The Effectiveness of Leadership in the Stop Smoking campaign

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Local authorities have the best opportunity to reduce the prevalence of tobacco smoking in their boroughs. Protecting children from the harmful effects of tobacco and helping smokers to stop is probably the best gift any local authority can give to its residents for Donald Read is a consultant in public health at Blackburn with Darwen borough council, and Dominic Harrison is director of public health at Blackburn and Darwen borough council.

Not already a member? Join us now for more comment, analysis and the latest job opportunities in local government. However, local authorities are ideally placed to mobilise their diverse resources to achieve the dual aims of protecting children from the harms of tobacco and helping people who do smoke to quit, and they can do so in a number of ways: Topics Public Leaders Network.

A previous IOM report found that there was insufficient evidence on the health effects of smokeless or modified tobacco products, although the International Agency for Research on Cancer has found that smokeless tobacco use causes cancer IARC, The evidence base on smokeless-tobacco products is not sufficiently robust to determine what health hazards other than cancer and periodontal disease are associated with smokeless or modified tobacco products.

Furthermore, the committee is concerned that such products may serve as starters or supplements for the use of smoked tobacco products. This dual use is a substantial concern as demonstrated by the number of military personnel who use both see the section on dual use in Chapter 5. The committee has insufficient evidence to make any recommendations with respect to the use of smokeless tobacco as an alternative to smoked tobacco. There is an evidence base that supports the use of nicotine-replacement therapies NRTs on an extended basis as a form of harm reduction if a person is trying to quit or has made a quit effort and is sustaining abstinence.

In the sections below, the committee examines the evidence base on various tobacco-cessation interventions, including medications and behavioral therapies. It then identifies the most effective practices for providing those treatments to the targeted audiences. Tobacco users today have access to a variety of evidence-based interventions that, if used appropriately, can significantly increase the likelihood that they will achieve long-term abstinence.

There is abundant evidence on effective tobacco-cessation interventions, and numerous groups have provided detailed and consistent recommendations for individual-level interventions. For example, the PHS guideline Fiore et al. A Blueprint for the Nation all conclude that the most effective way to achieve smoking cessation is to combine behavioral interventions that include person-to-person treatment with Food and Drug Administration FDA —approved pharmacologic treatments.

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Effective behavioral interventions include brief advice and assistance from a health-care provider during routine health-care visits, multisession outreach telephone counseling, and face-to-face group and individual counseling. Although all those interventions are effective, there is a dose—response relationship in behavioral treatments: The use of FDA-approved tobacco-cessation medications, alone or in conjunction with behavioral interventions, is effective in maintaining long-term abstinence.

Behavioral interventions focus on providing tobacco users with specific skills and supports to modify their tobacco use. Building from theoretical models of the determinants of tobacco use and cessation, the interventions typically have five key components: Those interventions can be offered in different formats such as face to face, over the telephone, and by computer with different numbers and lengths of contact. Abstinence rates increase as the length of counseling sessions increases from minimal under 3 minutes to longer than 10 minutes, as the number of sessions increases, and as the total contact time increases from 1—3 minutes to 91— minutes; however, contact time in excess of minutes does not appear to increase abstinence rates Fiore et al.

Seven medications have been approved by FDA for smoking cessation and are recommended by the PHS guideline alone or in combination as first-line medications Fiore et al. The first-line medications include several forms of NRTs—gum, lozenges, and patches are available over the counter, and nasal sprays and inhalers are available by prescription—and bupropion sustained-release SR and varenicline, which are available by prescription. Each of these medications has been shown to increase the likelihood of smoking cessation significantly Fiore et al. Nicotine gum, patches, and lozenges should be used for 6—14 weeks for both highly dependent and regular smokers.

In addition to recommending the use of the nicotine patch as a single medication, the guideline recommends several medications in combination with it, including nicotine gum or spray, bupropion SR, and inhaled nicotine. In an effort to assess the comparative effectiveness of the FDA-approved medications, various cessation medications were compared to the nicotine patch—the most commonly used cessation medication. The meta-analysis identified two medication regiments that were more effective than the nicotine patch: The guideline also recommends two second-line medications, defined as medications that FDA has not approved for tobacco-dependence treatment and about which there are more concerns for potential side effects than in the case of first-line medications: Because former smokers may relapse and current smokers may decide to quit smoking, it is important to ascertain smoking status at each office visit and to inform patients of the need to be aware of possible changes in their response to any medication, whether prescription or over the counter and whether used for tobacco cessation or for other conditions.

With behavioral counseling alone, there was a dose—response relationship between the number of counseling sessions and rates of cessation. Two or more sessions significantly increased cessation rates; the highest abstinence rates were observed with more than eight counseling sessions Furthermore, among patients who used multiple tobacco-cessation medications in combination with individual or group counseling, the cessation rates at 6 months increased with the number of medications. Although other tobacco-cessation interventions are available—such as self-help materials, rapid smoking, acupuncture, and hypnosis—results are inconclusive with regard to their effectiveness in helping tobacco users achieve long-term abstinence.

The PHS guideline states that rapid smoking also called aversive smoking was more effective than no psychosocial counseling or therapy, but it is not a recommended treatment Fiore et al. A Cochrane review on aversive smoking suggested that although it may be effective, more research was needed Hajek and Stead, Self-help materials, such as brochures and videos, as either the only interventions or in combination with other interventions, do not significantly increase abstinence rates Fiore et al. Acupuncture has also been assessed in both the guideline and a Cochrane review; the Cochran review found a slight positive effect White et al.

Neither the PHS guideline nor the Cochrane review found sufficient studies to assess the use of hypnosis for tobacco-use cessation. One study in veterans found that hypnosis increased abstinence at the 6-month and month follow-ups Carmody et al. The use of financial incentives for tobacco-use cessation has also been explored. A Cochrane review found that the use of financial incentives increased the rate of participation in smoking-cessation programs but did not increase long-term abstinence rates Cahill and Perera, Behavioral therapies are effective in increasing long-term tobacco cessation.

Cognitive strategies and problem-solving are particularly effective when offered in a multisession format. Available over-the-counter and prescription medications, when used appropriately, also improve the likelihood of long-term tobacco cessation. A combination of the tobacco-cessation pharmacotherapies and behavioral therapies described above is most effective in achieving long-term tobacco cessation. Other interventions—such as hypnosis, acupuncture, and financial incentives—have been assessed in a few studies, but there is insufficient information on their effectiveness in achieving long-term tobacco cessation.

An integral aspect of tobacco control is generating a desire and willingness in people to quit using tobacco. Motivation to quit may spring from encouragement from family and friends, increased awareness of the hazards of tobacco use because of public-education campaigns, in response to increased prices for tobacco products or restrictions to areas where they may be used, or advice from a healthcare provider.

A comprehensive tobacco-control program ensures that many sources of encouragement and support are made available. Individual interventions to promote tobacco-use cessation are effective and can help many people achieve and maintain abstinence, but if tobacco users are not aware of the treatments, cannot easily access them, cannot afford them, or do not use them when they are available, the effectiveness of the treatment is irrelevant. All of these barriers may prevent tobacco users from seeking or receiving treatment when they are motivated to quit. Inasmuch as most people who make a quit attempt relapse within 48 hours, removing barriers to treatment is paramount to maintaining abstinence.

Provision of tobacco-cessation services can occur in many settings and formats.


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Health-care providers can inform patients about the health effects of tobacco use and counsel them about treatment options for quitting, patients can be referred to proactive or reactive telephone quitlines that provide cessation counseling and often medications, and patients can access computer-based cessation programs that offer counseling, support, and medications—although the evidence base on the latter is lacking.

In this section, the committee considers the evidence base on those approaches for delivering tobacco-cessation services and the training needs of health-care professionals that provide them. The committee finds that a combination of in-person and other forms of program-delivery formats are likely to be the most effective in reaching the largest audience. A number of tobacco-cessation programs are used by health-care organizations see Box , but they have not all been evaluated formally for their effectiveness.

BecomeAnEx, sponsored by the National Alliance for Tobacco Cessation made up of the American Legacy Foundation and numerous other groups, government and nongovernment , is a three-step plan. It allows for personalizing more Assist smokers willing to quit by providing appropriate tobacco-dependence treatments.

The guideline also includes specific recommendations for program intensity, the type of counseling, and the inclusion of medications. The guideline recognizes that not all patients are willing or able to quit and provides interventions for these patients. Health-care providers can use motivational interviewing for patients unwilling to quit and to encourage future quit attempts, Fiore et al. Relevance—encourage patient to explain why quitting is relevant to them. Repetition—use a motivational intervention each time a patient is seen.

Feedback loops help providers to motivate tobacco users who are unwilling to quit and encourage former users or newly quitting users to prevent relapse. Although a meta-analysis Burke et al. Thus, it seems that the health-care providers were more likely to advise smokers to quit than to assist in cessation, or especially, to arrange cessation treatments, in spite of the fact that all of the health plans in the study provided comprehensive coverage for tobacco-cessation counseling and medications.

Those who were offered and used tobacco-cessation medications or counseling were significantly more likely be abstinent for 30 days at 12 months than those who did not odds ratio [OR], 2. The use of self-help materials alone OR, 0. The National Ambulatory Medical Care Survey found that participating physicians were as likely to ask their male patients as their female patients, in all age categories, about tobacco use In some medical facilities, a variety of health-care providers such as nurses, psychologists, counselors, and physicians may be responsible for the delivery of tobacco-cessation interventions.

In a meta-analysis examining the effectiveness of tobacco-cessation interventions by various health-care providers with or without NRTs, interventions without NRTs were most effective when delivered by a psychologist or physician. Counselors and nurses were also effective, but the difference compared with the placebo usual care was not statistically significant.

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When NRTs were combined with provider intervention, the effectiveness of most providers increased up to twofold Mojica et al. The PHS guideline found evidence that tobacco-cessation interventions offered by both physicians and nonphysicians such as nurses, psychologists, dentists, and counselors were more effective in increasing abstinence rates than no intervention.

Compared with no advice, brief advice from a primary-care physician was effective in increasing 6-month quit rates, and intensive interventions were slightly more effective than brief counseling Stead et al. In a Cochrane review of nursing interventions for smoking cessation, Rice and Stead conducted a meta-analysis of 31 studies and determined that nurse-provided interventions were more effective in reducing 6-month smoking rates than no intervention or usual care.

High-intensity interventions, such as an initial counseling session of 10 minutes or more with additional materials and at least one follow-up contact, were more effective than low-intensity interventions. Nursing intervention was most effective for inpatients in a hospital and to a smaller extent for nonhospitalized patients. Interventions offered during a screening health check were less effective. The use of additional materials such as leaflets by a nurse did not appear to promote smoking cessation Rice and Stead, Health-care providers other than primary-care clinicians and nurses have been considered as resources for tobacco-cessation counseling.

Pharmacists are frequently associated with medical facilities, particularly hospitals and large outpatient clinics. In addition to their obvious role in providing tobacco-cessation medications, including such over-the-counter medications as NRTs, some pharmacists have been trained to offer counseling and literature to their patients who use tobacco. In a Cochrane review of two studies conducted in the United Kingdom, only one study showed a significant association between pharmacist-provided counseling and record-keeping and self-reported month abstinence rates Sinclair et al.

A more recent review by Dent et al. Dentists are also well situated to counsel patients about tobacco use, particularly smokeless-tobacco use, which is associated with increased oral cancer and periodontal disease see Chapter 2. At 12 months, smokeless-tobacco users who had received tobacco-cessation counseling from their oral-health professional dentist or oral hygienist had greater abstinence rates than those who did not receive such counseling Carr and Ebbert, Multiple-session counseling in a health-care setting, preferably on an individual basis, is effective in achieving long-term tobacco cessation and may be provided by a variety of health-care providers in addition to physicians, such as nurses, dentists, and pharmacists.

DoD and VA both have large, complex health-care systems that should strive to offer barrier-free access to tobacco-cessation services both counseling and medications that reflect current evidence on effective programs. Programs should be available to all members of the target populations regardless of place, time, and status for example, active duty, deployed, reservist, at home and be offered by a variety of health-care professionals.

There is ample evidence that tobacco quitlines are efficacious Borland et al. Quitlines offer the advantage of generally being available when needed and free of charge for counseling.

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No appointments are necessary to access them, and patients can call them for individual counseling in privacy. Quitlines also help patients to overcome barriers to treatment, such as living at a considerable distance from a clinic or other treatment locations, being unable to attend counseling sessions because of work or social commitments, and waiting for the next tobacco-cessation program to begin. The statewide use of a quitline as part of a comprehensive tobacco-use cessation program began in California in the early s and was followed in Massachusetts.

Now all 50 states and the District of Columbia have tobacco quitlines http: Any adult in need of tobacco-use cessation services can call a national telephone number QUIT-NOW , which will route the caller to his or her state tobacco quitline; this referral service is sponsored by NCI. NCI also has a toll-free quitline at U-QUIT that has a smoking-cessation counselor available during the day for help in quitting and to provide answers to smoking-related questions in English or Spanish.

Although quitline access is available to all adults across a broad demographic spectrum, quitlines vary greatly in quality, intensity, and duration. Three factors increase their efficacy: All the quitlines offered multisession generally 5 sessions proactive telephone counseling, and some offered follow-up reactive sessions; the first session was usually 30 minutes long, and the follow-up sessions were shorter. Although many of the quitlines had specialized protocols for pregnant women, smokeless-tobacco users, ethnic populations, and people 12—17 years old, far fewer offered protocols for multiple addictions, people 18—24 years old, those with mental illness, or older adults.

Most of the quitlines had some criteria for receiving free medications, such as lack of insurance coverage. The North American Quitline Consortium NAQC was established to help federal and state health departments, quitline service providers, researchers, and service providers, such as the American Cancer Society, to improve quitline services. NAQC is one resource for information about current quitline services, improving quitline quality, and assessing quitline efficacy and research.

Although quitlines are acknowledged to be effective in reaching a large number of tobacco users and can be tailored to reach specific audiences, they do have limitations. Quitlines typically reach only a small proportion of their target populations and are chronically underfunded. The National Action Plan for Tobacco Cessation Fiore, recommended that state quitlines use at least four person-to-person proactive calls, that there be no cost to insurers for the use of the quitline by eligible tobacco users, and that all NRTs be made available to quitline users free of charge or that users receive vouchers for prescription medications.

The plan also called for states to receive earmarked grants to maintain their quitlines and for quitlines to meet national performance standards. Zhu and Anderson noted that the promotion of a quitline may prompt tobacco users to attempt to quit on their own even if they did not contact the quitline Zhu and Anderson, Quitlines therefore may reach a broader audience than only tobacco users who are seeking counseling, including their friends and family who may call to request information on how to support or initiate quit attempts by tobacco users.

The national action plan specifically states that military personnel and their families should be eligible to use the national quitline and that a toll-free number should be available for military personnel and their families stationed overseas. DoD and VA populations live in a variety of locations including small and remote communities and overseas, where in-person tobacco-cessation services may be scarce or nonexistent. Veterans, in particular, may find it difficult to access VA tobacco-cessation services if they are disabled or otherwise disadvantaged.

Quitlines, particularly proactive quitlines, are effective in reaching a large number of tobacco users and increasing abstinence rates over those achieved with usual care. Evidence indicates that a quitline should be proactive counselor-initiated and should provide four to six sessions and follow-up sessions as necessary. Several studies have assessed the effectiveness of computer-based tobacco-cessation interventions, but there is insufficient information on their effectiveness. Nevertheless, the committee considered these programs as more people, both civilian and military, turn to computers for a variety of health information, assistance, and support.

Many computer-based interventions have the advantage of being tailored to individual participants on the basis of their responses to questions, and they can be used to reach a large audience, including people who may not be contemplating quitting. Counseling may be conducted by telephone or e-mail with additional individualized resources, such as chat rooms, videos, graphics, journals, and action plans Etter, ; computer-based programs can also be combined with medication.

The efficacy of tailored computer-based tobacco-cessation programs is varied Strecher and Velicer, Etter surveyed current and former smokers about the quality and helpfulness of tobacco-cessation Web sites. Two of the most frequently visited sites were run by tobacco companies and were not considered helpful by participants. Two sites were ranked above average for quality and were nonprofit Anti-smoking. The program included social support and cognitive—behavioral coping skills.

One version of the program is available free to the public, and the other is an enhanced version available to commercial organizations. According to the National Institutes of Health Web site www. Computer-based tobacco-use cessation programs may be able to reach a large audience of tobacco users, but there is insufficient evidence of their effectiveness.

Many people see a health-care professional such as a primary-care physician or dentist at least once a year. Each visit can be an opportunity to ask patients about their tobacco use and educate them about adverse health effects and available interventions. But first, healthcare providers must themselves be aware of tobacco-cessation interventions and be comfortable in providing advice on these matters to their patients. Pregnant women were most frequently asked about their smoking status but were the least likely to receive smoking counseling.

The use of tobacco-cessation medication, primarily prescription bupropion, was recorded in only 1. A Cochrane review found that training of health-care providers increased the likelihood that they would offer evidence-based cessation interventions during patient visits Lancaster et al. Numerous training programs are available for health-care providers, some of them free of charge.

There is a lack of training among mental-health professionals, primary-care providers, and tobacco-cessation specialists with regard to tobacco-cessation interventions for patients with psychiatric disorders Williams and Ziedonis, Training psychiatrists to provide cognitive-behavior therapy to mental-health patients for tobacco cessation within the psychodynamic therapeutic model taught in most psychiatric residencies may be challenging inasmuch as only about half the psychiatry residencies require cognitive-behavior therapy training Prochaska et al.

Provider-level strategies for increasing patient use of cessation interventions include electronic or written prompts and reminders on medical charts or records such as the assessment and documentation of tobacco-use status as a vital sign at every health-care visit Fiore et al. Provider reminder systems have been shown to be effective in increasing tobacco cessation, particularly when combined with provider education CDC, a.

The software was developed in accordance with the current PHS guideline and includes a handheld version of the Fagerstrom Test for Nicotine Dependence. The tool guides clinicians through the appropriate questions and makes intervention recommendations, including prescription information, on the basis of the level of dependence. The HCSIT contains medication information, brief motivational interventions for tobacco users, and evidence-based recommendations from the PHS guideline.

For more information, see http: VA initiated a preceptor training program to improve delivery of tobacco-cessation treatment for veterans with mental disorders. The program uses a train-the-trainer format to educate more than VA mental-health and substance-use disorder providers from every Veteran Integrated Service Network about evidence-based clinical practices and mentors their progress in integrating smoking cessation into routine psychiatric care. The training of health-care providers in tobacco- cessation interventions is effective in increasing the likelihood that a patient will be asked about tobacco-use status, be advised to quit, and be assisted with tobacco- cessation services.

Computer-aided training and reminder systems help health providers to discuss tobacco cessation with their patients. A Blueprint for the Nation acknowledges that some tobacco users will have a more difficult time in quitting than others. Those populations have not traditionally been the focus of tobacco-control and cessation programs, and they may require modified or innovative approaches to help them quit. This may have particular relevance for DoD and VA: Other populations served by the VA and military health systems that may require different approaches for effective tobacco-cessation services include women, pregnant women, minority-group members, hospitalized tobacco users, older tobacco users, and smokeless-tobacco users.

In the sections below, the committee considers the evidence on tobacco-cessation interventions for special populations with an emphasis on treating those with mental-health disorders. Disproportionately higher rates of smoking see Chapter 3 for specifics are related to an increased risk of tobacco-related illness among those with psychiatric or mental disorders. For example, persons with chronic mental illness die about 25 years earlier compared to those without—mortality is primarily due to lung cancer and cardiovascular disease Colton and Manderscheid, , and half of premature deaths in alcoholics are attributable to cigarette smoking Hurt et al.

These statistics underscore the importance of developing effective treatments for patients with psychiatric comorbidities. Tobacco-cessation interventions in people with psychiatric disorders have been the subject of much research and several reviews Fagerstrom and Aubin, ; Hagman et al. Barriers impede the application of cessation treatments in mental-health populations, contributing to the high rates of tobacco use and low rates of cessation in this population Williams and Ziedonis, Foremost among these barriers is a seeming reluctance on the part of mental-health professionals to provide concurrent treatment for mental-health disorders and tobacco use.

In the past, cigarettes have even been used as tokens to reinforce positive behavior Gustafson, The National Ambulatory Medical Care Survey found that psychiatrists offered tobacco-cessation counseling to only 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.

Combating Tobacco Use in Military and Veteran Populations.

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 Patients with psychiatric disorders may use tobacco as a self-medication for their symptoms Fagerstrom and Aubin, ; Khantzian, ; Lerman et al.

However, as discussed in Chapter 3 , nicotine withdrawal may exacerbate some psychiatric symptoms if not properly controlled Fagerstrom and Aubin, 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 with alcohol dependence Fiore et al.

Although quit rates and relapse rates are higher in populations with psychiatric disorders, long-term abstinence can be achieved. In treating psychiatric patients for tobacco use, it must be remembered that traditional tobacco-cessation therapies may need modification to address issues specific to a psychiatric population such as self-medication, the particular psychiatric diagnoses, medications that the patients are already taking for their psychiatric symptoms, and the need for modified psychotherapy. Furthermore, in treating nicotine addiction, as in treating such other addictions as heroin addiction, it may be necessary to provide treatment for longer periods than the typical 12 weeks Schroeder, The committee notes that treatment of tobacco dependence in people who have psychiatric disorders requires a tailored approach to meet individual needs, treatment can be enhanced through a combination of medication and psychosocial therapy, and tobacco use can alter the effectiveness of a variety of medications.

Behavioral interventions have been applied for tobacco users with several mental-health disorders, including schizophrenia McChargue et al.

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The PHS guideline Fiore et al. Ziedonis found that cessation interventions for psychiatric patients may include telephone-based counseling, Internet-based approaches, and face-to-face counseling, but more research is needed. They caution, however, that the interventions may be most effective in those with less severe mental illnesses, including addictions, because the interventions tend to be brief or time-limited and are not tailored to a particular mental illness. In general, the FDA-approved tobacco-cessation medications that have been shown to be effective for the general population—NRTs gum, patch, spray, lozenge, and inhaler , bupropion, and varenicline—have also been shown to be effective in people with psychiatric disorders Fiore et al.

However, as with patients with any comorbidity, treating tobacco dependence in psychiatric patients requires an understanding of the specific condition, the medications that are being used to treat the condition, and the severity of the dependence. For example, Richmond and Zwar found that bupropion reduced withdrawal symptoms and was effective for smoking cessation in people with and without a history of depression or alcoholism. Heavier smokers may need higher doses of the cessation medications and additional NRTs Richmond and Zwar, Varenicline has been associated anecdotally with changes in behavior, agitation, depressed mood, suicidal ideation, and attempted and completed suicide in some tobacco users FDA, ; therefore, patients should be monitored closely for side effects, including depression and suicidal ideation, while on the drug.

More research on the association between varenicline and suicide is needed see the FDA website, www. A number of studies have found that the combination of medication and psychosocial treatments may be more effective than either alone for patients with mental illness Fiore et al. For example, Evins et al. The authors found that bupropion SR combined with cognitive behavioral therapy facilitated smoking reduction in some schizophrenic patients and stabilized psychiatric symptoms during attempts to quit Evins et al. Furthermore, repeat treatment delivered in the context of a continuing therapeutic relationship was more effective than brief, episodic treatment delivered by a specialist Fu et al.

Similar results were seen in patients with diagnosed psychotic disorders: There was a dose—response relationship between abstinence and attendance at the treatment sessions. An additional, potentially unexpected benefit of reducing or eliminating tobacco use by patients with mental illness is lowering of psychotropic medication dosages. Patients with serious mental illness, such as schizophrenia or bipolar disorder, are commonly given antipsychotic medications, such as olanzapine or clozapine.

Smokers who receive those medications may need about twice the dosage of nonsmokers, because of the effect of the polycyclic aromatic hydrocarbons in tobacco smoke on medication metabolism Desai et al. Other medications that are affected similarly include haloperidol and fluphenazine Desai et al. Cigarette smoking may also increase the clearance of benzodiazepines Smith et al. Health-care providers should be actively involved in working with patients to adjust medications and to inquire about side effects.

Tobacco users with mental illness may need to be treated for a longer period and with more intensive treatments than nonusers Collie et al. In the section below, the committee assesses the evidence on tobacco-cessation interventions for specific psychiatric disorders that may be seen in military personnel returning from Iraq and Afghanistan and in veterans from those and earlier conflicts: In a review by Fu et al.

Although several observational studies have shown that smokers with PTSD are less inclined to quit smoking than smokers without PTSD or with other psychiatric disorders, several clinical studies have indicated that smokers with PTSD or other mental disorders respond to tobacco-cessation treatment at levels nearly equivalent to those in smokers without mental disorders Fu et al.

For tobacco users with PTSD, there appears to be greater abstinence from tobacco use when cessation interventions are integrated into standard mental health care. In one study, veterans with PTSD who smoked were encouraged to make multiple attempts to quit that is, repeated treatment during a 6-month treatment period. The sample was small, but, given the effect size, the committee considers that this intervention merits further study. Other approaches that have been found effective in increasing tobacco-cessation rates in people with PTSD include supportive counseling and mood management, particularly before the quit attempt begins.

Unaided quit attempts result in higher relapse rates in the first week after quitting in smokers with PTSD than in smokers without a mental disorder Zvolensky et al. Research indicates that smokers with depression can be motivated to attempt to quit smoking and, with formal assistance, accept and use tobacco-cessation treatment Acton et al. Acceptance was not correlated with chronicity of depression history, severity of current depressive symptoms, severity of nicotine dependence, sex, age, or education Haug et al.

Recent research has shown that people in treatment for chronic depression can be treated for tobacco dependence with no adverse effects on their mental-health functioning or compensation with other substance use Prochaska et al. Meta-analyses of smoking-cessation trials published in — found that smokers with a history of depression were as likely as those without such a history to achieve short-term up to 3 months or long-term abstinence at least 6 months Covey et al.

Three randomized, controlled trials indicate that smokers with MDD are capable of achieving abstinence rates comparable with those of nondepressed smokers after similar interventions Hall et al. Contrary to expectation, CBT-D with ST did not produce significantly higher abstinence rates than ST alone in smokers with past MDD, perhaps because these smokers already fared well in nonpharmacologic standard treatment.

In sum, adding CBT-D to usual smoking-cessation treatment is efficacious in smokers with a history of recurrent depression. Cognitive-behavioral therapy with an emphasis on group cohesion and social support Ait-Daoud et al. The brief-contact intervention included a smoking-treatment referral list and a packet of educational materials at the first visit. Abstinence rates at 12 and 18 months were higher in depressed smokers who received the stepped-care intervention than in the brief-contact controls Hall et al.

An etiologic connection may exist between smoking and depression Aubin, ; Kotov et al. The variation in symptoms of MDD may affect smoking-cessation outcomes Burgess et al. Smokers with a history of MDD who were currently free from depression and not on antidepressant medication and who stopped smoking were at a significantly increased risk for a new episode of depression OR, 7.

The risk persisted during the 6-month follow-up period Glassman et al. Of importance for DoD is that the — National Epidemiologic Survey on Alcohol and Related Conditions found that the co-use of alcohol and tobacco was highest in men and women 18—24 years old Falk et al. However, although most alcoholics are interested in quitting tobacco at some point and some are concerned that doing so will make them drink more Joseph et al.

Concurrent treatment for tobacco use and alcohol dependence or abuse has been studied, but results are mixed. Some studies have shown that cessation rates tend to increase with length of sobriety if the two treatments are delivered concurrently Heffner et al. Tobacco-cessation rates were about 3 times as great in people with 3 months of sobriety or more as in people with shorter sobriety, although both groups relapsed at about the same rate.

Other studies of concurrent treatment found greater participation rates in tobacco-cessation treatment; however, long-term cessation rates did not differ significantly from those seen when smoking intervention was delayed for 6 months after alcohol treatment indicating that optimal timing has yet to be determined Joseph et al. Sequential treatments may be preferred for some people Kodl et al. In a study of outpatients in alcohol treatment, the longer the period of alcohol abstinence, the more receptive to quitting smoking were those with low scores on the Center for Epidemiologic Studies Depression Scale Hitsman et al.

Behavioral therapy alone was more effective in helping smokers with low scores on the Hamilton Rating Scale for Depression to achieve short-term tobacco abstinence, whereas the mood-management training was more effective in increasing abstinence in smokers with high depression scores Patten et al. Those studies suggest that treating people who have both depression and alcohol dependence for tobacco use requires assessing both disorders in addition to nicotine addiction.

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.

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, Download our fact sheet for the latest data on adult use and perceptions of e-cigarettes in Great Britain The Smoking in Pregnancy Challenge Group supports national ambitions to reduce rates of smoking in pregnancy.

ASH has been certified as a producer of reliable health and social care information. The implementation of smokefree prisons in England and Wales 27 November Adult use of e-cigarettes Great Britain Download our fact sheet for the latest data on adult use and perceptions of e-cigarettes in Great Britain Smoking in Pregnancy The Smoking in Pregnancy Challenge Group supports national ambitions to reduce rates of smoking in pregnancy. ASH receives funding from: