Cigarette Smoking Among Persons With

Schizophrenia or Bipolar Disorder in

Routine Clinical Settings, 1999–2011
Faith Dickerson, Ph.D., M.P.H.
Catherine R. Stallings, R.N.C., M.A.
Andrea E. Origoni, B.A.
Crystal Vaughan, M.S.
Sunil Khushalani, M.D.
Jennifer Schroeder, Ph.D.
Robert H. Yolken, M.D.

Objective: This study examined the prevalence of cigarette smoking and serious mental illnesses smoke ciga-
the quantity of cigarettes consumed by individuals with schizophrenia or rettes compared with those in the
bipolar disorder and by those with no psychiatric disorder in the period overall population (4,5). Among those
1999–2011. Methods: A total of 991 individuals with schizophrenia, bi- with serious mental illness, the preva-
polar disorder, or no psychiatric illness provided information about their lence of smoking has been found to be
cigarette smoking at recruitment into a research study for which they higher among persons with schizo-
were selected without regard to their smoking status. Differences among phrenia than among those with bipolar
groups and trends over time among new enrollees were examined with disorder or major depression (5). Pre-
multivariate models. Regression analyses were used to compare smoking vious studies also indicate that persons
between the schizophrenia and bipolar disorder groups. Results: There with serious mental illness smoke more
were marked differences in the prevalence of smoking and in the heavily, have longer smoking histories,
quantity of cigarettes consumed among the diagnostic groups. Overall, and have lower rates of smoking
64% of individuals with schizophrenia, 44% with bipolar disorder, and cessation than smokers in the overall
19% without psychiatric illness reported that they were current smokers. population (6–8). It is not surprising,
These group differences remained fairly constant over the observation then, that cigarette smoking contrib-
period, and there were no statistically significant time trends in smoking utes to the excess morbidity and
or cigarette consumption after adjustment for demographic covariates. mortality among people with schizo-
Within the psychiatric illness groups, smoking and cigarette consumption phrenia and other serious mental
were significantly associated with less education, a history of substance illnesses (9–11).
abuse, longer illness duration, Caucasian race, and schizophrenia di- Over the past decades there have
agnosis but not with psychiatric symptom severity. Conclusions: The been intense public health campaigns
prevalence of smoking has remained alarmingly high among individuals to reduce cigarette smoking in the
with schizophrenia and bipolar disorder in routine psychiatric settings. overall population. Although 42.4% of
Concerted efforts are urgently needed to promote smoking cessation in adults in the United States were
these groups. (Psychiatric Services 64:44–50, 2013; doi: 10.1176/appi. smokers in 1965, the prevalence had
ps.001432012) declined to 24.7% in 1997 and then to
19.3% in 2010, the most recent year

S
moking is the leading cause of disease and contributes to other health for which data are available (1,12).
preventable mortality in the problems, such as diabetes and obesity Attention to cigarette smoking among
United States (1). Smoking is (2,3). Previous studies have docu- persons with serious mental illness has
a risk factor for lung cancer and heart mented that many more people with lagged behind efforts in the overall
population despite the high preva-
Dr. Dickerson, Ms. Stallings, Ms. Origoni, Ms. Vaughan, and Dr. Khushalani are lence of smoking and the known
affiliated with the Stanley Research Center, Sheppard Pratt Health System, 6501 North health risks to persons with mental
Charles St., Baltimore, MD 21204 (e-mail: fdickerson@sheppardpratt.org). Dr. illness. This gap is due to a number
Schroeder is with Schroeder Statistical Consulting LLC, Ellicott City, Maryland. Dr. of factors, including inattention by
Yolken is with Johns Hopkins University, School of Medicine, Baltimore. health care providers and also the

44 PSYCHIATRIC SERVICES ' ps.psychiatryonline.org ' January 2013 Vol. 64 No. 1

relative isolation of persons with serious
mental illness from appeals aimed at
the mainstream population (5,13). Re-
cently, however, greater efforts have
been made to address smoking among
persons with mental illness, and there
are now more documented experien-
ces of successful quitting in this group
(14,15). However, it is not known to
what extent smoking has declined in
recent years among persons with
serious mental illness in routine care
(inpatient and outpatient) settings.
Previous studies also have exam-
ined the correlates of smoking and
quantity of cigarettes consumed by
persons with serious mental illness;
these variables have been associated
with male gender and older age—
findings that mirror trends in the
overall population (5,16,17) and with
Caucasian race in some studies (17–
20). Previous investigations have also
found that smoking by persons with
serious mental illness is associated
with co-occurring substance abuse
(5). Some studies have also found that
smokers with serious mental illness
have more severe psychiatric symp-
toms (17,18,21–24), poorer quality of
life (18), and more medical comor-
bidities (18,25) than nonsmokers and,
in schizophrenia specifically, smok-
ers are more likely to be receiving
first-generation rather than second-
generation antipsychotic medications
(17). However, much of the data for
these studies were collected prior to
2005, before the most recent efforts
to address smoking cessation in this
population.
This study was undertaken to de-
termine the prevalence of cigarette
smoking and the quantity of cigarettes
consumed by individuals with schizo-
phrenia, bipolar disorder, or no disor-
der who were participating in a research
program that recruited persons in the
period 1999–2011 without regard to
their smoking status.
Methods
Participants were individuals with
schizophrenia, bipolar disorder, or
no disorder who were enrolled in the
period January 1999 to December
2011 in a Stanley Research Program
study of the association between
antibodies to infectious agents and
serious mental illness. Recruitment
PSYCHIATRIC SERVICES ' ps.psychiatryonline.org ' January 2013 Vol. 64 No. 1
of the schizophrenia group began in
1999, and recruitment of the bipolar
disorder and no-disorder groups be-
gan in 2002. Details of the inclusion
and exclusion criteria and recruitment
procedures for the study populations
have previously been described (26–28).
The diagnosis of each of the partici-
pants in the psychiatric disorder groups
was made by a board-certified psychi-
atrist on the basis of the Structured
Clinical Interview for DSM-IV Axis I
Disorders (29). The participants with-
out psychiatric illness were screened
with the Structured Clinical Interview
for DSM-IV Axis I Disorders Non-
Patient Edition (30). All participants
provided written informed consent,
and the studies were approved by the
Sheppard Pratt Institutional Review
Board.
As part of the background inter-
view, each participant was asked “Are
you a current cigarette smoker?” And,
if the participant answered yes, the
interviewer followed up with “How
many packs per day do you smoke?”
All participants were also asked about
their education and other demo-
graphic variables, including maternal
education as a proxy for family socio-
economic status (31). All participants
in the groups with schizophrenia or
bipolar disorder were asked about the
duration of their disorder and were
evaluated on the Positive and Nega-
tive Syndrome Scale (PANSS) (32).
These participants were also catego-
rized for history of substance abuse
(apart from nicotine) on the basis of
their medical record and their re-
sponse to interview questions about
the use of alcohol and drugs. Medi-
cations received at the time of study
enrollment were based on the medical
chart and self-report.
Demographic and clinical charac-
teristics and smoking status were
compared among study groups using
analysis of variance for continuous
variables and chi square analysis for
dichotomous variables.
Logistic regression was used to
examine temporal trends in both
smoking prevalence and smoking
quantity (among smokers only); likeli-
hood ratio chi square tests deter-
mined whether these trends were
statistically significant (p,.05). Poly-
chotomous logistic regression was
used to model quantity of cigarettes
smoked; models evaluated whether
the log odds of each consumption
category (..5–1.0 packs per day
[ppd]; .1.0–1.5 ppd; and .1.5 ppd)
decreased relative to the lowest cate-
gory (#.5 ppd). First, temporal trends
in each smoking outcome were as-
sessed separately for each diagnostic
group; next, a model was fit that con-
sisted of diagnostic group plus year
plus their interaction. The demo-
graphic covariates age, race (Caucasian
versus non-Caucasian), and gender
were added to each model.
Logistic regression was also used
to examine correlates of both smok-
ing and cigarette consumption by
participants with schizophrenia or
bipolar disorder. As for the temporal
trends analysis, polychotomous logis-
tic regression was used to model the
quantity of cigarettes smoked, and
a categorical outcome variable was
coded with the following categories:
0; .0–.5 ppd, ..5–1.0 ppd, and .1.0
ppd. The independent variables that
were included in these models were
all variables that had a significant
bivariate association with the out-
come variable: duration of illness,
gender, race (Caucasian versus non-
Caucasian), education, maternal edu-
cation, substance abuse history, PANSS
total symptom score, and diagnostic
group (schizophrenia versus bipolar
disorder). Age was not included in the
model because the variable was highly
correlated with duration of illness.
Within each diagnostic group, the
association between smoking status
and selected medications (olanzapine,
clozapine, lithium, valproate, bupro-
pion, and varenicline) and types of
medications (second-generation anti-
psychotic and anticonvulsant) was ex-
amined with a series of chi square
analyses; any significant association was
followed up by multivariate analysis.
Results
Participant characteristics
The demographic and clinical charac-
teristics and smoking status of the 991
participants, by diagnostic group, are
presented in Table 1. A majority of
participants with psychiatric illness
were enrolled from local psychiatric
rehabilitation agencies (354 of 547,
65%), with the rest recruited from
45
Table 1
Demographic and clinical characteristics of 991 study participantsa

Schizophrenia Bipolar disorder No disorder

(N=421) (N=126) (N=444)

Characteristic N % N % N %

Age (M6SD) 41.7610.6 37.0613.3 33.1611.6

Male 247 59 34 27 159 36
Raceb
Caucasian 247 59 91 73 277 62
African American 165 39 27 21 129 29
Other 9 2 7 6 38 9
Education (M6SD years) 12.362.4 13.662.6 15.562.2
Maternal education (M6SD years) 12.362.9 12.863.2 13.462.9
History of substance abuse 245 58 95 75 — —
PANSS total symptom score (M6SD)c 71.4612.9 68.5612.9 — —
Duration of psychiatric illness (M6SD years) 21.0610.4 19.0612.2 — —
Current cigarette smoker 268 64 55 44 86 19
Quantity smoked (packs per day)
0 153 36 71 56 358 81
..0–.5 85 20 29 23 64 14
..5–1.0 115 27 18 14 17 4
.1.0–1.5 30 7 1 1 3 1
.1.5 38 9 7 6 2 ,1
a
Comparisons among groups: age, F=61.0, df=2 and 988, p,.001; gender, x2=62.96, df=2, p,.001; education, F=204.56, df=2 and 987, p,.001;
maternal education, F=15.53, df=2 and 988; p,.001; substance abuse, x2=12.0, df=1, p=.001; Positive and Negative Syndrome Scale total score
(PANSS), F=5.02, df=1 and 545, p=.026; duration of illness, not significant; current cigarette smoker, x2=175.2, df=2, p,.001
b
N=125 for the bipolar disorder group
c
Possible scores range from 30 to 210, with higher scores indicating more severe symptoms.

inpatient settings (132 of 547, 24%),
day hospital programs (29 of 547,
5%), or office practices (32 of 547,
6%) at the research program site;
recruitment setting was not signifi-
cantly associated with smoking status.
Almost all of the participants with
schizophrenia or bipolar disorder
(540 of 547, 99%) were receiving
psychotropic medication at the time
of their study enrollment. A total of
340 (81%) of the participants with
schizophrenia and 61 (48%) of par-
ticipants with bipolar disorder were
receiving second-generation antipsy-
chotic medications; 57 (14%) and 37
(29%), respectively, were receiving
lithium; 148 (35%) and 75 (60%),
respectively, were receiving an anti-
convulsant medication; and 77 (18%)
and 60 (48%), respectively, were re-
ceiving an antidepressant. A total of 43
(8%) were receiving bupropion, which
may be used for smoking cessation,
and no one was receiving varenicline,
a smoking cessation medication.
Smoking prevalence
and trends over time
During the years of the study recruit-
ment, a total of 268 of 421 (64%)
individuals with schizophrenia, 55 of
126 (44%) with bipolar disorder, and
86 of 444 (19%) participants without
psychiatric illness reported that they
were current smokers. The prevalence
of smoking in each group, by enroll-
ment year, is shown in Figure 1.
There was no statistically significant
effect of recruitment year on smoking
prevalence for any of the diagnostic
groups (schizophrenia, bipolar disorder,
or no disorder). An overall model
consisting of diagnostic group, year,
and diagnostic group 3 year interaction
showed a statistically significant main
effect for diagnostic group (x2=182.5,
df=2, p,.001) but no effect of year and
no interaction. Adjusting for the cova-
riates of age, race, and gender also did
not affect the results.
Consumption of cigarettes
and trends over time
The quantity of cigarettes smoked per
day by diagnostic group is shown in
Table 1 and by the smokers with
schizophrenia is shown in Figure 2.
There were statistically significant de-
creases in cigarette consumption over
the study period for smokers with
schizophrenia (x2=12.9, df=3, p,.005)
and for participants without mental
illness (x2=15.5, df=3, p=.002) but not
for smokers with bipolar disorder.
For the smokers with schizophre-
nia, the log odds of being in the
highest two consumption categories
(.1.0–1.5 ppd and .1.5 ppd) rela-
tive to the lowest category (#.5 ppd)
decreased significantly over time
(x2=10.3, df=1, p=.001, and x2=5.86,
df=1, p=.016, respectively). For par-
ticipants with no disorder, the likeli-
hood of being in the consumption
category .1.0–1.5 ppd, relative to the
lowest category, ,.5 ppd, showed a
trend toward statistical significance
(x2=2.92, df=1, p=.09). Adjusting for
the covariates age, race, and gender
did not change the results for the
participants without a disorder, but
the effect of year became non-
significant for the smokers with
schizophrenia.
An overall model consisting of di-
agnostic group, year, and diagnostic
group 3 year interaction showed
a highly significant effect of diagnostic
group (x2=65.4, df=6, p,.001),
whereas neither the effect of study
year nor the group 3 year interaction
achieved statistical significance. When

46 PSYCHIATRIC SERVICES ' ps.psychiatryonline.org ' January 2013 Vol. 64 No. 1

covariates age, race, and gender were Figure 1
added to the model, the effect of
Percentage of smokers by diagnostic group and year of enrollmenta
diagnostic group remained highly sig-
nificant (x2=50.8, df=6, p,.001), the 100 Schizophrenia (N=421)
effect of study year became non- 90 Bipolar disorder (N=126)
significant, and the interaction term 80 No disorder (N=444)
remained nonsignificant. 70

Correlates of tobacco
use with mental illness
As shown in Table 2, a multiple
logistic regression model showed
that across all years of study enroll-
ment, current smoking among the
participants with a psychiatric disor-
der was significantly associated with a
longer duration of psychiatric illness,
history of substance abuse, fewer
years of education, Caucasian race,
and schizophrenia compared with
bipolar disorder diagnosis. In this
model, we did not find a statistically
significant association between smok-
ing status and symptom severity as
measured by the PANSS total score,
gender, or socioeconomic status
measured by maternal education.
As also shown in Table 2, an ordinal
multiple logistic regression showed
that the quantity of cigarettes con-
sumed by the participants with mental
illness was significantly associated with
these same variables and with male
gender.
Within the bipolar disorder and
schizophrenia groups, there were no
statistically significant associations be-
tween smoking status and receipt of
selected specific medications (valproate,
clozapine, olanzapine, or lithium) or
classes of medication (anticonvulsant
or any second-generation agent) ex-
cept for bupropion, which was signif-
icantly and inversely associated with
smoking for persons with schizophre-
nia (x2=4.60, df=1, p=.032) but not for
Smokers (%)
60
50
40
30
20
10
0
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
a
Data are not shown for the bipolar disorder sample prior to 2007 or for the control group (no
psychiatric illness) for 2004 because N,10 for each of these years for these groups. Number of
persons in each of the other groups, by year, follows. For schizophrenia: 1999, 15; 2000, 21; 2001,
10; 2002, 27; 2003, 34; 2004, 15; 2005, 48; 2006, 21; 2007, 26; 2008, 49; 2009, 77; 2010, 41; 2011, 37.
For bipolar disorder: 2007, 15; 2008, 14; 2009, 20; 2010, 30; 2011, 33. For the no-disorder control
group: 2002, 71; 2003, 28; 2005, 66; 2006, 35; 2007, 45; 2008, 64; 2009, 61; 2010, 35; 2011, 39
diagnostic groups in this study. These The prevalence of smoking in our
group differences remained relatively sample is generally consistent with, but
constant over the observation period, at the lower end of, that observed in
and there were no significant time other recent U.S. cohorts of individu-
trends in prevalence of smoking or als with schizophrenia and bipolar
quantity of cigarettes consumed when disorder. In studies of schizophrenia
analyses adjusted for demographic published since 2000, the reported
covariates. prevalence of smoking ranges from
Figure 2
Quantity of cigarettes consumed (packs per day) by smokers with
schizophrenia, by year of study enrollmenta
>1.5 >.5–1.0
>1.0–1.5 >.0–.5
100
90
80
70
60
Percentage

those with bipolar disorder. In a mul- 50

tivariate analysis with both mental
illness groups, the odds of being a 40
smoker and the quantity of ciga-
rettes smoked were significantly 30
lower for persons receiving bupro-
pion (odds ratio=.41, 95% confidence 20
interval=.21–.80, p=.009; z=–2.70,
p=.007). 10

Discussion
We found marked differences in the
prevalence of smoking and in the quan-
tity of cigarette consumption among the
0
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
a
Number of smokers per year: 1999, 10; 2000, 11; 2001, 5; 2002, 20; 2003, 20; 2004, 10; 2005, 28;
2006, 13; 2007, 19; 2008, 30; 2009, 53; 2010, 24; 2011, 23

PSYCHIATRIC SERVICES ' ps.psychiatryonline.org ' January 2013 Vol. 64 No. 1 47

Table 2
Multivariate regression correlates of smoking and of cigarette consumption for 547 participants with a serious
mental illness
Risk factor
History of substance abuse
Years of education
Caucasian race
Duration of illness
Male gender
PANSS total symptom scorec
Maternal education
Diagnostic group (bipolar disorder
versus schizophrenia)
a
Cigarette consumption was measured in packs per day (ppd) smoked.
b
The reference group is nonsmokers (zero packs per day).
c
Symptoms were measured by the Positive and Negative Syndrome Scale.
61% to 88% (4,5,17,24). In the fewer
studies of smoking with bipolar disor-
der, the reported prevalence ranges
from 31% to 69% (6,19,20,33,34).
It is noteworthy that none of these
previous studies compared persons
enrolled at different time points to
determine time trends as we did in
this investigation.
In addition to showing differences
in smoking between individuals with
schizophrenia and individuals without
a psychiatric disorder, our study also
demonstrated that individuals with
schizophrenia are more likely to be
smokers and to consume larger num-
bers of cigarettes than individuals with
bipolar disorder. With the exception of
a study by Diaz and colleagues (34), no
studies have directly evaluated and
compared smoking among individuals
with schizophrenia and individuals with
bipolar disorder in the same investiga-
tion. We enrolled individuals with
either disorder from the same geo-
graphic area and treatment centers, and
our analytic model included covariates
that are also associated with smoking.
Therefore, our comparisons between
the two psychiatric groups are relatively
free of obvious confounders.
The demographic and clinical cor-
relates of smoking that we found are
generally consistent with previous
studies of smoking by persons with
mental illness and mirror trends in the
overall population: lower education
(1), male gender (1,4), a history of
substance abuse (5), and Caucasian
48
Current smoking status
ORb 95% CI p ORb
3.87 2.55–5.85 ,.001
.80 .72–.87 ,.001
1.70 1.12–2.57 .013
1.83 1.12–12.57 .016
1.41 .94–2.10 .094
1.00 .99–1.03 .207
.98 .91–1.05 .481
.42 .25–.68 ,.001
race, though the latter is not found in
all studies of persons with serious
mental illness nor in the U.S. overall
population (1,17–20). We found no
significant association between ciga-
rette smoking or quantity of cigarettes
consumed and the severity of psychi-
atric symptoms. Results of previous
studies are mixed on this topic
(17,18,21–24). Our data also suggest
that cigarette smoking is not associated
with the receipt of specific medications
except bupropion. However, we do
not know whether the lower amount
of smoking by persons receiving
bupropion was an effect of its use as
a smoking cessation medication.
Strengths of our study include that
we had a relatively large sample that
included two groups with psychiatric
illness and a control group with no
psychiatric illness. Smoking was as-
sessed among new study enrollees in
a period that exceeded a decade,
through 2011.
One limitation of our study was that
we did not biochemically verify smok-
ing status, although self-report of
smoking is considered valid in epide-
miological studies (1). Another limi-
tation was that we assessed smoking
status only at study entry, so we do not
know the change in smoking status or
in the quantity of cigarettes consumed
by participants over time. In addition,
we did not collect data on the duration
of smoking or quit attempts, which
would be informative about the to-
pography of smoking and provide data
PSYCHIATRIC SERVICES ' ps.psychiatryonline.org ' January 2013 Vol. 64 No. 1
Quantity of cigarettes consumeda
95% CI p
2.77 1.92–4.00 ,.001
.83 .77–.89 ,.001
2.35 1.66–3.32 ,.001
1.92 1.26–2.95 .003
1.43 1.02–2.00 .037
1.00 .99–1.01 .491
1.00 .94–1.05 .912
.40 .26–.61 ,.001
for additional comparisons between
the groups.
Although our recruitment efforts
were continual for the three diagnostic
groups throughout the study period,
enrollment into research studies is
affected by many factors, and we can-
not rule out the possibility that there
may be unmeasured confounders that
could distort the relationships among
the groups or the apparent effects of
time. It is also possible that the per-
sons who participated in our studies
are not fully representative of persons
with these disorders in clinical settings
because our participants voluntarily
consented to a research study. How-
ever, smoking status was not a basis for
inclusion in the study, so it is unlikely
that participation introduced any clear
bias with respect to smoking.
Finally, although our overall sample
size was relatively large, individuals
with bipolar disorder were underrep-
resented. In addition, we may have
had limited power to detect time
trends given the small number of
individuals for some recruitment years
for some diagnostic groups.
Conclusions
Our study demonstrates that the
relatively high prevalence rates of
smoking by individuals with schizo-
phrenia or with bipolar disorder have
persisted over the past decade despite
increasing environmental restrictions
on smoking, ongoing public health
campaigns, rising cigarette prices, and
growing stigma associated with smok-
ing in many segments of the U.S.
population (35). Recently, there have
been calls to action in the psychiatric
community (13,36) and distribution of
materials to promote smoking cessa-
tion among persons with serious men-
tal illness (37). A recommendation also
has been made in one major schizo-
phrenia practice guideline that people
with schizophrenia who want to quit or
reduce cigarette smoking should be
offered treatment with bupropion,
with or without nicotine replacement
therapy, and that this pharmacological
treatment should be accompanied by
a smoking cessation education or
support group (38). However, these
developments have not yet resulted in
any substantive changes in smoking
status or cigarette consumption for
patients with schizophrenia or bipolar
disorder in routine psychiatric settings.
These results add urgency to the need
for action to promote smoking cessa-
tion by persons with serious mental
illness.
Acknowledgments and disclosures
This study was funded by grant 07R-1690 from
the Stanley Medical Research Institute. The
authors thank Melanie Bennett, Ph.D., for
comments on a draft of the article.
Dr. Yolken is a member of the Stanley Medical
Research Institute Board of Directors and
Scientific Advisory Board. The terms of this
arrangement are being managed by the Johns
Hopkins University in accordance with its
conflict of interest policies. The other authors
report no competing interests.
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