Tobacco Quitlines and Persons With Mental Illnesses

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Tobacco Quitlines and Persons With Mental Illnesses: Perspective, Practice, and Direction Chad D. Morris, Gary J. Tedeschi, Jeanette A. Waxmonsky, Mandy May and Alexis A. Giese J Am Psychiatr Nurses Assoc 2009; 15; 32 DOI: 10.1177/1078390308330050 The online version of this article can be found at: http://jap.sagepub.com/cgi/content/abstract/15/1/32

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Tobacco Quitlines and Persons With Mental Illnesses: Perspective, Practice, and Direction Chad D. Morris, Gary J. Tedeschi, Jeanette A. Waxmonsky, Mandy May, and Alexis A. Giese

The prevalence of tobacco use among persons with mental illnesses is 2 to 3 times that of the general population, and these individuals suffer significant related health disparities. Many people with mental illnesses contact tobacco quitlines for cessation assistance. With free telephone counseling and in some cases nicotine replacement therapy, quitlines offer a potentially effective resource for this population. However, quitlines are still trying to determine how best to meet these callers’ unique needs. The authors discuss emerging practices regarding quitline services for persons with mental illnesses, as well as expert opinion for enhancing work with these individuals. J Am Psychiatr Nurses Assoc, 2009; 15(1), 32-40. DOI: 10.1177/1078390308330050

Keywords: quitline; mental illness; tobacco cessation; telephone counseling

All U.S. states and Canadian provinces use quitlines as a key component of tobacco control programs. Quitlines provide telephone counseling, self-help materials, and referrals for additional support. After the initial contact, quitline counselors may offer onthe-spot service or, subsequently, make proactive calls to help callers prepare to quit and prevent relapse (Anderson & Zhu, 2007; Fiore et al., 2008). In this article, we discuss quitline services for a distinctive group of callers, those with mental illnesses. When possible, we reference the limited literature available, but we also draw from our clinical and management experience to offer special considerations and recommendations for this population. One author is a psychologist and clinical director of a large quitline that has been exploring the unique needs of this population for several years. The other authors constitute a multidisciplinary behavioral Chad D. Morris, PhD, is an associate professor at University of Colorado Denver, Denver, CO; [email protected]. Gary J. Tedeschi, PhD, is a clinical director at University of California, San Diego, California Smokers’ Helpline, San Diego, CA. Jeanette A. Waxmonsky, PhD, is an assistant professor at University of Colorado Denver, Denver, CO. Mandy May, MPH, is a professional research assistant at University of Colorado Denver, Denver, CO. Alexis A. Giese, MD, is an associate professor at University of Colorado Denver, Denver, CO.

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health team that has investigated psychosocial and pharmacologic tobacco cessation interventions for persons with serious mental illnesses, including quitlines strategies. Several quitlines have recently begun to track mental health symptoms among callers. Even so, in our experience, quitline callers often exhibit a continuum of differences in cognition, emotion, or mood that are consistent with mental illnesses (American Psychiatric Association, 2000). At least one in five people has a diagnosable mental disorder during the course of any given year (U.S. Department of Health and Human Services, 1999). Startlingly, persons with mental illnesses and substance-use disorders consume over 30% of cigarettes and constitute 44% of the entire U.S. tobacco market (Grant, Hasin, Chou, Stinson, & Dawson, 2004; Lasser, et al., 2000). Persons with mental illnesses die up to 25 years earlier and suffer increased medical comorbidities compared with the general population (Brown, Inskip, & Barraclough, 2000; Colton & Manderscheid, 2006; Dixon, Postrado, Delahanty, Fischer, & Lehman, 1999; Joukamaa, et al., 2001; Osby, Correia, Brandt, Ekbom, & Sparen, 2000). Much of this excess morbidity and mortality is related to the high prevalence of tobacco use (National Association of State Mental Health Program Directors, 2006). This often overlooked issue is receiving heightened attention. Not only are clinicians, mental health centers, and

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Tobacco Quitlines and Mental Illness

substance-use disorder programs focusing on it, but tobacco quitlines too have begun to more closely examine specific strategies for this population (Tobacco Cessation Leadership Network, 2008). EVIDENCE OF QUITLINE EFFECTIVENESS The efficacy of quitlines for the general population has been widely demonstrated (Anderson & Zhu, 2007; Stead, Perera, & Lancaster, 2007; Zhu et al., 2002). Although only 4% to 7% of unaided quit attempts are successful (Fiore et al., 2008), quitlines improve this rate by increasing the percentage of smokers making quit attempts and reducing the probability of relapse (Cummins, Bailey, Campbell, Koon-Kirby, & Zhu, 2007; McAfee, 2007; Zhu et al., 2002). A recent Cochrane review showed a pooled odds ratio of 1.41 for quitline counseling compared with self-help materials (Stead et al., 2007). Quitlines have proven effective both in clinical trials and in real-world settings (Borland & Segan, 2006; Zhu et al., 2002). As a result of these successes, in 2004, the federal government supported the establishment of a national phone line, 1-800-QUIT-NOW, affording all U.S. tobacco users access to state-run quitlines. With easy access to these free programs, over 400,000 U.S. tobacco users contact quitlines each year (Cummins, Bailey, et al., 2007). Although proven effective for the general population, quitlines have not yet been studied for the disparity population of persons with mental illnesses. Tobacco use is among the most modifiable risk factors for excess mortality and morbidity (National Association of State Mental Health Program Directors, 2006; U.S. Department of Health and Human Services, 2004). Yet the public health community has been slow to implement established tobacco cessation interventions among populations with mental illnesses (Fiore et al., 2008). In fact, only recently have some states, national tobacco control agencies, and professional organizations begun considering persons with mental illnesses a priority population (Bonnie, Stratton, & Wallace, 2007; National Association of State Mental Health Program Directors, 2006; National Institutes of Health, 2006). The dearth of attention to smokers with mental illnesses may be due in part to several myths, the most prevalent being that this population is unable to quit smoking and is not motivated to quit (Morris, Waxmonsky, Graves, & Giese, in press). A rapidly emerging research base refutes these myths. The majority of smokers with mental illnesses

report their intention to quit (Joseph, Willenbring, Nugent, & Nelson, 2004; Prochaska et al., 2004). Although quit rates are lower than those for general populations, results are still substantial (e.g., Baker et al., 2006). Smokers with histories of major depression may have quit rates as high as 38% (Lasser et al., 2000), and those with schizophrenia as high as 10% to 30% (Addington, el-Guebaly, Campbell, Hodgins, & Addington, 1998; Baker et al., 2006). Moreover, studies show that treatment approaches found effective for the general population are also effective for smokers with mental illnesses, though greater medication dosages and duration of treatment are probably necessary (Fiore et al., 2008). Along with other standard cessation treatments, initial studies suggest that tailored quitline services might be effective for smokers with mental illnesses. One quitline study has found that the self-reported 7-day abstinence rate for those who reported having mental illnesses was 21.2%, compared with 26.9% for all callers during the same time period (Kreinbring & Dale, 2007). Another study found that self-reported 7-day point prevalence tobacco abstinence at 6 months among persons with mental illnesses did not differ from the overall quit rate; however, quit rates did vary by diagnosis (Hrywna et al., 2007). Preliminary 6-month results from yet another study suggest that quitline counseling plus nicotine replacement therapy led to a significant reduction in the self-reported number of cigarettes smoked per day, nicotine dependence, and depressive and psychotic symptoms (Waxmonsky, Morris, Graves, Giese, & Belikova, 2007). Although more research is needed, quitline services might be one important component of cessation strategies for this population. THE REALITY FOR QUITLINES Quitlines attract clients across a range of ethnic, socioeconomic, geographic, and psychiatric backgrounds, including clients at various stages of recovery from chemical dependency. It is our experience that smokers with mental illnesses have been calling quitlines since their inception, and the data available supports this assertion. Studies have found the rate of mental illnesses among callers to range from 20% to 33% (Hrywna et al., 2007; Kreinbring & Dale, 2007), as might be expected given the high percentage of persons with mental illness who smoke.

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ASSESSMENT AND TREATMENT CONSIDERATIONS

will equip quitline staff members to offer the most appropriate services possible.

Even though clients with mental illnesses and substance use disorders continue to call quitlines in substantial numbers, there is still some question about what role quitlines should play. Quitlines might directly offer tobacco cessation services but also act as portals to other needed health services. However, unless callers reveal that they have psychiatric illnesses, mental health issues in need of attention will not always be apparent. The chance for quitlines to intervene may be missed unless the initial client contact includes an assessment to determine psychiatric status. This raises the question of what type of assessment is most appropriate.

Psychiatric Stability

Assessment The North American Quitline Consortium recommends that the initial call include a minimum data set that assesses, among other things, basic demographics, smoking status, and tobacco dependence (Campbell, Ossip-Klein, Bailey, & Saul, 2007). Although these questions are important for helping callers get the tobacco related services they need, they do not specifically address mental health status. Although quitline personnel have not reached consensus on the best way to assess for mental health issues, several quitlines have developed protocols that include either direct or indirect inquiry. Indirect inquiry, with questions such as “Are you taking medication for any reason?” and “Are you currently attending counseling or recovery meetings?” can yield useful information but may not provide the most accurate mental health picture. Direct inquiry, which involves adding one or more specific questions on psychiatric health to the standard intake procedure, can provide more accurate information. The assessment can be as pointed as the Patient Health Questionnaire, which gives an indication of depression level (Spitzer, Kroenke, & Williams, 1999), or as broad as a question such as “Do you have any mental health issues that might affect your quitting, such as an anxiety disorder, depression, schizophrenia, bipolar disorder, alcohol or drug problem?” Because callers may not expect mental health questions from tobacco quitlines, it is important to make clear that the reason for asking is the known relationship between smoking and mental health and that the answers to these questions

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When smokers with mental illnesses call quitlines for help, there are important treatment factors to consider, ranging from their quit histories to biochemical factors to the need for concurrent treatment for mental health symptoms. However, a key factor is the current level of functioning, particularly psychiatric stability. Stable functioning, as defined by the expert advisory committee for the Bringing Everyone Along project (Tobacco Cessation Leadership Network, 2008), is “the absence of current acute major life or medication changes” (p. 10). Determining psychiatric stability requires assessing clients during calls and can be addressed with open-ended questions such as “How stable are your mental health symptoms currently?” “Are you currently in any mental health treatment?” “How is the treatment going for you?” and “How often are you in touch with your health care provider?” If clients exhibit psychiatric health concerns, such as severe depression or symptoms of psychosis, quitline staff members must help connect these clients to health care providers in the same manner that referrals would be made for physical health concerns. County crisis or mental health lines can help quitline staff members identify appropriate local referrals for these clients. Concurrent to any mental health referrals being made, the quitline can proceed with cessation work. Stable functioning also includes sufficient smoking cessation support from care providers and others (Tobacco Cessation Leadership Network, 2008). Even if clients are not currently in psychiatric distress, it is vital to reinforce their existing support bases and to help them build support for quitting. It has been our experience that clients with stable symptoms who have sufficient professional or personal support are most appropriate for the quitline setting. However, motivated callers lacking psychiatric stability should still receive help to the degree possible. If quitline staff members assist them in finding needed mental health services, rapport may be increased, setting the stage for future quitline help with smoking cessation when serious psychiatric symptoms abate. Quitting History It is difficult to predict how any one client’s mental health symptoms might be affected by quitting


Tobacco Quitlines and Mental Illness

smoking. However, most smokers have tried to quit at some point. A client’s experience during previous quit attempts provides a reference point for what might happen in the next quit attempt. Quitline staff members might ask, “When you quit smoking before, what changes, if any, did you notice in your mental health symptoms?” This kind of question opens the discussion for effective planning. Client and counselor can then devise strategies for trigger situations that were problematic in the past, and the counselor can reinforce plans for contact with a primary health care provider. Biochemical Factors It is critical for counselors to address the relationship between smoking and medications. Inhaled tobacco smoke affects the metabolism of common psychiatric medications. When a client stops smoking, medication levels in the blood may rise and cause adverse effects (Ziedonis, Williams, & Smelson, 2003), which may cause a client to return to smoking for symptom relief. Quitline counselors should encourage clients to inform their prescribing physicians of tobacco cessation attempts. Physicians can then monitor clients closely for changes in psychiatric symptoms and for the need to adjust medication dosages. Pharmacotherapy The U.S. Department of Health’s “Clinical Practice Guidelines for Treating Tobacco Use and Dependence” (Fiore et al., 2008) recommend that every client with psychiatric health issues be offered pharmacotherapy to aid in tobacco cessation attempts. However, this clientele will require individualized pharmacotherapy regimens, with dose level and duration dependent on need. Many clients in this group will require higher doses, combination treatments, and longer durations of pharmacotherapy (Fiore et al., 2008). Clients and practitioners are often concerned about the interaction of pharmacotherapy with other medications or with possible interference with drug and alcohol recovery. These issues must be addressed prior to cessation and monitored closely during the quitting process (Strasser et al., 2002). Also, there are additional considerations among persons with mental illnesses of different races or ethnicities. For example, although pharmacotherapy is recommended for all (Fiore et al., 2008), there may be some groups who have little experience and potentially little initial interest in using these aids. As one example, African American smokers are

significantly less likely than Caucasian smokers to have ever used nicotine replacement therapy for smoking cessation (Fu et al., 2008). Problem-Solving Focus Some clients may benefit from alterations to standard quitline protocols. For example, lower functioning clients with mental illnesses may have difficulty processing abstract concepts. Rather than focusing on insight-oriented treatment, counseling for this clientele might address the development of basic life skills or assistance with preexisting skills. Other alterations may better serve clients with schizophrenia. A recent Cochrane review suggested that a cognitivebehavioral approach, compared with a supportive therapy approach, is efficacious for these clients, though the authors cautioned that more research is needed (Buckley, Pettit, & Adams, 2007). Quitline counseling usually relies heavily on behavioral change strategies that include cognitive techniques. For clients with schizophrenia, quitline staff members might start by addressing only two main ideas, motivation and planning, using a cognitive-behavioral approach. Rather than discussing insight-oriented issues such as underlying reasons for behaviors, quitline staff members can keep the focus on identifying a clear reason to quit and on planning specific strategies (including pharmacotherapy) to deal with cravings and triggers. During planning, staff members can also stress the need for clients to be in touch with primary health and mental health care providers for added support and monitoring. Call Length and Frequency Extended quitline contact for callers with mental health concerns provides an opportunity for added support from quitline staff members and ideally encourages frequent monitoring of psychiatric symptoms by community health care providers. For general populations, prequit calls range from 30 to 40 minutes and usually end with the counselor helping the client set a quit date. Follow-up calls usually last only 10 to 15 minutes. The mean number of quitline sessions nationally is around five (Cummins, Bailey, et al., 2007). However, our experience is that cessation calls may need to be shorter and more frequent for clients with psychiatric health issues, especially for lower functioning clients. Reviewing too many topics during any one session may overwhelm a client. Focusing on just a few topic areas increases a client’s chances of retaining the information and applying it as


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intended. Furthermore, pushing a client with psychiatric health issues to set a quit date during the first call could be counterproductive. A protracted schedule with more frequent calls prior to and during the quitting process may be more appropriate. Still, working toward a quit attempt must remain the goal. Concurrent Treatment Adequate social support is crucial when clients with mental health issues are quitting smoking. For those who are stable and have psychiatric care already in place, quitline counseling can occur concurrent with the clients’ standard treatment and should include communication with their providers. For those who lack the needed mental health care, quitline staff members should encourage treatment with mental health providers and should assist clients with referrals. Ensuring this linkage to mental health providers can be a challenge, because quitlines provide services across entire states or regions. For these reasons, quitlines must have case management and referral procedures clearly laid out. Case Management and Referral Quitlines handle a large volume of calls, but not all are related to tobacco cessation. People in distress for other reasons, such as housing needs, financial problems, serious depression, and suicidal ideation, sometimes call toll-free numbers seeking help. Quitlines need to have risk assessment and emergency procedures as well as referral guidelines to help clients reach appropriate local services. If referral to an existing health care provider is not possible, quitline staff members can successfully use county crisis lines, county mental health numbers, and the 211 national referral number. As recommended by the Tobacco Cessation Leadership Network’s (2008) advisory committee, service providers such as quitline staff members must engage a range of health professionals to support clients’ quitting efforts. STAFF TRAINING CONSIDERATIONS Staff Readiness Careful attention to staff training and supervision needs, as well as to the unique needs of callers with mental illnesses, can minimize barriers to effective service. Anecdotally, many quitline counselors consider clients with reported or apparent psychiatric disorders time-consuming and challenging;

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many of these clients receive longer and more frequent calls, and they may have less ability to follow through. Quitline staff members, both professionals and paraprofessionals, may have little mental health background. A national survey of quitlines found that the availability of trained counselors is variable (Cummins, Bailey, et al., 2007). Some quitline counselors are professionally trained mental health providers or recipients of continuing education related to working with these clients, but most are not. Mental health counseling skills are typically not hiring criteria at quitlines. Even counselors with mental health experience can find the telephone setting different from previous work environments. These gaps can leave staff members at a loss when callers present with psychiatric symptoms. Additional skills and approaches are often necessary to work effectively with persons with mental illnesses. Targeted training may improve client outcomes and improve the morale for staff members. Staff Training Initial staff training should be augmented by continuing education and supervision. Such training should include a basic understanding of the interaction between mental illnesses and tobacco dependence, an orientation to how persons with mental illnesses present on quitline calls, brief assessment tools, motivational and cognitive behavioral therapy strategies, and procedures and resources for making referrals to mental health providers (Table 1). Ongoing supervision is needed to help staff members develop skills in creating and maintaining rapport and building realistic quit goals. Quitline staff members should not be expected to diagnose but rather to build quit strategies that match the functional abilities and readiness of callers. For example, for some clients, quitline staff members can present cessation strategies as simple, concrete steps, repeating content and asking callers to summarize information in their own words to assess for comprehension. Quality improvement strategies should include periodic role-playing and shadowing to assist quitline workers in continuing to develop skills in working with persons with mental illnesses. We also suggest live call monitoring and recorded call review by mental health experts, to the extent possible. Supervisors will also need to ensure that quitline materials are appropriate to the literacy and cognitive levels of the individuals they serve (Anderson & Zhu, 2007).


Tobacco Quitlines and Mental Illness TABLE 1. Recommended Quitline Staff Training Curriculum for Persons With Mental Illnesses • • • • • • • • • • • • • •

The continuum of mental illnesses Identification and common features of mental illnesses Common experiences among quitline staff members Assessment of symptoms versus functioning Assessment of quit history Assessment of nicotine withdrawal in the context of a mental illness Suggested call content, length, and frequency Best and emerging practices Biochemical issues Nicotine replacement therapy and other pharmacotherapy Rapport building and communication strategies Managing expectations and boundaries Relapse prevention Local referral resources

Scope of Practice Scope-of-practice issues must also be addressed. Quitline staff members require initial and ongoing training to define their roles as tobacco cessation specialists rather than mental health counselors. For example, in addition to requesting cessation strategies, callers in distress may indirectly or directly request mental health services from quitline counselors. Quitline staff members must be prepared to clarify service limitations and provide referrals as appropriate. PROGRAMMATIC CONSIDERATIONS Several program considerations affect how quitlines can best serve callers with mental illnesses. Key issues include mission consistency, evaluations of cost-effectiveness, policies and procedures, community linkage, and data infrastructure. Mission Consistency Quitline personnel must weigh program change against the organization’s mission and strategic plan. Although persons with mental illnesses are clearly already using quitline services, the creation of specialty programming may call for alterations to the organizational mission. Explicitly including specialty populations in the mission statement can help ensure that when quitline staff members identify members of these populations, assessment and specialized intervention will follow. This has been the case with other target populations, such as youth and pregnant users (Cummins, Tedeschi, et al., 2007; Tedeschi, Zhu, Anderson, Cummins, & Ribner,

2005). Another option is for quitlines to partner with mental health treatment programs, just as they do with chronic disease programs to treat tobacco users who have diabetes, asthma, cancer, heart disease, stroke, and other conditions (North American Quitline Consortium, 2007). For these partnerships, the most common collaboration is mutual promotion. Although a few quitline programs have developed special protocols for callers with mental illness, most are just beginning to consider approaching mental illness as they do other chronic conditions. Cost-Effectiveness As the scale of the health disparities of persons with mental illnesses becomes increasingly evident, a compelling case can be made on the basis of the dramatic morbidity and mortality statistics presented above. However, the potential cost-effectiveness of quitlines’ diverting resources to treat persons with mental illnesses has yet to be studied. Many of these individuals are high users of services (e.g., Chapman, Perry, & Strine, 2005; Moon & Shin, 2006; Thomas et al., 2005). Although smoking prevalence rates in the general population continue to decrease, they remain high for persons with mental illnesses (Lasser et al., 2000). There appears to be a “hardening of the target,” in which the remaining tobacco users are concentrated in the lower socioeconomic classes, are more nicotine dependent, and have more medical and psychiatric comorbidities (Lasser et al., 2000; Schroeder, 2007). Policies and Procedures The majority of quitlines determine services on the basis of smokers’ readiness to quit and/or insurance status: Callers ready to set quit dates and callers without insurance can receive more services (Cummins, Bailey, et al., 2007). Quitline personnel serving callers with mental illnesses can revisit these policies and include clients who are not yet ready to set quit dates, if they do not already do so. Also, to be fully equipped to serve callers with mental illnesses, quitlines can partner with state Medicaid and Medicare offices to ensure that tobacco cessation services are a covered benefit for these individuals. Liability concerns are a significant hurdle to creating specialty programs for persons with mental illnesses. Quitline personnel report concerns about becoming the de facto psychiatric provider of record when this is not within their scope of practice. They


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point out that if psychiatric conditions are assessed and documented, there may be a legal need to act on this knowledge. For individuals who are in psychiatric distress, there will be a need for quitline staff members to refer to appropriate and available psychiatric services. With 45 million uninsured persons in the United States (Institute of Medicine, 2003), many callers with mental illnesses will not have primary care providers, much less specialty psychiatric care. Given this reality, it is essential for quitlines to have protocols in place for callers posing harm to themselves or others. It is likely that many quitlines already have such protocols. Although they might be fine tuned for persons with reported or apparent mental illnesses, emergency protocols should arguably already be part of standard practice. Beyond this, quitline personnel can be assured that if they remain within their defined scope of practice, they would not be considered psychiatric providers of record, any more than they would be considered cardiac care specialists for callers with recorded histories of heart disease. One option might be to ask for verbal informed consent from all callers with chronic conditions, including psychiatric illness. This consent could affirm that the callers are receiving only tobacco cessation services from the quitline and that they will seek additionally needed health services elsewhere. A more preferable option would be a stronger system of mutual referral between quitlines and mental health services (Tobacco Cessation Leadership Network, 2008). Community Linkage Quitlines are most effective when working in coordination with other providers. Studies suggest that formal partnerships and referral mechanisms may decrease client ambivalence, give clinicians more confidence in clients’ follow-through, and lead to a 10-fold increase in quitline use (Cummins et al., 2002; Sherman et al., 2004). The use of mechanisms such as fax referrals from community providers allows quitlines to call potential clients proactively (Borland & Segan, 2006). Formal linkages with mental health providers can also assure quitline personnel that comorbid psychiatric issues are being monitored appropriately, making specialty programs for this population more attractive. Data Infrastructure As quitlines begin assessing for psychiatric issues, they must also create organizational data

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infrastructure to support and evaluate programmatic or policy changes. As with other chronic care programs, clinical information systems for quitlines are a key component that drive decision support (Wagner et al., 2001). Information technology, data, and evaluation sections must accommodate new psychiatric assessment domains and have the capacity to report back to multiple levels of the quitlines and possibly to referring providers. Assessment data can be used to track the effectiveness of tailored cessation interventions for persons with mental illnesses, including determining the optimal number of contacts, the average call length, and effective content for telephonic coaching. CONCLUSIONS In all efforts to provide smoking cessation help to persons with mental illnesses, there is a gap between science and service, and perhaps a missed opportunity (Schroeder, 2007). Few referral and treatment options are available, and those that exist do not necessarily tailor treatment to the needs of smokers with mental illnesses. For some time, we have recognized that this clientele has additional needs, but only recently have guidelines been proposed for meeting these needs via telephone counseling. Quitlines have demonstrated the potential to overcome common barriers to access such as transportation and cost (Zhu, Anderson, Johnson, Tedeschi, & Roeseler, 2000) and have successfully extended the reach of more traditional programs (Zhu et al., 1995). Quitlines might also begin to target the specialty population of persons with mental illnesses. Recently, quitline personnel have focused more attention on callers with mental health issues in an attempt to determine the most appropriate response, one that would best serve these callers while staying within the scope of quitline services. The recommendations in this article can help move quitlines, in partnership with community health providers, toward the study of effective tobacco cessation strategies for persons with mental illnesses. REFERENCES Addington, J., el-Guebaly, N., Campbell, W., Hodgins, D. C., & Addington, D. (1998). Smoking cessation treatment for patients with schizophrenia. American Journal of Psychiatry, 155(7), 974-976. American Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Arlington, VA: Author. Anderson, C. M., & Zhu, S. H. (2007). Tobacco quitlines: Looking back and looking ahead. Tobacco Control, 16(Suppl. 1), i81-i86.


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