Epidemiology and Significance of the Problem

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Several epidemiological and clinical studies since the 1980s have documented the high rates of cigarette smoking in psychiatric patients, particularly those with schizophrenia-related disorders (Chong and Choo 1996; de Leon et al. 1995; Diwan et al. 1998; el-Guebaly and Hodgins 1992; George et al. 1995; Goff et al. 1992; Hughes et al. 1986; Kelly and Mc-Credie 1999; Masterson and O'Shea 1984; McEvoy and Brown 1999; Menza et al. 1991; O'Farrell et al. 1983; Ziedonis et al. 1994).

This work was supported in part by grants R01-DA-13672, R01-DA-14039, and K12-DA-00167 to Dr. George from the National Institute on Drug Abuse (NIDA), and a Wodecroft Young Investigator Award to Dr. George from the National Alliance for Research on Schizophrenia and Depression (NARSAD).

Although smoking rates in the general population have substantially declined from 45% in the 1960s to about 25% currently (Vocci and DeWit 1999), rates of smoking in chronic psychiatric patients, especially those with schizophrenia, continue to be very high. In fact, one recent community-based study suggested that nearly 45% of all cigarette consumption in the United States is by individuals with mental disorders (Lasser et al. 2000). Surveys of cigarette smoking in schizophrenia in a myriad of inpatient and outpatient settings in several nations have found prevalence rates of 32%-92% (Table 5-1), with the variability in smoking rates attributable to such factors as disease chronicity, smoking accessibility, and social prohibitions on smoking behavior. What is not clear from these studies is the proportion of outpatient schizophrenic smokers that meet DSM-IV-TR criteria (American Psychiatric Association 2000) for nicotine dependence, because most studies have been conducted in treatment settings in which the likelihood of nicotine dependence is higher, whereas there is a paucity of data from structured surveys in community samples.

Although such dependence data are lacking, the generally high smoking prevalence noted in schizophrenia and other psychiatric populations may relate to an increased vulnerability to tobacco use and inability to achieve smoking cessation. This is particularly concerning because rates of smoking-related illnesses such as cardiovascular disease and certain cancers appear to be higher in patients with schizophrenia than in the general population (Lichtermann et al. 2001). Hence, there is an urgent need to address tobacco addiction in this population through the development of effective treatments, both pharmacological and psychosocial. A better understanding of the biology of tobacco addiction in schizophrenic patients may assist in the development of better treatments for tobacco use in this vulnerable population.

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