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Tobacco Treatment Specialists Across Healthcare: A Spotlight on Behavioral Health Settings

This occasional series highlights some of the practice areas where tobacco treatment specialists (TTS) work. In this post, we discuss the importance of smoke-free behavioral health treatment centers and tobacco cessation services for individuals with mental health and substance use conditions.

May is Mental Health Awareness Month, a yearly campaign that focuses on the importance of addressing mental health and disparities in treatment that exist for certain groups. During this month, Substance Abuse and Mental Health Services Administration (SAMHSA) is raising awareness about substance use prevention and the importance of positive mental health.


Individuals with behavioral health diagnoses are disproportionately impacted by the negative effects of tobacco use. Smoking doubles their risk of premature death. Heart disease, cancer, and lung disease—which can all be caused by smoking—are the leading causes of death for people with behavioral health issues. This group is also smoking at a higher level than the rest of the U.S. population. A report from 2019 showed that 27.2% of people with mental health conditions smoked in the last month, compared to 15.8% adults without a behavioral health diagnosis. Some groups, such as adults with schizophrenia or a substance use disorder, smoke at even higher rates—70-85% for people with schizophrenia and 65-85% for people in treatment for substance use disorders.

Part of the reason for this disparity is that individuals with mental health and substance use conditions are not always encouraged to quit tobacco use. According to the Centers for Disease Control and Prevention, only one-third of substance use disorder treatment centers and half of mental health facilities report having smoke-free campuses.


Marlena Parson, a Psychiatric Mental Health Nurse Practitioner with the Duke Smoking Cessation Program, understands the struggles faced when trying to address tobacco use in behavioral health settings. She has worked in mental health for 20 years providing both inpatient and outpatient psychiatric care with the Veterans Administration (VA) and Duke Psychiatry.


“Tobacco use was the problem on the problem list that you never quite got around to,” she explains. “There wasn’t much goal setting happening, and I often couldn’t follow up with patients for 4 months after starting a medication.”


Much like primary care, behavioral health providers are busy managing a variety of issues, so being able to refer patients out to dedicated smoking cessation providers who could dive into motivational interviewing was vital.

Addressing tobacco use is a must in behavioral health settings, says Marlena Parson, PMHNP. “You will see a 25% increase in success when you tackle smoking and other addictions at the same time because they are often feeding each other.”

The VA went smoke free during Marlena’s first year as a beside psych nurse. She recalls that there was still a lot of the dogma around keeping patients smoking so their medications will work.

“I was glad to be part of that culture shift,” she says, noting that the outdated idea of not encouraging patients to quit smoking while they are working on other mental health or substance use issues is still an issue. “In mental health, you have to model good behavior, and now I’m giving you cigarettes on a platter. That sends a mixed message.”


Her advice for behavioral health facilities planning to go smoke free: Give yourself lots of time to prepare—at least 1 year in advance—and get buy-in from staff, who should also be smoke free.


When Marlena works with patients facing mental health or substance use conditions, she tailors her smoking cessation message by focusing on the interface between their psychiatric symptoms and smoking behavior.

“Is there shame? Is smoking a way to be rebellious? I really like get to the emotional attachment that’s present. Understanding that is the foundation of understanding what the mourning process might look like as they quit.”

She also digs into the context of their tobacco use—family, early smoking years. “It is a good way to warm them up and establish rapport. I want them to feel like I know them beyond what’s on paper,” she says. “Now that we’ve talked about where they’ve been, they are usually ready to talk about where they want to go.”


Her biggest advice for people working with behavioral health clients: “Please always go smoke free as part of the treatment plan. Providers need to weave in the message that going smoke free will help every other aspect of their physical and mental health. It will make clients less vulnerable to depression and anxiety episodes. I don’t think we always do a great job of that.”


For more information on treating tobacco use in behavioral health settings, don’t miss our upcoming short course--Intensive Behavioral Health Approaches to Tobacco Treatment--on October 12, 2023. Visit https://www.dukeunctts.com/cme to learn more and register!

About The Author


Rachael Joyner is a family nurse practitioner with the Duke Smoking Cessation Program. She holds a National Certificate in Tobacco Treatment Practice and received her Doctorate in Nursing Practice from the University of Florida. She loves working collaboratively with patients to help them become tobacco free.

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