Helping People with Mental Illness in Massachusetts and Connecticut Quit Smoking


of all cigarettes in the United States are smoked by people with a mental health condition

ATTOC approach was tested at nine community mental health treatment centers in Connecticut and a psychosocial rehabilitation program in Massachusetts

of the 10 mental health facilities testing ATTOC established tobacco-free grounds

of people using ATTOC in Connecticut reported changes in smoking habits, and 13% reported quitting

Rates of nicotine dependence among people with mental illness are three to four times greater than rates in the general population; this group of tobacco users consumes 44 percent of all the cigarettes in the United States. As a result, this group has up to a 25-year shorter lifespan and accounts for half of smoking-related deaths in the United States. In the Worcester, Massachusetts, Genesis ClubExternal—a community facility designed to support people with mental illness—more than 75 percent of members use or have used tobacco. However, about half of the tobacco users want to reduce their use, and 38 percent want to quit altogether.

Historically, mental health treatment facilities have placed limited emphasis on tobacco use; many facilities have accepted tobacco use as a way for clients to manage stress and have tolerated smoking by staff on campus. Leaders of facilities who wanted to address tobacco addiction have lacked resources to train and support staff and clients.

To tackle this issue, the University of Massachusetts Medical School and UMass Memorial Health Care developed Addressing Tobacco through Organizational ChangeExternal (ATTOC), a 10-step process designed to help organizations change their culture and systematically improve their tobacco addiction treatment for clients and staff through staff training, improvement of clinical services, and program development.



ATTOC was piloted at the Genesis Club in Massachusetts and at nine mental health treatment centers in Connecticut. Connecticut mental health treatment centers

  • Hired and trained more than a dozen tobacco treatment counselors and trained clinical staff in assessment, treatment planning, and referral options and procedures
  • Initiated specialized services for clients with either high or low motivation to quit tobacco use
  • Modified clinical records to cue clinicians to include nicotine dependence diagnoses and specify related treatment goals
  • Provided training on FDA-approved tobacco cessation medications to prescribers, who then began prescribing them
  • Supplied carbon monoxide meters to help with assessment and to motivate clients to quit
  • Supported staff trying to quit smoking by providing education about insurance and cessation resources
  • Established tobacco-free grounds, prohibiting tobacco use by both staff and clients
  • Mentored leaders to sustain organizational change and treatment efforts after the pilot ended

After 90 days of ATTOC, 49% of participants had changed their smoking habits, 44% had tried to quit, and 13% had abstained for the last 30 or more days. Massachusetts Genesis Club members and staff

  • Developed a Promoting Healthy Lifestyles Clubhouse Toolkit, which includes wellness information and a version of ATTOC adapted for 25 staff and 375 active Genesis Club members
  • Developed a Toolkit training program now available to 332 Genesis clubhouses in 37 states and 33 countries
  • Conducted a weekly educational program to encourage members to take responsibility for their wellness
  • Used carbon monoxide meters to give feedback on tobacco use, conducting more than 500 readings in the first year
  • Made the clubhouse a tobacco-free facility with consensus among members and staff

More than 90 members and staff attended at least one wellness meeting and 50 made quit attempts, 8 without relapse.

Lessons Learned
  • Client engagement improves when the clinical chart, rehabilitation plan, or electronic health record prompts providers to address tobacco use in mental health treatment.
  • Policy changes that allow reimbursement for cessation services help sustain the ATTOC approach.
  • Client engagement and supportive leaders and staff can help integrate tobacco addiction treatments into mental health care.
  • Initiatives work best when they address all kinds of tobacco use, consistently emphasize the benefits of quitting, and help individuals who relapse.

Publication date: 07/23/2014

More Information
For story information, contact
University of Massachusetts Medical School
UMass Memorial Health Care
Douglas Ziedonis, MD, MPH
Chair, UMass Department of Psychiatry
Phone: 508-856-8641
For product information, contact
Centers for Disease Control and Prevention
1600 Clifton Road NE, Atlanta, GA 30333

The information in Public Health Practice Stories from the Field was provided by organizations external to CDC. Provision of this information by CDC is for informational purposes only and does not constitute an endorsement or recommendation by the US government or CDC.

Page last reviewed: October 5, 2018