Smoke, Smoke, Smoke That Cigarette

256 Perspectives in Psychiatric Care Vol. 42, No. 4, November, 2006

Blackwell Publishing IncMalden, USAPPCPerspectives in Psychiatric Care0031-5990© Blackwell Publishing 2006June 2006424

ORIGINAL ARTICLE

Biological Perspectives


Smoke, Smoke, Smoke That Cigarette

Norman L. Keltner, EdD, RN, and Joan S. Grant, DSN, RN, CS

Smoke! Smoke! Smoke that cigarette!Puff, Puff, Puff and if you smoke yourself to deathTell Saint Peter at the Golden GateThat you hate to make him waitBut you’ve just got to have another cigarette.

—Merle Travis

I

n 1947, Tex Williams recorded a Merle Travis songentitled

Smoke, Smoke, Smoke That Cigarette

. The songsaved Williams’s declining career. He died of cancerin 1985 after a lifetime habit of smoking two packsper day. While the general public’s taste for cigarettesmoking has declined steadily over the past fewdecades, the rate of smoking among people withschizophrenia has not. In 1965, 42% of Americanssmoked; today that number is about 20% (NationalCancer Institute, 2006). However, people withschizophrenia smoke at a considerably higher rate,with some researchers suggesting a threefold ormore increase in this habit. Data from some studiesindicate that 80% or more people with schizophreniasmoke (Cohn, Prud’homme, Streiner, Kameh, &Remington, 2004; Esterberg & Compton, 2005; Goffet al., 2005; Kuehn, 2006; Patkar et al. 2002; Sherman,2005). Personal experience and anecdotal reports sug-gest such a conclusion is indeed probable.

McEvoy (2005) points out that schizophrenics not onlysmoke more, they smoke “harder,” with significantlyhigher plasma nicotine levels achieved than in non-schizophrenic smokers. Smoking behaviors includemore puffs per cigarette, shorter puff intervals, andlarger puff volumes (Tidey, Rohsenow, Kaplan, &Swift, 2005). These behaviors may relate to a poor eco-nomic status among schizophrenics, creating the needto make every costly cigarette count (see Case Example).

Smoking and Schizophrenia

It ain’t cuz I don’t smoke ‘em myselfAnd I don’t reckon that it’ll hinder your healthI smoked ‘em all my life and I ain’t dead yet

The public health and legislative efforts of the 1966Surgeon General report and the Public Health CigaretteAct signed by President Nixon have had little effect onsmoking behaviors of people with schizophrenia.About half of all cigarettes sold in America are soldto people with mental disorders (Breslau, Novak, &Kessler, 2004). More specifically, schizophrenic patientssmoke cigarettes at a much higher rate than the gen-eral population (de Leon & Diaz, 2005) and spend adisproportionate amount of their income (

∼

20%) onthis addiction (Steinberg, Williams, & Ziedonis, 2004).

Case Example

Paul W. is a 47-year-old man diagnosed with schizo-phrenia. He lives in a board and care facility in ruralAlabama that provides shelter and three meals a day.After the facility is paid from Paul’s SSDI check, he isgiven $12 per week from which he must buy clothing,treats, sodas, fast food, over-the-counter medications,toiletries, and cigarettes. He spends almost all of hisallowance on the latter with the few remaining dollarsspent on sodas. While $12/week is a paltry sum foranyone, Paul’s strategies to make this money stretchare defeated by his addiction to cigarettes. Paul spendsmuch of his time at the Day Treatment Centerattempting to cajole peers into giving him one of theirprecious smokes.

Smoking is a lifestyle choice substantially compro-mising the health of people with schizophrenia and ishighly correlated to other comorbid illnesses found inthis population. This heavy smoking leads to a higherincidence of smoking-related conditions. For example,heart and respiratory disease deaths are 30% and 60%more likely among people with schizophrenia, respec-tively (Baxter, 1996; Dalack, Healy, Meador-Woodruff,& Dalack, 1998). Osby, Correia, Brandt, Ekbom, and

Norman L. Keltner, EdD, RN, and Joan S. Grant, DSN, RN, are Professors in the School of Nursing at the University of Alabama at Birmingham.

Perspectives in Psychiatric Care Vol. 42, No. 4, November, 2006 257

Sparen (2000) state this increase in mortality is doublethe general population’s rate, attributing many ofthese deaths to higher suicide rates among peoplewith schizophrenia. In fact, people with schizophreniaare 10 to 20 times more likely than the general popula-tion to commit suicide. However, more than two-thirdsof people with schizophrenia compared to almosthalf of the general population die from coronary heartdisease (Hennekens, Hennekens, Hollar, & Casey,2005).

Why Do People with Schizophrenia Smoke?

But nicotine slaves are all the sameAt a pettin’ party or a poker gameEverything gotta stop while they have a cigarette

People with schizophrenia initially smoke for thesame reasons other people smoke, including socialpressures (e.g., “its cool,” peer influence, others aroundthem smoke), cultural dimensions of smoking (e.g., somegroups and families smoke more than others [VanDongen, 1999]), and pragmatic reasons (e.g., smokingmay diminish boredom). Superimposed on theabove is the reality that smoking can provide structureto unstructured parts of a day. For example, non-schizophrenic people smoke when they drink alcohol,presumably after sex, and as a time filler. Smokingalso seems prevalent among individuals engaged inmundane and/or repetitive jobs and provides peoplewith something to do in otherwise awkward orpotentially anxious situations. It is not overreaching tosuggest most, if not all, of the above applies to individ-uals with schizophrenia, as well.

But people with schizophrenia may have evenmore compelling reasons to smoke. Nicotine causes anincrease in synaptic dopamine and it is thought thatpeople with schizophrenia may smoke to compensatefor downregulated dopamine expression and receptorbinding in some brain areas. Specifically, nicotinemodulates dopaminergic tracts that project to both limbicand prefrontal cortical areas (an area of downregulation).

Dopaminergic stimulation causes improved mood,sharpened cognition, and decreased appetite—all desir-able effects. Conversely, smoking cessation is linked toan irritable mood, mental dulling, and a soaring appetite.The latter is particularly noteworthy because peoplewith schizophrenia taking atypical antipsychotics tendto put on considerable weight (Keltner, 2006). A perfectstorm of antipsychotic-driven appetite enhancementand smoking cessation holds potential for even moreextravagant weight gain.

Dopamine cell bodies are located in the ventraltegmental area, just posterior to the substantia nigraof the midbrain. Nicotine enhances the release ofdopamine by stimulating nicotinic receptors in thispart of the brainstem. This modulatory activity signalsthe release of a greater amount of dopamine at theaxon terminal. Perhaps fortunately, nicotinic receptorsare not “on” all the time as they periodically sink backinto the postsynaptic membrane, temporarily render-ing themselves inaccessible to nicotine (Stahl, 2000).If this were not the case, their addictive capabilitieswould increase significantly.

The mesolimbic tract contains the reward pathway—a pathway always stimulated by abused substances.Theoretically, all pleasurable feelings result from aburst of dopamine bathing dopamine receptors of thenucleus accumbens—the end subcortical nuclei in thissystem. Since nicotine modulates dopamine projectionsthat “feed” the mesocortical tract as well, prefrontalfunctions such as cognition, inhibition, planning, andmotivation are modified. People often comment ona sharpened mental acuity when smoking. It is notmuch of a stretch to suggest schizophrenic patients,who suffer from cognitive dulling over time, may gaina favorable mental response too.

The dopaminergic–tracts paradigm essentially arguesthat motivation and pleasure are mesocortical andmesolimbic tract functions, respectively. The study ofnicotinic influences on the schizophrenic mind sug-gests a less dichotomous “division of labor,” however.As can be demonstrated, motivation is linked to bothprefrontal and limbic function. For example, activation



of the reward pathway is clearly motivating and as theability to experience reward/pleasure increases, apathy,motivation, depressed mood, and perhaps thinkingimprove as well.

Schizophrenic patients probably smoke for the abovestated reasons, but also for reductions in disease-related symptoms. McEvoy (2005) suggests the loss ofnormal auditory gating also can contribute directly toshort attention spans and auditory hallucinations inthese patients. In other words, whereas the generalpopulation may be able to screen out even the mostobtrusive background noise (e.g., living near an air-port), the person with schizophrenia may struggle toscreen out even low levels of environmental

noise.

Thislack of screening ability contributes to debilitatingattention problems and hallucinations (McEvoy).Nicotine may correct this deficit and may partiallyaccount for high rates of smoking among theseindividuals (Adler et al., 1998; Postma et al., 2006). Infact, Myers et al. (2004) found a significant improvementin the ability to screen out intrusive sounds amongsmokers when compared to nonsmokers in people withschizophrenia. McEvoy speculates inadequate gatingfor sensory and motor stimuli that disrupt perceptionsand motor programming is amenable to nicotinicstimulation in those respective areas. This improvedgating should allow these individuals to perceive theirenvironment more accurately and to engage in smoothermotor functions (see Table 1).

Conceptually, nicotinic enhancement of dopamineis not without problems however. The original bio-chemical hypothesis of schizophrenia proposed exces-sive levels of dopamine caused this psychosis—theso-called dopamine hypothesis of schizophrenia. Asour understanding of the four dopaminergic tractsdeveloped, this hypothesis was refined to imply thathyperdopaminergia of a single tract, the mesolimbictract, caused positive symptoms of schizophrenia. Ifthis were true, then one would suspect an increase inpositive symptoms associated with smoking. Whilethis might occur, psychological benefits of smoking(i.e., improvement in negative/cognitive symptoms)apparently outweigh this otherwise deleteriousconsequence.

What Is a Nurse to Do?

Evidently, beyond the addictive qualities of cigarettes,people with schizophrenia enjoy unique benefits thatspecifically modify unpleasant and debilitating symp-toms of their disorder. Nonetheless, cigarette smokingleads to a number of comorbid medical conditionsthat both compromise health and shorten lifespan. Thequestion posed is simple in its elegance: is the short-termquality of life (symptom improvement and enjoymentvia smoking) more important than long-term qualityof life (a life with fewer chronic health problems)?

Though we live in an era where smoking has suf-fered terrible public relation setbacks, there are manypsychiatric nurses and psychiatrists who think ifsmoking brings pleasure, albeit briefly, into the life ofa person with schizophrenia, then smoking should bepermitted.

Most psychiatric nurses, however, would hold tothe view that something so damaging as smokingcannot be justified, whatever the supposed short-termbenefits. This view is dominant and is in concert withpublic opinion. Further tangible support comes fromlong-term health outcome studies that clarify eliminat-ing even one risk factor can produce a significantpayback in long-term health (Wilson et al., 1998).

Table 1: Putative Positive Effects of Smoking in Schizophrenia

Improved cognition (Friedman, Stewart, & Gorman, 2004; Sacco, Bannon, & George, 2005)

Improved negative symptoms (Adler et al., 1998; Postma et al., 2006)

Protective effects against extrapyramidal symptoms (Decina et al., 1990; Salokangas et al., 1997)

Improved auditory gaiting (Adler et al., 1998; McEvoy et al., 2005)

Improved memory and attention (Sacco et al., 2005)


Perhaps almost as compelling is the fact that cigarettesmoking decreases the effect of many antipsychoticdrugs related to enzyme induction (this is not a nico-tine-driven consequence). Hence, smoking cigarettescompromises both health and treatment. For thesenurses, smoking reduction or cessation is the onlyreasonable goal for people with schizophrenia.

Smoking Cessation

The 2000 Public Health Service Clinical PracticeGuideline,

Treating Tobacco Use and Dependence

, providesrecommendations for evidence-based smoking cessa-tion treatments, with long-term abstinence rates of upto 25%. In the general population, sustained releasebupropion hydrochloride and nicotine replacementtherapy are effective medications. Furthermore, coun-seling programs as well as social support providedboth as part of and outside of treatment are effective(Fiore, Bailey, & Cohen, 2000). Person-to-person contact(i.e., individual, group, or proactive telephone coun-seling) is consistently effective (Fiore, 2000).

Bradshaw, Lovell, and Harris (2005) recognize theinadequacy of empirically based programs to assistpeople with schizophrenia to either reduce or stopsmoking. Despite the need to expand this research,there also are promising interventions for people withschizophrenia to assist them in quitting smoking.Potential promising strategies used either alone orin conjunction with another therapy for people withschizophrenia include sustained–release bupropionhydrochloride (Evins, Cather, et al., 2005; Swan, Valdes,Ring, et al., 2005), nicotine replacement therapy (Chou,Chen, Lee, Ku, & Lu, 2004; Els, 2004), atypical antipsy-chotic agents (George et al., 2000), and cognitivebehavioral therapy (Evins et al., 2004; Sacco, Bannon,& George, 2005). In general, treatments using two ormore strategies are better than those using only oneintervention. For example, abstinence rates are betterwhen combining sustained–release bupropion hydro-chloride with either nicotine (Ziedonis, Wyatt, & George,1998) or cognitive behavioral therapy (Evins et al.,

2004). Although this research is limited, long-termsmoking cessation rates (i.e., >2 years) of 22% for schiz-ophrenics are comparable to the general population(Evins et al., 2004) (also see Table 2).

Psychiatric nurses can make essential contributionsby assessing for symptoms and recommending healthpromotion activities related to the serious consequences(e.g., cardiovascular, pulmonary, cancer) of smokingfor people with schizophrenia and their families. Moni-toring routine diagnostic tests related to these healthproblems (e.g., chest X-rays, EKGs, lipid levels) areimportant. Encouraging healthy habits related todiet (e.g., reduced fat intake) and individualizedprescribed exercise programs that are based on bothphysical and psychiatric health problems also arevaluable. Furthermore, when people with schizophreniatry to quit smoking, assessment by mental healthprofessionals is essential related to nicotine withdrawalsymptoms, obfuscating or exacerbating symptoms ofschizophrenia. Dosages of psychiatric medicationsmay need adjusting because of increased serum levelsof these drugs.

In conclusion, smoking is a major health problemfor people with schizophrenia. Psychiatric nurses cancontribute significantly by providing relevant infor-mation about smoking and its health consequences,determining whether schizophrenics wish to quitsmoking and encouraging them to do so, monitoringfor symptoms related to nicotine withdrawal, and

Table 2. Either Single or Combination Smoking Cessation Strategies

Sustained–release bupropion hydrochloride (Welbutrin SR) (Evins, Cather et al., 2005; Evins, Deckersbach et al., 2005; Swan et al., 2005)

Nicotine replacement therapy (e.g., nicotine transdermal patch, gum) (Chou et al., 2004; Els, 2004)

Atypical antipsychotic agents (e.g., risperidone [Risperdal]), olanzapine [Zyprexa]) (George et al., 2000)

Cognitive behavioral therapy (Evins, 2004; Sacco, Bannon, & George, 2005)



encouraging participation in individualized healthpromotion activities.

Author contact [email protected] with a copy to the Editor:[email protected]

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Smoke, Smoke, Smoke That Cigarette