Patients with schizophrenia are treated in a variety of intensive-treatment settings (such as psychiatric hospitals, residential facilities, and day-treatment programs), and these settings provide an opportunity to deliver an intensive smoking-cessation treatment integrated with mental health care. However, only recently have some psychiatric treatment settings begun to address tobacco use. As with other psychiatric disorders, the percentage of people with schizophrenia who are smokers is more than twice the percentage of smokers in the general population (Kotov et al., 2008). People with schizophrenia appear to be able to quit tobacco with the support of psychosocial treatment, nicotine-dependence treatment medications, and social support (Workgroup on Substance Use Disorders, 2006). Although many experience difficulties and can relapse, some people with schizophrenia are interested in reducing their tobacco consumption (Forchuk et al., 2002). Patients with schizophrenia who smoke appear to be more severely ill than patients who do not smoke, although the severity of specific symptoms does not appear to differ between smokers and nonsmokers (Kotov et al., 2008). Clinical studies show that psychologic treatment interventions of different intensity have been effective, including one-to-one and group-based counseling using modified American Lung Association interventions, cognitive-behavioral therapy, social-skills training, and contingency monetary reinforcement. Much of the relevant literature on people with psychotic disorders, such as schizophrenia, has focused on interactions between antipsychotic medications and bupropion rather than on the efficacy of psychologic treatments. Most of the studies in this population using NRT or bupropion have included a psychologic-treatment component (Addington et al., 1998; Goldberg et al., 1996; Ziedonis and George, 1997).

Tobacco Users with Medical Comorbidities

Smoking is the leading cause of morbidity in the general population and is causally linked to the development of many cancers (particularly lung cancer), chronic obstructive pulmonary disease (COPD), and cardiovascular disease (CVD) (see Chapter 2). Smoking is also known to have an adverse effect on people who have those diseases and other illnesses, such as diabetes, that are not commonly linked to smoking. The 2006 National Health Interview Survey (NHIS) found that 36.9% of smokers with any smoking-related chronic disease continued to smoke, including almost 49% with emphysema, 41% with chronic bronchitis, 21% with lung cancer, 39% with other cancers, 29% with coronary heart disease, and 30% with stroke; only 19% of those with no chronic disease smoked (CDC, 2007a). A significant portion of veteran

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