9A.3People with substance use and mental disorders

Last update:  May 2022

Suggested citation: Greenhalgh, EM, & Scollo, MM. 9.A.3 People with mental illness. In Scollo, MM and Winstanley, MH [editors]. Tobacco in Australia: Facts and issues. Melbourne: Cancer Council Victoria; 2022. Available from: http://www.tobaccoinaustralia.org.au/chapter-9-disadvantage/in-depth/9a-3-people-with-substance-use-and-mental-disorders

In Australia, while the prevalence of smoking is declining in the overall community, it remains higher among people with mental illness.1 Compared to both the overall population and to people without mental illness, people with recent mental illness have higher smoking rates, higher levels of nicotine dependence, and a disproportionate health and financial burden from smoking.2,3  

This section includes information on: 

9A.3.1 Prevalence of smoking among people with mental health problems

9A.3.2 Contribution of smoking to health outcomes and social inequality

9A.3.3 Explanations for higher smoking prevalence

9A.3.4 Barriers to be overcome when quitting

9A.3.5 Interventions for reducing smoking

9A.3.5.1 Depression

9A.3.5.2 Anxiety

9A.3.5.3 Suicidal ideation

9A.3.5.4 Attention-deficit/hyperactivity disorder (ADHD)

9A.3.5.5 Substance use disorders

9A.3.5.6 Post-traumatic stress disorder (PTSD)

9A.3.5.7 Severe mental illness, including bipolar disorder and schizophrenia

9A.3.6 The role of health professionals and health settings

9A.3.1 Trends in the prevalence of smoking

9A.3.1.1 Latest estimates of prevalence

Mental health problems are common within the Australian population: in 2019, 17% of Australians aged 18+ reported that they had been diagnosed with and or/treated for one or more mental illnesses in the past year.4

People with mental illness have a substantially higher prevalence of smoking and those who smoke tend to smoke more heavily than the overall population.4 Data from the 2019 National Drug Strategy Household Survey showed that Australian adults who reported having been diagnosed or treated for mental illness in the past year were almost twice as likely to be a current smoker than those who had not been diagnosed or treated in the past year—see Figure 9A.3.1.5 Daily smokers were twice as likely to have high/very high levels of psychological distress compared with people who had never smoked (25% and 12%, respectively) and were twice as likely to have been diagnosed or treated for a mental health condition (29% and 14%).6

Figure 9A.3.1
Smoking status among Australians aged 18+ with and without mental illness diagnosed or treated in last year, 2019

 

Source: Centre for Behavioural Research in Cancer, analysis of data from from National Drug Strategy Household Survey 2019 5
Note: ^ comprises schizophrenia, bipolar disorder, an eating disorder and other form of psychosis; ^^ comprises each of these plus anxiety and/or depression

 

Smoking prevalence tends to increase alongside the severity of the psychiatric disorder.7 For example, two Australian studies conducted 10 years apart both found that among people living with psychotic disorders, about 70% of men and 60% of women are smokers.1, 8 Results from the 2017–18 National Health Survey show a similarly high prevalence of smoking among people with mental disorders, and also show the extremely high prevalence of smoking among those with harmful use or dependence on drugs and schizophrenia-related conditions—see Figure 9A.3.2.  

 

Figure 9A.3.2 Prevalence of daily smoking by mental disorder (ICD-10 classification), Australians aged 18+, 2017–8
Source: Australian Bureau of Statistics Table Builder,9 using data from the National Health Survey 2017–1810

 

Tobacco use commonly co-exists with other drug use.11 In 2017, of the Australian secondary school students who reported having used marijuana, amphetamines, hallucinogens or ecstasy, more than one-third said that they had used tobacco concurrently (39%, 36%, 38% and 42%, respectively).12 Data from the National Drug Strategy Household Survey also shows higher prevalence of drug use among adult smokers compared to non-smokers in 2019—see Table 9A.3.1. Controlling for age and sex, current smokers were about six times more likely to have used marijuana in the past 12 months than non-smokers, and about four and a half times more likely to have used any illicit drug (including marijuana) in the year prior to the survey.5

Table 9A.3.1
Past year use of other drugs among current smokers‡ and non-smokers#: by sex for Australians aged 18+ years, 2019 (%)

‡ Smoked daily, weekly or less than weekly
# Includes ex-smokers and never smokers (never smoked 100 cigarettes (manufactured and/or roll-your-own) or the equivalent amount of tobacco)
Source: Centre for Behavioural Research in Cancer analysis of 2019 National Drug Strategy Household Survey data.5

 

Similarly, smoking—especially daily smoking—is much more common among adults who meet the criteria for alcohol dependence, or who report drinking in ways that could be harmful or hazardous. In 2019, compared with those at low risk, adults who reported drinking alcohol at harmful or hazardous levels were more than twice as likely to report being a daily smoker, while those who met the criteria for alcohol dependence were more than three times as likely to be a daily smoker—see Figure 9A.3.3.13

Figure 9A.3.3 Smoking status of Australian adults (18+) at risk of alcohol dependence or harmful/hazardous alcohol use (ASSIST-Lite), 2019
Source: Greenhalgh E and Scollo M. Alcohol and tobacco use in Victoria and Australia: Results from the 2019 National Drug Strategy Household Survey. Melbourne: Centre for Behavioural Research in Cancer, Cancer Council Victoria, 2021.13

 

International data also show high smoking rates among those with mental illness. Research in the US14 and the UK15, 16 has found large disparities between smoking in the overall population and among people with mental illness.

Limited data suggest that smoking appears highly prevalent among young people with diagnoses of mental illness.17, 18 Australian research in 2017 found that among young people aged 15–25 attending youth mental health services, 29% had smoked in the past week.19 An earlier Australian study found that in 2013, among young people presenting for primary mental healthcare, 23% of 12–17 year olds, 36% of 18–19 year olds, and 41% of 20–30 year olds reported daily smoking.20

People with mental illness who smoke also report high levels of consumption. US studies21, 22 have estimated that while nicotine-dependent individuals with a comorbid psychiatric disorder make up only 7.1% of the population, they consume more than one-third of all cigarettes. Australian research found that in 2019, regular smokers with mental illness smoked an average of about one extra pack per week compared to those without mental illness (117 and 98 cigarettes per week, respectively).4 Among smokers with severe mental illness, other studies indicate average daily consumption of 30 cigarettes, with a range of 5–80 per day.23, 24

9A.3.1.2 Smoking prevalence over time

While the prevalence of smoking has declined over time in the overall community, it remains high among people with mental illness.1 For example, the prevalence of smoking among Australians with psychotic disorders remained steady at about 67% between 1997 and 2010, while smoking in the total Australian population declined from 26% to 19%.1 Similarly in the US, several studies have shown growing disparities over time between smoking in the overall population and among people with high levels of psychological distress and serious mental illness.25-28 As overall smoking rates decline, those with mental illness comprise a greater proportion of the remaining smokers—see Figure 9A.3.4.29 These findings suggest that tobacco control policies and cessation interventions that have effectively reduced smoking in the overall population may not have been as effective for people with mental illness.

Figure 9A.3.4 Proportion of daily smokers aged 18+ who report mental illness, Australia, 2019
Source: Australian Institute of Health and Welfare, National Drug Strategy Household Survey 201929

 

Nonetheless, there are some encouraging trends. Several US studies have shown reductions in smoking prevalence and increased quit rates over time among people with psychological distress and some mental disorders.30-32 Australian research has found that there was a significant decrease in regular smokers—see Figure 9A.3.5—and significant increases in never smokers and in the proportion of ever-smokers who had quit among people with mental illness between 2004 and 2019.4

Figure 9A.3.5 Proportion of regular (daily or at least weekly) smokers among those with and without mental illness, Australians aged 18+, 2004–2019. Shaded areas show 95% CIs
Source: Greenhalgh EM, Brennan E, Segan C, and Scollo M. Monitoring changes in smoking and quitting behaviours among Australians with and without mental illness over 15 years. Australian and New Zealand Journal of Public Health, 2021.4

 

Data from the ABS National Health Surveys similarly suggest some declines in daily smoking prevalence among those with mental illness and substance use problems—see Figure 9A.3.6.

Figure 9A.3.6 Prevalence of daily smoking by type of condition (ICD-10 classification), Australians aged 18+, 2011–12, 2014–5 and 2017–18
Source: Australian Bureau of Statistics Table Builder,9 using data from the Australian Health Survey 2011–12,33 National Health Survey 2014–15,34 and National Health Survey 2017–1835

 

9A. 3 .2 Contribution of smoking to health outcomes and social inequality

In 2018, mental and substance use disorders were the second leading cause of Australia’s disease burden, behind cancer and equal with cardiovascular disease and musculoskeletal conditions.36 High smoking rates among people with mental illness contribute to higher levels of tobacco-caused morbidity and mortality.37 Compared with the overall population, people with mental illness have a disproportionate health and financial burden from smoking.2, 3 Australian men with mental illness live 15.9 years less and women live 12 years less than those without mental illness,38 and most of the excess morbidity and mortality is attributable to smoking-related illnesses such as cardiovascular disease, respiratory disease, diabetes, and cancer.38-40 The gap in life expectancy between those with and without mental illness has also widened over time, largely due to smoking-related diseases.38 People with mental illness who smoke are far more likely to die from their smoking than as a result of their psychiatric condition.2, 38 One study found that among people with serious mental illness, those who smoked had a reduced life expectancy of 5–7 years compared with non-smokers.41

Research in the US estimated that from 2018 to 2060, approximately 484,000 smoking-attributable deaths will occur among adults with depression, but up to 264,000 of those deaths could be avoided with comprehensive tobacco control strategies.42 Another modelling study estimated that widespread uptake of any cessation treatment (behavioural counselling, pharmacological, or combination) among patients with depression in the US would avert 32,000 deaths and result in 138,000 life-years gained by 2100.43

People with mental illness and mental health workers often perceive smoking to be helpful in relieving or managing psychiatric symptoms.7, 44 However, recent evidence suggests that the reverse is true; people who quit smoking may experience improvements in their mental health and quality of life.44, 45 Smokers with mental illness who quit report lower levels of psychological distress4 and mental health symptoms46, 47 than those who continue to smoke. Quitting smoking has a similar sized effect to taking anti-depressants on improving mental health.48

As well as contributing to poorer health outcomes, smoking can also exacerbate financial stress among people with mental illness. Research in the UK estimated that smoking pushes an estimated 130,000 people with a common mental disorder into poverty per year.49 In the US, one study found that smokers with depression were more likely than those without depression to experience financial distress and smoking-induced deprivation, with about one-third of smokers with depression foregoing essentials to pay for tobacco.50 In Australia in 2000, it was estimated that people with a psychotic illness who smoked and were in receipt of a disability support pension spent more than one-third of their pension on tobacco products. Smoking plays an important role in the cycle of poverty and disadvantage experienced by people with mental illness.51

9A.3.3 Explanations for higher smoking prevalence

The mechanisms underlying the relationship between mental health conditions and smoking are complex, and vary between disorders.52 There are a number of potential explanations for why people with mental health problems are more likely to smoke; risk factors for smoking among the overall population are experienced to a greater degree, and there are also unique factors that contribute to the higher prevalence of smoking. These include:

  • negative attitudes held by healthcare providers toward patients quitting,53 including beliefs that smoking cessation will exacerbate mental illness.7 Many mental health institutions have a strong smoking culture and have traditionally condoned and encouraged smoking, with cigarettes used by staff to build rapport, calm, reward, or punish clients.54-57
  • self-medication, such that smoking is perceived to have a beneficial effect on cognition and mood, and to relieve symptoms of mental illness such as anxiety and stress.44, 58, 59
  • the psychosocial disadvantage of many people living with mental illness,60 including lower-than-average education levels and income,54 and high levels of unemployment.61
  • social inclusion, such that smoking can be perceived as a way to fit in, cope with exclusion, and alleviate stigma among people with severe mental illness.62, 63
  • a shared genetic predisposition to smoking and mental illness.58, 64-67

The self-medication hypothesis suggests that people with mental illness smoke to ease the symptoms of depression, schizophrenia, substance abuse and other disorders, and is the most common explanation for the very high prevalence of smoking among this group.54, 68 The hypothesis has also been expanded to suggest that smoking can relieve side effects of antipsychotic medication.57 Smokers with mental illness frequently cite stress and anxiety relief as reasons for smoking,61 and many erroneously believe that smoking is helpful for relaxation.17, 19 However, results from recent studies have not supported the self-medication hypothesis69, 70 (with the exception of ADHD—see Section 9A.3.5.4). The supposed beneficial effects of smoking on stress can be largely attributed to the temporary alleviation of nicotine withdrawal symptoms, which creates the false impression that smoking is relaxing.71 However, smoking actually increases stress levels overall.7 Several studies have shown that quitting smoking is associated with reduced depression, anxiety, and stress and improved positive mood and quality of life compared with continuing to smoke among people with psychiatric disorders.44, 45

A 2015 review of smoking among people with schizophrenia concluded that, despite some enhanced performance for cognitive tasks, smoking appears to be less beneficial on schizophrenic symptomology than generally assumed, while clearly increasing the risk of cancer and other smoking-related diseases responsible for early mortality.69 Another similarly highlights the lack of evidence for favourable effects on symptoms, but substantially increased health risks among smokers with schizophrenia.66 Two more recent meta-analyses found strong evidence that smoking is in fact associated with cognitive impairment among people with schizophrenia.72, 73 Another found evidence for more severe positive symptoms but less severe extrapyramidal side effects (e.g., involuntary muscle contraction, tremors) among people with schizophrenia who smoke compared with those who do not.74 A 2015 systematic review and meta-analysis concluded that daily tobacco use is associated with increased risk of psychosis and an earlier age at onset of psychotic illness. The authors propose that smoking could have a causal role in psychosis, which further brings into question the self-medication hypothesis.75 Another systematic review and meta-analysis suggested that smoking, and prenatal smoke exposure, may be an independent risk factor for schizophrenia.76 Smoking may also increase the risk of other mental illnesses,77 including anxiety, depression,7, 78, 79 and bipolar disorder.80

Another proposed explanation for the higher rates of smoking among people with mental health problems is that they do not want to quit or try to quit. However, Australian and international research has shown that smokers with mental illness are just as likely to attempt to quit and more likely to use cessation support. Nonetheless, they appear to experience less success maintaining cessation than people without mental illness.4, 16, 81 Although treating tobacco dependence in people with mental illness is challenging, several randomised treatment trials and systematic reviews have documented that success is possible.82 Smokers with mental illness are able to quit with standard cessation approaches with minimal effects on psychiatric symptoms.83

Socio-economic status (SES) is inversely related to smoking, such that the prevalence of smoking is substantially higher among lower socio-economic groups. Mental disorders are associated with low incomes and higher levels of debt;84 thus, there is likely interplay between low socioeconomic status, mental illness, and smoking. In 2011–12, 62% of working age Australians with a mental illness were employed, compared to 80% of those without a mental illness.85 One study found that smokers with mental illness frequently smoke to combat boredom, and suggested that the higher rates of unemployment among this group may contribute to more frequent experiences of boredom and therefore smoking.61

Looking at why and how some people resist smoking despite being at-risk can also shed light on potential protective factors.86 One small study with people diagnosed with mental illness found that strong, negative attitudes to smoking as children that have persisted into adulthood, lasting associations with smoking, a clear sense of ‘self’ separate from peers from an early age, and developing a range of coping strategies and external supports not related to smoking served as protective factors from taking up smoking.86

 

9A.3.4 Barriers to be overcome when quitting

People with mental health problems face a number of unique barriers to quitting, including misperceptions regarding the safety of stopping smoking, higher levels of nicotine dependence and withdrawal, lower degree of participation in programs, misperceptions of low motivation to quit, socio-economic factors, and systematic barriers to quitting in mental healthcare settings. A systematic review identified smoking for stress management, lack of support from health and other service providers, the high prevalence and acceptability of smoking in vulnerable communities, and the maintenance of mental health as perceived barriers among those with mental illness.87 An Australian study of smoking behaviours among institutionalised psychiatric populations found systematic barriers to quitting, including cigarettes being the currency by which economic, social and political exchange took place and complex processes of reinforcement to smoke. Escape from the smoking culture of the settings appeared to be extremely difficult for clients and staff.88

There is a common misperception within mental health settings that quitting smoking interferes with recovery from mental illness, eliminates a coping strategy, and leads to decompensation in mental health functioning.82 People with mental illness also report similar concerns, which can hinder quit attempts.89 However, several major reviews have found that quitting does not lead to deterioration in symptoms of schizophrenia, depression, or severe mental illness,90, 91 and is in fact associated with improvements in mental health among people with psychiatric disorders.44, 45 Smoking cessation also does not exacerbate anxiety or PTSD symptoms, or lead to psychiatric hospitalisation or increased use of alcohol or illicit drugs.55, 92 Indeed, smoking cessation interventions during addictions treatment appear to enhance rather than compromise long-term sobriety.93 Two studies examining whether the treatment of ADHD can enhance response to smoking cessation intervention found no association overall between abstinence and change in ADHD symptoms,94, 95 and another found that quitting can reduce anxiety and depressed mood in smokers with ADHD.96  Quitting is also associated with a decreased likelihood of suicide attempt.97 Lifetime history of major depression does not appear to be an independent risk factor for failure in smoking cessation treatment.98  

Another common misperception is that people with mental illness do not want to quit, which can lead to a lack of encouragement and support to do so.99 A review of smoking cessation in inpatient psychiatry settings found that it is rare or often delayed.100 A study of mental health centres found that the most common barrier to staff implementing smoking cessation treatment was a perceived lack of patient interest in quitting.101 Although the co-presence of mental illness can make quit attempts more challenging102 and less successful,103 smokers with mental disorders are motivated to quit.4, 104 Studies involving patients recruited from outpatient and inpatient psychiatric settings suggest that they are just as likely as the overall population to want to quit smoking.55

Further, contrary to common beliefs, greater psychiatric symptoms have been shown to predict greater, not lesser, motivation to quit smoking.105 In British surveys, about half of smokers with mental illness have expressed an interest in quitting when asked.106 In the US, 20–25% of smokers with mental illness report that they intend to quit smoking in the next 30 days, and another 40% say they intend to do so in the next six months.82 Another population-level study in the US found that smokers with mental illness were more likely than those without mental illness to attempt quitting, and just as likely to use cessation treatment.107 Inpatients with mental health disorders appear to be no less motivated to stop smoking than those without mental health disorders and their use of NRT during hospitalisation is similar.108 One Victorian study of consumers at a psychiatric disability rehabilitation and support service found that while smoking rates were almost four times higher than the total population, there was high interest in quitting and cutting down.109 US research found that, among a sample of women with PTSD symptomatology and serious mental illness, readiness and intention to quit smoking was high.110 Smokers with mental illness cite similar reasons for wanting to quit as the overall population. For example, one study found that health concerns (73%), cost (71%), advice from a doctor (54%), and advice from others (64%) prompted a desire to quit, while social support from family and friends (58%), direction from a doctor (46%), use of NRT (31%), and the advice of friend who had quit (23%) were factors that enabled quitting.111  

9A.3.5 Interventions for reducing smoking

Smoking has a disproportionate impact on the mental and physical health of people with mental illness, therefore treating nicotine dependence should be a high priority and form part of routine care.7 However, progress in the development of cessation treatments for people with mental health problems has traditionally been slow, in part because smokers with a current mental disorder have been excluded from most smoking cessation trials.112, 113 Given the growing body of evidence showing that quitting is typically not detrimental to psychiatric symptoms and, in fact, appears to improve mental health and wellbeing,44, 45, 114 cessation should be encouraged and supported among smokers with comorbid mental disorders as it is among smokers in the overall population.52 However, as with any other stressor, the stress of cessation could temporarily affect symptoms;55 therefore, monitoring of patients’ psychiatric status during the quitting process is warranted.52, 115 Nonetheless, people with a mental illness should be offered the same smoking cessation interventions that have been shown to be effective in the overall population,115, 116 with optimal treatment comprising a combination of behavioural counselling and NRT/pharmacotherapy.117, 118 Smokers with chronic mental illness can successfully quit with standard cessation approaches, and longer maintenance on pharmacotherapy can reduce the typically high rates of relapse without detrimental effects on psychiatric symptoms.83 Smokers with mental illness are as motivated to quit as those without mental illness,4 and despite lower overall success rates, can quit successfully.104  Integrating tobacco cessation interventions into routine mental health treatment, and providing more intensive intervention when required, forms an important part of reducing the large health disparities between those with and without a mental health problem.7, 52

An important consideration in treating nicotine dependence is the impact of smoking on psychiatric treatment. Smoking complicates the treatment and course of psychiatric disorders through its profound effect on the metabolism of pharmacotherapies, and is therefore one of the factors that leads to individual differences in drug responses.52 For example, smoking can interfere with the medications taken for schizophrenia and depression, therefore the doses of some psychotropic medications may need to be decreased following cessation.116, 119 Patients with mental illness can be offered the same cessation medications as the overall population,120 but should be monitored closely. The typically higher levels of nicotine dependence among smokers with mental illness mean that larger doses of NRT, combination pharmacotherapy, and a longer duration of therapy may be necessary.7 Several Australian studies have supported the effectiveness of integrated cessation interventions in community mental health settings.121, 122 Integrating cessation into mental healthcare can increase screening for smoking and the provision and uptake of cessation advice and support.123-125 Australian research has also found that cessation support after discharge from an inpatient psychiatric facility was effective in encouraging quit attempts and reducing cigarette consumption up to 6 months post-discharge.126

In Australia, Quitline is the most accessible behavioural intervention, and research has shown that such services can have positive impacts on smoking cessation among people with mental illness127 and are just as effective as face-to-face interventions.128 Many quitline services offer coordinated care with clinicians, and some have introduced monitoring of nicotine withdrawal symptoms and common medication side-effects for people with mental illness.129 However, although use of quitlines is more common among smokers with mental illness in Australia than among those without, they are underutilised.4 Interviews with Australian smokers with mental illness revealed that many held negative perceptions about the usefulness of Quitline, highlighting that strategies may be needed that raise awareness about the service.130 Other Australian research has shown that targeted videos providing smoking cessation information and advice to smokers with mental illness can be well-received and increase knowledge about quitting.131

9A.3.5.1 Depression

Compared to people without depression, people with depression are about twice as likely to be smokers, and are less likely to succeed in quit attempts.132, 133 Smokers also have significantly higher rates of lifetime depression.52  Compared to those without depression, smokers with depression are more nicotine dependent, more likely to suffer from negative mood changes after nicotine withdrawal, more likely to relapse, and experience disproportionate morbidity and mortality from smoking-related disease.132 Evidence suggests that major depression may be a risk factor for progression of nicotine dependence.134 Depression is also related to psychosocial characteristics that make it more difficult to stop smoking, for example, lower self-esteem and self-efficacy for quitting, and greater likelihood of unemployment, poorer social support networks and poorer physical health.135  

Findings from the Four Country (Canada, US, UK, and Australia) International Tobacco Control Study showed that smokers with depressive symptoms or diagnosis make more quit attempts than people without depression, but they were also more likely to relapse in the first month.136 Despite this, meta-analyses suggest that a lifetime history of major depressive disorder, in itself, does not predict failure to quit smoking.98 A 2015 review of depression and smoking concluded that: depressed smokers are motivated to quit; smoking cessation does not exacerbate symptoms of depression; depression does not have a negative impact on smoking cessation outcomes; and the self-medication hypothesis does not account for tobacco dependence and depression co-morbidity.137 Indeed, a growing body of evidence supports the beneficial role of quitting in reducing depression.44, 138

A meta-analysis of treatment trials in smokers with depression published in 2010 concluded that NRT was more effective than placebo, and that adding behavioural mood management to cessation counselling improved treatment outcomes.  Notably, only three trials included smokers with current depression, therefore the findings were most relevant to smokers with a history of depression.139 A 2013 Cochrane review evaluated the effectiveness of smoking cessation interventions in smokers with current or past depression. It concluded that adding a psychosocial mood management component to a standard smoking cessation intervention increases long-term cessation rates in smokers with both current and past depression when compared with the standard intervention alone. Bupropion was beneficial for smokers with a history of depression, but there was a lack of evidence regarding its use with smokers with current depression. There was not enough evidence regarding the effectiveness of other antidepressants for quitting in current or past depression, nor for the effectiveness of standard smoking treatments that do not target depression, such as nicotine replacement therapy and psychosocial smoking cessation interventions.132 A placebo controlled trial published in 2013 found that varenicline significantly increased continuous abstinence among people with depression up to a year, without exacerbating depression or anxiety.140 Another RCT similarly supported the use of varenicline for smoking cessation among people with depression. While bupropion, NRT, and combination bupropion and NRT were also effective, varenicline led to superior abstinence rates.141 A 2017 systematic review and meta-analysis concluded that smoking cessation interventions, particularly pharmacological treatments, appear to increase short-term and long-term smoking abstinence in individuals with current depression.138 A systematic review published in 2021 concluded that:

  • For smokers with current major depressive disorder, nicotine patch, varenicline, and staged care intervention (i.e., combined behavioural counselling, NRT, and bupropion) were more effective than placebo
  • For smokers with current depressive symptoms, nicotine gum was more effective than placebo, and fluoxetine plus nicotine was more effective than fluoxetine alone
  • For smokers with severe current depressive symptoms, nicotine inhaler plus fluoxetine and naltrexone were more effective than placebo.142

A recent review also notes that there appears to be a reduction in the concentration of serum levels of common anti-depressants (fluvoxamine, duloxetine, trazodone and mirtazapine) in people who smoke, which likely necessitates careful choice and adaptation of medications based on smoking and smoking cessation.119

9A.3.5.2 Anxiety

Among people with anxiety disorders, smoking rates appear to range from 31.5% for people with social phobia to 54.6% for people with generalised anxiety disorder.143 Obsessive-compulsive symptoms are also associated with tobacco dependence severity and greater withdrawal symptoms during quit attempts.144 Despite the high rates of smoking among those with anxiety disorders, and evidence showing that they are motivated to quit,145 there is a dearth of evidence regarding effective cessation interventions for this population.52  A randomised controlled trial published in 2011 found that anxiety diagnoses were common among treatment-seeking smokers and were related to increased motivation to smoke, elevated withdrawal, lack of response to pharmacotherapy, and impaired ability to quit smoking.146 Another study found that smokers with social anxiety disorder experienced higher levels of craving and urge to smoke during quit attempts, which could explain their worse cessation outcomes. Such smokers would likely benefit from additional treatment aimed at managing or reducing their social anxiety symptoms, and NRT also seemed to help alleviate the relationship between social anxiety and cravings.147

A subgroup analysis of a large randomised controlled trial examining the effectiveness of pharmacotherapies for smoking cessation in people with anxiety disorders found that they were more likely than those without psychiatric illness to experience neuropsychiatric adverse events during quit attempts, regardless of treatment. Nonetheless, findings supported the use of varenicline for cessation in those with generalised anxiety disorder and panic disorder, and the use of NRT for those with panic disorder.148 Another paper from the same trial reported that varenicline, bupropion, and nicotine patch are well tolerated and effective in adults with anxiety disorders. Varenicline showed greater effectiveness than bupropion, NRT, and placebo, and combination bupropion and NRT was more effective than placebo.141

9A.3.5.3 Suicidal ideation

Smoking is associated with suicidal ideation, suicide plan, suicide attempt, and suicide death,149, 150 but this association is reduced when a person quits.97 Among people with psychosis, one study estimated that smoking contributed to 21% of suicidal behaviours;151 reducing consumption may also reduce suicidality in this population.151 Smoking is also associated with suicide attempts among people with bipolar disorder.152 Researchers have suggested that smoking should be routinely screened for among people with suicidal ideation.150, 153

9A.3.5.4 Attention-deficit/hyperactivity disorder (ADHD)

ADHD is one of the most common psychiatric disorders, and is associated with a wide range of impairments and risks into adulthood.154 Smoking is one such risk, with young people with ADHD beginning smoking earlier, and being two to three times more likely to smoke, compared to those without ADHD. The substantially higher prevalence of smoking persists into adulthood, and adults with ADHD are also less likely to be successful at quitting.155-157 The risk of smoking also increases with the severity of symptoms.158, 159

There is a growing body of evidence that stimulant medication, which is a front-line treatment of ADHD, may influence smoking-related outcomes.155  Nicotine and stimulant medications operate on the same pathways in the brain, and both appear to help alleviate some of the symptoms of ADHD, which may help explain the very high rates of smoking among this group.160 Research has shown that nicotine is experienced as more pleasurable as reinforcing among young people with ADHD.161 ADHD medication (i.e., stimulant treatment) reduces smoking rates and smoking withdrawal, therefore early and consistent stimulant treatment of ADHD may reduce smoking risk.155, 162-164 Bupropion, NRT, and possibly varenicline—approved smoking cessation medications—have also shown efficacy in treating symptoms of ADHD;162, 165 however, further research is needed to examine its effectiveness in treating comorbid ADHD-smoking.52 One RCT found that varenicline reduced smoking and withdrawal in smokers with ADHD with high, but not low, hyperactivity/impulsivity symptoms.166 Non-pharmacological interventions, particularly cognitive-behavioural therapy, also show promise for the treatment of ADHD, and warrant further investigation for supporting cessation among this population.52 Limited evidence also suggests that financial incentives may be a useful approach for promoting short-term cessation in adult smokers with ADHD.167

9A.3.5.5 Substance use disorders

Smoking prevalence among people with substance use disorders is substantially higher than the overall population.11, 21, 31, 168-175 People with substance or alcohol use disorders also have greater nicotine dependence, lower quitting, and differences in quit attempts and withdrawal symptoms compared with people without such disorders.176 Many people who successfully overcome their substance use disorder will go on to die from a smoking-related disease.177 An Australian study examining alcohol misuse among smokers found that smokers were 3.8-fold more likely to have a higher level of alcohol consumption than non-smokers.178 Many health risks for dual use of alcohol and tobacco are multiplicative rather than simply additive. For example, the risk of oesophageal cancer is greater among heavy alcohol users as a result of alcohol allowing tobacco toxins to penetrate more deeply to basal layers.179 Similarly, there is evidence that smoking cannabis is a risk factor for many of the same illnesses as tobacco.180-182 Cannabis poses unique problems for users since it is often mixed with tobacco, potentially inducing double dependence. In 2019, 34% of smokers in Australia reported recent use of cannabis, compared to 8% of non-smokers.5

Treatment centres for substance use disorders have traditionally not prioritised treating nicotine addiction due to lack of staff training, lack of integration into usual care, and because of the common misperception that quitting may be detrimental to the treatment of alcohol or other drug use.183-185 Substance abuse counsellors often have limited knowledge of the smoking cessation medications available for those trying to quit186 and their implementation of tobacco cessation guidelines is inconsistent.187 A study of staff and management attitudes and practices in Australia found smoking received little systematic attention, with concerns about possible negative impact on other treatments, absence of policy, and lack of training being major impediments.188 Research in the US found that smokers with a substance use disorder who had undergone addiction treatment were less likely to quit smoking than those who had never received such treatment, possibly due to false beliefs about smoking as a coping strategy and staff attitudes that may discourage cessation.189 Some centres may even endorse occasional smoking by staff with clients190 or rely on cigarettes to stabilise mood in their patients.55, 191

Contrary to staff perceptions, smokers with substance use disorders are motivated to quit.192 However, despite this motivation to quit, there appears to be a wide variation in readiness to seek help to do so,55, 93, 191, 193 which may be due to a lack of confidence in or wariness of quitting multiple substances at once.193 Research in the US showed that when provided with a tobacco free treatment environment, patients with substance abuse and mental illness can and do make the decision to quit tobacco and maintain their abstinence, which in turn helps them to remain sober.194 While negative affect can hinder quit attempts, patients in an addictions treatment setting can successfully quit smoking regardless of current depressive symptoms.195 In the US, despite being lower than for people without the disorders, the smoking quit rates for people with alcohol use disorders has increased over time.31

Perhaps most importantly, smoking interventions and cessation during substance use treatment appear to enhance rather than compromise long-term abstinence from other addictive drugs.104, 196-199 Including cessation interventions in the course of addiction treatment can reduce consumption,200 increase the provision of advice to quit,201 increase use of cessation aids,170, 200, 202 and increase quit attempts among smokers.203, 204 A 2015 systematic review of smoking cessation interventions for adults in substance abuse treatment or recovery concluded that NRT, behavioural support, and combination approaches appear to increase smoking abstinence in those treated for substance use disorders. However, the authors note that higher quality studies are needed to strengthen the evidence base.205 Some research indicates that drug treatment clients can successfully quit smoking at rates similar to the overall population when given access to an intensive intervention.206 Several studies suggest that varenicline may promote smoking changes207 and concurrently help reduce heavy drinking in people with alcohol use disorders.208-211 However, use of bupropion by abstinent alcoholic smokers does not appear to increase long-term smoking cessation.212 A 2021 meta-analysis concluded that varenicline may promote smoking cessation in people with alcohol dependence, but there was no clear evidence for the use of naltrexone, topiramate or bupropion.213 For methadone maintenance patients, varenicline214 and NRT215 may be effective for promoting tobacco abstinence.

Several studies have explored the role of contingency management (i.e., financial incentives) in promoting abstinence. One study found that contingency management was associated with more short-term abstinence and lowered nicotine addiction among current and former injecting drug users.216 Several studies have supported the use of contingency management when combined with pharmacotherapies and/or behavioural counselling.217-219 Contingency management may also promote smoking reduction in more severe substance abusers, such as those in residential services and opioid-maintained patients,220-222 and also among pregnant women with substance use disorders.223 Such interventions appear to increase abstinence self-efficacy among residential substance abuse treatment patients.224 Increasing tolerance for withdrawal and abstinence discomfort, addressing expectations, and increasing motivation may also be important when implementing incentive programs.225 Other strategies include brief advice plus NRT, which appears to be a cost-effective way to reduce smoking for smokers in residential alcohol treatment,226 and an Australian study found that a group program showed promise for reducing smoking among people attending residential alcohol and other substance dependence treatment.227 Digital interventions228 and quitlines229  may also be helpful for addressing co-use of tobacco and other drugs.

As with mental health and correction services, public health experts have identified a need for policy and training initiatives to address past neglect of tobacco control issues.230, 231 Systematic intervention around the 5As framework, tailored to the needs of client groups, would provide a good foundation for this work. Factors promoting smoking cessation programs within substance abuse treatment settings include supportive systems and integration within other treatments,125 educating providers about the beneficial effects of cessation for their clients, staff training, and encouraging and assisting staff to quit.191 One study found that an intervention based on organisational change helped to shift the treatment system culture and increase tobacco services in a residential addiction treatment setting.231 Policies that mandate smoking cessation interventions as part of substance use disorder treatment can increase adoption and implementation.232

Future clinical research in this area and its translation into practice may be improved by recruiting and retaining a broader range of people with drug dependencies, particularly those who are not currently being reached through mainstream interventions, and by longer-term follow-up.233 Research as to the role of social bonding around tobacco use and its normalisation in drug treatment settings may be useful in guiding future practice.193

9A.3.5.6 Post-traumatic stress disorder (PTSD)

The prevalence of current smoking in individuals with PTSD is substantially greater than that for the overall population.234-236 A systematic review found that smokers were about twice as likely to have PTSD than non-smokers in the overall population, and more than one-third of people with PTSD were current daily smokers.234 Another review concluded that there appears to be a causal relationship between PTSD and smoking that may be bidirectional. PTSD, rather than trauma exposure itself, appears to have a greater influence on a person’s risk of smoking, and specific PTSD symptoms may contribute to smoking and disrupt cessation attempts.237 Evidence suggests that people with PTSD smoke to cope with negative affect and anxiety,83, 234, 235 and PTSD is associated with higher levels of consumption (i.e., more cigarettes smoked per day).238 Nonetheless, evidence suggests that PTSD is associated with more overall quit attempts (albeit with less success), and there has been a decline in smoking among people with PTSD over time.234

To date, there have been a small number of studies examining smoking cessation interventions in smokers with PTSD. Given their greater difficulty maintaining quit attempts, people with PTSD may benefit from more intensive and targeted interventions,235 and from proactive outreach to initiate treatment.239 A systematic review published in 2018 examined integrated, specialised treatments for comorbid smoking—PTSD, including preliminary treatment studies and RCTs in both veteran and general clinical samples. It concluded that mobile technology shows promise for providing effective, lower cost, and wide-reaching PTSD—smoking intervention. There is also evidence to support the integration of smoking cessations aids (e.g., varenicline) and smoking cessation counselling into existing PTSD treatments (i.e., prolonged exposure), particularly for people experiencing elevated PTSD symptom severity.234

9A.3.5.7 Severe mental illness

Severe mental illness, or serious mental illness (SMI), are umbrella terms that generally refer to diagnoses of bipolar disorder or schizophrenia. People with SMI generally have very high rates of nicotine dependence and smoking—between 40% and 80%—and people with SMI who smoke have poorer mental and physical health outcomes than those who do not smoke.240 Nonetheless, evidence suggests that smokers with SMI are motivated to quit and often seek help for quitting.241 A systematic review published in 2021 of cessation interventions for people with SMI concluded that it is currently unclear which interventions are most effective, including the optimal intensity, duration, and modality of treatment, due to mixed findings and methodological limitations. However, it identified common evidenced-based components across studies that supported smoking cessation and/or reduction, including cessation medications (e.g., NRT, bupropion), motivational enhancement techniques, and cessation education and skills training.240 A meta-analysis of RCTs published in 2019 concluded that varenicline is effective at 3- and 6-months for people with SMI. While bupropion and NRT showed short-term effectiveness, this was not sustained.242 The largest RCT to date examining cessation interventions for people with SMI concluded that a tailored combined pharmacological and behavioural approach was effective in supporting short- and long-term quitting.243, 244

Another review supported the effectiveness of tailored person-based smoking cessation interventions for people with SMI.245 An Australian RCT found that telephone-delivered smoking cessation support led to significant reductions in cardiovascular disease risk and smoking across 36 months among people with psychotic disorders.246 Although a number of guidelines have been developed for smoking cessation in people with severe mental illness, a review found that they varied considerably in quality, and many did not adequately describe their methods or report conflicts of interest.247

9A.3.5.7.1 Bipolar disorder

People with bipolar disorder are about three and a half times more likely to smoke than the overall population, and have much lower quit rates than smokers without a comorbid condition.248, 249 Research in the US and Europe has consistently found that the prevalence of smoking is approximately two to three times higher among people with bipolar disorder than in the overall population.52  In addition to contributing to increased morbidity and mortality, smoking has also been implicated in the progression of bipolar disorder.250  However, despite these high rates of comorbidity and related morbidity, there is only a modest field of research focusing on smoking among individuals with bipolar disorder.251 To date, there have only been a small number of clinical studies on cessation interventions among smokers with bipolar disorder. Researchers have highlighted challenges in recruitment and low eligibility rates as significant hurdles to such studies, and have noted that many health professionals remain wary of encouraging cessation among people with bipolar disorder.249 Nonetheless, recent research has attempted to address this gap.

Two very small studies found that buproprion252 and varenicline253 were well-tolerated and led to reduced smoking. Subsequent larger studies have also supported the effectiveness of varenicline. One included 247 smokers with schizophrenia or bipolar disorder. Participants received 12-week treatment with both varenicline and cognitive behavioural therapy, and those who had two weeks or more of continuous abstinence at week 12 were randomly assigned to receive cognitive behavioural therapy and varenicline or placebo from weeks 12 to 52. After a year, those treated with varenicline were more than six times more likely to be abstinent (60%) than those treated with placebo (19%). Importantly, there were no impacts on psychiatric symptoms.254 Another randomised controlled trial of varenicline included 60 smokers with bipolar disorder. At three months (end of treatment), significantly more participants quit smoking with varenicline (48.4%) than with placebo (10.3%). At six months, about 19% of those treated with varenicline remained abstinent compared to about 7% assigned to placebo. Psychopathology scores remained stable, although varenicline-treated participants reported significantly more abnormal dreams. The authors call for medication trials of longer duration, and vigilance for neuropsychiatric adverse events.255 A subgroup analysis of a large randomised controlled trial examining the effectiveness of pharmacotherapies for smoking cessation in people with bipolar disorder concluded that varenicline may be a tolerable and effective cessation treatment.256 Web-based interventions also show promise for smokers with bipolar disorder.257 An RCT examining a novel, targeted, web-based intervention based on acceptance and commitment therapy combined with nicotine patches, showed promising acceptability and effectiveness among smokers with bipolar disorder.258

9A.3.5.7.2 Schizophrenia

Schizophrenia is a chronic and severe mental illness that affects about one in 100 people.259 A meta-analysis of studies from 20 different countries found that people with schizophrenia have more than five times the odds of current smoking than the overall population.260 Smokers with schizophrenia smoke more heavily and are more nicotine dependent,261 and extract more nicotine from each cigarette.262 Tobacco-related conditions are responsible for about half of total deaths in people with schizophrenia.263 Despite wanting to quit,264 a recent meta-analysis found that the prevalence of smoking cessation was 15% in schizophrenia patients, compared with 23% in healthy controls.265 These lower success rates are partly because of the increased level of nicotine dependence among smokers with schizophrenia, and reduced access to treatments.266 People with schizophrenia also report smoking to manage stress and negative affect, and to maintain social relationships.59 They may also perceive themselves to be at lower risk of smoking related-disease.267

Healthcare services have traditionally condoned or encouraged smoking and failed to offer tobacco cessation interventions to patients with schizophrenia,59 mainly due to beliefs about the benefits of smoking to symptoms, stigma, lack of information, or perceived hopelessness regarding abstinence.268, 269 However, in recent times there has been considerable interest in developing effective smoking treatment for this population,52 particularly in light of research showing that smoking is associated with poorer clinical outcomes.270, 271 Guidelines have been published that include cessation interventions for smokers with schizophrenia,116 and studies have highlighted that early interventions with young people at risk of psychosis can be effective.272 Smokers with a psychotic disorder are capable of long-term reduction and abstinence with appropriate intervention and support.273 Once people with schizophrenia have successfully quit, the use of antipsychotics may need to be reviewed, as tobacco smoke can differentially affect drug metabolism and the effects of antipsychotic medications.7, 274  

A 2013 Cochrane review of interventions for smoking cessation and reduction in individuals with schizophrenia concluded that bupropion increases smoking abstinence rates in smokers, without any deterioration of mental state. Varenicline may also improve smoking cessation rates, but the authors noted a possibility of adverse psychiatric effects, such as increased suicidality. There is some evidence that contingent reinforcement (i.e., monetary rewards) may help people with schizophrenia to quit and reduce smoking in the short term.269 Building on the Cochrane review, a 2015 systematic review and meta-analysis concluded that while there did not appear to be any adverse psychiatric outcomes, varenicline was not found to be superior to placebo for quitting among people with schizophrenia.275 Another 2015 review of smoking cessation in people with schizophrenia concluded that the most promising evidence is for bupropion, and that pharmacological interventions do not appear to increase adverse events. It suggested that the lack of evidence for NRT and varenicline may be due to the paucity of research. Behavioural and psychosocial interventions are also promising, particularly when combined with pharmacotherapy. The authors highlight the importance of carefully monitoring antipsychotic levels, and suggest that encouraging physical activity may help to negate potential weight gain and diabetes risk following cessation.276 A further review of the evidence recommended that people with schizophrenia should receive varenicline or bupropion with or without nicotine replacement therapy in combination with behavioural treatment. Maintenance pharmacotherapy for 1 year appears to improve sustained abstinence rates.277

Results from a large randomised controlled trial were published in 2016, which found that varenicline was more effective than bupropion and nicotine patch in smokers both with and without psychiatric disorders (including schizophrenia), whereas bupropion and nicotine patch were similarly effective, and both more so than placebo. The authors also examined the safety of the medications, and concluded that they can be used safely by psychiatrically stable smokers; there was no increase in neuropsychiatric adverse events attributable to varenicline or bupropion relative to nicotine patch or placebo.120 In September 2016, the FDA released a preliminary review of this trial, suggesting a number of problems with the study. The review supported similar conclusions about the relative rates of events: in patients without prior psychiatric history, events did not seem to be more frequent in varenicline, bupropion, or NRT-treated patients than in placebo-treated patients. The review also found that among patients attempting to quit, events were more common in those with psychiatric history than those without, regardless of which treatment they received. Of concern however, was a possible increased risk of neuropsychiatric events in patients with psychiatric history in the varenicline or bupropion group compared to placebo. This trended toward statistical significance, but was not observed in NRT-treated patients.278

Additional recent randomised controlled trials,279, 280 reviews,281 and meta-analyses282-284 have supported the safety and efficacy of varenicline for reducing smoking in people with schizophrenia. A 2017 review recommends that smokers with schizophrenia should receive varenicline, bupropion with or without NRT, or NRT, all in combination with behavioural treatment for at least 12 weeks. Maintenance pharmacotherapy may reduce relapse and improve sustained abstinence rates. It notes that controlled trials in smokers with schizophrenia consistently show no greater rate of neuropsychiatric adverse events with pharmacotherapies than with placebo.285 A 2018 review concluded that varenicline appears to be an effective and safe drug for smoking cessation in patients with schizophrenia,283 and another in 2020 concluded that maintenance pharmacotherapy with varenicline and sustained-release bupropion are both well-tolerated among people with schizophrenia.286 Findings from a 2020 meta-analysis suggest that varenicline might be superior to bupropion for people with schizophrenia, but calls for more comparative/combination studies.284 Several recent reviews have also supported the effectiveness of multimodal interventions (i.e., combining pharmacological and non-pharmacological treatments) for reducing smoking among people with schizophrenia without worsening psychiatric symptoms.287, 288

There has also been some interest in the use of electronic cigarettes for smoking cessation among people with schizophrenia; however there is currently only very limited research on their efficacy.289 See Section 18B.6 for further discussion. One review notes that nicotine is likely responsible for the potential role of smoking in the onset of schizophrenia, which should be considered in discussion of e-cigarettes.290

9A.3.6 Role of health professionals and health settings

Medical and mental health professionals have traditionally overlooked the importance of addressing tobacco use with their patients.54 Smoking is often not asked about or recorded as a standard part of psychiatric assessment, and even when it is, inclusion of smoking cessation in treatment planning is often inconsistent.54, 291, 292 This may be partly due to the erroneous beliefs held by some mental health workers that smoking is one of the few pleasures clients have, that smoking reduces stress and anxiety,60, 293 that those with mental illness are not motivated to quit,99 or that there are more pressing concerns for patients with acute psychiatric symptoms.82 They may also hold fatalistic views that smoking and failed quit attempts are inevitable.63

International evidence suggests that cessation support for inpatient smokers by staff is likely to be severely compromised by low levels of knowledge and awareness of tobacco dependence.294 Several Australian surveys have found strong support for the provision of smoking cessation treatment among mental health service staff;295, 296 however staff report significant barriers to providing such care.295 Commonly cited barriers include inadequate resources, cultural norms, client resistance, and lack of training and confidence.232, 297-301 More experienced staff, and those with tobacco cessation training, are more likely to help their clients quit smoking.292, 302, 303

Healthcare professionals, including physicians, psychiatrists, and psychologists, have an important role in the recognition and treatment of tobacco use disorders in patients with psychiatric illnesses, and providing cessation treatment for all patients who smoke should form part of routine care.7, 304, 305 Australians with mental illness who smoke report that mental health professionals are a preferred and trusted source of cessation information.130 A 2015 systematic review and meta-analysis concluded that while there has been progress, offering smoking cessation advice should receive a higher priority in everyday clinical practice for patients with a mental health diagnosis.306 Encouraging longitudinal research in the US found that smokers who had seen mental health professionals for mental health problems had higher odds of having made attempts to quit in the past year, and were more likely to have used cessation assistance.307 However, another longitudinal US study looking only at psychiatrists found that they are screening for tobacco use at declining rates, and the proportion of smokers provided with treatment remains low,308 and a UK study found that smoking cessation medication prescribing appeared to be declining in primary care.309 Australian research also found that the provision of cessation interventions in acute psychiatric units is inconsistent and generally suboptimal.310

As in the overall population, people with mental illness should be given advice and support to quit using the 5As framework.311 Given that people with mental illness are often highly nicotine dependent, and are more likely to socialise with smokers, more intensive interventions may have greater success. This might involve NRT or other pharmacotherapies, as well as referral to a specialised individual program, such as the Quitline, or a group program. The integration of cessation treatment into existing care by health professionals results in greater engagement, greater use of cessation pharmacotherapy, and increased likelihood of abstinence.125, 312 An Australian study found that introducing a ’smokers’ clinic‘ to a mental health setting helped those with mental illness to reduce or quit smoking and led to a sustained increase in the delivery of cessation interventions among health professionals.121 Researchers have developed a comprehensive guide for healthcare professionals to integrate smoking cessation treatment into routine care, and note that by drawing on evidence-based methods such as behavioural support and CBT, smoking cessation can be addressed in a compassionate and respectful manner.48 Quit Victoria has suggested a number of strategies that mental health services could implement to reduce smoking-related harms, including:

  • routinely asking clients about their smoking and recording responses
  • referring clients and staff to Quitline, a doctor, or a local quit smoking program
  • establishing or reviewing smokefree policy
  • encouraging staff to complete further training in smoking cessation
  • displaying posters and print resources
  • referring staff and clients to the  Quit website for information on services and smoking care medications.313

An important part of providing smoking cessation support for those with mental health disorders is for mental health services to develop comprehensive policy on smokefree environments, documenting tobacco use, and continuing support on discharge. This requires leadership from management, staff training, and consistency across services.314-316 An audit of an Australian psychiatric hospital found that the setting did not conform to current clinical practice guidelines as it often failed to document smoking status, despite nicotine dependence being the most commonly diagnosed psychiatric disorder.317 Another Australian study of public psychiatric inpatient units found that over one-third of inpatients started smoking during their admission, and that staff often provided cigarettes to patients. Only half of respondents reported that all patients were assessed for smoking status. The study suggests that failure of psychiatric services to provide smoking care is systematic and not related to particular types of services.318

Some psychiatric services have become smokefree319 and there is evidence that hospitalisation in a smokefree environment is associated with increases in patients’ expectancies about quitting and staying a non-smoker,320 and with reduction in cigarette consumption.321 A systematic review concluded that smokefree psychiatric hospitalisation may have a positive impact on patients' smoking-related behaviours, motivation, and beliefs, both during admission and up to 3 months post discharge.322 During smokefree psychiatric hospitalisations, offering patients NRT directly on admission, educating patients on the benefits of NRT, and increasing the dosage for more dependent smokers can help with managing nicotine withdrawal.323 Community support post-discharge may also help smokers to maintain abstinence.324   Psychiatric hospitals in the US that voluntarily adopted such bans have documented little-to-no disturbance in patients’ behaviour and time savings for staff members.82 A study in France found that staff members of a psychiatric facility were exposed to substantially lower levels of secondhand smoke post-ban.325

However, an Australian study published in 2015 found that adherence to smokefree policy in an inpatient psychiatric facility was poor, with more than four in five smokers still smoking, and only about half perceiving staff to be supportive of the policy.326 Two Australian studies have found that about only about half of psychiatric patients feel positively about bans,326, 327 while another found that only about one quarter of mental health staff agreed with a total smoking ban.328 Compliance and enforcement can be challenging in the context of high smoking prevalence and complex needs of patients.329 Some patients also perceive the restrictions to be a form of punishment.330 There have been debates regarding the ethics of implementing complete smoking bans in psychiatric hospitals; proponents argue that the ‘smoking culture’ creates disproportionate harm among people with mental illness, while opponents argue that it is unethical to deprive patients of autonomy and impose treatment.331, 332

Together, evidence suggests that there is a critical need to engage healthcare providers, policy-makers, and mental health advocates in the effort to increase access to:

  • evidence-based tobacco treatment for smokers with mental health disorders
  • smokefree environments for mental health treatment
  • training for clinicians in cessation treatment
  • systems for routinely identifying patients who smoke, advising cessation and providing treatment or referral.82

References

1. Cooper J, Mancuso SG, Borland R, Slade T, Galletly C, et al. Tobacco smoking among people living with a psychotic illness: the second Australian Survey of Psychosis. Australian and New Zealand Journal of Psychiatry, 2012; 46(9):851–63. Available from: https://www.ncbi.nlm.nih.gov/pubmed/22645396 

2. Williams JM, Steinberg ML, Griffiths KG, and Cooperman N. Smokers with behavioral health comorbidity should be designated a tobacco use disparity group. American Journal of Public Health, 2013; 103(9):1549–55. Available from: https://www.ncbi.nlm.nih.gov/pubmed/23865661 

3. Forman-Hoffman VL, Hedden SL, Glasheen C, Davies C, and Colpe LJ. The role of mental illness on cigarette dependence and successful quitting in a nationally representative, household-based sample of U.S. adults. Annals of Epidemiology, 2016; 26(7):447–54. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27247163 

4. Greenhalgh EM, Brennan E, Segan C, and Scollo M. Monitoring changes in smoking and quitting behaviours among Australians with and without mental illness over 15 years. Australian and New Zealand Journal of Public Health, 2022; 46(2):223–9. Available from: https://www.ncbi.nlm.nih.gov/pubmed/34821438 

5. Australian Institute of Health and Welfare. National Drug Strategy Household Survey, 2019. ADA Dataverse, 2021. Available from: https://dataverse.ada.edu.au/dataset.xhtml?persistentId=doi:10.26193/WRHDUL 

6. Australian Institute of Health and Welfare. Data tables: National Drug Strategy Household Survey 2019 - 2. Tobacco smoking chapter, Supplementary data tables. Canberra: AIHW, 2020. Available from: https://www.aihw.gov.au/reports/illicit-use-of-drugs/national-drug-strategy-household-survey-2019/data 

7. Mendelsohn CP, Kirby DP, and Castle DJ. Smoking and mental illness. An update for psychiatrists. Australas Psychiatry, 2015; 23(1):37–43. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25512967 

8. Jablensky A, McGrath J, Herrman H, Castle D, Gureje O, et al. People living with psychotic Illness:  an Australian study 1997-98. Mental Health Branch, Commonwealth Department of Health and Aged Care, Canberra, 1999.

9. Australian Bureau of Statistics. TableBuilder. Available from: http://www.abs.gov.au/websitedbs/d3310114.nsf/home/about+tablebuilder 

10. Australian Bureau of Statistics. 4364.0.55.001 - National Health Survey: First Results, 2017-18 Available from: https://www.abs.gov.au/statistics/health/health-conditions-and-risks/national-health-survey-first-results/latest-release 

11. Baker A, Ivers R, Bowman J, Butler T, Kay-Lambkin F, et al. Where there's smoke, there's fire: high prevalence of smoking among some sub-populations and recommendations for intervention. Drug and Alcohol Review, 2006; 25:85–96. Available from: http://www.informaworld.com/smpp/content~content=a741424195~db=all~order=page 

12. Guerin N and White V. ASSAD 2017 Statistics & Trends: Australian Secondary Students’ Use of Tobacco, Alcohol, Over-the-counter Drugs, and Illicit Substances in 2017. Second Edition. Cancer Council Victoria, 2020. Available from: https://www.health.gov.au/resources/publications/secondary-school-students-use-of-tobacco-alcohol-and-other-drugs-in-2017 

13. Greenhalgh E and Scollo M. Alcohol and tobacco use in Victoria and Australia: Results from the 2019 National Drug Strategy Household Survey. Melbourne: Centre for Behavioural Research in Cancer, Cancer Council Victoria, 2021.

14. Smith PH, Chhipa M, Bystrik J, Roy J, Goodwin RD, et al. Cigarette smoking among those with mental disorders in the US population: 2012-2013 update. Tobacco Control, 2020; 29(1):29-35. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30377242 

15. Richardson S, McNeill A, and Brose LS. Smoking and quitting behaviours by mental health conditions in Great Britain (1993-2014). Addictive Behaviors, 2019; 90:14-9. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30352340 

16. Richardson S, McNeill A, and Brose LS. Smoking and quitting behaviours by mental health conditions in Great Britain (1993-2014). Addictive Behaviors, 2019; 90:14–9. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30352340 

17. DeHay T, Morris C, May MG, Devine K, and Waxmonsky J. Tobacco use in youth with mental illnesses. Journal of Behavioral Medicine, 2012; 35(2):139–48. Available from: https://www.ncbi.nlm.nih.gov/pubmed/21479646 

18. Lee J and Thrul J. Trends in opioid misuse by cigarette smoking status among US adolescents: Results from National Survey on Drug Use and Health 2015-2018. Preventive Medicine, 2021; 153:106829. Available from: https://www.ncbi.nlm.nih.gov/pubmed/34624387 

19. Brown E, O'Donoghue B, White SL, Chanen A, Bedi G, et al. Tobacco smoking in young people seeking treatment for mental ill-health: what are their attitudes, knowledge and behaviours towards quitting? Ir J Psychol Med, 2021; 38(1):30–9. Available from: https://www.ncbi.nlm.nih.gov/pubmed/32317033 

20. Hermens DF, Scott EM, White D, Lynch M, Lagopoulos J, et al. Frequent alcohol, nicotine or cannabis use is common in young persons presenting for mental healthcare: a cross-sectional study. BMJ Open, 2013; 3(2):e002229. Available from: https://www.ncbi.nlm.nih.gov/pubmed/23381649 

21. Lasser K, Boyd JW, Woolhandler S, Himmelstein DU, McCormick D, et al. Smoking and mental illness: A population-based prevalence study. Journal of the American Medical Association, 2000; 284(20):2606–10. Available from: https://www.ncbi.nlm.nih.gov/pubmed/11086367 

22. Grant BF, Hasin DS, Chou SP, Stinson FS, and Dawson DA. Nicotine dependence and psychiatric disorders in the United States: results from the national epidemiologic survey on alcohol and related conditions. Arch Gen Psychiatry, 2004; 61(11):1107–15. Available from: https://www.ncbi.nlm.nih.gov/pubmed/15520358 

23. Ashton M, Miller CL, Bowden JA, and Bertossa S. People with mental illness can tackle tobacco. Australian and New Zealand Journal of Psychiatry, 2010; 44(11):1021–8. Available from: https://www.ncbi.nlm.nih.gov/pubmed/21034185 

24. Baker A, Richmond R, Haile M, Lewin TJ, Carr VJ, et al. Characteristics of smokers with a psychotic disorder and implications for smoking interventions. Psychiatry Res, 2007; 150(2):141–52. Available from: https://www.ncbi.nlm.nih.gov/pubmed/17289155 

25. Lawrence D and Williams JM. Trends in smoking rates by level of psychological distress-time series analysis of US national health interview survey data 1997-2014. Nicotine & Tobacco Research, 2016; 18(6):1463–70. Available from: https://www.ncbi.nlm.nih.gov/pubmed/26705303 

26. Steinberg ML, Williams JM, and Li Y. Poor mental health and reduced decline in smoking prevalence. American Journal of Preventive Medicine, 2015; 49(3):362–9. Available from: https://www.ncbi.nlm.nih.gov/pubmed/26071864 

27. Weinberger AH, Gbedemah M, Wall MM, Hasin DS, Zvolensky MJ, et al. Cigarette use is increasing among people with illicit substance use disorders in the United States, 2002-14: emerging disparities in vulnerable populations. Addiction, 2018; 113(4):719–28. Available from: https://www.ncbi.nlm.nih.gov/pubmed/29265574 

28. Dickerson F, Schroeder J, Katsafanas E, Khushalani S, Origoni AE, et al. Cigarette smoking by patients with serious mental illness, 1999-2016: An increasing disparity. Psychiatric Services, 2018; 69(2):147–53. Available from: https://www.ncbi.nlm.nih.gov/pubmed/28945183 

29. Australian Institute of Health and Welfare. National Drug Strategy Household Survey 2019. Drug Statistics series no. 32 Cat. no. PHE 270 Canberra: AIHW, 2020. Available from: https://www.aihw.gov.au/getmedia/3564474e-f7ad-461c-b918-7f8de03d1294/aihw-phe-270-NDSHS-2019.pdf.aspx?inline=true 

30. Kulik MC and Glantz SA. Softening among US Smokers with psychological distress: More quit attempts and lower consumption as smoking drops. American Journal of Preventive Medicine, 2017; 53(6):810–7. Available from: https://www.ncbi.nlm.nih.gov/pubmed/29029966 

31. Weinberger AH, Gbedemah M, and Goodwin RD. Cigarette smoking quit rates among adults with and without alcohol use disorders and heavy alcohol use, 2002-2015: A representative sample of the United States population. Drug and Alcohol Dependence, 2017; 180:204–7. Available from: https://www.ncbi.nlm.nih.gov/pubmed/28918239 

32. Han B, Volkow ND, Blanco C, Tipperman D, Einstein EB, et al. Trends in prevalence of cigarette smoking among US adults with major depression or substance use disorders, 2006-2019. Journal of the American Medical Association, 2022; 327(16):1566–76. Available from: https://www.ncbi.nlm.nih.gov/pubmed/35471512 

33. Australian Bureau of Statistics. 4364.0.55.001 - Australian Health Survey: First Results, 2011–12. 2012. Available from: http://www.abs.gov.au/ausstats/abs@.nsf/lookup/4364.0.55.001main+features12011-12 

34. Australian Bureau of Statistics. 4364.0.55.001–National Health Survey: First Results, 2014–15  Available from: http://www.abs.gov.au/ausstats/abs@.nsf/Lookup/by%20Subject/4364.0.55.001~2014-15~Main%20Features~Key%20findings~1 

  35. Australian Bureau of Statistics. National Health Survey 2017–18: First results.  2018. Available from: https://www.abs.gov.au/statistics/health/health-conditions-and-risks/national-health-survey-first-results/2017-18

36. Australian Institute of Health and Welfare. Australian Burden of Disease Study 2018: key findings. Australian Burden of Disease Study series 24. Cat. no. BOD 30, Canberra: AIHW 2021. Available from: https://www.aihw.gov.au/reports/burden-of-disease/burden-of-disease-study-2018-key-findings/contents/key-findings 

37. Lawrence D, Holman C, and Jablensky A. Duty to Care.  Preventable physical illness in people with mental illness. Perth: The University of Western Australia, 2001.

38. Lawrence D, Hancock KJ, and Kisely S. The gap in life expectancy from preventable physical illness in psychiatric patients in Western Australia: retrospective analysis of population based registers. British Medical Journal, 2013; 346:f2539. Available from: https://www.ncbi.nlm.nih.gov/pubmed/23694688 

39. Tam J, Warner KE, and Meza R. Smoking and the reduced life expectancy of individuals with serious mental illness. American Journal of Preventive Medicine, 2016; 51(6):958–66. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27522471 

40. Pedersen ALW, Lindekilde CR, Andersen K, Hjorth P, and Gildberg FA. Health behaviours of forensic mental health service users, in relation to smoking, alcohol consumption, dietary behaviours and physical activity-A mixed methods systematic review. J Psychiatr Ment Health Nurs, 2021; 28(3):444–61. Available from: https://www.ncbi.nlm.nih.gov/pubmed/32916759 

41. Chesney E, Robson D, Patel R, Shetty H, Richardson S, et al. The impact of cigarette smoking on life expectancy in schizophrenia, schizoaffective disorder and bipolar affective disorder: An electronic case register cohort study. Schizophr Res, 2021; 238:29–35. Available from: https://www.ncbi.nlm.nih.gov/pubmed/34563995 

42. Tam J, Taylor GMJ, Zivin K, Warner KE, and Meza R. Modeling smoking-attributable mortality among adults with major depression in the United States. Preventive Medicine, 2020; 140:106241. Available from: https://www.ncbi.nlm.nih.gov/pubmed/32860820 

43. Tam J, Warner KE, Zivin K, Taylor GMJ, and Meza R. The potential impact of widespread cessation treatment for smokers with depression. American Journal of Preventive Medicine, 2021; 61(5):674–82. Available from: https://www.ncbi.nlm.nih.gov/pubmed/34244005 

44. Taylor G, McNeill A, Girling A, Farley A, Lindson-Hawley N, et al. Change in mental health after smoking cessation: systematic review and meta-analysis. British Medical Journal, 2014; 348:g1151. Available from: https://www.ncbi.nlm.nih.gov/pubmed/24524926 

45. Taylor GM, Lindson N, Farley A, Leinberger-Jabari A, Sawyer K, et al. Smoking cessation for improving mental health. Cochrane Database of Systematic Reviews, 2021; 3(3):CD013522. Available from: https://www.ncbi.nlm.nih.gov/pubmed/33687070 

46. Liu NH, Wu C, Perez-Stable EJ, and Munoz RF. Longitudinal association between smoking abstinence and depression severity in those with baseline current, past, and no history of major depressive episode in an international online tobacco cessation study. Nicotine & Tobacco Research, 2021; 23(2):267–75. Available from: https://www.ncbi.nlm.nih.gov/pubmed/32149344 

47. Yonek JC, Meacham MC, Shumway M, Tolou-Shams M, and Satre DD. Smoking reduction is associated with lower alcohol consumption and depressive symptoms among young adults over one year. Drug and Alcohol Dependence, 2021; 227:108922. Available from: https://www.ncbi.nlm.nih.gov/pubmed/34364192 

48. Taylor GMJ, Baker AL, Fox N, Kessler DS, Aveyard P, et al. Addressing concerns about smoking cessation and mental health: theoretical review and practical guide for healthcare professionals. BJPsych Adv, 2021; 27(2):85–95. Available from: https://www.ncbi.nlm.nih.gov/pubmed/34513007 

49. Salt V and Osborne C. Mental health, smoking and poverty: benefits of supporting smokers to quit. BJPsych Bull, 2020; 44(5):213–8. Available from: https://www.ncbi.nlm.nih.gov/pubmed/32847647 

50. Rogers ES. Financial distress and smoking-induced deprivation in smokers with depression. American Journal of Health Behavior, 2019; 43(1):219–27. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30522579 

51. Lawn S. Australians with mental illness who smoke. The British Journal of Psychiatry, 2001; 178(1):85. Available from: https://www.ncbi.nlm.nih.gov/pubmed/11136222 

52. Minichino A, Bersani FS, Calo WK, Spagnoli F, Francesconi M, et al. Smoking behaviour and mental health disorders--mutual influences and implications for therapy. International Journal of Environmental Research and Public Health, 2013; 10(10):4790–811. Available from: https://www.ncbi.nlm.nih.gov/pubmed/24157506 

53. Dwyer T, Bradshaw J, and Happell B. Comparison of mental health nurses' attitudes towards smoking and smoking behaviour. International Journal of Mental Health Nursing, 2009; 18(6):424–33. Available from: https://www.ncbi.nlm.nih.gov/pubmed/19883414 

54. Ragg M and Ahmed T, Smoke and mirrors: a review of the literature on smoking and mental illness. Tackiling Tobacco Program Research Series No 1 Sydney: Cancer Council NSW; 2008. Available from: http://www.cancerdirectory.com.au/resource/view?slug=Smoke-and-Mirrors-A-review-of-the-literature-on-smoking-and-mental-illness&page=1

55. Hall SM and Prochaska JJ. Treatment of smokers with co-occurring disorders: emphasis on integration in mental health and addiction treatment settings. Annu Rev Clin Psychol, 2009; 5:409–31. Available from: https://www.ncbi.nlm.nih.gov/pubmed/19327035 

56. Lawn S and Pols R. Nicotine withdrawal: pathway to aggression and assault in the locked psychiatric ward? Australasian Psychiatry, 2003; 11(2):199–203. Available from: https://journals.sagepub.com/doi/abs/10.1046/j.1039-8562.2003.00548.x 

57. Olivier D, Lubman D, and Fraser R. Tobacco smoking within psychiatric inpatient settings: biopsychosocial perspective. Australia and New Zealand Journal of Psychiatry, 2007; 41(7):572–80. Available from: http://www.informaworld.com/smpp/content~db=all?content=10.1080/00048670701392809 

58. Aubin HJ, Rollema H, Svensson TH, and Winterer G. Smoking, quitting, and psychiatric disease: a review. Neurosci Biobehav Rev, 2012; 36(1):271–84. Available from: https://www.ncbi.nlm.nih.gov/pubmed/21723317 

59. Lum A, Skelton E, Wynne O, and Bonevski B. A systematic review of psychosocial barriers and facilitators to smoking cessation in people living with schizophrenia. Front Psychiatry, 2018; 9:565. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30459658 

60. Reilly P, Murphy L, and Alderton D. Challenging the smoking culture within a mental health service supportively. International Journal of Mental Health Nursing, 2006; 15(4):272–8. Available from: https://pubmed.ncbi.nlm.nih.gov/17064324/ 

61. Peckham E, Bradshaw TJ, Brabyn S, Knowles S, and Gilbody S. Exploring why people with SMI smoke and why they may want to quit: baseline data from the SCIMITAR RCT. J Psychiatr Ment Health Nurs, 2016; 23(5):282–9. Available from: https://www.ncbi.nlm.nih.gov/pubmed/26147943 

62. Trainor K and Leavey G. Barriers and Facilitators to Smoking Cessation Among People With Severe Mental Illness: A Critical Appraisal of Qualitative Studies. Nicotine & Tobacco Research, 2017; 19(1):14–23. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27613905 

63. Twyman L, Cowles C, Walsberger SC, Baker AL, Bonevski B, et al. 'They're going to smoke anyway': A qualitative study of community mental health staff and consumer perspectives on the role of social and living environments in tobacco use and cessation. Front Psychiatry, 2019; 10:503. Available from: https://www.ncbi.nlm.nih.gov/pubmed/31379622 

64. Chang LH, Whitfield JB, Liu M, Medland SE, Hickie IB, et al. Associations between polygenic risk for tobacco and alcohol use and liability to tobacco and alcohol use, and psychiatric disorders in an independent sample of 13,999 Australian adults. Drug and Alcohol Dependence, 2019; 205:107704. Available from: https://www.ncbi.nlm.nih.gov/pubmed/31731259 

65. Peterson RE, Bigdeli TB, Ripke S, Bacanu SA, Gejman PV, et al. Genome-wide analyses of smoking behaviors in schizophrenia: Findings from the Psychiatric Genomics Consortium. Journal of Psychiatric Research, 2021; 137:215–24. Available from: https://www.ncbi.nlm.nih.gov/pubmed/33691233 

66. Sagud M, Vuksan-Cusa B, Jaksic N, Mihaljevic-Peles A, Rojnic Kuzman M, et al. Smoking in schizophrenia: An updated review. Psychiatr Danub, 2018; 30(Suppl 4):216–23. Available from: https://www.ncbi.nlm.nih.gov/pubmed/29864763

67. Barkhuizen W, Dudbridge F, and Ronald A. Genetic overlap and causal associations between smoking behaviours and mental health. Sci Rep, 2021; 11(1):14871. Available from: https://www.ncbi.nlm.nih.gov/pubmed/34290290 

68. Morisano D, Bacher I, Audrain-McGovern J, and George TP. Mechanisms underlying the comorbidity of tobacco use in mental health and addictive disorders. Can J Psychiatry, 2009; 54(6):356–67. Available from: https://www.ncbi.nlm.nih.gov/pubmed/19527556 

69. Manzella F, Maloney SE, and Taylor GT. Smoking in schizophrenic patients: A critique of the self-medication hypothesis. World J Psychiatry, 2015; 5(1):35–46. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25815253 

70. Boggs DL, Surti TS, Esterlis I, Pittman B, Cosgrove K, et al. Minimal effects of prolonged smoking abstinence or resumption on cognitive performance challenge the "self-medication" hypothesis in schizophrenia. Schizophr Res, 2018; 194:62–9. Available from: https://www.ncbi.nlm.nih.gov/pubmed/28392208 

71. Kassel JD, Stroud LR, and Paronis CA. Smoking, stress, and negative affect: correlation, causation, and context across stages of smoking. Psychol Bull, 2003; 129(2):270–304. Available from: https://www.ncbi.nlm.nih.gov/pubmed/12696841 

72. Coustals N, Martelli C, Brunet-Lecomte M, Petillion A, Romeo B, et al. Chronic smoking and cognition in patients with schizophrenia: A meta-analysis. Schizophr Res, 2020; 222:113–21. Available from: https://www.ncbi.nlm.nih.gov/pubmed/32507373 

73. Wang YY, Wang S, Zheng W, Zhong BL, Ng CH, et al. Cognitive functions in smoking and non-smoking patients with schizophrenia: A systematic review and meta-analysis of comparative studies. Psychiatry Res, 2019; 272:155–63. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30583258 

74. Huang H, Dong M, Zhang L, Zhong BL, Ng CH, et al. Psychopathology and extrapyramidal side effects in smoking and non-smoking patients with schizophrenia: Systematic review and meta-analysis of comparative studies. Prog Neuropsychopharmacol Biol Psychiatry, 2019; 92:476–82. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30794823 

75. Gurillo P, Jauhar S, Murray RM, and MacCabe JH. Does tobacco use cause psychosis? Systematic review and meta-analysis. The Lancet Psychiatry, 2015; 2(8):718–25. Available from: http://dx.doi.org/10.1016/S2215-0366(15)00152-2 

76. Hunter A, Murray R, Asher L, and Leonardi-Bee J. The effects of tobacco smoking, and prenatal tobacco smoke exposure, on risk of schizophrenia: A systematic review and meta-analysis. Nicotine & Tobacco Research, 2020; 22(1):3–10. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30102383 

77. Lee B, Levy DE, Macy JT, Elam KK, Bidulescu A, et al. Smoking trajectories from adolescence to early adulthood as a longitudinal predictor of mental health in adulthood: evidence from 21 years of a nationally representative cohort. Addiction, 2022; 117(6):1727–36. Available from: https://www.ncbi.nlm.nih.gov/pubmed/34817100 

78. Sanchez-Villegas A, Gea A, Lahortiga-Ramos F, Martinez-Gonzalez J, Molero P, et al. Bidirectional association between tobacco use and depression risk in the SUN cohort study. Adicciones, 2021; 0(0):1725. Available from: https://www.ncbi.nlm.nih.gov/pubmed/34882246 

79. Wootton RE, Richmond RC, Stuijfzand BG, Lawn RB, Sallis HM, et al. Evidence for causal effects of lifetime smoking on risk for depression and schizophrenia: a Mendelian randomisation study. Psychological Medicine, 2020; 50(14):2435–43. Available from: https://www.ncbi.nlm.nih.gov/pubmed/31689377 

80. Vermeulen JM, Wootton RE, Treur JL, Sallis HM, Jones HJ, et al. Smoking and the risk for bipolar disorder: evidence from a bidirectional Mendelian randomisation study. The British Journal of Psychiatry, 2021; 218(2):88–94. Available from: https://www.ncbi.nlm.nih.gov/pubmed/31526406 

81. Snell M, Harless D, Shin S, Cunningham P, and Barnes A. A longitudinal assessment of nicotine dependence, mental health, and attempts to quit Smoking: Evidence from waves 1-4 of the Population Assessment of Tobacco and Health (PATH) study. Addictive Behaviors, 2021; 115:106787. Available from: https://www.ncbi.nlm.nih.gov/pubmed/33383566 

82. Prochaska JJ. Smoking and mental illness--breaking the link. New England Journal of Medicine, 2011; 365(3):196–8. Available from: https://www.ncbi.nlm.nih.gov/pubmed/21774707 

83. Tidey JW and Miller ME. Smoking cessation and reduction in people with chronic mental illness. British Medical Journal, 2015; 351:h4065. Available from: https://www.ncbi.nlm.nih.gov/pubmed/26391240 

84. Jenkins R, Bhugra D, Bebbington P, Brugha T, Farrell M, et al. Debt, income and mental disorder in the general population. Psychological Medicine, 2008; 38(10):1485–93. Available from: https://www.ncbi.nlm.nih.gov/pubmed/18184442 

85. Department of Health, National mental health report. Australian Government; 2013.

86. Lawn S, Hersh D, Ward PR, Tsourtos G, Muller R, et al. 'I just saw it as something that would pull you down, rather than lift you up': resilience in never-smokers with mental illness. Health Education Research, 2011; 26(1):26–38. Available from: https://www.ncbi.nlm.nih.gov/pubmed/21062967 

87. Twyman L, Bonevski B, Paul C, and Bryant J. Perceived barriers to smoking cessation in selected vulnerable groups: a systematic review of the qualitative and quantitative literature. BMJ Open, 2014; 4(12):e006414. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25534212 

88. Lawn S. Systematic barriers to quitting smoking among institutionalised public mental health service populations: a comparison of two Australian sites. The International Journal of Social Psychiatry, 2004; 50(3):201–15. Available from: https://pubmed.ncbi.nlm.nih.gov/15511114/ 

89. Sundgren E, Hallqvist J, and Fredriksson L. Health for smokers with schizophrenia - a struggle to maintain a dignified life. Disability and Rehabilitation, 2016; 38(5):416–22. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25958996 

90. Ragg M, Gordon R, Ahmed T, and Allan J. The impact of smoking cessation on schizophrenia and major depression. Australas Psychiatry, 2013; 21(3):238–45. Available from: https://www.ncbi.nlm.nih.gov/pubmed/23616382 

91. Banham L and Gilbody S. Smoking cessation in severe mental illness: what works? Addiction, 2010; 105(7):1176–89. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20491721 

92. Bolam B, West R, and Gunnell D. Does smoking cessation cause depression and anxiety? Findings from the ATTEMPT cohort. Nicotine & Tobacco Research, 2011; 13(3):209–14. Available from: https://www.ncbi.nlm.nih.gov/pubmed/21330275 

93. Prochaska JJ, Delucchi K, and Hall SM. A meta-analysis of smoking cessation interventions with individuals in substance abuse treatment or recovery. Journal of Consulting and Clinical Psychology, 2004; 72(6):1144–56. Available from: https://www.ncbi.nlm.nih.gov/pubmed/15612860 

94. Winhusen TM, Somoza EC, Brigham GS, Liu DS, Green CA, et al. Impact of attention-deficit/hyperactivity disorder (ADHD) treatment on smoking cessation intervention in ADHD smokers: a randomized, double-blind, placebo-controlled trial. Journal of Clinical Psychiatry, 2010; 71(12):1680–8. Available from: https://www.ncbi.nlm.nih.gov/pubmed/20492837 

95. Covey LS, Hu MC, Winhusen T, Weissman J, Berlin I, et al. OROS-methylphenidate or placebo for adult smokers with attention deficit hyperactivity disorder: racial/ethnic differences. Drug and Alcohol Dependence, 2010; 110(1-2):156–9. Available from: https://www.ncbi.nlm.nih.gov/pubmed/20219292 

96. Covey LS, Hu MC, Winhusen T, Lima J, Berlin I, et al. Anxiety and depressed mood decline following smoking abstinence in adult smokers with attention deficit hyperactivity disorder. Journal of Substance Abuse Treatment, 2015; 59:104–8. Available from: https://www.ncbi.nlm.nih.gov/pubmed/26272693 

97. Yaworski D, Robinson J, Sareen J, and Bolton JM. The relation between nicotine dependence and suicide attempts in the general population. Canadian Journal of Psychiatry, 2011; 56(3):161–70. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21443823 

98. Hitsman B, Borrelli B, McChargue DE, Spring B, and Niaura R. History of depression and smoking cessation outcome: a meta-analysis. Journal of Consulting and Clinical Psychology, 2003; 71(4):657–63. Available from: https://www.ncbi.nlm.nih.gov/pubmed/12924670 

99. Siru R, Hulse GK, and Tait RJ. Assessing motivation to quit smoking in people with mental illness: a review. Addiction, 2009; 104(5):719–33. Available from: https://www.ncbi.nlm.nih.gov/pubmed/19413788 

100. Kagabo R, Gordon AJ, and Okuyemi K. Smoking cessation in inpatient psychiatry treatment facilities: A review. Addictive Behaviors Reports, 2020; 11:100255. Available from: https://www.ncbi.nlm.nih.gov/pubmed/32467844 

101. Brown CH, Medoff D, Dickerson FB, Fang LJ, Lucksted A, et al. Factors influencing implementation of smoking cessation treatment within community mental health centers. Journal of Dual Diagnosis, 2015; 11(2):145–50. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25985201 

102. Cook BL, Wayne GF, Kafali EN, Liu Z, Shu C, et al. Trends in smoking among adults with mental illness and association between mental health treatment and smoking cessation. Journal of the American Medical Association, 2014; 311(2):172–82. Available from: https://www.ncbi.nlm.nih.gov/pubmed/24399556 

103. Tidey JW, Colby SM, and Xavier EM. Effects of smoking abstinence on cigarette craving, nicotine withdrawal, and nicotine reinforcement in smokers with and without schizophrenia. Nicotine & Tobacco Research, 2014; 16(3):326–34. Available from: https://www.ncbi.nlm.nih.gov/pubmed/24113929 

104. Prochaska JJ. Failure to treat tobacco use in mental health and addiction treatment settings: a form of harm reduction? Drug and Alcohol Dependence, 2010; 110(3):177–82. Available from: https://www.ncbi.nlm.nih.gov/pubmed/20378281 

105. Anzai N, Young-Wolff KC, and Prochaska JJ. Symptom severity and readiness to quit among hospitalized smokers with mental illness. Psychiatric Services, 2015; 66(4):443–4. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25828988 

106. McNeill A. Smoking and mental health: a review of the literature. London: Smokefree London Programme, 2001. Available from: http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.622.6748&rep=rep1&type=pdf 

107. Morris CD, Burns EK, Waxmonsky JA, and Levinson AH. Smoking cessation behaviors among persons with psychiatric diagnoses: results from a population-level state survey. Drug and Alcohol Dependence, 2014; 136:63–8. Available from: https://www.ncbi.nlm.nih.gov/pubmed/24417963 

108. Siru R, Hulse GK, Khan RJ, and Tait RJ. Motivation to quit smoking among hospitalised individuals with and without mental health disorders. Australian and New Zealand Journal of Psychiatry, 2010; 44(7):640–7. Available from: https://www.ncbi.nlm.nih.gov/pubmed/20560851 

109. Moeller-Saxone K. Cigarette smoking and interest in quitting among consumers at a Psychiatric Disability Rehabilitation and Support Service in Victoria. Australian and New Zealand Journal of Public Health, 2008; 32(5):479–81. Available from: http://onlinelibrary.wiley.com/doi/10.1111/j.1753-6405.2008.00283.x/abstract 

110. Young-Wolff KC, Fromont SC, Delucchi K, Hall SE, Hall SM, et al. PTSD symptomatology and readiness to quit smoking among women with serious mental illness. Addictive Behaviors, 2014; 39(8):1231–4. Available from: https://www.ncbi.nlm.nih.gov/pubmed/24813548 

111. Dickerson F, Bennett M, Dixon L, Burke E, Vaughan C, et al. Smoking cessation in persons with serious mental illnesses: the experience of successful quitters. Psychiatric Rehabilitation Journal, 2011; 34(4):311–6. Available from: https://www.ncbi.nlm.nih.gov/pubmed/21459747 

112. Hitsman B, Moss TG, Montoya ID, and George TP. Treatment of tobacco dependence in mental health and addictive disorders. Can J Psychiatry, 2009; 54(6):368–78. Available from: https://www.ncbi.nlm.nih.gov/pubmed/19527557 

113. Talukder SR, Lappin JM, Boland V, McRobbie H, and Courtney RJ. Inequity in smoking cessation clinical trials testing pharmacotherapies: exclusion of smokers with mental health disorders. Tobacco Control, 2021. Available from: https://www.ncbi.nlm.nih.gov/pubmed/34862325 

114. Cavazos-Rehg PA, Breslau N, Hatsukami D, Krauss MJ, Spitznagel EL, et al. Smoking cessation is associated with lower rates of mood/anxiety and alcohol use disorders. Psychological Medicine, 2014; 44(12):2523–35. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25055171 

115. Correa JB, Lawrence D, McKenna BS, Gaznick N, Saccone PA, et al. Psychiatric comorbidity and multimorbidity in the EAGLES trial: Descriptive correlates and associations with neuropsychiatric adverse events, treatment adherence, and smoking cessation. Nicotine & Tobacco Research, 2021; 23(10):1646–55. Available from: https://www.ncbi.nlm.nih.gov/pubmed/33788933 

116. The Royal Australian College of General Practitioners, Supporting smoking cessation: a guide for health professionals. Melbourne: RACGP; 2014. Available from: http://www.racgp.org.au/your-practice/guidelines/smoking-cessation/

117. Patnode CD, Henderson JT, Thompson JH, Senger CA, Fortmann SP, et al. Behavioral counseling and pharmacotherapy interventions for tobacco cessation in adults, including pregnant women: A review of reviews for the US Preventive Services Task Force. Annals of Internal Medicine, 2015; 163(8):608–21. Available from: https://www.ncbi.nlm.nih.gov/pubmed/26389650 

118. Lightfoot K, Panagiotaki G, and Nobes G. Effectiveness of psychological interventions for smoking cessation in adults with mental health problems: A systematic review. British Journal of Health Psychology, 2020; 25(3):615–38. Available from: https://www.ncbi.nlm.nih.gov/pubmed/32678937 

119. Oliveira P, Ribeiro J, Donato H, and Madeira N. Smoking and antidepressants pharmacokinetics: a systematic review. Annals of General Psychiatry, 2017; 16:17. Available from: https://www.ncbi.nlm.nih.gov/pubmed/28286537 

120. Anthenelli RM, Benowitz NL, West R, St Aubin L, McRae T, et al. Neuropsychiatric safety and efficacy of varenicline, bupropion, and nicotine patch in smokers with and without psychiatric disorders (EAGLES): a double-blind, randomised, placebo-controlled clinical trial. The Lancet, 2016; 387(10037):2507–20. Available from: https://doi.org/10.1016/S0140-6736(16)30272-0  

121. Davis A, Ngo H, and Coleman M. An evaluation of a pilot specialist smoking cessation clinic in a mental health setting. Australas Psychiatry, 2019; 27(3):275–8. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30507301 

122. Johnson SE, Mitrou F, Lawrence D, Zubrick SR, Wolstencroft K, et al. Feasibility of a consumer centred tobacco management intervention in community mental health services in Australia. Community Ment Health J, 2020; 56(7):1354–65. Available from: https://www.ncbi.nlm.nih.gov/pubmed/32036516 

123. Lappin JM, Thomas D, Curtis J, Blowfield S, Gatsi M, et al. Targeted intervention to reduce smoking among people with severe mental illness: Implementation of a smoking cessation intervention in an inpatient mental health setting. Medicina (Kaunas), 2020; 56(4). Available from: https://www.ncbi.nlm.nih.gov/pubmed/32344790 

124. Plever S, McCarthy I, Anzolin M, Emmerson B, Allan J, et al. Queensland smoking care in adult acute mental health inpatient units: Supporting practice change. Australian and New Zealand Journal of Psychiatry, 2020; 54(9):919–27. Available from: https://www.ncbi.nlm.nih.gov/pubmed/32375495 

125. Skelton E, Tzelepis F, Shakeshaft A, Guillaumier A, McCrabb S, et al. Integrating smoking cessation care in alcohol and other drug treatment settings using an organizational change intervention: a systematic review. Addiction, 2018; 113(12):2158–72. Available from: https://www.ncbi.nlm.nih.gov/pubmed/29920839 

126. Stockings EA, Bowman JA, Baker AL, Terry M, Clancy R, et al. Impact of a postdischarge smoking cessation intervention for smokers admitted to an inpatient psychiatric facility: a randomized controlled trial. Nicotine & Tobacco Research, 2014; 16(11):1417–28. Available from: https://www.ncbi.nlm.nih.gov/pubmed/24939916 

127. Schwindt R, Hudmon KS, Knisely M, Davis L, and Pike C. Impact of Tobacco Quitlines on Smoking Cessation in Persons With Mental Illness: A Systematic Review. Journal of Drug Education, 2017; 47(1-2):68-81. Available from: https://www.ncbi.nlm.nih.gov/pubmed/29534595 

128. Baker AL, Richmond R, Kay-Lambkin FJ, Filia SL, Castle D, et al. Randomized Controlled Trial of a Healthy Lifestyle Intervention Among Smokers With Psychotic Disorders. Nicotine and Tobacco Research, 2015; 17(8):946-54. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25744962 

129. Segan CJ, Baker AL, Turner A, and Williams JM. Nicotine Withdrawal, Relapse of Mental Illness, or Medication Side-Effect? Implementing a Monitoring Tool for People With Mental Illness Into Quitline Counseling. J Dual Diagn, 2017; 13(1):60-6. Available from: https://www.ncbi.nlm.nih.gov/pubmed/28067594 

130. Sharma-Kumar R, Meurk C, Ford P, Beere D, and Gartner C. Are Australian smokers with mental illness receiving adequate smoking cessation and harm reduction information? International Journal of Mental Health Nursing, 2018; 27(6):1673–88. Available from: https://www.ncbi.nlm.nih.gov/pubmed/29718549 

131. Sharma-Kumar R, Puljevic C, Morphett K, Meurk C, and Gartner C. The acceptability and effectiveness of videos promoting smoking cessation among Australians experiencing mental illness. Health Educ Behav, 2021:10901981211034738. Available from: https://www.ncbi.nlm.nih.gov/pubmed/34496656 

132. van der Meer RM, Willemsen MC, Smit F, and Cuijpers P. Smoking cessation interventions for smokers with current or past depression. Cochrane Database of Systematic Reviews, 2013; 8(8):CD006102. Available from: https://www.ncbi.nlm.nih.gov/pubmed/23963776 

133. Weinberger AH, Pilver CE, Desai RA, Mazure CM, and McKee SA. The relationship of major depressive disorder and gender to changes in smoking for current and former smokers: longitudinal evaluation in the US population. Addiction, 2012; 107(10):1847–56. Available from: https://www.ncbi.nlm.nih.gov/pubmed/22429388 

134. Khaled SM, Bulloch AG, Williams JV, Lavorato DH, and Patten SB. Major depression is a risk factor for shorter time to first cigarette irrespective of the number of cigarettes smoked per day: evidence from a National Population Health Survey. Nicotine & Tobacco Research, 2011; 13(11):1059–67. Available from: https://www.ncbi.nlm.nih.gov/pubmed/21832274 

135. van der Meer RM, Willemsen MC, Smit F, and Cuijpers P. Smoking cessation interventions for smokers with current or past depression. Cochrane Database of Systematic Reviews, 2006; 3:CD006102. Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD006102/abstract 

136. Cooper J, Borland R, McKee SA, Yong HH, and Dugue PA. Depression motivates quit attempts but predicts relapse: differential findings for gender from the International Tobacco Control Study. Addiction, 2016; 111(8):1438–47. Available from: https://www.ncbi.nlm.nih.gov/pubmed/26888199 

137. Morozova M, Rabin RA, and George TP. Co-morbid tobacco use disorder and depression: A re-evaluation of smoking cessation therapy in depressed smokers. American Journal on Addictions, 2015; 24(8):687–94. Available from: https://www.ncbi.nlm.nih.gov/pubmed/26354720 

138. Secades-Villa R, Gonzalez-Roz A, Garcia-Perez A, and Becona E. Psychological, pharmacological, and combined smoking cessation interventions for smokers with current depression: A systematic review and meta-analysis. PLoS One, 2017; 12(12):e0188849. Available from: https://www.ncbi.nlm.nih.gov/pubmed/29206852 

139. Gierisch J, Bastian L, Calhoun P, McDuffie J, Williams J, et al. Comparative effectiveness of smoking cessation treatments for patients with depression: a systematic review and meta-analysis of the evidence, Department of Veterans Affairs, Veterans Health Administration, and Health Services Research & Development Service, Editors. 2010. Available from: http://www.ncbi.nlm.nih.gov/books/NBK51226/pdf/TOC.pdf

140. Anthenelli RM, Morris C, Ramey TS, Dubrava SJ, Tsilkos K, et al. Effects of varenicline on smoking cessation in adults with stably treated current or past major depression: a randomized trial. Annals of Internal Medicine, 2013; 159(6):390–400. Available from: https://www.ncbi.nlm.nih.gov/pubmed/24042367 

141. Evins AE, Benowitz NL, West R, Russ C, McRae T, et al. Neuropsychiatric safety and efficacy of varenicline, bupropion, and nicotine patch in smokers with psychotic, anxiety, and mood disorders in the EAGLES trial. J Clin Psychopharmacol, 2019; 39(2):108–16. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30811371 

142. Aldi GA, Bertoli G, Ferraro F, Pezzuto A, and Cosci F. Effectiveness of pharmacological or psychological interventions for smoking cessation in smokers with major depression or depressive symptoms: A systematic review of the literature. Substance Abuse, 2018; 39(3):289–306. Available from: https://www.ncbi.nlm.nih.gov/pubmed/29436984 

143. Ziedonis D, Hitsman B, Beckham J, Zvolensky M, Adler L, et al. Tobacco use and cessation in psychiatric disorders: National Institute of Mental Health report. Nicotine & Tobacco Research, 2008; 10(12):1691–715. Available from: http://www.informaworld.com/smpp/content~db=all?content=10.1080/14622200802443569 

144. G SC, C RG, M JZ, M ML, N BS, et al. Obsessive-compulsive symptoms and cigarette smoking: an initial cross-sectional test of mechanisms of co-occurrence. Cogn Behav Ther, 2020; 49(5):385–97. Available from: https://www.ncbi.nlm.nih.gov/pubmed/32324104 

145. Petroulia I, Kyriakos CN, Papadakis S, Tzavara C, Filippidis FT, et al. Patterns of tobacco use, quit attempts, readiness to quit and self-efficacy among smokers with anxiety or depression: Findings among six countries of the EUREST-PLUS ITC Europe Surveys. Tobacco Induced Diseases, 2018; 16:A9. Available from: https://www.ncbi.nlm.nih.gov/pubmed/31516463 

146. Piper ME, Cook JW, Schlam TR, Jorenby DE, and Baker TB. Anxiety diagnoses in smokers seeking cessation treatment: relations with tobacco dependence, withdrawal, outcome and response to treatment. Addiction, 2011; 106(2):418–27. Available from: https://www.ncbi.nlm.nih.gov/pubmed/20973856 

147. Kimbrel NA, Morissette SB, Gulliver SB, Langdon KJ, and Zvolensky MJ. The effect of social anxiety on urge and craving among smokers with and without anxiety disorders. Drug and Alcohol Dependence, 2014; 135:59–64. Available from: https://www.ncbi.nlm.nih.gov/pubmed/24331637 

148. Ayers CR, Heffner JL, Russ C, Lawrence D, McRae T, et al. Efficacy and safety of pharmacotherapies for smoking cessation in anxiety disorders: Subgroup analysis of the randomized, active- and placebo-controlled EAGLES trial. Depress Anxiety, 2020; 37(3):247–60. Available from: https://www.ncbi.nlm.nih.gov/pubmed/31850603 

149. Poorolajal J and Darvishi N. Smoking and Suicide: A Meta-Analysis. PLoS One, 2016; 11(7):e0156348. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27391330 

150. Echeverria I, Cotaina M, Jovani A, Mora R, Haro G, et al. Proposal for the inclusion of tobacco use in suicide risk scales: Results of a meta-analysis. International Journal of Environmental Research and Public Health, 2021; 18(11). Available from: https://www.ncbi.nlm.nih.gov/pubmed/34198855 

151. Sankaranarayanan A, Clark V, Baker A, Palazzi K, Lewin TJ, et al. Reducing smoking reduces suicidality among individuals with psychosis: Complementary outcomes from a Healthy Lifestyles intervention study. Psychiatry Res, 2016; 243:407–12. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27450743 

152. Icick R, Melle I, Etain B, Ringen PA, Aminoff SR, et al. Tobacco smoking and other substance use disorders associated with recurrent suicide attempts in bipolar disorder. J Affect Disord, 2019; 256:348–57. Available from: https://www.ncbi.nlm.nih.gov/pubmed/31202989 

153. Wilhelm K, Handley T, and Reddy P. A case for identifying smoking in presentations to the emergency department with suicidality. Australas Psychiatry, 2018; 26(2):176–80. Available from: https://www.ncbi.nlm.nih.gov/pubmed/29417825 

154. Willcutt EG. The prevalence of DSM-IV attention-deficit/hyperactivity disorder: a meta-analytic review. Neurotherapeutics, 2012; 9(3):490–9. Available from: https://www.ncbi.nlm.nih.gov/pubmed/22976615 

155. Schoenfelder EN, Faraone SV, and Kollins SH. Stimulant treatment of ADHD and cigarette smoking: a meta-analysis. Pediatrics, 2014; 133(6):1070–80. Available from: https://www.ncbi.nlm.nih.gov/pubmed/24819571 

156. McClernon FJ and Kollins SH. ADHD and smoking: from genes to brain to behavior. Annals of the New York Academy of Sciences, 2008; 1141:131–47. Available from: https://www.ncbi.nlm.nih.gov/pubmed/18991955 

157. Lee SS, Humphreys KL, Flory K, Liu R, and Glass K. Prospective association of childhood attention-deficit/hyperactivity disorder (ADHD) and substance use and abuse/dependence: a meta-analytic review. Clin Psychol Rev, 2011; 31(3):328–41. Available from: https://www.ncbi.nlm.nih.gov/pubmed/21382538 

158. Kollins SH, McClernon FJ, and Fuemmeler BF. Association between smoking and attention-deficit/hyperactivity disorder symptoms in a population-based sample of young adults. Arch Gen Psychiatry, 2005; 62(10):1142–7. Available from: https://www.ncbi.nlm.nih.gov/pubmed/16203959 

159. Mitchell JT, Howard AL, Belendiuk KA, Kennedy TM, Stehli A, et al. Cigarette smoking progression among young adults diagnosed with ADHD in childhood: A 16-year longitudinal study of children with and without adhd. Nicotine & Tobacco Research, 2019; 21(5):638–47. Available from: https://www.ncbi.nlm.nih.gov/pubmed/29538764 

160. US Department of Health and Human Services. The health consequences of smoking: a report of the Surgeon General. Atlanta, Georgia: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2004. Available from: http://www.cdc.gov/tobacco/data_statistics/sgr/index.htm 

161. Kollins SH, Sweitzer MM, McClernon FJ, and Perkins KA. Increased subjective and reinforcing effects of initial nicotine exposure in young adults with attention deficit hyperactivity disorder (ADHD) compared to matched peers: results from an experimental model of first-time tobacco use. Neuropsychopharmacology, 2020; 45(5):851–6. Available from: https://www.ncbi.nlm.nih.gov/pubmed/31785588 

162. van Amsterdam J, van der Velde B, Schulte M, and van den Brink W. Causal factors of increased smoking in ADHD: A systematic review. Substance Use and Misuse, 2018; 53(3):432–45. Available from: https://www.ncbi.nlm.nih.gov/pubmed/29039714 

163. Luo SX, Covey LS, Hu MC, Winhusen TM, and Nunes EV. Differential posttreatment outcomes of methylphenidate for smoking cessation for individuals with ADHD. American Journal on Addictions, 2019; 28(6):497–502. Available from: https://www.ncbi.nlm.nih.gov/pubmed/31538372 

164. Luo SX, Wall M, Covey L, Hu MC, Scodes JM, et al. Exploring longitudinal course and treatment-baseline severity interactions in secondary outcomes of smoking cessation treatment in individuals with attention-deficit hyperactivity disorder. American Journal of Drug and Alcohol Abuse, 2018; 44(6):653–9. Available from: https://www.ncbi.nlm.nih.gov/pubmed/29370538 

165. Wilens TE, Spencer TJ, Biederman J, Girard K, Doyle R, et al. A controlled clinical trial of bupropion for attention deficit hyperactivity disorder in adults. American Journal of Psychiatry, 2001; 158(2):282–8. Available from: https://www.ncbi.nlm.nih.gov/pubmed/11156812 

166. Bidwell LC, Karoly HC, Hutchison KE, and Bryan AD. ADHD symptoms impact smoking outcomes and withdrawal in response to Varenicline treatment for smoking cessation. Drug and Alcohol Dependence, 2017; 179:18–24. Available from: https://www.ncbi.nlm.nih.gov/pubmed/28738266 

167. Kollins SH, McClernon FJ, and Van Voorhees EE. Monetary incentives promote smoking abstinence in adults with attention deficit hyperactivity disorder (ADHD). Experimental and Clinical Psychopharmacology, 2010; 18(3):221–8. Available from: https://www.ncbi.nlm.nih.gov/pubmed/20545386 

168. Reichler H, Baker A, Lewin T, and Carr V. Smoking among in-patients with drug-related problems in an Australian psychiatric hospital. Drug and Alcohol Review, 2001; 20(2):231–7. Available from: http://www.informaworld.com/smpp/content~content=a713659508~db=all~order=page 

169. Guydish J, Passalacqua E, Pagano A, Martinez C, Le T, et al. An international systematic review of smoking prevalence in addiction treatment. Addiction, 2016; 111(2):220–30. Available from: https://www.ncbi.nlm.nih.gov/pubmed/26392127 

170. Kwon I, Montebello M, and Bittoun R. Tobacco dependence management in a smoke-free inpatient drug and alcohol unit. Australas Psychiatry, 2021; 29(1):14–21. Available from: https://www.ncbi.nlm.nih.gov/pubmed/33301381

171. Rajabi A, Dehghani M, Shojaei A, Farjam M, and Motevalian SA. Association between tobacco smoking and opioid use: A meta-analysis. Addictive Behaviors, 2019; 92:225–35. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30685521 

172. Weinberger AH, Pacek LR, Wall MM, Zvolensky MJ, Copeland J, et al. Trends in cannabis use disorder by cigarette smoking status in the United States, 2002-2016. Drug and Alcohol Dependence, 2018; 191:45–51. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30077055 

173. Degenhardt L and Hall W. The relationship between tobacco use, substance-use disorders and mental health: results from the National Survey of Mental Health and Well-being. Nicotine & Tobacco Research, 2001; 3(3):225–34. Available from: http://www.informaworld.com/smpp/content~db=all?content=10.1080/14622200110050457 

174. Guydish J, Passalacqua E, Tajima B, Chan M, Chun J, et al. Smoking prevalence in addiction treatment: a review. Nicotine & Tobacco Research, 2011; 13(6):401–11. Available from: https://www.ncbi.nlm.nih.gov/pubmed/21464202

175. Degenhardt L and Hall W. Patterns of co-morbidity between alcohol use and other substance use in the Australian population. Drug and Alcohol Review, 2003; 22(1):7–13. Available from: https://pubmed.ncbi.nlm.nih.gov/12745353/ 

176. Weinberger AH, Funk AP, and Goodwin RD. A review of epidemiologic research on smoking behavior among persons with alcohol and illicit substance use disorders. Preventive Medicine, 2016; 92:148–59. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27196143 

177. Hurt RD, Offord KP, Croghan IT, Gomez-Dahl L, Kottke TE, et al. Mortality following inpatient addictions treatment. Role of tobacco use in a community-based cohort. Journal of the American Medical Association, 1996; 275(14):1097–103. Available from: https://www.ncbi.nlm.nih.gov/pubmed/8601929 

178. Hobden B, Bryant J, Forshaw K, Oldmeadow C, Evans TJ, et al. Prevalence and characteristics associated with concurrent smoking and alcohol misuse within Australian general practice patients. Aust Health Rev, 2020; 44(1):125–31. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30543764 

179. Bien TH and Burge R. Smoking and drinking: a review of the literature. Int J Addict, 1990; 25(12):1429–54. Available from: https://www.ncbi.nlm.nih.gov/pubmed/2094682 

180. Hashibe M, Straif K, Tashkin D, Morgenstern H, Greenland S, et al. Epidemiological review of marijuana use and cancer risk. Alcohol, 2005; 35(3):265–75.

181. Ashton CH. Adverse effects of cannabis and cannabinoids. Br J Anaesth, 1999; 83(4):637–49. Available from: https://www.ncbi.nlm.nih.gov/pubmed/10673884 

182. Kalant H. Adverse effects of cannabis on health: an update of the literature since 1996. Progress in Neuro-Psychopharmacology & Biological Psychiatry, 2004; 28(849-63).

183. Guydish J, Passalacqua E, Tajima B, and Manser ST. Staff smoking and other barriers to nicotine dependence intervention in addiction treatment settings: a review. J Psychoactive Drugs, 2007; 39(4):423–33. Available from: https://www.ncbi.nlm.nih.gov/pubmed/18303699 

184. Fuller BE, Guydish J, Tsoh J, Reid MS, Resnick M, et al. Attitudes toward the integration of smoking cessation treatment into drug abuse clinics. Journal of Substance Abuse Treatment, 2007; 32(1):53–60. Available from: https://www.ncbi.nlm.nih.gov/pubmed/17175398 

185. Gentry S, Craig J, Holland R, and Notley C. Smoking cessation for substance misusers: A systematic review of qualitative studies on participant and provider beliefs and perceptions. Drug and Alcohol Dependence, 2017; 180:178–92. Available from: https://www.ncbi.nlm.nih.gov/pubmed/28910690 

186. Rothrauff TC and Eby LT. Counselors' knowledge of the adoption of tobacco cessation medications in substance abuse treatment programs. American Journal on Addictions, 2011; 20(1):56–62. Available from: https://www.ncbi.nlm.nih.gov/pubmed/21175921 

187. Rothrauff TC, Eby LT, and Public Health S. Substance abuse counselors' implementation of tobacco cessation guidelines. J Psychoactive Drugs, 2011; 43(1):6–13. Available from: https://www.ncbi.nlm.nih.gov/pubmed/21615002 

188. Walsh RA, Bowman JA, Tzelepis F, and Lecathelinais C. Smoking cessation interventions in Australian drug treatment agencies: a national survey of attitudes and practices. Drug and Alcohol Review, 2005; 24(3):235–44. Available from: https://www.ncbi.nlm.nih.gov/pubmed/16096127 

189. Shu C and Cook BL. Examining the association between substance use disorder treatment and smoking cessation. Addiction, 2015; 110(6):1015–24. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25683883 

190. Walsh RA, Bowman JA, Tzelepis F, and Lecathelinais C. Regulation of environmental tobacco smoke by Australian drug treatment agencies. Australian and New Zealand Journal of Public Health, 2005; 29(3):276–8. Available from: https://www.ncbi.nlm.nih.gov/pubmed/15991778 

191. Baca C and Yahne C. Smoking cessation during substance abuse treatment: What you need to know. Journal of Substance Abuse Treatment, 2008; 36(2):205–19. Available from: http://www.journalofsubstanceabusetreatment.com/article/S0740-5472(08)00097-4/abstract 

192. Cookson C, Strang J, Ratschen E, Sutherland G, Finch E, et al. Smoking and its treatment in addiction services: clients' and staff behaviour and attitudes. BMC Health Services Research, 2014; 14:304. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25017205 

193. Toussaint DW, VanDeMark NR, Silverstein M, and Stone E. Exploring factors related to readiness to change tobacco use for clients in substance abuse treatment. Journal of Drug Issues, 2009; 39(2). Available from: https://journals.sagepub.com/doi/abs/10.1177/002204260903900203 

194. Stuyt EB. Enforced abstinence from tobacco during in-patient dual-diagnosis treatment improves substance abuse treatment outcomes in smokers. American Journal on Addictions, 2015; 24(3):252–7. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25907814 

195. Zawertailo LA, Baliunas D, Ivanova A, and Selby PL. Individualized treatment for tobacco dependence in addictions treatment settings: The role of current depressive symptoms on outcomes at 3 and 6 months. Nicotine & Tobacco Research, 2015; 17(8):937–45. Available from: https://www.ncbi.nlm.nih.gov/pubmed/26180218 

196. Winhusen TM, Kropp F, Theobald J, and Lewis DF. Achieving smoking abstinence is associated with decreased cocaine use in cocaine-dependent patients receiving smoking-cessation treatment. Drug and Alcohol Dependence, 2014; 134:391–5. Available from: https://www.ncbi.nlm.nih.gov/pubmed/24128381 

197. Winhusen TM, Brigham GS, Kropp F, Lindblad R, Gardin JG, 2nd, et al. A randomized trial of concurrent smoking-cessation and substance use disorder treatment in stimulant-dependent smokers. Journal of Clinical Psychiatry, 2014; 75(4):336–43. Available from: https://www.ncbi.nlm.nih.gov/pubmed/24345356 

198. McKelvey K, Thrul J, and Ramo D. Impact of quitting smoking and smoking cessation treatment on substance use outcomes: An updated and narrative review. Addictive Behaviors, 2017; 65:161–70. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27816663 

199. Walsh H, McNeill A, Purssell E, and Duaso M. A systematic review and Bayesian meta-analysis of interventions which target or assess co-use of tobacco and cannabis in single- or multi-substance interventions. Addiction, 2020; 115(10):1800–14. Available from: https://www.ncbi.nlm.nih.gov/pubmed/32003088 

200. Guillaumier A, Skelton E, Shakeshaft A, Farrell M, Tzelepis F, et al. Effect of increasing the delivery of smoking cessation care in alcohol and other drug treatment centres: a cluster-randomized controlled trial. Addiction, 2020; 115(7):1345–55. Available from: https://www.ncbi.nlm.nih.gov/pubmed/31762105 

201. Skelton E, Tzelepis F, Shakeshaft A, Guillaumier A, Wood W, et al. Integrating smoking cessation care into routine service delivery in a medically supervised injecting facility: An acceptability study. Addictive Behaviors, 2018; 84:193–200. Available from: https://www.ncbi.nlm.nih.gov/pubmed/29723802 

202. Guillaumier A, Skelton E, Tzelepis F, D'Este C, Paul C, et al. Patterns and predictors of nicotine replacement therapy use among alcohol and other drug clients enrolled in a smoking cessation randomised controlled trial. Addictive Behaviors, 2021; 119:106935. Available from: https://www.ncbi.nlm.nih.gov/pubmed/33848758 

203. Martinez C, Guydish J, Le T, Tajima B, and Passalacqua E. Predictors of quit attempts among smokers enrolled in substance abuse treatment. Addictive Behaviors, 2015; 40:1–6. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25218064 

204. McPherson S, Orr M, Lederhos C, McDonell M, Leickly E, et al. Decreases in smoking during treatment for methamphetamine-use disorders: preliminary evidence. Behav Pharmacol, 2018; 29(4):370–4. Available from: https://www.ncbi.nlm.nih.gov/pubmed/29035917 

205. Thurgood SL, McNeill A, Clark-Carter D, and Brose LS. A systematic review of smoking cessation interventions for adults in substance abuse treatment or recovery. Nicotine & Tobacco Research, 2016; 18(5):993–1001. Available from: https://www.ncbi.nlm.nih.gov/pubmed/26069036 

206. Khara M and Okoli CT. The tobacco-dependence clinic: intensive tobacco-dependence treatment in an addiction services outpatient setting. American Journal on Addictions, 2011; 20(1):45–55. Available from: https://www.ncbi.nlm.nih.gov/pubmed/21175920 

207. Zawertailo L, Ivanova A, Ng G, Le Foll B, and Selby P. Safety and efficacy of varenicline for smoking cessation in alcohol-dependent smokers in concurrent treatment for alcohol use disorder: A pilot, randomized placebo-controlled trial. J Clin Psychopharmacol, 2020; 40(2):130–6. Available from: https://www.ncbi.nlm.nih.gov/pubmed/32068562 

208. Fucito LM, Toll BA, Wu R, Romano DM, Tek E, et al. A preliminary investigation of varenicline for heavy drinking smokers. Psychopharmacology (Berl), 2011; 215(4):655–63. Available from: https://www.ncbi.nlm.nih.gov/pubmed/21221531 

209. Hurt RT, Ebbert JO, Croghan IT, Schroeder DR, Hurt RD, et al. Varenicline for tobacco-dependence treatment in alcohol-dependent smokers: A randomized controlled trial. Drug and Alcohol Dependence, 2018; 184:12–7. Available from: https://www.ncbi.nlm.nih.gov/pubmed/29324248 

210. O'Malley SS, Zweben A, Fucito LM, Wu R, Piepmeier ME, et al. Effect of varenicline combined with medical management on alcohol use disorder with comorbid cigarette smoking: A randomized clinical trial. JAMA Psychiatry, 2018; 75(2):129–38. Available from: https://www.ncbi.nlm.nih.gov/pubmed/29261824 

211. Ray LA, Green R, Enders C, Leventhal AM, Grodin EN, et al. Efficacy of Combining Varenicline and Naltrexone for Smoking Cessation and Drinking Reduction: A Randomized Clinical Trial. American Journal of Psychiatry, 2021; 178(9):818–28. Available from: https://www.ncbi.nlm.nih.gov/pubmed/34080890 

212. Hays JT, Hurt RD, Decker PA, Croghan IT, Offord KP, et al. A randomized, controlled trial of bupropion sustained-release for preventing tobacco relapse in recovering alcoholics. Nicotine & Tobacco Research, 2009; 11(7):859–67. Available from: https://www.ncbi.nlm.nih.gov/pubmed/19483180 

213. Guo K, Li J, Li J, Chen N, Li Y, et al. The effects of pharmacological interventions on smoking cessation in people with alcohol dependence: A systematic review and meta-analysis of nine randomized controlled trials. International Journal of Clinical Practice, 2021; 75(11):e14594. Available from: https://www.ncbi.nlm.nih.gov/pubmed/34228852 

214. Poling J, Rounsaville B, Gonsai K, Severino K, and Sofuoglu M. The safety and efficacy of varenicline in cocaine using smokers maintained on methadone: a pilot study. American Journal on Addictions, 2010; 19(5):401–8. Available from: https://www.ncbi.nlm.nih.gov/pubmed/20716302 

215. Yee A, Hoong MC, Joyce YC, and Loh HS. Smoking cessation among methadone-maintained patients: A meta-analysis. Substance Use and Misuse, 2018; 53(2):276–85. Available from: https://www.ncbi.nlm.nih.gov/pubmed/28857640 

216. Drummond MB, Astemborski J, Lambert AA, Goldberg S, Stitzer ML, et al. A randomized study of contingency management and spirometric lung age for motivating smoking cessation among injection drug users. BMC Public Health, 2014; 14:761. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25074396 

217. Rohsenow DJ, Tidey JW, Martin RA, Colby SM, Sirota AD, et al. Contingent vouchers and motivational interviewing for cigarette smokers in residential substance abuse treatment. Journal of Substance Abuse Treatment, 2015; 55:29–38. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25805668 

218. Cooney JL, Cooper S, Grant C, Sevarino K, Krishnan-Sarin S, et al. A randomized trial of contingency management for smoking cessation during intensive outpatient alcohol treatment. Journal of Substance Abuse Treatment, 2017; 72:89–96. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27542442 

219. Aonso-Diego G, Gonzalez-Roz A, Krotter A, Garcia-Perez A, and Secades-Villa R. Contingency management for smoking cessation among individuals with substance use disorders: In-treatment and post-treatment effects. Addictive Behaviors, 2021; 119:106920. Available from: https://www.ncbi.nlm.nih.gov/pubmed/33798921 

220. Alessi SM, Petry NM, and Urso J. Contingency management promotes smoking reductions in residential substance abuse patients. Journal of Applied Behavior Analysis, 2008; 41(4):617–22. Available from: https://www.ncbi.nlm.nih.gov/pubmed/19192865 

221. Dunn K, Sigmon S, Thomas C, Heil S, and Higgins S. Voucher-based contingent reinforcement of smoking abstinence among methadone-maintained patients: a pilot study. Journal of Applied Behavior Analysis, 2008; 41(4):527–38. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19192857 

222. Dunn KE, Sigmon SC, Reimann EF, Badger GJ, Heil SH, et al. A contingency-management intervention to promote initial smoking cessation among opioid-maintained patients. Experimental and Clinical Psychopharmacology, 2010; 18(1):37–50. Available from: https://www.ncbi.nlm.nih.gov/pubmed/20158293 

223. Jackson MA, Baker AL, Gould GS, Brown AL, Dunlop AJ, et al. Smoking cessation interventions for pregnant women attending treatment for substance use disorders: A systematic review. Addiction, 2022; 117(4):847–60. Available from: https://www.ncbi.nlm.nih.gov/pubmed/34374145 

224. Alessi SM and Petry NM. Smoking reductions and increased self-efficacy in a randomized controlled trial of smoking abstinence-contingent incentives in residential substance abuse treatment patients. Nicotine & Tobacco Research, 2014; 16(11):1436–45. Available from: https://www.ncbi.nlm.nih.gov/pubmed/24935755 

225. Rohsenow DJ, Tidey JW, Kahler CW, Martin RA, Colby SM, et al. Intolerance for withdrawal discomfort and motivation predict voucher-based smoking treatment outcomes for smokers with substance use disorders. Addictive Behaviors, 2015; 43:18–24. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25531536 

226. Rohsenow DJ, Martin RA, Monti PM, Colby SM, Day AM, et al. Motivational interviewing versus brief advice for cigarette smokers in residential alcohol treatment. Journal of Substance Abuse Treatment, 2014; 46(3):346–55. Available from: https://www.ncbi.nlm.nih.gov/pubmed/24210533 

227. Kelly PJ, Baker AL, Townsend CJ, Deane FP, Callister R, et al. Healthy recovery: A pilot study of a smoking and other health behavior change intervention for people attending residential alcohol and other substance dependence treatment. Journal of Dual Diagnosis, 2019; 15(3):207–16. Available from: https://www.ncbi.nlm.nih.gov/pubmed/31122158 

228. Nguyen N, Nguyen C, and Thrul J. Digital health for assessment and intervention targeting tobacco and cannabis co-use. Curr Addict Rep, 2020; 7(3):268–79. Available from: https://www.ncbi.nlm.nih.gov/pubmed/33643768 

229. McClure JB and Lapham G. Tobacco quitline engagement and outcomes among primary care patients reporting use of tobacco or dual tobacco and cannabis: An observational study. Substance Abuse, 2021; 42(4):417–22. Available from: https://www.ncbi.nlm.nih.gov/pubmed/33270541 

230. Bowman J and Walsh R. Smoking intervention within alcohol and other drug treatment services: a selective review with suggestions for practical management. Drug and Alcohol Review, 2003; 22(1):73–82. Available from: https://onlinelibrary.wiley.com/doi/abs/10.1080/0959523021000059857 

231. Guydish J, Ziedonis D, Tajima B, Seward G, Passalacqua E, et al. Addressing Tobacco Through Organizational Change (ATTOC) in residential addiction treatment settings. Drug and Alcohol Dependence, 2012; 121(1-2):30–7. Available from: https://www.ncbi.nlm.nih.gov/pubmed/21906892 

232. Knudsen HK. Implementation of smoking cessation treatment in substance use disorder treatment settings: a review. American Journal of Drug and Alcohol Abuse, 2017; 43(2):215–25. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27314884 

233. Allsop S, Carter O, and Lenton S. Enhancing clinical research with alcohol, tobacco and cannabis problems and dependence. Drug and Alcohol Review, 2010; 29(5):483–90. Available from: https://www.ncbi.nlm.nih.gov/pubmed/20887571 

234. Kearns NT, Carl E, Stein AT, Vujanovic AA, Zvolensky MJ, et al. Posttraumatic stress disorder and cigarette smoking: A systematic review. Depress Anxiety, 2018; 35(11):1056–72. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30192425 

235. Pericot-Valverde I, Elliott RJ, Miller ME, Tidey JW, and Gaalema DE. Posttraumatic stress disorder and tobacco use: A systematic review and meta-analysis. Addictive Behaviors, 2018; 84:238–47. Available from: https://www.ncbi.nlm.nih.gov/pubmed/29753221 

236. van den Berk-Clark C, Secrest S, Walls J, Hallberg E, Lustman PJ, et al. Association between posttraumatic stress disorder and lack of exercise, poor diet, obesity, and co-occuring smoking: A systematic review and meta-analysis. Health Psychology, 2018; 37(5):407–16. Available from: https://www.ncbi.nlm.nih.gov/pubmed/29698016 

237. Mould DR and Meibohm B. Drug development of therapeutic monoclonal antibodies. BioDrugs, 2016; 30(4):275–93. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27342605 

238. Flanagan JC, Hakes JK, McClure EA, Snead AL, and Back SE. Effects of intimate partner violence, PTSD, and alcohol use on cigarette smoking in a nationally representative sample. American Journal on Addictions, 2016; 25(4):283–90. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27196699 

239. Hammett PJ, Japuntich SJ, Sherman SE, Rogers ES, Danan ER, et al. Proactive tobacco treatment for veterans with posttraumatic stress disorder. Psychol Trauma, 2021; 13(1):114–22. Available from: https://www.ncbi.nlm.nih.gov/pubmed/32614201 

240. Hawes MR, Roth KB, and Cabassa LJ. Systematic review of psychosocial smoking cessation interventions for people with serious mental illness. Journal of Dual Diagnosis, 2021; 17(3):216–35. Available from: https://www.ncbi.nlm.nih.gov/pubmed/34281493 

241. Kertes J, Stein Reisner O, Grunhaus L, Nezry R, Alcalay T, et al. Comparison of smoking cessation program registration, participation, smoking cessation medication utilization, and abstinence rates between smokers with and without schizophrenia, schizo-affective disorder, or bipolar disorder. Nicotine & Tobacco Research, 2022; 24(5):670–8. Available from: https://www.ncbi.nlm.nih.gov/pubmed/34626108 

242. Pearsall R, Smith DJ, and Geddes JR. Pharmacological and behavioural interventions to promote smoking cessation in adults with schizophrenia and bipolar disorders: a systematic review and meta-analysis of randomised trials. BMJ Open, 2019; 9(11):e027389. Available from: https://www.ncbi.nlm.nih.gov/pubmed/31784428 

243. Gilbody S, Peckham E, Bailey D, Arundel C, Heron P, et al. Smoking cessation in severe mental illness: combined long-term quit rates from the UK SCIMITAR trials programme. The British Journal of Psychiatry, 2021; 218(2):95–7. Available from: https://www.ncbi.nlm.nih.gov/pubmed/31685048 

244. Peckham E, Arundel C, Bailey D, Crosland S, Fairhurst C, et al. A bespoke smoking cessation service compared with treatment as usual for people with severe mental ill health: the SCIMITAR+ RCT. Health Technology Assessment, 2019; 23(50):1–116. Available from: https://www.ncbi.nlm.nih.gov/pubmed/31549622 

245. Spanakis P, Peckham E, Young B, Heron P, Bailey D, et al. A systematic review of behavioural smoking cessation interventions for people with severe mental ill health-what works? Addiction, 2022; 117(6):1526–42. Available from: https://www.ncbi.nlm.nih.gov/pubmed/34697848 

246. Baker AL, Richmond R, Kay-Lambkin FJ, Filia SL, Castle D, et al. Randomised controlled trial of a healthy lifestyle intervention among smokers with psychotic disorders: Outcomes to 36 months. Australian and New Zealand Journal of Psychiatry, 2018; 52(3):239–52. Available from: https://www.ncbi.nlm.nih.gov/pubmed/28610482 

247. Sharma R, Alla K, Pfeffer D, Meurk C, Ford P, et al. An appraisal of practice guidelines for smoking cessation in people with severe mental illness. Australian and New Zealand Journal of Psychiatry, 2017; 51(11):1106–20. Available from: https://www.ncbi.nlm.nih.gov/pubmed/28859486 

248. Jackson JG, Diaz FJ, Lopez L, and de Leon J. A combined analysis of worldwide studies demonstrates an association between bipolar disorder and tobacco smoking behaviors in adults. Bipolar Disorders, 2015; 17(6):575–97. Available from: https://www.ncbi.nlm.nih.gov/pubmed/26238269 

249. George TP, Wu BS, and Weinberger AH. A review of smoking cessation in bipolar disorder: Implications for future research. Journal of Dual Diagnosis, 2012; 8(2):126–30. Available from: https://www.ncbi.nlm.nih.gov/pubmed/22737046 

250. Slyepchenko A, Brunoni AR, McIntyre RS, Quevedo J, and Carvalho AF. The adverse effects of smoking on health outcomes in bipolar disorder: A review and synthesis of biological mechanisms. Curr Mol Med, 2016; 16(2):187–205. Available from: https://www.ncbi.nlm.nih.gov/pubmed/26812916 

251. Thomson D, Berk M, Dodd S, Rapado-Castro M, Quirk SE, et al. Tobacco use in bipolar disorder. Clinical Psychopharmacology and Neuroscience, 2015; 13(1):1–11. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25912533 

252. Weinberger AH, Vessicchio JC, Sacco KA, Creeden CL, Chengappa KN, et al. A preliminary study of sustained-release bupropion for smoking cessation in bipolar disorder. J Clin Psychopharmacol, 2008; 28(5):584–7. Available from: https://www.ncbi.nlm.nih.gov/pubmed/18794666 

253. Wu BS, Weinberger AH, Mancuso E, Wing VC, Haji-Khamneh B, et al. A preliminary feasibility study of varenicline for smoking cessation in bipolar disorder. Journal of Dual Diagnosis, 2012; 8(2):131–2. Available from: https://www.ncbi.nlm.nih.gov/pubmed/22962546 

254. Evins AE, Cather C, Pratt SA, Pachas GN, Hoeppner SS, et al. Maintenance treatment with varenicline for smoking cessation in patients with schizophrenia and bipolar disorder: a randomized clinical trial. Journal of the American Medical Association, 2014; 311(2):145–54. Available from: https://www.ncbi.nlm.nih.gov/pubmed/24399553 

255. Chengappa KN, Perkins KA, Brar JS, Schlicht PJ, Turkin SR, et al. Varenicline for smoking cessation in bipolar disorder: a randomized, double-blind, placebo-controlled study. Journal of Clinical Psychiatry, 2014; 75(7):765–72. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25006684 

256. Heffner JL, Evins AE, Russ C, Lawrence D, Ayers CR, et al. Safety and efficacy of first-line smoking cessation pharmacotherapies in bipolar disorders: Subgroup analysis of a randomized clinical trial. J Affect Disord, 2019; 256:267–77. Available from: https://www.ncbi.nlm.nih.gov/pubmed/31195244 

257. Heffner JL, Mull KE, Watson NL, McClure JB, and Bricker JB. Smokers with bipolar disorder, other affective disorders, and no mental health conditions: Comparison of baseline characteristics and success at quitting in a large 12-month behavioral intervention randomized trial. Drug and Alcohol Dependence, 2018; 193:35–41. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30340143 

258. Heffner JL, Kelly MM, Waxmonsky J, Mattocks K, Serfozo E, et al. Pilot randomized controlled trial of web-delivered acceptance and commitment therapy versus Smokefree.Gov for smokers with bipolar disorder. Nicotine & Tobacco Research, 2020; 22(9):1543–52. Available from: https://www.ncbi.nlm.nih.gov/pubmed/31883336 

259. McGrath JJ and Susser ES. New directions in the epidemiology of schizophrenia. Medical Journal of Australia, 2009; 190(S4):S7–9. Available from: https://www.ncbi.nlm.nih.gov/pubmed/19220176 

260. de Leon J and Diaz FJ. A meta-analysis of worldwide studies demonstrates an association between schizophrenia and tobacco smoking behaviors. Schizophr Res, 2005; 76(2-3):135–57. Available from: https://www.ncbi.nlm.nih.gov/pubmed/15949648 

261. Williams J and Ziedonis D. Addressing tobacco among individuals with a mental illness or an addiction. Addictive Behaviors, 2004; 29(6):1067–83. Available from: https://pubmed.ncbi.nlm.nih.gov/15236808/ 

262. Williams JM, Gandhi KK, Lu SE, Kumar S, Steinberg ML, et al. Shorter interpuff interval is associated with higher nicotine intake in smokers with schizophrenia. Drug and Alcohol Dependence, 2011; 118(2-3):313–9. Available from: https://www.ncbi.nlm.nih.gov/pubmed/21596491 

263. Callaghan RC, Veldhuizen S, Jeysingh T, Orlan C, Graham C, et al. Patterns of tobacco-related mortality among individuals diagnosed with schizophrenia, bipolar disorder, or depression. Journal of Psychiatric Research, 2014; 48(1):102–10. Available from: https://www.ncbi.nlm.nih.gov/pubmed/24139811 

264. Cocks N, Brophy L, Segan C, Stratford A, Jones S, et al. Psychosocial factors affecting smoking cessation among people living with schizophrenia: A lived experience lens. Front Psychiatry, 2019; 10:565. Available from: https://www.ncbi.nlm.nih.gov/pubmed/31474884 

265. Zeng LN, Zong QQ, Zhang L, Feng Y, Ng CH, et al. Worldwide prevalence of smoking cessation in schizophrenia patients: A meta-analysis of comparative and observational studies. Asian J Psychiatr, 2020; 54:102190. Available from: https://www.ncbi.nlm.nih.gov/pubmed/32622029 

266. Williams JM and Foulds J. Successful tobacco dependence treatment in schizophrenia. American Journal of Psychiatry, 2007; 164(2):222–7; quiz 373. Available from: https://www.ncbi.nlm.nih.gov/pubmed/17267783 

267. Kelly DL, Raley HG, Lo S, Wright K, Liu F, et al. Perception of smoking risks and motivation to quit among nontreatment-seeking smokers with and without schizophrenia. Schizophrenia Bulletin, 2012; 38(3):543–51. Available from: https://www.ncbi.nlm.nih.gov/pubmed/21041835 

268. Williams JM and Ziedonis DM. Snuffing out tobacco dependence. Ten reasons behavioral health providers need to be involved. Behav Healthc, 2006; 26(5):27–31. Available from: https://www.ncbi.nlm.nih.gov/pubmed/16736916 

269. Tsoi DT, Porwal M, and Webster AC. Interventions for smoking cessation and reduction in individuals with schizophrenia. Cochrane Database of Systematic Reviews, 2013; 2(2):CD007253. Available from: https://www.ncbi.nlm.nih.gov/pubmed/23450574 

270. Oluwoye O, Monroe-DeVita M, Burduli E, Chwastiak L, McPherson S, et al. Impact of tobacco, alcohol and cannabis use on treatment outcomes among patients experiencing first episode psychosis: Data from the national RAISE-ETP study. Early Interv Psychiatry, 2019; 13(1):142–6. Available from: https://www.ncbi.nlm.nih.gov/pubmed/29356438 

271. Clark V, Conrad AM, Lewin TJ, Baker AL, Halpin SA, et al. Addiction vulnerability: Exploring relationships among cigarette smoking, substance misuse, and early psychosis. Journal of Dual Diagnosis, 2018; 14(2):78–88. Available from: https://www.ncbi.nlm.nih.gov/pubmed/29261427 

272. Curtis J, Zhang C, McGuigan B, Pavel-Wood E, Morell R, et al. y-QUIT: Smoking prevalence, engagement, and effectiveness of an individualized smoking cessation intervention in youth with severe mental illness. Front Psychiatry, 2018; 9:683. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30618864 

273. Baker A, Richmond R, Lewin TJ, and Kay-Lambkin F. Cigarette smoking and psychosis: naturalistic follow up 4 years after an intervention trial. Australian and New Zealand Journal of Psychiatry, 2010; 44(4):342–50. Available from: https://www.ncbi.nlm.nih.gov/pubmed/20307166 

274. Miyauchi M, Kishida I, Suda A, Shiraishi Y, Fujibayashi M, et al. Long term effects of smoking cessation in hospitalized schizophrenia patients. BMC Psychiatry, 2017; 17(1):87. Available from: https://www.ncbi.nlm.nih.gov/pubmed/28270120 

275. Kishi T and Iwata N. Varenicline for smoking cessation in people with schizophrenia: systematic review and meta-analysis. European Archives of Psychiatry and Clinical Neuroscience, 2015; 265(3):259–68. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25283510 

276. Stubbs B, Vancampfort D, Bobes J, De Hert M, and Mitchell AJ. How can we promote smoking cessation in people with schizophrenia in practice? A clinical overview. Acta Psychiatrica Scandinavica, 2015; 132(2):122–30. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25754402 

277. Evins AE and Cather C. Effective cessation strategies for smokers with schizophrenia. Int Rev Neurobiol, 2015; 124:133–47. Available from: https://www.ncbi.nlm.nih.gov/pubmed/26472528 

278. US Food and Drug Administration (FDA). Joint Meeting of the Psychopharmacologic Drugs Advisory Committee and Drug Safety and Risk Management Advisory Committee. 2016. Available from: http://www.fda.gov/downloads/AdvisoryCommittees/CommitteesMeetingMaterials/Drugs/PsychopharmacologicDrugsAdvisoryCommittee/UCM520103.pdf 

279. Jeon DW, Shim JC, Kong BG, Moon JJ, Seo YS, et al. Adjunctive varenicline treatment for smoking reduction in patients with schizophrenia: A randomized double-blind placebo-controlled trial. Schizophr Res, 2016; 176(2-3):206–11. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27543252 

280. Smith RC, Amiaz R, Si TM, Maayan L, Jin H, et al. Varenicline effects on smoking, cognition, and psychiatric symptoms in schizophrenia: A double-blind randomized trial. PLoS One, 2016; 11(1):e0143490. Available from: https://www.ncbi.nlm.nih.gov/pubmed/26730716 

281. Shawen AE and Drayton SJ. Review of pharmacotherapy for smoking cessation in patients with schizophrenia. Ment Health Clin, 2018; 8(2):78–85. Available from: https://www.ncbi.nlm.nih.gov/pubmed/29955550 

282. Wu Q, Gilbody S, Peckham E, Brabyn S, and Parrott S. Varenicline for smoking cessation and reduction in people with severe mental illnesses: Systematic review and meta-analysis. Addiction, 2016; 111(9):1554–67. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27043328 

283. Ahmed S, Virani S, Kotapati VP, Bachu R, Adnan M, et al. Efficacy and Safety of Varenicline for Smoking Cessation in Schizophrenia: A Meta-Analysis. Front Psychiatry, 2018; 9:428. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30283363 

284. Siskind DJ, Wu BT, Wong TT, Firth J, and Kisely S. Pharmacological interventions for smoking cessation among people with schizophrenia spectrum disorders: a systematic review, meta-analysis, and network meta-analysis. Lancet Psychiatry, 2020; 7(9):762–74. Available from: https://www.ncbi.nlm.nih.gov/pubmed/32828166 

285. Cather C, Pachas GN, Cieslak KM, and Evins AE. Achieving smoking cessation in individuals with schizophrenia: Special considerations. CNS Drugs, 2017; 31(6):471–81. Available from: https://www.ncbi.nlm.nih.gov/pubmed/28550660 

286. Kozak K and George TP. Pharmacotherapy for smoking cessation in schizophrenia: a systematic review. Expert Opin Pharmacother, 2020; 21(5):581–90. Available from: https://www.ncbi.nlm.nih.gov/pubmed/32011186 

287. Pinho S, Rocha V, and Vieira-Coelho MA. Effectiveness of multimodal interventions focused on smoking cessation in patients with schizophrenia: A systematic review. Schizophr Res, 2021; 231:145–53. Available from: https://www.ncbi.nlm.nih.gov/pubmed/33857662 

288. Rajalu BM, Jayarajan D, Muliyala KP, Sharma P, Gandhi S, et al. Non-pharmacological interventions for smoking in persons with schizophrenia spectrum disorders - A systematic review. Asian J Psychiatr, 2021; 56:102530. Available from: https://www.ncbi.nlm.nih.gov/pubmed/33465747 

289. Ding JB and Hu K. Cigarette smoking and schizophrenia: Etiology, clinical, pharmacological, and treatment implications. Schizophr Res Treatment, 2021; 2021:7698030. Available from: https://www.ncbi.nlm.nih.gov/pubmed/34938579 

290. Scott JG, Matuschka L, Niemela S, Miettunen J, Emmerson B, et al. Evidence of a causal relationship between smoking tobacco and schizophrenia spectrum disorders. Front Psychiatry, 2018; 9:607. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30515111 

291. Skelton E, Tzelepis F, Shakeshaft A, Guillaumier A, Dunlop A, et al. Smoking cessation care provision in Australian alcohol and other drug treatment services: A cross-sectional survey of staff self-reported practices. Journal of Substance Abuse Treatment, 2017; 77:101–6. Available from: https://www.ncbi.nlm.nih.gov/pubmed/28476261 

292. Sharma R, Meurk C, Bell S, Ford P, and Gartner C. Australian mental health care practitioners' practices and attitudes for encouraging smoking cessation and tobacco harm reduction in smokers with severe mental illness. International Journal of Mental Health Nursing, 2018; 27(1):247–57. Available from: https://www.ncbi.nlm.nih.gov/pubmed/28160384 

293. Abrantes A, Strong D, Lloyd-Richardson E, Niaura R, Kahler C, et al. Regular exercise as a protective factor in relapse following smoking cessation treatment. American Journal on Addictions, 2009; 18(1):100–1. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19219672 

294. Ratschen E, Britton J, Doody GA, Leonardi-Bee J, and McNeill A. Tobacco dependence, treatment and smoke-free policies: a survey of mental health professionals' knowledge and attitudes. General Hospital Psychiatry, 2009; 31(6):576–82. Available from: https://www.ncbi.nlm.nih.gov/pubmed/19892217 

295. Skelton E, Tzelepis F, Shakeshaft A, Guillaumier A, Dunlop A, et al. Addressing tobacco in Australian alcohol and other drug treatment settings: a cross-sectional survey of staff attitudes and perceived barriers. Substance Abuse Treatment, Prevention, and Policy, 2017; 12(1):20. Available from: https://www.ncbi.nlm.nih.gov/pubmed/28464898 

296. Wye P, Bowman J, Wiggers J, Baker A, Carr V, et al. Providing nicotine dependence treatment to psychiatric inpatients: the views of Australian nurse managers. J Psychiatr Ment Health Nurs, 2010; 17(4):319–27. Available from: https://www.ncbi.nlm.nih.gov/pubmed/20529182 

297. Pagano A, Tajima B, and Guydish J. Barriers and facilitators to tobacco cessation in a nationwide sample of addiction treatment programs. Journal of Substance Abuse Treatment, 2016; 67:22–9. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27296658 

298. Sheals K, Tombor I, McNeill A, and Shahab L. A mixed-method systematic review and meta-analysis of mental health professionals' attitudes toward smoking and smoking cessation among people with mental illnesses. Addiction, 2016; 111(9):1536–53. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27003925 

299. Minian N, Noormohamed A, Lingam M, Zawertailo L, Le Foll B, et al. Integrating a brief alcohol intervention with tobacco addiction treatment in primary care: qualitative study of health care practitioner perceptions. Addiction Science & Clinical Practice, 2021; 16(1):17. Available from: https://www.ncbi.nlm.nih.gov/pubmed/33726843 

300. Malone V, Harrison R, and Daker-White G. Mental health service user and staff perspectives on tobacco addiction and smoking cessation: A meta-synthesis of published qualitative studies. J Psychiatr Ment Health Nurs, 2018; 25(4):270–82. Available from: https://www.ncbi.nlm.nih.gov/pubmed/29498459 

301. Short B, Giles L, Karageorge A, and Bauer L. Exploring and reorienting psychiatrists' attitudes regarding smoking cessation and its potential to improve mental health outcomes: a pilot study. Australas Psychiatry, 2021; 29(6):663–7. Available from: https://www.ncbi.nlm.nih.gov/pubmed/34488489 

302. Johnson JL, Malchy LA, Ratner PA, Hossain S, Procyshyn RM, et al. Community mental healthcare providers' attitudes and practices related to smoking cessation interventions for people living with severe mental illness. Patient Education and Counseling, 2009; 77(2):289–95. Available from: https://www.ncbi.nlm.nih.gov/pubmed/19398293 

303. Schwindt RG, McNelis AM, and Sharp D. Evaluation of a theory-based education program to motivate nursing students to intervene with their seriously mentally ill clients who use tobacco. Archives of Psychiatric Nursing, 2014; 28(4):277–83. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25017562 

304. Williams JM, Stroup TS, Brunette MF, and Raney LE. Tobacco use and mental illness: a wake-up call for psychiatrists. Psychiatric Services, 2014; 65(12):1406–8. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25270381 

305. Cerimele JM, Halperin AC, and Saxon AJ. Tobacco use treatment in primary care patients with psychiatric illness. Journal of the American Board of Family Medicine, 2014; 27(3):399–410. Available from: https://www.ncbi.nlm.nih.gov/pubmed/24808119 

306. Mitchell AJ, Vancampfort D, De Hert M, and Stubbs B. Do people with mental illness receive adequate smoking cessation advice? A systematic review and meta-analysis. General Hospital Psychiatry, 2015; 37(1):14–23. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25510845 

307. Shi Y. Smoking cessation among people seeking mental health treatment. Psychiatric Services, 2014; 65(7):957–60. Available from: https://www.ncbi.nlm.nih.gov/pubmed/26037007 

308. Rogers E and Sherman S. Tobacco use screening and treatment by outpatient psychiatrists before and after release of the American Psychiatric Association treatment guidelines for nicotine dependence. American Journal of Public Health, 2014; 104(1):90–5. Available from: https://www.ncbi.nlm.nih.gov/pubmed/24228666 

309. Taylor GMJ, Itani T, Thomas KH, Rai D, Jones T, et al. Prescribing prevalence, effectiveness, and mental health safety of smoking cessation medicines in patients with mental disorders. Nicotine & Tobacco Research, 2020; 22(1):48–57. Available from: https://www.ncbi.nlm.nih.gov/pubmed/31289809 

310. Metse AP, Wiggers J, Wye P, and Bowman JA. Patient receipt of smoking cessation care in four Australian acute psychiatric facilities. International Journal of Mental Health Nursing, 2018; 27(5):1556–63. Available from: https://www.ncbi.nlm.nih.gov/pubmed/29573164 

311. [No authors listed]. An official position statement of the Association of Women’s Health, Obstetric & Neonatal Nursing. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 2010; 39(5):611–3. Available from: http://onlinelibrary.wiley.com/doi/10.1111/j.1552-6909.2010.01178.x/full 

312. McFall M, Saxon AJ, Malte CA, Chow B, Bailey S, et al. Integrating tobacco cessation into mental health care for posttraumatic stress disorder: a randomized controlled trial. Journal of the American Medical Association, 2010; 304(22):2485–93. Available from: https://www.ncbi.nlm.nih.gov/pubmed/21139110 

313. Quit Victoria. Mental health settings. Available from: https://www.quit.org.au/resources/mental-health/ 

314. Adams CE, Baillie LE, and Copeland AL. The Smoking-Related Weight and Eating Episodes Test (SWEET): development and preliminary validation. Nicotine & Tobacco Research, 2011; 13(11):1123–31. Available from: https://www.ncbi.nlm.nih.gov/pubmed/21849410 

315. Ashton M. Policy within mental health services- pro-actively addressing tobacco. in The Mental Health Service Conference. Sydney. Year.

316. Skelton E, Tzelepis F, Shakeshaft A, Guillaumier A, Wood W, et al. Integrating smoking cessation care into a medically supervised injecting facility using an organizational change intervention: A qualitative study of staff and client views. International Journal of Environmental Research and Public Health, 2019; 16(11). Available from: https://www.ncbi.nlm.nih.gov/pubmed/31185619 

317. Wye P, Bowman J, Wiggers J, Baker A, Carr V, et al. An audit of the prevalence of recorded nicotine dependence treatment in an Australian psychiatric hospital. Australian and New Zealand Journal of Public Health, 2010; 34(3):298–303. Available from: https://www.ncbi.nlm.nih.gov/pubmed/20618273 

318. Wye PM, Bowman JA, Wiggers JH, Baker A, Knight J, et al. Smoking restrictions and treatment for smoking: policies and procedures in psychiatric inpatient units in Australia. Psychiatric Services, 2009; 60(1):100–7. Available from: https://www.ncbi.nlm.nih.gov/pubmed/19114578 

319. Abrams DB, Graham AL, Levy DT, Mabry PL, and Orleans CT. Boosting population quits through evidence-based cessation treatment and policy. American Journal of Preventive Medicine, 2010; 38(3 Suppl):S351–63. Available from: https://www.ncbi.nlm.nih.gov/pubmed/20176308 

320. Shmueli D, Fletcher L, Hall S, Hall S, and Prochaska J. Changes in psychiatric patients' thoughts about quitting smoking during a smoke-free hospitalization. Nicotine & Tobacco Research, 2008; 10(5):875–81. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18569762 

321. Keizer I, Descloux V, and Eytan A. Variations in smoking after admission to psychiatric inpatient units and impact of a partial smoking ban on smoking and on smoking-related perceptions. Int J Soc Psychiatry, 2009; 55(2):109–23. Available from: https://www.ncbi.nlm.nih.gov/pubmed/19240201 

322. Stockings EA, Bowman JA, Prochaska JJ, Baker AL, Clancy R, et al. The impact of a smoke-free psychiatric hospitalization on patient smoking outcomes: a systematic review. Australian and New Zealand Journal of Psychiatry, 2014; 48(7):617–33. Available from: https://www.ncbi.nlm.nih.gov/pubmed/24819934 

323. Leyro TM, Hall SM, Hickman N, Kim R, Hall SE, et al. Clinical management of tobacco dependence in inpatient psychiatry: provider practices and patient utilization. Psychiatric Services, 2013; 64(11):1161–5. Available from: https://www.ncbi.nlm.nih.gov/pubmed/24185538 

324. Prochaska JJ, Fletcher L, Hall SE, and Hall SM. Return to smoking following a smoke-free psychiatric hospitalization. American Journal on Addictions, 2006; 15(1):15–22. Available from: https://www.ncbi.nlm.nih.gov/pubmed/16449089 

325. Vorspan F, Bloch V, Guillem E, Dupuy G, Pirnay S, et al. Smoking ban in a psychiatry department: are nonsmoking employees less exposed to environmental tobacco smoke? European Psychiatry, 2009; 24(8):529–32. Available from: https://www.ncbi.nlm.nih.gov/pubmed/19540729 

326. Stockings EA, Bowman JA, Bartlem KM, McElwaine KM, Baker AL, et al. Implementation of a smoke-free policy in an inpatient psychiatric facility: Patient-reported adherence, support, and receipt of nicotine-dependence treatment. International Journal of Mental Health Nursing, 2015; 24(4):342–9. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25970237 

327. Filia SL, Gurvich CT, Horvat A, Shelton CL, Katona LJ, et al. Inpatient views and experiences before and after implementing a totally smoke-free policy in the acute psychiatry hospital setting. International Journal of Mental Health Nursing, 2015; 24(4):350–9. Available from: https://www.ncbi.nlm.nih.gov/pubmed/26189488 

328. Magor-Blatch LE and Rugendyke AR. Going smoke-free: attitudes of mental health professionals to policy change. J Psychiatr Ment Health Nurs, 2016; 23(5):290–302. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27278902 

329. Dean TD, Cross W, and Munro I. An exploration of the perspectives of associate nurse unit managers regarding the implementation of smoke-free policies in adult mental health inpatient units. Issues Ment Health Nurs, 2018; 39(4):328–36. Available from: https://www.ncbi.nlm.nih.gov/pubmed/29436879 

330. de Oliveira RM and Furegato AR. The decreasing number of cigarettes during psychiatric hospitalization: intervention or punishment? Revista Brasileira de Enfermagem, 2015; 68(1):69–76, –83. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25946498 

331. Chapman S. A complete smoking ban in psychiatric hospitals is ethically wrong. British Medical Journal, 2015; 351:h6288. Available from: https://www.ncbi.nlm.nih.gov/pubmed/26607749 

332. Arnott D, Wessely S, and Fitzpatrick M. Should psychiatric hospitals completely ban smoking? British Medical Journal, 2015; 351:h5654. Available from: https://www.ncbi.nlm.nih.gov/pubmed/26536887