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Nicotine dependence and illness severity in schizophrenia

  • Rajeev Krishnadas (a1), Sameer Jauhar (a2), Susan Telfer (a3), Somashekara Shivashankar (a4) and Robin G. McCreadie (a5)...

Reasons for the increased prevalence of cigarette smoking in schizophrenia are unclear. Studies assessing clinical symptoms have sampled heterogeneous populations, with discrepant findings.


To examine the relationship between clinical features, social adjustment and nicotine dependence in a geographically defined population of people with schizophrenia.


Cross-sectional clinical study of 131 people with schizophrenia in Nithsdale, Scotland.


Smokers were younger, mostly males and three times more likely to be unemployed. Those with severe nicotine dependence had greater scores on the positive subscale of the Positive and Negative Syndrome Scale (PANSS), and were prescribed higher doses of antipsychotic. Those with mild–moderate dependence had greater scores on the PANSS negative subscale. Greater symptom severity was associated with poorer social adjustment. Psychopathology and social adjustment were similar in quitters and never-smokers.


Our findings indicate an association between nicotine dependence, clinical symptoms and social adjustment in schizophrenia. Although causal links cannot be inferred, identifying the relationship between nicotine dependence and psychopathology may have some value in the management of smoking in schizophrenia. Further longitudinal studies are required to explore this relationship.

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Corresponding author
Rajeev Krishnadas, Sackler Institute of Psychobiological Research, University of Glasgow, Southern General Hospital, Glasgow G51 4TF, UK. Email:
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Nicotine dependence and illness severity in schizophrenia

  • Rajeev Krishnadas (a1), Sameer Jauhar (a2), Susan Telfer (a3), Somashekara Shivashankar (a4) and Robin G. McCreadie (a5)...
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Nicotine dependence and illness severity in schizophrenia

MARTINS O. ISERHIENRHIEN, Staff Grade Psychiatrist
05 December 2012

This article addresses a common problem in current psychiatric practice. The National Health Service may want to pride itself in the factthat the 'no smoking' policy is largely implemented in most of its sites except of course the mental health services. The Mental Health Services appear to have recognised that implementing it wholesale in their acute and long stay wards is not practicable as nursing the patients will becomeall the more difficult. This article, though a survey and hence difficult to draw any causal link, has given some credence to the fact that mental health patients may to some extent be 'self-medicating' with nicotine so as to 'get some life back' that has been 'stolen' from them by the antipsychotics. But unfortunately for them they end up being prescribed higher doses of the antipsychotic medications with all the attendant consequences. There has always been a high prevalence of smoking among psychiatric patients, up to 62% as quoted by this article. I currently work in a 45 bedded rehabilitation unit and the smoking rate in the unit is always between 90 - 100%. And most of the disruptions to the smooth running of the ward can be traced to attempts to restrict access to smoking. The possibility of nicotine dependence among these patients is therefore not in doubt. The need for more research in this area cannot be over emphasised. And until we acquire more understanding of the underlyingphysiological basis between schizophrenia and increased nicotine use, the National Health Service 'no smoking' policy in its current approach may remain unsuccessful within the Mental Health Services.

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Conflict of interest: None declared

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Smokers versus Non-Smokers

Elizabeth Cummings, Senior Registrar
26 October 2012

A junior colleague presented the article(1) at a recent journal club,prompting considerable debate and angst, before glibness descended. The room contained mostly non-smokers, and a few fond ex-smokers.

We appreciate the value of such an investigation, especially given the author's rather disappointing finding that smoking rates amongst patients with schizophrenia remain stubbornly unchanged over a ten year period (1). We would have reservations over the use of a single PANSS score, a single snapshot in time of symptom burden, which appeared to us short of optimum given that the cluster of symptoms and impairments seen in schizophrenia typically varies considerably within a single individual across time (2).Pragmatists all, we have tended to define our patients in a binary way, assmokers or non-smokers. We were surprised at the sub-dividing of smokers into a relatively small (n=20) and a larger (n=50) group, especially as this gave rise to what appeared to be contradictory results.

The ex-smokers, teetering on the brink, taking long inhalations, indicated that they would be taking the following messages home:

"If you are a smoker, smoke more for fewer negative symptoms". (Those in the severe dependence category scored lower than those in the mild dependence category on the PANNS negative score)."If you are a non-smoker, smoke a bit, for fewer positive symptoms". (Those in the mild dependence category scored lower on PANSS negative scores.)The ex-smokers then went outside, murmuring about avoiding Parkinson's (3)and Ulcerative Colitis (4). Could the authors help by clarifying the results of a smoking/non-smoking analysis?

1.Krishnadas R, Jauhar S, Telfer S, Shivashankar S, McCreadie RG. Nicotine dependence and illness severity in schizophrenia. The British Journal of Psychiatry. 2012.2.Eaton WW, Thara R, Federman B, Melton B, Liang K-y. Structure and Course of Positive and Negative Symptoms in Schizophrenia. Arch Gen Psychiatry. 1995;52(2):127-34.3.Hern?n MA, Takkouche B, Caama?o-Isorna F, Gestal-Otero JJ. A meta-analysis of coffee drinking, cigarette smoking, and the risk of Parkinson's disease. Annals of Neurology. 2002;52(3):276-84.4.Logan RF, Edmond M, Somerville KW, Langman MJ. Smoking and ulcerative colitis. British medical journal (Clinical research ed). 1984;288(6419):751-3.

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Re:Nicotine dependence in patients with Schizophrenia

Rajeev Krishnadas, Clinical Lecturer
26 October 2012

Dear Editor,

We would like to thank Drs Basu and Nebhinani for their interest in our paper. We agree with them that recent studies have questioned the psychometric properties of FTND in this population. Indeed, as Steinberg et al suggest, we may have underestimated nicotine dependence by using FTND.(1) We have acknowledged this shortcoming in the article. We conducted a Principal components analysis (PCA) on our dataset, in accordance with Steinberg et al. Our results revealed a two factor structure similar to that of Radzius et al, explaining 53% of the total variance. (2) The first factor reflected the degree of urgency to restore nicotine levels after night-time abstinence, and the second factor reflected the persistence with which nicotine levels are maintained duringwaking hours, thereby tapping into different domains of nicotine dependence itself. This is in contrast to Steinberg et al who found two factors that were non-meaningful. In addition to other limitations acknowledged by Steinberg et al, the use of exploratory factor analysis techniques have a number of methodological concerns. Most importantly, interpreting the results of any exploratory analyses like PCA is heuristicand may not necessarily reflect the truth in the given data. (3) This is probably one of the reasons why studies that have used such approaches have shown inconsistent factor structure for the FTND, even in non-psychiatric samples. Such studies should be interpreted with caution. In addition, as Drs Basu and Nebhinani rightly point out, reducing a complex,overlapping and holistic concept such as dependence into a few simple meaningful factors may not be theoretically correct or possible. (4) At a pragmatic level a measure such as pack years (which measures just amount and duration of smoking) may be a useful measure of lifetime nicotine consumption. We are however unaware of any studies that have validated FTND (or its modifications) or pack years using a gold standard diagnosticcriterion for nicotine dependence in the schizophrenia population. The closest we came to was Patkar et al who found a significant correlation (r= .89) between FTND scores and DSM IV diagnosis of nicotine dependence. (5) While it is possible that psychopathology may have affected the FTND scores, in our study, the scale administration was facilitated by two clinicians (SS and ST) thereby lending some objectivity to the measurement. All participants gave written informed consent. We consideredantipsychotic type as a covariate in the model. With regards other potential confounding factors, our relatively small sample size meant thatwe did not have enough power to stratify the sample or to add more covariates into the model. It should however be noted that adding variables that may themselves significantly covary with nicotine dependence (independent variable)- like smokeless nicotine / substance useand physical co-morbidity - to our model, in view of controlling for theireffects, would have decreased the variance explained by nicotine use itself and therefore would have been deemed inappropriate in this setting. (6)

Reference1.Steinberg ML, Williams JM, Steinberg HR, Krejci JA, Ziedonis DM. Applicability of the Fagerstrom Test for Nicotine Dependence in smokers with schizophrenia. Addict Behav. 2005; 30(1): 49-59.2.Radzius A, Gallo JJ, Epstein DH, Gorelick DA, Cadet JL, Uhl GE, et al. A factor analysis of the Fagerstrom Test for Nicotine Dependence (FTND). Nicotine Tob Res. 2003; 5(2): 255-40.3.Darlington R. Factor analysis. RJ. Applied factor analysis [by] R. J. Rummel. Evanston, Northwestern University Press, 1970.5.Patkar AA, Gopalakrishnan R, Lundy A, Leone FT, Certa KM, Weinstein SP.Relationship between tobacco smoking and positive and negative symptoms inschizophrenia. J Nerv Ment Dis. 2002; 190(9): 604-10.6.Miller GA, Chapman JP. Misunderstanding analysis of covariance. J Abnorm Psychol. 2001; 110(1): 40-8.

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Conflict of interest: None declared

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Nicotine dependence in patients with Schizophrenia

Aniruddha Basu, Psychiatrist
12 October 2012

We read with interest the important and clinically relevant study titled 'Nicotine dependence and illness severity in schizophrenia' by Krishnadas et al.1 Patients with severe nicotine dependence had greater scores on the positive subscale of the positive and negative syndrome scale (PANSS) and mild-moderate dependence had greater scores on the PANSS negative subscale compared with non-smokers. As rightly pointed outby the authors, this finding is in contrast to a previous study2 done in the same area and similar others.3 The reason appears to be the use of Fagerstrom Test for nicotine dependence (FTND) in this study, which has limited psychometric properties in patients with schizophrenia. They have argued for the validity of FTND in schizophrenia, by citing the article byWeiberger et al.4 Notwithstanding, the methodological superiority of the study in terms of presence of a proper control group, the difficulty of using FTND in schizophrenics cannot be denied on a pragmatic basis. It has been widely accepted since last few decades that dependence is a more holistic concept and cannot be attributed only to amount or duration of smoking. However, Steinberg et al5 has raised objections against the questions in FTND like 'time to first smoking', 'difficulty abstaining from cigarette in forbidden places' and 'frequency of smoking in the firsthours after waking' up by means of factor analysis study on schizophrenia patients. In fact, modification of FTND for serious mentally ill population has been suggested in view of their frequent impairment in judgment and insight. Such appropriate scale was also useful in this studybecause all the patients were residents of supported accommodation and there was lack of any objective assessment of nicotine use. Moreover, the emphasis on the amount smoked even in cross-sectional study like this would have better helped to verify the authors hypothesis that 'those withsevere dependence have successfully overcome negative symptoms by increasing their level of nicotine dependence', though a longitudinal study is essential in settling this issue. We advocate the concept of pack-years in this regard. The authors adjusted the results for many co-variants but left out severalimportant variables which may act as important confounders such as use of smokeless nicotine, other substance use, presence of physical disorders, and type of antipsychotics, other psychotropic medications. They have alsonot mentioned whether the consent from participants was taken or not. The fact that daily dose of medication was greater in the severely dependent group raises the possibility of a pharmacokinetic interaction orindicates the presence of a poor prognosis sub-type with neurobiological underpinnings which is to be clarified in future studies. In this study, majority of patients were smoking to relax, to socialise better, or to alleviate their loneliness, anxiety and depressive symptoms.This makes strong case for holistic treatment approach, rather than just prescribing antipsychotic medication as many of the mentioned attributing factors can be addressed with multimodal treatment approach.


1.Krishnadas R, Jauhar S, Telfer S, Shivashankar S, McCreadie RG. Nicotine dependence and illness severity in schizophrenia. Br J Psychiatry2012; 201: 306-12.

2. Kelly C, McCreadie RG. Smoking habits, current symptoms, and premorbid characteristics of schizophrenic patients in Nithsdale, Scotland. Am J Psychiatry 1999; 156: 1751-7.

3. Smith RC, Singh A, Infante M, Khandat A, Kloos A. Effects of cigarette smoking and nicotine nasal spray on psychiatric symptoms and cognition in schizophrenia. Neuropsychopharmacology 2002; 27: 479-97.

4. Weinberger AH, Reutenauer EL, Allen TM, Termine A, Vessicchio JC,Sacco KA, et al. Reliability of the Fagerstr?m Test for Nicotine Dependence, Minnesota Nicotine Withdrawal Scale, and Tiffany Questionnairefor Smoking Urges in smokers with and without schizophrenia. Drug Alcohol Depend 2007; 86: 278-82.

5. Steinberg ML, Williams JM, Steinberg HR, Krejci JA, Ziedonis DM. Applicability of the Fagerstr?m Test for Nicotine Dependence in smokers with schizophrenia. Addict Behav 2005; 30: 49-59.

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