Improve patients’ health, help them kick addiction with this practical approach.

Mr. V, age 49, has stable but symptomatic schizophrenia and a 33-year cigarette smoking history. He is very concerned because his primary care physician told him he has 2 serious smoking-related health problems: diabetes and hypertension. He tried a smoking cessation program for the general public, but it was a poor fit because of his schizophrenia symptoms.

Despite adhering to his medications (ziprasidone, 20 mg hs; perphenazine, 8 mg hs; lorazepam, 1 mg hs; zonisamide, 200 mg/d, and benztropine mesylate, 2 mg hs), Mr. V has residual auditory hallucinations, paranoid ideation, and impaired concentration and attention. He smokes approximately 1.5 packs per day, particularly when very ill, to alleviate chronic boredom, and to diminish distress from the hallucinations. All of his friends smoke, and they do not support his attempts to quit.

Obstacles to smoking cessation for schizophrenia patients

Smokers with schizophrenia are more nicotine-dependent, more likely to become medically ill, and less likely to receive help in quitting, compared with the general population. They:

 
•   begin smoking at a higher rate before diagnosis or treatment for schizophrenia, compared with persons who do not go on to develop the disorder  
• smoke each cigarette more intensely, extracting more nicotine per cigarette  
• have higher rates of smoking-related illness and medical morbidity  
• are much less likely to receive physician advice to quit smoking.

Many persons with severe mental illness are misinformed about the risks and benefits of smoking vs nicotine dependence treatment. They often fear and overestimate the medical risks of nicotine replacement therapies. Many believe smoking relieves depression and anxiety, whereas nicotine actually is anxiogenic. Nicotine may improve some aspects of cognitive dysfunction in schizophrenia, which could be a disincentive for patients to quit smoking.

This article reviews these empiric studies and suggests practical ways for clinicians to create smoking cessation and relapse prevention plans for individuals with schizophrenia.

Successfully treating nicotine dependence can seem a formidable challenge in patients with schizophrenia:

 
•   72% to 90% smoke cigarettes, compared with 21% of the general population  
•   They tend to smoke heavily, spending about one-third of their incomes on cigarettes.  
•   Their negative symptoms (such as apathy), positive symptoms (such as disorganized thinking), and cognitive impairment can reduce motivation to quit and adhere to a smoking cessation strategy.  
•   Sociologic and physiologic aspects of schizophrenia reinforce their smoking habit

Even so, smokers with schizophrenia can be highly motivated and persistent in attempting to quit. Promising results have been reported in trials when psychopharmacologic treatments are combined with cognitive and behavioral interventions.

Jennifer D. Gottlieb, PhD
Schizophrenia clinical and research program, Massachusetts General Hospital, Instructor in psychiatry, Harvard Medical School

A. Eden Evins, MD, MPH
Schizophrenia and depression clinical and research programs Director, Center for Addiction Medicine and addiction research program, Massachusetts General Hospital, Assistant professor of psychiatry Harvard Medical School

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