Within the word clouds, font size was not too variable, suggesting agreement in the reasons for smoking and recommendations for treatment. The word clouds, as Rapamycin clinical trial a visual display of word frequency, are a useful adjunctive tool to be interpreted within the larger meaning and context of the words (McNaught & Lam, 2010). Although Figure 2 depicts the popularity of strategies, long-term tobacco abstinence will likely be supported through a combination of approaches. Interventions delivered in health care settings offer the appeal of broad reach and integration within ongoing medical care. Yet, historically, tobacco use in the mental health setting has been normalized. A culture shift is needed. In this qualitative study, the providers interviewed were highly trained clinicians in high-performing clinical sites.

As such, the findings reflect a best-case scenario and, notably, suggest great room and receptivity for improvement. The adolescents largely viewed the mental health setting as a safe place to tackle issues with which they struggle such as smoking. To increase clinician prioritization and delivery of tobacco treatment, recent research in adult drug treatment programs supports the evidence of organizational interventions consisting of staff training, consultation, policy development, leadership support, and access to cessation medication (Guydish et al., 2012). An emphasis on tobacco treatment��s broader possible effects for enhancing sobriety and mental wellness may be particularly helpful (Prochaska, Delucchi, & Hall, 2004; Prochaska et al., 2008).

At the patient level, clinical trials research is needed to evaluate the acceptability and efficacy of tobacco cessation interventions with youth in mental health settings. FUNDING This work was supported by the National Institute on Drug Abuse (#K23 DA018691, #K05 DA016752, and #P50 DA09253) and the State of California Tobacco-Related Disease Research Program (#13KT-0152). DECLARATION OF INTERESTS The authors have no competing interests to declare related to this research. ACKNOWLEDGMENTS We acknowledge Christianne Wa for transcribing the interviews, Howard Liu for secondary coding of the interviews, and our clinical collaborators Ken Epstein, MSW, Alan Louie, MD, Celia Moreno, MD, and Susan Smiga, MD, for the opportunity to work with adolescent and young adult patients and mental health providers at their outpatient sites.

In 2011, the lifetime prevalence of cigarette smoking in 8th grade was 18.4% rising to 40.0% by 12th grade (Johnston, Cilengitide O��Malley, Bachman, & Schulenberg, 2012), indicating the importance of understanding the patterns of growth in smoking across this developmental period. The present study investigated individual trajectory classes of cigarette smoking across adolescence, and examined their precursors and consequences.