Psychiatry Research 119 (2003) 177–182

Brief report
Low prevalence of smoking in patients with autism spectrum
disorders
Susanne Bejerota,*, Lena Nylanderb
a
Department of Psychiatry, Institute of Clinical Neuroscience, Karolinska Institute, St. Goran’s Hospital, SE-112 81 Stockholm,
Sweden
b
Department of Neuroscience, Psychiatry, University Hospital, Lund, Sweden

Received 10 May 2002; received in revised form 22 April 2003; accepted 4 May 2003

Abstract

Psychiatric patients are significantly more often smokers than the general population, the only known exception
being obsessive–compulsive disorder (OCD) and catatonic schizophrenia. We have investigated nicotine use in
subjects with autism spectrum disorders (ASD). Ninety-five subjects (25 females and 70 males) consecutively
diagnosed with any ASD and of normal intelligence were included in the study. Only 12.6% were smokers, compared
with 19% in the general population and 47% in a control group of 161 outpatients diagnosed with schizophrenia or
a schizophreniform disorder. The results suggest that smoking is rare among subjects with ASD, while the opposite
was shown for schizophrenia. If replicated, this finding could suggest biological differences between non-catatonic
schizophrenia and ASD, and support the theory of a biological link between ASD and a subtype of OCD, and
between ASD and catatonic schizophrenia.
䊚 2003 Elsevier Ireland Ltd. All rights reserved.

Keywords: Obsessive–compulsive disorder; Obsessive–compulsive personality disorder; Autistic disorder; Smoking; Nicotine;
Catatonia; Schizophrenia

1. Introduction have reported high percentages, especially among

Cigarette smokers have an increased lifetime
prevalence of major depression, alcohol and drug
abuseydependence, agoraphobia, unstableyacting
out and anxiousyfearful personality and personality
disorders (Black et al., 1999). Studies on the
prevalence of smoking among psychiatric patients
*Corresponding author. Birger Jarlsg. 131 B, SE-113 56
Stockholm, Sweden. Tel.: q46-8-672-24-19; fax: q46-8-612-
45-32.
E-mail address: susanne.bejerot@chello.se (S. Bejerot).
patients with schizophrenia (Glass, 1990; Goff et
al., 1992; Pohl et al., 1992; Sonntag et al., 2000;
Poirier et al., 2002), although a strikingly low
prevalence of smoking has been reported among
patients with a catatonic subtype of schizophrenia
as compared with paranoid, undifferentiated and
residual subtypes (Beratis et al., 2001). Otherwise,
the only exception hitherto reported has been
patients suffering from obsessive–compulsive dis-
order (OCD) (Bejerot and Humble, 1999). A
strong connection between non-smoking and

0165-1781/03/$ - see front matter 䊚 2003 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/S0165-1781(03)00123-9
178 S. Bejerot, L. Nylander / Psychiatry Research 119 (2003) 177–182
obsessive–compulsive personality traits in OCD
subjects has been reported (Bejerot et al., 2000).
Also, unexpectedly, a higher number of various
personality disorders were associated with non-
smoking in OCD (Bejerot, 2000).
Autism spectrum disorders (ASD) may occa-
sionally coexist with OCD. Autistic traits were
obvious in 20% of the subjects with OCD (Bejerot
et al., 2001) and OCD is overrepresented in rela-
tives of patients with autism (Bolton et al., 1998;
Gillott et al., 2001). Biological links between the
disorders have been hypothesized (Gross-Isseroff
et al., 2001).
Asperger’s disorder and autistic disorder are
both ASD, and could also be viewed as innate
personality disorders. It has been claimed that the
symptomatology of obsessive–compulsive person-
ality disorder, as outlined in DSM-IV, is strikingly
similar to that of autistic psychopathy as described
by Hans Asperger (Gillberg and Billstedt, 2000).
Also, several other personality disorders, such as
schizoid, schizotypal and avoidant personality dis-
orders, appear to be of relevance for Asperger’s
disorder and autistic disorder. It has been suggested
that a schizoid personality pattern in childhood is
identical to Asperger’s syndrome (Rutter, 1987).
Also, schizoid personality, as recently outlined by
Westen and Shedler (1999a,b), is a clinically
relevant and exact description of an ASD. Some
studies also suggest an association between schiz-
ophrenia and schizoid personality (Thaker et al.,
1993).
Our aim has been to elucidate nicotine use in
subjects of normal intelligence with any ASD,
since we believe that questions on nicotine use
can shed some light on the biological understand-
ing of different psychiatric disorders.
2. Methods
2.1. Subjects
Ninety-five subjects of normal intelligence with
a diagnosis of ASD and a control group of 161
patients with schizophrenia or schizophreniform
disorder were included in this study.
2.1.1. Subjects with autism spectrum disorder
A total of 127 subjects with a diagnosis of
autistic disorder, Asperger’s disorder or atypical
autism were included in the ASD group. Twenty-
six subjects were also diagnosed with mental
retardation and were, therefore, excluded from the
study. Three subjects were excluded owing to
insufficient information regarding nicotine habits
and three patients owing to a history of psychosis.
Consequently, 95 subjects (25 females and 70
males) were included in the ASD group. LN
assessed all consecutively at a psychiatric outpa-
tient clinic in Lund, Sweden, between 1994 and
2002. Eighty-seven subjects were diagnosed as
having Asperger’s disorder, three subjects were
diagnosed with autistic disorder and five with
atypical autism. None of them lived in supervised
placements. All had been in mainstream class-
rooms, although six subjects received some addi-
tional help in school, and another three had an
assistant at school.
The median age was 31 years (range, 18–58).
Fourteen percent (9 females and 33 males) had at
least initiated a college education as compared
with 31% with at least a junior college education
in the general population in Sweden (Statistics
Sweden, 2001).
2.1.2. Control group: patients with schizophreniay
schizophreniform disorder
A control group of 161 patients (72 females and
89 males) diagnosed with schizophrenia or schi-
zophreniform disorder served as comparison sub-
jects. They were recruited from three different
clinics: (1) A group of 47 patients with schizo-
phrenia (19 females and 28 males) were inter-
viewed about their nicotine habits by a nurse
during 2003. They were patients at the same
psychiatric outpatient clinic in Lund, Sweden,
where the ASD group was assessed. (2) Another
30 patients with schizophrenia (11 females and 19
males) at a psychiatric outpatient clinic in the
center of Stockholm were asked the same questions
in 2003. (3) In addition, 84 outpatients with
schizophrenia (42 females and 42 males) at anoth-
er clinic in Stockholm had been assessed with the
Fagerstrom test for nicotine dependence in 2001.
 S. Bejerot, L. Nylander / Psychiatry Research 119 (2003) 177–182
Median age in the total schizophrenia group was
46 (range 21–80).
2.2. Diagnostic procedures
2.2.1. Diagnostic procedures for the autism spec-
trum disorder group
All subjects with ASD were thoroughly inter-
viewed for several hours on several occasions by
a psychiatrist and in 80 cases also by an experi-
enced neuropsychologist. Twenty-one subjects
were diagnosed according to the Diagnostic Inter-
view for Social and Communication Disorders
(DISCO), an extensive interviewer-based schedule
for use with parents and caregivers (Leekam et
al., 2002). Another structured clinical interview,
the Asperger Syndrome (and high-functioning
autism) Diagnostic Interview (ASDI) (Gillberg et
al., 2001), was applied in another 42 patients, in
addition to a clinical interview. Additional infor-
mation from relatives regarding early symptoms
was obtained in 81% of the patients (Ns77).
Some patients refused to involve relatives, while
others did not have any family connections.
The DSM-IV diagnostic criteria were applied to
all patients. In addition, the Gillberg criteria for
Asperger’s syndrome were used (Gillberg, 1995).
Six subjects had previously been diagnosed with
an autistic disorder by other clinicians. LN diag-
nosed all other subjects; however, three had
already received an ASD diagnosis in childhood.
Formal IQ testing was performed in most, but not
all, subjects, in order to elucidate IQ profiles. LN
has many years of experience in clinical psychi-
atric work, extensive training in assessing ASD
and 10 years’ clinical experience in working with
adults with ASD.
2.2.2. Diagnostic procedures in the control group
The procedures used to diagnose the patients
with schizophrenia are not known in detail. The
vast majority of these patients were diagnosed
several years before the study began and are
viewed as suffering from a chronic psychotic
disorder. They have regular appointments with
psychiatrists and nurses at the specialized outpa-
tient clinics, and are all well known to the staff.
179
2.2.3. Nicotine habits
All subjects responded to questions about tobac-
co use. Present smoking was rigorously defined as
consumption of at least one cigarette daily for at
least the last 6 months. Additionally, they were
asked about previous smoking and other use of
nicotine on a daily basis, i.e. snuff, nicotine pads
or nicotine chewing gum.
Forty-four of the smokers in the schizophrenic
group were assessed according to the Fagerstrom
test for nicotine dependence. This is a widely used
and validated six-item questionnaire to assess
severity of smoking (Heatherton et al., 1991).
2.2.4. Nicotine habits in the general population
The prevalence of smoking is rapidly declining
in Sweden. Only 19% of the population smoke
(females 18%, males 20%) compared with 25% a
decade ago. Among younger people, smoking is
even more infrequent; in the age group between
25 and 34 years, only 16% are smokers. However,
people with lower levels of education are more
often smokers; 25% of unskilled workers smoke
(females 25%, males 26%), and persons on sick
pension or unemployed persons of both sexes
smoke in 34% of cases (Statistics Sweden, 2001).
2.3. Statistics
Comparisons between smokers and non-smokers
were performed using t-tests (two-tailed) for con-
tinuous variables and x2-tests (Fisher exact P,
two-tailed) for categorical variables. The software
used for statistical analysis was STATISTICA 6.0.
3. Results
Twelve (12.6%) (2 females and 10 males with
ASD) were presently smokers (3 smoked a pipe)
and two males and one female used snuff. In total,
15 subjects (15.8%) used nicotine on a daily basis;
however, only one smoked as many as 20 ciga-
rettes per day. None used nicotine pads or nicotine
chewing gum on a daily basis, but one reported
using nicotine chewing gum occasionally to
improve concentration. Eight had previously been
smokers (2 females and 6 males) and one of them
uses snuff today. The vast majority (76.8%) had
180 S. Bejerot, L. Nylander / Psychiatry Research 119 (2003) 177–182
Table 1
Number, mean age and percentage of smokers among ASD subjects, patients with schizophrenia and the general population aged
25–44
Group No. of
subjects
ASD 95
Schizophrenia group 161
National normative sample, 2001
ASD, Autism spectrum disorder; F, female; M, male.
never used nicotine on a daily basis. One of the
three patients that were excluded owing to a history
of psychosis was a smoker; none used snuff (Table
1).
Among the schizophrenia group, 49% (Ns79)
smoked on a daily basis (51% of the females and
47% of the males). In addition, 16 (10%) used
snuff on a daily basis, usually in combination with
cigarettes. In all, 54.7% (56% of the males and
53% of the females) in the schizophrenia group
used nicotine on a daily basis. Fifty percent (22
out of 44) of those who were assessed with the
Fagerstrom test for nicotine dependence were clas-
sified as highly dependent on nicotine as they
scored 6 and above. The mean score for the whole
group was 5.4.
There was a significant difference in smoking
habits between the ASD group and the schizophre-
nia group (x2s34.6, Ps0.0000). When the com-
parison was made by gender, the differences
remained (females: x2s14.5, Ps0.0004; males:
x2s19.3, Ps0.0000). However, there was a large
age difference between the two groups, and we,
therefore, carried out a sub-analysis of nicotine
dependence in all subjects between the ages of 25
and 34 to correct for this difference. Twenty-five
subjects with schizophrenia (mean ages31.3) and
34 subjects with ASD (mean ages29.2) were
compared. Only 17.6% in the ASD group used
nicotine on a daily basis as compared with 48%
in the schizophrenia group (x2s6.26, Ps0.02).
4. Discussion
The results of the present study suggest that
patients with autistic disorders have an extremely
low prevalence of smoking. Only 12.6% of the
No. Sex Mean Smokers
FyM (%) age (%)
FyM FyM FyM
25y70 26y74 30y32 8y14
72y89 45y55 47y46 51y47
50y50 Range 25–44 20y17
subjects with an autistic disorder smoked, as com-
pared with 19% daily smokers in the adult popu-
lation of Sweden (Statistics Sweden, 2001) and
49% among outpatients diagnosed with schizo-
phrenia. The low rate of smoking among subjects
with ASD corresponds to the low smoking rate
previously shown in patients with OCD and espe-
cially with OCD comorbid with obsessive–com-
pulsive personality disorder (Bejerot and Humble,
1999; Bejerot et al., 2000) and in the catatonic
subtype of schizophrenia (Beratis et al., 2001).
Interestingly, catatonia has been reported in 17%
of adult patients with ASD (Wing and Shah,
2000).
The smoking rate in the general population in
Sweden is low and declining. It has decreased by
6% in 10 years’ time; in consequence, the smoking
rate among Swedish patients with schizophrenia is
much lower than has been reported elsewhere.
Psychological factors in smoking may differ
between males and females. Girls at the top of the
social pecking order who project an image of high
self-esteem have been reported as most likely to
smoke, whereas boys of high social status are less
vulnerable, since sports and a desire to be fit
protect them to some extent (Michell and Amos,
1997). We do not believe, however, that our
subjects, who were mainly men, belonged to a
group with high social status in school. More
likely, they were loners. If not, resistance to group
pressure, which is usually associated with the
rigidity and stubbornness of subjects with an
obsessive–compulsive personality as well as those
with Asperger’s disorder or autistic disorder, may
well explain the low smoking rate in our group.
Furthermore, these personality traits, so frequently
 S. Bejerot, L. Nylander / Psychiatry Research 119 (2003) 177–182
observed in ASD, do not seem to be easily
influenced by reinforcement and reward, i.e. the
functions that nicotine is thought to influence (Pich
et al., 1997).
Whether there are neurochemically mediated
mechanisms for the low smoking rate among
subjects with ASD remains to be investigated. The
dopamine DRD2 gene has been found to be
involved in substance use disorders including nic-
otine in the general population (Noble, 2000). A
strong association between a high degree of
detachment (a personality trait that includes lack
of closeness and warmth in personal relations) and
low D2-receptor density has been reported (Farde
et al., 1997; Laakso et al., 2000). On the other
hand, pharmacological interventions with neuro-
leptics that block D2 receptors seem to offer some
clinical benefit in autism (Buitelaar and Willem-
sen-Swinkels, 2000) but may not influence symp-
toms like detachment.
The essential features of an autistic disorder,
according to DSM-IV, are the presence of markedly
abnormal or impaired development in social inter-
action and communication, and a markedly restrict-
ed repertoire of interests and activities.
In addition, subjects with ASD and of normal
intelligence sometimes suffer from severe psychi-
atric problems in adulthood, often diagnosed as
depression, paranoia, borderline personality disor-
der, pseudo-neurotic schizophrenia (Wing, 1981),
schizophrenia (McKenna et al., 1994) and proba-
bly also OCD (Bolton et al., 1998; Bejerot et al.,
2001).
According to our results, subjects with ASD are
not likely to smoke, as opposed to subjects with
other psychiatric disorders, especially schizophre-
nia. Sometimes, persons with ASD are misdiag-
nosed and are perceived as suffering from
treatment-resistant schizophrenia. In such cases,
smoking habits may provide a hint as to whether
to consider that the diagnosis might be wrong.
In conclusion, we propose, if it can be replicated
in other studies, that there are biological differenc-
es reflected by differences in liability for nicotine
dependence between ASD and non-catatonic schiz-
ophrenia. Our finding also supports a biological
link between ASD and a subgroup of OCD with
181
obsessive–compulsive personality traits, as well as
a link with catatonic schizophrenia.
4.1. Limitations of the study
The major limitations of the study include the
following: (1) We did not use a structured clinical
interview for ascertainment of axis I and II co-
morbidity of personality disorders. (2) Possible
biases preclude control of variables such as gender
and education. (3) We did not obtain detailed
information on nicotine dependence in the ASD
group, nor did we use a standardized assessment
scale for nicotine dependence in the majority of
the patients. (4) A standardized assessment scale
for ASD was not applied in all cases. (5) In the
control group, there may have been a bias in the
reported prevalence of smoking, as we do not
know how many refused to answer these questions.
(6) The control group was significantly older and
the sex ratio between the groups differed
considerably.
Acknowledgments
We thank Dr Mats Humble for valuable com-
ments. We also are extremely grateful to the staff
at Gragasen
˚ ˚ in Lund and the staff at the psychiatric
¨
outpatients’ clinics at Norrtull and Ostermalm for
collecting nicotine data on the schizophrenia
group.
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