Position statement - The role of mental health services in supporting people experiencing mental health issues to stop smoking

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Tobacco control > Position statement - The role of mental health services in supporting people experiencing mental health issues to stop smoking

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Position statement - The role of mental health services in supporting people experiencing mental health issues to stop smoking


Key recommendations and messages

Mental health services should be encouraged to routinely ask all clients about their smoking status and offer evidence-based tailored cessation support. As part of this process services should review their policies on smoking to create supportive smokefree environments to protect both staff and clients from secondhand smoke and to support smokers who are trying to quit. Consistent with recovery principles, these supports and policies should be developed in partnership with people with a lived experience of mental health issues, their family members and carers, and service provider staff.

1. Smoking rates among people with mental health issues are much higher compared to the general population. Smoking is a significant contributor to the health and financial inequalities experienced by people with mental health issues.

2. There are a range of complex factors contributing to the higher rates of smoking among people experiencing mental health issues. These need to be understood to provide the appropriate support.

3. There is growing recognition among people experiencing mental health issues, carers and mental health services that addressing physical health is equally important as supporting mental wellbeing. In addition to improving physical health, evidence indicates that addressing smoking can improve mental health including a reduction in medication.

4. People experiencing mental illness are interested in quitting and can do so successfully with the right support. Tailored support and quitting medications have been shown to be effective for people living with mental health issues.

5. Mental health service providers can play a critical role in supporting people experiencing mental health issues to quit smoking by providing tailored quitting support and medication and by creating supportive smokefree environments.


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Background

With the growing recognition of the disproportionately high smoking rates and related harms among people experiencing mental health issues, there is a current debate about whether all mental health services should provide support for cessation as part of routine care and working towards going smokefree. Failing to address smoking has the potential to worsen health inequalities for people experiencing mental illness and further their stigmatisation. ("Mental health services" in this document includes inpatient hospital settings, forensic settings and community-managed mental health services."

Cancer Council Australia and the National Heart Foundation of Australia support the position that there are many benefits to mental health services addressing tobacco use as part of routine care and providing supportive smokefree environments. These include improved mental and physical health for many Australians experiencing mental health issues.

Cancer Council Australia and the National Heart Foundation of Australia support the development and implementation of cessation support and supportive smokefree environment policies in a manner that is consistent with recovery-oriented mental health practice and service delivery. The National Framework for Recovery-oriented Mental Health Services[1] identifies that the term ‘recovery’ in the context of mental health and wellbeing has no single description or definition because recovery is different for everyone. However, it is recognised that the principles of hope, self-determination, self-management, empowerment, advocacy and equality are critical to an individual’s journey towards recovery. These principles translate into services that are person-centred and led, strengths based and that empower individuals to exercise control over their own lives[1].

Recovery-oriented mental health services are required to strike a balance between maximising choice and positive risk taking on the one hand and (among other things) duty of care issues and promoting safety on the other[1]. It must be acknowledged that a smokefree policy(whether it is a partial or full ban) may have the effect of limiting a person’s choice to smoke in personal living spaces as well as private and shared outdoor spaces provided by a mental health service. However, as explored in this position statement, we believe there are important reasons for mental health services to provide smokefree areas in some or all areas of their service and that a smokefree policy can be developed and implemented in a manner that is consistent with recovery principles. This will involve developing and implementing smokefree policies and supports in partnership with people with a lived experience of mental health issues, their families and carers, health care providers and workers.

1. Smoking rates among people with mental health issues are much higher compared to the general population. Smoking is a significant contributor to the health and financial inequalities experienced by people with mental health issues.

Although smoking rates in Australia have been steadily declining in the general population, for some groups of people smoking rates have remained largely unchanged over the past 20 years, including for people experiencing mental health issues[2]. Approximately 32% of people experiencing mental health issues smoke[3] compared to the national rate of 12.8%[4]. Smoking rates are even higher in people experiencing severe mental illness. Over 66% amongst adults living with psychosis smoke[2] and the highest levels of smoking have been observed in psychiatric inpatient units where rates of smoking have been estimated to be 70%[5][6]. In addition smokers experiencing mental health issues are more heavily addicted to tobacco than smokers in general[6] and tend to smoke each cigarette more intensely and have an increased nicotine intake per cigarette[7][8]. It is estimated that more than 42% of all cigarettes in Australia are smoked by people experiencing mental health issues[8].

This disproportionate rate of smoking contributes to a reduction in life expectancy of 10-20 years compared to the general population[9][10][11]. The risk of excess mortality is due to higher than average rates of lung cancer, [8][12][13][14] cardiovascular disease[8][14], respiratory illness[14] and other physical illnesses[15].

Smoking also contributes to the vicious cycle of poverty and disadvantage in which many people experiencing mental illness are trapped[16]. The economic disadvantage endured as a result of unemployment and dependence on government benefits is further exacerbated by expenditure on smoking. It has been estimated that those supported by welfare benefits spend up to a third of their income on tobacco[17][18].

Although smoking may seem a low priority compared to helping people with their mental health issues, smoking causes chronic illness and premature death, contributes to social isolation and financial stress and can actually exacerbate mental health issues[19]. For these reasons, it is time to see smoking cessation support as a priority.

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2. There are a range of complex factors contributing to the higher rates of smoking among people experiencing mental health issues. These need to be understood to provide the appropriate support.

There are a range of complex factors contributing to the higher rates of smoking among people experiencing mental health issues. These include physical, psychological, social and historical factors[18][19][20].

The direction of causation between smoking and mental illness remains mixed and poorly understood[6][18]. Some research suggests that smoking causes mental illness while other research suggests that mental illness causes people to smoke. There is also some evidence that inherent factors such as genes can predispose people with mental illness and issues to addiction and to a higher risk of smoking[21].

Social factors are critical in understanding the relationship between smoking and mental health. There is a strong association between mental health issues and socio-economic disadvantage such as low income, limited education, unemployment, living in stressful environments and easy access to tobacco.(6, 21) These are all known risk factors for smoking[22]. There is also evidence that smokers experiencing mental health issues have less access to smoking cessation supports[23].

Historically a number of misconceptions and lack of awareness of the disproportionately higher smoking rates and related harms among people experiencing mental health issues have contributed to an acceptance of smoking in mental health services. Misconceptions include that smokers experiencing mental illness are not motivated to quit smoking, quitting smoking could lead to an exacerbation in symptoms, and that smoking is an effective mechanism to build therapeutic relationships between staff and patients[24][25][26][27][28][29]. A growing body of evidence has demonstrated that these beliefs are unfounded and therefore should pose no barrier to mental health services supporting their clients to quit smoking[6].

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3. There is growing recognition among people experiencing mental health issues, carers and mental health services that addressing physical health is equally important as supporting mental wellbeing. In addition to improving physical health, evidence indicates that addressing smoking can improve mental health including a reduction in medication.

Nationally and internationally within the mental health sector there has been a call to give higher priority to addressing the physical health needs of people experiencing mental health issues[6][30]. In 2014 the National Mental Health Commission’s report ‘Contributing Lives, Thriving Communities. Report of the National Review of Mental Health Programmes and Services’ recommended eight national targets including ‘more people with poor mental health will have better physical health and live longer'[31].’ To achieve this they recommended setting targets to reduce smoking rates. These recommendations and targets reinforce the recommendations made by the Expert Reference Group to the COAG Working Group on Mental Health Reforms in September 2013.

The physical health benefits of stopping smoking have been well documented but there is increasing evidence on the mental health benefits. Evidence shows that smoking is associated with higher mental health symptom burden[19] and stopping smoking can improve mental wellbeing with improvements in depression, anxiety, stress and psychological quality of life[6][32]. Research also suggests that smoking cessation does not interfere with treatment and can improve treatment outcomes [19][27][33] including decreasing the risk of rehospitalisation[34].

Smoking cessation can also result in a reduction in dosage of some medications e.g. benzodiazapines, clozapine, fluvoxamine etc[6][35]. Smoking can reduce plasma levels up to 50% and increase the rate of metabolism of several psychotropic drugs. This means that people who smoke are more likely to need higher doses of these drugs to achieve similar blood levels to non-smokers and in the event of stopping smoking reduction in dosage of medication will be needed to compensate for this effect[6].

For people experiencing mental health issues, quitting smoking can lead to benefits such as:

  • a reduction in medication and fewer medication side effects
  • lower stress levels
  • greater confidence
  • less financial pressure
  • improved wellbeing
  • a positive support to the mental health recovery process[35].

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4. People experiencing mental illness are interested in quitting and can do so successfully with the right support. Tailored support and quitting medications have been shown to be effective for people living with mental health issues.

People with mental health issues who smoke are interested and motivated to quit[12][36][37]. Studies recruited from both inpatient and outpatient psychiatric settings suggest that people experiencing mental health issues are equally as likely as the general population to want to quit smoking[33]. The preparedness to quit of smokers experiencing mental health issues appears to be unrelated to their psychiatric diagnosis, symptom severity, or the coexistence of substance use[38].

Cessation supports that work with the general population, such as combining supportive counselling with quitting medications, have also been found to be effective with people experiencing mental health issues[6][8][34][39]. Quitting medications are particularly effective in smokers with high nicotine dependence. It has been recommended that for people experiencing mental health issues tailored cessation support is required to take into account social and cultural circumstances, any mental health needs and the management and monitoring of medications[6][40]. For some, nicotine replacement therapy (NRT) may be required in high doses, for longer periods and offered with more intensive behavioural support than the general population[6][23][41]. Medication will also need to be monitored and adjusted following smoking cessation as smoking can affect the way that some drugs are metabolised[5][6]. These additional considerations can be effectively managed and pose no barrier to supporting people with mental health issues to quit.

5. Mental health service providers can play a critical role in supporting people experiencing mental health issues to quit smoking by providing tailored quitting support and medication and by creating supportive smokefree environments.

Mental health services have regular and long-term contact with clients, concern for client wellbeing, and skills in supporting behavioural change, which make them well suited to supporting people experiencing mental health issues to quit smoking[42][43][44][45]. Research shows that the integration of smoking cessation support in mental health services into existing care has been effective in reducing smoking[46][47][48][49][50]. It has been shown to produce greater engagement, greater use of cessation medicines and increased likelihood of remaining quit[18].

Adoption of supportive smokefree policies and creating smokefree areas in mental health services protect people working, living in and visiting services from secondhand smoke and reduce triggers for smoking. Creating supportive smokefree environments encourages a change in beliefs and behaviour by presenting a consistent message that smoking is harmful and that the service is committed to improving the health and wellbeing of its clients. It encourages and supports clients and staff to stop smoking altogether or cut down the number of cigarettes they smoke and enhances the effectiveness of smoking cessation supports by reducing opportunities for relapse[51]. A review of smokefree policies in inpatient settings found no increase in violence or aggression post-policy implementation[6][52][53][54]. Research has indicated that adopting a smokefree policy was associated with a positive impact, for example, fewer services reported seclusion or restraint related to smoking, coercion, and smoking related health conditions as well as no increases in elopement or fires[52][54].

The introduction of smokefree policies in public places shared by the community is generally well supported by both smoking and non-smoking community members. However, environments that constitute both workplaces for staff and personal living spaces, such as inpatient hospital settings, forensic hospital settings or private living spaces provided by a community service organisation, give rise to more complex considerations with respect to smoking. This is particularly the case in mental health settings, given the important role that empowerment and choice play in mental health recovery.

Mental health services, in partnership with people with a lived experience of mental health issues, their family members and carers, and service provider staff, should decide whether to have some or all areas in and around the service smokefree. It is important to note that research shows that total smokefree policies are more effective and easier to implement than partial smokefree policies (eg, where smoking is still permitted in outdoor areas of premise)[26][29][55]. The provision of NRT, counselling and supporting patients takes less time than that required to supervise smoking as well as distribute and collect cigarettes and lighting materials, which can be a source of conflict and incident reports[56][57].

Implementing a smokefree environments policy, in and of itself, has not been shown to have any impact on achieving smoking cessation unless it is part of a more comprehensive approach to smoking cessation. Smokefree policies need to be embedded within a larger programme that encourages and supports smokers to quit smoking including the provision of quitting medications/pharmacotherapy in combination with behavioural support[43][58].

Where smokefree environments policies have been effectively implemented in mental health services, key features have included:

  • extensive consultation and coordination;
  • staff education and support;
  • patient preparation;
  • available and effective use of nicotine replacement therapy and other quitting medications; and
  • full management support and clear leadership[50][59].

The significant harms resulting from smoking and exposure to second hand smoke mean that every person using the service as well as staff and volunteers, deserve to be provided with a smokefree environment. Supportive smokefree policies in conjunction with a comprehensive smoking cessation support can significantly contribute to a reduction in the disproportionate health inequalities in this vulnerable population. The benefits to the physical and mental health of the individual (both service user and staff member) are considerable[6][60] by providing them with choices to improve their health and welfare in a supportive, trusted environment.

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Conclusion and next steps

The serious health and financial harm caused by smoking among people experiencing mental illness needs to be addressed as a priority. It is unfair if we are less concerned about smoking among people experiencing mental illness than we are about smoking among other groups. Everyone has the right to be supported to live free from tobacco. Mental health services have a vital role to play in reducing smoking rates and thereby improving the health and wellbeing of their clients.

Cancer Council Australia and the National Heart Foundation of Australia recommend systems-level changes within mental health services including practices designed to integrate the identification of smokers and subsequent offering and receipt of evidence-based cessation treatments into routine care and providing supportive smokefree environments. Any strategy is developed in partnership with people with a lived experience of mental illness and their families and carers, and be consistent with principles of recovery.

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Recommendations

To achieve this goal Cancer Council Australia and the Heart Foundation of Australia recommends implementing a range of strategies including:

  • All people accessing a mental health service are asked about their smoking status and that this information is recorded;
  • All smokers are offered evidence based cessation support tailored to the individual’s needs and recovery principles and includes plans for cessation support post exit from the service;
  • All mental health services provide a supportive smokefree environment this includes implementing smokefree policies (partial or full bans) and providing cessation support to all clients and staff;
  • All mental health services work in partnership with staff, clients, family members and carers to design and implement any smokefree policy and accompanying support;
  • Staff are provided with training and support related to cessation support including understanding nicotine withdrawal; and
  • Mental health services provide clear and visible leadership for the preparation, successful implementation and sustainability of policy.

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References

  1. 1.0 1.1 1.2 Australian Health Ministers' Advisory Council. A National framework for recovery-oriented mental health services: policy and theory. Canberra: Commonwealth of Australia; 2013 Available from: http://www.health.gov.au/internet/main/publishing.nsf/content/mental-pubs-n-recovpol.
  2. 2.0 2.1 Morgan VA, Waterreus A, Jablensky A, Mackinnon A, McGrath JJ, Carr V, et al. People living with psychotic illness 2010: report on the second Australian national survey. Canberra: Commonwealth of Australia; 2011.
  3. Australian Bureau of Statistics. National Survey of Mental Health and Wellbeing: Summary of Results, 2007. Canberra: ABS; 2008 Available from: http://www.abs.gov.au/AUSSTATS/abs@.nsf/DetailsPage/4326.02007?OpenDocument.
  4. Australian Institute of Health and Welfare. National Drug Strategy Household Survey : Highlights from the 2013 survey. Canberra: AIHW; 2014 Available from: http://www.aihw.gov.au/alcohol-and-other-drugs/ndshs-2013/.
  5. 5.0 5.1 Campion J, Checininski K, Nurse J and McNeill A. moking by people with mental illness and benefits of smoke free mental health services. Adv Psychiatr Treat 2008;14:217-28.
  6. 6.00 6.01 6.02 6.03 6.04 6.05 6.06 6.07 6.08 6.09 6.10 6.11 6.12 6.13 Royal College of Physicians and Royal College of Psychiatrists. Smoking and mental health. London: The Lavenham Press Ltd; 2013 Available from: https://www.rcplondon.ac.uk/sites/default/files/smoking_and_mental_health_-_full_report_web.pdf.
  7. Williams J, Ziedonis D and Foulds J. Increased nicotine and cotinine levels in smokers with schizophrenia and schizoaffective illness is not a metabolic effect. Schizophr Res 2005;79:323-35.
  8. 8.0 8.1 8.2 8.3 8.4 Access Economics. Smoking and Mental Illness: Costs. Canberra: Report for SANE Australia.; 2007.
  9. Brown S, Inskip H, Barraclough B. Causes of the excess mortality of schizophrenia. Br J Psychiatry 2000 Sep;177:212-7 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/11040880.
  10. Brown S, Kim M, Mitchell C, Inskip H. Twenty-five year mortality of a community cohort with schizophrenia. Br J Psychiatry 2010 Feb;196(2):116-21 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/20118455.
  11. Australian Institute of Health and Welfare. Australia's Health 2006. Canberra: AIHW; 2006. Contract No.: Cat. No. AUS 73. Available from: http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=6442453483.
  12. 12.0 12.1 Ragg M, Ahmed T. Smoke and mirrors: a review of the literature on smoking and mental illness. Sydney: Cancer Council NSW; 2008 Available from: http://askthequestion.com.au/wp-content/uploads/2011/05/CAN-1021-Smoke-and-Mirrors.pdf.
  13. Carney C, Woolsen, R, Jones, L, Noyes, R, and Doebbeling, B. Occurrence of cancer among people with mental health claims in an insured population. Psychosom Med 2004;66:735-43. Abstract available at http://journals.lww.com/psychosomaticmedicine/Abstract/2004/09000/Occurrence_of_Cancer_Among_People_With_Mental.17.aspx.
  14. 14.0 14.1 14.2 Lawrence D, Hancock KJ, Kisely S. The gap in life expectancy from preventable physical illness in psychiatric patients in Western Australia: retrospective analysis of population based registers. BMJ 2013 May 21;346:f2539 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/23694688.
  15. Coghlan R, Lawrence D, Holman D, and Jablensky A. A Duty to Care. Physical illness in people with mental illness. Perth: University of Western Australia; 2001.
  16. Lawn S. Australians with mental illness who smoke. Br J Psychiatry 2001;178(1):85 Abstract available at http://bjp.rcpsych.org/content/178/1/85.1.
  17. Wu Q, Szatkowski L, Britton J, Parrott S. Economic cost of smoking in people with mental disorders in the UK. Tob Control 2015 Sep;24(5):462-8 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/25008858.
  18. 18.0 18.1 18.2 18.3 Ellerman D, Ford C, and Stillman S. Tobacco in Australia: Facts and Issues.4th edition. [homepage on the internet] Melbourne: Cancer Council Victoria; 2012 Available from: http://www.tobaccoinaustralia.org.au/chapter-7-cessation/7-12-smoking-and-mental-health.
  19. 19.0 19.1 19.2 19.3 Cerimele JM, Halperin AC, Saxon AJ. Tobacco use treatment in primary care patients with psychiatric illness. J Am Board Fam Med 2014 May;27(3):399-410 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/24808119.
  20. Mental Health Network NHS Confederation. Smoking and mental health: briefing. London: NHS Confederation; 2013 Available from: http://www.nhsconfed.org/~/media/Confederation/Files/Publications/Documents/smoking_mentalhealth0913.pdf.
  21. Morisano D, Bacher I, Audrain-McGovern J and George T. Mechanisms underlying the comorbidity of tobacco use in mental health and addictive disorders. Can J Psychiatry 2009;54(6):356-67.
  22. Australian National Preventive Health Agency. Smoking and Disadvantage. Evidence Brief. Canberra: Commonwealth of Australia; 2013 Available from: http://www.health.gov.au/internet/anpha/publishing.nsf/Content/667CA10FF85FD2CDCA257B8C0031F7D3/$File/Screen%20res-Smoking&Disad_ev%20brief.pdf.
  23. 23.0 23.1 Williams JM, Zimmermann MH, Steinberg ML, Gandhi KK, Delnevo C, Steinberg MB, et al. A comprehensive model for mental health tobacco recovery in new jersey. Adm Policy Ment Health 2011 Sep;38(5):368-83 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/21076862.
  24. Ratschen E, Britton J, McNeill A. The smoking culture in psychiatry: time for change. Br J Psychiatry 2011 Jan;198(1):6-7 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/21200069.
  25. Lawn S and Condon J.. Psychiatric nurses’ ethical stance on cigarette smoking by patients: determinants of and dilemmas in their role in supporting cessation. Int J Ment Health 2006;15(111):118.
  26. 26.0 26.1 Lawn S, Pols R. Smoking bans in psychiatric inpatient settings? A review of the research. Aust N Z J Psychiatry 2005 Oct;39(10):866-85 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/16168014.
  27. 27.0 27.1 Prochaska J. Smoking and mental illness: breaking the link. N Engl J Med 2011;365:196-8.
  28. Williams JM, Ziedonis D. Addressing tobacco among individuals with a mental illness or an addiction. Addict Behav 2004 Aug;29(6):1067-83 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/15236808.
  29. 29.0 29.1 Jochelsen K, and Majrwski, B. Clearing the Air: debating smoke-free policies in psychiatric units. London: Kings Fund; 2006 Available from: http://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/clearing-the-air-debating-smoke-free-policies-psychiatric-units-karen-jochelson-bill-majrowski-kings-fund-18-july-2006.pdf.
  30. National Mental Health Commission. A Contributing Life, the 2012 National Report Card on Mental Health and Suicide Prevention. Sydney: NMHC; 2012 Available from: http://www.mentalhealthcommission.gov.au/our-2013-report-card/2012-report-card.aspx.
  31. National Mental Health Commission. The National Review of Mental Health Programmes and Services. Sydney: NMHC; 2014 Available from: http://www.mentalhealthcommission.gov.au/our-reports/review-of-mental-health-programmes-and-services.aspx.
  32. Prochaska J. Quitting smoking is associated with long term improvements in mood. BMJ 2014;348(g1562) Abstract available at http://www.bmj.com/content/348/bmj.g1562.
  33. 33.0 33.1 Hall S and Prochaska JJ. Treatment of smokers with co-occurring disorders: emphasis on integration in mental health and addiction settings. Annu Rev Clin Psychol 2009;5:409-31.
  34. 34.0 34.1 Prochaska JJ, Hall SE, Delucchi K, Hall SM. Efficacy of initiating tobacco dependence treatment in inpatient psychiatry: a randomized controlled trial. Am J Public Health 2014 Aug;104(8):1557-65 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/23948001.
  35. 35.0 35.1 Baker A, Richmond R, Haile M, Lewin TJ, Carr VJ, Taylor RL, et al. A randomized controlled trial of a smoking cessation intervention among people with a psychotic disorder. Am J Psychiatry 2006 Nov;163(11):1934-42 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/17074945.
  36. Caosella A, Ossip-Klein D, and Owens C. Smoking attitudes, beliefs, and readiness to change among acute and long-term inpatients with psychiatric diagnoses. Addic Behav 1999;24:332-44.
  37. Siru R, Hulse GK, Tait RJ. Assessing motivation to quit smoking in people with mental illness: a review. Addiction 2009 May;104(5):719-33 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/19413788.
  38. Rogers A, and Pilgrim D.. Mental Health and Inequality. Hampshire: Palgrave Macmillan; 2003.
  39. Banham L, Gilbody S. Smoking cessation in severe mental illness: what works? Addiction 2010 Jul;105(7):1176-89 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/20491721.
  40. Gierisch J, Bastian L, Calhoun P, McDuffe J, and Williams J. Smoking cessation interventions for patients with depression: a systematic review and meta-analysis. J Gen Int Med 2012;27:351-60. Abstract available at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3286553/.
  41. Fiore M, Jaen CR, Baker TB, Bailey WC, Benowitz NL, Curry SJ et al.. Treating tobacco use and dependence: 2008 update. Rockville, MD: US: Department of Health and Human Services, Public Health Service; [cited 2008].
  42. Bryant J, Bonevski B, Paul C, O'Brien J, Oakes W. Developing cessation interventions for the social and community service setting: a qualitative study of barriers to quitting among disadvantaged Australian smokers. BMC Public Health 2011 Jun 24;11:493 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/21699730.
  43. 43.0 43.1 Bonevski B, Paul C, D'Este C, Sanson-Fisher R, West R, Girgis A, et al. RCT of a client-centred, caseworker-delivered smoking cessation intervention for a socially disadvantaged population. BMC Public Health 2011 Jan 31;11(1):70 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/21281519.
  44. Bowman J, Walsh RA. Smoking intervention within alcohol and other drug treatment services: a selective review with suggestions for practical management. Drug Alcohol Review 2003.
  45. Okuyemi KS, Thomas JL, Hall S, Nollen NL, Richter KP, Jeffries SK, et al. Smoking cessation in homeless populations: a pilot clinical trial. Nicotine Tob Res 2006 Oct;8(5):689-99 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/17008196.
  46. Bittoun R, Nynycz S, Ross D, Foley K, and Ross L. A protocol for a smokefree mental health facility. J Smok Cessat 2013;1-3 Abstract available at http://journals.cambridge.org/action/displayAbstract?fromPage=online&aid=8921927&fileId=S1834261212000229.
  47. Dixon LB, Medoff D, Goldberg R, Lucksted A, Kreyenbuhl J, DiClemente C, et al. Is implementation of the 5 A's of smoking cessation at community mental health centers effective for reduction of smoking by patients with serious mental illness? Am J Addict 2009 Sep;18(5):386-92 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/19874158.
  48. Drach LL, Morris D, Cushing C, Romoli C, Harris RL. Promoting smoke-free environments and tobacco cessation in residential treatment facilities for mental health and substance addictions, Oregon, 2010. Prev Chronic Dis 2012;9:E23 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/22172190.
  49. Health Development Agency. Homelessness, smoking and health. London, UK: National Health Service; 2004 Available from: http://www.nice.org.uk/nicemedia/documents/homelessness_smoking.pdf.
  50. 50.0 50.1 Parker C, McNeill A, Ratschen E. Tailored tobacco dependence support for mental health patients: a model for inpatient and community services. Addiction 2012 Dec;107 Suppl 2:18-25 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/23121356.
  51. O’Brien J, Jardine A, Oakes W, & Salmon A. Integrating smoking care in community service organisations to reach disadvantaged people: findings from the Smoking Matters project. Health Promot J Austr 2010;21(3).
  52. 52.0 52.1 Hollen V, Ortiz G, Schacht L, Mojarrad MG, Lane GM Jr, Parks JJ. Effects of adopting a smoke-free policy in state psychiatric hospitals. Psychiatr Serv 2010 Sep;61(9):899-904 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/20810588.
  53. Voci S, Bondy S, Zawertailo L, Walker L, George TP, Selby P. Impact of a smoke-free policy in a large psychiatric hospital on staff attitudes and patient behavior. Gen Hosp Psychiatry 2010 Nov;32(6):623-30 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/21112455.
  54. 54.0 54.1 Corman I, Creasey S, McNeill A, Ferriter M, Huckstep B, and D’Silva K. Impact of a total smoking ban in a high secure hospital. The Psychiatrist 2010;34:413-7.
  55. El-Guebaly N, Cathcart J, Currie S, Brown D, Gloster S. Public health and therapeutic aspects of smoking bans in mental health and addiction settings. Psychiatr Serv 2002 Dec;53(12):1617-22 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/12461225.
  56. Moss T, Weinberger A, Vessicchia J, Mancuso V, Cushing S, Pett M, Kitchen K, Selby P, and George T. A tobacco reconceptualization in psychiatry: toward the development of tobacco free psychiatric facilities. Am J Addict 2010;19:293-311. Abstract available at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2918288/.
  57. Prochaska J. Ten critical reasons for treating tobacco dependence in inpatient psychiatry. J Am Psychiatr Nurses Assoc 2009;15:404- 9 Abstract available at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2844659/.
  58. Lawrence D, Lawn S, Kisely S, Bates A, Mitrou F, Zubrick SR. The potential impact of smoke-free facilities on smoking cessation in people with mental illness. Aust N Z J Psychiatry 2011 Dec;45(12):1053-60 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/22017657.
  59. Lawn S, Campion J. Factors associated with success of smoke-free initiatives in Australian psychiatric inpatient units. Psychiatr Serv 2010 Mar;61(3):300-5 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/20194408.
  60. National Institute for Health and Care Excellence.. Smoking cessation in secondary care: acute, maternity and mental health. UK: NICE; 2013 Available from: https://www.nice.org.uk/guidance/ph48.

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