Prochaska, J. J., Hall, S. M., Tsoh, J. Y., Eisendrath, S., Rossi, J. S., Redding, C. A., & ... Gorecki, J. A. (2008). Treating Tobacco Dependence in Clinically Depressed Smokers: Effect of Smoking Cessation on Mental Health Functioning. American Journal Of Public Health, 98(3), 446-448.
24 Morris, C., Waxmonsky, J., May, M., Tinkelman, D., Dickinson, M., & Giese, A. (2011). Smoking Reduction for Persons with Mental Illnesses: 6-Month Results from Community-Based Interventions. Community Mental Health Journal, 47(6), 694-702.
25 Chisolm, M., Brigham, E., Lookatch, S., Tuten, M., & Strain, E. (2010, October). Cigarette smoking knowledge, attitudes, and practices of patients and staff at a perinatal substance abuse treatment center. Retrieved July 28, 2020, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2937089/
26 Prochaska, J. (2017, March). Smoking, Mental Illness, and Public Health. Retrieved July 28, 2020, from https://www.annualreviews.org/doi/full/10.1146/annurev-publhealth-031816...