the high rates of smoking in schizophrenia is a problem that should be handled by the psychiatrists

1. WALID SARHAN F. R. C. Psych.

2.  Jordan 47%males 6%female
 Tunisia 56%males 6.6% females
 Saudi Arabia 22%males 2.2%females
 Algeria 33.9% males2.4% females
 Egypt 37.6% males 0.5 %females
 22%of the world's population aged 15+ are
smokers.
WHO

3. The hookah (also known as the
water pipe, shisha, nargileh, arghileh
or hubble-bubble) poses a special tobacco
problem in the Middle East.
Epidemic in young females

4.  Reported prevalence rates of smoking
range from 56% to 88% Schizophrenics
tend to smoke high-tar cigarettes,
inhale more deeply, and smoke for
longer periods of time.
(Kelly&McCreadie 2000)
4

5.  In the past cigarettes have been used in
hospitals as rewards.??
 High rates of unemployment , decreased
amount of social activities and general
boredom may contribute to smoking in
schizophrenia.
 Some patients may use smoking as a form
of self medication to relieve negative
symptoms or even EPS.

6.  People with schizophrenia who smoke
require higher doses of neuroleptics than
nonsmokers.
 Nicotine may increase the plasma clearance
for some antipsychotic medications.
 It has also been demonstrated that
smoking may reduce the effect of
benzodiazepines.

7.  Psychiatric outpatients (n=271); Hughes, 1986
 Smokers (%)
◦ Schizophrenia 88
◦ Mania 70
◦ Major depression 49
◦ Anxiety disorder 47
◦ personality disorder 46
◦ Adjustment disorder 45
◦ Controls (n=411) 30

8.  Increased propensity to dependence
 Illness modulation effect
 Side effect reduction
 Immediate self-medicating effect
 Social factors

9.  Aspects of the illness might lead more
patients to smoke
 Smoking might be an etiological factor
in schizophrenia
 Genetic and/or environmental factors
might lead both to nicotine addiction
and to schizophrenia

10.  Dopamine (DA) system
 Mesolimbic Dopamine system
◦ Ventral Tegmental Area (VTA)
◦ Nucleus Accumbens (NAc)
◦ Projections to Medial Prefrontal Cortex

13.  Schizophrenia
◦ Hypoactivity of the Mesocortical tract- midbrain
(VTA) to frontal and DLPFC causes negative
symptoms
 DA activation in reward pathways from drugs
 More reinforcing
 Negative symptom relief

14.  Heavy smoking common (>25 cpd)
 Highly nicotine dependent
◦ Fagerstrom measures of nicotine dependence in the
moderate to severe range (6-7)
 Rapid smoking (2 or more cigarettes within
10-minute periods)
 Smoking cigarettes completely to butts

15. It has been proposed that
smokers with schizophrenia
are more efficient smokers,
who absorb more nicotine per
cigarette than do smokers
without this disorder.

16. ◦ Major nicotine metabolite
◦ Stable compound
◦ Half-life 16 hours
◦ Easy to measure in body fluids for 3-
5 days after nicotine exposure.
◦ Less dependent on the time to last
cigarette than is nicotine.

17.  One objective of this study was to
measure serum nicotine and cotinine
levels in 100 smokers with
schizophrenia and schizoaffective
disorder and to compare these to
control smokers without mental
illness.

18.  Cotinine and nicotine levels of smokers with
schizophrenia and schizoaffective disorder
were 1.3 times higher than control smokers
without major mental illness
 3HC: Cotinine ratios were not different
between groups
 Diagnosis of schizophrenia predictor of
higher cotinine level
(Williams et al., in press, Schizophrenia Research)

19.  Cigarettes perhaps beneficial in
performing simple, timed,
repetitive, tasks
 Reaction time
 Attention
◦ (finger tapping, visual search)
(Andersson, 1975, Stevens, 1976, Gonzales &
Harris, 1980, Wesnes and Warburton, 1984)

20.  Smokers do worse on complex tasks
◦ tasks of manipulation of short term memory
(working memory),
◦ long term memory
◦ comprehension
 At heavy task demands and complex problem
solving, performance deficit is most
pronounced
 Non-smokers outperform smokers in many
tasks

21.  Abstinent schizophrenics worse visuospatial
working memory (George 2002)
 Improved verbal memory with high dose
NNS (Smith 2002)
 Improved working memory with nicotine
patch and increased (fMRI) activation in
anterior cingulate and bilateral thalamus
(Jacobsen 2004)
 Lack of improvement in verbal memory with
nicotine gum/patch (Levin 1996; Harris 2004)

22.  Smokers with schizophrenia spent
median $142.50 (range $57-319)/
month on cigarettes
 Median public assistance benefit was
$596
 27.36% of monthly income on
cigarettes
(Steinberg, Williams and Ziedonis, Tobacco Control
2004)

23.  The life expectancy of patients with
schizophrenia is approximately 20%
shorter than that of the general
population
 Smoking-related fatal disease is more
prominent than in the general
population
(Brown et al., 2000; Br J Psychiatry)

24.  Higher standardized mortality
rates than the general population
for
◦Cardiovascular disease 2.3x
◦Respiratory disease 3.2x
 Both of which highly linked to
smoking

25.  Smoking must be implicated in the
increased mortality in schizophrenia
 Smokers require higher doses of
antipsychotic medication
 A substantial proportion of the income of
smokers with schizophrenia is spent on
cigarettes
 Patients with schizophrenia have to be
offered treatment for their nicotine
addiction

26.  Reframing our assumptions
Don’t want to quit Low motivation
Can’t quit Lack skills to quit
It’s all they have Enabling
It helps them Illness modulating
They will become Ignorance and fear
violent

27.  Biological Factors
 Psychological Factors
 Social Factors
 Knowledge Deficit/ Cognitive
Factors
 Institutional Factors

28.  Motivational assessments and interventions
 Slow pace, repetition
 Alternative goals, eventual abstinence
 Focused skill building, role plays
 Relapse prevention skills
 Strengthen self-efficacy
 Psychoeducation
 Support

29. - among a cohort of chronic institutionalized
schizophrenic patients, smoking cessation and
reduction outcomes were not correlated with
NRT dose, and the cessation rate was much
lower than rates in similar studies.
- It indicates that long-term hospitalized
schizophrenic patients have more difficulties
with quitting smoking. More effective integrative
moking cessation programs should be
Hsing-Kang Chen et al
European Archives of Psychiatry and Clinical Neuroscience
February 2013, Volume 263, Issue 1, pp 75-82

30.  Bupropion and CBT (Evins et al)
 12 weeks Bupropion 150mg QD and weekly
group
 N=19
 Abstinence (CO<9)
 Reduction in smoking
◦ >50% reduction in cpd
◦ >30% reduction in CO level

31.  18 (n=19) completed 6 months study
 CBT attendance was 86%
 One bupropion patient abstinent at 12 weeks
 None placebo group
 66% bupropion reduced smoking
11% placebo group reduced smoking
No difference in positive symptoms
between groups

32.  This evidence supports that currently
recommended doses of nicotine
replacement therapy are inadequate
for many smokers
 In heavy smokers, this under dosing
may be one of the reasons for the
limited efficacy of transdermal
nicotine

33.  Rapid absorption
 Rapid onset of action
 More immediate craving relief
 Dosed intermittently
 Pulsatile delivery of nicotine that more
closely mimics smoking a compared to
the patch.
 NNS effective in highly dependent
smokers
 ? More desirable for persons with
schizophrenia

35. 78 Smokers with Schizophrenia / Schizoaffective
Dx
At least 10 cigarettes per day
Not currently in tobacco dependence treatment
Motivational
Interviewing
N=32
Psychoeducation
N=34
Minimal Control
N=12
One week and one month post-intervention
follow-up by R.A. blind to treatment condition
Steinberg ML, Ziedonis DM, Krejci JA, Brandon TH. Motivational Interviewing With Personalized
Feedback: A Brief Intervention for Motivating Smokers With Schizophrenia To Seek Treatment for
Tobacco Dependence. Journal of Consulting & Clinical Psychology, in press.

36. 25.8%
32.3%
0.0%
11.4%
0.0% 0.0%
0%
5%
10%
15%
20%
25%
30%
35%
Motivational (N=32) Psychoeducational
(N=34)
Control (N=12)
Figure 1. Percentage of participants receiving each intervention following up on
referral to tobacco dependence treatment at one-week and one-month post-
intervention
One-Week One-Month
Steinberg ML, Ziedonis DM, Krejci JA, Brandon TH. Motivational Interviewing With
Personalized Feedback: A Brief Intervention for Motivating Smokers With Schizophrenia To
Seek Treatment for Tobacco Dependence. Journal of Consulting & Clinical Psychology, in
press.

37. Interventions for smoking
cessation and reduction in
individuals with schizophrenia
Daniel T Tsoi,Mamta Porwal,Angela C Webster
Cochrane Tobacco Addiction Group
Published Online: 28 FEB 2013
Assessed as up-to-date: 10 JAN 2013
DOI: 10.1002/14651858.CD007253.pub3
Copyright © 2013 The Cochrane Collaboration. Published by John
Wiley & Sons, Ltd.

38. Interventions for smoking cessation
and reduction in individuals with
schizophrenia
Our review supports the effectiveness of
bupropion for smoking cessation in
patients with schizophrenia.
The evidence is relatively weak with
wide confidence intervals, especially for
longer-term benefit, because of the low
number of participants
Daniel T Tsoi, Mamta Porwal, Angela C
Published Online: 28 FEB 2013
Assessed as up-to-date: 10 JAN 2013
DOI: 10.1002/14651858.CD007253.pub3
Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

39. Interventions for smoking cessation and
reduction in individuals with schizophrenia
We found no evidence of any significant
deterioration of mental state secondary to use of
bupropion in people with schizophrenia.
Bupropion use in individuals with schizophrenia
did not increase the risk of seizure. The evidence
for bupropion as an aid to smoking reduction in
people with schizophrenia is inconclusive.
Daniel T Tsoi, Mamta Porwal, Angela C
Published Online: 28 FEB 2013
Assessed as up-to-date: 10 JAN 2013
DOI: 10.1002/14651858.CD007253.pub3
Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

40. Interventions for smoking cessation and
reduction in individuals with
schizophrenia
• We also found some evidence in support of varenicline
for smoking cessation among individuals with
schizophrenia.
• Compared with the bupropion trials, the number of
participants is lower and the evidence weaker with
wider confidence intervals.
• There is no evidence at present to suggest that the
varenicline's effectiveness will last in the longer term.
Daniel T Tsoi, Mamta Porwal, Angela C
Published Online: 28 FEB 2013
Assessed as up-to-date: 10 JAN 2013
DOI: 10.1002/14651858.CD007253.pub3
Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

41. Interventions for smoking cessation and
reduction in individuals with
schizophrenia
There is no evidence that varenicline worsens
symptoms in schizophrenia, there is some
concern about serious adverse events such as
suicidal ideation or behaviour among
schizophrenia patients on varenicline.
Based on the current data, we do not think
this possibility can be fully ruled out.
Daniel T Tsoi, Mamta Porwal, Angela C
Published Online: 28 FEB 2013
Assessed as up-to-date: 10 JAN 2013
DOI: 10.1002/14651858.CD007253.pub3
Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

42. Interventions for smoking cessation and
reduction in individuals with
schizophrenia
There is some evidence that rewards using
money may increase smoking cessation
and reduction rates among people with
schizophrenia.
However, we do not find any evidence for a
sustained effect, after the rewards are
withdrawn. For other drug treatments
(including NRT) and psychosocial
interventions, we did not find sufficient
convincing evidence in to support their use
in clinical practice.

43.  Advances in Psychiatric Treatment (2000) 6: 327-331 doi: 10.1192/apt.6.5.327
 Effects of cigarette smoking on spatial working memory and attentional deficits in
schizophrenia: involvement of nicotinic receptor mechanisms (June, 2005)
 Nicotinic effects on cognitive function: behavioral characterization,
pharmacological specification, and anatomic localization (October, 2005)
 Nicotine improves delayed recognition in schizophrenic patients. (March, 2004)
 Effects of nicotine on cognitive deficits in schizophrenia (2004)
 Nicotinic treatment for cognitive dysfunction (2002)
 Development of nicotinic drug therapy for cognitive disorders. (March, 2000)
 Normalization of auditory physiology by cigarette smoking in schizophrenic
patients (December, 1993)
 Effects of smoking abstinence on visuospatial working memory function in
schizophrenia (January, 2002)
 Search on "Google Scholar" for "schizophrenia nicotine" research

44.  Kelly c.,McCreadie R. Cigarette smoking and schizophrenia,
Advances in Psychiatric Treatment (2000) 6: 327-331 doi:
 Addington, J., el-Guebaly, N., Campbell, W., et al (1998) Smoking
cessation treatment for patients with schizophrenia. American
Journal of Psychiatry, 155, 974–976.
 Hughes, J. R., Hatsukami, D. K., Mitchell, J. E., et al (1986)
Prevalence of smoking among psychiatric outpatients. American
Journal of Psychiatry, 143, 993–997.
 Cullen K.R., et.al Cigarette smoking and white matter
microstructure in schizophrenia Psychiatry Research:
Neuroimaging, Volume 201, Issue 2, 28 February 2012, Pages
152–158.
 Zhang X.Y.,Cigarette smoking, psychopathology and cognitive
function in first-episode drug-naive patients with schizophrenia:
a case-control studyPsychological Medicine, available on
CJO2012. doi:10.1017/S0033291712002590.
 Cooper J.,Tobacco smoking among people living with a psychotic
illness: the second Australian survey of psychosis. Aust N Z J
Psychiatry. 2012 Sep;46(9):851-63. doi:
10.1177/0004867412449876. Epub 2012 May 29.

45. Daniel T Tsoi, Mamta Porwal, Angela C
Published Online: 28 FEB 2013
Assessed as up-to-date: 10 JAN 2013
DOI: 10.1002/14651858.CD007253.pub3
Copyright © 2013 The Cochrane
Collaboration. Published by John Wiley & Sons,
Ltd.

46. www.walidsarhan.net