TOBACCO AND

SCHIZOPHRENIA
Mini Lecture 3
Module: Tobacco and Mental Health

Objectives of the Mini Lecture

GOAL OF MINI LECTURE: Provide students with knowledge
on the association between tobacco and schizophrenia.
LEARNING OBJECTIVES
Learners will be able to:
To describe the burden of schizophrenia, and its
association with other chronic diseases
To illustrate the biological, psychological and social factor
associated with tobacco use in schizophrenia patients
To mention how cessation can be addressed in clinical
management of schizophrenia patients.

CORE SLIDES

Tobacco and Schizophrenia

Mini Lecture 3
Module: Tobacco and Mental Health

The Burden of Schizophrenia

Schizophrenia is one of the most common psychiatric
illnesses being treated. Patient can exhibit positive and
negative psychotic symptoms leading to social and
occupational dysfunction for at least 6 months.
(Ziedonis et al., 2008)

Global burden of schizophrenia:

Median incidence: 15.2 per 100,000 population
Median prevalence: 460 per 100,000 population
Median lifetime morbid risk: 720 per 100,000 population
Median standardized mortality ratio of all cause: 2.6
(Eaton et al., 2008)

Schizophrenia and Chronic

Diseases
Schizophrenia patients have poorer health care, higher
burden of NCD risk factors and NCD premature deaths
than the general population.
Schizophrenic have 20% shorter life expectancy
Common NCD risk factors in schizophrenic: smoking,
obesity and dyslipidemia, hypertension, insulin
resistance, diabetes, sedentary life style, poor nutrition
2/3 of schizophrenia patients died of CVD vs. half of
general population
High burden of respiratory diseases due to smoking.
(Hennekens et al., 2005; Ziedonis et al., 2008)

Smoking in schizophrenia patients

Results from 42 studies in 18 countries showed that:
Smoking in schizophrenic patients is six times more common
than in general population (prevalence 70-85%)
More common in male patients (OR 7.2 in male vs. 3.3 in
female)
50% smoked more than 25 cigarettes per day
Schizophrenic patients typically puffs more and deeper when
they smoke, thus they have a higher level of nicotine and
cotinine.
Quitting rate: 9% in schizophrenia patients vs. 14-49% in
general population.
(de Leon and Diaz, 2005)

Tobacco use and schizophrenia

A complex interaction between biological, psychological, and
social factors in the association between tobacco use and
schizophrenia.
Biological factors: nicotine improves sensory gating and
visuospatial working memory
Psychological factors: patients used tobacco and its
perceived positive effects for self-treatment
Social factors: cigarettes used in social exchange and as
form of bonding - main barrier in promoting smoking
cessation in mental health institutions
(Ziedonis et al., 2008)

Treating tobacco addiction in

schizophrenia patients
Cessation is better achieved in patients with higher
motivation to quit and lower level of tobacco dependence
Combination of psychosocial treatment improves chances
that patients will quit.
The Polycyclic aromatic hydrocarbons (PAH) in cigarettes
affects the metabolisms of antipsychotic drugs, therefore the
medication has to be closely monitor during and after
quitting.
(Fagerstrom and Aubin, 2009; Ziedonis et al., 2008)

Schizophrenia treatment can

influence tobacco dependence
Typical antipsychotic (ex. haloperidol) increases smoking
Atypical antipsychotic (ex. clozapine) reduces smoking
significantly in heavy smokers. (San et al., 2007; Ziedonis et al., 2008)
Clozapine is the only atypical antipsychotic which has 5HT3
receptor antagonist activity and can improve P50 gating.
Alpha-7 nicotine receptor (7) agonist agent (ex. DMXB-A)
improves memory, P50 response, and attention. 7-agonist
is more potent and have slower decreasing response than
nicotine. (Ziedonis et al., 2008)

OPTIONAL SLIDES

Tobacco and Schizophrenia

Mini Lecture 3
Module: Tobacco and Mental Health

Tobacco use and schizophrenia:

the biological factor
Nicotine improved deficit in auditory sensory gating, led
to better filter to distracting stimuli and better focus
attention, and ultimately improving cognitive function.
Nicotine improved visuospatial working memory, led to
better visualization of relative positions of items.
Improvement of visuospatial working memory is related
to prefrontal cortical dopamine activity. Activation of
anterior cingulated and bilateral thalamus improves
visuospatial working memory.
(Ziedonis et al., 2008)

Tobacco use and schizophrenia:

the psychosocial factor
Schizophrenia patients perceived a lot of positive effects
of smoking, and smoking is used as self-treatment of
psychological symptoms. It has tremendous costs on
patients health
There are many social factors in schizophrenia patients
that leads to a higher risk of smoking and tobacco use in
the group of population.
(Ziedonis et al., 2008)

Smoking and anti-psychotic

treatments
Schizophrenia patients who smoke experience less extra
pyramidal symptoms and other antipsychotic drug sideeffects misuse of nicotine as self-medication
Polycyclic aromatic hydrocarbons (PAH) in tobacco
smoke can induce P450 1A2 isoenzyme, and affects the
metabolism of antipsychotic medications (olanzapine,
clozapine, haloperidol, and fluphenazine)
Induced P450 1A2 isoenzyme leads to lower blood levels
of antipsychotic medications among smoker.
Increased antipsychotic side effects are therefore should
be monitored during smoking cessation treatment.
(Ziedonis et al., 2008; Green, 2005)

Cessation medication in
schizophrenia patients
Combination of atypical schizophrenia treatments and nicotine
dependence treatments
Buproprion: help reducing smoking and expired air CO
Nicotine patch: safe, well-tolerated, short long-term
abstinence than expected
Nicotine nasal spray: short-term reduction in schizophrenia
symptoms and impaired cognition
There is very limited data about the effects of smoking
cessation treatment in schizophrenic patients.
(Fagerstrom and Aubin, 2009; Ziedonis et al., 2008)