As part of a detailed study of the smoking habits of all known people with schizophrenia living in Nithsdale, south-west Scotland (n=168; Reference Kelly, McCreadie and MacEwanKelly & McCreadie, 1999) we found that 58% were current smokers, a rate more than twice that found in the local general population (28%). Those found to smoke, smoked on average 26 cigarettes per day. Ninety per cent of sufferers had started smoking before the onset of the illness. We concluded that smoking may be a marker of the neurodevelopmental form of the illness, and may be another environmental risk factor for schizophrenia in vulnerable individuals.

In our review of the literature, one publication (Reference Marsh and McKayMarsh & McKay, 1994) drew our attention to the fact that smokers are often those who can least afford the habit, and that a proportion of their state benefits is immediately returned to the UK Treasury in the form of tobacco tax. Certainly, more of our smoking patients (21%) than our non-smoking patients (6%) told us that they did not have enough money to take care of their needs (χ²=4.15, d.f.=1, P=0.04). This finding prompted us to do some simple arithmetic.

CALCULATIONS

At the time of writing, the cost of one of the cheaper brands of cigarettes (our patients generally smoke cheaper brands) is £2.79 for a packet of 20. Of this, the tobacco and value-added taxes amount to £2.44 (information from Tobacco Manufacturers Association, London, July 1998). Therefore, a person with schizophrenia who smokes 26 cigarettes per day gives to the government £22.50 per week in the form of tax, or £1154 per year. Few people with schizophrenia work; in the most recent review of our patients in Nithsdale (Reference Kelly, McCreadie and MacEwanKelly et al, 1998) only 8% were in employment. A ‘typical’ person with schizophrenia in Nithsdale is young, male, single and unemployed, and lives in social (‘council’) housing (69% of young males were smokers). The individual's state benefits, excluding housing benefit, are likely to be £71.80, £85.40 or £123.15 per week depending on assessed level of disability; these are ‘money in hand’ figures (information from Department of Social Security, Dumfries, July 1998). Hence, such a patient who smokes 26 cigarettes per day returns 18-31% of his benefits to the Treasury.

With a prevalence of psychosis at 4 per 1000 of the population aged 16-64 years (Reference Jenkins, Bebbington and BrughaJenkins et al, 1998), there are probably at least 200 000 people with schizophrenia in the UK. If 60% smoke, and smoke on average 26 cigarettes per day, the contribution to the Treasury is £139 million per year. The direct treatment costs of schizophrenia have been variously estimated at around £397 million per year in the UK (Reference Davies and DrummondDavies & Drummond, 1994) and £714 million in England (Reference KnappKnapp, 1997). Whatever the exact figure, people with schizophrenia are, through their smoking habits, contributing substantially to the cost of their own care.

COMMENT

We have argued elsewhere (Reference Kelly, McCreadie and MacEwanKelly & McCreadie, 1999) that smoking in schizophrenia sufferers is intimately associated with the disease process. Most of these people are also unemployed as a result of the illness. This double blow of smoking and unemployment hits the patients very hard, financially. The state loses less; what it gives to this vulnerable group in our community with one hand it takes back with the other.