Picture an AA meeting, and a gigantic coffee urn and a cloud of smoke come to mind.
In fact, the two men who started AA, Dr. Bob and Bill W. both died from tobacco-related illnesses.
Public health experts say smoking is still pervasive among people living with addiction and mental illness, and it's often not seen as a priority in treatment settings.
For example, smoking rates in Philadelphia have dropped significantly over 10 years, but haven't budged among people with mental illnesses and substance-abuse issues.
Smoking is often seen as a "lesser evil" in mental health and addiction treatment settings, explained Ryan Coffman, tobacco policy manager for Philadelphia's Department of Public Health. It's not a priority, and some providers assume it helps their clients cope.
Research shows the opposite to be true, says Coffman. "Individuals living with mental illness and substance-abuse disorders who smoke have more severe symptoms, poorer well-being and functioning, they have more hospitalizations, and are at a greater risk for suicide," he said.
Research also shows that people who quit smoking along with quitting other drugs have better recovery outcomes.
Philadelphia is increasing efforts to train mental health providers on tobacco-cessation programs, and to provide them with the most up-to-date resources available to their clients, Coffman said.
But for these efforts to really take root, a major cultural shift will have to occur, said University of Pennsylvania psychiatrist Robert Schnoll, who studies tobacco cessation.
"Research indicates that upwards of 25 percent of mental health care facilities still permit smoking on the grounds and on the premises," he explained. "There's pervasive use of cigarettes, or cigarette breaks, as a reward for pro-social behavior, so that's certainly one of the issues we need to address going forward."
Some providers think their clients don't care about tobacco cessation, he said, or don't understand the benefits. Some also simply don't see it as their responsibility.
Research also indicates that smoking rates are high among people who work in mental health treatment settings, Schnoll said.