In an era where tobacco use is increasingly recognized as a critical public health challenge, particularly among vulnerable populations, a groundbreaking systematic review published in BMC Psychiatry exposes the persistent hurdles and promising strategies for addressing tobacco dependence in mental health settings. Despite overall declines in smoking rates across the general population, individuals living with mental illness continue to experience disproportionately high rates of tobacco use, which contributes to severe health disparities and complicates psychiatric care. The urgent need to amplify tobacco treatment interventions in these specialized environments forms the crux of this comprehensive analysis.
This systematic review, authored by Kacmarek et al., synthesizes evidence from twenty rigorous studies identified out of an exhaustive search of over seven hundred articles spanning multiple biomedical and psychological databases through the end of 2024. Their investigation concentrated on real-world implementation strategies employed across mental health settings, focusing on how these strategies influence the behavior of healthcare providers in delivering evidence-based tobacco interventions. The researchers leveraged sophisticated frameworks including the Expert Recommendations for Implementing Change (ERIC) taxonomy to categorize strategies, the capability-opportunity-motivation (COM) behavioral model to analyze mechanisms of change, and the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework to evaluate outcomes.
At the heart of the inquiry was the five-step 5As approach—Ask, Advise, Assess, Assist, and Arrange—acknowledged as the gold standard for tobacco counseling. The review meticulously documented changes in clinician adoption of these intervention components as well as the extent of patient engagement after implementation efforts. Notably, the data revealed pronounced improvements post-implementation, especially in the ‘Assist’ component where referral rates dramatically increased by up to 42% in outpatient care and 11% in inpatient settings. Such findings underscore the nuanced dynamics of healthcare delivery in mental health contexts and highlight the critical role of tailored strategies.
An intriguing aspect of the review is its illumination of distinct differences between outpatient and inpatient mental health environments concerning which implementation domains most effectively enhance engagement with tobacco cessation pharmacotherapies, such as nicotine replacement therapy (NRT). In outpatient settings, approaches centered on ‘engaging consumers’—empowering and involving patients directly—were linked with significant upticks in NRT utilization. Conversely, inpatient settings benefited more from strategies that emphasized ‘supporting clinicians’ through education, resources, and modifying organizational infrastructure. This dichotomy suggests a complex interplay between contextual factors and implementation success, reinforcing the necessity for setting-specific tactics.
Despite these advances, the authors caution that over half of the reviewed studies exhibited serious biases, primarily due to confounding variables, which tempered the certainty of some conclusions. This highlights a pervasive challenge in implementation science: isolating the genuine effects of interventions amidst the complex, real-world clinical milieu where multiple overlapping factors influence outcomes. The review advocates for more rigorous experimental designs and formal analyses to validate hypothesized moderators like treatment setting and mediators such as clinician capability, opportunity, and motivation that drive practice change.
Furthermore, an essential takeaway from this review is the paramount importance of simultaneously targeting medication administration and counseling—the two pillars of successful tobacco cessation treatment—to optimize clinical impact. Future efforts must not only increase the reach of evidence-based interventions but also ensure fidelity and integration of comprehensive treatment modalities in routine care workflows within mental health facilities.
The study also calls for pioneering collaborations between clinical practitioners and researchers to develop innovative, feasible methods to monitor and evaluate smoking behavior change in practical, resource-constrained environments. Such partnerships are vital for translating theoretical models into actionable, scalable programs that can bridge the persistent tobacco-related health equity gap experienced by individuals with mental illness.
The inherent complexity of tobacco treatment implementation in mental health settings requires a sophisticated understanding of behavioral, organizational, and contextual factors. This review provides a critical roadmap demonstrating that while substantial progress has been made, considerable work remains. Strategic engagement of consumers and infrastructure transformation emerge as pivotal levers for change, yet the quest to refine and replicate successful interventions continues.
In conclusion, the work of Kacmarek and colleagues significantly enriches the discourse on improving tobacco cessation services within mental health care by illuminating specific strategies that enhance provider practices and patient engagement. Their findings emphasize that bespoke, setting-sensitive approaches that harmonize clinician support, infrastructure change, and patient empowerment can drive meaningful increases in tobacco treatment reach. As the global burden of tobacco-related illness persists, this review signals a clarion call for intensified research-practice partnerships that can catalyze sustained improvements in clinical care and ultimately, patient outcomes.
Subject of Research: Tobacco treatment implementation in mental health settings
Article Title: Implementation strategies to increase tobacco treatment in mental health settings: a systematic review
Article References:
Kacmarek, C.N., Vivino, A.A., Smith, H.C. et al. Implementation strategies to increase tobacco treatment in mental health settings: a systematic review. BMC Psychiatry 25, 945 (2025). https://doi.org/10.1186/s12888-025-07248-7
Image Credits: AI Generated
DOI: https://doi.org/10.1186/s12888-025-07248-7
Keywords: tobacco cessation, mental health, implementation strategies, 5As, nicotine replacement therapy, behavioral health, healthcare provider behavior, evidence-based interventions, health disparities, systematic review
