Not long ago, conventional wisdom held that psychiatric hospitals could not be entirely smoke free. Such policies, it was thought, would be impossible to enforce, and attempts to do so would increase the risk of patient violence and fires from clandestine smoking. Now we know that these concerns are unfounded. Well-implemented smoke-free policies have resulted in care environments that show improved outcomes in smoking-related incidents of restraint and seclusion, and staff resistance has not been insurmountable. In fact, patients and staff alike can and should be significant resources for successful implementation of smoke-free policies. Mental health care settings can create environments that promote a tobacco-free lifestyle to consumers, in the same way that virtually all medical centers and hospitals across the country have already done.

However, the adoption of smoke-free policies is only a first step toward addressing the devastating health effects and early death that smoking causes among mental health consumers. In this issue Hollen and colleagues report survey data showing that many state psychiatric hospitals that have adopted smoke-free policies have not taken the next step by offering evidence-based smoking cessation interventions or providing staff with specialty training in smoking cessation.

Our knowledge of smoking and serious mental illness has grown tremendously in recent years. Although nicotine dependence is at the heart of cigarette addiction, the clinical reality becomes more complex with serious mental illness. Multiple lines of evidence suggest that the nicotinic cholinergic system may play a role in the pathophysiology of schizophrenia and make it more difficult for individuals with schizophrenia to quit smoking. Smoking interacts with psychoactive drug metabolism. Quit attempts, if not well managed, can be thwarted by symptom emergence or drug interactions. When people with serious mental illness engage in mainstream smoking cessation approaches, their failure rate is about twice that of the general population. Even so, evidence abounds that people with serious mental illness want to quit smoking and look for help in doing so. Treatment interventions, both psychosocial and pharmacologic, must be developed that specifically address the needs of this population.

Cigarette smoking by people living with serious mental illness is a problem that requires the full attention of psychiatrists and mental health professionals, who understand the complexity of serious mental illness and who are uniquely equipped to help patients plan for success in their efforts to quit. When smoke-free policies reflect significant increases in specialty training and intensification of treatment for nicotine dependence, we will know that the glass is becoming fuller.