Abstract Background Tobacco dependence among people with mental health problems is an issue that deserves attention both from a clinical and from a public health perspective. Research suggests that Stop Smoking Services often fail to ask clients about underlying mental health problems and thus fail to put in place the treatment adaptations and liaison procedures often required to meet the needs of clients with a mental health condition who want to stop smoking. This study assesses the recording of mental health problems in a large NHS stop smoking service in England and examines the effect of implementing a short screening procedure on recording mental health conditions. Methods Treatment records from the Stop Smoking Service covering a period of 13 months were audited. The prevalence of reported mental health problems in the six month period before the implementation of the mental health screening procedure was compared with that of the six month period following implementation. The screening procedure was only implemented in the support services directly provided by the Stop Smoking Service. Comparisons were also made with third-party sections of the service where no such screening procedure was introduced. Results The prevalence of reported mental health problems among a total of n = 4999 clients rose from less than 1% before implementation of the screening procedure to nearly 12% in the period following implementation, with the change being statistically significant. No significant rise was observed over the same period in the sections of the service where no screening procedure was implemented. Conclusions The absence of standard procedures to record mental health problems among service users in many stop smoking services is currently likely to prevent the detection of co morbidity. Implementing a simple screening procedure appears suitable to increase the routine recording of mental health problems in a stop smoking service, which is an essential step to ensure services can be tailored and delivered appropriately to the client group.</p

Chloe Todd

E Ratschen

Elena Ratschen

J Campion

JR Hughes

L McNally

Lisa McNally

R Siru

S Brown

English

PubMed

Abstract Background Tobacco dependence among people with mental health problems is an issue that deserves attention both from a clinical and from a public health perspective. Research suggests that Stop Smoking Services often fail to ask clients about underlying mental health problems and thus fail to put in place the treatment adaptations and liaison procedures often required to meet the needs of clients with a mental health condition who want to stop smoking. This study assesses the recording of mental health problems in a large NHS stop smoking service in England and examines the effect of implementing a short screening procedure on recording mental health conditions. Methods Treatment records from the Stop Smoking Service covering a period of 13 months were audited. The prevalence of reported mental health problems in the six month period before the implementation of the mental health screening procedure was compared with that of the six month period following implementation. The screening procedure was only implemented in the support services directly provided by the Stop Smoking Service. Comparisons were also made with third-party sections of the service where no such screening procedure was introduced. Results The prevalence of reported mental health problems among a total of n = 4999 clients rose from less than 1% before implementation of the screening procedure to nearly 12% in the period following implementation, with the change being statistically significant. No significant rise was observed over the same period in the sections of the service where no screening procedure was implemented. Conclusions The absence of standard procedures to record mental health problems among service users in many stop smoking services is currently likely to prevent the detection of co morbidity. Implementing a simple screening procedure appears suitable to increase the routine recording of mental health problems in a stop smoking service, which is an essential step to ensure services can be tailored and delivered appropriately to the client group.</p

Ratschen Elena

Todd Chloe

McNally Lisa

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BMC Health Services Research

The prevalence of mental health problems among users of NHS stop smoking services: effects of implementing a routine screening procedure

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RESEARCH ARTICLE Open Access
The prevalence of mental health problems
among users of NHS stop smoking services:
effects of implementing a routine screening
procedure
Lisa McNally1*, Chloe Todd1 and Elena Ratschen2
Abstract
Background: Tobacco dependence among people with mental health problems is an issue that deserves
attention both from a clinical and from a public health perspective. Research suggests that Stop Smoking Services
often fail to ask clients about underlying mental health problems and thus fail to put in place the treatment
adaptations and liaison procedures often required to meet the needs of clients with a mental health condition
who want to stop smoking. This study assesses the recording of mental health problems in a large NHS stop
smoking service in England and examines the effect of implementing a short screening procedure on recording
mental health conditions.
Methods: Treatment records from the Stop Smoking Service covering a period of 13 months were audited. The
prevalence of reported mental health problems in the six month period before the implementation of the mental
health screening procedure was compared with that of the six month period following implementation. The
screening procedure was only implemented in the support services directly provided by the Stop Smoking Service.
Comparisons were also made with third-party sections of the service where no such screening procedure was
introduced.
Results: The prevalence of reported mental health problems among a total of n = 4999 clients rose from less than
1% before implementation of the screening procedure to nearly 12% in the period following implementation, with
the change being statistically significant. No significant rise was observed over the same period in the sections of
the service where no screening procedure was implemented.
Conclusions: The absence of standard procedures to record mental health problems among service users in many
stop smoking services is currently likely to prevent the detection of co morbidity. Implementing a simple screening
procedure appears suitable to increase the routine recording of mental health problems in a stop smoking service,
which is an essential step to ensure services can be tailored and delivered appropriately to the client group.
Background
There have been a number of calls for smoking cessa-
tion support to be made more accessible and appropri-
ately tailored to those living with mental health
conditions [1,2]. These calls have been based on the
very high levels of smoking in this group and the
resulting, well-documented consequences in relation to
both physical [3] and mental well being [2], which in
conjunction contribute considerably to the health
inequalities experienced by this population.
Review level evidence suggests that levels of motiva-
tion to quit smoking among people with mental health
conditions can be comparable to that found within the
general population [4]. Complex psychosocial and neu-
robiological factors associated with the link between
smoking and mental illness however pose challenges to
* Correspondence: lisa.mcnally@surreypct.nhs.uk
1Public Health Department, Surrey NHS Primary Care Trust, Cedar Court,
Leatherhead, Surrey, KT22 9AE, UK
Full list of author information is available at the end of the article
McNally et al. BMC Health Services Research 2011, 11:190
http://www.biomedcentral.com/1472-6963/11/190
© 2011 McNally et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons
Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in
any medium, provided the original work is properly cited.
addressing the issue in this group. Smoking, for exam-
ple, still constitutes the norm rather than the exception
in many mental health settings, and while it is ‘de-nor-
malised’ in the rest of society, the smoking culture in
mental health settings appears to be prevailing. Impor-
tant neurobiological links refer to metabolic interactions
between psychotropic medication and constituents in
tobacco smoke, which require higher doses of medica-
tion for smokers to achieve therapeutic blood levels, and
consequently necessitate a review and potential decrease
of dosage following cessation [2]. Awareness that with-
drawal from nicotine may pose a challenge to mental
well-being [5] and can, if untreated, mimic or exacerbate
symptoms of mental illness1, is important, and enhanced
mood or stress management intervention may need to
be incorporated into quit support. Appropriately tailored
support and liaison with all treatment providers are
therefore paramount to ensure that smoking treatment
can be safe and successful [6].
Recent research suggests that the majority of NHS
Stop Smoking Services do not proactively screen for
mental health problems or collect data on the propor-
tion of their clients that have mental health issues [7].
Therefore, it may be that these services are regularly
supporting smokers with mental health conditions to
quit without knowledge of those problems and without
making the appropriate adjustments to their treatment
programme.
The AIMS procedure [7] has been proposed to enable
efficient screening and recording of mental health status
for NHS Stop Smoking Services. AIMS is an acronym
for Ask, Inform, Medication &Support. It is intended to
ensure that Stop Smoking Service ask all smokers
requesting support to quit about their mental health,
inform the client’s mental healthcare provider about the
quit attempt, ensure the issue of medication metabolism
is addressed and then tailor the stop smoking support to
the specific mental health needs of the client (eg: flexible
sessions, enhanced psychological support).
The aim of this study is to review NHS Stop Smoking
Service data in order to assess the prevalence of
recorded mental health conditions on the database of a
large NHS Stop Smoking Service, and to examine
changes in recording prevalence before and after imple-
menting the AIMS screening procedure.
Methods
The study data were taken from an audit of a large Eng-
lish NHS Stop Smoking Service (Surrey) covering a total
population of over 1 million people and a period of 13
months (from May 2009 to May 2010). The treatment
provided by the Stop Smoking Service falls into two
main categories: Direct services are those provided
directly by the Stop Smoking Service team within
specialist (group-based) clinics or via telephone support.
In contrast, Third-Party services are commissioned by
the Stop Smoking Service and are provided by suitably
trained professionals in General Practice or Community
Pharmacy settings.
Six months into the data collection period, the AIMS
screening procedure was implemented within the
directly provided services. Hence from this point, all cli-
ents using directly provided services were routinely
being asked whether or not they have any mental health
problems (as well as about the nature of any current
treatment if applicable). Screening for mental health
problems took place at the first point of contact
between the client and the Stop Smoking Service.
The ‘inclusion’ criteria for recording were based purely
on clients’ self report and their definition of symptoms
as representing a mental health problem or condition.
Mental health problems were recorded even if there had
been no formal diagnosis or treatment received. Stop
Smoking Service staff did not have access to the clients’
medical records or any other sources of data that may
have provided information on clients’ mental health
history.
No screening procedure was implemented across the
Third Party services. The professionals commissioned to
provide these services were not informed of the screen-
ing procedure implementation within the direct services.
The recorded prevalence of mental heath conditions
across the six-month period before the implementation
of the screening procedure (Period 1 - May 09 to Octo-
ber 09) was compared with the recorded prevalence
across the six-month period after implementation (Per-
iod 2 - December 09 to May 10) using Chi-Squared
tests. Separate analyses were carried out for both Direct
and Third Party services. The month in which the
AIMS Procedure was first implemented into the direct
services (November 09) was excluded from all analyses
so as to allow for a transition period during which staff
within the direct services became familiar with using the
AIMS screening procedure.
Results
A total number of n = 4999 clients were recorded as
having set a quit date in the study period (once Novem-
ber was excluded). Among this sample, 51% were female
and the average age was 44 years (std = 14.64). A total
of 1667 quitters used treatment provided with the Direct
stop smoking services and 3332 quitters used services
provided by the Third-Party providers in General Prac-
tice or Community Pharmacy. In total, 106 quitters
reported mental health problems (see Figure 1)
Across all services, the recorded prevalence of current
mental health problems among clients was significantly
higher in Period 2 (4.1%) than it had been in Period 1
McNally et al. BMC Health Services Research 2011, 11:190
http://www.biomedcentral.com/1472-6963/11/190
Page 2 of 4
(0.7%) (Chi2 = 67.68, p < 0.001). Examining third party
services alone (where AIMS had not been implemented),
there was no significant increase in the prevalence of
mental health problems (0.7% to 0.8%: Chi2 = 0.24, ns).
However, there was a significant increase among clients
using direct services (where AIMS had been implemen-
ted) (0.8% to 11.7%: Chi2 = 100.34, p < 0.001) (see Fig-
ure 2).
Among the 106 clients reporting current mental
health problems, only 2 were not also currently engaged
in treatment for these problems. Among clients receiv-
ing mental health treatment, 27 (25%) were in receipt of
specialist care (defined as having a care coordinator or
psychiatrist); the remaining clients were receiving men-
tal healthcare delivered within General Practice.
Discussion
In the absence of routine and proactive screening for
mental health conditions, the recorded prevalence of
such conditions among clients setting a date to quit
smoking was below 1% across both directly provided
and Third-Party provided stop smoking services. Follow-
ing the introduction of routine screening for mental
health conditions within direct services, the recorded
prevalence rose to nearly 12% (more than 1 client in
every 9). Except in two cases, clients reporting mental
health problems were also currently receiving mental
health treatment, with a quarter of these under the care
of specialist mental health services.
Limitations of this study include the fact that there
will inevitably have been uncontrolled variance in how
clients defined a ‘current mental health problem’. It
seems clear that, at least in this study, clients were nor-
mally only reporting such problems if they were receiv-
ing treatment for them. The ‘true’ prevalence of mental
health problems among the sample, including those
undiagnosed, is therefore likely to have been underesti-
mated. According to the Adult Psychiatric Morbidity
Survey (APMS), as many as 23% of the population are
affected by a mental health condition, if mild and mod-
erate conditions are included [8].
It is also notable that the location for this study
(South East England) is likely to have a lower than aver-
age prevalence of mental health problems among its
residents. For example, the APMS data suggests
approximately 10% of men in the South East have a
common mental health problem compared to 15% in
the North West [8]. Following this ratio, the mental
health prevalence of 12% found among Stop Smoking
Service Clients in Surrey may therefore appear as
approximately 18% in a North West service.
Overall, this study suggests that NHS Stop Smoking
Services are currently likely to treat a significant number
of clients each year while being unaware that they have
current mental health problems. This may be a particu-
lar issue when clients access quit support outside of pri-
mary care settings and where medical records may not
be readily available (recent data suggests that 55% of
quit attempts in England occur outside of primary care
settings) [9]. The adoption of a simple screening proce-
dure such as AIMS into service routines is feasible and
can significantly increase the extent to which service
providers are aware of client’s mental health problems.
The findings of this study have clear implications for
practice within NHS Stop Smoking Services. As mentioned
earlier, when supporting a client with a mental health con-
dition to stop smoking, it is essential to put in place appro-
priately tailored support in relation to medication and/or
psychological well-being [7]. The present study suggests
that at least 1 in 9 clients of NHS Stop Smoking Services
will have a current mental health condition and require
such treatment adaptations. However, in the absence of
routine mental health screening, NHS Stop Smoking Ser-
vice staff will often remain unaware that a mental health
condition exists and such adaptations will therefore not
occur. Given previous evidence that the majority of NHS
Stop Smoking Services do not operate mental health
screening procedures or treatment protocols [7] there is
an urgent need for a widespread change in practice.
Conclusions
A significant number of people approaching NHS Stop
Smoking Services may also happen to be living with
 Period 1 Period 2 
Direct 8 
 
73 
Third Party 13 
 
12 
Figure 1 Distribution of clients recorded as having a mental
health problem by service type and study period (n = 106).
0%
2%
4%
6%
8%
10%
12%
14%
Period 1 Period 2
Direct
Third Party
Figure 2 Prevalence of reported mental health problems by
service type and study period.
McNally et al. BMC Health Services Research 2011, 11:190
http://www.biomedcentral.com/1472-6963/11/190
Page 3 of 4
mental health conditions. If these services are to offer a
consistently safe and effective intervention for all of its
clients, then routine screening of all clients for mental
health problems should be undertaken.
Acknowledgements
This study was carried out in collaboration with the NHS Stop Smoking
Service at NHS Surrey. The authors wish to thank the staff of the service for
their support.
Author details
1Public Health Department, Surrey NHS Primary Care Trust, Cedar Court,
Leatherhead, Surrey, KT22 9AE, UK. 2UK Centre for Tobacco Control Studies,
University of Nottingham, Clinical Sciences Building, City Hospital,
Nottingham, NG5 1PB, UK.
Authors’ contributions
LM designed the study, screening procedures and led on the writing of the
manuscript. ER and CT both contributed to the analysis and interpretation of
data, as well as drafting and revising the manuscript. All authors have given
final approval of the version published.
Competing interests
LM has previously received funding for her work from pharmaceutical
companies.
Received: 4 April 2011 Accepted: 16 August 2011
Published: 16 August 2011
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schizophrenia. Br J Psychiatry 2000, 177:212-217.
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with mental illness: a review. Addiction 2009, 104:719-733.
5. Hughes JR: Depression during tobacco abstinence. Nicotine and Tobacco
Research 2007, 9:443-446.
6. McNally L: Quitting in Mind: A Guide to Implementing Stop Smoking
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Crossref

RESEARCH ARTICLE Open AccessThe prevalence of mental health problemsamong users of NHS stop smoking services:effects of implementing a routine screeningprocedureLisa McNally1*, Chloe Todd1 and Elena Ratschen2AbstractBackground: Tobacco dependence among people with mental health problems is an issue that deservesattention both from a clinical and from a public health perspective. Research suggests that Stop Smoking Servicesoften fail to ask clients about underlying mental health problems and thus fail to put in place the treatmentadaptations and liaison procedures often required to meet the needs of clients with a mental health conditionwho want to stop smoking. This study assesses the recording of mental health problems in a large NHS stopsmoking service in England and examines the effect of implementing a short screening procedure on recordingmental health conditions.Methods: Treatment records from the Stop Smoking Service covering a period of 13 months were audited. Theprevalence of reported mental health problems in the six month period before the implementation of the mentalhealth screening procedure was compared with that of the six month period following implementation. Thescreening procedure was only implemented in the support services directly provided by the Stop Smoking Service.Comparisons were also made with third-party sections of the service where no such screening procedure wasintroduced.Results: The prevalence of reported mental health problems among a total of n = 4999 clients rose from less than1% before implementation of the screening procedure to nearly 12% in the period following implementation, withthe change being statistically significant. No significant rise was observed over the same period in the sections ofthe service where no screening procedure was implemented.Conclusions: The absence of standard procedures to record mental health problems among service users in manystop smoking services is currently likely to prevent the detection of co morbidity. Implementing a simple screeningprocedure appears suitable to increase the routine recording of mental health problems in a stop smoking service,which is an essential step to ensure services can be tailored and delivered appropriately to the client group.BackgroundThere have been a number of calls for smoking cessa-tion support to be made more accessible and appropri-ately tailored to those living with mental healthconditions [1,2]. These calls have been based on thevery high levels of smoking in this group and theresulting, well-documented consequences in relation toboth physical [3] and mental well being [2], which inconjunction contribute considerably to the healthinequalities experienced by this population.Review level evidence suggests that levels of motiva-tion to quit smoking among people with mental healthconditions can be comparable to that found within thegeneral population [4]. Complex psychosocial and neu-robiological factors associated with the link betweensmoking and mental illness however pose challenges to* Correspondence: lisa.mcnally@surreypct.nhs.uk1Public Health Department, Surrey NHS Primary Care Trust, Cedar Court,Leatherhead, Surrey, KT22 9AE, UKFull list of author information is available at the end of the articleMcNally et al. BMC Health Services Research 2011, 11:190http://www.biomedcentral.com/1472-6963/11/190© 2011 McNally et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative CommonsAttribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction inany medium, provided the original work is properly cited.addressing the issue in this group. Smoking, for exam-ple, still constitutes the norm rather than the exceptionin many mental health settings, and while it is ‘de-nor-malised’ in the rest of society, the smoking culture inmental health settings appears to be prevailing. Impor-tant neurobiological links refer to metabolic interactionsbetween psychotropic medication and constituents intobacco smoke, which require higher doses of medica-tion for smokers to achieve therapeutic blood levels, andconsequently necessitate a review and potential decreaseof dosage following cessation [2]. Awareness that with-drawal from nicotine may pose a challenge to mentalwell-being [5] and can, if untreated, mimic or exacerbatesymptoms of mental illness1, is important, and enhancedmood or stress management intervention may need tobe incorporated into quit support. Appropriately tailoredsupport and liaison with all treatment providers aretherefore paramount to ensure that smoking treatmentcan be safe and successful [6].Recent research suggests that the majority of NHSStop Smoking Services do not proactively screen formental health problems or collect data on the propor-tion of their clients that have mental health issues [7].Therefore, it may be that these services are regularlysupporting smokers with mental health conditions toquit without knowledge of those problems and withoutmaking the appropriate adjustments to their treatmentprogramme.The AIMS procedure [7] has been proposed to enableefficient screening and recording of mental health statusfor NHS Stop Smoking Services. AIMS is an acronymfor Ask, Inform, Medication &Support. It is intended toensure that Stop Smoking Service ask all smokersrequesting support to quit about their mental health,inform the client’s mental healthcare provider about thequit attempt, ensure the issue of medication metabolismis addressed and then tailor the stop smoking support tothe specific mental health needs of the client (eg: flexiblesessions, enhanced psychological support).The aim of this study is to review NHS Stop SmokingService data in order to assess the prevalence ofrecorded mental health conditions on the database of alarge NHS Stop Smoking Service, and to examinechanges in recording prevalence before and after imple-menting the AIMS screening procedure.MethodsThe study data were taken from an audit of a large Eng-lish NHS Stop Smoking Service (Surrey) covering a totalpopulation of over 1 million people and a period of 13months (from May 2009 to May 2010). The treatmentprovided by the Stop Smoking Service falls into twomain categories: Direct services are those provideddirectly by the Stop Smoking Service team withinspecialist (group-based) clinics or via telephone support.In contrast, Third-Party services are commissioned bythe Stop Smoking Service and are provided by suitablytrained professionals in General Practice or CommunityPharmacy settings.Six months into the data collection period, the AIMSscreening procedure was implemented within thedirectly provided services. Hence from this point, all cli-ents using directly provided services were routinelybeing asked whether or not they have any mental healthproblems (as well as about the nature of any currenttreatment if applicable). Screening for mental healthproblems took place at the first point of contactbetween the client and the Stop Smoking Service.The ‘inclusion’ criteria for recording were based purelyon clients’ self report and their definition of symptomsas representing a mental health problem or condition.Mental health problems were recorded even if there hadbeen no formal diagnosis or treatment received. StopSmoking Service staff did not have access to the clients’medical records or any other sources of data that mayhave provided information on clients’ mental healthhistory.No screening procedure was implemented across theThird Party services. The professionals commissioned toprovide these services were not informed of the screen-ing procedure implementation within the direct services.The recorded prevalence of mental heath conditionsacross the six-month period before the implementationof the screening procedure (Period 1 - May 09 to Octo-ber 09) was compared with the recorded prevalenceacross the six-month period after implementation (Per-iod 2 - December 09 to May 10) using Chi-Squaredtests. Separate analyses were carried out for both Directand Third Party services. The month in which theAIMS Procedure was first implemented into the directservices (November 09) was excluded from all analysesso as to allow for a transition period during which staffwithin the direct services became familiar with using theAIMS screening procedure.ResultsA total number of n = 4999 clients were recorded ashaving set a quit date in the study period (once Novem-ber was excluded). Among this sample, 51% were femaleand the average age was 44 years (std = 14.64). A totalof 1667 quitters used treatment provided with the Directstop smoking services and 3332 quitters used servicesprovided by the Third-Party providers in General Prac-tice or Community Pharmacy. In total, 106 quittersreported mental health problems (see Figure 1)Across all services, the recorded prevalence of currentmental health problems among clients was significantlyhigher in Period 2 (4.1%) than it had been in Period 1McNally et al. BMC Health Services Research 2011, 11:190http://www.biomedcentral.com/1472-6963/11/190Page 2 of 4(0.7%) (Chi2 = 67.68, p < 0.001). Examining third partyservices alone (where AIMS had not been implemented),there was no significant increase in the prevalence ofmental health problems (0.7% to 0.8%: Chi2 = 0.24, ns).However, there was a significant increase among clientsusing direct services (where AIMS had been implemen-ted) (0.8% to 11.7%: Chi2 = 100.34, p < 0.001) (see Fig-ure 2).Among the 106 clients reporting current mentalhealth problems, only 2 were not also currently engagedin treatment for these problems. Among clients receiv-ing mental health treatment, 27 (25%) were in receipt ofspecialist care (defined as having a care coordinator orpsychiatrist); the remaining clients were receiving men-tal healthcare delivered within General Practice.DiscussionIn the absence of routine and proactive screening formental health conditions, the recorded prevalence ofsuch conditions among clients setting a date to quitsmoking was below 1% across both directly providedand Third-Party provided stop smoking services. Follow-ing the introduction of routine screening for mentalhealth conditions within direct services, the recordedprevalence rose to nearly 12% (more than 1 client inevery 9). Except in two cases, clients reporting mentalhealth problems were also currently receiving mentalhealth treatment, with a quarter of these under the careof specialist mental health services.Limitations of this study include the fact that therewill inevitably have been uncontrolled variance in howclients defined a ‘current mental health problem’. Itseems clear that, at least in this study, clients were nor-mally only reporting such problems if they were receiv-ing treatment for them. The ‘true’ prevalence of mentalhealth problems among the sample, including thoseundiagnosed, is therefore likely to have been underesti-mated. According to the Adult Psychiatric MorbiditySurvey (APMS), as many as 23% of the population areaffected by a mental health condition, if mild and mod-erate conditions are included [8].It is also notable that the location for this study(South East England) is likely to have a lower than aver-age prevalence of mental health problems among itsresidents. For example, the APMS data suggestsapproximately 10% of men in the South East have acommon mental health problem compared to 15% inthe North West [8]. Following this ratio, the mentalhealth prevalence of 12% found among Stop SmokingService Clients in Surrey may therefore appear asapproximately 18% in a North West service.Overall, this study suggests that NHS Stop SmokingServices are currently likely to treat a significant numberof clients each year while being unaware that they havecurrent mental health problems. This may be a particu-lar issue when clients access quit support outside of pri-mary care settings and where medical records may notbe readily available (recent data suggests that 55% ofquit attempts in England occur outside of primary caresettings) [9]. The adoption of a simple screening proce-dure such as AIMS into service routines is feasible andcan significantly increase the extent to which serviceproviders are aware of client’s mental health problems.The findings of this study have clear implications forpractice within NHS Stop Smoking Services. As mentionedearlier, when supporting a client with a mental health con-dition to stop smoking, it is essential to put in place appro-priately tailored support in relation to medication and/orpsychological well-being [7]. The present study suggeststhat at least 1 in 9 clients of NHS Stop Smoking Serviceswill have a current mental health condition and requiresuch treatment adaptations. However, in the absence ofroutine mental health screening, NHS Stop Smoking Ser-vice staff will often remain unaware that a mental healthcondition exists and such adaptations will therefore notoccur. Given previous evidence that the majority of NHSStop Smoking Services do not operate mental healthscreening procedures or treatment protocols [7] there isan urgent need for a widespread change in practice.ConclusionsA significant number of people approaching NHS StopSmoking Services may also happen to be living with Period 1 Period 2 Direct 8 73 Third Party 13 12 Figure 1 Distribution of clients recorded as having a mentalhealth problem by service type and study period (n = 106).0%2%4%6%8%10%12%14%Period 1 Period 2DirectThird PartyFigure 2 Prevalence of reported mental health problems byservice type and study period.McNally et al. BMC Health Services Research 2011, 11:190http://www.biomedcentral.com/1472-6963/11/190Page 3 of 4mental health conditions. If these services are to offer aconsistently safe and effective intervention for all of itsclients, then routine screening of all clients for mentalhealth problems should be undertaken.AcknowledgementsThis study was carried out in collaboration with the NHS Stop SmokingService at NHS Surrey. The authors wish to thank the staff of the service fortheir support.Author details1Public Health Department, Surrey NHS Primary Care Trust, Cedar Court,Leatherhead, Surrey, KT22 9AE, UK. 2UK Centre for Tobacco Control Studies,University of Nottingham, Clinical Sciences Building, City Hospital,Nottingham, NG5 1PB, UK.Authors’ contributionsLM designed the study, screening procedures and led on the writing of themanuscript. ER and CT both contributed to the analysis and interpretation ofdata, as well as drafting and revising the manuscript. All authors have givenfinal approval of the version published.Competing interestsLM has previously received funding for her work from pharmaceuticalcompanies.Received: 4 April 2011 Accepted: 16 August 2011Published: 16 August 2011References1. Ratschen E, Britton J, McNeill A: The smoking culture in psychiatry: timefor change. British Journal of Psychiatry 2011, 198:6-7.2. Campion J, Checinski K, Nurse J, McNeill A: Smoking by people withmental illness and benefits of smoke-free mental health services.Advances in Psychiatric Treatment 2008, 14:217-228.3. Brown S, Barraclough B, Inskip H: Causes of the excess mortality ofschizophrenia. Br J Psychiatry 2000, 177:212-217.4. Siru R, Hulse G, Tait R: Assessing motivation to quit smoking in peoplewith mental illness: a review. Addiction 2009, 104:719-733.5. Hughes JR: Depression during tobacco abstinence. Nicotine and TobaccoResearch 2007, 9:443-446.6. McNally L: Quitting in Mind: A Guide to Implementing Stop SmokingSupport in Mental Health Settings.[http://www.quittinginmind.net/index.html.].7. McNally L, Ratschen E: The delivery of stop smoking support to peoplewith mental health conditions: A survey of NHS stop smoking services.BMC Health Services Research 2010, 10:179.8. Health & Social Care Information Centre: Adult psychiatric morbidity inEngland, 2007: Results of a household survey.[http://www.ic.nhs.uk].9. Health & Social Care Information Centre: Statistics on NHS Stop SmokingServices: England, April 2009 - March 2010.[http://www.ic.nhs.uk].Pre-publication historyThe pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6963/11/190/prepubdoi:10.1186/1472-6963-11-190Cite this article as: McNally et al.: The prevalence of mental healthproblems among users of NHS stop smoking services: effects ofimplementing a routine screening procedure. BMC Health ServicesResearch 2011 11:190.Submit your next manuscript to BioMed Centraland take full advantage of: • Convenient online submission• Thorough peer review• No space constraints or color figure charges• Immediate publication on acceptance• Inclusion in PubMed, CAS, Scopus and Google Scholar• Research which is freely available for redistributionSubmit your manuscript at www.biomedcentral.com/submitMcNally et al. BMC Health Services Research 2011, 11:190http://www.biomedcentral.com/1472-6963/11/190Page 4 of 4

A: Smoking by people with mental illness and benefits of smoke-free mental health services. Advances in Psychiatric Treatment

A: The smoking culture in psychiatry: time for change.

Assessing motivation to quit smoking in people with mental illness: a review. Addiction

Depression during tobacco abstinence. Nicotine and Tobacco Research

E: The delivery of stop smoking support to people with mental health conditions: A survey of NHS stop smoking services.

Inskip H: Causes of the excess mortality of schizophrenia.

Quitting in Mind: A Guide to Implementing Stop Smoking Support in Mental Health Settings.[http://www.quittinginmind.net/index.

Social Care Information Centre: Adult psychiatric morbidity in England,

Social Care Information Centre: Statistics on NHS Stop Smoking Services: England,

http://doaj.org/search?source=%7B%22query%22%3A%7B%22bool%22%3A%7B%22must%22%3A%5B%7B%22term%22%3A%7B%22id%22%3A%22467b4467835f468bb89c46f46b31c0ae%22%7D%7D%5D%7D%7D%7D

The prevalence of mental health problems among users of NHS stop smoking services: effects of implementing a routine screening procedure

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