In spite of the 1996 publication of the American Psychiatric Association guideline recommending that psychiatric patients receive routine treatment for tobacco use (American Psychiatric Association, 1996), the proportion of mental-health patients counseled about smoking by their primary-care physicians (23%) or their psychiatrists (18%) is low (Thorndike et al., 2001). The National Ambulatory Medical Care Survey found that psychiatrists offered tobacco-cessation counseling to only 12.4% of their patients who smoked (Himelhoch and Daumit, 2003). More counseling was offered to patients who were over 50 years old, had diabetes, had hypertension, had obesity, lived in a rural location, or were in their initial visit. A study of 250 hospitalized psychiatric smokers found that only 105 were actually identified as current smokers in their medical records and none had received a diagnosis of nicotine dependence or withdrawal (the facility was smoke-free) or had cessation services as part of their hospital treatment; however, NRT was prescribed for 56% of the smokers, almost all of whom used it (Prochaska et al., 2004a). Ziedonis et al. (2008) noted that mental-health providers may be ideal for delivering tobacco-cessation treatment because there is a therapeutic alliance between patient and provider; patients will return for treatment for their psychiatric symptoms regardless of their cessation status, and the provider can use these opportunities to encourage repeated attempts to quit; and it is relatively cost-efficient in that tobacco-cessation treatment can be delivered during planned visits to the provider (Ziedonis et al., 2008).

Although people with psychiatric disorders have higher rates of tobacco use than people without these disorders, many of them are interested in quitting and will attempt to quit. The National Comorbidity Survey found that smokers with history of mental illness in the past month had a self-reported quit rate of 30.5% compared with a quit rate of 42.5% for those without any mental illness (Lasser et al., 2000). Patients with psychiatric disorders may use tobacco as a self-medication for their symptoms (Fagerstrom and Aubin, 2009; Khantzian, 1997; Lerman et al., 1998) because nicotine has been associated with improved psychomotor function in people with depression (Malpass and Higgs, 2007) and has been associated with enhanced attention, sensory gating, and working memory in those with schizophrenia (Dalack and Meador-Woodruff, 1996; Strasser et al., 2002; Ziedonis et al., 2007). However, as discussed in Chapter 3, nicotine withdrawal may exacerbate some psychiatric symptoms if not properly controlled (Fagerstrom and Aubin, 2009).

The best time to start tobacco-cessation treatment is not clear; some studies indicate that it can be concurrent with treatment for psychiatric disorders, but some evidence suggests that it is more effective if given when psychiatric symptoms are less severe, particularly in those

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