Treatment Considerations for Smokers

Treatment Considerations

Smokers with behavioral health conditions may require more intensive tobacco cessation treatment and support from programs and practitioners when they quit smoking. The type and intensity of treatment will vary from smoker to smoker.

Primary Considerations

  • Determine the need for involvement from primary care and other health care providers--a team approach ensures that clients have the strongest support possible, which increases the likelihood of clients quitting for good.
  • Determine the need for more intensive behavioral therapy--smokers with behavioral health conditions may require a longer duration of behavioral and pharmacological treatment for tobacco dependence.
  • Address psychotropic medication issues--smokers who are taking psychotropic medications may notice a change in how medications work after they quit smoking. Since smoking almost doubles the clearance of some psychotropic medications, potency levels can change considerably during the quitting process.1 Medication dosage may need to be adjusted in some cases.

Treatment Planning

  • Tailor treatment planning based on functional status--more than any specific psychiatric diagnoses, it is important to assess clients’ current level of functioning when devising interventions.
  • Assess current stability of psychiatric symptoms and recovery--Important questions to ask include: How are the client’s symptoms currently? Is the client in treatment for these symptoms? How consistent is the client with treatment? How is the treatment working?
  • Psychiatric stability also includes: No major life changes, no major medication changes, & no active intoxication or withdrawal from other substances.
  • Review quitting history--most smokers have tried to quit before. While it is difficult to predict what kind of experience clients will have when they quit, previous quit attempts can give a good indication of what to expect this time. What changes, if any, did the client notice in his or her mental health symptoms when quitting in the past?
  • Discuss biochemical factors--nicotine acts much like a psychotropic medication on brain chemistry. When clients quit using nicotine they may notice a change in their symptoms. Also, smoking causes some medications to be metabolized more quickly, so blood levels of medications can change when quitting. For this reason, medications may need to be adjusted. For more information on drug interactions with smoking click here.
  • Decide on counseling content and duration--the type of content covered in cessation counseling will be based on clients’ level of functioning. For example, lower functioning clients may require shorter sessions covering concrete topics such as behavioral strategies to overcome cravings, rather than insight-oriented topics such as motivation and self-efficacy.

Other Clinical Considerations

  • Apply the appropriate counseling style--how much direction vs. facilitations should a clinician provide? Whenever possible, it is important to engage clients into their own treatment planning. For higher functioning clients, discussions about motivation, confidence, insight, and accountability work well, along with discussions of specific behavioral strategies to quit smoking. For higher functioning smokers, a more facilitative approach is appropriate. For lower functioning clients, clinicians will often need to employ a more directive approach, one which provides concrete suggestions throughout the sessions. In short, clinicians should provide direction and support based on the client’s level of functioning, resources, skills, and needs.
  • Encourage client contact with prescribing physicians and other health care providers--it is important for smokers with behavioral health conditions to be in touch with their physicians during the quitting process, for ongoing management of mental health symptoms and medications.Smokers will often need assistance in finding sources of professional and social support in their local areas. Clinicians can serve as advocates to help clients connect to community resources.

1 Desai, H.D., Seabolt, J., & Jann, M.W. (2001). Smoking in Patients Receiving Psychotropic Medications. NS Drugs. 15(6), 469-494.

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Provider Toolkit-Pharmacotherapy for Smoking Cessation