Smoking Widespread Among Institutionalized Schizophrenics

March 16, 2011 (Vienna, Austria) — The overwhelming majority of institutionalized schizophrenic patients smoke, supporting the need for in-house smoking cessation programs, new suggests.

Presented here at EPA 2011: 19th European Congress of Psychiatry, the study showed that 96 of 100 institutionalized patients with schizophrenia smoked and slightly more than 20% of these individuals smoked more than 30 cigarettes a day.

"Smoking cessation programs need to be implemented in order to help institutionalized schizophrenics kick the habit," Shashi K. Agarwal, MD, an internist in private practice in East Orange, New Jersey, told Medscape Medical News.

"Smoking is frequently ignored and even encouraged by the institution staff who maintain that smoking keeps the residents occupied and thereby less disruptive.

Dr. Shashi K. Agarwal (left) and Neal K. Agarwal (right)

"Withholding cigarettes is often used as a punishment for noncompliance, and, conversely, an extra cigarette is sometimes dangled as a reward for a positive action," he said.

He added that patients also claim that smoking helps them combat boredom.

Dr. Agarwal and coauthor Neil K. Agarwal, a biomedical engineering student at Rutgers University in Piscataway, New Jersey, interviewed 100 consecutive schizophrenic patients who resided in a community-based boarding home about their smoking history.

Study participants were 18 years or older and had been referred for their annual physical examinations. All patients were undergoing psychiatric care.

High Rates of Lung Cancer, Cardiovascular Disease

Research has shown that 41% of psychiatric patients in the United States smoke cigarettes, which is twice the rate in patients without a psychiatric diagnosis. Psychiatric patients have been found to inhale more deeply and have higher levels of nicotine metabolites in their blood.

Smoking is particularly problematic in schizophrenic patients. In fact, about 70% to 85% of noninstitutionalized schizophrenic patients are smokers. Multiple factors, including genetic, biochemical, socioeconomic, cultural, and environmental, contribute to nicotine addiction in this population.

Smoking reduces the negative psychotic symptoms and delays or prevents the onset of extrapyramidal side effects as a result of nicotine-mediated regulation of dopaminergic transmission in the mesolimbic and nigrostriatal systems. Thus, smoking is often a form of self-medication in these patients, whereas abstinence from cigarettes often leads to behavioral deterioration.

However, patients also have much higher rates of physical morbidity and mortality. Smoking-related illnesses, such as lung cancer and cardiovascular disease, are 2 to 6 times more common in patients with chronic psychiatric disorders. It may shorten their lifespan by as much as 25 years compared with the general population.

Call to Action for Psychiatrists

Overall, 96 of 100 patients reported that they were current smokers. Thirty-two active smokers (33%) said they smoked up to 10 cigarettes per day, 42 (44%) said they smoked up to 20 cigarettes per day, whereas 22 (23%) said they smoked 30 or more cigarettes per day.

Dr. Agarwal called on psychiatrists to actively encourage institutionalized schizophrenics to curb their smoking.

"Studies suggest that reduction or even cessation of smoking in schizophrenia patients can be achieved in noninstitutionalized schizophrenics, and we believe that positive results can be achieved in the institutionalized population as well," he said.

Concrete smoking cessation advice should be offered during psychiatric counseling on a regular basis, he said. The nicotine patch or gum, when used on a long-term basis, appears to be effective.

He also noted that smoking bans have been successfully implemented in psychiatric hospital inpatient units and added that similar strategies should be adopted in residential psychiatric institutions.

"Such measures will not only improve the physical health of these patients but also protect the staff and visitors from the deleterious effects of second-hand smoke," he said.

Butting Out 'Essential'

"The finding that patients with schizophrenia who are institutionalized smoke more cigarettes per day than other patients is interesting, but it is not surprising," Dolores Malaspina, MD, Anita and Joseph Steckler Professor of Psychiatry and Environmental Medicine at NYU Langone Medical Center, New York City, told Medscape Medical News.

"It is possible that smoking susceptibility is a marker for a more severe illness course or a subtype of the disease, which goes along with the need for institutionalized care. These patients may also have more boredom and/or less motivation, which might reflect institutionalization or be illness variants that also led to the institutionalization."

Given extremely high rates of cardiovascular death in patients with schizophrenia, it is essential that measures be discovered to reduce smoking rates in these people, she said.

Neither of the study authors nor Dr. Malaspina has disclosed any relevant financial relationships.

EPA 2011: 19th European Congress of Psychiatry: P03-168. Presented on March 15, 2011.

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