COMMENTARY

Cigarette Smoking in Individuals With Schizophrenia

Michael T. Compton, MD, MPH

November 16, 2005

Overview

Cigarette smoking is the leading preventable cause of death in the United States, and it is associated with harm to nearly every organ of the body.[1] The high rates of cigarette smoking among individuals with mental illnesses, and the extremely high rates among those with schizophrenia in particular, represent an important public health challenge.

Cigarette smoking in the context of schizophrenia and other psychotic disorders is likely related to both neurobiological and psychosocial/environmental factors. Tobacco use in people with schizophrenia leads to elevated rates of physical diseases and accelerated metabolism of some antipsychotic medications (sometimes necessitating a higher dose). Impairments in motivation and stress management skills may place individuals with schizophrenia at a disadvantage when they try to abstain from smoking.

All patients should be screened for cigarette smoking, and those who do smoke should be offered smoking cessation treatments. Effective treatment options for smoking cessation include both pharmacologic agents and behavioral approaches. Ultimately, preventing the use of tobacco, both in the general population and in those with mental illnesses, will have the greatest impact in terms of reducing morbidity and mortality.

Cigarette Smoking: The Leading Preventable Cause of Disease and Death

Many chronic medical conditions, such as hypertension and cardiovascular disease, are related to cigarette smoking and other adverse health behaviors. Cigarette smoking is the leading preventable cause of the death in the United States[2] because of its association with a variety of malignant neoplasms (eg, lung cancer; cardiovascular diseases such as ischemic heart disease and cerebrovascular disease; and respiratory diseases, including chronic obstructive pulmonary disease). In 2000, approximately 435,000 deaths in the United States (18% of total deaths) were attributable to smoking.[3] Roughly 24% of men and 21% of women are current smokers. In addition to enormous healthcare expenditures, cigarette smoking is associated with remarkably high estimates of years of potential life lost, as well as an estimated $92 billion in annual productivity losses.[4]

Prevalence of Cigarette Smoking Among Individuals With Schizophrenia

Data from the National Comorbidity Survey revealed that whereas the population prevalence of current smoking among those with no mental illness was 22.5%, some 41% of those reporting a mental illness were current smokers.[5] People with mental illnesses also consumed more cigarettes -- current smokers without mental illnesses had a mean peak consumption of 22.6 cigarettes per day, compared with 26.2 by those with a mental illness. Furthermore, those with a diagnosable psychiatric disorder consume an estimated 34% to 44% of all cigarettes smoked in the United States.[5,6]

Individuals with schizophrenia in particular have extremely high rates of smoking, ranging from 58% to 90%,[7-14] with most studies finding a prevalence rate of about 90%.[15] In addition, a 2005 meta-analysis of 42 studies from 20 countries demonstrated that heavy smoking and high nicotine dependence were more frequent in smokers with schizophrenia than in smokers in the general population.[16]

Potential Explanations for the Association Between Smoking and Schizophrenia

The causes of the very high prevalence of cigarette smoking in individuals with serious mental illnesses are complex and multifactorial. Most of the literature examining reasons for the association between smoking and schizophrenia focuses on the neurobiologic effects of nicotine, such as its interactions with dopaminergic circuits.[11,13,17-19] Consuming nicotine may ameliorate some of the negative symptoms of schizophrenia, such as amotivation, anhedonia, and social isolation. Nicotine also may improve auditory gating impairments in persons with schizophrenia, which in turn may enhance attention, sensory processing, and the ability to interact with their environments.[17,18,20]

Although cigarette smoking may partially ameliorate specific psychiatric symptoms (such as negative symptoms) and cognitive measures,[21-28] the general "self-medication" hypothesis (improvement in negative, cognitive, or depressive symptoms and reduction of antipsychotic side effects) has not been supported by all studies. The higher prevalence of smoking found among individuals (before the onset of their illness) who later develop schizophrenia may further indicate that impaired nicotinic neurotransmission is involved in the pathophysiology of schizophrenia.[29]

Psychosocial factors also may contribute to the elevated prevalence of cigarette smoking among individuals with schizophrenia. For example, in past decades, smoking became an accepted part of the culture of many psychiatric treatment facilities and residential programs.[15] Thus, initiation and maintenance of cigarette smoking in the context of schizophrenia and related illnesses are probably related to both neurobiologic effects and psychosocial and environmental factors.

Consequences of Cigarette Smoking Among Individuals With Schizophrenia

Individuals with serious mental illnesses, and especially schizophrenia-spectrum disorders, have elevated rates of diseases related to smoking-related behaviors, such as chronic obstructive pulmonary disease.[30-32] Smoking also increases the metabolism of some antipsychotic medications[17,18,33] because of induction of cytochrome P450 hepatic enzymes.[34] Thus, patients with schizophrenia who smoke may require higher doses of antipsychotics, increasing their risk of experiencing side effects and adverse events.[18,23]

Another important issue related to the association between schizophrenia and cigarette smoking is that rates of successful cessation may be lower among persons with schizophrenia. At least until recently, many hospitals did not enforce smoking bans, and cigarettes were sometimes used as a positive reinforcement for treatment adherence or behavioral management.[23,26,35] Low perceived susceptibility to harmful health outcomes among patients with schizophrenia may affect motivation to quit smoking. Poor motivation and impairments in coping and stress management skills may further place individuals with schizophrenia at a disadvantage in terms of smoking abstinence.[24]

Screening and Assessment for Cigarette Smoking Among Patients With Schizophrenia

Because of the public health importance of cigarette smoking, all patients should be screened for tobacco use and offered smoking cessation treatments.[36] Using the "5 As" (ask, advise, assess, assist, and arrange) may be an effective strategy for clinicians to use to encourage their patients to quit smoking.[37] Although psychiatric patients are commonly asked about their smoking practices,[38] it appears that even among the known smokers, counseling on tobacco use is rarely provided to psychiatric patients. Data from the National Ambulatory Medical Care Survey indicate that psychiatrists offered smoking cessation counseling at only 12.4% of visits with patients who smoke,[39] suggesting that psychiatrists may be missing opportunities to offer smoking cessation counseling.

Many individuals living with schizophrenia do want to quit smoking, however, and some interventions are proving to be effective for smoking cessation in this population. Forchuk and colleagues[25] found that 40% of participants with schizophrenia indicated that they wanted to quit smoking in the near future. Motivation-enhancing techniques can be successful in moving individuals through the stages of change from precontemplation to action, and may be particularly effective with persons suffering from mental illnesses.[40,41]

Treatment Options for Smoking Cessation in the Context of Schizophrenia

Although smokers with serious mental illnesses may perceive smoking as more rewarding than do nonpsychiatric smokers,[42] several studies have documented motivation and readiness to change among individuals with schizophrenia who smoke cigarettes.[43,44] Emerging evidence also suggests that treatments (pharmacotherapy and counseling) that are documented to be effective in other clinical populations are also valuable in reducing smoking rates among individuals with serious mental illnesses.

Smoking cessation interventions should include both nicotine replacement therapies[45-47] and behavioral approaches.[41,48-52] Nicotine replacement therapy is available in gum, lozenge, inhaler, nasal spray, and transdermal patch forms.[37] The use of atypical antipsychotic agents (rather than conventional agents) and sustained-release bupropion may also be helpful.[11,13,22,49,53-55]

Smoke-free inpatient psychiatric units have been widely implemented, and these policies appear to cause no major untoward behavioral indicators or compliance effects.[56] However, the policies appear to have had little effect on smoking cessation, indicating that they need to be implemented as part of a broader program that includes smoking cessation treatments.[57]

El-Guebaly and colleagues[58] summarized the literature and concluded that across a variety of types of smoking interventions, quit-rates for psychiatric patients are only marginally lower than those for nonpsychiatric populations. Psychiatrists and other mental health clinicians should aim to help their patients achieve smoking cessation.[56,59] Recent studies suggest that the same counseling and pharmacologic treatments proven to be effective in the general population also are likely to be effective for psychiatric patients.[60] Ongoing research is examining the ways in which particular treatments need to be modified to meet the needs of individuals with psychiatric illnesses.

Prevention of Cigarette Smoking Among Individuals With Mental Illnesses

Primary prevention consists of engaging in health promotion or specific protective interventions that modify risk factors to reduce the incidence of disease. Because tobacco use is such an important risk factor for a number of diseases, the primary prevention of cigarette smoking itself (preventing the initiation of smoking) is an admirable population-based goal. Most smokers begin using tobacco before the age of 21 years, and the greatest impact on preventing smoking-related morbidity and mortality in the general population will likely come from campaigns targeting youth.[61,62] Anti-smoking media campaigns and taxing tobacco products are effective in reducing cigarette consumption in the general population.[62-65] Public health strategies for reducing tobacco use among individuals with serious mental illnesses should begin to incorporate population-based strategies to reduce the initiation of tobacco use.

Conclusions

Clinicians should be aware of the magnitude of the problem of cigarette smoking among individuals with serious mental illnesses, and especially in those with schizophrenia and related psychotic disorders. Many patients want to quit smoking but have difficulty doing so because of a number of obstacles, including the potentially beneficial effects of nicotine in terms of symptoms and cognitive functioning and psychosocial factors that may promote ongoing smoking. Nonetheless, clinicians should screen patients for cigarette smoking, assess their readiness for cessation,[66] work with them to enhance motivations for quitting, and provide proven, effective cessation treatments, including nicotine replacement therapy, sustained-release bupropion, and behavioral approaches. In doing so, patients will benefit through improved physical health and reduced mortality.

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