Tobacco

You Don't Have to Be Crazy to Smoke, But It Helps

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Steven A. Schroeder, former president of the Robert Wood Johnson Foundation and now director of the University of California at San Francisco's Smoking Cessation Leadership Center, thinks it's time to stop coddling mental patients by allowing them to smoke. In a Washington Post op-ed piece, he reports:

Almost half of all cigarettes sold in the United States (44 percent) are consumed by people with mental illness. This is because so many people who have mental illnesses smoke (50 to 80 percent, compared with less than 20 percent of the general population) and because they smoke so many cigarettes a day—often three packs. Furthermore, smokers with mental illness are much more likely to smoke their cigarettes right down to the filters.

I'm confused. Since "nicotine dependence" is listed in the Diagnostic and Statistical Manual of Mental Disorders (code 305.1), aren't smokers mentally ill by definition?

[Thanks to Alan Vanneman for the tip.]

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  1. This is sad and true

    My younger brother is schizophrenic, and has spent off/on time as an inpatient.

    Inpatients usually have a ‘break room’ where they basically can smoke all day. One of my best friends as a young kid coincidentally turned out to be the head nurse in charge of the ward where my brother was a patient, and he explained that (for whatever reason) allowing the patients to smoke gives them a chance to calm the fuck down and socialize amongst themselves without as many risks of conflict/freak out.

    It could be that mentally ill people benefit from the effects of nicotine, in that it can sharpen and organize their thinking… or at least that the ritual of smoking gives them some kind of palliative effect. In any case, as soon as my brother got out of the hospital, it took him like 3 weeks to quit. He never liked it in the first place, but said, “in there, there’s not much else to do”.

  2. So, isn’t this win-win for the socialized medicine types? They die earlier from smoking-related diseases and thus reduce the societal costs of mental illness?

    Oh right, this is just more silly puppet-theater polemics from the prohibitionists. Seems that nothing is below their shame threshold any longer (and nothing is too outrageous for the apathetic public to swallow whole.)

  3. From what I understand, psychiatrists have quite a few anecdotal observations concerning schizophrenia in particular and nicotine. Yes, yes, the plural of anecdote is not data, and correlation is not causation, but it’s an interesting enough observation that from what I understand there’s an active area of research on that topic, to try to figure out whether nicotine has some unique effects on schizophrenics. The goal, as I understand it, is to try to learn something about the mechanism of the disease* and maybe even something about the chemical pathways that could be targeted for treatment.

    *Yes, I know, some say that mental illness isn’t real. Humor me here. If you like, pretend that I’m mentally ill and don’t know any better.

  4. So people who smoke are mentally ill. Does that include everyone who used to smoke too?

    Furthermore, smokers with mental illness are much more likely to smoke their cigarettes right down to the filters.

    OH NOES, they want to get the full value out of their outrageously taxed habit?

  5. Mom was a psyche nurse. She dealt with a lot of addicted and mentally ill teenagers.

    “Take away the coke, take away the heroin, take away the alcohol, but don’t take away my cigarettes!” Even the sickest junkies would say that.

  6. I worked as a nicotine addiction counselor for a while (I’m too ugly to strip). A lot of the clients were open about their mental illenss issues and they felt that nicotine helped them calm down. My attitude was that if you think your bathroom tile is talking to you, cutting back on the cigs should be a real low priority.

  7. there have been studies on the effects of nicotine in Tourette syndrome. preliminary evidence presented in a talk I saw supported that nicotine, either in the form of smoking cigs or nicotine gum, helped to extend and enhance the effect of the drugs given to help control the symptoms of Tourette syndrome.

    there are molecular receptors on the neurons called nicotinic receptors for their reactivity to nicotine, so perhaps this isn’t all that shocking

  8. My attitude was that if you think your bathroom tile is talking to you, cutting back on the cigs should be a real low priority.

    QTMFT

  9. Are we including depression, social anxiety disorder, attention deficit disorder, and eating disorders as part of the mental illnesses?

  10. The mentally ill often find comfort and stability in routine rituals, which is what smoking seems to be for them. They get nervous, upset, whatever, and they go have a smoke and it calms them down. Or so I’ve observed without actually doing any kind of controlled study.

  11. So people who smoke are mentally ill.

    That’s not at all what the article says.

    Does that include everyone who used to smoke too?

    Of course not.

  12. Hmm. Probably up to fifty per cent of all people working in the mental health field are mentally ill. too. So many first began their studies in order to figure out what was wrong with themselves.

  13. Most people who have some sort of psychological problem, when diagnosed, are almost always told to immediately stop smoking – and are given prescriptions for Wllbutrin, Prozac, etc. Those prescriptions never end.

    Of course, those meds are covered by insurance. So the people are told to replace their tax-generating habit with a new socialized habit. The dependency however never goes away.

  14. Neil-

    So people who smoke are mentally ill.

    That’s not at all what the article says.

    Well, actually, it does say that here:

    I’m confused. Since “nicotine dependence” is listed in the Diagnostic and Statistical Manual of Mental Disorders (code 305.1), aren’t smokers mentally ill by definition?

    It might be true. It’s the same logic used on firearm owners, if you make it illegal to own firearms, suddenly you have a whole new class of “criminals” to deal with. If you make smokers mental cases and nicotine a subset of “drugs”, regardless of my personal beliefs if you’re crazy or not to smoke, suddenly it’s more appealing to people to take drugs away from crazy people.

  15. Here’s a mental health facility that is going smoke-free – and not just the patients:

    With the intent to promote wellness, the Thomas B. Finan Center campus, which also houses the Brandenburg Center, Archway Station’s Longview Apartments, the Massie and Jackson units, and the Jefferson School, will become tobacco-free effective Jan. 2.

    Use or possession of any form of tobacco product will be prohibited anywhere on the campus. This includes all work locations, grounds, parking lots, private vehicles on the center’s property and all state-owned vehicles.

    “Research shows that smoking, chewing tobacco and rubbing snuff are major causes of preventable disease and death in this country,” said Judy Hott, CEO at the Finan Center. “Individuals with serious mental illness, on average, die 25 years earlier than those without a serious mental illness. Tobacco use has been found to be a leading cause. As a health care system, it is our goal to provide our patients, visitors and staff with an environment as hazard-free as possible.”

  16. My guess is that Judy Hott is about to learn a hard lesson regarding (1) the ingenuity of inmates and (2) the fact that the lesser of two evils (in this case tobacco) is in fact a hell of lot less evil.

    Regarding her banning tobacco in private vehicles at a health facility parking lot:

    (1) Does that include visitors? Just WTF does she plan to do to the people who are visiting her patients and have a can of snuff in their pickup?

    (2) Are there any “tobacco-sniffing” dogs (yet)?

  17. Almost half of all cigarettes sold in the United States (44 percent) are consumed by people with mental illness.

    In other news, 72% of all statistics are completely made up.

  18. We used to put these people in homes where they used up tax dollars. We finally got them to PAY taxes instead of spending them, and this Schroder idiot wants to fuck that up.

  19. Use or possession of any form of tobacco product will be prohibited anywhere on the campus. This includes all work locations, grounds, parking lots, private vehicles on the center’s property and all state-owned vehicles.

    Wow. Even my high school didn’t bust grapes about having cigarettes in our cars.

    It was in North Carolina, though…

  20. man, i’d like to see someone take an existing inpatient mental ward that is used to their “5 hours a day in the breakroom, chain smoking”, and tell them they’ve got to do yoga or watercolors instead.

    That shit would be like, “ATTICA!ATTICA!” cots on fire, guards mauled, Bad Boys style riot.

    Or, they could just up their lithium so much that they cant so much as wipe their drool, much less chain-smoke.

    Seriously though. The horrible thing is i’ve seen both extremes of mental illness up close(raging insanity vs. doped zombieness), and it’s something i wouldnt wish on my worst enemy. Either to happen to them, or someone they love. Its just godawful.

  21. ‘m confused. Since “nicotine dependence” is listed in the Diagnostic and Statistical Manual of Mental Disorders (code 305.1), aren’t smokers mentally ill by definition?

    I’m not sure whether this is supposed to be a bit of snarky hyperbole, but on the chance that it’s an honest question–no, all smokers are not mentally ill by defintion. The DSM diagnosis requires “that the individual continues use of the substance despite significant substance-related problems.”

  22. (2) Are there any “tobacco-sniffing” dogs (yet)?

    That function will be performed by the nicotine-starved inmates. Sniff, sniff.

  23. Another isolated event:

    My neighbor’s daughter has schizo-effective disorder. Her psychiatrist told her explicitly not to quit smoking and told her parents that they should enable her to smoke regularly. I doubt that it was an effort to “coddle” her.

  24. Mom was a psyche nurse. She dealt with a lot of addicted and mentally ill teenagers.

    “Take away the coke, take away the heroin, take away the alcohol, but don’t take away my cigarettes!” Even the sickest junkies would say that.

    Joe, serious question, does your mom have any diseases related to second-hand smoke?

  25. The DSM diagnosis requires “that the individual continues use of the substance despite significant substance-related problems.”

    So what does that even mean? That sounds like a definition that might apply to, say, heroine–not tobacco.

  26. Oh, btw, kids, NPR did this story a while back and there’s an extremely unintentionally funny comment made by the reporter in the story.

    There was some discussion about the fact that if mental institutions banned smoking, then patients seeking treatment might not do so because they would fear not being able to smoke. The reporter said something to the effect of “maybe mental patients don’t have as much to fear as they think”. *pause for irony*

    Mental patients who have irrational fears? Say it ain’t so.

    NPR has inadvertently solved the problem of mental illness: just describe your intentions, carefully and logically and the patient will no longer believe that the catholic church is putting listening devices into their brains.

    Link: http://www.npr.org/templates/story/story.php?storyId=15599846

  27. Thus further discouraging the mentally ill from getting help. Brilliant plan.

  28. Jennifer, see my post right above yours. If you listen to the link, it’s worth a chuckle.

  29. When I quit smoking, I suddenly felt stupid. It was hard to think, hard to concentrate. It took me about a year to get back up to my normal level of (what I felt was) mental acuity. I almost went back to smoking because of it.

    I figure there are two reasons for this. The first is that nicotine is a mild stimulant. The second is that smoking gave me a chance to step outside on a frequent basis, to quietly ponder the programming problem I was working on for five minutes while I puffed.

  30. My neighbor’s daughter has schizo-effective disorder

    affective you mean.

    “effective” is what *I* am 🙂

  31. Jacob Sullum,

    I’m confused. Since “nicotine dependence” is listed in the Diagnostic and Statistical Manual of Mental Disorders (code 305.1), aren’t smokers mentally ill by definition?

    Disingenuous would be too generous.

    Either you really are ignorant of how a DSM diagnosis is rendered (you have a BS degree in psychology? Right?), or you are intentionally misrepresenting the position/point that SS is trying to make.

    This leaves the reader to decide: Ignorant or biased? Or both?

    Options you have taken off the table: informed, objective, honest…

  32. I think I just told this story on another thread, but it may have been a long time ago. I can’t recall.

    I work in the Mental Health Industry and I can attest to the larger-than-usual number of smokers. The thing is, as so many people have mentioned, there are a lot of reasons why it is not such a bad thing for these people. On top of the aforementioned, I have also heard that smoking takes some of the sting out of the side effects of psychotropic drugs.

    We had one guy come in and take over management of a group home. One of the first things he did was ban smoking. I’m happy to say that he was fired as soon as the complaints started to come in.

    The thing is, many people think that mentally ill people are still, well, adults or human beings at least, and that they retain a certain amount of control over their lives. Imagine that.

  33. It is fairly well established that Nicotine improves symptoms in schizophrenics, albeit only for a few minutes at a time, which would explain the 3 packs a day. Why this isn’t more widely known or pursued more vigourously scientifically comes down to a-holes like the ones behind this policy.
    As with cannabinoids, there are gobs of basic research supporting the beneficial effects of nicotine in a number of mental disorders, but the media seem disinterested in publicizing it (present media excepted).

  34. How very insightful, Neu Mejicano.

  35. Science News, Sept. 8, 2007 (Vol. 172, No. 10 , p. 148)

    The article “Live Wires: Axons can influence nerve impulses” describes research on nicotine’s influence on communication between neurons by axon. This was with mice. Sane mice, as far as I know.

    Anyway:
    QUOTE
    …scientists exposed the axons of isolated mouse neurons to nicotine, which mimics a natural chemical messenger in the brain called acetylcholine…. Without nicotine, a weak input signal triggered the neurons to fire only 35 percent of the time. With axons exposed to nicotine, neurons in the tissue samples fired twice as often…

    …Marina Picciotto, a psychiatrist and nicotine expert at Yale University [comments:] “It’s only now that work on nicotinic receptors [on axons] is showing the role they play in modulating sensory input.” Poor communication between the thalamus and cortex could contribute to disorders such as schizophrenia, some scientists hypothesize. If so, the new research could help explain why roughly 90 percent of people with schizophrenia smoke. “It may be that they’re doing it to self-medicate,” Picciotto says.
    UNQUOTE

    Smoking may be “calming” and allow for some social interaction, but it may in addition have an effect at a very low level of brain function.

    Or, maybe the evil talking mice in their brains demand they smoke.

  36. You don’t have to be crazy to smoke, but — uh, wait a sec . . .YES, you DO!

    Smoking, like any other drug addiction, is the triumph of insanity over intellect.

    This is why I support laws to keep smoke away from non-smokers. You have the right to smoke, but you don’t have the right to force ME to smoke.

    At the same time, I opposed Utah’s recent law which prohibits smoking in barrooms and other “private clubs.” For those of you who have been smoking awhile, let me explain. When you do it in public, you are taking over space which isn’t yours. When you do it in private, that’s your space, and I can choose to participate or not.

  37. As I see it they are saying that crazy smoke a lot. Smoking shortens the average life span of smokers. They want to stop crazy people from smoking. In other words they want to increase the life span of the crazy in the world, thus increasing their percentage in the population. why?

    Exactly what is the purpose of having a crazy person involuntarily extend their life span? The crazy person would be less happy since he clearly wants to smoke. And the rest of us just have to deal with more crazy people.

  38. When you do it in public, you are taking over space which isn’t yours,

    JGR:

    We libertarians are acutely aware that “public” space isn’t “ours”.

    “You can’t be in here, this is public property!”

    or

    When everyone owns it, nobody does.

    or

    All public property is theft.

  39. I don’t have any stats, but based on personal experience, there’s something to this.

    I’m borderline clinically depressed, have been since about puberty. A lot of it is chemical, and if I’m extremely careful with my diet and meds, I can function pretty well. When I fall off that beam, though, things quickly can spiral out of control, causing tertiary problems that just make it worse.

    I’ve been a pretty heavy smoker since I was about 16. Things start going to hell when I quit – the balance of the stress of quitting, trying to predict and cope with an offbalance system, and having to function at the same time is… difficult. The second time I tried, I lost a top 5% income job and my then-fiance.

    There’s a definite link, in my experience.

    — Posting this not under my usual pseudonym, because stigma attaches to the loonies, and also because I don’t want a confessional attached to my usual username.

  40. Given this data, and data suggesting people of lower income and education are more likely to be smokers, it is morally questionable to tax cigarettes at a greater rate than general merchandise. But then again, its kinda fun to kick a guy when he’s down.

  41. I just love the “quit smoking because it has bad side effects; here’s your lithium” attitude.

  42. The second time I tried, I lost a top 5% income job and my then-fiance.

    Sorry to hear that, anoony. I don’t smoke, but I know what you mean about easily falling off the euthymia beam into the croc pit. Ever thought of smoking things besides cigarettes? 😉

  43. Studies have shown that long-term nicotine addiction actually exacerbates many mental conditions, especially depression.

    “Almost half of all cigarettes sold in the United States (44 percent) are consumed by people with mental illness.”

    Tobacco Industry:

    We don’t target kids; we only target the 1/2 our customer base who are mentally ill. This is not new; we’ve known this for decades. And you should see the fun we’re having in the developing world!

  44. Actually Gene it is a bit more complicated than that. It does not exacerbate schizophrenia, most evidence suggests transient improvement, and quitting smoking is one of the more reliable ways to induce a major depressive episode. In the long term depressives are better off smoke free, but during a hospitalization, which in depressives is typically after a suicide attempt, demanding they quit smoking is akin to punishing them for not being successful suicides. At the very least it seems a bit un-hippocratic to make the disorder you are treating worse in order to satisfy a faddish public health goal.

  45. I’m well aware of the complexity, and and aware you too may be using a bit of shorthand in the interest of brevity. Even so, I can’t help but think the inherent but unstated qualifications in your post must be deliberate. You appear not to have read the article, which addresses many of your “concerns” in a normal, reasonable way–the article’s basically about the consensus among mental health clinicians and advocates for the mentally ill.

    But to address just a few seemingly deliberate misdirections in your post:

    “transient improvement”–of course, relieving withdrawal symptoms provides “transient improvement.” Addicted patients are also deprived of alcohol, heroin and cocaine..

    “make the disorder you are treating worse …”

    More silliness. As with other withdrawal problems, there are a number of established methods for easing the transition, and professionals are actively seeking more. No one wants to increase a patient’s distress. Read the article.

    “. . . in order to satisfy a faddish public health goal.”

    AH! Now which underground image management firm developed that little gem?

    And so, with your last words your agenda rises to the fore. It’s so “faddish” to save lives and spare millions the ravages of addiction and the loss of loved ones. A “fad” that has been in progress for 5 decades, and has enjoyed the support of the vast majority of the public and public figures.

    I can only respond with what a recent study found:

    “Documents indicate the tobacco industry monitored or directly funded research supporting the idea that individuals with schizophrenia were less susceptible to the harms of tobacco and that they needed tobacco as self-medication. The tobacco industry promoted smoking in psychiatric settings by providing cigarettes and supporting efforts to block hospital smoking bans. The tobacco industry engaged in a variety of direct and indirect efforts that likely contributed to the slowed decline in smoking prevalence in schizophrenia . . . “

  46. “The tobacco industry promoted smoking in psychiatric settings by providing cigarettes and supporting efforts to block hospital smoking bans”

    That’s terrible. In other news, mean-spirited executives at McDonalds promote obesity by “providing hamburgers” and blocking efforts to outlaw fast food sales. Ditto for makers of dirt bikes, ATVs, snowmobiles, firearms, and everything else the health profession knows loudly we shouldn’t have.

    “As with other withdrawal problems, there are a number of established methods for easing the transition…”

    Aside from a properly executed suicide, the most established method would be having a cigarette. I’d think after a suicide attempt, quiting smoking would be a concern for another day. Likewise, that would not seem to be the ideal time to inform the patient of the hazards of eating raw fish, rock climbing, motorcycling, or whatever other few joys this person may have in his life. But what do I know – telling other people how to live their lives is not a big part mine.

  47. >>But what do I know . . .

    Virtually nothing about this issue, as your imaginings make clear. But that doesn’t stop you from snarking away from a position of sheer, unapologetic ignorance. It’s doubtful you even read the article, which is written with intelligence and empathy– and does discuss the kind of “well-intended but uninformed compassion” you ostensibly exhibit.

    You can inform yourself. Or jabber on. Whatever.

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