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The Link Between Smoking and Schizophrenia

Medically Reviewed by Melinda Ratini, DO, MS on May 12, 2022

If you have schizophrenia, you are more likely than others to smoke cigarettes. While the numbers vary, some reports say that more than 80% of people with schizophrenia smoke. That’s compared with about 12% of adults in the U.S. as of 2020. While these numbers change over time and depend on where you look, it’s clear there’s a link between schizophrenia and smoking.

While many people have stopped smoking in recent years, if you have schizophrenia you may find it harder to stop. Public health efforts to get more people to quit haven’t put much of a dent in the smoking rates for people with schizophrenia.

The reasons why people with schizophrenia tend to smoke and have trouble quitting aren’t entirely clear. Biology, psychology, and social factors probably all play some role. In other words, it’s complicated. Researchers are still studying these questions to see what they can learn and how it might help more people with schizophrenia avoid smoking or quit.

Does Smoking Cause Schizophrenia?

It’s possible.

There is some evidence that smoking may raise your risk of schizophrenia. People who smoke more also have a higher risk than those who smoke less. People who later develop schizophrenia often smoked before their diagnosis.

Why? It’s possible that the effects of nicotine in the brain and release of dopamine, a neurotransmitter that plays a role in how we feel pleasure, might somehow increase the risk for schizophrenia. But people who smoke often use other substances, too, so it’s hard to say.

Most people who smoke don’t get schizophrenia, but it’s still possible that smoking raises the risk. One study in Israel showed that the risk of developing schizophrenia more than doubled in those who smoked more than 10 cigarettes a day compared with nonsmokers. Other studies suggest that people who develop psychosis often smoked heavily before their symptoms of mental illness start.

Still, it’s hard to say which comes first – smoking or schizophrenia. The evidence that smoking is a cause of schizophrenia isn’t conclusive.

Could the Link Between Schizophrenia and Smoking Be Genetic?

Yes, this might be a factor, too. The genes you carry do influence your risk of schizophrenia. They also influence your chances of taking up smoking. There’s some evidence that these genes may overlap. If true, then people who are more likely to get schizophrenia based on their genetics may also be more likely to smoke for the same reason. But the evidence on this is somewhat mixed.

Is Smoking a Way to Self-Medicate?

Many doctors believe that people with schizophrenia might smoke as a way to self-medicate. But it’s still not really clear how this works or if it’s true. When you smoke a cigarette, nicotine from the tobacco goes into your bloodstream. This makes glands above your kidneys release adrenaline. As a result, your blood pressure, breathing, and heart rate go up. Adrenaline makes you feel good.

Nicotine also affects your brain. Nicotine may help with some of the changes in the brain when you have schizophrenia. For example, if you have schizophrenia, you’ll have less activity in a part of the brain called the prefrontal cortex. This part of the brain is important for making decisions and solving problems. It also plays a role in memory. One study showed that nicotine might help to restore activity in this part of the brain.

But the study was done on mice, not people. Still, the findings led researchers to suggest that nicotine might be used to treat schizophrenia. If that’s true, it could help explain why people with schizophrenia so often smoke.

Other studies support the idea that smoking may improve memory and the ability to focus in people with schizophrenia. Receptors in the brain that respond to nicotine often don’t work as well when you have schizophrenia. Those changes can mean you have differences in brain chemistry, including lower levels of dopamine. Nicotine might help boost these levels.

Some research also suggests that smoking may help with certain side effects of medicines you may take for schizophrenia, such as involuntary movements you can’t control

But not everyone thinks that smoking really helps people with schizophrenia feel or function better. For one thing, people with schizophrenia who smoke the most tend to have worse symptoms than those who smoke less. A study in China also found that people with schizophrenia who smoke more often end up in the hospital.

Studies of people with schizophrenia who smoke compared with those who’d quit also found no difference in their symptoms. There’s no evidence either that people with schizophrenia who quit end up with worse symptoms.

Still, if you have schizophrenia and you smoke, you may have a harder time stopping than other people. Even if smoking seems to help with your symptoms, it’s still a good idea to quit given all the health problems it can cause. Talk to your doctor; they may be able to help you quit and reassure you that quitting won’t make your schizophrenia symptoms worse.

Smoking, Schizophrenia, and Social Factors

People with schizophrenia often have other risk factors for smoking. These include:

  • Less education
  • Low income
  • Not having a job
  • Having a positive view of smoking
  • Lack of support to quit

Most hospitals don’t allow smoking now, but this wasn’t always true. Mental health services also sometimes did things in the past that encouraged smoking. For instance, giving out “tobacco tickets” as a reward.

Smoking for people with schizophrenia is often a social activity. You may smoke out of boredom. It may be a way to manage stress. Whether smoking actually helps schizophrenia symptoms or not, many people may think that it does. They may see smoking as something that is their choice and that’s within their control. All of these factors make it more likely that people with schizophrenia will smoke. They also make it harder to stop.

How to Quit Smoking When You Have Schizophrenia

If you have schizophrenia, it’s still a good idea, and possible, to quit. One study of young people with a psychotic illness found that a 12-week program including medicine, motivational interviewing, and behavior change techniques worked in about 1 in 4 people. The study was small, but it shows that interventions to help you quit smoking if you have schizophrenia can work.

Most studies of treatments to stop smoking haven’t included people with schizophrenia or other mental health problems. But interventions to stop smoking are safe and can work when you have schizophrenia.

One report suggests taking varenicline or bupropion (Aplenzin, Wellbutrin XL), both approved to help people stop smoking. Either medicine can be taken with or without nicotine replacement therapies such as a nicotine patch. It’s best to have behavior therapy, too. Treatment to help you stop smoking should last at least 12 weeks, but it may be better to keep at it for a year. Ask your doctor if they can help or refer you to a program to stop smoking.

If you or a loved one has schizophrenia and wants to stop smoking, you’re not alone. Most people with a serious mental illness who smoke say they want to stop. It’s not easy for anyone to quit smoking, but proven methods to help people quit can help you, too.

Show Sources

SOURCES:

CDC: “Smoking & Tobacco Use.”

Drug and Alcohol Dependence: “Prefrontal Cognitive Dysfunction is Associated with Tobacco Dependence Treatment Failure in Smokers with Schizophrenia.”

Asian Journal of Psychiatry: “Worldwide prevalence of smoking cessation in schizophrenia patients: A meta-analysis of comparative and observational studies.”

Psychiatry: “Smoking and Schizophrenia.”

Current Opinions in Psychiatry: “Smoking in schizophrenia: recent findings about an old problem.”

Nature Medicine: “Nicotine reverses hypofrontality in animal models of addiction and schizophrenia.”

BJPsych Advances: “Tobacco smoking and schizophrenia: re-examining the evidence.”

Journal of Dual Diagnosis: “Smoking, Genetics and Schizophrenia: Evidence for Self Medication.”

International Review of Neurobiology: “Effective Cessation Strategies for Smokers with Schizophrenia.”

National Institute on Drug Abuse: “Mind Matters: The Body's Response to Nicotine, Tobacco and Vaping.”

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