Background: People with mental illness have a higher prevalence of smoking and poorer cessation outcomes than the general population. Health and welfare professionals commonly regard smoking cessation as a lower priority amongst this group. Beliefs that smoking can be a benefit to their clients and that cessation poses a danger to the management of their symptoms are common. This has led to the exemption of psychiatric facilities from policies requiring health facilities to be smoke free in NSW. We undertook a systematic review of the literature around the relationship between smoking and mental illness to assess the level of evidence for commonly held beliefs.

Discussion: Beliefs that smoking is beneficial to clients and cessation poses a potential harm can be 'self-exempting beliefs' which protect health professionals from the difficult responsibility to reduce the considerable harms caused by smoking in their clients. In addition to the health and financial burdens, nicotine dependency poses a risk to vulnerable clients who can be manipulated by staff using their dependency as a form of behaviour management.

Conclusion: There is a need to address the concerns and reluctance of mental health and welfare professionals to address smoking in people with mental illnesses through evidence based policies implemented with high level management support.