Smoking rates among people living with schizophrenia, bipolar disorder, and major depressive disorder remain two to four times higher than in the general population — a disparity that shortens lives and widens health inequity. Understanding what drives or derails cessation attempts in this group is essential for designing interventions that actually work, rather than ones built around assumptions from neurotypical cohorts.
This systematic review, drawing on 65 studies selected from nearly 15,000 screened records and spanning MEDLINE, EMBASE, CINAHL, Web of Science, and Scopus through late 2025, used best-fit framework synthesis to map patient-reported values and preferences across schizophrenia, bipolar disorder, MDD, and PTSD diagnoses. Financial cost emerged as the dominant structural barrier to cessation, while personalized engagement with healthcare providers — rather than digital or self-directed tools — was the clearly preferred intervention modality. Social support was identified as a meaningful facilitator. Motivation itself was highly variable and substantially shaped by perceived nicotine dependence and entrenched smoking routines. Most included studies were rated moderate to high quality on the Mixed Methods Appraisal Tool.
This synthesis matters because it challenges a one-size-fits-all cessation paradigm. The field has long recognized that varenicline and bupropion are pharmacologically effective in this population, yet uptake and completion rates remain poor. This review suggests the bottleneck is less pharmacological than relational and economic — a finding that redirects attention toward care delivery structure and insurance coverage rather than drug selection alone. The emphasis on in-person provider interaction is particularly notable given the growing push toward telehealth and app-based cessation tools. For health systems serving high-risk psychiatric populations, these preferences argue for integrated, staffed cessation support embedded within mental health care, not bolted on as a separate referral. Limitations include the observational and self-report nature of most underlying studies, geographic concentration in high-income English-speaking settings, and the challenge of generalizing across heterogeneous diagnostic categories.