Schizophrenia Bulletin vol. 38 no. 3 pp. 543–551, 2012 doi:10.1093/schbul/sbq124 Advance Access publication on November 1, 2010

Perception of Smoking Risks and Motivation to Quit Among Nontreatment-Seeking Smokers With and Without Schizophrenia

Deanna L. Kelly1,*, Heather G. Raley1, Suzanne Lo2, Katherine Wright1, Fang Liu1, Robert P. McMahon1, Eric T. Moolchan3, Stephanie Feldman1, Charles M. Richardson1, Heidi J. Wehring1, and Stephen J. Heishman2 1

Maryland Psychiatric Research Center, University of Maryland, Baltimore School of Medicine, Box 21247, Baltimore, MD 21228; Intramural Research Program, National Institute on Drug Abuse, National Institutes of Health, Baltimore, MD; 3Alkermes, Inc., Cambridge, MA 2

*To whom correspondence should be addressed; tel: 410-402-6860, fax: 410-402-6038, e-mail: [email protected]

Objective: We examined perceived consequences/benefits of cigarette smoking and motivation for quitting in nontreatment-seeking smokers who had schizophrenia or schizoaffective disorder (N 5 100) or had no Axis I psychiatric disorder (normals, N 5 100). Methods: Participants completed questionnaires and provided a breath carbon monoxide (CO) sample 10–15 minutes after smoking 1 preferredbrand cigarette. Primary assessments included the Smoking Consequences Questionnaire-Adult, the Reasons for Quitting Scale, and the Stages of Change. Results: There were no differences between the schizophrenia and control group in mean age of smoking onset (16.2 5.4 vs 15.6 5.5 y, P 5 .44), number of cigarettes daily (17.9 11.6 vs 17.0 7.9, P 5 0.51), or in breath CO (28.0 14.5 vs 22.9 8.0 ppm, P 5 .61). Compared with normals, people with schizophrenia report greater stimulation/state enhancement (P < .0001) and social facilitation (P < .004) from smoking. People with schizophrenia had less appreciation of health risks associated with smoking than normal controls (P < .0001) and were less motivated to quit smoking than normal controls (P 5 .002), even though they were as likely to be in the preparation stage of change. Immediate reinforcement (P 5 .04) and health concerns (P 5 .002) were rated lower as motivators for considering quitting smoking in schizophrenia than normals. People with schizophrenia reported greater motivation to stop smoking due to social pressure/ rewards than normals (P 5 .047). Conclusions: This study underscores the degree to which people with schizophrenia perceive the state-enhancing effects of smoking and their lower appreciation for health risks of smoking compared with normal controls.

Introduction People with schizophrenia have a high prevalence of smoking with reported rates of 58%–90%.1,2 This is considerably higher than smoking rates of 24%3 in the general public and approximately 50% in people with other psychiatric diagnoses.4,5 Additionally, people with schizophrenia who smoke are also heavier smokers than smokers in the general population.6 Although the causes of this high prevalence are not known, increased smoking in schizophrenia is believed to be due to a complex interaction of psychological, behavioral, and environmental factors. It was believed in the past that heavy and frequent cigarette smoking in people with schizophrenia was attributable to boredom, institutionalization, or cigarette rewards for good behavior on treatment units.7 More recently, it has been recognized that smoking represents more than ‘‘something to do.’’ Cigarette smoking may partially represent an attempt at self-medication to control symptoms not addressed by antipsychotic medications.8 Studies of the effects of nicotine in people with schizophrenia have shown improvements in areas including learning and memory, eye tracking, prepulse inhibition of acoustic startle response, and P50 sensory inhibition.9–12 Additionally, smoking is associated with reduced akathisia.13 There is evidence implicating the nicotinic cholinergic system, specifically the alpha7 nicotinic receptor, in the pathophysiology of schizophrenia.14 Activation of the nicotinic acetylcholine receptors can increase glutamate release onto layer V pyramidal neurons of the prefrontal cortex. This is important because schizophrenia pathology also involves abnormal cortical activation, n-methyl-D-aspartate (NMDA) hypofunction, and difficulty with cognition.15 NMDA hypofunction may contribute to cognitive impairments associated

Key words: smoking/schizophrenia/motivation/health risks

Ó The Author 2010. Published by Oxford University Press on behalf of the Maryland Psychiatric Research Center. All rights reserved. For permissions, please email: [email protected].

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with schizophrenia, and agents targeting both nicotinic and NMDA receptors may show promise for improving cognitive deficits present in many people with this illness.16,17 Thus, evidence suggests that nicotinic modulation plays a role in reasons for smoking in schizophrenia patients ie potentially different from reasons for smoking in normal controls. Smoking in schizophrenia may be an attempt to reverse glutamatergic dysfunction, improve cognitive symptoms, and improve symptomatology; this may partially explain the significantly higher rate of smoking in this population. Smoking is the single greatest preventable cause of death in our society. Our group has recently demonstrated that, in smokers compared with nonsmokers with schizophrenia, the risk of mortality is doubled, and the risk of cardiac-related morality is increased about 12-fold.18 To date, results of long-term pharmacological and behavioral treatment studies in this population have been modest with relatively small sample sizes and few successful quitters at study endpoint.4,19–24 Recently, one of the largest randomized controlled trial for a smoking intervention in patients with psychotic disorders was completed and published.4 The investigators assigned 151 patients to routine care and 147 patients to an 8 session, individually administered treatment intervention consisting of nicotine replacement therapy, motivational interviewing, and cognitive behavioral therapy. Although the study showed modest benefits for intensive medication and behavioral support (11% continuous abstinence at 3 mo), this result was driven by the subjects who participated in all treatment sessions. It is noteworthy that the 6-month abstinence rates were 5% and point prevalence abstinence rates were 10%, demonstrating that even with intense treatment, the abstinence rates are much lower than other psychiatric populations. However, accumulating data including recent meta-analyses show that bupropion is effective for increasing smoking abstinence in schizophrenia in the short term (7 trials N = 340, risk ratio [2.84]; 95% CI 1.02–7.58). Six-month data in this metaanalysis are also accumulating to suggest that bupropion is effective for longer term treatment as well.25 Banham and Gilbody26 also reported similar abstinence rates with bupropion in their recent meta-analysis and reported this to be comparable with figures for the general population. Of particular note, the recent Schizophrenia Patient Outcomes Team guidelines now recommend bupropion (6 nicotine replacement therapy) and psychosocial treatment for smokers with schizophrenia.27 Thus, while people with schizophrenia may have a more difficult time achieving abstinence with both behavioral and pharmacological treatments, clinicians should be aware that effective treatments are available, and until better strategies are proven in this population, smoking cessation treatment such as bupropion should be considered to address smoking cessation as a treatment goal in people with this illness. 544

To enable researchers and clinicians to select or adapt treatments for the specific needs of this population particularly in hopes of long-term abstinence, better understanding is needed of perceptions of smoking risks, rewards of smoking, and the motivation for quitting among people with schizophrenia. Tobacco dependence is a serious addiction that should be addressed as part of recovery-based mental health treatment.20 It remains largely unknown, however, how people with schizophrenia perceive smoking risks and how these perceptions might influence their motivation to quit smoking. Understanding these issues is critical because treatment for tobacco dependence in schizophrenia has been largely ineffective to date. This study examined knowledge and perception of smoking risks and motivation for quitting in 200 nontreatment-seeking smokers (100 with schizophrenia and 100 normal controls). Study Design and Methods Participants This study included smokers who were not seeking treatment for tobacco dependence. Two groups were recruited, those with a Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition, Text revised) (DSM-IV) diagnosis of schizophrenia or schizoaffective disorder (noted throughout as ‘‘schizophrenia’’) and those with no major DSM-IV Axis I disorder (‘‘normal controls’’). Status as schizophrenia or normal control was confirmed by the Structured Clinical Interview for Axis I DSM-IV Disorders (SCID). All participants were between the ages of 18 and 65 years old, smoked at least 5 cigarettes/day, had a breath carbon monoxide (CO) measure of 8 ppm, and were not interested in reducing or quitting tobacco use at the time of the study. Patient volunteers were recruited from the Maryland Psychiatric Research Center Outpatient and Inpatient Programs and its related study network. Normal control smoking volunteers were recruited by the National Institute on Drug Abuse (NIDA) via print, radio, and television advertisements for participation in a study not offering treatment. After complete description of the study to the subjects, written informed consent was obtained. The single study visit was 2–3 hours in length. Subjects completed pencil and paper questionnaires with a trained Master’s Level Research Associate present for questions. Subjects were paid for their time in the study and reimbursed for their travel to the study site. Study procedures and consent forms were reviewed and approved by the University of Maryland and NIDA Institutional Review Boards. Procedures The study consisted of 1 visit, at which each subject, after signing consent, participated in a semi-structured interview and answered clinical and demographic

Perceived Smoking Risks and Schizophrenia

information. Following consent, screening procedures took place, including a breath CO measurement and SCID. At the conclusion of the screening and demographic interviews, the subject was asked to smoke a cigarette of their choice prior to the study assessments to standardize the time of last tobacco exposure. If the subject had no cigarettes with him/her, a cigarette, lighter, and ashtray were provided. After the cigarette, study assessments began and CO measurement was obtained approximately 10–15 minutes after the last cigarette. For the CO measurement, subjects exhaled fully, inhaled deeply, and held their breath for 20 seconds before exhaling into a portable breath CO monitor (Vitalograph, Lenexa, Kansas). Vitalograph readings range from 0 to 199 ppm with accuracy of 63 ppm. Measures Primary Measures. Participants completed the following primary assessments: Smoking Consequences Questionnaire-Adult (SCQ-A),23 the Reasons for Quitting Scale (RFQ),19 and a global Likert question (0–7) asking ‘‘I am motivated to quit smoking?’’ (anchors: 1, strongly agree; 4, undecided; and 7, strongly disagree).24 This global Likert question pertained to their current motivation. The SCQ-A assesses beliefs people have about the consequences of smoking a cigarette. It has good internal consistency as assessed by Cronbach’s alpha and adequate test-retest reliability in psychiatric conditions.28 The SCQ-A is a 55-item scale presenting short statements, which subjects rate on a scale of 0–9 (unlikely to likely) indicating that how likely they believe a possible consequence is for them. Scoring for the SCQ-A is summarized into 10 domains. The RFQ scale is a 20-item Likert scale assessing 4 dimensions of motivation to quit smoking: health concerns, self-control, immediate reinforcement, and social influence. Health concerns include shortened life span, others who have died from smoking, concern over own health and body, physical symptoms, and serious-associated illnesses. Self-control includes better selfliking, prove to one’s self, feelings of self-control, proven one can accomplish a goal, and prove one can overcome addiction. Immediate reinforcements included ridding themselves of cigarette smells, saving money from cigarette-related costs (eg, dry cleaning), and saving time from cleaning smoking-related messes. Social influences included nagging family, ultimatums, special gifts, and financial rewards. The first 2 dimensions of the RFQ assess intrinsic motivation and the latter 2 extrinsic motivation. The level of intrinsic relative to extrinsic motivation was calculated as a difference score with the extrinsic scale scores subtracted from the intrinsic score.29 Secondary Measures. Participants completed the Fagerstro¨m Test for Nicotine Dependence (FTND),30 the Stages of Change (SOC),31 and the Tobacco Craving

Questionnaire-Short Form32 (assessed twice; results not presented here). The Quality of Life Index-brief version was used to evaluate perceived health.33 The FTND is reported for outpatients only because this scale is not applicable to participants in smoking-limited inpatient environments. Statistical Analysis. Differences between normal control smokers and smokers with schizophrenia in smoking perceptions/risk and motivation were examined on 10 domains of the SCQA and 4 domains of the RFQ, the SOC, and the FTND. Three subjects in the schizophrenia group did not complete the SOC (N = 97). Comparisons between groups were conducted using Student’s t test or chisquare tests where appropriate. As a secondary aim, ANCOVA was performed to test whether age, sex, or race modified the magnitude of differences between normal smokers and smokers with schizophrenia on these measures. In addition, nicotine dependence was characterized by the FTND as high (score of 6 or higher) or low to moderate dependence (score of 5 or less). High vs low to moderate nicotine dependence was considered as a potential modifier of group differences in the SCQ-A and RFQ domains, using group 3 dependence level interactions terms in the ANCOVA models. To control for multiple comparisons, the Benjamin-Hochberg stepwise modification of the Bonferroni procedure was used to maintain a false discovery rate of 0.0534 for analyses of the multiple subscales within the SCQ-A and RFQ. Post hoc comparisons of inpatient and outpatient groups were examined to report within group differences on clinical variables, the RFQ, the SOC, and the SCQ-A. Power calculations were performed a priori to ensure adequate power (80%) to test for differences in total and subscales of the SCQ-A and RFQ. All statistical analyses were conducted using SAS version 9.1.3. All tests were 2-sided with alpha = 0.05. Results Population Two hundred smokers were enrolled into this study (N = 100 schizophrenia and N = 100 normal controls). The demographic and clinical characteristics are listed in table 1. The schizophrenia group was significantly older and had higher percentages of Caucasians enrolled. Few respondents in either group were currently married (schizophrenia 4% and normal control 9%). The schizophrenia group had similar smoking histories compared with controls. Inpatient and outpatient schizophrenia groups were examined separately to see if those currently hospitalized as inpatients in a volunteer research setting, differed from outpatients. The only difference was that inpatients with schizophrenia smoked fewer cigarettes daily. 545

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Table 1. Demographic and Clinical Characteristics

Age (y) Sex (male) Race Caucasian African American Other races Level of education (y) Marital status Presently married Widowed Divorced/separated Single Level of family supporta Outpatient status (schizophrenia only) FTND (total)b Number of cigarettes smoked daily Outpatients, N = 72 Inpatients, N = 28 Expired COc Age at beginning of regular smoking (y) Age at first puff (y) Age at first whole cigarette (y) Self-report health ratingd Self-report physical conditiond Self-report emotional well-beingd

Schizophrenia (N = 100)

Normal Controls (N = 100)

Statistics

43.3 6 11.4 71 (71%)

37.1 6 10.6 65 (65%)

t = 3.99, df = 198, P = .00009 v2 = 0.83, df = 1, P = .36 v2 = 17.2, df = 2, P = .0002

61 (61%) 37 (37%) 2 (2%)

32 (32%) 66 (66%) 2 (2%)

12.0

11.8

6

2.0

6

1.8

4 (4%) 1 (1%) 17 (18%) 73 (77%)

9 (9%) 2 (2%) 22 (22%) 66 (67%)

63.1 6 29.7 72 (72%) 5.5 6 2.0 (N = 72) 17.9 6 11.6

65.9 6 33.4 N.A. 5.3 6 2.0 17.0 6 7.9

21.4 9.0

6

28.0 16.2 14.1 15.1 4.8 4.6 4.7

6

6

6 6 6 6 6 6

11.8 3.8 14.5 5.4 4.8 4.6 1.4 1.4 1.5

t = 0.9, df = 193, P = .39 v2 = 3.2, df = 3, P = .37

t = 0.63, df = 193, P = .53 N.A. t = 0.5, df = 165, P = .62 t = 0.67, df = 174, P = .51 t = 7.91, df = 96, P < .001.

22.9 15.6 13.3 15.0 5.1 5.1 5.2

6 6 6 6 6 6 6

8.0 5.5 5.1 5.0 1.2 1.3 1.3

t t t t t t t

= = = = = = =

0.27, df = 1 P = .61 0.78, df = 192, P = .44 1.12, df = 192, P = .27 0.05, df = 192, P = .96 1.67, df = 196, P = .097 2.69, df = 196, P = .008 2.07, df = 196, P = .04

Note: CO, carbon monoxide; FTND, Fagerstro¨m Test for Nicotine Dependence. There were no differences in clinical data between inpatients and outpatients except for number of cigarettes per day, noted above. Inpatients were in a volunteer program with smoking and ground privileges. a 100 mm visual analog scale (100, fully supportive; 0, no support). b Only applicable to outpatients due to the inability of inpatients to smoke first thing in the morning (questions on dependency relating to morning cigarettes). c Approximately 10–15 minutes after smoking cigarette. d Self-rating item from the Quality of Life Index—Short Version (7 item Delighted–Terrible Scale; 1, terrible; 2, unhappy; 3, mostly dissatisfied; 4, mixed, about equally satisfied and dissatisfied; 5, mostly satisfied; 6, pleased; and 7, delighted).

Cigarette Smoking Quit Attempts Overall, 88/100 (88%) of schizophrenia smokers and 83/ 100 (83%) of normal controls ever reported trying to quit smoking for at least 24 hours (P = .33). Of those who had tried to quit in the past, the median longest period of abstinence in those with schizophrenia was 75.4 days (interquartile range: 358.3 d). The median longest period of abstinence in the normal group was 45.0 days (interquartile range: 362.3 d) (Wilcoxon v2 = 1.24, df = 1, P = .27). The SOC Questionnaire showed that 14/97 (14%) of people with schizophrenia and 17/100 (17%) of normal controls were in the preparation stage, 12/97 (12%) of patients and 21/100 (21%) of normals were in the contemplation stage, and 71/97 (73%) of patients and 62/100 (62%) of normals were in the precontemplation stage (not thinking of quitting). Differences between people with schizophrenia and controls in the percentages at 546

each stage of change were not statistically significant (v2 = 3.29, df = 2, P = .19). Scores on the global Likert question, ‘‘I am motivated to quit smoking,’’ (scored 1–7) were 4.2 6 1.9 and 3.4 6 2.0 in the schizophrenia and normal groups, respectively (t = 3.1, df = 195, P = .002). Thus, people with schizophrenia rated themselves as less motivated to quit smoking, despite a similar SOC characterization. There were no differences in inpatient and outpatients with schizophrenia on the SOC characterization. Reasons for Quitting The total score and 4 dimensions of the RFQ were calculated (table 2). The total score on the RFQ in the schizophrenia and normal control groups was 37.7 6 18.8 and 41.6 6 16.1, respectively (t = 1.57, df = 196, adjusted P = .14). The level of intrinsic motivation relative

Perceived Smoking Risks and Schizophrenia

Table 2. Reasons for Quitting Scale Schizophrenia Total score Level of intrinsic relative to extrinsic motivation Health concerns (intrinsic) Self-control (intrinsic) Immediate reinforcement (extrinsic) Social pressure (extrinsic)

37.7 1.0

6

2.2 2.0 2.0 1.3

6

6

6 6 6

Normal Controls

Statistics

Adjusted P Value

18.8 1.4

41.6 1.7

6

t = 1.57, df = 196, P = .12 t = 3.67, df = 196, P = .0003

P = .14 P = .002

1.3 1.1 1.1 1.1

2.8 2.2 2.3 1.0

6

6

6 6 6

16.1 1.5 1.0 1.1 0.9 1.0

t= t= t= t=

3.43, 1.33, 2.39, 2.17,

df df df df

= = = =

196, 196, 196, 196,

P P P P

= = = =

.0007 .18 .02 .03

P P P P

= = = =

.002 .18 .04 .047

Note: The Reasons for Quitting Scale scoring: 0, not at all true; 1, a little true; 2, moderately true; 3, quite true; and 4, extremely true. All dimensions contain 5 questions that ask, eg, ‘‘I would consider quitting smoking because I am concerned that I will suffer from a serious illness if I don’t quit smoking.’’ Higher scores indicated a greater consideration of the dimension in quitting smoking. Post hoc comparisons included inpatient and outpatient differences. Immediate reinforcement was rated higher in the outpatients (2.1 6 1.1) compared with inpatient groups (1.7 6 1.0) (t = 2.5, df = 196, adjusted P = .035). No other differences were noted by hospitalization status.

to extrinsic motivation was calculated as 1.0 6 1.4 and 1.7 6 1.5 for schizophrenia and normal controls, respectively (t = 3.67, df = 196, adjusted P = .002). Examining the dimensions of the RFQ, people with schizophrenia were significantly less likely to consider quitting for health concerns (t = 3.43, df = 196, adjusted P = .002) and immediate reinforcement (t = 2.39, df = 196, adjusted P = .04). While both groups rated social pressure to quit very low as a potential motivator, scores were lower in the normal control group than those with schizophrenia (t = 2.17, df = 196, adjusted p = .047). Immediate reinforcement was rated higher in the outpatients (2.1 6 1.1) compared with inpatient groups (1.7 6 1.0) (t = 2.5, df = 196, adjusted P = .035). However, no other differences were noted on the RFQ scale by hospitalization status.

Understanding Smoking Consequences Although differences between people with and without schizophrenia were not significant on the smoking consequences total score, compared with normal controls, people with schizophrenia reported that cigarette smoking was associated with greater stimulation/state enhancement (t = 5.21, df = 195, adjusted P < .0001) and social facilitation (t = 3.34, df = 195, adjusted P = .004). Trends toward greater improvement in negative feelings (t = 2.05, df = 195, P = .04, adjusted P = .09) and taste/sensiomotor manipulation (t = 2.19, df = 195, P = .03, adjusted P = .08) in patients with schizophrenia compared with normal controls were also noted (table 3). People with schizophrenia had a significantly lower appreciation than controls of health risks as a consequence

Table 3. Smoking Consequences Questionnaire Schizophrenia Total SCQ-A score Negative affect reduction Stimulation/state enhancement Health risks Taste/sensorimotor manipulation Social facilitation Appetite/weight control Craving/addiction Negative physical feelings Boredom reduction Social impression

299.2 6.1 5.2 6.5 5.4 5.2 4.3 6.3 3.0 6.6 4.2

6 6 6 6 6 6 6 6 6 6 6

82.0 2.1 2.1 2.5 2.0 2.1 2.6 1.9 2.3 1.9 2.2

Normal Controls

Statistics

Adjusted P Value

283.8 6.4 3.6 8.0 4.8 4.1 4.1 6.7 2.4 6.0 3.7

t t t t t t t t t t t

P P P P P P P P P P P

6 6 6 6 6 6 6 6 6 6 6

76.9 2.3 2.2 1.6 2.2 2.3 2.8 1.4 2.2 2.4 2.5

= 1.37, df = 195, P = .17 = 0.94, df = 195, P = .34 = 5.21, df = 195, P < .0001 = 4.85, df = 160, P < .0001 = 2.19, df = 195, P = .03 = 3.34, df = 195, P = .001 = 0.55, df = 195, P = .58 = 1.64, df = 181, P = .10 = 2.05, df = 195, P = .04 = 1.71, df = 188, P = .09 = 1.44, df = 195, P = .15

= .21 = .38 < .0001 < .001 = .08 = .004 = .58 = .16 = .09 = .16 = .21

Note: SCQ-A, Smoking Consequences Questionnaire-Adult. The mean score of each domain is reported. The scale is scored on a Likert scale of 0–10. 0, completely unlikely; 1, extremely unlikely; 2, very unlikely; 3, somewhat unlikely; 4, a little unlikely; 5, a little likely; 6, somewhat likely; 7, very likely; 8, extremely likely; and 9, completely likely. An example of a question is ‘‘cigarettes keep me from overeating.’’ The scale measures the beliefs about the consequences of smoking a cigarette. Post hoc testing found no significant differences between inpatients and outpatients with schizophrenia on the SCQ, except for inpatients rating higher stimulation/state enhancement as compared with outpatients (5.7 6 2.0 vs 5.0 6 2.1, t = 3.29, adjusted P = .013).

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of cigarette smoking (t = 4.85, df = 160, adjusted P < .0001). Post hoc testing found no significant differences between inpatients and outpatients with schizophrenia on the SCQ, except for inpatients rating higher stimulation/state enhancement as compared with outpatients (5.7 6 2.0 vs 5.0 6 2.1, t = 3.29, df = 195, adjusted P = .013). Multivariate Analyses Controlling for Age, Race, Sex, and Nicotine Dependence Multivariate analyses were performed to examining schizophrenia outpatient-control differences on the RFQ and the SCQ-A controlling for age, sex, race, and low vs high scores on the FTND. There were no significant group interactions with age, race, or sex on the RFQ and the SCQ-A or any of the factor domains. However, on the health consequences item of the SCQ, there was a significant group by FTND interaction (F = 9.3, df = 1, 156, P = .003). This interaction was driven by those with high FTND scores in the schizophrenia outpatient group having a greater understanding of the health consequences of cigarettes than those with low FTND scores (mean 6 SE for difference between schizophrenia participants with high vs low FTND = 2.2 6 0.5) as compared with normal controls (mean 6 SE for high vs low FTND difference = 0.3 6 0.4). Among participants in the high FTND group, the schizophrenianormal control difference was 0.3 6 0.5; among low FTND participants, the schizophrenia-controls difference was 2.2 6 0.5. Thus, reduced (compared with normal controls) understanding of health risks in people with schizophrenia was most prominent among schizophrenia participants with low scores on the FTND. Likewise, the low-dependence group with schizophrenia were the least likely to quit smoking cigarettes for potential health consequences as rated by the RFQ scale (F = 7.04, df = 1, 157, P = .009 for group 3 FTND interaction). The association between FTND scores and RFQ ratings of self-control as a reason for quitting was reversed in patients with schizophrenia compared with normal controls (P = .013 for group 3 FTND interaction). In pairwise tests, the patients with schizophrenia having low dependence were less likely to rate self-control as a motivating factor for quitting than healthy controls with low-dependence scores. Other pairwise comparisons did not differ.

Discussion Smoking remains a significant health problem. People with schizophrenia constitute a population in which smoking rates remain high, and abstinence rates are low. We know little about personal and population factors that may influence or help motivate people with this illness to consider quitting smoking. This study found sig548

nificant differences in beliefs about smoking consequences and motivation for quitting among people with and without schizophrenia. The majority of subjects in both groups (62% controls and 73% schizophrenics) were in the precontemplation stage and were not currently considering quitting smoking. Those with schizophrenia had, on average, lower self-rated motivation to quit smoking. However, over 80% in each group had at least 1 previous quit attempt for 24 hours (88% schizophrenia and 83% controls), and the average number of previous quit attempts was similar number in people with schizophrenia and controls. Other studies have reported that up to two-thirds of people with schizophrenia would ideally like to quit smoking.1 These results suggest that motivating people with schizophrenia to further quit attempts may be feasible with proper education and treatment. Interestingly, people with schizophrenia had lower appreciation for health risks associated with cigarette smoking than controls. Furthermore, potential health consequences were found to be a less compelling reason as a consideration for a potential quit attempt in people with schizophrenia than in controls. In controls, understanding and perception of risks of smoking were similar among participants with high or low levels of dependence on cigarettes. Among participants with schizophrenia, however, overall understanding and perception of risks of smoking were lower in those with lower nicotine dependence. People with schizophrenia rated themselves on average somewhat lower than controls on physical and emotional aspects of quality of life (table 1). Tidey and Rohsenow35 found that health concerns were higher in smokers, both with and without schizophrenia, who were motivated to quit smoking compared with those not motivated to quit. Motivation to quit smoking in schizophrenia might increase if more tailored information on the negative health consequences of smoking were provided to people with schizophrenia. Reasons for smoking and perceived consequences of smoking differed between people with schizophrenia and normal controls. Those with schizophrenia reported significantly higher stimulation and state enhancement and a trend for taste/sensorimotor pleasure compared with the normal controls. Others have also reported that people with schizophrenia have a heightened reward value of smoking cigarettes compared with controls.36 People with schizophrenia in our study also reported greater increases in social facilitation and a trend for greater reductions in negative physical feelings and compared with the normal controls. Few studies have reported why people with schizophrenia smoke and their knowledge of the consequences of smoking. Some studies found that people with schizophrenia smoke for sedative effects, control of negative symptoms and addiction, and stress reduction and stimulation; however, these studies lacked a control

Perceived Smoking Risks and Schizophrenia

group.37,38 Luckstead et al39, in a focus group study, found that improvements in psychiatric symptoms, cognitive function, and social interactions were rated by patients with schizophrenia as reasons for smoking. A small comparison study (N = 61 schizophrenia inpatients and N = 33 health workers) found that stimulation and sensorimotor manipulation were significantly greater reasons for smoking in people with schizophrenia compared with controls.40 Gurpegui et al41 found that compared with normal controls, people with schizophrenia gave higher ratings to improvements in mood, alertness, concentration, calmness, and agility as reasons for smoking. Thus, stimulating effects and sensorimotor pleasure may be strong motivators for smoking in people with schizophrenia and should be considerations in treatment plans aimed at this population. Overall, the intrinsic motivators for smoking cessation were significantly higher in the control group. Others have found that intrinsic motivation was associated with a greater readiness to quit smoking in the general population.19 Extrinsic motivators also differed between the groups. Immediate reinforcements like ridding themselves of cigarette smells, saving money from cigaretterelated costs (eg, dry cleaning), and saving time from cleaning smoking-related messes were rated significantly higher as potential motivators for quitting smoking among normal controls than among people with schizophrenia. However, social pressure to quit was felt to be a more likely motivator in the schizophrenia group than among controls. Social pressure included ultimatums, negative family feelings and special, and financial incentives. Therefore, adding more family involvement and reward incentives to current behavioral techniques may improve successful smoking cessation treatment plans. One study of 26 people with schizophrenia found that participants felt they would require more incentives than other smoking populations.36 Roll et al42 and Tidey et al43 reported that contingency monetary reinforcement for smoking reduction might be efficacious in people with schizophrenia. One consideration is that decisional balance stemming from competing intrinsic and extrinsic motivation might be different between groups based on features of the disease process and social isolation. Of note, our study did find similar results in the Reasons for Quitting scale as did Baker et al38 in their study of 298 people with schizophrenia (no control group) in all domains of the scale. A strength of this study was that 200 people were stringently characterized as to diagnosis (schizophrenia vs no major Axis I disorder) and were recruited to undergo an interview and assessments on smoking behavior, perceptions, and motivating factors. Importantly, control subjects and those with schizophrenia were similar in smoking histories, breath CO, and the number of cigarettes smoked daily. The study was limited by the lack of data on specific psychiatric symptoms or substance

abuse44 in the schizophrenia group. Another limitation was that the control group may not be fully representative of smokers in the general population, as suggested by the high percentage (67%) reporting themselves never married. Nonetheless, this study underscores the degree to which people with schizophrenia perceive the stateenhancing effects of smoking and the lower appreciation for health risks associated with cigarette smoking in patients with schizophrenia compared with the controls, particularly in those with schizophrenia showing low to moderate nicotine dependence. Also, motivators for quitting are different in schizophrenia compared with the general population, and this may be, in part, due to possible self-medication in the schizophrenia group. Given the impact of extrinsic motivators, people with schizophrenia might be more motivated than controls to consider smoking cessation if monetary incentives and rewards were received. The results of this study call for better educational efforts on the health risks associated with cigarette smoking in people with schizophrenia and continued research to improve behavioral strategies that may increase the motivation and success of smoking abstinence in people with schizophrenia. Recent evidence demonstrates that some pharmacological agents (ie, buproprion) may be helpful for treatment of tobacco dependence in schizophrenia,25 and the combination of behavioral and pharmacological treatment27 could maximize treatment outcomes for smokers with schizophrenia. Funding Intramural Research Program of the National Institutes of Health, National Institute on Drug Abuse, and National Institute on Drug Abuse Residential Research Support Services Contract HHSN271200599091CADB, NO-1DA-5-9909 (PI: Deanna L. Kelly). Acknowledgments Preliminary results of this manuscript were presented at the Society for Research in Nicotine and Tobacco, Baltimore, MD, USA, February 2010, and the Schizophrenia International Research Society Meeting, Florence, Italy, April 2010. References 1. Moeller-Saxone K. Cigarette smoking and interest in quitting among consumers at a Psychiatric Disability Rehabilitation and Support Service in Victoria. Aust N Z J Public Health. 2008;32:479–481. 2. Chaves L, Shirakawa I. Nicotine use in patients with schizophrenia evaluated by the Fagerstrom Tolerance Questionnaire: a descriptive analysis from a Brazilian sample. Rev Bras Psiquiatr. 2008;30:350–352.

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3. National Survey of Drug Use and Health (NSDUH).US Department of Health and Human Services, Substance Abuse and Mental Health Services Administration 2009. http://www.oas.samhsa. gov/NSDUH/2k8NSDUH/2k8results.cfm#Ch4. Accessed December 4, 2009. 4. Baker A, Richmond R, Haile M, et al. A randomized controlled trial of a smoking cessation intervention among people with a psychotic disorder. Am J Psychiatry. 2006;163: 1934–1942. 5. Herran A, de Santiago A, Sandoya M, Fernandez MJ, DiezManrique JF, Vazquez-Barquero JL. Determinants of smoking behaviour in outpatients with schizophrenia. Schizophr Res. 2000;41:373–381. 6. Kelly C, McCreadie RG. Smoking habits, current symptoms, and premorbid characteristics of schizophrenic patients in Nithsdale, Scotland. Am J Psychiatry. 1999;156: 1751–1757. 7. Hughes JR, Hatsukami DK, Mitchell JE, Dahlgren LA. Prevalence of smoking among psychiatric outpatients. Am J Psychiatry. 1986;143:993–997. 8. Simosky JK, Stevens KE, Freedman R. Nicotinic agonists and psychosis. Curr Drug Targets CNS Neurol Disord. 2002;1:149–162. 9. Rezvani AH, Levin ED. Cognitive effects of nicotine. Biol Psychiatry. 2001;49:258–267. 10. Hutchison KE, Niaura R, Swift R. The effects of smoking high nicotine cigarettes on prepulse inhibition, startle latency, and subjective responses. Psychopharmacology (Berl). 2000; 150:244–252. 11. Jacobsen LK, D’Souza DC, Mencl WE, Pugh KR, Skudlarski P, Krystal JH. Nicotine effects on brain function and functional connectivity in schizophrenia. Biol Psychiatry. 2004;55:850–858. 12. Barr RS, Culhane MA, Jubelt LE, et al. The effects of transdermal nicotine on cognition in nonsmokers with schizophrenia and nonpsychiatric controls. Neuropsychopharmacology. 2008;33:480–490. 13. Barnes M, Lawford BR, Burton SC, et al. Smoking and schizophrenia: is symptom profile related to smoking and which antipsychotic medication is of benefit in reducing cigarette use? Aust N Z J Psychiatry. 2006;40:575–580. 14. Martin LF, Freedman R. Schizophrenia and the alpha7 nicotinic acetylcholine receptor. Int Rev Neurobiol. 2007;78:225–246. 15. Lambe EK, Picciotto MR, Aghajanian GK. Nicotine induces glutamate release from thalamocortical terminals in prefrontal cortex. Neuropsychopharmacology. 2003;28:216– 225. 16. Coyle JT. Glutamate and schizophrenia: beyond the dopamine hypothesis. Cell Mol Neurobiol. 2006;26:365–384. 17. Kantrowitz JT, Javitt DC. N-methyl-d-aspartate (NMDA) receptor dysfunction or dysregulation: the final common pathway on the road to schizophrenia? Brain Res Bull. 2010;83:108–121. 18. Kelly DL, McMahon RP, Wehring HJ, et al. Cigarette smoking and mortality risk in people with schizophrenia. Schizophr Bull. 2011;37(4):832–838. 19. Curry S, Wagner EH, Grothaus LC. Intrinsic and extrinsic motivation for smoking cessation. J Consult Clin Psychol. 1990;58:310–316. 20. Williams JM, Foulds J. Successful tobacco dependence treatment in schizophrenia. Am J Psychiatry. 2007;164:222–227 quiz 373.

550

21. Fagerstrom K, Aubin HJ. Management of smoking cessation in patients with psychiatric disorders. Curr Med Res Opin. 2009;25:511–518. 22. de Leon J, Susce MT, Diaz FJ, Rendon DM, Velasquez DM. Variables associated with alcohol, drug, and daily smoking cessation in patients with severe mental illnesses. J Clin Psychiatry. 2005;66:1447–1455. 23. Copeland AL, Brandon TH, Quinn EP. The Smoking Consequences Questionnaire-Adult: measurement of smoking outcome expectancies of experienced smokers. Psycholo Assess. 1995;7:484–493. 24. Boardman T, Catley D, Mayo MS, Ahluwalia JS. Selfefficacy and motivation to quit during participation in a smoking cessation program. Int J Behav Med. 2005;12:266–272. 25. Tsoi DT, Porwal M, Webster AC. Interventions for smoking cessation and reduction in individuals with schizophrenia. Cochrane Database Syst Rev. 2010;6:CD007253. 26. Banham L, Gilbody S. Smoking cessation in severe mental illness: what works? Addiction.105:1176–1189. 27. Buchanan RW, Kreyenbuhl J, Kelly DL, et al. The 2009 schizophrenia PORT psychopharmacological treatment recommendations and summary statements. Schizophr Bull. 2010;36:71–93. 28. Buckley TC, Kamholz BW, Mozley SL, et al. A psychometric evaluation of the Smoking Consequences QuestionnaireAdult in smokers with psychiatric conditions. Nicotine Tob Res. 2005;7:739–745. 29. Curry SJ, Grothaus L, McBride C. Reasons for quitting: intrinsic and extrinsic motivation for smoking cessation in a population-based sample of smokers. Addict Behav. 1997;22:727–739. 30. Heatherton TF, Kozlowski LT, Frecker RC, Fagerstrom KO. The Fagerstrom Test for Nicotine Dependence: a revision of the Fagerstrom Tolerance Questionnaire. Br J Addict. 1991;86:1119–1127. 31. DiClemente CC, Prochaska JO, Fairhurst SK, Velicer WF, Velasquez MM, Rossi JS. The process of smoking cessation: an analysis of precontemplation, contemplation, and preparation stages of change. J Consult Clin Psychol. 1991;59:295– 304. 32. Heishman SJ, Singleton EG, Pickworth WB. Reliability and validity of a Short Form of the Tobacco Craving Questionnaire. Nicotine Tob Res. 2008;10:643–651. 33. Lehman AF. A quality of life interview for the chronically mentally ill. Eval Program Plann. 1988;11:51–62. 34. Benjamini Y, Hochberg Y. Controlling the false discovery rate: a practical and powerful approach to multiple testing. J R Stat Soc Ser B. 1995;57:289–300. 35. Tidey JW, Rohsenow DJ. Smoking expectancies and intention to quit in smokers with schizophrenia, schizoaffective disorder and non-psychiatric controls. Schizophr Res. 2009;115:310–316. 36. Spring B, Pingitore R, McChargue DE. Reward value of cigarette smoking for comparably heavy smoking schizophrenic, depressed, and nonpatient smokers. Am J Psychiatry. 2003;160:316–322. 37. Forchuk C, Norman R, Malla A, et al. Schizophrenia and the motivation for smoking. Perspect Psychiatr Care. 2002;38:41–49. 38. Baker A, Richmond R, Haile M, et al. Characteristics of smokers with a psychotic disorder and implications for smoking interventions. Psychiatry Res. 2007;150:141–152.

Perceived Smoking Risks and Schizophrenia

39. Lucksted A, Dixon LB, Sembly JB. A focus group pilot study of tobacco smoking among psychosocial rehabilitation clients. Psychiatr Serv. 2000;51:1544–1548. 40. Barr AM, Procyshyn RM, Hui P, Johnson JL, Honer WG. Self-reported motivation to smoke in schizophrenia is related to antipsychotic drug treatment. Schizophr Res. 2008;100:252–260. 41. Gurpegui M, Martinez-Ortega JM, Jurado D, Aguilar MC, Diaz FJ, de Leon J. Subjective effects and the main reason for smoking in outpatients with schizophrenia: a case-control study. Compr Psychiatry. 2007;48:186–191.

42. Roll JM, Higgins ST, Steingard S, McGinley M. Use of monetary reinforcement to reduce the cigarette smoking of persons with schizophrenia: a feasibility study. Exp Clin Psychopharmacol. 1998;6:157–161. 43. Tidey JW, O’Neill SC, Higgins ST. Contingent monetary reinforcement of smoking reductions, with and without transdermal nicotine, in outpatients with schizophrenia. Exp Clin Psychopharmacol. 2002;10:241–247. 44. Fowler IL, Carr VJ, Carter NT, Lewin TJ. Patterns of current and lifetime substance use in schizophrenia. Schizophr Bull. 1998;24:443–455.

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