The National Institute of Mental Health (NIMH) convened a meeting in September 2005 to review tobacco use and dependence and smoking cessation among those with mental disorders, especially individuals with anxiety disorders, depression, or schizophrenia. Smoking rates are exceptionally high among these individuals and contribute to the high rates of medical morbidity and mortality in these individuals. Numerous biological, psychological, and social factors may explain these high smoking rates, including the lack of smoking cessation treatment in mental health settings. Historically, "self-medication" and "individual rights" have been concerns used to rationalize allowing ongoing tobacco use and limited smoking cessation efforts in many mental health treatment settings. Although research has shown that tobacco use can reduce or ameliorate certain psychiatric symptoms, overreliance on the self-medication hypothesis to explain the high rates of tobacco use in psychiatric populations may result in inadequate attention to other potential explanations for this addictive behavior among those with mental disorders. A more complete understanding of nicotine and tobacco use in psychiatric patients also can lead to new psychiatric treatments and a better understanding of mental illness. Greater collaboration between mental health researchers and nicotine and tobacco researchers is needed to better understand and develop new treatments for cooccurring nicotine dependence and mental illness. Despite an accumulating literature for some specific psychiatric disorders and tobacco use and cessation, many unstudied research questions remain and are a focus and an emphasis of this review.

The present study tested the hypothesis that limited ability to tolerate physical and psychological distress is associated with early relapse from smoking cessation. Specifically, the authors exposed 16 current smokers who had failed to sustain any previous quit attempt for more than 24 hr (immediate relapsers) and 16 smokers with at least 1 sustained quit attempt of 3 months or longer (delayed relapsers) to psychological (mental arithmetic) and physical (carbon dioxide inhalation-breath holding) stressors. Relative to delayed relapsers, immediate relapsers were characterized by higher baseline levels of affective vulnerability, by greater levels of dysphoria and urge to smoke after 12 hr of nicotine deprivation, and by less task persistence on the stressors, suggesting that these may be risk factors for early lapse in the context of quitting smoking.

Smokers with past major depressive disorder participating in a smoking cessation treatment study were interviewed at 6, 26, and 29 weeks postquit to retrospectively assess their smoking behavior using the timeline follow-back (TLFB) method. Participants also completed calendars by self-monitoring the number of cigarettes smoked each day for two 4-week periods over the 26-week follow-up. The 3-and 20-week test-retest reliabilities of the smoking TLFB interview were high. Agreement between participants' daily monitored smoking calendars and their self-reports from the TLFB interview was also high, providing strong evidence for the validity of the TLFB method for smoking. A smoking TLFB interview provides the opportunity to assess patterns of change in smoking and cessation longitudinally over extended time frames.The assessment of smoking behavior is of critical importance to smoking cessation research. Recent directions in smoking research have emphasized that quitting smoking is a process taking place over a period of time rather than an absolute outcome. Understanding the natural history of smoking and the natural

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