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"It's mandatory to smoke," she explained. "It's a mental institution, and we have to smoke by law."

That was 18 months ago, and Annelle's confusion was understandable. Until recently, Louisiana law required psychiatric hospitals to accommodate smokers — unlike rules banning smoking at most other health facilities. The law was changed last year, and by March 30, smoking is supposed to end at Louisiana's two remaining state psychiatric hospitals.

After decades in which smoking by people with mental illness was supported and even encouraged — a legacy that experts say is causing patients to die prematurely from smoking-related illnesses — Louisiana's move reflects a growing effort by federal, state and other health officials to reverse course.

But these efforts are hardly simple given the longstanding obstacles.

Hospitals often used cigarettes as incentives or rewards for taking medicine, following rules or attending therapy. Some programs still do. And smoking was endorsed by advocates for people with mental illness and family members, who sometimes sued to preserve smoking rights, considering cigarettes one of the few pleasures patients were allowed.

New data from the Centers for Disease Control and Prevention shows that the nearly 46 million adults with mental illness have a smoking rate 70 percent higher than those without mental illness, and consume about a third of the cigarettes in the country, though they make up one-fifth of the adult population.

People with psychiatric disorders are often "smoking heavier, their puffs are longer and they're smoking it down to the end of the cigarette," said William Riley, chief of the Science of Research and Technology Branch at the National Cancer Institute. With some diagnoses, like schizophrenia, rates are especially high.

A report by the National Association of State Mental Health Program Directors said data suggested that people with the most serious mental illnesses die on average 25 years earlier than the general population, with many from smoking-exacerbated conditions like heart or lung disease.

Now more treatment facilities are banning smoking, with some finding it easier than expected. Others still allow it, usually outside on their grounds during scheduled times. About a fifth of state hospitals are not smoke-free, a survey issued in 2012 by the State Mental Health Program Directors association found. Occasionally, hospitals that banned smoking have reinstated it to avoid losing patients.

Moreover, smoking is so deeply ingrained that smoke-free hospitals can only dent the problem; many patients are now hospitalized only for short stints and resume smoking later.

New research suggests scientific underpinnings for some of the affinity, said Dr. Nora D. Volkow, director of the National Institute on Drug Abuse. Nicotine has antidepressant effects and, for people with schizophrenia, helps dampen extraneous thoughts and voices, she and other experts said.

Other chemicals in cigarette smoke set off a perilous cycle, causing some medications to be metabolized faster, making them less effective and allowing symptoms to return. Because patients feel sicker, they may seek even more comfort from nicotine. "You may think, 'Well, I need to smoke more,' " said Dr. Steven Schroeder, a professor of health and health care at the University of California, San Francisco.

Then, as smoking increases, "blood levels of their medication go down, and they end up back in the hospital," said Judith Prochaska, an associate professor of medicine at Stanford University's Prevention Research Center.

Socially, smoking provides "cover rituals for patients having psychiatric symptoms," said Dr. Rona Hu, medical director of the acute psychiatric inpatient unit at Stanford Hospital in Palo Alto, Calif. "You tamp the box, you kind of play with the lighter, you can exhale and look into the middle distance and not look like you're hallucinating."

Dr. Thomas R. Frieden, director of the C.D.C., said hospitals had historically resisted going smoke-free, fearing it would interfere with treatment. "In my very first job as an aide in a psychiatric hospital," he said, "if patients behaved better they got additional cigarettes."

Southeast Louisiana Hospital used such practices when Annelle was there. (The hospital was recently privatized, and she is at another state facility.) Patricia Gonzales, a former director of hospital services for the Office of Behavioral Health in Louisiana, said staff members would say, for example, " 'John, if you don't get up and get the bed made, you're not going to get your morning smoke break.' "

Smoke breaks were even used to persuade patients to get medical care. "We had a couple of patients who needed important CAT scans and M.R.I.'s, and that's how we did it," said Dr. Schoener LaPrairie, a former staff psychiatrist.

At hospitals across the country, staff members asked tobacco companies for free cigarettes. In 2000, Dr. Elizabeth Roberson, then a psychiatrist at Hawaii State Hospital, wrote to R. J. Reynolds, seeking donated cigarettes for a patient. "Whenever he runs out of cigarettes he becomes highly agitated to the point where he has seriously injured staff and other patients," she wrote. "Providing a cigarette is generally much more effective at decreasing agitation than most medications I can provide."

Dr. E. Fuller Torrey, a psychiatrist and advocate for people with mental illness, wrote such a letter as inpatient psychiatric medical director at St. Elizabeths Hospital in Washington, D.C., in 1980. "We often said we could get patients to do almost anything for cigarettes," he said in an interview.

He wrote R. J. Reynolds requesting "5,000 cigarettes a week" because federal regulations had "abruptly terminated the hospital's practice of providing a modest number of cigarettes." The company denied his request, saying it received so many, it "cannot possibly grant all of them."

A 2007 article by Dr. Prochaska and others said documents suggested that the tobacco industry encouraged smoking among people with mental illness through advertising and industry-supported research showing that nicotine elevates mood. It mentioned a 1986 magazine advertisement with a doubled image of a pack of Merit cigarettes, under the word "Schizophrenic," that said, in part: "Big taste, lower tar, all in one. For New Merit, having two sides is just normal behavior." Dr. Prochaska's article said it was unclear if that language was meant to appeal to people with mental illness or all consumers.

David Howard, an R. J. Reynolds spokesman, declined to comment. David Sylvia, a spokesman for Philip Morris USA, said it was difficult to comment "on stuff that was reported to take place multiple decades ago." Regarding the 1986 ad, he said the company did not "have anybody who can delve back into what they were thinking about when they developed that Merit ad."

Until relatively recently, many relatives and advocates described smoking as an enjoyable personal liberty for patients. In Maine and Connecticut, advocates and patients went to court in 2006 and 2007 in unsuccessful attempts to prevent tobacco bans in state psychiatric hospitals.

"We ignored it for way too long," said Dr. Kenneth Duckworth, medical director for the National Alliance on Mental Illness, the country's largest mental health advocacy organization. "We were facilitating it."

The organization changed its official policy only in 2009. Earlier, it advocated that treatment centers accommodate smokers unable to stop, even if state laws needed to be changed. Now, it supports smoke-free facilities, noting that "smoking has been inappropriately accepted and even encouraged in therapeutic settings."

Policies in private and community facilities, which treat more patients than state hospitals, vary. Some states ban smoking only in state hospitals, as New Jersey did in 2009.

The experience of Princeton House Behavioral Health, a private New Jersey hospital, illustrates the issue's complexity. In 2006, Princeton House banned smoking. And although some patients smuggled in cigarettes, "there weren't as many problems as people thought," said Jonathan Krejci, director of clinical programs.

But the ban began threatening the hospital's financial viability because prospective patients were going to competitors that were not smoke-free.

"They would say, 'Where else can I go where they'll allow smoking?' " said Richard Wohl, senior vice president. Eighteen months after the ban began, Princeton House lifted it. Now, it has four daily "fresh air" breaks in outdoor courtyards where patients can smoke, Dr. Krejci said.

"You have to understand," said Gary Snyderman, director of nursing services. "We are a health care facility, so we're not happy about it."

Some hospitals have had success offering nicotine patches and cessation programs. After the Veterans Affairs hospital in Palo Alto banned smoking, fewer patients were restrained for behavioral problems, and attempts like sticking aluminum foil in electrical outlets to light cigarettes stopped, said Dr. John Brooks, former director of inpatient psychiatry there.

And hospitals have found that while smoking calms some patients, allowing smoke breaks can increase agitation because "everybody is only thinking of when they can get that next cigarette," said Joe Parks, medical director of the Department of Mental Health in Missouri. He said patients pressure others for cigarettes, including by "bribing with sexual favors."

Douglas Tipperman, lead public health adviser on tobacco prevention for the Substance Abuse and Mental Health Services Administration, said surveys showed that smokers with mental illness often want to quit, and can with extra support. But they face stiff obstacles, including stress and fewer resources.

At Southeast Louisiana Hospital, where hospital officials requested that patients' last names be withheld, Sarah W., 55, who has paranoid schizophrenia, smoked 16 cigarettes a day, buying a carton of Hat's Off at the canteen weekly. Suffering from diabetes and high blood pressure, she tried quitting, sometimes gradually, and "sometimes I cold turkey," she said. Neither worked.

Dr. Torrey, the psychiatrist and advocate, said his sister, who had schizophrenia, died of lung disease undoubtedly related to her intense smoking. Still, he said, "if they really have no other pleasures," as he believes was true for his sister, "I personally would let them smoke, even though I understand that it hastens their death."

In San Francisco, one of Dr. Hu's patients, Garrett Masuda, has been on a roller coaster with smoking for years. After receiving a diagnosis of schizophrenia as a graduate student, he became a two-pack-a-day smoker. Smoking lessens two voices "speaking to me in a whisper," he said, and calling him "mean things, like loser."

Mr. Masuda was able to hold jobs in retail stores, but smoking interfered with his schizophrenia medication, Risperdal, and led to his being rehospitalized twice, Dr. Hu said.

One hospitalization occurred after he refused to fly home from a visit to Vancouver, convinced "people on the plane were out to get me"; another when he feared "someone was out to break into the house and hurt me," he said.

Dr. Hu increased his Risperdal, "chasing the dose up and up because of the smoking," she said.

But while Mr. Masuda had to stop smoking at Stanford Hospital, which became successfully smoke-free in 2007, he resumed smoking after he left. Even when he began working at a medical foundation with a tobacco ban, he got around it by "hot boxing," smoking in his car, windows rolled up, in the parking lot.

And ratcheting up his Risperdal dose caused problems: sleepiness and involuntary eye movements. But when Dr. Hu tried medications less affected by smoking, they worked less well. And when she combined lower-dose Risperdal with other medications, eye-rolling movements continued, interfering with Mr. Masuda's job as a Macy's cashier. Customers became unnerved, and so did he as his internal voices criticized them.

Desperate, Mr. Masuda moved in with his parents and mostly quit smoking. But he was so highly stressed that he took excessive breaks at work, and was fired. Now he is 37, unemployed and smoking. He hopes he can stop, he said, because he knows smoking "will just make it worse."