All providers of mental health services are in a unique position to provide tobacco cessation interventions due to expertise in behavior change and interpersonal counseling.
Who are Mental Health Professionals?
Mental health professionals include psychiatrists, psychologists, psychiatric nurses, social workers, licensed therapists, addiction counselors, and other licensed counselors.1
Screening for Tobacco Use and Dependence
Screening for tobacco use and dependence is one of the most important first steps for mental health professionals in the treatment of their patients’ tobacco dependence. Screening is simple, takes only a few minutes, and allows mental health professionals to better understand the overall health of their patients. Unfortunately, many mental health professionals do not currently screen their patients for tobacco use and dependence.
- In a study done by Philips and Brandon (2004), less than one in three of 256 psychologists reported asking all of their clients about smoking; thus, smokers who could potentially benefit from treatment remained unidentified and missed the opportunity to receive cessation help.2
- In another study done in 2010, over two thirds of the surveyed mental health workers felt being involved in their patients’ smoking cessation was important, but only about a quarter of those surveyed actually addressed tobacco use with their patients.3
For more information on screening, go to the page on Screening, Brief Intervention, Referral, and Treatment (SBIRT).
Treating Tobacco Use and Dependence (TTUD)4
In a 2010 study, 80.0% of people with schizophrenia, 68.8% of people with bipolar disorder, and 46.0% of people with generalized anxiety disorder currently smoke. Therefore, mental health professionals must have resources available to provide a smoking cessation intervention.5 Treating Tobacco Use and Dependence (TTUD)4, a clinical practice guideline, was published to assist clinicians in implementing effective tobacco cessation interventions. This guideline recommends that all clinicians should have a systematic routine for identifying smokers. There are five steps involved in providing a minimal intervention, called the "5 A's": Ask, Advise, Assess, Assist, and Arrange, which are explained individually in detail on our Brief Interventions page. Despite the introduction of the TTUD4, research has found that the recommendations have not been widely implemented by psychologists.
- A Kentucky study found that although psychologists in that state believed that tobacco use and cessation were important to address in treatment, few reported active participation in helping clients quit and only one of three knew about the TTUD.6
- Of 143 psychologists surveyed in Oklahoma, 83.9% reported an absence of training in the assessment or treatment of tobacco use and only 14.7% knew of the TTUD.7
Resources The Smoking Cessation Leadership Center, a national program office of the Robert Wood Johnson Foundation, provides some resources to help mental health professionals promote the use of smoking cessation interventions among colleagues.
Types of Interventions
For more information on the treatment of tobacco dependence in individuals who have a Co-Occurring Mental Illness, please visit our other page.
Brief interventions are short discussions with patients about their tobacco use and dependence in order to encourage them to quit smoking and equip them with the resources necessary to do so. Brief interventions take around 5-15 minutes to carry out. Although brief interventions yield slightly lower smoking cessation rates than prolonged interventions, they are still quite effective and have the advantages of being both time- and cost-efficient. One key to the effectiveness of brief interventions is following up after the brief intervention with the individual (see Psychosocial Interventions page). Similar to screening, only a minority of mental health professionals currently carry out brief interventions with their smoking patients.8 The recommended approach is the 5 A’s method, which is described in detail on our Brief Interventions page.
- In one study done on an in-patient psychiatric unit in 2009, less than 40% of psychiatrists and nurses had advised their patients to quit smoking and less than 30% of psychiatrists and nurses had been informed of resources and ways for the patients to quit smoking.8
- In three different studies comparing brief interventions to prolonged interventions, brief interventions were found to be more cost effective than prolonged interventions, but had lower smoking cessation rates than the individuals who underwent prolonged interventions.9, 10, 11
- In a 2011 study, less than 25% of mental health counselors scheduled follow-ups to smoking cessation interventions with their patients12
Prolonged interventions include multiple counseling and assessment sessions with a mental health professional and are usually combined with bupropion or nicotine replacement treatment (NRT).15 Prolonged interventions are more effective than other interventions (i.e., brief interventions and self-help materials), but inherently require a longer time commitment from mental health professionals conducting the prolonged interventions. However, the research on the long-term effectiveness of prolonged interventions is still inconclusive.13 For more information on different forms of psychosocial interventions, visit our Psychosocial Interventions page.
- A meta-analysis done by the TTUD found that patients who had undergone high intensity counseling (more than 10 minutes) were 130% more likely to remain abstinent from smoking than patients who had no contact, whereas patients who underwent low-intensity counseling (3-10 minutes) were about 60% more likely to remain abstinent from smoking than the no-contact patients.4
- Patients who had 31-90 minutes of contact in smoking cessation interventions were about 200% more likely to remain abstinent from smoking than patients who had no contact minutes, whereas patients who only had 4-30 minutes of contact were 90% more likely to remain abstinent from smoking compared to the no contact patients.4
- Patients who had undergone more than 8 person-to-person sessions of smoking cessation therapy were 130% more likely to remain abstinent than patients who had undergone 0-1 sessions of therapy.4
- In a 2007 study of an out-patient psychiatric unit comparing brief interventions (15 minute counseling session and 5 minute follow-up) versus prolonged interventions (3 one hour counseling sessions and 8 weeks of NRT), the patients who underwent the prolonged intervention were significantly more likely to have quit smoking than those undergoing the brief intervention. However, after 6 months, no significant difference was found between the two groups.13
- In a 2010 study of individuals with mental disorders, patients who attended 10 sessions of therapy were significantly more likely to quit smoking than those who attended at least one session but less than 10 sessions of therapy, at the 12-month follow-up. Also, among the participants who attended all 10 sessions but did not quit smoking, the number of cigarettes smoked per day significantly decreased and their motivation for quitting smoking remained high at the 12 month follow-up (84% of remaining smokers wanted to quit smoking).14
- A meta-analysis of smoking cessation in individuals with severe mental illness (SMI), found that bupropion combined with group therapy is one of the most effective smoking cessation treatments for patients with SMI.15
Barriers to Success
- In a study of mental health counselors’ perceptions of smoking cessation, about 30% of the counselors cited not being trained in smoking cessation skills as a barrier to their involvement in patients’ tobacco dependence. As well, counselors who rated themselves as well prepared were significantly more likely to use the recommended 5 A’s approach than counselors who did not rate themselves as prepared.11
- From Philips & Brandon (2004),2 psychologist training should be expanded to include:
- The costs of tobacco use
- The co-occurrence of tobacco use and other mental health & substance use disorders
- The effectiveness of intervention
- The use of 5 A's interventions
Mental Health Staff’s Personal Smoking Habits
Smoking is prevalent among mental health professionals. 16 Even more specifically, smoking is more prevalent in the community of mental health nurses than in nurses of other units. As a result, mental health professionals’ own smoking habits affect their attitudes towards the smoking habits of their patients.16
- In a 2009 study comparing the attitudes of mental health nurses who smoke versus mental health nurses who don’t smoke, 83% of non-smoking nurses felt it was important that health-care facilities encourage anti-smoking , whereas only 44% of smoking nurses felt the same way.16
- In the same 2009 study, significantly more smoking nurses than non-smoking nurses felt that patients had a right to smoke at health-care facilities and should be provided designated areas to smoke.16
Myth: A smoking ban would not be beneficial to my patients or my mental health facility.
Smoking cessation interventions and policies are effective and result in mental health patients quitting smoking. Smoking bans are beneficial to the motivation and smoking habits of patients17, but some mental health professionals believe otherwise.18
- In a 2008 study where a smoking ban was implemented at a psychiatric hospital and no smoking cessation intervention was completed, patients felt significantly more likely to be successful in quitting smoking and felt that they would have significantly less difficulty quitting smoking after their hospitalization. Furthermore, patients smoked significantly fewer cigarettes per day three months after their hospitalization than before.17
- A 2010 study found that while 67% of psychiatric staff (both clinical and non-clinical) support a smoking ban, 71% of staff responded that they did not feel a smoking ban would increase the quality of care given, and 72% of staff felt that patients would continue to smoke despite the smoking ban.18
Myth: Smoking cessation will negatively affect patients’ mental health symptoms.
Many mental health professionals believe that if their patients quit smoking, the symptoms of other mental disorders will intensify. Research, however, shows this to be untrue:
- Two studies found that there were no statistically significant differences in the psychiatric symptoms between patients who quit smoking and patients who continued to smoke, both immediately after the study and after the follow-up to each study.5, 19
- Two other studies found that the psychotic and depressive symptoms of patients who had quit smoking decreased more than the patients who continued to smoke, but the differences in rates were not statistically significant.20, 21
Smoking Cessation Program for Mental Health Professionals
Fax to Assist If you are employed by a HIPAA-covered facility, please consider joining our Fax to Assist Program.
Did you know that the Medicaid population is significantly more likely to use tobacco than the general population? Do you want to enhance your skills at reaching and intervening with Medicaid patients who use tobacco? MDQuit has an online training to teach you the strategies that can be utilized will all patients—regardless of their health insurance status. You can sign-up for this FREE self-paced online training by going to https://HABITSLabTraining.litmos.com/self-signup/ and entering the training code, "medicaid".
1 Mental Health America: Types of mental health professionals. (n.d.). Mental Health America: Welcome. Retrieved March 7, 2012, from http://www.mentalhealthamerica.net/go/help/finding-help/find-treatment/t...
2 Phillips, K.M., & Brandon, T.H. (2004). Do psychologists adhere to the clinical practice guidelines for tobacco cessation? A survey of practitioners. Professional Psychology: Research and Practice, 35(3), 281-285.
3 Ashton, M., Lawn, S., & Hosking, J. R. (2010). Mental health workers’ views on addressing tobacco use. Australian & New Zealand Journal Of Psychiatry, 44(9), 846-851.
4 Fiore, M.C., Bailey, W.C., Cohen, S.J., Dorfman, S.F., Goldstein, M.G., Gritz, E.R., et al. (2000). Treating tobacco use and dependence—Clinical practice guideline. Rockville, MD: U.S. Department of Health and Human Services, Public Health Services.
5 Schroeder, S., & Morris, C. (2010). Confronting a neglected epidemic: tobacco cessation for persons with mental illnesses and substance abuse problems. Annual Review Of Public Health, 31297.
6 Miller, B.F., Lotz, C.S., Worth, C.T., Sorelll, C.L., & J.L. Studts. Knowledge, attitudes, and clinical practices involving tobacco cessation among Kentucky psychologists. Poster presented at the 2004 International Scientific Conference of The International Society for the Prevention of Tobacco Induced Diseases.
7 Leffingwell, T.R., & Babitzke, A.C. (2006). Tobacco intervention practices of licensed psychologists. Journal of Clinical Psychology, 62, 313-323.
8 Solty, H., Crockford, D., White, W. D., & Currie, S. (2009). Cigarette Smoking, Nicotine Dependence, and Motivation for Smoking Cessation in Psychiatric Inpatients. (English). Canadian Journal Of Psychiatry, 54(1), 36-45.
9 Barnett, P., Wong, W., & Hall, S. (2008). The cost-effectiveness of a smoking cessation program for out-patients in treatment for depression. Addiction, 103(5), 834-840.
10 Heather, N. (1989). Psychology and brief interventions. British Journal Of Addiction, 84(4), 357-370.
11 Sawa, M., Selvaraj, M., Brown, R., Parker, P., & Meehan, J. (2011). Brief interventions and referrals on smoking cessation. Mental Health Practice, 14(9), 30-33.
12 Sidani, J. E., Price, J. H., Dake, J. A., Jordan, T. R., & Price, J. A. (2011). Practices and Perceptions of Mental Health Counselors in Addressing Smoking Cessation. Journal Of Mental Health Counseling, 33(3), 264-282.
13 Cooney, N. L., Litt, M. D., Cooney, J. L., Pilkey, D. T., Steinberg, H. R., & Oncken, C. A. (2007). Concurrent brief versus intensive smoking intervention during alcohol dependence treatment. Psychology Of Addictive Behaviors, 21(4), 570-575.
14 Ashton, M., Miller, C. L., Bowden, J. A., & Bertossa, S. (2010). People with mental illness can tackle tobacco. Australian & New Zealand Journal Of Psychiatry, 44(11), 1021-1028.
15 Banham, L., & Gilbody, S. (2010). Smoking cessation in severe mental illness: what works?. Addiction, 105(7), 1176-1189.
16 Dwyer, T., Bradshaw, J., & Happell, B. (2009). Comparison of mental health nurses' attitudes towards smoking and smoking behaviour. International Journal Of Mental Health Nursing, 18(6), 424-433.
17 Shmueli, D., Fletcher, L., Hall, S. E., Hall, S. M., & Prochaska, J. J. (2008). Changes in psychiatric patients' thoughts about quitting smoking during a smoke-free hospitalization. Nicotine & Tobacco Research, 10(5), 875-881.
18 Wye, P., Bowman, J., Wiggers, J., Baker, A., Knight, J., Carr, V., & ... Clancy, R. (2010). Total smoking bans in psychiatric inpatient services: a survey of perceived benefits, barriers and support among staff. BMC Public Health, 10372-382.
19 Prochaska, J. J., Hall, S. M., Tsoh, J. Y., Eisendrath, S., Rossi, J. S., Redding, C. A., & ... Gorecki, J. A. (2008). Treating Tobacco Dependence in Clinically Depressed Smokers: Effect of Smoking Cessation on Mental Health Functioning. American Journal Of Public Health, 98(3), 446-448.
20 Morris, C., Waxmonsky, J., May, M., Tinkelman, D., Dickinson, M., & Giese, A. (2011). Smoking Reduction for Persons with Mental Illnesses: 6-Month Results from Community-Based Interventions. Community Mental Health Journal, 47(6), 694-702.
21 Mino, Y., Shigemi, J., Otsu, T., Tsuda, T., & Babazono, A. (2000). Does smoking cessation improve mental health?. Psychiatry & Clinical Neurosciences, 54(2), 169-172.