What is the evidence for smoking in people with schizophrenia?

Moderate to high quality evidence found small effects of more severe positive symptoms and less severe extrapyramidal symptoms in smokers with schizophrenia compared to non-smokers with schizophrenia. There were no differences in negative symptoms, depression, anxiety, tardive dyskinesia, or parkinsonism.

Moderate quality evidence suggests the most commonly reported reasons for smoking were relaxation/stress reduction, dysphoria relief, sociability, craving/addiction. The most commonly reported reasons for quitting were self-control, health concerns, social influence. The following factors were identified as barriers to smoking cessation: cravings and addiction, perceived risk of negative affect, social pressures, stress and boredom reduction, and weight management. Knowledge about health risks of smoking, physician advice and social pressures to quit helped facilitate smoking cessation.

Craving scores were higher in people with schizophrenia and a substance use disorder (tobacco, cannabis, or cocaine) compared to people without schizophrenia and a substance use disorder. Scores were greater for relief (desire for the reduction of negative effects of withdrawal) than reward (desire for the rewarding effects of drugs).

There was a medium-sized effect of reduced clozapine blood levels in smokers compared to non-smokers with schizophrenia. Clozapine dose was higher in the smoking group; those who quit smoking could have clozapine dose decreased.

High quality evidence found small impairments in attention, working memory, learning, reasoning/problem solving, and speed of processing in smokers vs. non-smokers with schizophrenia. There were no differences in delayed memory, executive functioning (abstraction/shifting or inhibition), or language.

March 2022

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Drug and alcohol use, abuse, or dependence are concerns for people with mental disorders due to their association with poor clinical and social outcomes such as high rates of suicide, HIV, homelessness, aggression, and incarceration. Comorbid substance use places additional burden on patients, families, psychiatric services, and government resources due to high rates of treatment non-adherence and relapse.

Tobacco smoking is also very common and poses considerable health risks, potential interference with the metabolism of psychotropic medications, and financial burden. Heavy cigarette use may contribute to the increased mortality and reduced life expectancy reported within the mental illness population.

What is the evidence for substance use in people with PTSD?

Moderate to high quality evidence finds a medium-sized increased rate of current smoking in people with PTSD, with the effect largest in males aged 20-30 years. Higher rates of drug and alcohol misuse were found in people with more severe PTSD symptoms compared to people with less severe PTSD symptoms. PTSD symptoms include intrusions, avoidance, hyperarousal, and negative thoughts and mood.

In prisoners with PTSD, there was a small to medium-sized increased rate of substance use disorders when compared to prisoners without PTSD. Rates were highest in male prisoners, in adult prisoners, and in prisoners with any lifetime rather than current PTSD diagnosis.

August 2021

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Tobacco smoking is very common among people with schizophrenia, who often show particularly heavy usage. This poses considerable health risks, may interfere with antipsychotic medications and may place a financial burden on the individual. Heavy cigarette use may contribute to the increased mortality and reduced life expectancy reported within the schizophrenia population.

What is the evidence for medications for smoking cessation?

Moderate quality evidence finds medium-sized effects of more smoking cessation with bupropion or varenicline than with placebo, assessed at 3-month follow-up. Varenicline also reduced the number of cigarettes smoked per day and resulted in more abstaining smoking behaviour.

October 2020

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Tobacco smoking is very common among people with a mental illness, who often show particularly heavy use. This poses considerable health risks, potential interference with the metabolism of medications, as well as financial burden for the individual. Heavy cigarette use may contribute to increased mortality and reduced life expectancy.

What is the evidence for smoking?

Moderate to high quality evidence suggests small to medium-sized, increased rate of smoking in people with bipolar disorder compared to the general population, and compared to people with major depression. There was a small decreased rate of smoking in people with bipolar disorder compared to people with schizophrenia.

Moderate to low quality evidence suggests varenicline (champix/chantix) may reduce rates of smoking.

October 2021

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Tobacco smoking is very common among people with schizophrenia, who often show particularly heavy usage. This poses considerable health risks, may interfere with antipsychotic medications and may place a financial burden on the individual. Heavy cigarette use may contribute to the increased mortality and reduced life expectancy reported within the schizophrenia population. This topic considers the evidence for the rates of smoking among people with schizophrenia. Please also see the topic on the effects of smoking on the course and outcomes of the disorder.

What is the evidence for smoking?

Moderate quality evidence suggests around 65% of people with schizophrenia have a tobacco use disorder or nicotine dependence, with rates higher in males than females.

Compared with the general population, moderate quality evidence finds higher rates of current smoking, heavy smoking, and lifetime smoking, and lower rates of smoking cessation in people with schizophrenia, with the prevalence of smoking cessation in people with schizophrenia is around 14%.

People with first-episode psychosis, and those at ultra high-risk of psychosis also show higher rates of smoking than the general population, with rates of ~57% and ~33% respectively. There is also a medium-sized increased risk of psychotic disorders, and an earlier age of psychosis onset in smokers compared to non-smokers.

Compared with people with other mental disorders, moderate quality evidence suggests people with schizophrenia show a small to medium-sized effect of higher rates of current smoking, and lower rates of smoking cessation.

March 2022

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