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8/9/2019 The Correlation Between Smoking and Schizophrenia
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Abstract
Introduction: In schizophrenia, the number of patients who smoke is very high,
nearly three times the rate in the general population and higher than the elevated rates
of smoking in patients with other psychiatric illnesses. Usually they start smoke at
mid teens and start before their illness began. Patients with schizophrenia who smoke
are also heavier smokers than those in the general population and those with other
psychiatric disorders.
Discussion: They are three possibility why patient with schizophrenia smoke
at excessive
rates. The three possibility are something about the illness leads patients
to smoke; smoking is another risk factor for schizophrenia; or a third factor leads to
both schizophrenia and smoking.
Conclusion: As we know, smoke will affect patients life. Smoke influence the
health, financial and social life of patient with schizophrenia. So, cessation smoking in
schizophrenia, will be a challenge to improve quality life of the patient.
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Introduction
Schizophrenia is a clinical syndrome of variable, but profoundly disruptive,
psychopathology that involves cognition, emotion, perception, and other aspects
behavior. The expression of these manifestations varies across patients and over time,
but the effect of the illness is always severe and is usually long lasting. The disorder
usually begins before age 25, persists throughout life, and affects person of all social
class. (6)
Cigarette smoking is a major preventable cause of disease worldwide.
According to The World Health Organization (WHO), there are one billion smokers
worldwide, and they smoke six trillion cigarettes a year. The WHO also estimates that
tobacco kills more than 3 million persons each year. (6)
In schizophrenia, the number of patients who smoke is very high. One study
reported the prevalence to be 88%, nearly three times the rate in the general
population and higher than the elevated rates of smoking in patients with other
psychiatric illnesses. The increased prevalence persists even after adjustment for
marital status, alcohol use and socio-economic status. A number of more recent cross-
sectional studies from different countries have reported high rates of smoking in
patients with schizophrenia. Smoking occurs at much higher rates than other types of
substance misuse or dependence, which have been shown also to be elevated among
patients with schizophrenia. (4)
The average age when patients with schizophrenia started smoking was the
same as in the general population, namely mid-teens; 90% of patients who smoked
had started smoking before their illness began. Patients with schizophrenia who
smoke are also heavier smokers than those in the general population and those with
other psychiatric disorders. (4)
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In one study, 68% of patients with schizophrenia who smoked were classed
as heavy smokers (25 or more cigarettes daily) compared with only 11% of the
general population who smoke. Patients with schizophrenia who smoked had much
higher levels of the nicotine metabolite cotinine in comparison with other smokers.
Excessive smoking tends to be a lifelong habit among patients with schizophrenia.
The proportion of those who quit is lower than in the general population. (4)
Unburned cured tobacco contains nicotine, carcinogens, and other toxins
capable of causing gum disease and oral cancer. When tobacco is burned, the resultant
smoke contains, in addition to nicotine, carbon monoxide and 4000 other compounds
that result from volatilization, pyrolysis, and pyrosynthesis of tobacco and various
chemical additives used in making different tobacco products. (1)
The psychoactive component of tobacco is nicotine, which affects the central
nervous system (CNS) by acting as an agonist at the nicotinic subtype of acetylcholine
receptors. About 25 percent of the nicotine inhaled during smoking reaches the brain
within 15 seconds. The half life of nicotine is about 2 hours. Nicotine is believed to
produce its positive reinforcing and addictive properties by activating the
dopaminergic pathway projecting from the ventral tegmental area to the cerebral
cortex and the limbic system. In addition to activating this dopamine reward system,
nicotine causes an increase in the concentrations of circulating norepinephrine and
epinephrine and an increase in the release of vasopressin, -endorphin,
adrenocorticotropic hormone (ACTH), and cortisol. These hormones are thought to
contribute to the basic stimulatory effects of nicotine on the CNS. (4)
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Discussion
Why do patients with schizophrenia smoke at these excessive rates? There
are three possible explanations for the association: something about the illness leads
patients to smoke; smoking is another risk factor for schizophrenia; or a third factor
leads to both schizophrenia and smoking. (4)
The first possibility has received most attention. It has been suggested that
smoking may be a marker of a more severe illness process. Smokers are more often
young and male; they have an earlier onset of illness, increased numbers ofhospital
admissions and receive higher doses of neuroleptic
medication. Cigarette smoking
may decrease antipsychotic side effects through a pharmacokinetic interaction.
Smoking results in increased metabolism of neuroleptics. This pharmacokinetic effect
has been shown to result in 1) an increased average dose of antipsychotic medication
to achieve similar blood levels in smokers compared with nonsmokers or 2) similar
average doses of antipsychotics with lower blood levels in smokers compared with
nonsmokers. (2, 4)
Three groups have demonstrated increased clearance of neuroleptics
associated with cigarette smoking, ranging from 44% to 67% for orally administered
haloperidol and fluphenazine and 133% for fluphenazine decanoate. Most surveys
have found a correspondingly higher mean neuroleptic daily dose administered to
smokers than to non smokers. One study demonstrated lower levels ofchlorpromazine- induced sedation in smokers, which they attributed to lower
chlorpromazine plasma concentrations. Another study demonstrated changes in
chlorpromazine plasma concentrations and side effects in a schizophrenic patient who
stopped and subsequently resumed smoking. (3)
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Another suggestion is that patients smoke as a form of self-medicationwith
nicotine, which may help regulate a dysfunctional mesolimbic dopamine system. It
hasalso been shown that nicotine administration enhances cognitive performance on a
number of tasks. However, in general, patients with schizophrenia who smoke report
similar reasons to othersmokers ("addicted", "relaxation" and "to calm down"). (4)
Cigarette smoking might affect schizophrenic symptoms and antipsychotic
actions through the modulation of dopamine activity. Nicotinic acetylcholine
receptors have been identified on mesolimbic and nigrostriatal dopaminergic neurons.
Smoking may increase dopamine release in the pre-frontal cortex and alleviate
positive and negative symptoms. In rats, acute administration of nicotine stimulates
release of dopamine in the striatum and nucleus accumbens by acting on presynaptic
nicotine receptors. Nicotine also acutely elevates levels of the enzyme tyrosine
hydroxylase in the nucleus accumbens, indicating enhanced dopamine turnover. Some
evidence suggests that the stimulatory effect of anticholinergic agents on
dopaminergic activity may result in part from an increase in acetylcholine acting on
nicotinic receptors. So, patients with schizophrenia may smoke heavily as a result of
antipsychotic medication, which produces marked dopamine receptor blockade.
Possibly, a very high level of smoking is necessary to overcome this blockade and
produce the reward effects. (3)
Most patients who smoke began to do so
before psychotic aspects of the
illness appeared, premorbidcharacteristics are perhaps important. It is noteworthy that
patients who smoked were as children more poorlyadjusted socially than those who
were not smokers. (4)
A second explanation for the association between schizophrenia and
smoking is that smoking acts as an etiological risk factorfor schizophrenia. It may be
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that repeated activation by nicotine of the mesolimbic system over a long time
precipitates the onset of schizophrenia in vulnerable individuals. One study explain
that the earlier the age of starting smoking, the earlier was the onset of psychotic
illness in women. Among the adolescents in one study, who had been screened and
found not to be suffering from major psychopathology, cigarette smoking was
associated with greater risk for later hospitalization for schizophrenia. This higher
prevalence remained significant after we controlled for possible confounders
associated with smoking behavior. There was a significant association between the
number of cigarettes smoked and the risk for schizophrenia, with heavier smoking
being associated with greater risk for schizophrenia. (4, 7)
Interestingly, nicotine acts like other drugs of addiction such as cocaine and
amphetamine, activating the mesolimbic dopaminesystem; this effect appears to be of
critical importance for the reinforcing and reward properties of the drug. The nicotine
in cigarettes causes chronic activation of mesolimbic dopamine neurotransmission,
which in predisposed individuals might increase the risk of the appearance of
psychosis, thus giving cigarettes a causative role in the pathway toward the later
appearance of schizophrenia. Also, nicotine has been shown to increase burstactivity
in the dopamine neurons of the ventral tegmental area,a form of firing pattern of these
cells that is physiologically associated with basic motivational processes underlying
learning
and cognition.(4,7)
Third, genetic and/or environmental factors might predispose individuals to
develop both schizophrenia and nicotine addiction. The modes of genetic transmission
in schizophrenia are unknown, but several genes appear to make a contribution to
schizophrenia. One of specific candidate genes that influential in schizophrenia is
alpha-7 nicotinic receptor (CHRNA7). The CHRNA7 receptor is decreased in
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expression in the hippocampus, cortex, and reticular nucleus of the thalamus in
schizophrenic subjects.. The CHRNA7 receptor is one of the genes differentially
regulated by smoking in schizophrenia, at both the mRNA and protein levels.
Generally, the expression of differentially regulated genes was abnormal in
schizophrenic nonsmokers and was brought to control levels by smoking, suggesting
that smoking is normalizing gene expression in the patients. The regulatory region
haplotypes seem to be related to both smoking and schizophrenia. A single haplotype
was strongly associated with abnormal auditory gating (P50). Two haplotypes were
associated with both smoking and schizophrenia, but the association was strongest
with smoking. The data suggest that the CHRNA7 genotype may regulate smoking
behavior. Much work in the genetics of both schizophrenia and nicotine addiction has
focusedon the dopamine receptor system. (4, 5, 6)
Correlations between smoking and movement disorders have also received
special attention. Several crosssectional reports have suggested that cigarette smoking
is associated with a decrease in the likelihood of idiopathic Parkinsons disease. It has
been speculated that this may be due to the effect of nicotine on striatal dopamine
systems affected in this condition. Similarly, there is evidence to suggest that smoking
is associated with a reduced incidence of neuroleptic-induced parkinsonism. Several
studies found that measures of neuroleptic-induced parkinsonism were lower among
smokers than among nonsmokers with schizophrenia who were treated with
neuroleptics. (2)
Several studies suggest that tardive dyskinesia and smoking
may also be associated. One study reported that tardive dyskinesia
was more prevalent among smokers than among nonsmokers with
schizophrenia who were treated with neuroleptics, Another study
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reported results from a large, older male population sample and
found that dyskinesias were strongly and independently associated
with exposure to neuroleptics and daily cigarette smoking. Indeed,
the risk of dyskinesias increased with the number of cigarettes
smoked per day. (2)
Schizophrenia is associated with a 20% reduced life expectancy and
increased rates of smoking-related respiratory and cardiovascular diseases compared
to members of the general population. Besides health, tobacco use results in other
consequences, with smokers suffering financially and socially. Smokers with
schizophrenia spend almost one-third of their monthly disability income on cigarettes.
Smoking influences community integration because smokers have less income to
spend on clothing and housing. (8)
Despite the magnitude of tobacco use problems, quit rates for seriously
mentally ill smokers are significantly lower than in the general population. Individuals
with schizophrenia are able to quit smoking, although the success is about half that of
other groups. Contributing factors likely include lower motivation to quit tobacco use,
fewer lifetime quit attempts, and increased severity of nicotine dependence. (8)
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Conclusion
In schizophrenia, the number of patients who smoke is very high, nearly
three times the rate in the general population and higher than the elevated rates of
smoking in patients with other psychiatric illnesses. Patients with schizophrenia
usually start smoking about mid-teens and start smoking before their illness began.
They were classified as heavy smokers. Excessive smoking tends to be a lifelong
habit among patients with schizophrenia. So, it is not easy for patient with
schizophrenia to quit smoking.
But, why do patients with schizophrenia smoke at these excessive rates?
There are three possible explanations for the association:something about the illness
leads patients to smoke; smoking is another risk factor for schizophrenia; or a third
factorleads to both schizophrenia and smoking.
The first possibility is related with the medication. Cigarette smoking may
decrease antipsychotic side effects. Beside that, smoke as a form of self-medication
for patient and nicotine enhances cognitive performance of the patient. Another
possibility is that smoking acts as an etiological risk factorfor schizophrenia. And the
third, genetic and/or environmental factors might predispose individuals to develop
both schizophrenia and nicotine addiction. Much work in the genetics of both
schizophreniaand nicotine addiction has focusedon the dopamine receptor system.
Smoke influence the health of patient with schizophrenia. Besides that,
tobacco use results in other consequences, with smokers suffering financially and
socially. But there is one problem, quit rates for seriously mentally ill smokers are
significantly lower than in the general population. But, still patient is able to quit
smoke.
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References
1. Burns DM. Nicotine Addiction. In: Kasper DL, Fauci AS, Longo DL, et al,ed.
Harrisons Principles of Internal Medicine volume 2 16th edition. McGraw
Hill, 2005. p 2573.
2. Dalack GW, Healy DJ, Meador-Woodruff JH. Nicotine Dependence in
Schizophrenia: Clinical Phenomena and Laboratory Findings. Am J Psychiatry
1998; 1490-1501.
3. Goff DC, Henderson DC, Amico A. Cigarette Smoking in Schizophrenia:
Relationship to Psychopathology and Medication Side Effects. AmJ
Psychiatry 1992; 149:1189-1194
4. Kelly C, McCreadie R. Cigarette Smoking and Schizophrenia. Advances in
Psychiatric Treatment (2000) 6: 327-331.
5. Leonard S. Human Genetic Determinants of Schizophrenia and Nicotine
Addiction. Available at:http://www.nida.nih.gov/whatsnew/meetings/
frontiers2005/neurobiological.htmlAccessed November 23, 2008.
6. Sadock BJ, Sadock VA. Kaplan and Sadocks Synopsis of Psychiatry
Behavioral Sciences/Clinical Psychiatry 10th edition. Philadelphia: Lippincott
Williams and Wilkins. 2007. p 438-40; 467-71
7. Weiser M, Reichenberg A, Grotto I, et al. Higher Rates of Cigarette Smoking
in Male Adolescents Before the Onset of Schizophrenia: A Historical-
Prospective Cohort Study. Am J Psychiatry 2004; 161:1219-1223.
8. Williams JM, Foulds J. Successful Tobacco Dependence Treatment in
Schizophrenia. Am J Psychiatry 164:222-227, February 2007
http://www.nida.nih.gov/whatsnew/meetings/http://www.nida.nih.gov/whatsnew/meetings/http://www.nida.nih.gov/whatsnew/meetings/frontiers2005/neurobiological.htmlhttp://www.nida.nih.gov/whatsnew/meetings/frontiers2005/neurobiological.htmlhttp://www.nida.nih.gov/whatsnew/meetings/frontiers2005/neurobiological.htmlhttp://www.nida.nih.gov/whatsnew/meetings/http://www.nida.nih.gov/whatsnew/meetings/frontiers2005/neurobiological.htmlhttp://www.nida.nih.gov/whatsnew/meetings/frontiers2005/neurobiological.html8/9/2019 The Correlation Between Smoking and Schizophrenia
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The Correlations Between Smoking and Schizophrenia
by
Osman Wijaya
03005165
Faculty of Medicine
Trisakti University
Jakarta
2008