Mental illness and smoking cessation

Prevalence

On average, smoking is three times more prevalent among people with schizophrenia, than the general population.

Smoking rates among the mentally ill are not declining commensurate with the general population. Overseas data collected since the early 1980s showed that smoking rates among the mentally ill maintained a consistency around 80%, while among the general population they dropped by 4.2% to 29.1%.¹

Very little research has been done in Australia. One study conducted at the Centre for Young People's Mental Health in Parkville, Victoria, found that 75% of their sample were smokers.² Other research conducted in an outpatient setting in Melbourne reported that 76% of those surveyed were smokers.³ These findings contrast with the general Australian population, of whom approximately 25% are smokers.⁴

In overseas studies, gender differences in smoking patterns have been found. More men than women with schizophrenia smoke. Men are more likely to smoke more than 20 cigarettes per day and prefer high tar cigarettes. More men than women had been smoking for longer than 16 years.⁵

Interactions with the illness

Smoking is linked with greater severity of psychotic symptoms. Smokers have an earlier onset of schizophrenia and require a greater number of hospitalisations than non-smokers.⁵

People with schizophrenia who smoke tend to require larger doses of neuroleptic medication to gain a therapeutic effect than non-smokers.⁵ Because of this they may experience increased side effects such as movement disorders. Interestingly, the agents in cigarettes suggested to be responsible for the increased metabolism of neuroleptic medication are the tumour initiators in tar.

Preliminary research indicates that new atypical antipsychotic medication is associated with reduced smoking rates. Further research is required to validate these findings.⁶

In contrast, nicotine is said to have some beneficial effects on schizophrenia. Nicotine increases dopaminergic activity in the brain. Decreased dopaminergic activity in particular parts of the brain is said to be one of the factors responsible for the negative symptoms of schizophrenia - such as lack of motivation, active coping, environmental attention and engagement and emotional responsivity.⁷

Because of these beneficial effects, it can be suggested that people with schizophrenia are medicating themselves. Smoking provides the fastest route for nicotine into the brain (it takes approximately eight seconds) and appears to offer temporary relief of symptoms. Research is equivocal on the long term effects of nicotine on brain function, with some concern that it actually decreases dopaminergic activity.⁷

Two of the major causes of death in this group, pneumonia and cardiovascular diseases are smoking related. Smoking is also closely related to alcohol abuse, which is a major unnatural cause of death among people with schizophrenia.⁸

Effectiveness of smoke free policies and staff attitudes

Anecdotal evidence in Australian hospitals suggests that inpatients are ‘inadvertently' reinforced for their smoking by taking time out from the pressures of the wards in the smoking section outside.

Historically, staff have used cigarettes as rewards and there is some evidence that this continues and that staff may resist quit smoking messages because they believe that "it is one of their (patients) only pleasures".

Research indicates that smoking staff tend to expect and experience more problems with implementing smoking bans than non-smoking staff.⁹

While hospitals have introduced smokefree policies, smoking remains a problem for staff and management. Reports include staff time required to monitor patients who try to smoke indoors; the fire risk of clandestine smoking; and the requirement to build special balconies so that inpatients could smoke at night and yet not be at risk of suicide.

In addition, with many of the mentally ill homeless, in boarding houses or in the family home, such policies and zones have less impact on smokers and increase the risks of passive smoking to those with whom they live. The problems of passive smoking are rendered invisible and fragmented because policies do not extend into the wider community.

Community concerns

There is considerable concern that current measures to reduce smoking through increasing prices are hurting people with schizophrenia, without commensurate efforts to assist them to quit. Recent figures suggest that people with schizophrenia are spending up to 35% of their income on smoking.

Current quit smoking strategies may fail to influence people with schizophrenia because the strategies are aimed at rational decision makers who are influenced by social reinforcers. Schizophrenia can affect the information processing capabilities required in receiving and responding appropriately to information about the dangers of smoking.³

Quitting and reducing the uptake of smoking is easier when smoking becomes inconvenient and disliked by one's peers. With such high smoking prevalence rates, it is clear that the social forces which have helped so many people in the general population to quit have not penetrated this group.

A number of studies found that people with schizophrenia report smoking because it relieves boredom and offers opportunities to socialize when 88% of them are unemployed and isolated. However, smoking is an expensive, physically damaging and stigmatising way of meeting these needs.

References

1. US Department of Health and Human Services. Reducing the Health Consequences of Smoking. 25 years of Progress. A Report of the Surgeon General. Rockvill, Maryland: US Department of Health and Human Services, Public Health Service, Centers for Disease Control, Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 1989.
2. Elkins K, Curry C, Harrigan S, McGorry P. Cigarette smoking and psychosis: the first episode experience. Mental illness and smoking cessation: an urgent public health issus. Forum proceedings 19 November 1996. Carlton South, Vic: Victorian Smoking and Health Program, 1997.
3. Polgar S, McGartland M, Hales T. Cigarette smoking and schizophrenia: a public health issue. Aust J Primary Health Interchange 1996; 2: 21-28.
4. Hill D, White V. Australian adult smoking prevalence in 1992. Aust J Public Health 1995; 19: 305-308.
5. Goff D, Henderson DC, Amico E. Cigarette smoking in schizophrenia: relationship to psychopathology and medication side effects. Am J Psychiatry 1992; 149 : 1189-1194.
6. George TP, Sernyak MJ, Ziedonis DM, Wood SW. Effects of clozapine on smoking in chronic schizophrenic outpatients. J Clin Psychiatry 1995; 56: 344-346.
7. Lohr JB, Kirsten F. Smoking and schizophrenia. Schizophrenia Research 1992; 8 : 93-102.
8. Haefner H, Bickel H. Physical morbidity and mortality in psychiatric patients. In: Ohman R et al. (ed.) Interaction between mental and physical illness: needed areas of research. Berlin; New York: Springer-Verlag, c1989.
9. Smith WR, Grant BL. Effects of a smoking ban on a general hospital psychiatric service. Hospital and Community Psychiatry 1989; 40: 497-502.