Last updated: 15-Jan-2007
Special Populations
Most cessation interventions tend to use generic approaches, though the population of tobacco users is quite heterogenous. The theory behind considering the specific treatment needs of special populations is that treatment success may be increased.[1] Smokers may be stratified in many ways (e.g., heavy vs. light, stages-of-change, patient vs. non-patient, age, socioeconomic status, geographic location).[2] The categories below deal with certain populations where there are unusual prevalence rates and / or unusual health risks. Recognizing that teen smoking has already been covered in other sections, the three other populations that stand out are pregnant women, First Nations peoples and the mentally ill. The fine-tuning of such categories in some sense has no end-point; for example, the subset of the mentally ill who abuse alcohol or other substances, as well as tobacco, represent special challenges and opportunities.[3] Note that some aspects of intervening with smokers of low socioeconomic status will be handled below in the section on lessons learned from tobacco control.
Pregnant Women
The negative foetal health impacts of smoking and ETS exposure during pregnancy are well-attested, especially low birthweight. Cigarette smoking may account for up to 14% of preterm deliveries,[4] as well as a proportion of miscarriages, stillbirths, placental problems and other pregnancy complications.[5] Smoking during the prenatal period is the most important modifiable risk factor for poor pregnancy outcomes in developed countries.[6]
Three significant facts are known about smoking rates among pregnant women in countries such as Canada and the US:
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As is clear from the above figures, despite considerable public focus and prevention efforts, half or more of pregnant women who are smokers continue to smoke throughout their pregnancy; this represents 19 to 22% of all pregnancies in Canada.[10] An estimated 4,600 babies may have been born to smoking mothers in 1999 in B.C.[11]
Several studies have demonstrated that stopping smoking during pregnancy has health benefits for mother and child.[14] Pregnancy represents a period of high motivation among women to quit smoking (for the sake of their baby’s health) and usually have relatively intensive contact with healthcare providers. Thus it represent a “special window of opportunity” to encourage smoking cessation.[15]
Intervention Research
It is vital to pursue further research around effective interventions for
cessation in pregnant smokers and, of equal significance, prevention of postpartum relapse.[16] One implication of the latter initiative is the growing evidence of harmful impacts on newborns and infants created by smoking mothers (e.g., increased rates of asthma, lower respiratory disease, and SIDS).[17] Working towards a reduction of neonatal health effects becomes a component of general ETS exposure campaigns, especially those targeted towards exposure in childhood (see the related subsection above).
Continuing analysis is needed of the socioeconomic factors and health correlates related to smoking initiation among women of child-bearing age,[18] cessation resistance among pregnant women, and the disappointing relapse rates. For example, a recent Canadian study showed that 3 factors were especially associated with ongoing smoking during pregnancy—having other smokers in the household, having other children in the household, and not having post-secondary education.[19] Studies from New Zealand, Britain and other jurisdictions agree that “socioeconomically deprived women were more likely to continue to smoke beyond the first trimester of pregnancy and that this needs to be taken into account in the provision of smoking cessation support.”[20]
Intervention Categories
Several reviews have been completed of interventions targeting pregnant smokers, though it is perhaps significant that they did not uncover much active research since the 1990s. Most of the investigation has focused on behavioural interventions, which fall roughly into three categories: high intensity, low intensity and minimal.[21] A brief description of each category is given below, followed by fuller treatments of the intervention results. Other types of interventions will be noted at the end.
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High-intensity: usually involves several lengthy face-to-face contacts and multiple strategies with smoking mothers.
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Low-intensity: involves a similar initial contact as in minimal interventions (see below), but with continued brief reinforcement contacts.
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Minimal: delivers a single, brief cessation message to mothers in person or by mail, usually using self-help manuals, messages from healthcare providers, pamphlets or videotapes.
High-intensity Interventions
The 2003 Cochrane review included 34 studies on smoking cessation in pregnant women.[22] The interventions in the trials with positive results were described as intensive, often with a goal of tailoring the details of the plan to each individual smoker.[23] For example, one 1997 Australian study with good results included the following intervention components: brief physician advice, educational video, midwife counselling, self-help manual, possibility of a prize upon success, follow-up counselling, involvement of an adult partner where possible, and (for those resistant to cessation) encouragement to attend an external anti-smoking course.[24]
Many of the reviewed cessation projects demonstrated positive results. The 8 highest quality trials showed an average reduction of 8% in continued smoking rates in late pregnancy; for example, in the 1997 study described above, the rate of smoking in the third trimester dropped from 95% to 87% with treatment.[25]
Low-intensity & Minimal Interventions
A 1999 meta-analysis of 16 RCTs[26] suggested that low-intensity approaches also can work, often matching the
results of high-intensity approaches.[27] Even a single, 5 to 15 minute counselling session with appropriate self-help materials (and possibly brief follow-up) could more than double the cessation rate in pregnant women compared with the rate of “spontaneous” cessation.[28] One 1996 study, using such methods, increased the cessation rate from 10 to 20%.[29]
The brief interview format of choice today follows the “5 A’s”—ask, advise, assess, assist and arrange. The format was introduced by the US Public Health Service as a general guideline to clinicians concerning smoking cessation,[30] so it does not represent a unique protocol for pregnant smokers. The adaptation of the 5 A’s to the context of pregnant smokers is currently being evaluated in a total of 13 sites in Canada and the US.[31]
Ineffective “Counselling” Interventions
It is important to note that the positive result for brief counselling does not mean that anything will work. A review of the very minimal intervention which is current policy in the UK (written information distributed at the first prenatal visit) concluded that it was not effective.[32]
Peer counselling and partner support approaches have likewise offered mixed results. These forms of intervention depend on positive, motivated involvement either from a non-professional usually not known by the patient (i.e., a peer) or from an intimate partner or sometimes a friend or colleague (i.e., a partner). A study of peer counselling, which involved a cessation program for prenatal smokers led by women from the community, showed reduced consumption but no improvement in cessation rates.[33] In the partner support trial, the partners of smoking pregnant women received counselling and materials to increase their ability to be an encourager; partners who smoked also received cessation aids and related counselling. The pregnant women showed no improvement in smoking cessation, even though the partner quit rates were 3 times higher with the intervention. [34]
Pharmacological Interventions
In spite of some foetal risks associated with nicotine replacement therapy (NRT), the benefits of this intervention are being increasingly considered with reference to pregnant smokers.[35] Further clinical studies of efficacy and safety are needed, especially given the over-the-counter availability of NRT agents.[36] In a related area, an advisory was issued by Health Canada in August, 2004, about the potential adverse events in newborns with pregnant women using products such as bupropion. As noted earlier, bupropion is effective in aiding cessation attempts, possibly because it counteracts withdrawal symptoms such as depression.
Policy Interventions
A US study suggested that “the decline in smoking over time among pregnant women was primarily due to the overall decline in smoking initiation rates among women of childbearing age, not to an increased rate of smoking cessation related to pregnancy.”[37] Another significant fact is that the largest group of women who stop smoking in pregnancy is those who have already stopped smoking on their own before the first prenatal visit.[38] This suggests that population-level approaches to cessation may be as warranted as clinical interventions. For example, a somewhat surprising result in the arena of regulation / taxation is that higher taxes on cigarettes provided a direct disincentive to continuing smoking during pregnancy and to postpartum relapse; a 10% increase in taxes was estimated to increase the probability of a pregnant woman quitting by 10%, with a similar positive impact on relapse rates.[39]
First Nations
The rate of tobacco use among British Columbian First Nation peoples is close to double that of other British Columbians.[40],[41] In B.C., 54% of Aboriginal teenagers and 65% of those aged 20-24 misuse tobacco.[42],[43] It
has also been shown that the proportion of non-smoking Aboriginals exposed to ETS daily is twice that observed for other non-smoking residents in the province.[44],[45] On a positive note, compared to other Canadian Aboriginals,
British Columbian First Nations have the lowest smoking rates. Aboriginal smoking rates are highest in the Northwest Territories (71% of NWT Aboriginals smoke).[46] For a variety of reasons, including traditional use of tobacco, easy access and low cost of tobacco on reserves, and a general acceptance of tobacco use among aboriginal communities,[47],[48] existing tobacco cessation programs have not been as successful with First Nation peoples compared with other populations in Canada.[49] Therefore, intervention programs developed specifically for First Nations are of particular interest.
Most B.C. programs designed to prevent initiation and encourage cessation among Aboriginal peoples are generally community-based and include education, participation of elders and other leaders in program development, and supportive involvement of peers and family.[50] Emphasis is put on distinguishing non-traditional use of commercial tobacco from culturally appropriate use.[51] Evaluations of the majority of BC programs are scarce.
The Honour Your Health Challenge, a component of B.C.’s Aboriginal Strategy, involved training aboriginal people to provide support in culturally-appropriate activities related to reducing tobacco misuse. Results from a survey representing 74% of the program participants were positive; the participants demonstrated an increase in knowledge, awareness and access to resources.[52] There is no data on the impact on cessation rates or smoking prevalence.
Some research has been conducted on pharmacotherapy agents to reduce tobacco use among First Nations, but the appropriateness and effectiveness of this intervention was not clear.[53]
Increasing tobacco prices has been shown to decrease use, primarily among youth, but this subject has not been rigorously researched within the context of the Aboriginal community.[54]
International Comparisons
The first conclusion from a wider literature search is that much more research is needed in the arena of aboriginal tobacco control. That research needs to be as B.C-focused as possible, since inter-cultural transferability of programs and results is not clear.
One US study showed positive results after providing native American youth with the problem-solving, personal coping and interpersonal communication skills needed to help them resist pressures toward substance abuse.[55] Over the course of the 3.5 year study, rates of smokeless tobacco use among youth with the acquired skills were 43% less than those among youth who did not receive the skills. Cigarette use was unaffected by the intervention. As well, combining skills development with other community intervention showed no added benefit.
Evaluations were found in the literature of five tobacco intervention programs for indigenous Australians. Three of these studies demonstrated some effectiveness. Evaluation of a mainstream advertising campaign showed that knowledge about tobacco had increased.[56] A study to assess the effectiveness of free nicotine patches for indigenous people showed that this program might benefit a small number of smokers; 15% of participants reported that they had quit smoking.[57] Training health professionals in delivering a brief intervention resulted in some changes to practice; however, the study found no evidence that any patient had quit smoking at six- months follow-up.[58] A trial of a CD-ROM resource for use with indigenous school children and a pilot study of smoke-free workplaces did not show any impact on smoking rates.[59]
Mental Illness
Diseases caused by smoking are the second largest killer of people who have a mental illness.[60] The lifetime prevalence of smoking among people suffering from various forms of mental illness is approximately 60%, compared to about 40% in the general population.[61] One study[62] suggested that almost a third of current US smokers have some form of mental illness, including schizophrenia, bipolar disorder, depression or other categories.[63] The risk for depression increases as the number of “nicotine dependence symptoms” increases,[64] while other research concludes that smoking initiation precedes and predicts depression and bipolar disorder.[65],[66],[67] Conversely, the presence of active psychiatric disorders predicts an increased risk for first onset of daily smoking and for progression to nicotine dependence and, consequently, for the development of chronic disease.[68],[69],[70],[71]
Canada’s National Population Health Survey confirms the connection between depression and smoking. Adolescents with depressive symptoms are more likely than other adolescents to start smoking. On the other hand, people who smoked daily in Canada had increased chances of having a major depressive episode compared with non-smokers—with the odds being almost double for men.[72]
Although progress has been made in understanding the “biology” (including the genetics) of the connection between smoking and mental illness, the phenomenon is not fully understood.[73] What is well-known is that smoking cessation often leads to a worsening of symptoms in all of the disorders.[74] One suggestion is that tobacco may be a form of “self-medication.” It was already noted in the preceding general discussion of non-pharmacological therapies that smoking has an anti-depressant effect. This may be one of the benefits of smoking which causes schizophrenic and depressed smokers to rate the “reward value” of smoking more highly than does the general smoking population.[75],[76],[77]
The association between smoking and mental illness has at least four implications for cessation treatment:
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In helping patients give up smoking, healthcare providers need to be aware of any underlying mental health problems that may need attention.
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Adding psychiatric components to treatments should be considered.
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Those treating nicotine dependence must be prepared to monitor and respond to any emergence of depression during the intervention, and should consider the potential benefit of antidepressants.
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There may be an advantage to integrating tobacco dependence treatment with mental health settings.
Approaches to Cessation
In spite of the assumed obstacles to cessation, smokers with a history of mental illness can show substantial quit rates.[78],[79],[80] One Canadian study found that people with mental disorders were very motivated to join a cessation group.[81] It is suggested that programs should be tailored for such populations, as the symptoms of mental illness and the resulting affective, cognitive and social difficulties, may mean that existing cessation approaches are not appropriate.[82]
There is little published literature about targeted treatments, and even less evidence of effectiveness. The types of interventions that have been tried with smokers exhibiting mental illness include:
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Individual counselling, often in conjunction with nicotine replacement therapy (NRT) or other drug treatment; the two approaches together are sometimes called combination therapy.
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One significant form of counselling intervention is cognitive-behavioural therapy (CBT).[83] CBT combines two kinds of psychotherapy, cognitive therapy and behaviour therapy. Behaviour therapy helps patients to weaken the connections between troublesome situations and habitual reactions.[84] Cognitive therapy teaches how certain thinking patterns are causing symptoms.
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Another form of counselling is motivational interviewing (MI), an intensive, directive, client-centered counselling style for eliciting behaviour change by helping clients to explore and resolve ambivalence. Practitioners of MI propose that the word "motivational" be used only when there is a primary focus on increasing readiness for change.[85]
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Group counselling, using a variety of formats which are to some extent modified to accommodate the limitations of mentally ill participants. Again, such therapy is often accompanied by pharmacological interventions.
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Policy interventions such as total or partial smoking bans in mental health settings.
General practice guidelines have been developed in Australia for smoking cessation in schizophrenia.[86] The guidelines are based partly on the stages-of-change model and include NRT, group counselling and frequent monitoring.
Intervention Results
A 2002 review of cessation strategies in samples of persons with mental illness found 8 studies related to schizophrenia, and 8 related to depression.[87] The studies of persons with schizophrenia mostly were based on small clinical samples. The focus of the investigations was drug treatment and group work, rather than individual counselling (consistent with the thrust of the Australian guidelines noted above). Nicotine patches and anti-psychotic drugs such as clozapine seem to help reduce smoking, but it takes the addition of group therapy to create significant quit rates; one study demonstrated cessation rates of 42% post treatment, 16% at 3 months and 12% at 6 months.[88]
The studies of people with depression used larger samples. It is important to note that the individuals recruited for such trials, while having a history of major depression, usually were not suffering from a current depressive episode. The most effective interventions involved a combination of cognitive-behavioural therapy and standard smoking cessation strategies, including pharmacotherapy. Quit rates ranged from 31 to 72% at the end of treatment and from 12 to 46% at 12 months. How these rates compared to any control group was not reported in the review. More recent studies with NRT have confirmed its effectiveness in patients with a history of depression, with improvement in cessation rates similar to the non-depressive population.[89],[90]
Assessing and comparing the wide range of counselling theories and modalities in the literature is difficult. One 2004 study showed higher rates of cessation among depressed patients using cognitive-behavioural therapy in group sessions compared with basic health education.[91] A randomized controlled trial of motivational interviewing versus brief advice, applied to adolescents with psychiatric disorders, showed no difference in smoking cessation outcomes.[92]
A recent comprehensive review of bans on smoking in mental health settings showed that such policies, on their own, had little or no effect on smoking cessation.[93]
[1] Hatsukami DK. Targeting treatments to special populations Nicotine & Tobacco Research 1999; 1(Suppl 2): S195-200, 207-10.
[2] For instance, one study identified these specific traits in youth susceptible to smoking: lower economic status, living in a single-parent home, lack of parental support, lower self-image, low levels of academic achievement and lack of skills to resist influences to use tobacco. US Centers for Disease Control and Prevention. Preventing Tobacco Use Among Young People: A Report of the Surgeon-General, 1994. Also, the recently-published B.C. tobacco control policy has chosen to focus on (in addition to aboriginals): young adults (20-24 years) who have the highest smoking rate, and middle-aged adults (25-44 years) who are beginning to manifest smoking-related chronic diseases.
[3] Unrod M, Cook T, Myers MG et al. Smoking cessation efforts among substance abusers with and without psychiatric comorbidity Addictive Behavior 2004; 29(5): 1009-13.
[4] Kramer MS. Determinants of low birth weight: methodological assessment and meta-analysis Bulletin of the World Health Organization 1987; 65: 663-737.
[5] British Medical Association. Smoking and Reproductive Life. February 2004.
[6] Colman G, Grossman M, Joyce T. The effect of cigarette excise taxes on smoking before, during and after pregnancy Journal of Health Economics 2003; 22: 1053-72.
[7] Fingerhut LA, Kleinman JC, Kendrick JS. Smoking before, during, and after pregnancy American Journal of Public Health 1990; 80(5): 541-4.
[8] Colman GJ, Joyce T. Trends in smoking before, during, and after pregnancy in ten states American Journal of Preventive Medicine 2003; 24(1): 29-35.
[9] Johnson IL, Ashley MJ, Reynolds D et al. Prevalence of smoking associated with pregnancy in three Southern Ontario Health Units Canadian Journal of Public Health 2004; 95(3): 209-13.
[10] Albrecht SA, Maloni JA, Thomas KT et al. Smoking cessation counselling for pregnant women who smoke: scientific basis for practice for AWHONN’s SUCCESS Project Journal of Obstetric, Gynecolgic, and Neonatal Nursing 2004; 33(3): 298-305.
[11] Bridge J, Turpin B. The Cost of Smoking in British Columbia and the Economics of Tobacco Control. Health Canada, February 2004.
[12] McBride CM, Curry SJ, Lando HA et al. Prevention of relapse in women who quit smoking during pregnancy American Journal of Public Health 1999; 89(5): 706-11.
[13] Dolen-Mullen P, Richardson MA, Quin VP et al. Postpartum return to smoking: who is at risk and when American Journal of Health Promotion 1997; 11(5): 323-30.
[14] British Medical Association. Smoking and Reproductive Life. February 2004.
[15] Orleans CT, Barker DC, Kaufman NJ et al. Helping pregnant smokers quit: meeting the challenge in the next decade Tobacco Control 9 (Suppl III): 6-11.
[16] Fang WL, Goldstein AO, Butzen AY et al. Smoking cessation in pregnancy: a review of postpartum relapse prevention strategies.
[17] British Medical Association. Smoking and Reproductive Life. February 2004.
[18] The rate of smoking among women peaks between age 25 and 44, which overlaps with the childbearing years.
[19] Paterson JM, Neimanis IM, Bain E. Stopping smoking during pregnancy: are we on the right track? Canadian Journal of Public Health 2003; 94(4): 297-9.
[20] McLeod D, Pullon S, Cookson T. Factors that influence changes in smoking behaviour during pregnancy New Zealand Medical Journal 2003; 116(1173): U418.
[21] Valanis B, Lichtenstein E, Mullooly JP et al. Maternal smoking cessation and relapse prevention during health care visits American Journal of Preventive Medicine 2001; 20(1): 1-8.
[22] Lumley J, Oliver S, Waters E. Interventions for promoting smoking cessation during pregnancy Cochrane Tobacco Addiction Group Cochrane Database of Systematic Reviews. 3, 2004.
[23] Windsor RA, Boyd NR, Orleans CT. A meta-evaluation of smoking cessation intervention research among pregnant women: improving the science and art Health Education Research 1998; 13(3): 419-38.
[24] Walsh RA, Redman S, Brinsmead MW et al. A smoking cessation program at a public antenatal clinic American Journal of Public Health 1997; 87(7): 1201-4.
[25] Walsh RA, Redman S, Brinsmead MW et al. A smoking cessation program at a public antenatal clinic American Journal of Public Health 1997; 87(7): 1201-4.
[26] Dolen-Mullen P. Maternal smoking during pregnancy and evidence-based intervention to promote cessation. In: Spangler JG, ed. Primary care: clinics in office practice. Philadelphia: WB Saunders, 1999; 26: 577-89.
[27] Valanis B, Lichtenstein E, Mullooly JP et al. Maternal smoking cessation and relapse prevention during health care visits American Journal of Preventive Medicine 2001; 20(1): 1-8.
[28] Melvin CL, Dolen-Mullen P, Windsor RA et al. Recommended cessation counselling for pregnant women who smoke: a review of the evidence Tobacco Control 2000; 9(Suppl 3): 80-4.
[29] Hartmann KE, Thorp JM, Pahel-Short L et al. A randomized controlled trial of smoking cessation intervention in pregnancy in an academic clinic Obstetrics & Gynecology 1996; 87(4): 621-6.
[30] A helpful summary of this quideline is available at http://www.smokefreefamilies.uab.edu/smokces.doc (accessed October 2004).
[31] Albrecht SA, Maloni JA, Thomas KT et al. Smoking cessation counselling for pregnant women who smoke: scientific basis for practice for AWHONN’s SUCCESS Project Journal of Obstetric, Gynecolgic, and Neonatal Nursing 2004; 33(3): 298-305.
[32] Acharya G, Jauniaux E, Sathia L et al. Evaluation of the impact of current antismoking advice in the UK on women with planned pregnancies Journal of Obstetrics and Gynaecology 2002; 22(5): 498-500.
[33] Malchodi CS, Oncken C, Dornelas EA et al. The effects of peer counselling on smoking and reduction Obstetrics & Gynecology 2003; 101(3): 504-10.
[34] McBride CM, Baucom DH, Peterson BL et al. Prenatal and postpartum smoking abstinence: a partner-assisted approach American Journal of Preventive Medicine 2004; 27(3): 232-8.
[35] Benowitz NL, Dempsey DA, Goldenberg RL et al. The use of pharmacotherapies for smoking cessation during pregnancy Tobacco Control 2000; 9(Suppl III): 91-4.
[36] Ebrahim SH, Merritt RK, Floyd RL. Smoking and women's health: opportunities to reduce the burden of smoking during pregnancy Canadian Medical Association Journal 2000; 163(3):288-9.
[37] Ebrahim SH, Floyd RL, Merritt RK et al. Trends in pregnancy-related smoking rates in the United States, 1987-1996 Journal of the American Medical Association 2000; 283(3): 361-6.
[38] Lumley J, Oliver S, Waters E. Interventions for promoting smoking cessation during pregnancy Cochrane Tobacco Addiction Group Cochrane Database of Systematic Reviews. 3, 2004.
[39] Colman G, Grossman M, Joyce T. The effect of cigarette excise taxes on smoking before, during and after pregnancy Journal of Health Economics 2003; 22: 1053-72.
[40] Wardman AE, Khan N. Tobacco cessation pharmacotherapy use among First Nations persons residing within British Columbia Nicotine Tobacco Research 2004; 6(4):689-92.
[41] Angus Reid Group. Tobacco use in British Columbia, 1997. Available at http://healthplanning.gov.bc.ca/tobacrs/index.html (accessed October 2004).
[42] Tobacco Control – Tobacco Facts. Available at http://www.tobaccofacts.org/tob_control/strategy.html (accessed October 2004).
[43] Angus Reid Group. Tobacco use in British Columbia, 1997. Available at http://healthplanning.gov.bc.ca/tobacrs/index.html (accessed October 2004).
[44] Angus Reid Group. Tobacco use in British Columbia, 1997. Available at http://healthplanning.gov.bc.ca/tobacrs/index.html (accessed October 2004).
[45] Ministry of Health. Targeting our efforts: BC’s tobacco control strategy, 2004.
[46] Health Canada. Guide to tobacco use cessation programs in Canada: priority populations, no date. Available at www.hc-sc.gc.ca/hecs-sesc/tobacco/quitting/cessation/tobrpt2.html (accessed October 2004).
[47] Alberta Alcohol and Drug Abuse Commission. Framework for developing tobacco reduction strategies for young adults R.A. Malatest & Associates, 2003.
[48] Ministry of Health. Honouring our Health: An aboriginal tobacco strategy for British Columbia, 2001.
[49] Health Canada. Guide to tobacco use cessation programs in Canada, no date. Available at www.hc-sc.gc.ca/hecs-sesc/tobacco/quitting/cessation/tobrpt2.html (accessed October 2004).
[50] Ministry of Health. Honouring our Health: An aboriginal tobacco strategy for British Columbia, 2001.
[51] Ministry of Health. Honouring our Health: An aboriginal tobacco strategy for British Columbia, 2001.
[52] Tobacco Control – Tobacco Facts. Available at http://www.tobaccofacts.org/tob_control/strategy.htm (accessed October 2004).
[53] Wardman AE, Khan N. Tobacco cessation pharmacotherapy use among First Nations persons residing within British Columbia Nicotine & Tobacco Research 2004; 6(4): 689-92.
[54] Ministry of Health. Honouring our Health: An aboriginal tobacco strategy for British Columbia, 2001.
[55] Schinke SP, Tepavac L, Cole KC. Preventing substance use among native American youth: three-year results Addictive Behaviors 2000; 25(3): 387-97.
[56] Ivers E. A review of tobacco interventions for Indigenous Australians Australian & New Zealand Journal of Public Health 2003; 27(3): 294-9.
[57] Ivers RG, Farrington M, Burns CB et al. A study of the use of free nicotine patches by Indigenous people Australian & New Zealand Journal of Public Health 2003; 27(5): 486-90.
[58] Harvey D, Tsey K, Cadet-James Y et al. An evaluation of tobacco brief intervention training in three indigenous health care settings in north Queensland Australian & New Zealand Journal of Public Health 2002; 26(5): 426-31.
[59] Ivers E. A review of tobacco interventions for Indigenous Australians Australian & New Zealand Journal of Public Health 2003; 27(3): 294-9.
[60] Source: http://www.sane.org/ (accessed October 2004).
[61] Lasser K, Boyd JW, Woolhandler S et al. Smoking and mental illness: a population-based prevalence study Journal of the American Medical Association 2000; 284(20): 2606-10.
[62] Leonard S, Adler LE, Benhammou K et al. Smoking and mental illness Pharmacology, Biochemistry & Behavior 2001; 70: 561-70.
[63] Other categories of mental illness include posttraumatic stress disorder, attention-deficit disorder, obsessive-compulsive disorder, and anxiety. Addictive disorders, and especially nicotine dependence, of course represent special areas of interest.
[64] John U, Meyer C, Rumpf HJ et al. Depressive disorders are related to nicotine dependence in the population but do not necessarily hamper smoking cessation Journal of Clinical Psychiatry 2004; 65(2): 169-76.
[65] Scarinci IC, Thomas J, Brantley PJ et al. Examination of the temporal relationship between smoking and major depressive disorder among low-income women in public primary care clinics American Journal of Health Promotion 2002; 16(6): 323-30.
[66] Gonzalez-Pinto A, Gutierrez M, Ezcurra J et al. Tobacco smoking and bipolar disorder Journal of Clinical Psychiatry 1998; 59(5): 225-8.
[67] This interesting result does not suggest that smoking cessation would prevent the onset of mood disorders, as ex-smokers show the same risk for such onset as current smokers. Breslau N, Novak SP, Kessler RC. Daily smoking and the subsequent onset of psychiatric disorders Psychological Medicine 2004; 34: 323-33.
[68] Breslau N, Novak SP, Kessler RC. Psychiatric disorders and stages of smoking Biological Psychiatry 2004; 55(1): 69-761.
[69] Ismail K, Sloggett A, DeStavola B. Do common mental disorders increase cigarette smoking? American Journal of Epidemiology 2000; 152(7): 651-7.
[70] Strine TW, Balluz L, Chapman DP et al. Risk behaviors and healthcare coverage among adults by frequent mental distress status, 2001 American Journal of Preventive Medicine. 2004; 26(3): 213-6.
[71] Caroline P, Carney RF, Woolson LJ et al. Occurrence of cancer among people with mental health claims in an insured population Psychosomatic Medicine 2004; 66: 735-743.
[72] Source: http://www.statcan.ca/english/studies/82-003/archive/1999/hrar1999011003s0a05.pdf (accessed October 2004).
[73] McChargue DE, Spring B, Cook JW et al. Reinforcement expectations explain the relationship between depressive history and smoking status in college students Addictive Behaviors 2004; 29(5): 991-4.
[74] Dalack GW, Becks L, Hill E et al. Nicotine withdrawal and psychiatric symptoms in cigarette smokers with schizophrenia Neuropsychopharmacology 1999; 21(2): 195-202.
[75] Spring B, Pingitore R, McChargue DE. Reward value of cigarette smoking for comparably heavy smoking schizophrenic, depressed, and nonpatient smokers American Journal of Psychiatry 2003; 160(2): 316-22.
[76] McChargue DE, Spring B, Cook JW et al. Reinforcement expectations explain the relationship between depressive history and smoking status in college students Addictive Behaviors 2004; 29(5): 991-4.
[77] One Australian review provided this inventory of possible benefits of smoking to schizophrenic patients: improved cognition, relaxation, antidepressant effect, modification of psychotic symptoms, reduced side effects from antipsychotic drugs. Smoking cessation in schizophrenia: general practice guidelines, 2001. Source: http://www.racgp.org.au/document.asp?id=5319 (accessed October 2004).
[78] Lasser K, Boyd JW, Woolhandler S et al. Smoking and mental illness: a population-based prevalence study Journal of the American Medical Association 2000; 284(20): 2606-10.
[79] Hitsman B, Borrelli B, McChargue DE et al. History of depression and smoking cessation outcome: a meta-analysis Journal of Consulting & Clinical Psychology 2003; 71(4): 657-63.
[80] John U, Meyer C, Rumpf HJ et al. Depressive disorders are related to nicotine dependence in the population but do not necessarily hamper smoking cessation Journal of Clinical Psychiatry 2004; 65(2): 169-76.
[81] Addington J, el-Guebaly N, Addington D et al. Readiness to stop smoking in schizophrenia Canadian Journal of Psychiatry 1997; 42: 49-52.
[82] Addington J. Group treatment for smoking cessation among persons with schizophrenia Psychiatric Services 1998; 49(7): 925-8.
[83] Source: http://www.cognitivetherapy.com/basics.html (accessed October 2004).
[84] Behavioural counselling is sometimes used to prevent relapse.
[85] Source: http://motivationalinterview.org/clinical/whatismi.html (accessed October 2004).
[86] Smoking cessation in schizophrenia: general practice guidelines, 2001.
Source: http://www.racgp.org.au/document.asp?id=5319 (accessed October 2004).
[87] el-Guebaly N, Cathcart J, Currie S et al. Smoking cessation approaches for persons with mental illness or addictive disorders Psychiatric Services 2002; 53(9): 1166-70.
[88] Addington J, el-Guebaly N, Campbell W et al. Smoking cessation treatment for patients with schizophrenia American Journal of Psychiatry 1998; 155: 974-76.
[89] Thorsteinsson HS, Gillin JC, Patten CA et al. The effects of transdermal nicotine therapy for smoking cessation on depressive symptoms in patients with major depression Neuropsychopharmacology 2001; 24(4): 350-8.
[90] John U, Meyer C, Rumpf HJ et al. Depressive disorders are related to nicotine dependence in the population but do not necessarily hamper smoking cessation Journal of Clinical Psychiatry 2004; 65(2): 169-76.
[91] Haas AL, Munoz RF, Humfleet GL et al. Influences of mood, depression history, and treatment modality on outcomes in smoking cessation Journal of Consulting & Clinical Psychology 2004; 72(4): 563-70.
[92] Brown RA, Ramsey SE, Strong DR et al. Effects of motivational interviewing on smoking cessation in adolescents with psychiatric disorders Tobacco Control 2003; 12 (Suppl 4): 3-10.
[93] el-Guebaly N, Cathcart J, Currie S et al. Public health and therapeutic aspects of smoking bans in mental health and addiction settings Psychiatric Services 2002; 53(12):1617-22