Prevalence of Smoking Among Psychiatric Outpatients

John R. Hughes, M.D., Dorothy K. Hatsukami, Ph.D.,

James E. Mitchell, M.D., and Lisa A. Dahlgren, B.A.

studies failed to eliminate the possibility that factors

The prevalence of smoking among psychiatric other than a psychiatric disorder were responsible for
outpatients (N=2 77) was significantly higher than the higher prevalence of smoking. For example, psy-
among either local or national population-based chiatric patients are more likely than nonpsychiatric
samples (N= 1,440 and 1 7,000) (52% versus 30% subjects to be of low socioeconomic status (1 1) and
and 33%). The higher prevalence was not unmarried (11) and to use alcohol (12), all of which
associated with the age, sex, marital status, have been associated with a higher prevalence of
socioeconomic status, alcohol use, coffee use, or smoking (13). None of the prior studies examined
institutionalization of the psychiatric patients. these possible confounds. The generalizability of prior
Smoking was
especially prevalent among patients prevalence figures may be limited because previous
with schizophrenia (88%) or mania (70%) and studies examined very select populations, e.g., insti-
among the more severely ill patients. Hypotheses tutionalized schizophrenic patients (7), veterans (10),
about why psychiatric patients are more likely to and pregnant women (9).
smoke and why they do not have a high rate of In the present study we compared the current prey-
smoking-induced illnesses are presented. alence of smoking of psychiatric patients and two
(Am J Psychiatry 143:993-997, 1986) population-based samples of control subjects. In our
analysis, we statistically controlled for any differences
in age, sex, marital status, socioeconomic status, and
T here are several reasons why practicing psychia- alcohol use between patients and control subjects. In
trists should know the smoking status of their addition, we studied a heterogeneous group of outpa-
patients. Smoking improves and tobacco withdrawal tients seen in a general psychiatry clinic. We believed
worsens mood, anxiety, and cognition (1, 2). Smoking these procedures would produce a more valid, gener-
also decreases the therapeutic effects and worsens the alizable, and comprehensive estimate of whether the
side effects of several psychoactive drugs (3). Research presence of a psychiatric disorder per se is associated
psychiatrists should also be aware of the smoking with a higher prevalence of smoking.
status of their subjects. For example, smoking and
tobacco withdrawal influence the major neurotrans-
mitter systems involved in psychiatric disorders (4). METHOD
Smoking also influences the relationship between psy-
chiatric disorders and relative mortality (5). Eligible subjects were patients who participated in
Studies have reported a higher prevalence of smok- an intake evaluation in the general psychiatry clinic at
ing among psychiatric patients (S0%-84%, depending the University of Minnesota Medical Center between
on diagnosis) than among nonpsychiatric control sub- March 1980 and August 1982. Of these patients, 277
jects (27%-58%) (6-10). However, the validity and fulfilled our inclusion criteria, i.e., filled out the intake
generalizability of these prevalence figures may be questionnaire, were 18 years of age or older, and had
limited. Their validity may be limited because prior a single diagnosis. In addition, we selected only sub-
jects who had an adjustment, affective, anxiety, psy-
Presented at a meeting of the Midwest Society for Behavioral chotic, or personality disorder because only these
Medicine, Ames, Iowa, Jan. 25, 1985. Received July 15, 1985; diagnostic groups had a sufficient sample size (10 or
revised Dec. 19, 1985; accepted Feb. 18, 1986. From the Depart- more subjects) to warrant analysis. The two control
ment of Psychiatry, University of Minnesota, Minneapolis. Address
groups consisted of random, population-based sam-
reprint requests to Dr. Hughes, Department of Psychiatry, Univer-
sity of Vermont College of Medicine, Burlington, VT 05405.
ples of 1,440 Minnesotans and of 17,000 U.S. citizens
Supported by grants DA-03728, DA-02988, and DA-04066 and examined in 1981 and 1980, respectively. The local
by Research Scientist Development Award DA-00109 (to Dr. sample was collected by the Minnesota Department of
Hughes) from the National Institute on Drug Abuse and by funds for
Health (14); the national sample was collected by the
psychiatric research from the State of Minnesota.
The authors thank the Minnesota Department of Health, Steven
National Health Interview Survey (15).
Gust, and Joni Jensen for their help. Information on the smoking habits of the psychiatric
Copyright © 1986 American Psychiatric Association. patients was obtained from the intake questionnaire.

Am J Psychiatry 143:8, August 1986 993

SMOKING AMONG PSYCHIATRIC OUTPATIENTS

TABLE 1. Comparison of Selected Characteristics of 277 Psychi- FIGURE 1. Relationship Between Prevalence of Smoking and Age,
atric Outpatients and a Population-Based Control Group of 1,440 Sex, Socioeconomic Status, Marital Status, and Alcohol Use Among
Minnesotans Psychiatric Outpatients and Population-Based Samples of Minne-
sota and U.S. Control Subjectsa
Psychiatric Minnesota
Outpatients Control Subjects - Psychiatric outpatients
Minnesota control subjects
Characteristic N % N %

Men 105 38 576 40

Married 72 26a 907 63
Socioeconomic status1”
I 8 3 259 18
II 53 19 201 14
III 102 37 288 20
IV 89 32 432 30
V 25 9 259 18
Use alcohol 116 42 979 68
Use coffee 163 S9 -

asignificantly different from control subjects (2=124.O, df=1,

p<.Ol).
bFrom Hollingshead and Redlich (11).
CSignificant difference between outpatients and control subjects
(262.4, df=4, p<.01).

Smokers were identified as those who answered yes to

the question “Do you smoke cigarettes now?” Infor-
mation on the smoking habits of the two control
groups was obtained from a brief telephone survey.
Psychiatric diagnosis was based on DSM-III criteria
and was obtained by agreement between a psychiatry
resident and faculty after a 1-2-hour interview.
Statistical tests were limited to comparisons of psy-
chiatric patients and Minnesota control subjects be-
r Nondrinker
cause the latter group was thought to be more similar
MARITALSTATUS ALCOHOL USE
to the outpatients in demographic characteristics and
had given more detailed information on smoking hab- aFor the age and sex comparison, there were 203 psychiatric
its than the national control subjects. Statistical corn- outpatients and 798 Minnesota control subjects; there were fewer
parisons were chi-square tests with Yates’ correction than 10 subjects in some age groups for the psychiatric outpatients.
(16). For socioeconomic status, marital status, and alcohol use, the
numbers of psychiatric outpatients and Minnesota control subjects
were 104 and 326, 127 and 423, and 128 and 425, respectively.
The significant differences shown were between the psychiatric
RESULTS outpatients and Minnesota control subjects.
bx2.5.9, df=1, p<.OS.
C23#{149}9, df=1, pcz.OS.
Psychiatric patients were younger than the Minne- dx24.3, df=1, p<.OS.
sota control subjects (mean age±SD=31.9±12.2 ver- eX24.7, df=1, p<.OS.
sus 43.7±17.7 years; t13.1, df1585, p<OO1). 1x210.6, df=1, p<.Ol.
They were also less likely to be married, to be in the Hollingshead and Redlich (11). Classes I and II were com-
highest or lowest socioeconomic groups, or to be using bined due to the small number of subjects in class I.

alcohol (table 1). The sex distribution was similar in }X28.S, df=1, p<.Ol.

the two groups. Coffee use among Minnesota control ‘21S9, df=1, p<.Ol.

subjects was not recorded. Coffee use was less preva-

lent among the psychiatric patients (59%) than that (table 2). The prevalence of smoking also varied by
reported in other nonpsychiatric population-based severity of illness. Patients who had been hospitalized
samples (i.e., 82%) (17). previously for psychiatric symptoms had a higher
More of the psychiatric patients smoked than either prevalence of smoking than patients who had not been
the Minnesota or U.S. control subjects (52% versus hospitalized (62% versus 3 8 % ; x2 1 4. 8 , df 1,
30% and 33%; dfl, p<.OOl, for patients p<.Ol). Similarly, patients who had ever been pre-
versus Minnesota control subjects). The higher preva- scribed psychotropic medications had a higher preva-
lence of smoking was consistent across age, sex, mar- lence of smoking than those who had not (61% versus
ital status, socioeconomic status, and alcohol use 41%; 26.6, dfl, p<.0l). The prevalence of heavy
groups (figure 1). The prevalence of smoking varied by smoking (one or more packs of cigarettes a day) was
diagnosis (226.S, df6, p<.OOl); patients with similar for psychiatric patients and Minnesota and
schizophrenia or mania had the highest prevalence U.S. control subjects (66%, 68%, and 66%).

994 Am J Psychiatry 143:8, August 1986

 HUGHES, HATSUKAMI, MITCHELL, ET AL

TABLE 2. Prevalence of Smoking Among Diagnostic Subgroups of and thus again probably produced a conservative
2 17 Psychiatric Outpatients and a Population-Based Control Group estimate.
of 1,359 Minnesotans
Individuals who abuse drugs have a higher than
Smokersa average rate of several psychiatric disorders (12, 20).
0/
One of the major implications of this finding has been
Group N io
to prompt clinicians to seek and treat psychiatric
Psychiatric outpatients disorders among drug abusers. In our study the prey-
Schizophrenia (N=24) 21 88b
Mania (N=1O)
7 7#{216}C alence of smoking was higher than expected among
Major depressive disorder (N45) 22
49d those with schizophrenia, mania, depression, anxiety,
Anxiety disorder (N34) 16 47C and personality disorders. This finding could be turned
Personality disorder (N46) 21 46 around to suggest that smokers have a higher rate of
Adjustment disorder (N=S8) 26 4S
these disorders than nonsmokers, and thus therapists
Control subjects 411 30
should be alert to signs of these disorders among
aThe significant differences shown
were between the psychiatric smoking patients. However, we do not believe this
outpatients and control subjects.
bx2360 df=1, p<.Ol. interpretation is warranted on the basis of our data.
C,274, df=1, p<.Ol. Such a conclusion requires a direct comparison of the
ix27.1, df=1, p<.O1. prevalence of these disorders in population-based sam-
cX2=4.4, df=1, p<.OS.
ples of smokers and nonsmokers.
df=1, p<.OS.
Another hypothesis from prior research on psychi-
atric disorders among drug abusers is that some mdi-
viduals abuse drugs for relief from psychiatric symp-
DISCUSSION toms. Again, our data are limited to psychiatric pa-
tients; however, there are several hypotheses as to why
Our major finding is that the prevalence of smoking psychiatric patients are more likely to smoke (21).
among psychiatric outpatients is 1.6 times that of They 1) have neurotransmitter (e.g., noradrenaline)
population-based control groups. Although previous deficiencies that are increased by smoking (6); 2) are
studies have found a high prevalence of smoking more often bored and use smoking as a behavioral
among psychiatric patients, (6-10, 18), none of them “filler” (22); 3) have problems with aggression, con-
eliminated the possibility that the high prevalence rates centration, or relaxation, all of which can be improved
were due not to the presence of a psychiatric disorder by smoking (6, 23); 4) have higher levels of extrover-
but rather to the age, sex, marital status, socioeco- sion, impulsivity, or other personality traits associated
nomic status, or alcohol use of the patients. In the with smoking (24); 5) use smoking to offset the
present study, psychiatric patients had consistently sedative effects of drugs (3, 25, 26); or 6) are more
higher prevalences of smoking than control groups likely to become dependent on drugs (12). None of
matched (post hoc) for these factors. Thus, these these hypotheses has been directly tested. In one study
factors could not account for the higher prevalence of the prevalence and intensity of smoking did not vary
smoking among our patients. Our results also suggest with the onset or remission of depression (27). This
that the higher prevalence of smoking is not due to finding suggests that the association of smoking and
excessive coffee drinking, as the prevalence of coffee psychiatric disorder represents a trait, not state, phe-
drinking in the psychiatric patients was lower than in nomenon.
the normal population (17). Finally, our results suggest The high prevalence of smoking among psychiatric
the higher prevalence of smoking is not due to institu- patients is of significance to clinicians for several
tionalization because only outpatients were examined. reasons. Smoking or abstinence from smoking can
Despite these assets, the validity of our results can be obscure the diagnosis of psychiatric disorders. For
questioned because we failed to use more objective example, smoking can abate the symptoms of anxiety
measures of psychiatric diagnosis (e.g., standardized (1, 2, 4), improve cognition (2), and cause tremor (28).
interviews) or of smoking status (e.g., carbon monox- Abstinence from smoking can cause anxiety, insomnia,
ide in the breath). In rebuttal, we would point out that increased eating, difficulty in concentration, restless-
we used a consensual diagnosis based on established ness, irritability, headaches, and decreased tremor
criteria (i.e., DSM-III), that patients with questionable (29). Empirical studies indicate that these effects can
diagnoses were excluded, and that the self-reported influence the accuracy of the diagnosis of major disor-
prevalence of smoking is usually an underestimate of ders such as drug withdrawal and Parkinsonism (30).
the true prevalence of smoking (19). Thus, any bias Smoking can also influence the efficacy of treatment.
from these procedures would underestimate the asso- For example, smoking decreases the blood levels of
ciation between psychiatric disorders and smoking many psychoactive drugs (31). Independent of this
status. The generalizability of our results can also be effect (25), smoking offsets the sedative effects of
questioned because we examined only patients being benzodiazepines (3) and neuroleptics (25, 26). Smok-
seen for evaluation and only patients with a single ing also worsens neuroleptic side effects (28).
psychiatric disorder. These procedures probably Se- The high prevalence of smoking is also of signifi-
lected patients with less severe psychiatric disorders cance to investigators in psychiatry. Smoking modifies

Am J Psychiatry 143:8, August 1986 995

SMOKING AMONG PSYCHiATRIC OUTPATiENTS

neurotransmitter systems that influence anxiety, 10. O’Farrell TJ, Connors GJ, Upper D: Addictive behaviors among
hospitalized psychiatric patients. Addict Behav 18:329-333,
mood, and cognition. For example, smoking increases
1983
(2, 23, 32) and tobacco withdrawal decreases (33, 34) 11. Hollingshead AB, Redlich FC: Social Class and Mental Illness:
cholinergic and noradrenergic functioning. Thus, A Community Study. New York, John Wiley & Sons, 1958
smoking or abstinence from smoking among subjects 12. Solomon J: Alcoholism and clinical psychiatry, in Alcoholism
being studied may obscure the relationship of these and Clinical Psychiatry. Edited by Solomon J New York,
Plenum, 1982
systems to psychiatric disorders.
13. Kozlowski LT: Psychosocial influences on cigarette smoking, in
Smoking also interacts with the assessment of the Smoking and Health-A Report of the Surgeon General:
relative mortality of psychiatric patients. Smoking DHEW Publication PHS 79-50066. Washington, DC, US Gov-
causes increased mortality from several illnesses, espe- ernment Printing Office, 1979
14. Minnesota Depratment of Health: Smoking: Health Risks.
cially cancer and cardiovascular disease (35). Yet
Minneapolis, Minnesota Department of Health, 1983
recent studies of psychiatric patients have failed to find 15. Trends in US Cigarette Use, 1965 to 1980, the Health Conse-
the expected above-average mortality from natural quences of Smoking, Cardiovascular Disease, Appendix B:
causes (36, 37). Even more striking are findings that DHHS Publication PHS 84-50204. Washington, DC, US Gov-
patients with schizophrenia, who have the highest ernment Printing Office, 1984
16. Siegel 5: Nonparametric Statistics for the Behavioral Sciences.
prevalence of smoking, have a lower rate of lung
New York, McGraw-Hill, 1956
cancer than nonpsychiatric control subjects (38-40). 17. Istvan J, Matarazzo J: Tobacco, alcohol, and caffeine use: a
Several reasons why psychiatric patients may not have review of their interrelationships. Psychol Bull 95:301-326,
a high rate of smoking-induced illnesses can be hy- 1984
18. Rassidakis NC, Kelepouris M, Goulis K, et al: On the incidence
pothesized. The most obvious is that some psychiatric
of malignancy among schizophrenic patients. Agressologie
patients die early from unnatural causes (e.g., suicide 14:269-273, 1973
and accidents) (36, 37, 40) before the onset of 19. Grabowski J, Bell CS (eds): Measurement in the Analysis and
smoking-induced illnesses. Other hypotheses are that Treatment of Smoking Behavior, 1 983 : NIDA Research Mono-
schizophrenic patients have a metabolic defect that graph 48. Rockville, Md, National Institute on Drug Abuse,
1983
protects them from cancer (41), that phenothiazines
20. Pickens RW, Heston LL (eds): Psychiatric Factors in Drug
and other psychoactive drugs have anti-tumor effects Abuse. New York, Grune & Stratton, 1979
(42), and that social isolation and hospitalization 21. Jaffee J, Kanzler M: Smoking as a psychiatric disorder. Ibid
protect schizophrenic patients from stress-induced car- 22. Slifer BL: Schedule-induction of nicotine self-administration.
Pharmacol Biochem Behav 19:1005-1009, 1983
diovascular disorders and cancer (38, 39). None of
23. Ashton H, Stepney F: Smoking: Psychology and Pharmacology.
these hypotheses has been adequately tested. New York, Tavistock Publications, 1982
The high prevalence of smoking in psychiatric pa- 24. Eysenck HJ: Smoking, Health and Personality. New York, Basic
tients has one more implication-i.e., our profession Books, 1965
should begin advising patients to stop smoking. 5ev- 25. Pantuck EJ, Pantuck CB, Anderson KE, et al: Cigarette smoking
and chlorpromazine disposition and actions. Clin Pharmacol
eral large, well-designed studies have clearly docu-
Ther 31:533-538, 1982
mented that brief advice (less than 10 minutes) from 26. Swett C Jr: Drowsiness due to chlorpromazine in relation to
physicians increases smoking cessation rates (43, 44). cigarette smoking. Arch Gen Psychiatry 31:211-213, 1974
Many psychiatric outpatients are seen during a remis- 27. Aneshensel CS, Huba GJ: Depression, alcohol use and smoking

sion of their illness for prophylactic drug therapy or over one year: a four wave longitudinal causal model. J Abnorm
Psychol 92:134-150, 1983
psychotherapy. These visits would be an excellent time 28. May PRA, Lee MA, Bacon RC: Quantitative assessment of
to advise them to stop smoking. neuroleptic-induced extrapyramidal symptoms: clinical and
nonclinical approaches. Clin Neuropharmacol 6:535-55 1,
REFERENCES 1983
29. Hughes JR, Hatsukami D: Signs and symptoms of tobacco
I . Gilbert DG: Paradoxical tranquilizing and emotion-reducing withdrawal. Arch Gen Psychiatry 43:289-294, 1986
effects of nicotine. Psychol Bull 86:643-662, 1979 30. Kessler II: Parkinson’s disease in epidemiologic perspective, in
2. Wesnes K, Warburton DM: Nicotine, smoking and human Neurological Epidemiology, Principles and Clinical Applica-
performance. Pharmacol Ther 12:189-208, 1983 tions: Advances in Neurology, vol 19. Edited by Schoenberg BS.
3. Miller RR: Effects of smoking on drug action. Clin Pharmacol New York, Raven Press, 1978
Ther 22:749-756, 1977 31. Dawson GW, Vestal RE, Jusko WJ: Smoking and drug metab-
4. Balfour DJK: The effects of nicotine on brain neurotransmitter olism, in Nicotine and the Tobacco Smoking Habit. Edited by
systems, in Nicotine and the Tobacco Smoking Habit. Edited by Balfour DJK. New York, Pergamon Press, 1984
Balfour DJK. New York, Pergamon Press, 1984 32. Pomerleau OF, Fertig JB, Seyler E, et al: Neuroendocrine
S. Jancar J: Cancer in the long stay hospital. Br J Psychiatry reactivity to nicotine in smokers. Psychopharmacology
134:550-551, 1978 81:61-67, 1983
6. Hall GH: The pharmacology of tobacco smoking in relation to 33. Elgerot A: Psychological and physiological changes during
schizophrenia, in Biochemistry of Schizophrenia and Addiction. tobacco abstinence in habitual smokers. J Clin Psychol
Edited by Hemmings G. Lancaster, England, MTP Press, 1980 34:759-764, 1978
7. Masterson E, O’Shea B: Smoking and malignancy in schizo- 34. Myrsten A-L, Elgerot A, Edgren B: Effects of abstinence from
phrenia. Br J Psychiatry 145:429-432, 1984 tobacco smoking on physiological and psychological arousal
8. Mathew RJ, Weinman ML, Mirabi M: Physical symptoms of levels in habitual smokers. Psychosom Med 39:25-38, 1977
depression. Br J Psychiatry 139:293-296, 1981 35. US Department of Health and Human Services: Smoking and
9. McNeil TF, Kaij L, Malmquist-Larsson A: Pregnant women Health-A Report of the Surgeon General: DHEW Publication
with nonorganic psychosis: life situation and experience of PHS 79-5066. Washington, DC, US Government Printing
pregnancy. Acta Psychiatr Scand 68:445-447, 1983 Office, 1979

996 Am J Psychiatry 143:8, August 1986

 HUGHES, HATSUKAMI, MITCHELL, ET AL

36. Black DW, Warrack G, Winokur G: The Iowa record linkage schizophrenia and affective disorder. J Clin Psychiatry 44:42-
study, Iii: excess mortality among patients with “functional 46, 1983
disorders.” Arch Gen Psychiatry 42:82-88, 1984 41. Levi RN, Waxman 5: Schizophrenia, epilepsy, cancer, methio-
37. Martin RL, Cloninger CR, Guze SG, et al: Mortality in a nine and folate metabolism. Lancet 2:11-13, 1975
follow-up of 500 psychiatric outpatients, II: cause-specific mor- 42. Driscoll JS, Melnick NR, Quisen FR, et al: Psychotropic drugs
tality. Arch Gen Psychiatry 42:58-66, 1984 as potential antitumor agents: a selective screening study.
38. Baldwin JA: Schizophrenia and physical disease. Psychol Med Cancer Treat Rep 62:45-74, 1978
9:611-618, 1979 43. Hughes JR, Kottke TE: Doctors helping smokers: real world
39. Fox BH, Howell MA: Cancer risk among psychiatric patients: a tactics. Minn Med (in press)
hypothesis. Int J Epidemiol 3:207-208, 1974 44. Pederson L: Compliance with physician advice to quit smoking:
40. Tsuang MT, Perkins K, Simpson JC: Physical diseases in a review of the literature.Prey Med 11:71-84, 1982

Am J Psychiatry 143:8, August 1986 997