The majority of patients with schizophrenia smoke, often prior to onset of psychosis. In a typical community mental health center, you can expect that 7 of 10 patients with schizophrenia smoke, a conservative estimate. Patients with schizophrenia are heavy smokers (often >20 cigarettes/day), suggesting that many patients are severely addicted to nicotine. Smoking is not only one of the Framingham risk factors for heart disease, but it also causes a host of smoking-related lung diseases that can lead to early death or reduce quality of life (e.g., chronic obstructive pulmonary disease).

Traditionally, smoking was seen to be part of the mental health culture; the smoke break continues to be part of many hospital routines to combat boredom. Mental health counselors who smoked saw smoking with patients as an opportunity for engagement rather than as a problem. Some remain
confused about the potential benefits of smoking in this population, such as calming patients or treating a presumed nicotinic deficit. As a result, nicotine dependence has not been addressed as vigorously in this patient population as in the rest of society. This attitude is changing, albeit slowly.

I cannot overemphasize the pernicious effects of low expectations. From social science research, we know that nothing is more effective in creating poor outcomes than low expectations. I have been taught by many patients with schizophrenia that smoking cessation is possible, even in cases that seemed beyond hope. As Mark Twain recognized, sustained abstinence requires more than one attempt—on average, five attempts in ex-smokers from the general population. It is, however, incorrect to claim that severely addicted patients with schizophrenia do as well with smoking cessation as normal control-population cohorts. In some patients, harm reduction (smoking less) might be all that can be accomplished in a given quit attempt. Smoking less, however, can lead to compensatory smoking with higher exposure to carbon monoxide (CO) and carcinogens. The literature is also pointing toward higher relapse rates in patients with schizophrenia once pharmacologic smoking cessation treatment is withdrawn, indicating that some degree of treatment might have to be provided on an ongoing basis (Evins et al., 2005).