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Among those who use tobacco, nearly one-third of high school females and more than one-half of high school males report using more than 1 tobacco product in the last 30 days.1 Persons with psychiatric diagnoses have much higher rates of smoking than the general population.2 Persons with mental illness and/or substance abuse consume 44% of all cigarettes sold in the United States, despite being only 22% of the population.2 Etiology and Pathophysiology The evidence on the mechanisms by which smoking causes disease indicates that there is no risk-free level of exposure to tobacco smoke.3 Inhaling the complex chemical mixture of combustion compounds in tobacco smoke causes adverse health outcomes, particularly cancer and cardiovascular and pulmonary diseases, through mechanisms that include DNA damage, inflammation, and oxidative stress.3 There is sufficient evidence to infer that a causal relationship exists between active smoking and (a) impaired lung growth during childhood and adolescence

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