**The Characteristics of Nicotine Addiction Among Patients with Schizophrenia**

Ewa Wojtyna and Agnieszka Wiszniewicz

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/54308

### **1. Introduction**

[75] Thase, M., Nierenberg, A., Vrijland, P., Van Oers, H., et al. Remission with mirtaza‐ pine and selective serotonin reuptake inhibitors: a meta-analysis of individual pa‐ tient data from 15 controlled trials of acute phase treatment of major depression. Int

[76] Van Harten, J. Clinical pharmacokinetics of selective serotonin reuptake inhibi‐

[77] Duloxetine and Venlafaxine-xr in the treatment of major depressive disorder: a metaanalysis of randomised clinical trials. The Annals of Pharmacotherapy: , 39,

[78] VittenglJR, Clark LA, Jarrett RB. Continuation- phase cognitive therapy's effects on remission and recovery from depression. J Consult ClinPsychol (2009). , 77, 367-371.

[79] Weaver DR.Melatonin and circadian rhythmicity in vertebrates.Physiological roles and pharmacological effects. In: Turek FW, Zee PC, eds. Regulation of sleep and cir‐

[80] Weissaman MM, Markowitz JC & Klerman GL.Clinician's quick guide to interperso‐

[81] WHO.Facts and Figures. (http://www.euro.who.int/en/what-we-do/health-topics/ noncommunicable-diseases/mental-health/facts-and-figures)- accessed on 1st August

cadian rhythms. New York: Dekker, (1999). , 1999, 197-262.

nal psychotherapy. (2007). New York: Oxford University Press

Clin Psychopharmacol (2010). , 25, 189-198.

288 Mental Disorders - Theoretical and Empirical Perspectives

tors.Clin Pharmacokinet (1993). , 24, 203-220.

1798-1807.

2012

Premature death connected mainly with somatic disorders is observed among patients with schizophrenia. The major reason for this phenomenon are metabolic disorders caused on the one hand by side effects of pharmacological treatment [1], on the other by genetically determined differences in metabolism. Finally, the importance of behavioral factor, which is the lifestyle of patients with schizophrenia, must not be ignored here. Obesity, physical inactivity, poor diet, and smoking are the major factors contributing to the development and intensification of cardiovascular diseases. These factors are so im‐ portant because they can be modified, as opposed to the genetic factors or necessary pharmacological treatment.

This article addresses the issue of nicotine addiction among patients with schizophrenia.

### **1.1. Schizophrenia and nicotine addiction**

### *1.1.1. Scope of phenomenon*

The phenomenon of tobacco dependence involves 60-90% of patients with schizophrenia, and it is a much higher rate than among the general population, where the percentage of smokers varies between 25-4*7%* [2-6].

A study by de Leon et al. [7] and Gurpegui et al. [8] has shown that in adults (over twenty years old) who are in the group of increased susceptibility to schizophrenia, or are already suffering from the disease there is a significantly higher risk of taking up smoking than among the general population [9]. No wonder then that the problem of

nicotine addiction and its consequences is becoming more and more urgent in clinical psychiatry.

*1.1.3. Biological determinants of smoking*

The empirical data available suggest the existence of common risk factors for schizophrenia (and other mental illnesses) and smoking. The possibility of a genetic risk factor, particularly associated with the regulation of cholinergic neurotransmission is emphasized here [31-35].

The Characteristics of Nicotine Addiction Among Patients with Schizophrenia

http://dx.doi.org/10.5772/54308

291

Self-medication hypothesis is based on the assumption that the use of psychoactive substan‐ ces helps patients compensate for neurobiological deficits underlying a variety of ailments [36, 37]. Accordingly, intuitive reaching for cigarettes by schizophrenics would facilitate both dealing with the symptoms of the disease – positive and negative or with cognitive im‐

However, the importance of smoking in coping with the disease symptoms is not clear [38]. Some studies show an improvement within the range of negative symptoms by increasing the dopamine release in the prefrontal cortex [39-42]. These results, however, are subject to a number of constraints - sample size and methodological limitations. It is also worth remem‐ bering that research on animal models indicated that while occasional acute administration of nicotine did increase the dopamine release in the brain, chronic administration of nicotine resulted in a decrease in dopamine level, but these effects varied in different areas of the

There is more data on the relief of drug-induced symptoms and on the cognitive deficits.

Referring the self-medication hypothesis to the problem of antipsychotic treatment [38], it should be assumed that smoking helps to reduce the adverse symptoms of antipsychotic treatment. The mechanism that may explain the reduced severity of extrapyramidal symp‐ toms associated with high-dose neuroleptic treatment, may be the nicotine-induced acceler‐ ation of drug metabolism by cytochrome P450 (CYP1A2, CYP2D6 polymorphisms) [4, 44]. Thus alleviation of drug induced effects of the CYP1A2 metabolized neuroleptics can be ex‐ pected but there should be no such effects in case of drugs metabolized in a different way. The empirical data do not provide conclusive evidence that heavy smoking has a really im‐ portant role in alleviating the side effects of antipsychotic treatment, especially such as tar‐

Antipsychotic drugs with anticholinergic properties influence the expression of nicotine ace‐ tylcholine receptors (nAChRs) [45]. This translates into a deterioration of neurotransmission

*1.1.3.1. Genetic background*

*1.1.3.2. Self-medication hypothesis*

brain [41-43].

*1.1.3.2.1. Neuroleptics*

dive dyskinesis or akathisia [38].

in the cholinergic system in patients with schizophrenia.

pairment, as well as with the side effects of treatment.

Schizophrenics are most often among the so-called heavy smokers, which means, first of all, smoking at least 20 cigarettes a day, and often a shorter interpuff interval, and smoking cig‐ arettes with a higher nicotine content [3, 10].

In this group of patients a higher risk of dependence on nicotine is observed [11], as well as a more severe abstinence syndrome when trying to quit smoking [12]. This last phenomenon probably results from the fact that in schizophrenics there are, independent of metabolism, higher levels of nicotine and cotinine than in the blood of non-schizo‐ phrenics smoking the same amounts of cigarettes [13]. This fact can be explained by a greater number of puffs per cigarette and shorter interpuff intervals [10]. It is not sur‐ prising, therefore, that schizophrenics stop smoking more rarely than non-psychotic peo‐ ple [14], and the treatment of nicotine addiction - behavioral and pharmacological - in this group is much less effective [15-18].

### *1.1.2. Health consequences of smoking in schizophrenics*

Research shows that patients suffering from schizophrenia live roughly 20% shorter than healthy people, while cigarette smoking is here one of the main risk factors for premature death [19]. It was also shown that due to smoking these patients die on average 10 years ear‐ lier than the general population [20, 21].

This increased mortality is largely the result of cancer, cerebrovascular disease, respiratory diseases, and coronary heart disease. It is estimated that approximately 33% of psychotic pa‐ tients suffer from this illness and in this group it accounts for more premature deaths than suicide [22].

This phenomenon is particularly relevant in the light of reports which indicate that in schiz‐ ophrenics who smoke regularly there is a higher risk of coronary heart disease and stroke than in the general population [23]. It is estimated that, in the group with schizophrenia, the risk of death from cardiovascular problems is about 2.2 times higher than among the general population [24].

Also, in schizophrenia patients, respiratory diseases [25, 26] such as chronic obstructive pul‐ monary disorder (COPD) and pneumonia are frequently observed. Although lung cancer occurs less frequently in patients with schizophrenia than among the general population, the effects of cigarette smoking are clearly seen here [27]. In the case of COPD and lung can‐ cer, cigarette smoking is undoubtedly a significant etiologic factor [28]. Smoking can also in‐ crease susceptibility to pneumonia [29]. As shown in the Copeland et al. [26] study, COPD and pneumonia are the diseases more frequently occurring in the last year of life in schizo‐ phrenics than in those mentally healthy. In this group of patients the risk of dying from res‐ piratory diseases is estimated to be approximately 3.2 times higher than among the general population [30].

### *1.1.3. Biological determinants of smoking*

### *1.1.3.1. Genetic background*

nicotine addiction and its consequences is becoming more and more urgent in clinical

Schizophrenics are most often among the so-called heavy smokers, which means, first of all, smoking at least 20 cigarettes a day, and often a shorter interpuff interval, and smoking cig‐

In this group of patients a higher risk of dependence on nicotine is observed [11], as well as a more severe abstinence syndrome when trying to quit smoking [12]. This last phenomenon probably results from the fact that in schizophrenics there are, independent of metabolism, higher levels of nicotine and cotinine than in the blood of non-schizo‐ phrenics smoking the same amounts of cigarettes [13]. This fact can be explained by a greater number of puffs per cigarette and shorter interpuff intervals [10]. It is not sur‐ prising, therefore, that schizophrenics stop smoking more rarely than non-psychotic peo‐ ple [14], and the treatment of nicotine addiction - behavioral and pharmacological - in

Research shows that patients suffering from schizophrenia live roughly 20% shorter than healthy people, while cigarette smoking is here one of the main risk factors for premature death [19]. It was also shown that due to smoking these patients die on average 10 years ear‐

This increased mortality is largely the result of cancer, cerebrovascular disease, respiratory diseases, and coronary heart disease. It is estimated that approximately 33% of psychotic pa‐ tients suffer from this illness and in this group it accounts for more premature deaths than

This phenomenon is particularly relevant in the light of reports which indicate that in schiz‐ ophrenics who smoke regularly there is a higher risk of coronary heart disease and stroke than in the general population [23]. It is estimated that, in the group with schizophrenia, the risk of death from cardiovascular problems is about 2.2 times higher than among the general

Also, in schizophrenia patients, respiratory diseases [25, 26] such as chronic obstructive pul‐ monary disorder (COPD) and pneumonia are frequently observed. Although lung cancer occurs less frequently in patients with schizophrenia than among the general population, the effects of cigarette smoking are clearly seen here [27]. In the case of COPD and lung can‐ cer, cigarette smoking is undoubtedly a significant etiologic factor [28]. Smoking can also in‐ crease susceptibility to pneumonia [29]. As shown in the Copeland et al. [26] study, COPD and pneumonia are the diseases more frequently occurring in the last year of life in schizo‐ phrenics than in those mentally healthy. In this group of patients the risk of dying from res‐ piratory diseases is estimated to be approximately 3.2 times higher than among the general

psychiatry.

suicide [22].

population [24].

population [30].

arettes with a higher nicotine content [3, 10].

290 Mental Disorders - Theoretical and Empirical Perspectives

this group is much less effective [15-18].

lier than the general population [20, 21].

*1.1.2. Health consequences of smoking in schizophrenics*

The empirical data available suggest the existence of common risk factors for schizophrenia (and other mental illnesses) and smoking. The possibility of a genetic risk factor, particularly associated with the regulation of cholinergic neurotransmission is emphasized here [31-35].

### *1.1.3.2. Self-medication hypothesis*

Self-medication hypothesis is based on the assumption that the use of psychoactive substan‐ ces helps patients compensate for neurobiological deficits underlying a variety of ailments [36, 37]. Accordingly, intuitive reaching for cigarettes by schizophrenics would facilitate both dealing with the symptoms of the disease – positive and negative or with cognitive im‐ pairment, as well as with the side effects of treatment.

However, the importance of smoking in coping with the disease symptoms is not clear [38]. Some studies show an improvement within the range of negative symptoms by increasing the dopamine release in the prefrontal cortex [39-42]. These results, however, are subject to a number of constraints - sample size and methodological limitations. It is also worth remem‐ bering that research on animal models indicated that while occasional acute administration of nicotine did increase the dopamine release in the brain, chronic administration of nicotine resulted in a decrease in dopamine level, but these effects varied in different areas of the brain [41-43].

There is more data on the relief of drug-induced symptoms and on the cognitive deficits.

#### *1.1.3.2.1. Neuroleptics*

Referring the self-medication hypothesis to the problem of antipsychotic treatment [38], it should be assumed that smoking helps to reduce the adverse symptoms of antipsychotic treatment. The mechanism that may explain the reduced severity of extrapyramidal symp‐ toms associated with high-dose neuroleptic treatment, may be the nicotine-induced acceler‐ ation of drug metabolism by cytochrome P450 (CYP1A2, CYP2D6 polymorphisms) [4, 44]. Thus alleviation of drug induced effects of the CYP1A2 metabolized neuroleptics can be ex‐ pected but there should be no such effects in case of drugs metabolized in a different way. The empirical data do not provide conclusive evidence that heavy smoking has a really im‐ portant role in alleviating the side effects of antipsychotic treatment, especially such as tar‐ dive dyskinesis or akathisia [38].

Antipsychotic drugs with anticholinergic properties influence the expression of nicotine ace‐ tylcholine receptors (nAChRs) [45]. This translates into a deterioration of neurotransmission in the cholinergic system in patients with schizophrenia.

### *1.1.3.2.2. Cognitive factors – The role of the cholinergic system*

The cholinergic neurotransmission is one of the key phenomena important for cognitive functioning. This applies in particular to such areas of the brain as the prefrontal cortex and hippocampus, whose functions are regulated by cholinergic projections from other parts of the brain [46]. Cholinergic system dysfunction is manifested, among others, in impaired cog‐ nitive functions such as memory and attention disorders. On the other hand stimulation of this system results in memory improvement.

Schizophrenics often emphasize that smoking is the fulfillment of a strong need related to addiction, it is also an opportunity to escape and helps to control emotions. In Solway et al. clinical studies [53] the psychotic patients singled out three main roles that smoking plays in their daily functioning. Smoking is a tool used to control stress, helps to make interpersonal contacts and meet the need for peace and comfort. Facilitating interpersonal relations occurs here by entering a group of smokers, which helps to cope with the sense of exclusion and of being different (tobacco use is thus understood as supporting the development of social net‐ works and a source of social support). Solway et al. [53], however, draw attention to the fact that the respondents are increasingly aware of the fact that smoking - contrary to expecta‐ tions - does not accomplish its purpose in terms of interpersonal contacts. Although many of the schizophrenics examined began to smoke in order to reduce discomfort in social situa‐ tions, there is currently a trend towards unfavorable attitudes to smokers, which, in individ‐ uals suffering from mental illnesses, may create an additional barrier in the process of

The Characteristics of Nicotine Addiction Among Patients with Schizophrenia

http://dx.doi.org/10.5772/54308

293

People suffering from schizophrenia find it more difficult to quit smoking partly because of the withdrawal symptoms, including irritability, poor concentration, impatience and anxiety [6], and partly because they do not have enough support and motivation to do it successful‐ ly. The balance of gains and losses related to smoking cessation is in favor of the benefits of tobacco use [53]. The decision to maintain the addiction is often connected with the opinions functioning in society (especially among relatives), suggesting many obstacles and losses re‐

According to de Leon et al. [54] the socio-economic status and poor education about the neg‐ ative effects of smoking have a major impact on the initiation of smoking in people with se‐ vere mental illnesses. De Leon et al. [54] also suggest that in some countries where tobacco use by women is prohibited, the relationship between smoking and schizophrenia cannot be proven. This points to the fact that the number of cigarettes smoked by people with schizo‐ phrenia depends on their availability [54]. In Poland, the price of cigarettes is relatively high compared to the income of the mentally ill. However, patients cope with these economic constraints by selecting the cheapest cigarettes, usually without a filter, from illegal sources, or they roll the cheap tobacco cigarettes. Also, the surrounding people often provide the pa‐ tient with cigarettes. In the Solway's research [53] some smokers suffering from severe men‐ tal illnesses stated that the reason for their initiation of smoking was the addiction of one of

In the Solway's research [53], some respondents answered that they do not feel the need for smoking when cigarettes are not in sight, but at the time of distress, anxiety, or in a situation where there is a person smoking nearby, they feel a strong desire to smoke a cigarette. Meanwhile, in Poland, the functioning of patients is often based on life in communities which are dominated by smokers. Many smokers define the sole physical act of holding a

In conclusion, a number of biological and psychosocial phenomena are observed in patients with schizophrenia that exacerbate the problem of nicotine addiction and hinder the process of smoking cessation. A better understanding of the mechanisms associated with cigarette

socializing.

sulting from the process of smoking cessation.

their family members or friends.

cigarette as a highly satisfactory form of relaxation.

Research shows that administration of nicotine to schizophrenics, both smokers and nonsmokers, activating the cholinergic system, reduces the cognitive deficits connected with e.g. working memory, attention, and spatial organization [47-49].

It was also observed that in schizophrenics cognitive deficits worsen with the increase of withdrawal symptoms, and restarting smoking alleviates these unwanted changes in cogni‐ tive functioning [49]. This suggests that the treatment of cognitive deficits connected with schizophrenia could contribute to increasing the chance of successful smoking cessation, and indirectly to improving the patient's overall health.

#### *1.1.4. Psychological determinants of smoking*

As shown above, in a group of schizophrenics there are a number of biological factors, spe‐ cific to a lesser or greater extent to schizophrenia which explain the increased incidence of nicotine dependence in this group of patients. However, these factors are not the only ones that are relevant here. The psychosocial factors should not be ignored, especially that these factors are largely modifiable, and thus possible to be included in a therapeutic process.

Many reasons for smoking, mentioned by patients suffering from schizophrenia, are similar to those mentioned by healthy people. Some of the common arguments are: pleasure, addic‐ tion, weight control, the need for relaxation, or a desire to calm down.

Schmitz et al. [50] presume the possibility of an increased susceptibility to nicotine addiction in people who have difficulty coping with stress, tension, anxiety, or depression. Anxiety and depressive disorders have been repeatedly identified as a risk factor for taking up and continuing smoking [51]. In psychotic patients, the coexistence of these various disorders can further increase the tendency to smoking.

Patients with schizophrenia often emphasize that cigarettes are for them a product of first necessity, just like food, and help them endure life with the illness and prevent schizophre‐ nia relapses [52]. Not without reason, therefore, schizophrenics often mention the sedative effect of nicotine as the main reason for smoking [38]. This temporary way of dealing with unpleasant symptoms, however, puts in motion a vicious circle, because the inability to cease smoking is also the cause of stress and can lead to a greater anxiety than in the begin‐ ning. After lighting a cigarette waiting for the calming effect is also important. However, in many cases of agitation, such an effect does not appear, which results in smoking more and more cigarettes in the hope that a higher dose of nicotine will eventually help [38].

Schizophrenics often emphasize that smoking is the fulfillment of a strong need related to addiction, it is also an opportunity to escape and helps to control emotions. In Solway et al. clinical studies [53] the psychotic patients singled out three main roles that smoking plays in their daily functioning. Smoking is a tool used to control stress, helps to make interpersonal contacts and meet the need for peace and comfort. Facilitating interpersonal relations occurs here by entering a group of smokers, which helps to cope with the sense of exclusion and of being different (tobacco use is thus understood as supporting the development of social net‐ works and a source of social support). Solway et al. [53], however, draw attention to the fact that the respondents are increasingly aware of the fact that smoking - contrary to expecta‐ tions - does not accomplish its purpose in terms of interpersonal contacts. Although many of the schizophrenics examined began to smoke in order to reduce discomfort in social situa‐ tions, there is currently a trend towards unfavorable attitudes to smokers, which, in individ‐ uals suffering from mental illnesses, may create an additional barrier in the process of socializing.

*1.1.3.2.2. Cognitive factors – The role of the cholinergic system*

working memory, attention, and spatial organization [47-49].

and indirectly to improving the patient's overall health.

*1.1.4. Psychological determinants of smoking*

can further increase the tendency to smoking.

this system results in memory improvement.

292 Mental Disorders - Theoretical and Empirical Perspectives

The cholinergic neurotransmission is one of the key phenomena important for cognitive functioning. This applies in particular to such areas of the brain as the prefrontal cortex and hippocampus, whose functions are regulated by cholinergic projections from other parts of the brain [46]. Cholinergic system dysfunction is manifested, among others, in impaired cog‐ nitive functions such as memory and attention disorders. On the other hand stimulation of

Research shows that administration of nicotine to schizophrenics, both smokers and nonsmokers, activating the cholinergic system, reduces the cognitive deficits connected with e.g.

It was also observed that in schizophrenics cognitive deficits worsen with the increase of withdrawal symptoms, and restarting smoking alleviates these unwanted changes in cogni‐ tive functioning [49]. This suggests that the treatment of cognitive deficits connected with schizophrenia could contribute to increasing the chance of successful smoking cessation,

As shown above, in a group of schizophrenics there are a number of biological factors, spe‐ cific to a lesser or greater extent to schizophrenia which explain the increased incidence of nicotine dependence in this group of patients. However, these factors are not the only ones that are relevant here. The psychosocial factors should not be ignored, especially that these factors are largely modifiable, and thus possible to be included in a therapeutic process.

Many reasons for smoking, mentioned by patients suffering from schizophrenia, are similar to those mentioned by healthy people. Some of the common arguments are: pleasure, addic‐

Schmitz et al. [50] presume the possibility of an increased susceptibility to nicotine addiction in people who have difficulty coping with stress, tension, anxiety, or depression. Anxiety and depressive disorders have been repeatedly identified as a risk factor for taking up and continuing smoking [51]. In psychotic patients, the coexistence of these various disorders

Patients with schizophrenia often emphasize that cigarettes are for them a product of first necessity, just like food, and help them endure life with the illness and prevent schizophre‐ nia relapses [52]. Not without reason, therefore, schizophrenics often mention the sedative effect of nicotine as the main reason for smoking [38]. This temporary way of dealing with unpleasant symptoms, however, puts in motion a vicious circle, because the inability to cease smoking is also the cause of stress and can lead to a greater anxiety than in the begin‐ ning. After lighting a cigarette waiting for the calming effect is also important. However, in many cases of agitation, such an effect does not appear, which results in smoking more and

more cigarettes in the hope that a higher dose of nicotine will eventually help [38].

tion, weight control, the need for relaxation, or a desire to calm down.

People suffering from schizophrenia find it more difficult to quit smoking partly because of the withdrawal symptoms, including irritability, poor concentration, impatience and anxiety [6], and partly because they do not have enough support and motivation to do it successful‐ ly. The balance of gains and losses related to smoking cessation is in favor of the benefits of tobacco use [53]. The decision to maintain the addiction is often connected with the opinions functioning in society (especially among relatives), suggesting many obstacles and losses re‐ sulting from the process of smoking cessation.

According to de Leon et al. [54] the socio-economic status and poor education about the neg‐ ative effects of smoking have a major impact on the initiation of smoking in people with se‐ vere mental illnesses. De Leon et al. [54] also suggest that in some countries where tobacco use by women is prohibited, the relationship between smoking and schizophrenia cannot be proven. This points to the fact that the number of cigarettes smoked by people with schizo‐ phrenia depends on their availability [54]. In Poland, the price of cigarettes is relatively high compared to the income of the mentally ill. However, patients cope with these economic constraints by selecting the cheapest cigarettes, usually without a filter, from illegal sources, or they roll the cheap tobacco cigarettes. Also, the surrounding people often provide the pa‐ tient with cigarettes. In the Solway's research [53] some smokers suffering from severe men‐ tal illnesses stated that the reason for their initiation of smoking was the addiction of one of their family members or friends.

In the Solway's research [53], some respondents answered that they do not feel the need for smoking when cigarettes are not in sight, but at the time of distress, anxiety, or in a situation where there is a person smoking nearby, they feel a strong desire to smoke a cigarette. Meanwhile, in Poland, the functioning of patients is often based on life in communities which are dominated by smokers. Many smokers define the sole physical act of holding a cigarette as a highly satisfactory form of relaxation.

In conclusion, a number of biological and psychosocial phenomena are observed in patients with schizophrenia that exacerbate the problem of nicotine addiction and hinder the process of smoking cessation. A better understanding of the mechanisms associated with cigarette smoking in this group of patients may help to improve their quality of life, their general health, but also reduce the economic effects associated with the treatment and the conse‐ quences of tobacco-related diseases in schizophrenics.

*2.3.2. Fagerström test for nicotine dependence*

attempt to compensate for these deficiencies.

*2.3.3. The test of motivation for smoking cessation*

mum of 24 hours) can be indicated in the past year [58].

action (i.e. the act of smoking cessation).

the presence of a severe symptom.

*2.3.5. Hospital Anxiety and Depression Scale (HADS)*

smoking cessation.

*2.3.4. The test of readiness to change*

The study used the Fagerström Test for Nicotine Dependence (FTND) in order to estimate the severity of nicotine dependence [55]. This tool consists of 8 questions concerning factors associated with smoking. The result obtained is in the range of 0-11 points. The 0-4 points result corresponds to a low degree of dependence, 5-7 points – to a high degree, and the re‐ sult of more than 7 points corresponds to a very high dependence. Although Steinberg et al. [56] demonstrated that, in the schizophrenic group, this tool carries the risk of underestimat‐ ing the size of the problem, yet, in this study, the introduction of a detailed interview is an

The Characteristics of Nicotine Addiction Among Patients with Schizophrenia

http://dx.doi.org/10.5772/54308

295

The test of motivation for smoking cessation consists of 12 items containing statements about the smoker dependent factors that contribute to smoking cessation (e.g., *Do you decide to quit smoking for yourself?, Do you know why you smoke?, Do you know how to cope in crisis situations?*). The respondent gave his own answers to these items by indicating whether the statement referred to him or not. The Cronbach's α coefficient for this scale is 0.91. Predomi‐ nance of positive responses (> = 6 points) corresponds to a relatively strong motivation to

This tool has been designed on the basis of the Transtheoretical Model of Behavioral Change (TTM) [57] assumptions. According to this model, the current smokers are at the stage of precontemplation, contemplation or preparation. The precontemplation stage is defined as the lack of need for changes in behavior. At the stage of contemplation an intention to change behavior within the next 6 months emerges (here: to stop smoking) (but making this change is not planned within the next 30 days). And finally, the preparation stage is referred to as planning changes within the next month and attempts to stop smoking (lasting a mini‐

The Test of Readiness to Change used in this research consists of 8 questions, making it pos‐ sible to identify persons at the stage of precontemplation, contemplation, preparation, and

The Hospital Anxiety and Depression Scale (HADS) is a widely used, short, 14 item tool for studying anxiety and depression [59]. Each of the tool subscales consists of seven statements to which the tested person responds on a four point scale, where 0 corre‐ sponds to no intensity or to the weakest intensity of a given symptom, and 3 indicates

This questionnaire was initially recommended as an ambulatory screening tool, but is now also commonly used to assess symptoms of depression and anxiety in different groups of

### *1.1.5. Aim of the research*

The research was designed to characterize nicotine dependence in schizophrenics compared to smokers not having mental health problems. Indirectly, the research was also to deter‐ mine whether the affective psychological factors such as anxiety or depression and the level of distress are important predictors of smoking in a group of psychotic patients.

### **2. Material and methods**

#### **2.1. Participants**

204 smokers participated in the research, including 104 people with paranoid schizophrenia and 100 healthy persons. The schizophrenic smokers recruited for the research were in re‐ mission of psychotic symptoms or had residual symptoms and their condition was stable. These people have been treated for schizophrenia for at least 1 year. The control group were smokers who have not been diagnosed with a serious mental or somatic illness. At the time of the research, all the participants were in the active phase of nicotine dependence.

### **2.2 Design of research**

The research was cross-sectional and was carried out in Mental Health Outpatient Clinics and Psychiatric Day Hospitals. The control group, consisting of mentally healthy people, was recruited in the Occupational Medicine Outpatient Clinics, where they came for period‐ ic employee medical examinations. The research participants underwent a structured inter‐ view concerning smoking, and then the respondents were asked to complete five self-report questionnaires.

#### **2.3. Tools**

#### *2.3.1. Interview*

The interview with the respondents concerned their smoking history and included ques‐ tions about the time of smoking initiation, the addiction process over time, the daily rituals related to smoking, number of attempts to stop smoking, length of periods of abstinence, the average number of puffs per cigarette, and the type of cigarettes smoked. Also, in the inter‐ view information was obtained about basic socio-demographic data, such as economic sta‐ tus, family, place of residence. In the case of patients with schizophrenia the interview contained additional questions about the course of the disease and its treatment.

### *2.3.2. Fagerström test for nicotine dependence*

smoking in this group of patients may help to improve their quality of life, their general health, but also reduce the economic effects associated with the treatment and the conse‐

The research was designed to characterize nicotine dependence in schizophrenics compared to smokers not having mental health problems. Indirectly, the research was also to deter‐ mine whether the affective psychological factors such as anxiety or depression and the level

204 smokers participated in the research, including 104 people with paranoid schizophrenia and 100 healthy persons. The schizophrenic smokers recruited for the research were in re‐ mission of psychotic symptoms or had residual symptoms and their condition was stable. These people have been treated for schizophrenia for at least 1 year. The control group were smokers who have not been diagnosed with a serious mental or somatic illness. At the time

The research was cross-sectional and was carried out in Mental Health Outpatient Clinics and Psychiatric Day Hospitals. The control group, consisting of mentally healthy people, was recruited in the Occupational Medicine Outpatient Clinics, where they came for period‐ ic employee medical examinations. The research participants underwent a structured inter‐ view concerning smoking, and then the respondents were asked to complete five self-report

The interview with the respondents concerned their smoking history and included ques‐ tions about the time of smoking initiation, the addiction process over time, the daily rituals related to smoking, number of attempts to stop smoking, length of periods of abstinence, the average number of puffs per cigarette, and the type of cigarettes smoked. Also, in the inter‐ view information was obtained about basic socio-demographic data, such as economic sta‐ tus, family, place of residence. In the case of patients with schizophrenia the interview

contained additional questions about the course of the disease and its treatment.

of the research, all the participants were in the active phase of nicotine dependence.

of distress are important predictors of smoking in a group of psychotic patients.

quences of tobacco-related diseases in schizophrenics.

294 Mental Disorders - Theoretical and Empirical Perspectives

*1.1.5. Aim of the research*

**2. Material and methods**

**2.2 Design of research**

questionnaires.

*2.3.1. Interview*

**2.3. Tools**

**2.1. Participants**

The study used the Fagerström Test for Nicotine Dependence (FTND) in order to estimate the severity of nicotine dependence [55]. This tool consists of 8 questions concerning factors associated with smoking. The result obtained is in the range of 0-11 points. The 0-4 points result corresponds to a low degree of dependence, 5-7 points – to a high degree, and the re‐ sult of more than 7 points corresponds to a very high dependence. Although Steinberg et al. [56] demonstrated that, in the schizophrenic group, this tool carries the risk of underestimat‐ ing the size of the problem, yet, in this study, the introduction of a detailed interview is an attempt to compensate for these deficiencies.

### *2.3.3. The test of motivation for smoking cessation*

The test of motivation for smoking cessation consists of 12 items containing statements about the smoker dependent factors that contribute to smoking cessation (e.g., *Do you decide to quit smoking for yourself?, Do you know why you smoke?, Do you know how to cope in crisis situations?*). The respondent gave his own answers to these items by indicating whether the statement referred to him or not. The Cronbach's α coefficient for this scale is 0.91. Predomi‐ nance of positive responses (> = 6 points) corresponds to a relatively strong motivation to smoking cessation.

#### *2.3.4. The test of readiness to change*

This tool has been designed on the basis of the Transtheoretical Model of Behavioral Change (TTM) [57] assumptions. According to this model, the current smokers are at the stage of precontemplation, contemplation or preparation. The precontemplation stage is defined as the lack of need for changes in behavior. At the stage of contemplation an intention to change behavior within the next 6 months emerges (here: to stop smoking) (but making this change is not planned within the next 30 days). And finally, the preparation stage is referred to as planning changes within the next month and attempts to stop smoking (lasting a mini‐ mum of 24 hours) can be indicated in the past year [58].

The Test of Readiness to Change used in this research consists of 8 questions, making it pos‐ sible to identify persons at the stage of precontemplation, contemplation, preparation, and action (i.e. the act of smoking cessation).

#### *2.3.5. Hospital Anxiety and Depression Scale (HADS)*

The Hospital Anxiety and Depression Scale (HADS) is a widely used, short, 14 item tool for studying anxiety and depression [59]. Each of the tool subscales consists of seven statements to which the tested person responds on a four point scale, where 0 corre‐ sponds to no intensity or to the weakest intensity of a given symptom, and 3 indicates the presence of a severe symptom.

This questionnaire was initially recommended as an ambulatory screening tool, but is now also commonly used to assess symptoms of depression and anxiety in different groups of patients [60]. The sensitivity and specificity of this tool is satisfactory and is about 0.8 [61]. In our study, the scale reliability (Cronbach's α coefficient) was 0.86 for the depression subscale and 0.87 for the anxiety scale, which is consistent with the results obtained by other re‐ searchers [62, 63].

**Smokers (N=204) Schizophrenics (N=104) Non-psychiatric (N=100)**

The Characteristics of Nicotine Addiction Among Patients with Schizophrenia

http://dx.doi.org/10.5772/54308

297

Male 61 (58.7) 54 (54.0) Female 43 (41.3) 46 (46.0)

Mean (SD) 44.31 (13.94) 44.02 (11.40) Range 20 – 67 20 – 65

Single 32 (30.8) 25 (25.0) Married 39 (37.5) 48 (48.0) Widowed 13 (12.5) 15 (15.0) Divorced 20 (19.2) 12 (12.0)

Primary 29 (27.9) 5 (5.0) Vocational 54 (51.9) 35 (35.0) Secondary 20 (19.2) 42 (42.0) Higher 1 (1.0) 18 (18.0)

With family 54 (52.0) 59 (59.0) Alone 15 (14.4) 41 (41.0)

Poor 60 (57.7) 18 (18.0) Average 31 (29.8) 56 (56.0) Good 13 (12.5) 26 (26.0)

Employed 18 (17.3) 69 (69.0) Unemployed 23 (22.1) 16 (16.0) Disability Pension 50 (48.1) 9 (9.0) Retirement 13 (12.5) 6 (6.0)

**Table 1.** Socio-demographic characteristics of the smokers with schizophrenia and non-psychiatric controls.

In a nursing home 35 (33.6) -

Gender [*n(%)*]

Age [years]

Marital status [*n(%)*]

Level of education [*n(%)*]

Residence[*n(%)*]

Financial Situation [*n(%)*]

Employment status [*n(%)*]

### *2.3.6. Distress thermometer*

The Distress Thermometer is a single item screening tool that allows a subjective assessment of the severity of distress in the recent time. The respondent marks, on a scale of 0 to 10, how high was the level of stress he or she experienced during the last week. The validation stud‐ ies of the Polish version of the tool have shown that the 4 point or more result indicates a high risk of comorbid depression and / or anxiety [64].

### **3. Results**

The demographic characteristics of the respondents are shown in Table 1. The schizophren‐ ics were more often single people, less educated, unemployed, and of worse financial situa‐ tion than those in the control group.

Table 2 presents the comparison of the schizophrenics and the control group in terms of smoking.

The psychotic patients smoked more, took a greater number of puffs, showed a higher level of dependence and were less motivated to give up smoking than the mentally healthy persons.

It was also observed that the schizophrenics taking atypical medications (*n* = 58), smoked less and took puffs less frequently than those treated with conventional drugs (*n* = 46). There were no differences between the groups with respect to the age of smoking initiation (first cigarette), while the schizophrenics started smoking on a daily basis earlier than the healthy individuals. Those in the control group made attempts to quit smoking more often, and their abstinence periods were longer. It was also observed that as the period of being ill with schizophrenia gets longer, the number of cigarettes smoked grows (*r* = 0.16*, p <*0.05) and the level of dependence increases (*r* = 0.31*, p <*0.01).

Most schizophrenics had no intention to quit smoking, while people in the control group were more often at the contemplation or preparation stage for smoking cessation (Table 3).

Other motives for smoking cessation were also shown. In the mentally healthy individuals the major motive was their relatives' pressure, the desire to save money and, to a lesser ex‐ tent, the beginning of health problems. The dominant motive in the schizophrenics, howev‐ er, was the appearance of tobacco-related disease, manifested mainly by shortness of breath. The rarest motive turned out to be the pressure of relatives.


patients [60]. The sensitivity and specificity of this tool is satisfactory and is about 0.8 [61]. In our study, the scale reliability (Cronbach's α coefficient) was 0.86 for the depression subscale and 0.87 for the anxiety scale, which is consistent with the results obtained by other re‐

The Distress Thermometer is a single item screening tool that allows a subjective assessment of the severity of distress in the recent time. The respondent marks, on a scale of 0 to 10, how high was the level of stress he or she experienced during the last week. The validation stud‐ ies of the Polish version of the tool have shown that the 4 point or more result indicates a

The demographic characteristics of the respondents are shown in Table 1. The schizophren‐ ics were more often single people, less educated, unemployed, and of worse financial situa‐

Table 2 presents the comparison of the schizophrenics and the control group in terms of

The psychotic patients smoked more, took a greater number of puffs, showed a higher level of dependence and were less motivated to give up smoking than the mentally

It was also observed that the schizophrenics taking atypical medications (*n* = 58), smoked less and took puffs less frequently than those treated with conventional drugs (*n* = 46). There were no differences between the groups with respect to the age of smoking initiation (first cigarette), while the schizophrenics started smoking on a daily basis earlier than the healthy individuals. Those in the control group made attempts to quit smoking more often, and their abstinence periods were longer. It was also observed that as the period of being ill with schizophrenia gets longer, the number of cigarettes smoked grows (*r* = 0.16*, p <*0.05) and the

Most schizophrenics had no intention to quit smoking, while people in the control group were more often at the contemplation or preparation stage for smoking cessation (Table 3).

Other motives for smoking cessation were also shown. In the mentally healthy individuals the major motive was their relatives' pressure, the desire to save money and, to a lesser ex‐ tent, the beginning of health problems. The dominant motive in the schizophrenics, howev‐ er, was the appearance of tobacco-related disease, manifested mainly by shortness of breath.

searchers [62, 63].

**3. Results**

smoking.

healthy persons.

*2.3.6. Distress thermometer*

296 Mental Disorders - Theoretical and Empirical Perspectives

tion than those in the control group.

level of dependence increases (*r* = 0.31*, p <*0.01).

The rarest motive turned out to be the pressure of relatives.

high risk of comorbid depression and / or anxiety [64].

**Table 1.** Socio-demographic characteristics of the smokers with schizophrenia and non-psychiatric controls.


In the schizophrenics a higher level of distress and anxiety was observed than in the control group. Depression of the psychotic patients was also higher than in the healthy persons, but

**Schizophrenics (N=104) Non-psychiatric**

*t* **subgroups** *M (SD)*

typical treat. 9.49 (4.27)a 5.70\*\*\* atypical treat. 7.50 (5.97)a 2.68

typical treat. 7.53 (3.72) 2.01 atypical treat. 6.87 (3.10) 0.68

typical treat. 5.67 (2.67)b 3.64\*\*\* atypical treat. 5.31 (1.92)b 2.79\*

In the subgroup of schizophrenics, in the patients treated with atypical neuroleptics, a lower level of distress appeared (but still significantly higher than in the control group)

The analysis of the correlation between the affective factors and distress and the parameters characterizing smoking, indicated that in both groups – in the schizophrenics and in the con‐ trol group - higher levels of anxiety, depression and distress are associated with a greater

To determine the predictive power of the affective factors and distress for the number of cig‐

Affective factors and distress explain a greater percentage of variance of the number of ciga‐

arettes smoked multivariate linear regression analysis was carried out (table 6).

**(N=100)**

The Characteristics of Nicotine Addiction Among Patients with Schizophrenia

6.28 (3.44)

6.56 (3.10)

4.20 (2.37)

**Comparisons**

http://dx.doi.org/10.5772/54308

299

5.28\*\*\*

1.94

3.47\*\*

= 0.56) than in the group of schizo‐

the difference did not reach statistical significance (table 4).

all 9.20 (4.43)

all 7.48 (3.65)

all 5.42 (2.64)

 comparison between typical and atypical treatment subgroups: *t=4.32 (p<0.001)* b comparison between typical and atypical treatment subgroups: *t=2.15 (p<0.05)*

**Table 4.** Level of anxiety, depression and distress among participants

rettes in the group of mentally healthy persons (*adj.R2*

number of cigarettes smoked (table 5).

= 0.34).

**Factors**

Anxiety

Depression

Distress

a

and anxiety.

phrenics (*adj.R2*

Notes: *\* p<0.05; \*\* p<0.01; \*\*\* p<0.001* typical treat. – typical neuroleptics (n=46) atypical treat. – atypical neuroleptics (n=58)

FTND – Fagerström Test for Nicotine Dependence

**Table 2.** Smoking characteristic of schizophrenic patients and healthy participants.


**Table 3.** Readiness to smoking cessation


In the schizophrenics a higher level of distress and anxiety was observed than in the control group. Depression of the psychotic patients was also higher than in the healthy persons, but the difference did not reach statistical significance (table 4).

Notes: *\* p<0.05; \*\* p<0.01; \*\*\* p<0.001*

**Smoking Schizophrenics**

Cigarettes

298 Mental Disorders - Theoretical and Empirical Perspectives

Range [*n* (%)]

Nicotine dependence

Smoking cessation

FTND – Fagerström Test for Nicotine Dependence

**Table 3.** Readiness to smoking cessation

**Table 2.** Smoking characteristic of schizophrenic patients and healthy participants.

**Stage of change Schizophrenics (** *<sup>N</sup>* **=104)**

Notes: \*\* p<0.01; \*\*\* p<0.001

**(N=104)**

Cigarettes smoked per day [*M*(*SD*)] 25.98 (13.40) 20.09 (8.58) 3.72\*\*\*

Nicotine yield of cigarettes [*M*(*SD*)] 1.03 (0.22) 0.85 (0.22) 5.97\*\*\* Puffs per cigarette [*M*(*SD*)] 12.12 (3.57) 8.64 (2.39) 8.14\*\*\*

Min to first cigarette of the day [*M*(*SD*)] 7.23 (4.58) 7.54 (3.97) 0.36

Years of daily smoking [*M*(*SD*)] 23.87 (14.26) 24.35 (12.02) -0.26 Age of first smoking [*M*(*SD*)] 17.00 (4.49) 17.31 (5.59) 0.43 Age of daily smoking [*M*(*SD*)] 19.67 (3.84) 20.44 (8.53) 0.83

Motivation to quit [*M*(*SD*)] 5.47 (3.54) 8.39 (2.24) -7.07\*\*\* Past quit attempts [*M*(*SD*)] 2.05 (1.78) 3.92 (3.04) -5.34\*\*\*

Longest abstinence period [months] [*M*(*SD*)] 3.39 (4.55) 5.52 (6.18) -2.80\*\*

*n* **(%)**

Precontemplation 61 (58.6) 29 (29.0) Contemplation 35 (33.7) 46 (46.0) Preparation 8 (7.7) 25 (25.0)

FTND [*M*(*SD*)] 7.63 (2.62) 6.30 (1.95) 4.12\*\*\*

1-10 14 (13.5) 20 (20.0) 11-20 42 (40.4) 46 (46.0) 21-30 28 (26.9) 30 (30.0) "/>30 20 (19.2) 4 (4.0)

**Non-psychiatric (N=100)**

**Comparisons** *t*

**Non-psychiatric (** *N* **=100)** *n* **(%)**

typical treat. – typical neuroleptics (n=46)

atypical treat. – atypical neuroleptics (n=58)

a comparison between typical and atypical treatment subgroups: *t=4.32 (p<0.001)*

b comparison between typical and atypical treatment subgroups: *t=2.15 (p<0.05)*

**Table 4.** Level of anxiety, depression and distress among participants

In the subgroup of schizophrenics, in the patients treated with atypical neuroleptics, a lower level of distress appeared (but still significantly higher than in the control group) and anxiety.

The analysis of the correlation between the affective factors and distress and the parameters characterizing smoking, indicated that in both groups – in the schizophrenics and in the con‐ trol group - higher levels of anxiety, depression and distress are associated with a greater number of cigarettes smoked (table 5).

To determine the predictive power of the affective factors and distress for the number of cig‐ arettes smoked multivariate linear regression analysis was carried out (table 6).

Affective factors and distress explain a greater percentage of variance of the number of ciga‐ rettes in the group of mentally healthy persons (*adj.R2* = 0.56) than in the group of schizo‐ phrenics (*adj.R2* = 0.34).


65]. In the group of mentally ill patients, similarly as in the Tidey et al. [10] studies, a variation in the number of cigarettes smoked and the number of puffs taken was ob‐ served depending on the type of treatment applied. The fact that patients taking atypi‐ cals smoked less than the patients receiving typical medication, may result from the different effect of taking these drugs. Several studies have shown that atypical drugs such as clozapine and olanzapine, are conducive to reducing smoking, reduce the desire to smoke and, finally, relieve the withdrawal symptoms [10, 66, 67]. Also, in patients taking atypicals, a lower level of distress is observed [68]. In this study, distress turned out to be a significant predictor of smoking, therefore it is possible that this mechanism is important in explaining the observed difference. In the presented work, however, nei‐ ther the timing nor the doses of the administered medication were controlled, so these

The Characteristics of Nicotine Addiction Among Patients with Schizophrenia

http://dx.doi.org/10.5772/54308

301

The analysis of the factors motivating schizophrenics to stop smoking indicates a very seri‐ ous problem. Only a significant deterioration of health, to be precise, shortness of breath making smoking impossible, inclined patients to consider reducing or giving up smoking. Lack of finances and bans on smoking in public places and in the place of residence were not a sufficient bareer for people with schizophrenia. Lack of pressure from the close envi‐ ronment to reduce smoking should also be noted. This may result from the fact that the clos‐ est people here are often smokers themselves (often these are other patients). Interviews with the patients showed that most often it was the family who supplied the patients with

The results of the study show the important role of affective factors and a feeling of dis‐ tress in nicotine dependence. This importance is greater in the group of healthy persons than in schizophrenics, but the results obtained in this study (26% of the explained var‐ iance of the number of cigarettes smoked) suggest introducing psychological (and/or pharmacological) interactions, aimed at improving coping with stress and reducing the negative affect. These results also confirm the fact that cigarette smoking in schizophren‐ ics is probably, to a much greater extent than in the mentally healthy, determined by

The study also confirmed a significant relationship between distress and the number of ciga‐ rettes smoked. These results are consistent with other studies. It should be noted, that dis‐ tress may have different sources and may be understood differently by the respondents. It is therefore a very general construct, and in this study should be understood as the so called

The relationship between distress, affective factors, and cigarette smoking has important clinical implications. First of all - apart from the typical pharmacological treatment and nico‐ tine replacement therapy – psychological treatment should be implemented into programs

cigarettes, and thus contributed to continuing this addiction in schizophrenics.

dependencies are worth researching more closely in the future.

factors other than affective [31-37].

aggregate variable [69].

**5. Conclusion**

FTND – Fagerström Test for Nicotine Dependence

**Table 5.** Correlation between the affective factors and distress and the parameters characterizing smoking.


**Table 6.** Predictors of numbers of cigarettes smoked per day (multivariate linear regression model).

In both groups, the strongest predictor of smoking was distress and the predictive power of anxiety and depression was distributed differently in the group of schizophrenics and the control group. In the mentally ill patients depression was more strongly correlated with smoking, and in the control group, a stronger correlation with the number of cigarettes smoked was observed for anxiety.

### **4. Discussion**

The study confirmed the observations of other researchers that schizophrenics smoke more than the mentally healthy and take a greater number of puffs per cigarette [10, 65]. In the group of mentally ill patients, similarly as in the Tidey et al. [10] studies, a variation in the number of cigarettes smoked and the number of puffs taken was ob‐ served depending on the type of treatment applied. The fact that patients taking atypi‐ cals smoked less than the patients receiving typical medication, may result from the different effect of taking these drugs. Several studies have shown that atypical drugs such as clozapine and olanzapine, are conducive to reducing smoking, reduce the desire to smoke and, finally, relieve the withdrawal symptoms [10, 66, 67]. Also, in patients taking atypicals, a lower level of distress is observed [68]. In this study, distress turned out to be a significant predictor of smoking, therefore it is possible that this mechanism is important in explaining the observed difference. In the presented work, however, nei‐ ther the timing nor the doses of the administered medication were controlled, so these dependencies are worth researching more closely in the future.

The analysis of the factors motivating schizophrenics to stop smoking indicates a very seri‐ ous problem. Only a significant deterioration of health, to be precise, shortness of breath making smoking impossible, inclined patients to consider reducing or giving up smoking. Lack of finances and bans on smoking in public places and in the place of residence were not a sufficient bareer for people with schizophrenia. Lack of pressure from the close envi‐ ronment to reduce smoking should also be noted. This may result from the fact that the clos‐ est people here are often smokers themselves (often these are other patients). Interviews with the patients showed that most often it was the family who supplied the patients with cigarettes, and thus contributed to continuing this addiction in schizophrenics.

The results of the study show the important role of affective factors and a feeling of dis‐ tress in nicotine dependence. This importance is greater in the group of healthy persons than in schizophrenics, but the results obtained in this study (26% of the explained var‐ iance of the number of cigarettes smoked) suggest introducing psychological (and/or pharmacological) interactions, aimed at improving coping with stress and reducing the negative affect. These results also confirm the fact that cigarette smoking in schizophren‐ ics is probably, to a much greater extent than in the mentally healthy, determined by factors other than affective [31-37].

The study also confirmed a significant relationship between distress and the number of ciga‐ rettes smoked. These results are consistent with other studies. It should be noted, that dis‐ tress may have different sources and may be understood differently by the respondents. It is therefore a very general construct, and in this study should be understood as the so called aggregate variable [69].

### **5. Conclusion**

**Smoking Anxiety Depression Distress**

Cigarettes smoked per day 0.57\*\*\* 0.64\*\*\* 0.67\*\*\* Puffs per cigarette -0.07 -0.03 -0,04 Nicotine dependence (FTND) 0.53\*\*\* 0.49\*\*\* 0.55\*\*\* Motivation to quit -0.02 0.04 0.13

Cigarettes smoked per day 0.56\*\*\* 0.21\* 0.62\*\*\* Puffs per cigarette 0.12 -0.01 0.07 Nicotine dependence (FTND) 0.55\*\*\* 0.17 0.53\*\*\* Motivation to quit -0.14 -0.02 -0.06

**Table 5.** Correlation between the affective factors and distress and the parameters characterizing smoking.

Anxiety 0.14 0.04 0.48\*\*\* 0.24 Depression 0.36\*\* 0.11 0.18 0.05 Distress 0.47\*\*\* 0.19 0.55\*\*\* 0.27

In both groups, the strongest predictor of smoking was distress and the predictive power of anxiety and depression was distributed differently in the group of schizophrenics and the control group. In the mentally ill patients depression was more strongly correlated with smoking, and in the control group, a stronger correlation with the number of cigarettes

The study confirmed the observations of other researchers that schizophrenics smoke more than the mentally healthy and take a greater number of puffs per cigarette [10,

*adj.R2*=0.34 *adj.R2*=0.56 **β ΔR***<sup>2</sup>* **β ΔR***<sup>2</sup>*

Non-psychiatric smokers (*N*=100)

Schizophrenic patients (*N*=104)

**Table 6.** Predictors of numbers of cigarettes smoked per day (multivariate linear regression model).

**Schizophrenic patients**

300 Mental Disorders - Theoretical and Empirical Perspectives

**Non-psychiatric participants**

FTND – Fagerström Test for Nicotine Dependence

Notes: *\* p<0.05; \*\*\* p<0.001*

**Factors**

Notes: *\*\* p<0.01; \*\*\* p<0.001*

**4. Discussion**

smoked was observed for anxiety.

The relationship between distress, affective factors, and cigarette smoking has important clinical implications. First of all - apart from the typical pharmacological treatment and nico‐ tine replacement therapy – psychological treatment should be implemented into programs for nicotine dependence to improve the functioning of schizophrenics in terms of coping with stress and maintaining good mood.

[7] de Leon J, Diaz FJ, Rogers T, Browne D, Dinsmore L. Initiation of daily smoking and nicotine dependence in schizophrenia and mood disorders. Schizophrenia Research

The Characteristics of Nicotine Addiction Among Patients with Schizophrenia

http://dx.doi.org/10.5772/54308

303

[8] Gurpegui M, Martínez-Ortega JM, Aguilar MC, Diaz FJ, Quintana HM, de Leon J. Smoking initiation and schizophrenia: A replication study in a Spanish sample.

[9] Dome P, Lazary J, Kalapos MP, Rihmer Z. Smoking, nicotine and neuropsychiatric

[10] Tidey JW, Rohsenow DJ, Kaplan GB, Swift RM. Cigarette smoking topography in smokers with schizophrenia and matched non-psychiatric controls. Drug and Alco‐

[11] Spring B, Pingitore R, McChargue DE. Reward value of cigarette smoking for compa‐ rably heavy smoking schizophrenic, depressed, and nonpatient smokers. American

[12] Weinberger AH, Sacco KA, Creeden CI, Vessicchio JC, Jatlow PI, George TP. Effects of acute abstinence, reinstatement, and mecamylamine on biochemical and behavio‐ ral measures of cigarette smoking in schizophrenia. Schizophrenia Research 2007; 91;

[13] Williams JM, Ziedonis DM, Abanyie F, Steinberg ML, Foulds J, Benowitz NL. In‐ creased nicotine and cotinine levels in smokers with schizophrenia and schizoaffec‐ tive disorder is not a metabolic effect. Schizophrenia Research 2005; 79(2-3) 323-35. [14] Lasser K, Boyd JW, Woolhandler S, Himmelstein DU, McCormick D, Bor DH. Smok‐ ing and mental illness: A population-based prevalence study. JAMA 2000; 284;

[15] Addington J, el-Guebaly N, Campbell W, Hodgins DC, Addington D. Smoking cessa‐ tion treatment for patients with schizophrenia. American Journal of Psychiatry 1998;

[16] George TP, Ziedonis DM, Feingold A, Pepper WT, Satterburg CA, Winkel J, Rounsa‐ ville BJ, Kosten TR. Nicotine transdermal patch and atypical antipsychotic medica‐ tions for smoking cessation in schizophrenia. American Journal of Psychiatry 2000;

[17] George TP, Vessicchio JC, Termine A, Bregartnera TA, Feingold A, Rounsaville BJ, Kosten TR. A placebo controlled trial of bupropion for smoking cessation in schizo‐

[18] Richmond R, Zwar N. Therapeutic review of bupropion slow release. Drug and Al‐

[19] Hennekens CH, Hennekens AR, Hollar D, Casey DE. Schizophrenia and increased risks of cardiovascular disease. American Heart Journal 2005; 150;1115–1121.

phrenia. Biological Psychiatry 2002; 52(1) 53–61.

cohol Review 2003;22; 203–220.

disorders. Neuroscience and Biobehavioral Reviews 2010; 34(3) 295-342.

2002; 56; 47-54.

217-225.

2606-2610.

155; 974-976.

157; 1835-1842.

Schizophrenia Research 2005; 76; 113-118.

hol Dependence 2005; 80; 259–265.

Journal of Psychiatry 2003; 160; 316-322.

Secondly, it seems interesting to study the causes of the perceived distress. Knowing the sources of stress and the strategies of coping with it can help to build more effective pro‐ grams supporting the treatment of nicotine addiction.

Weak pressure of the environment on the mentally ill to quit smoking, and even strengthen‐ ing the addiction by the closest ones, points to a need for actions targeted at the schizo‐ phrenics' environment. Such interventions should be aimed at increasing the knowledge about smoking and its consequences, including families in the process of motivating to quit smoking and improving support given to patients.

### **Author details**

Ewa Wojtyna and Agnieszka Wiszniewicz

\*Address all correspondence to: ewa.wojtyna@us.edu.pl

Institute of Psychology, University of Silesia, Katowice, Poland

### **References**


[7] de Leon J, Diaz FJ, Rogers T, Browne D, Dinsmore L. Initiation of daily smoking and nicotine dependence in schizophrenia and mood disorders. Schizophrenia Research 2002; 56; 47-54.

for nicotine dependence to improve the functioning of schizophrenics in terms of coping

Secondly, it seems interesting to study the causes of the perceived distress. Knowing the sources of stress and the strategies of coping with it can help to build more effective pro‐

Weak pressure of the environment on the mentally ill to quit smoking, and even strengthen‐ ing the addiction by the closest ones, points to a need for actions targeted at the schizo‐ phrenics' environment. Such interventions should be aimed at increasing the knowledge about smoking and its consequences, including families in the process of motivating to quit

[1] Stahl SM. Podstawy psychofarmakologii [Essentiale psychopharmacology]. Gdańsk:

[2] Chapman S, Ragg M, McGeechan K. Citation bias in reported smoking prevalence in people with schizophrenia. The Australian And New Zealand Journal Of Psychiatry

[3] de Leon J, Diaz F. A meta-analysis of worldwide studies demonstrates an association between schizophrenia and tobacco smoking behaviors. Schizophrenia Research

[4] Dervaux A, Laqueille X. Tabac et schizophrénie: aspects épidémiologiques et clin‐

[5] Goff DC, Cather C, Evins, AE, Henderson DC, Freudenreich O, Copeland PM, Bierer M, Duckworth K, Sacks FM. Medical morbidity and mortality in schizophrenia:

[6] Wang CY, Xiang YT, Weng YZ, Bo QJ, Chiu HF, Chan SS, Lee EH, Ungvari GS. Ciga‐ rette smoking in patients with schizophrenia in China: prospective, multicentre study. The Australian And New Zealand Journal Of Psychiatry 2010; 44(5) 456-462.

Guidelines for psychiatrists. Journal of Clinical Psychiatry 2005; 66(2) 183-194.

with stress and maintaining good mood.

302 Mental Disorders - Theoretical and Empirical Perspectives

grams supporting the treatment of nicotine addiction.

smoking and improving support given to patients.

\*Address all correspondence to: ewa.wojtyna@us.edu.pl

iquess. L'encéphale 2008; 34(3) 299–305.

Institute of Psychology, University of Silesia, Katowice, Poland

Ewa Wojtyna and Agnieszka Wiszniewicz

**Author details**

**References**

ViaMedica; 2009.

2009; 43(3) 277-282.

2005; 76; 135-157.


[20] Hannerz H, Borga P, Borritz M. Life expectancies for individuals with psychiatric di‐ agnoses. Public Health 2001; 115; 328–337.

[34] Leonard S, Gault J, Adams C, Breese CR, Rollins Y, Adler LE, Olincy A, Freedman R. Nicotinic receptors, smoking and schizophrenia. Restorative Neurology and Neuro‐

The Characteristics of Nicotine Addiction Among Patients with Schizophrenia

http://dx.doi.org/10.5772/54308

305

[35] Leonard S, Gault J, Hopkins J, Logel J, Vianzon R, Short M, Drebing C, Berger R, Venn D, Sirota P, Zerbe GO, Olincy A, Ross RG, Adler LE, Freedman R. Association of promoter variants in the alpha-7-nicotinic acetylocholine receptor subunit gene with an inhibitory deficit found in schizophrenia. Archive of General Psychiatry

[36] Khantzian EJ. The self-medication hypothesis of addictive disorders: Focus on heroin and cocaine dependence. American Journal of Psychiatry 1985; 142; 1259-1264. [37] Markou A, Kosten TR, Kobb GF. Neurobiological similarities in depression and drug dependence: a self-medication hypothesis. Neuropsychopharmacology 1998; 18;

[38] de Leon J, Diaz FJ, Aguilar MC, Jurado D, Gurpegui M. Does smoking reduce akathi‐ sia? Testing a narrow version of the self-medication hypothesis. Schizophrenia Re‐

[39] Domino EF, Mirzoyan D, Tsukada H. N-methyl-D-aspartate antagonists as drug models of schizophrenia: a surprising link to tobacco smoking. Progress in Neuro-

[40] Glassman AH, Covey LS, Dalack GW, Stetner F, Rivelli SK, Fleiss J, Cooper TB. Smoking cessation, clonidine, and vulnerability to nicotine among dependent smok‐

[41] Lohr JB, Flynn K. Smoking and schizophrenia. Schizophrenia Research 1992; 8; 93–

[42] Lyon E. A Review of the effects of nicotine on schizophrenia and antipsychotic medi‐

[43] Brody AL, Mandelkern MA, Jarvik ME, Lee GS, Smith EC, Huang JC, Bota RG, Bart‐ zokis G, London ED. Differences between smokers and nonsmokers in regional gray

[44] Carrillo JA, Herraiz AG, Ramos SI, Gervasin G, Vizcaino S, Benitez J. Role of the smoking-induced cytochrome P450 (CYP)1A2 and polymorphic CYP2D6 in steadystate concentration of olanzapine. Journal of Clinical Psychopharmacology 2003;

[45] Grinevich VP, Papke RL, Lippiello PM, Bencherif M. Atypical antipsychotics as non‐ competitive inhibitors of alpha4beta2 and alpha7 neuronal nicotinic receptors. Neu‐

[46] Hasselmo ME, Sarter M. Modes and models of forebrain cholinergic neuromodula‐

matter volumes and densities. Biological Psychiatry 2004; 55(1) 77-84.

Psychopharmacology and Biological Psychiatry 2004; 28(5) 801-811.

ers. Clinical Pharmacology and Therapeutics 1993; 54(6) 670–679.

cations. Psychiatric Services 1999; 50; 1346-1350.

ropharmacology 2009; 57(2) 183–191.

tion of cognition. Neuropharmacology 2011; 36; 52-73.

science 1998; 12(2-3) 195-201.

search 2006; 86(1-3), 256-268.

2002; 59; 1085-1096.

135-174.

102.

23(2) 119–127.


[34] Leonard S, Gault J, Adams C, Breese CR, Rollins Y, Adler LE, Olincy A, Freedman R. Nicotinic receptors, smoking and schizophrenia. Restorative Neurology and Neuro‐ science 1998; 12(2-3) 195-201.

[20] Hannerz H, Borga P, Borritz M. Life expectancies for individuals with psychiatric di‐

[21] Culhane MA, Schoenfeld DA, Barr RS, Cather C, Deckersbach T, Freudenreich O, Goff DC, Rigotti NA, Evins AE. Predictors of early abstinence in smokers with schiz‐

[22] Baker A, Lubman DI, Hides L. Smoking and schizophrenia: Treatment approaches

[23] Takeuchi T, Nakao M, Shinozaki Y, Yano E. Validity of self-reported smoking in schizophrenia patients. Psychiatry and Clinical Neurosciences 2010; 64: 274–278.

[24] Curkendall SM, Mo J, Glasser DB, Rose Stang M, Jones JK. Cardiovascular disease in patients with schizophrenia in Saskatchewan, Canada. Journal of Clinical Psychiatry

[25] Chafetz L, White M, Collins-Bride G, Nickens J. The poor general health of the se‐ verely mentally ill: Impact of schizophrenic diagnosis. Community Mental Health

[26] Copeland LA, Mortensen EM, Zeber JE, Pugh MJ, Restrepo MI, Dalack GW. Pulmo‐ nary disease among inpatient decedents: Impact of schizophrenia. Progress in Neu‐

[27] Bushe CJ, Hodgson R. Schizophrenia and cancer: in 2010 do we understand the con‐

[28] Shapiro SD, Ingenito EP. The pathogenesis of chronic obstructive pulmonary disease: advances in the past 100 years. American Journal of Respiratory Cell and Molecular

[29] Sherman CB. The health consequence of cigarette smoking. Pulmonary diseases.

[30] Joukamaa M, Heliövaara M, Knekt P, Aromaa A, Raitasalo R, Lehtinen V. Mental disorders and cause specific mortality. British Journal of Psychiatry 2001; 179(6) 498–

[31] Chambers RA, Krystal JH, Self DW. A neurobiological basis for substance abuse co‐

[32] de Leon J. Smoking and vulnerability for schizophrenia. Schizophrenia Bulletin 1996;

[33] D'Souza MS, Markou A. Schizophrenia ad tobacco smoking comorbidity: nAChR ag‐ onists in the treatment of schizophrenia-associated cognitive deficits. Neuropharma‐

morbidity in schizophrenia. Biological Psychiatry 2001; 50; 71-83.

ro-Psychopharmacology and Biological Psychiatry 2007; 31(3) 720-726.

nection? Canadian Journal of Psychiatry 2010; 55(12) 761-767.

Medical Clinics of North America 1992; 76(2) 355–371.

ophrenia. Journal of Clinical Psychiatry 2008; 69(11) 1743–1750.

within primary care. Primary Psychiatry 2010; 17(1) 49-54.

agnoses. Public Health 2001; 115; 328–337.

304 Mental Disorders - Theoretical and Empirical Perspectives

2004; 65(5) 715-720.

Journal 2005; 41(2) 169-184.

Biology 2005; 32(5) 367-372.

502.

22; 405–409.

cology 2012; 62; 1564-1573.


[47] Barr RS, Culhane MA, Jubelt LE, Mufti RS, Dyer MA, Weiss AP, Deckersbach T, Kel‐ ly JF, Freudenreich O, Goff DC, Evins AE. The effects of transdermal nicotine on cog‐ nition in nonsmokers with schizophrenia and nonpsychiatric controls. Neuropsychopharmacology 2008; 33(3) 480-490.

[59] Zigmond A, Snaith R. The Hospital Anxiety and Depression Scale. Acta Psychiatrica

The Characteristics of Nicotine Addiction Among Patients with Schizophrenia

http://dx.doi.org/10.5772/54308

307

[60] McCue P, Buchanan T, Martin CR. Screening for psychological distress using internet administration of the Hospital Anxiety and Depression Scale (HADS) in individuals with chronic fatigue syndrome. British Journal of Clinical Psychology 2006; 45(4)

[61] Bjelland I, Dahl A, Haug T, Neckelmann D. The validity of the Hospital Anxiety and Depression Scale: An updated literature review. Journal of Psychosomatic Research

[62] McPherson A, Martin CR. Is the Hospital Anxiety and Depression Scale (HADS) an appropriate screening tool for use in an alcohol-dependent population? Journal of

[63] Olsson I, Mykletun A, Dahl A. The Hospital Anxiety and Depression Rating Scale: a cross-sectional study of psychometrics and case finding abilities in general practice.

[64] Wojtyna E. Termometr Dystresu jako narzędzie przesiewowe u osób chorych psy‐

[65] Olincy A, Young DA, Freedman R. Increased levels of the nicotine metabolite coti‐ nine in schizophrenic smokers compared to other smokers. Biological Psychiatry

[66] McEvoy J, Freudenreich O, McGee M, VanderZwaag C, Levin E, Rose J. Clozapine decreases smoking in patients with chronic schizophrenia. Biologic Psychiatry 1995;

[67] Hutchison KE, Rutter MC, Niaura R, Swift RM, Pickworth WB, Sobik L. Olanzapine attenuates cue-elicited craving for tobacco. Psychopharmacology 2004; 175; 407-413.

[68] Ritsner M, Perelroyzen G, Ilan H, Gibel A. Subjective response to antipsychotics od schizophrenia patients treated in routine clinical practice: A naturalistic comparative

[69] Spendel Z. O pewnych niebezpieczeństwach nadużywania etykiet zastępczych. Niespecyficzne Zmienne Zagregowane (NZZ) w badaniach psychologicznych. In: Popiołek K, Bańka A (eds.) Kryzysy, katastrofy, kataklizmy w kontekście narastania

zagrożeń. Poznań: Stowarzyszenie Psychologia i Architektura; 2007. p335-356.

study. Journal of Clinical Psychopharmacology 2004; 24(3) 245-254.

Scandinavica 1983; 67(6) 361-370.

Clinical Nursing 2011; 20; 1507–1517.

BMC Psychiatry 2005, 5; 46.

chicznie. (in press).

1997; 42; 1-5.

37; 550-552.

483–498.

2002; 52; 69-77.


[59] Zigmond A, Snaith R. The Hospital Anxiety and Depression Scale. Acta Psychiatrica Scandinavica 1983; 67(6) 361-370.

[47] Barr RS, Culhane MA, Jubelt LE, Mufti RS, Dyer MA, Weiss AP, Deckersbach T, Kel‐ ly JF, Freudenreich O, Goff DC, Evins AE. The effects of transdermal nicotine on cog‐ nition in nonsmokers with schizophrenia and nonpsychiatric controls.

[48] Harris B, Kongs S, Allensworth D, Martin L, Tregellas J, Sullivan B, Zerbe G, Freed‐ man R. Effects of nicotine on cognitive deficits in schizophrenia. Neuropsychophar‐

[49] Sacco K, Termine A, Seyal A, Dudas M, Vessicchio J, Krishnan-Sarin S, Jatlow PI, Wexler BE, George TP. Effects of cigarette smoking on spatial working memory and attentional deficits in schizophrenia: Involvement of nicotinic receptor mechanisms.

[50] Schmitz N, Kruse J, Kugler J. Disabilities, quality of life, and mental disorders associ‐ ated with smoking and nicotine dependence. American Journal of Psychiatry 2003;

[51] Ziedonis D, Hitsman B, Beckham JC, Zvolensky M, Adler LE, Audrain-McGovern J, Breslau N, Brown RA, George TP, Williams J, Calhoun PS, Riley WT. Tobacco use and cessation in psychiatric disorders: National Institute of Mental Health report.

[52] Forchuk C, Norman R, Malla A, Martin ML, McLean T, Cheng S, Diaz K, McIntosh E, Rickwood A, Vos S, Gibney C. Schizophrenia and the motivation for smoking, Per‐

[53] Solway ES. The lived experiences of tobacco use, dependence, and cessation: Insights and perspectives of people with mental illness. Health and Social Work 2011; 36(1)

[54] de Leon J, Gurpegui M, Diaz FJ. Epidemiology of comorbid tobacco use and schizo‐ phrenia: Thinking about risks and protective factors. Journal of Dual Diagnosis 2007;

[55] Heatherton TF, Kozlowski LT, Frecker RC, Fagerström KO. The Fagerström Test for Nicotine Dependence: A revision of the Fagerström Tolerance Questionnaire. British

[56] Steinberg ML, Williams JM, Steinberg HR, Krejci JA, Ziedonis DM. Applicability of the Fagerström Test for Nicotine Dependence in smokers with schizophrenia. Addic‐

[57] Prochaska JO, DiClemente CC, Norcross JC. In search of how people change. Appli‐ cations to addictive behaviors. American Psychologist 1992; 47(9) 1102–1114.

[58] DiClemente CC, Prochaska JO, Fairhurst SK, Velicer WF, Velasqquez MM, Rossi JS. The process of smoking cessation: An analysis of precontemplation, contemplation, and preparation stages of change. Journal of Consulting and Clinical Psychology

Neuropsychopharmacology 2008; 33(3) 480-490.

Archives of General Psychiatry 2005; 62; 649-659.

Nicotine and Tobacco Research 2008; 10(12) 1691-1715.

spectives in Psychiatric Care 2002; 38(2) 41–49.

Journal of Addiction 1991; 86(9) 1119–1127.

tive Behaviors 2005; 30(1) 49-59.

1991; 59; 295-304.

macology 2004; 29; 1378-1385.

306 Mental Disorders - Theoretical and Empirical Perspectives

160; 1670-1676.

19-32.

3(3/4) 9-25.


**Chapter 14**

**Post Traumatic Eco-Stress Disorder (PTESD): A**

**Qualitative Study from Sundarban Delta, India**

International Classification of Diseases, ICD– 10, [78] defined PTSD (code F43.1) as: "Arises as a delayed or protracted response to a stressful event or situation (of either brief or long duration) of an exceptionally threatening or catastrophic nature, which is likely to cause per‐ vasive distress in almost anyone…. Typical features include episodes of repeated reliving of the trauma in intrusive memories ("flashbacks"), dreams or nightmares, occurring against the persisting background of a sense of "numbness" and emotional blunting, detachment from other people, unresponsiveness to surroundings, anhedonia, and avoidance of activi‐ ties and situations reminiscent of the trauma. There is usually a state of autonomic hyperar‐ ousal with hypervigilance, an enhanced startle reaction, and insomnia. Anxiety and depression are commonly associated with the above symptoms and signs, and suicidal idea‐ tion is not infrequent. The onset follows the trauma with a latency period that may range from a few weeks to months. The course is fluctuating but recovery can be expected in the majority of cases. In a small proportion of cases the condition may follow a chronic course over many years, with eventual transition to an enduring personality change." *PTSD was first recognized as a clinical entity in the third edition of the* the Diagnostic and Statistical Manual

In the last 30 years considerable research has accumulated which has provided deep insight not only into the epidemiology but also the conceptual framework of different categories of trauma and its differential impacts and coping psychodynamics. The classification of causes

and reproduction in any medium, provided the original work is properly cited.

© 2013 Chowdhury et al.; licensee InTech. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

© 2013 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution,

of trauma based on available research findings may be categorized as follows:

Arabinda N. Chowdhury, Ranajit Mondal, Mrinal K Biswas and Arabinda Brahma

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/52409

of Mental Disorders in 1980.

**1. Introduction**

**Chapter 14**
