Why Do Schizophrenics Smoke Cigarettes?




Psychiatry and Psychology CategoryFor health care workers in psychiatric hospitals, it is no secret: one of the major issues confronting psychiatric facilities seeking to institute blanket no-smoking policies concerns chronic inpatients with schizophrenia. Patients with schizophrenia are almost always heavy cigarette smokers, given a choice. As Edward Lyon wrote in an analysis of studies and surveys performed throughout the 1990s: “Many patients in psychiatric hospitals would smoke two, three, or even four packs of cigarettes a day if an unlimited supply of cigarettes were available.”

Generally, the rate of inpatient smoking among schizophrenics is three to four times higher than the general smoking population. In one British study of 100 institutionalized schizophrenics cited by Lyon, 92% of the men and 82% of the women were smokers. Moreover, schizophrenics smoke more cigarettes per day than other smokers do, and they commonly smoke high-tar, unfiltered cigarettes — niche brands for heavy smokers used by only 1% of the total smoking population.

CigarettesAustralian research performed in 2001 found that because of high rates of smoking, “people with mental illness have 30% more heart disease and 30% more respiratory disorders,” according to Ann Crocker, now a professor of Clinical Psychiatry at McGill University.

Not only do an estimated 80% of schizophrenics smoke, compared to roughly 25% of the total adult population, psychiatric facilities report that depressives and those with anxiety disorders also smoke in great numbers.

Why?

The review of studies through 1999, undertaken by Lyon and published in Psychiatric Services, shows unequivocally that schizophrenic smokers are self-medicating to improve processing of auditory stimuli and to reduce many of the cognitive symptoms of the disease. “Neurobiological factors provide the strongest explanation for the link between smoking and schizophrenia,” Lyons writes, “because a direct neurochemical interaction can be demonstrated.”

Of particular interest is the interaction between nicotine and dopamine in the nucleus accumbens and prefrontal cortex.  Several of the symptoms of schizophrenia appear to be associated with dopamine release in these brain areas. A 2005 German study concluded that nicotine improved cognitive functions related to attention and memory. “There is substantial evidence that nicotine could be used by patients with schizophrenia as a ‘self-medication’ to improve deficits in attention, cognition, and information processing and to reduce side effects of antipsychotic medication,” the German researchers concluded.

In addition, the process known as “sensory gating,” which lowers response levels to repeated auditory stimuli, so that a schizophrenic’s response to a second stimulus is greater than a normal person’s, is also impacted by cigarettes.  Sensory gating may be involved in the auditory hallucinations common to schizophrenics. Receptors for nicotine are involved in sensory gating, and several studies have shown that sensory gating among schizophrenics is markedly improved after smoking.

There is an additional reason why smoking is an issue of importance for health professionals. According to Lyon, “Several studies have reported that smokers require higher levels of antipsychotics than nonsmokers. Smoking can lower the blood levels of some antipsychotics by as much as 50%…. For example, Ziedonis and associates found that the average antipsychotic dosage for smokers in their sample was 590 mg in chlorpromazine equivalents compared with 375 mg for nonsmokers.”

Smoking among inpatient psychiatric patients is not trivial. Neither is the decision to institute smoking bans in psychiatric hospitals, a move that is understandably unpopular with patients.

References

Lyon, E. (1999). A Review of the Effects of Nicotine on Schizophrenia and Antipsychotic Medications. Psychiatric Services, 50, 1346-1350.

Cattapan-Ludewig, K. (2005). Why do schizophrenic patients smoke? Nervenarzt, 76 (3), 287-294.

Mueser, K., Crocker, A., Frisman, L., Drake, R., Covell, N., & Essock, S. (2005). Conduct Disorder and Antisocial Personality Disorder in Persons With Severe Psychiatric and Substance Use Disorders Schizophrenia Bulletin, 32 (4), 626-636 DOI: 10.1093/schbul/sbj068

Adler, L., Hoffer, L. Wiser, A. (1993). Normalization of auditory physiology by cigarette smoking in schizophrenic patients. American Journal of Psychiatry, 150, 1856-1861.

  • Jordan Embree

    As, I had a short 4-day trip to the mental hospital I can attest, almost all of the smoked. Low blood sugar and high caffeine consumption are also common among mental patients. Personally I think there is a link here.

  • http://addiction-dirkh.blogspot.com Dirk Hanson

    Low blood sugar and high caffeine intake are also characteristic of many active alcoholics and other addicts.

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  • http://theaddictionchannel.com/ Jon Heller

    Nice job breaking it down…

    Not mentioned is the supposed release of seratonin during repetitive motions (i.e, hand to mouth). As someone who has spent time on both sides of the desk, smoking, chewing gum, rubbing your forearm… any of these would usually bring a small amount of comfort. And when you’re waiting for the meds to work, a small amount of comfort is as good as all the comfort in the world…

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  • Murfomurf

    I don’t know how psychiatric clinics and hospitals could consider no-smoking policies for their patients- it’s so obvious it’s self medication, and most psych patients will tell you quite unequivocally how it makes them feel/not feel. I think most ordinary human beings in the community eventually smoke to self-medicate, even if they started for a dare as a teenager. At the psychiatric hospital and general hospital psych wards here in South Australia there are smoking areas and rooms especially for patients, which I think is a humane provision. However, patients tell me that they feel discriminated against and almost “criminalised” because they must smoke in special places, instead of in their own living rooms or bedrooms as many can do at home. They say that having their smoking stigmatised makes it more difficult for them to recover from their psychotic episodes which have brought them into hospital- so what can be done? They don’t want to stop smoking- the behaviours involved are habitual and serve multiple purposes for them; they need the nicotine (whatever it does to their brains, lungs, blood vessels); some feel smoking is a part of their core self image. On the other hand, many of these mentally ill people live in group accommodation with other unemployed and disabled people- they have very low incomes/pensions, yet they spend a terrific amount on tobacco/cigarettes- many supported accommodation hostels actually make rollie cigarettes in vast numbers for the residents- or residents are employed to roll them- just to save a little money. It seems to me we have to study the role of nicotine and smoking behaviour more thoroughly to see if it is possible to humanely divorce mentally ill people from their habits without destroying any remaining capacity for wellness.

  • http://addiction-dirkh.blogspot.com Dirk Hanson

    Amen to that. I do think that smoking areas in clinics are a workable compromise that both patients and staff should learn to accept. It’s not stigmatizing smoking so much as accomodating those who are allergic to or discomfited by cigarette smoke. What stigmatizes smoking and adds to the recovery burden of patients is a blanket ban on smoking on the premises, no exceptions allowed. That might work in an office building, but presents added health dimensions in a hospital for the mentally ill.

  • Joe Smith

    Something is missing here, and that is social interaction. In closed environments, and especially those with people whose ability to communicate may be compromised by illness or medication, there are very few ways of making or maintaining friendships. I have seen cigarettes used as gift exchange between patients in mental hospitals – not just for the chemical effect, which I do not doubt, but also because the physical offering and accepting of cigarettes provides a non-verbal way of establishing a relationship.

    It’s worth noting that people in these institutions may have no other gift to give; even the gift of time may be deeply compromised if people are unable to pay attention, sit quietly, or have enough concentration to focus on a chain of conversation. Simply saying “Want a cigarette? Thank you” may be the only meaningful communication they have with fellow patients.

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  • http://intentions.wordpress.com Jane

    One useful thing I took from this article. If you are one of those poor souls who is under an assisted outpatient treatment order then you are being medicated against your will. Antipsychotics are dangerous brain, gland and nervous system damaging drugs that are standard issue now for people with bipolar and schizophrenia.

    It’s good to know that smoking can severely diminish the effects of antipsychotics. If I was under an AOT order the first thing I would do is pretend that the sedation and stupidity inducing effects of the antipsychotic were much worse then they were in order to be put on a low dose. Then I would start smoking again and I would smoke all day in the hope I could feel my old self again and have my faculties, memory, artistic inspiration and cerebration back.

  • http://daedalus2u.blogspot.com/// daedalus2u

    Nicotine is not the only pharmacologically active substance in tobacco smoke. Carbon monoxide is something that should be considered too. CO does have cross-talk with many heme containing proteins that are the receptors for nitric oxide. The EC50 for NO on sGC is ~ 10 nM/L, less than a ppb by wt. Enough CO ia inhaled during smoking to significantly populate heme proteins with CO.

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  • Alex Jenson

    Very interesting article.
    The primary reason I believe patients smoke is as a form of comfort and stress relief.
    When you feel overwhelmed by the psychosis you are going through, smoking is the one thing that can connect you to the mundane, ordinary world that you have become so disconnected from. It is a physical process and you also view it as a ‘normal’ activity. It helps you to feel that you are not so much different to anyone else, and it also helps provide structure to your day…(lack of structure being one of the root caues of schizophrenia I think). If you have a mental routine where you know where and when you are going to smoke, this provides a little more structure and routine – important elements in surviving any period of time in the mental health system. While smoking is obviously unhealthy, I don’t believe that patients should be denied access to them simply because they are under mental health care. If they have not gone voluntarily, the removal of cigarettes will probably cause alot of mental distress. Even voluntary patients should be permitted to smoke. When you are in the depths of psychosis, unhealthy as it might be, it is still an important lifeline. I don’t smoke at all now, but back in 1999 when I was very poorly, it would have been unthinkable to be denied a cigarette at one of the lowest points of my life.

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  • Maria

    When I was on haloperidol and rendered into a state of complete zombification,there was only one tiny window in the day when I felt like the happy, alive person I was before the onset of my psychotic episode and the ensuing forced medication.It was when I smoked my first cigarette of the day. Even though it was 30 years ago, and I was only on the drug for 3 months, that memory of my brief moment of happiness each morning is still as vivid as if it were yesterday. .

  • Edahn

    This was a big issue when I was working in the California State Hospital system as an advocate. One other reason there’s so much smoking is because state hospital life is totally restrictive. Smoking a cigarette is one of the few activities patients can engage in in private that has a somewhat meditative quality. Listening to music — another cherished activity — is another. An interesting study, imo, would be to look at smoking rates of patients IN THE SAME HOSPITAL with schizophrenia and non-schizophrenia diagnoses and see if there’s a difference.

  • http://www.ukcia.org Derek Williams

    It’s long been of interest to me that there exists such an obvious link between tobacco smoking and serious mental illness, yet there has never – to my knowledge – been any suspicion of there being a causal link between tobacco use and the illness.

    During the recent cannabis and mental health scare great play was made of the claim that cannabis altered the dopeamine balance in the brain and for a while this was suggested as a possible causal mechanism., yet this was never mentioned in respect of tobacco.

    Whilst it’s important of course to remmeber that a correlation of use of a particular substance and metnal illness doesn’t imply a causal role, the correlation betwen tobacco use and mental illness is far greater than any such correlation for cannabis.

    Is there any research which looks at the rates of severe mental illness amongst young people who started smoking as young teenagers? I’m not aware of any but it would be interesting to see if psychosis rates are higher amongst young smokers than non-smokers.

  • JHoff

    Its well known that before anti-psychotics nicotine was a treatment for psychosis and schizophrenia. If the mentally ill respond so well to it, why don’t they combine nicotine with therapy? There are other ways to get nicotine. I have a brother who is schizophrenic, and when he was well he hated smokers. He now smokes as much as he can. Its sad. I wouldn’t even think of asking him to quit. Obviously he sees a benefit. Can’t the health care community see the benefit and make this healthier?

  • http://addiction-dirkh.blogspot.com Dirk Hanson

    It’s not a terribly popular idea, but I think that schizophrenics and the alzheimer’s-prone elderly might benefit from the use of nicotine patches as maintenance medicine.

  • http://www.mrclay.org/ Steve Clay

    This sounds like a population which could really benefit from e-cigarettes.

  • http://www.allaboutaddiction.com Mirjam

    It is interesting to think about the relationship of a mental illness, such as schizophrenia, to cigarette smoking. I would like to read more about it.

  • maxwood

    I note that it took months and over 20 comments before Steve Clay finally appeared and mentioned e-cigarettes. As the technology develops, e-cigarettes permit exact titration of nicotine (or other ingredients) as needed, supply the psychological comforts of handling a cigarette, and are inoffensive enough that they should reasonably be exempt from smoking bans.

    Edahn (Oct. 4, ’09) also had an excellent idea concerning music. Consider that even merely listening permits acquiring a structured memory of tunes and compositions which supplies some of the experience of having relations with a family. (Symphony– the word could mean “similar to a family”– contains examples of interrelations between tunes, themes, movements, instrumental timbres, etc. which exercise the family perception.)

    Now add the obvious and very inexpensive (compared to some of those drugs) recourse of supplying a collection of instruments to which patients can have access, and hopefully whatever leadership assistance is needed to form an orchestra in which patients can participate and cooperate in a joint creation of quasi-family experience. And blowing a clarinet sure beats sucking on a hot burning overdose cigarette.

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  • http://trtrtrukfteftgvcsdfgv.com Marchelle Luvene

    Awsome info and straight to the point. I don’t know if this is truly the best place to ask but do you guys have any ideea where to hire some professional writers? Thank you :)

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  • Frank Tsu

    The brain receptors that are associated with nicotine addiction are also in play with schizophrenics.
    http://www.dailyrx.com/news-article/why-smoking-calms-schizophrenia-11392.html
    The brain receptors called alpha-7 subunit are found reduced in schizophrenics.

  • PolymathCDP

    First of all, I like smoking, and will not quit by choice. Second of all, the hospital is boring to the point of being abusive and smoking ameliorates that. Thirdly, restricting a person’s choices for no proven reason is an harassment unrelated to treatment, other than it is likewise unlawful.

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  • leeanne macpherson

    ok 1st of all i am a smoker,not a heavy smoker yet i still smoke,my son has recently been diagnosed with schizophrenia and i have noticed the increase in his smoking habits.If what i am reading is true there should be somewhere within the complex where they should be able smoke for relaxation,instead of having to go out on the streets where at this time they do not feel safe being.

  • Aine

    Nicotinic acid, also known as vitamin B3 or niacin, has been found to be very helpful in quitting addiction to nicotine. Look up the pamphlets that Bill Wilson, AA founder, wrote about niacin and addiction. High doses of niacin treat schizophrenia. See the work of Abram Hoffer, MD, for studies about the efficacy of niacin for nicotine addiction, schizophrenia, and depresson and anxiety.

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  • Elenore

    Thank you!

Dirk Hanson, MA

Dirk Hanson, MA, is a freelance science writer and the author of "The Chemical Carousel: What Science Tells Us About Beating Addiction." He is also the author of ''The New Alchemists: Silicon Valley and the Microelectronics Revolution.'' He has worked as a business and science reporter for numerous magazines and trade publications. He currently edits the Addiction Inbox blog, and is senior contributing editor for the addiction and recovery website, The Fix.
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