Cigarette Smoking With Serious Mental Illness: US Provider and Veteran Beliefs About How to Quit

Veterans with serious mental illness (SMI) have high cigarette smoking rates and want to quit, but mental health providers are often reluctant to treat smoking. This study compared how providers and veterans in a United States Veteran Affairs Medical Center (VA) SMI clinics view smoking and treatment.

Twenty SMI providers and 20 veterans with SMI who smoked cigarettes were interviewed. A rapid evaluation matrix approach was used to code interviews based on the Theory of Planned Behavior (attitudes, self-efficacy, and norms). This paper focuses on themes identified in the attitudes and self-efficacy domains.

Veterans had a high interest in quitting smoking but low self-efficacy to quit. In regard to attitudes, veterans had specific beliefs about how and when to quit. Provider attitudes involved anticipating mixed interest in quitting among their veterans and anticipating low quit rates. Eighteen (90%) veterans were at least contemplating quitting. Many providers interpreted ambivalence about quitting as low readiness to quit and viewed the smoking/return-to-smoking cycle of addiction as an indicator that veterans with SMI could not quit. Veterans also believed they could not quit until they were "ready" or strong enough to do so, which impeded initiating smoking discussion with providers.

Providers and veterans share unhelpful attitudes about quitting smoking, which discouraged treatment and reinforced unhelpful attitudes. These qualitative findings shed light on the underlying mechanisms of infrequent tobacco treatment in mental health settings via the Theory of Planned Behavior to guide efforts to improve reach of tobacco treatment in these settings.

Comparing the perspectives of providers and veterans from the same setting is a rare contribution to tobacco treatment literature. Provider and veteran attitudes about quitting smoking interacted and led smoking to persist unaddressed despite veteran interest in quitting. Providers may benefit from education about how to effectively treat smoking to dispel myths that impede treatment and feel more comfortable integrating smoking treatment into routine care.