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To quantify the extent to which smokers with indicators of poor mental health receive smoking cessation support in primary care consultations compared with those without.Cross-sectional study within a database of electronic primary care medical records.A total of 495 general practices in the United Kingdom contributing data to The Health Improvement Network (THIN) database.A total of 2 493 085 patients aged 16+ registered with a THIN practice for the year from 1 July 2009 to 30 June 2010.The proportion of patients with a diagnostic Read code or British National Formulary (BNF) drug code indicating a mental health diagnosis or psychoactive medication prescription, respectively, who smoke and who have cessation advice or a smoking cessation medication prescription recorded during consultations within the 1-year study period.Of 32 154 smokers, 50.6% [95% confidence interval (CI): 50.0–51.2] with a mental health diagnosis and 49.3% (95% CI: 49.0–49.7) of 96 285 smokers prescribed a psychoactive medication had a record of cessation advice, higher than the prevalence of advice recording in smokers without these indicators (33.4%, 95% CI: 33.3–33.6). Similarly, smoking cessation medication prescribing was higher: 11.2% (95% CI: 10.8–11.6) of smokers with a mental health diagnosis and 11.0% (95% CI: 10.8–11.2) of smokers prescribed psychoactive medication received a prescription, compared with 6.73% of smokers without these indicators (95% CI: 6.65–6.81). Smoking cessation support was offered in a lower proportion of consultations for smokers with indicators of poor mental health than for those without. Advice was recorded in 7.9% of consultations with smokers with a mental health diagnosis, 8.2% of consultations with smokers prescribed psychoactive medication and 12.3% of consultations with smokers without these indicators; comparable figures for prescribing of cessation medication were 2.9%, 3.2% and 4.4%, respectively.Approximately half of smokers with indicators of poor mental health receive advice to quit during primary care consultations in the United Kingdom, and one in 10 receive a cessation medication. Interventions are lower per consultation for smokers with mental health indicators compared with smokers without mental health indicators.