This study sought to examine the practices and perceptions of clinical mental health counselors in addressing smoking cessation with clients. A survey instrument was mailed to 700 clinical members of the American Mental Health Counselors Association. Of those who responded (n-330; 53.1% response rate), the majority (58.9%) had not considered asking all clients about their smoking status at every visit. Counselors reported low use of the guidelines for smoking cessation intervention and for recommending pharmacotherapy. Levels of both efficacy and outcome expectations were significantly higher among counselors who reported regular use of smoking cessation interventions. Although 86.7% of counselors reported high confidence in assisting their clients in quitting smoking, there is a dearth of professional training for this.
Cigarette smoking is often referred to as "the leading cause of preventable death in the United States" (CDC, 2002, p. 300) and has been implicated in the deaths of at least 400,000 Americans annually (CDC, 2002; Mokdad, Marks, Stroup, & Gerberding, 2004; Rivara et al., 2004). It has been designated a major risk factor for heart disease (Khot et al., 2003; Mensah, Brown, Croft, & Greenlund, 2005) and has been implicated in some 90% of lung cancer cases (Peto et al., 2000). Individuals who smoke are from two to six times more likely to develop chronic obstructive pulmonary disease than nonsmokers (Meyer, Mannino, Redd, & Olson, 2002; Shahab, Jarvis, Britton, & West, 2006).
Individuals with a mental illness have higher smoking rates than the general population. Analyses of data from the National Comorbidity Study found that individuals with a mental illness are twice as likely to smoke than those without (Lasser et al., 2000) and are also at greater risk of transitioning to nicotine dependence (Breslau, Novak, & Kessler, 2004). Among those with mental illnesses, the highest rates of smoking are seen in those with schizophrenia (Morris, Giese, Tumbull, Dickinson, & Johnson-Nagel, 2006; Vanable, Carey, Carey, & Maisto, 2003); depression (Lasser et al., 2000; Morris et al., 2006; Variable et al., 2003); and substance abuse disorders (Grant, Hasin, Chou, Stinson, & Dawson, 2004; Lasser et al., 2000). Although individuals with mental illnesses comprise only 30% of the US population, it is estimated that they consume 46% of all cigarettes (Grant et al., 2004). Smoking-related diseases are the leading causes of death for those with a mental illness.
Edwards (2004) in a review article stated that excess mortality and morbidity from smoking begins to decrease almost immediately after cessation. In fact, over 10 years the risk of lung cancer for former smokers decreases to about half that of smokers; in just one year their risk of heart disease decreases to about half that of smokers and after 15 years to the same risk as nonsmokers. Smoking cessation interventions by health care professionals have proved effective in helping patients to quit smoking (An et al., 2008; Kreuter, Chheda, & Gull, 2000; Milch, Edmunson, Beshansky, Griffith, & Selker, 2004).
In an attempt to guide clinicians through a brief intervention for smoking cessation, the U.S. Public Health Service has published a Clinical Practice Guideline for treatment of tobacco use and dependence (U.S. Public Health Service, 2008). The intervention is based on use of the 5 As and 5 Rs with all clients. The 5 As consists of the following steps: (1) ask all clients about their smoking status at every clinical visit; (2) advise all patients identified as smokers to quit; (3) assess the willingness to quit of all patients identified as smokers; (4) assist all patients identified as smokers in quitting; (5) arrange for follow-up by telephone or in person. The 5 Rs, which should be used with patients who are unwilling to attempt to quit, consists of the clinician (1) explaining to the patient the personal relevance of quitting smoking; (2) identifying the potential risks of continuing to smoke; (3) identifying the potential rewards that can be realized by quitting smoking; (4) identifying possible roadblocks that may make it harder to quit; (5) repeating all the previous messages at every visit with the smoker who is not motivated to quit. …