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Special Populations with Higher Rates of Cigarette Smoking: Identification and Implications for Tobacco Control

Robert B. Wallace

Department of Epidemiology

College of Public Health

University of Iowa


While the overall national prevalence of cigarette smoking among American adults is about 20–22 percent (CDC 2004b), several population groups have been identified with higher than average rates. It is axiomatic in public health that attention to populations with higher levels of unhealthy exposures such as tobacco should lead to improved and more efficient population outcomes. With regard to community tobacco control programs, it is apparent that high-risk populations have received less than full attention. For example, tobacco taxation policies, elementary school education programs, and youth access regulation—three important cornerstones of community-based tobacco control—are not particularly targeted to those at special risk or exposure other than attention to one specific demographic group (youth).

The purpose of this chapter is to identify populations that either have greater than average cigarette smoking rates or are at higher risk for acquiring smoking behaviors, and to derive some implications for community tobacco control efforts. Specifically, this chapter:

  • Identifies a substantial number of population groups with higher than average levels of tobacco use and attempts to assess the quality of evidence that these groups indeed possess such smoking rates;

  • Addresses the overlapping nature of risk factors for higher smoking rates among these potential target populations; and

  • Discusses the implications of these high-utilization or high-risk groups for tobacco control policies in the United States.

THE BASIC PREMISE: SPECIAL BEHAVIORS AND INCREASED TOBACCO USE

The basic approach to this chapter is to identify individual and group characteristics and behaviors that are empirically associated with demonstrably higher use rates for tobacco products, particularly cigarette smoking, by using a targeted but not exhaustive literature review. As discussed below, some of these groups are defined by one or more demographic features. Other groups have characteristics and “behaviors” that are regarded as psychiatric symptomatology or frank psychiatric Axis I or II disorders, with widely accepted manifestations and a clear nosologic presence (Joseph et al. 2004). Some groups with high smoking prevalence rates have been recognized for decades, such as patients with schizophrenia, who have high cigarette consumption rates (Masterson and O’Shea 1984).

However, in addition to the mental conditions that have been associated with higher smoking levels, many other “special” behaviors and behavioral characteristics not directly comprising



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Ending the Tobacco Problem: A Blueprint for the Nation P Special Populations with Higher Rates of Cigarette Smoking: Identification and Implications for Tobacco Control Robert B. Wallace Department of Epidemiology College of Public Health University of Iowa While the overall national prevalence of cigarette smoking among American adults is about 20–22 percent (CDC 2004b), several population groups have been identified with higher than average rates. It is axiomatic in public health that attention to populations with higher levels of unhealthy exposures such as tobacco should lead to improved and more efficient population outcomes. With regard to community tobacco control programs, it is apparent that high-risk populations have received less than full attention. For example, tobacco taxation policies, elementary school education programs, and youth access regulation—three important cornerstones of community-based tobacco control—are not particularly targeted to those at special risk or exposure other than attention to one specific demographic group (youth). The purpose of this chapter is to identify populations that either have greater than average cigarette smoking rates or are at higher risk for acquiring smoking behaviors, and to derive some implications for community tobacco control efforts. Specifically, this chapter: Identifies a substantial number of population groups with higher than average levels of tobacco use and attempts to assess the quality of evidence that these groups indeed possess such smoking rates; Addresses the overlapping nature of risk factors for higher smoking rates among these potential target populations; and Discusses the implications of these high-utilization or high-risk groups for tobacco control policies in the United States. THE BASIC PREMISE: SPECIAL BEHAVIORS AND INCREASED TOBACCO USE The basic approach to this chapter is to identify individual and group characteristics and behaviors that are empirically associated with demonstrably higher use rates for tobacco products, particularly cigarette smoking, by using a targeted but not exhaustive literature review. As discussed below, some of these groups are defined by one or more demographic features. Other groups have characteristics and “behaviors” that are regarded as psychiatric symptomatology or frank psychiatric Axis I or II disorders, with widely accepted manifestations and a clear nosologic presence (Joseph et al. 2004). Some groups with high smoking prevalence rates have been recognized for decades, such as patients with schizophrenia, who have high cigarette consumption rates (Masterson and O’Shea 1984). However, in addition to the mental conditions that have been associated with higher smoking levels, many other “special” behaviors and behavioral characteristics not directly comprising

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Ending the Tobacco Problem: A Blueprint for the Nation mental illness have been suggested to be associated with increased tobacco use, leading to research into personality traits among smokers. An example is the reported association between a personality trait, such as sensation seeking, and tobacco use among college students (Zuckerman and Kuhlman 2000). The empirical focus on particular individual behaviors is extremely important and avoids the issue of whether such behaviors necessarily represent diseases or behavioral deviations in need of clinical management per se, a potential problem with the biomedical model of health and disease (Brandt and Gardner 2000). Of course, our understanding of the genesis of these traits is often incomplete, as are the biological explanations for tobacco use rates and risks in general. DEMOGRAPHIC CHARACTERISTICS AND SMOKING HABITS Cigarette smoking rates differ across broad demographic groups in the United States. Rates are higher in men than in women and among younger persons than older persons. African American and Hispanic adults have similar smoking prevalence rates to whites, whereas Asians overall have somewhat lower rates than whites and American Indians/Alaska Natives have somewhat higher rates than whites (CDC 2004b). Of particular interest, smoking rates are also higher among lower-socioeconomic groups (CDC 2004a). These socioeconomic disparities in tobacco exposure have been the subject of research with respect to explaining variation in tobacco use and resulting health status (King et al. 2004). It has also been suggested that young, “working class” adults have been important targets for commercial tobacco marketing (Barbeau et al. 2004). The themes of poverty, lower socioeconomic status (SES), and health and social disparities pervade many of the high risk groups for tobacco use. However, the relation between lower SES and higher tobacco use rates is complex and multifactorial and requires substantial further inquiry. While some tobacco control programs have attempted intervention based on SES or broad demographic characteristics per se, many high-risk populations enriched with lower-SES individuals are identified largely by their intersection with various social institutions, such as the health care system, prisons, school counseling programs, and homeless shelters. TOBACCO USE AND PSYCHIATRIC DISORDERS Patients and survey respondents with clinical or research diagnoses of many important major mental illnesses have been reported to have higher rates of cigarette smoking and nicotine dependence. These include schizophrenia, major depressive disorder, any alcohol use disorder, any substance abuse disorder, anxiety disorders, mania, and personality disorders (Breslau 1995; Breslau et al. 1991; Breslau et al. 1993; Breslau et al. 1994; Fagerstrom et al. 1996; Grant et al. 2004; Hughes et al. 1986; Lasser et al. 2000). Some studies find higher smoking rates with increasing severity of the psychiatric condition, and these findings have been observed in both white and non-white populations (de Leon et al. 2002). In addition, other psychiatric conditions less frequently studied have been associated with a higher prevalence of smoking, including social phobia, agoraphobia, panic disorder, panic attacks, dysthymia, antisocial behavior and conduct disorders, and post-traumatic stress disorder (Lasser et al. 2000). Studies on the association of mental illness and smoking have varied designs, inclusion criteria, and other methods. Some are clinic-based, while others are in geographically defined populations. Participation rates vary and, in some of the clinical studies, are unspecified. Patient diagnoses in clinical studies are usually based on individual practitioner designations, without

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Ending the Tobacco Problem: A Blueprint for the Nation specific attention to diagnostic criteria, while those in population studies are often based on structured, standardized instruments adopted for epidemiological study. Most studies record actual cigarette or other tobacco use, while a few focus only on defined “tobacco use disorders” or the severity of nicotine dependence (Fagerstrom et al. 1996). Studies also differ in representation of various age, gender, and racial or ethnic groups. Patients in studies comprising clinical series, while of substantial value, may vary in terms of their mental illness severity, persistence, and age at onset. Often, the relation of age at onset of the psychiatric disorder vis-à-vis age at smoking initiation is not specified, but this temporal relationship may have important implications for identifying adolescents at high risk for smoking based on emerging manifestations of psychiatric disorders. However, despite methodological variation in studies of these mental disorders and smoking, these associations appear to be robust, reproducible, and of an important magnitude. Indeed, Grant and colleagues (2004) calculated that while nicotine-dependent adults make up only 12.8 percent of the American adult population, they consume 57.5 percent of the cigarettes sold (Grant et al. 2004). Their study also suggests that adult Americans with psychiatric morbidity or comorbidity account for 70 percent of national cigarette sales. Thus, patients with mental illness should be an important part of community tobacco control programs, for both prevention and cessation efforts. Since psychiatric comorbidity is common among smokers, a concerted effort to apply smoking cessation programs to these individuals has been recognized. A 1996 American Psychiatric Association guideline recommended routine treatment of smoking among patients with psychiatric disorders (APA 1996). However, for both resource and other reasons, determining the optimal interventions and ultimate effectiveness of such programs and motivating health professionals to invoke cessation programs are challenging. In the National Ambulatory Medical Care Survey, a medical record-based representative survey of primary care physicians in the United States, physicians were more likely to identify smoking status among patients with psychiatric disorders than among those without (Thorndike et al. 2001), but patients with mental illness were only modestly more likely to be counseled on smoking cessation (23 versus 18 percent of visits, respectively). Smokers with psychiatric comorbidity appear to be genuinely interested in smoking cessation programs. Among 120 smoking patients in four diverse mental health treatment settings, Lucksted and colleagues (2004) reported that 82 percent desired to stop or cut down on cigarette use (Lucksted et al. 2004). Saxon and colleagues (2003) reported that in a Department of Veterans Affairs psychiatric outpatient program, many were interested in smoking cessation but the programs were only minimally successful (Saxon et al. 2003). Whether psychopathology affects the response to cessation programs is not fully studied. Cinciripini and colleagues (2003) reported that post-cessation depression was associated with increased recidivism (Cinciripini et al. 2003), while Gariti and colleagues (2000) found no association between having an Axis I or II diagnosis and smoking cessation treatment success (Gariti et al. 2000). Clearly, more research is needed to explore the methods and effectiveness of smoking cessation treatment among persons with psychiatric comorbidity. SMOKING-RELATED BEHAVIORAL AND MENTAL HEALTH ISSUES AMONG CHILDREN AND ADOLESCENTS Elsewhere in this volume, Flay (Appendix D) discusses the techniques and success rates for prevention of smoking initiation with general, school-based intervention programs, both freestanding and in concert with other community-based interventions. He concludes that several

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Ending the Tobacco Problem: A Blueprint for the Nation middle and high school programs can lead to a significant reduction in smoking prevalence, although there is decay through the later high school years, with little evidence for continued effectiveness at the 12th grade or beyond. In general, these programs are intended for delivery to general school populations for the target age ranges. Over the past few decades it has become clear that some children and adolescents are at identifiably greater risk of initiating and maintaining smoking. Some of these groups are identified below. The following sections are devoted to the behaviors and conditions among adolescents that are associated with the risk of cigarette smoking onset and maintenance. Attention-Deficit/Hyperactivity Disorder and Smoking One particularly important behavioral syndrome among children is Attention-Deficit / Hyperactivity Disorder (ADHD), an important public health problem thought to occur in 3–10 percent of child populations (Daley 2004). Children with this syndrome have a higher risk of cigarette use initiation and smoking maintenance, as well as abuse of other substances, than there are in non-ADHD contrast groups (Daley 2004; Lambert and Hartsough 1998; Wilens et al. 1997), although this association may in part be due to concomitant psychiatric comorbidity (Wilens 2004). Because ADHD risk has been reported to be increased among children whose mothers smoked during pregnancy (Thapar et al. 2003), both familial and environmental causes have been invoked to explain this association. Conversely, ADHD has been reported to be more common among those with substance abuse disorders and has also been associated with antisocial behaviors and conduct disorder (Flory and Lyman 2003; Schubiner et al. 2000). The presence of these conditions in themselves has obvious and important implications for delivering successful tobacco education programs. The ADHD syndrome extends into adulthood, and the disorder tends to impair academic, social, and occupational function, as well as frequently being associated with substance abuse (including smoking) and other psychiatric comorbidity (Wilens and Dodson 2004). Among adults with ADHD, substance abuse, including nicotine dependence, occurred more frequently than expected by chance, raising the prospect that pharmacological treatment of ADHD may reduce the risk of substance abuse in these individuals (Wilens 2004). Childhood Behaviors, Behavioral Exposures, and the Risk of Smoking Initiation Certain types of childhood behaviors have been associated with increased general substance use, and cigarette smoking in particular. For example, there is growing evidence that smoking rates, along with other psychiatric comorbidity, are higher among girls and women with a history of sexual abuse earlier in life (De Von Figueroa-Moseley et al. 2004; Nichols and Harlow 2004). There is also an emerging literature exploring a host of adverse experiences extending beyond direct physical or sexual abuse that are associated with substantially increased risks of smoking initiation, such as the presence of depressed affect, suicide attempts, sexually transmitted disease, and an impoverished, dysfunctional household environment (Dube et al. 2003; Mcnutt et al. 2002). In keeping with findings of strong associations between psychiatric conditions and an increased prevalence of smoking, various behavioral syndromes and mental disorders that are associated with increased smoking rates, in addition to ADHD, have been identified in children and adolescents. In a review of the literature through 2001, these included disruptive behaviors (e.g., oppositional defiant disorder and conduct disorder), anxiety disorders, major depression, and

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Ending the Tobacco Problem: A Blueprint for the Nation drug and alcohol use disorders (Upadhyaya et al. 2002). In addition, increased smoking rates have been reported among children and adolescents with depressive symptoms or major depression; as noted above, some of these individuals had also been victims of early physical and sexual abuse (Diaz et al. 2002; Glied and Pine 2002). Eating disorders and concerns about body weight, particularly among adolescent females, also have been associated with increased smoking rates (Potter et al. 2004). In a study evaluating substance abuse screening instruments in adolescents, adolescent cigarette smoking was associated with a wide range of mental health symptoms (Chang et al. 2005). It has been observed that with the exception of ADHD, conduct disorder, and anxiety disorders, the onset of cigarette smoking generally precedes the onset of the diagnosed psychiatric disorder (Dierker et al. 2002). Thus, identifying children who smoke may have a role in the prevention or amelioration of future psychiatric morbidity. With respect to the school environment and other social and institutional settings, the problem of conduct disorder is particularly relevant. Hyperactivity (also part of the ADHD syndrome) and socially disruptive behaviors are often identified early in school children. Conduct disorder, along with a history of parental smoking, predicts higher rates of daily adolescent smoking (Clark and Cornelius 2004; Rohde et al. 2004). Among children and adolescents with in-patient psychiatric admissions, the odds of smoking were increased thirteenfold among those with conduct disorder (Upadhyaya et al. 2003). Conduct disorder has also been associated with alcohol and other substance abuse as well as heavy smoking (Cornelius et al. 2001). Conduct disorder and antisocial personality among adolescents are associated with increased risk of substance abuse and violent crime as adults (Moffitt et al. 2002), which along with problems in cognitive development may explain in part the high rates of smoking among persons in prisons and jails (see below) (Feinstein and Bynner 2004). DEFINED ADULT POPULATIONS WITH HIGH RATES OF CIGARETTE SMOKING There are important and sometimes large adult populations that have been recognized to have higher than average prevalence rates for cigarette consumption; some of these groups have been approached by community-based tobacco control programs. Several of these groups have higher rates of impoverishment or at least lower SES, and some have substantial prevalence rates for psychiatric comorbidity. As noted above, both of these characteristics are associated with higher smoking rates, and the groups below are defined by their intersection with social institutions where they can be identified and potentially receive smoking cessation and other appropriate treatments. Smoking Among Inmates in Correctional Institutions Cigarette smoking rates are generally believed to be extremely high in correctional institutions. While there have been relatively few exhaustive quantitative surveys of smoking rates in jails and prisons, such smoking rates and concerns about health consequences among inmates have been described (Voglewede and Noel 2004). Lightfoot and Hodgins (1988) reported a 77 percent smoking rate in the past 6 months among inmates in a male penitentiary (Lightfoot and Hodgins 1988). Hughes and Boland (1992) reported a current smoking rate among American penitentiary inmates of 79 percent (Hughes and Boland 1992). Durrah and Rosenberg (2004) reported a current smoking prevalence of 71 percent among women arrested in New York City (Durrah and Rosenberg 2004). High rates of smoking among prisoners are not surprising given

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Ending the Tobacco Problem: A Blueprint for the Nation the rates of incarceration for substance abuse, the generally lower SES of inmates, and the high rates of psychiatric comorbidity (Andersen 2004). The peer-reviewed literature on smoking cessation programs among prisoners is extremely limited. However, there is a report of the impact of a total smoking ban in a maximum security psychiatric hospital (Hempel et al. 2002). Ultimately, the ban was accepted by both patients and staff, and there was a post-ban decline in sick call, disruptive behavior, and verbal aggression rates among patients. Smoking Among Military Recruits Higher than expected rates of tobacco consumption have been reported among incoming recruits and active duty military personnel in the United States. Chisick and colleagues (1998) reported the highest rates among white males on active duty: 43 percent cigarette smoking and 24 percent smokeless tobacco use (Chisick et al. 1998). Ward and colleagues (2003) reported a smoking rate of over 24 percent among Air Force recruits (Ward et al. 2003). Among Naval recruits, Ames and colleagues (2002) reported that about half used tobacco in the year prior to enlistment (Ames et al. 2002). Shahar and Carol (1991) reported that smoking rates in one cohort actually increased during basic training (Shahar and Carel 1991). Since military recruit populations tend to be overrepresented with persons of lower educational attainment and lower SES in general, they are likely to be at greater risk for smoking. Smoking Among Homeless Persons It is very difficult to conduct representative surveys of homeless persons, and thus it is difficult to determine population health characteristics. In one study from Pittsburgh, comprising homeless persons receiving medical or social services at nine sites, 69 percent of the homeless clients were current smokers (Connor et al. 2002). Reports of tobacco use prevalence rates among homeless persons internationally have ranged from 75 to 85 percent, and are consistent with the high rate of mental illness and substance abuse seen among homeless patients in the United States and elsewhere (Folsom and Jeste 2002; Martens 2001). In the United States, tobacco industry documents uncovered as part of the Master Settlement Agreement (MSA) revealed a marketing program aimed in part at homeless persons (Stevens et al. 2004). No peer-reviewed reports on smoking cessation programs among the homeless were identified. However, some homeless smokers in a series from an urban academic medical center did express an interest in quitting and smoking cessation counseling (Arnsten et al. 2004). Smoking Among Lesbian, Gay, Bisexual, or Transgender Populations While the literature is limited, and small-area population surveys are not necessarily representative of large geographic regions, there is evidence that cigarette smoking is more common among Lesbian, Gay, Bisexual, or Transgender (LGBT) communities than among the general population (Greenwood et al. 2005;Ryan et al. 2001; Stevens et al. 2004; Tang et al. 2004). As in homeless persons, documents uncovered as part of the MSA revealed an industrial tobacco marketing program to the urban gay and lesbian community (Stevens et al. 2004). There is also an emerging and relevant literature suggesting that mental health problems may be higher among LGBTs than the general population (Cochran et al. 2003; Diamant and Wold 2003; Mays and Cochran 2001). However, no large-scale, robust, population-based surveys of this issue have been identified; most studies were conducted on clinical, network, or small-scale population samples.

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Ending the Tobacco Problem: A Blueprint for the Nation Smoking and Gambling Substantial clinical observation and a few surveys have suggested a strong positive association between smoking and gambling disorders and gambling behavior. For example, 43 percent of those calling a gambling helpline reported daily tobacco use (Potenza et al. 2004) and daily smoking was present in about two-thirds of persons seeking psychiatric treatment for gambling (Petry and Oncken 2002). In an Australian household survey, persons among households containing smokers were more likely to engage in gambling behaviors (Siahpush et al. 2004). It may be reasonable to consider screening persons for gambling behaviors or disorders within primary care or other clinical and psychiatric settings, in order to identify smokers and those with other psychiatric comorbidity, and then invoke appropriate smoking cessation programs. Of note, it has been reported that ordinances banning smoking in charitable public gaming settings had no adverse effect on the level of monetary profits (Glantz and Wilson-Loots 2003). Smoking Among Disabled Populations The term disability is used in several contexts, but generally refers to dysfunction, difficulty, or dependence in executing defined tasks that are associated with daily living in the community. As thus defined, having a disability may be associated with mental illness, and smoking prevalence rates are higher than among comparable populations without disabilities. Smoking rates may also be elevated among those with common chronic disabling conditions to which smoking is etiologically related, such as cardiopulmonary disease, stroke, lung disease, cancer, and intermittent claudication (Kuhn et al. 2005; Regensteiner 2004; Twardella et al. 2004). Even in the presence of overt disease and during the rehabilitation process, there are opportunities for conducting smoking cessation programs. However, few population or geographic surveys of smoking rates among those with physical disabilities have been conducted. A survey of adults with disabilities in Massachusetts found somewhat higher smoking rates among those with disabilities related to orthopedic conditions (Brawarsky et al. 2002), but not affective or sensory conditions. In a survey of persons with major disabilities living in six independent living facilities, changes in smoking were associated with concomitant changes in health-related quality of life scores (Mitra et al. 2004). Persons with disabilities are not spared the adverse health outcomes of smoking. In addition to major chronic illnesses, for example, McGeary and colleagues (2004) found that smoking interfered with the rehabilitation of patients after spinal injuries and surgery (McGeary et al. 2004). Populations with disabilities use a substantial amount of health care, a situation that may offer an important opportunity for smoking prevention and cessation interventions. IMPLICATIONS OF SPECIAL HIGH-RISK OR HIGH TOBACCO-CONSUMPTION GROUPS FOR TOBACCO CONTROL EFFORTS Cigarette consumption is not distributed randomly across the American adult population. Rather, consumption rates are clearly overrepresented among those of lower SES and those with mental illness and related behavioral symptoms and behaviors. Further, adolescents evincing mental health symptoms or conditions, behavioral disruptions, or learning disorders are at greater risk of becoming regular smokers. These findings have important implications for tobacco control, although none contradicts the historically and scientifically proven general population approaches to tobacco control, such as taxation policy, indoor and outdoor smoking bans, and enhanced tobacco product labeling. Nor does this overrepresentation deny the important role of

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Ending the Tobacco Problem: A Blueprint for the Nation physiological nicotine addiction as a major cause of cigarette smoking maintenance. However, it does suggest that additional approaches to tobacco control are needed as part of an effective control program, despite the existing challenges. Since it appears that many current and future smokers have elements of impoverishment or lower SES, mental illness or abnormal behavioral symptoms, and higher rates of learning disorders or school dropout, conventional educational and advertising programs, whatever their basic efficacy, may not have the level of impact desired. Many persons in these higher-risk groups will intersect with various social and health systems and care institutions, where opportunities for more intensive tobacco prevention and treatment programs are possible, even if the fundamental missions of these institutions lie elsewhere. Most importantly, these findings suggest that community tobacco control programs must target these high-risk, high-prevalence populations in order to improve general control effectiveness beyond current achievements. Thus, given these considerations, a number of high-priority tobacco control measures are suggested: There appears to be adequate evidence that many children at high risk of later cigarette smoking can be identified through their school performance and problem behaviors. While the evidence is scant that targeted educational and social interventions directed at children with manifestations such as learning disorders, abnormal mental symptoms, overt mental illness, or conduct disorder are effective, such programs need to be investigated to determine if they can complement existing general educational activities. It is appreciated that this may require substantial resources at a time when school and child health funds are limited. Efforts should be made to enhance receipt of clinical smoking cessation wherever mental health clinical treatments are undertaken. There is evidence that most patients with mental conditions are willing to accept antismoking treatments, but are not often offered such regimens. Several strategies in applying smoking cessation treatments could result in enhancing treatment effectiveness for nicotine dependence: Promoting clinical guideline development and enforcement within mental health settings, such as those promulgated by the American Psychiatric Association (APA 1996). Implementing health care institutional programs for surveillance of smokers, as contained in standards promulgated by the Joint Commission for Accreditation of Healthcare Organizations. This should specifically include psychiatric facilities. Training mental health professionals to attain skills in the prevention and treatment of nicotine dependence. Extending and enforcing policies of smoke-free psychiatric in-patient facilities. It has been noted that it is difficult to motivate patients to stop smoking unless the facility itself is smoke-free (APA 1996). Other community settings with high concentrations of smokers and those with mental illness, such as homeless shelters, should also consider smoke-free policies. Extending smoking cessation research to include persons with mental health diagnoses. Offer smoking cessation treatments within the justice systems where institutional practices will allow it. Particularly, the maintenance of smoke-free prisons and jails, in concert with provision of resources to treat smoking behaviors, may facilitate smoking cessation in a very

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Ending the Tobacco Problem: A Blueprint for the Nation hard-to-reach group. Environmental antismoking provisions should apply to staff as well as to inmates. Assure that antismoking treatments are available as part of the benefit package for all state- and federally funded general health insurance or care delivery programs. State and local tobacco control programs should monitor for attempts to market tobacco products to high-risk populations.

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