Smoking and Mental Illness : The Frontal Cortex

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Jonah Lehrer is a contributing editor at Wired. He's also written for The New Yorker, Seed, Nature, and the New York Times and is a contributor to Radiolab. He's the author of Proust Was A Neuroscientist. His new book is How We Decide.

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Smoking and Mental Illness

Posted on: November 19, 2007 12:26 PM, by Jonah Lehrer

The statistics are troubling:

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.

Obviously, it's extremely important that we encourage people with mental illness to quit smoking. As this excellent op-ed by Steven Schroeder notes, mental health professionals have often tacitly encouraged people with psychiatric disorders to use cigarettes as a crutch.

The reasoning goes something like: "Poor Joe is suffering so much from his illness and gets such pleasure from his cigarettes that I don't want to take them away from him." Another reason lies in the extent to which smoking is integrated into mental health treatment. In psychiatric hospitals the denial of the opportunity to take a smoke break is used as a disciplinary tool, and cigarettes have become part of the culture -- often being traded for goods or sexual favors as a form of currency.

But I wonder if something else is also going on, and that smoking acts as a form of self-medication for people with mental illness. The one virtue of nicotine as a drug is that it's extremely consistent: when you light a cigarette you know exactly what kind of rush you are about to get. For people beset by a woefully unpredictable mind, there might be something reassuring about the pharmacological regularity of smoking. And then there's the calming effect. (Odd for a stimulant, I know.) One of my friends quit smoking and immediately took up meditation, because he said he missed focusing on nothing but his breathing for twenty minutes a day. We eat on the run, we drink coffee in our cars, but I'm often impressed by how smokers will just puff on a cigarette and stare off into the distance. The smoking break, in other words, is a form of toxic contemplation, a rare moment of calm amid the helter-skelter. Does this moment of (carcinogenic) repose help people with mental illness? Do they crave a chance to be still?

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Comments (24)

There is also the social factor of smoke breaks.

Posted by: Nate | November 19, 2007 12:54 PM

Interesting, I too quit smoking and took up meditation. I didn't comprehend a correlation though.
I considered smoking to be self medication without a doubt.
Having an addiction is like giving yourself an itch that you know exactly how to scratch. Of all the things out of my control, this one is most definitely in my control and it felt very good to relieve it.

Posted by: Zed | November 19, 2007 1:49 PM

Now someone will start litigation based on marketing to a vulnerable population!

Posted by: Ted | November 19, 2007 2:08 PM

I worked in a group home for people with metal illness for 3 years and smoking is absolutely part of the culture for those members of the community who were the most institutionalized.

I was working primarily with individuals suffering from severe schizophrenia which limited their ability to take part in many daily adult activities, such as working, child rearing, house maintenance, ect. Without participating in these (let's face it) time consuming and thoughtful activities, many people with mental illness are left with little to occupy them; smoking becomes a way to pass the time.

I don't argue the hypothesis that smoking is a form of self-medicating, I am almost certain that it is, but I think the larger reason is to stave off the boredom that comes with literally having nothing else to do. As for smoking cigarette's down to the filter, I'd be willing to bet it's because they lack the funds to be able to buy all the cigarettes they want making every puff precious.

Posted by: J | November 19, 2007 2:42 PM

I used to smoke roughly a pack a day, and when I quit my powers of concentration took a huge hit. I do a lot of software engineering, and the ability to get concentrate for more than 5-10 minutes on a task became difficult. I was spending a huge amount of effort trying to keep my thoughts on track rather than, you know, actually thinking. It took I would say about 12 weeks to get back to "normal". I was a tech lead for a multi million dollar project during this time, and while I myself noticed deterioration and shuffled around some responsibilities to my staff, nothing fell apart. But I did have to figure out ways to compensate for the cognitive deficit that was created by my system adjusting to the lack of nicotine. The physical cravings went away after 3 days, but the mental effects lasted much longer.

For me, the effect of nicotine was very clear a concentration enhancer, and I would use it that way. It was both a thought-provoker and something which would deal with the mental thrashing of having too many ideas interrupting themselves. I think it's "relaxing" in the sense that it directs your mental energy. My sleeping is actually a lot better now after I've quit, and I'm certainly more relaxed over all. But I lost a trick which would consistently get me "into the zone" mentally.

I guess in some way this idea that taking a break breathing deeply is what makes you feel relaxed, but this is a theory I've only heard advanced by non-smokers.

Posted by: Will Schenk | November 19, 2007 3:28 PM

I, too, worked in a group home for about a year and yes, a lot of people smoked well over a pack a day. The theory going around the members of the home was that smoking ameliorated some of the effects of the psychotropic medications. I have no idea whether this is true.

As an ex-smoker, I can also confirm Will Schenk's observation. There's a famous story about the composer Alban Berg offering a colleague a cigarette and the other composer declined, saying he didn't smoke. Berg was shocked and said, "But how can you compose?"

One final thing. Tobacco must be one of the most addictive substances in the world. It's been thirty years and barely a day goes by when I don't have thoughts about taking it up again (not that I ever would). I've known heroin addicts who have told me that cigarettes are far harder to quit. Although I've never tried heroin, I have no reason to disbelieve them.

Posted by: tristero | November 20, 2007 5:13 AM

As a former smoker, my theory is that smoking contributes to perpetuating mental illness in a patient. Think about it; living day-in and day-out knowing that you are continuing a behavior which will ultimately make you ill and kill you. Heavy, right? From my experience I am enormously mentally healthier in comparison with when I smoked. In my opinion, smoking indicates a perpetual death wish. Consciously or subconsciously it is certainly a behavior that must be stopped if rehabilitation of the patient is to occur.

Posted by: Miranda | November 20, 2007 6:49 AM

Oh my. Miranda, you need to step way back. It looks like you all have things to learn, I recommend spending time at The Icarus Project (google it), or the link that brings me here:

http://www.furiousseasons.com/archives/2007/11/black_monday.html

Peace out.

Posted by: flawedplan | November 20, 2007 8:30 AM

There seems little doubt me that people with mental health problems are more likely to smoke, however, when I gave up smoking for two years - I came to the conclusion that I was 'happier' being a smoker. But I did start smoking when I was nine and to be fair I can not say for certain that I would not be 'happier' if I had never started in the first place (I am in my forties now). But in the unlikely event that I should ever seek help for a mental illness, I would not take kindly to being coerced in to giving up smoking and I would bitterly resent being forced to - which seems to be the direction that many professional tobacco control advocates are pushing for. And I can say for certain that any institutionalized attempt to stop me from smoking would dissuade me from seeking help if I needed it.

Fredrik Eich

Posted by: Fredrik Eich | November 20, 2007 3:58 PM

by the time they're on 3 packs a day, i'd guess the major thing they're craving is nicotine (call it a hunch!)

Posted by: brian | November 20, 2007 5:07 PM

I would like to know what mental hospitals allow their patients enough time to smoke 3 packs a day (I want to go there). Having resided in several psych hospitals, not one allowed more than 20 minutes at a time to get a smoke in. If you do the math, I would have had to smoke 1 cigerette every minute on each of the 3 breaks to smoke 3 packs a day. Hardly would give me time to smoke each one to the filter or even stare off into space! To further your education regarding mental illness and smoking, not all mental patients smoke and believe it or not, the decision to let patients smoke has more to do with controlling patients than to do with allowing a mental patient pleasure. This has got to be one of the most assnine articles I have every read.

Posted by: Jane | November 20, 2007 5:55 PM

I know a number of sober Alcoholics who smoke.

It's social - they all go out and light up together. It's also a substitute buzz.

I think the general feeling is that alcohol will kill them faster than tobacco. Ideally once they get past not drinking they'll cut out tobacco, and many do.

Posted by: AnnR | November 20, 2007 9:52 PM

Very interesting, and a hot topic in neuroscience classes right now. My best friend is bipolar and has smoked for a variety of reasons starting from around age 14. She told me that her therapist actually advised her to continue smoking as a way to get those deep breathing, "calming" moments regularly during the day (she is particularly manic). I don't know how much it helps... sometimes when she is manic she actually manically smokes up to 5 cigarettes in an hour and it seems to actually worsen the mania and build on itself(though this relationship is obviously very difficult to actually discern). When she's depressed or anxious and smokes, it seems more ameliorative and calming. Strangely enough, then, it seems to both worsen and improve her illness, depending on when she uses it!

Posted by: Katy | November 20, 2007 10:01 PM

Trying to diagnose and analyze your best friend, despite some staggering "empirical" evidence you have there, hardly seems productive. Nor does it clear up the vagueries surrounding the term "people with mental illness" that only contributes to the harmful stigma surrounding psychiatry in general. The message I gleaned from this post was a condescending one: "Obviously, it's extremely important that we encourage people with mental illness to quit smoking." Shouldn't we (or they, depending on how you choose your words) all?

Posted by: Ashley | November 20, 2007 11:55 PM

Woah, harsh. I'm not sure if you are responding to my post, or to the topic in general, but your "Best friend" comment seems pointed at me, so I'll retaliate. Though perhaps my tone seemed condescending, I was not trying to completely generalize my comments on what my experience with my friend who deals with BPD/bipolar and nicotine addiction...Nor was I suggesting that she quit or not quit..I was just noting how at different times smoking seems to either heighten her mania or alleviate her depression. I was merely suggesting that perhaps nicotine can have multiple effects on a VARIETY of mental illness, or a variety of symptoms within the same disorder; but perhaps my biased and un-experimental vantage point yields nothing but an uninteresting anecdote. And to argue that my anecdotal thoughts are not productive and harmful is a bit much. Who are you to say it is unhelpful?? Maybe in HER particular case, if I notice that smoking seems related to an increased mania, she might keep that in mind and limit her smoking at that point. Maybe she won't, and maybe they aren't related, but how do you know? Also, I never once generalized her situation to "they".

Posted by: Katy | November 22, 2007 2:22 AM

Hey Katy,

I should have separated my comments by a paragraph break. Only the first sentence was a response to your comment, while the rest was a response to the main post. I did not intend to accuse you of making generalizations or presenting a tone of condescension (because I don't think you did), rather I was simply voicing frustration over the limited information/perspective of the main post. Sorry for the confusion.

Posted by: Ashley | November 23, 2007 4:36 PM

You know, I wasn't sure if that was the case or not, but I'm glad I didn't come off as completely condescending, because I definitely was not trying to! definitely don't apologize, I took that too personally when it wasn't even directed at me! maybe I should take a smoking break and chill out =)

Posted by: Katy | November 24, 2007 10:56 AM

This is a disappointing post. Jonah has let his anti-smoking feelings get in the way of objectively analyzing this phenomenon. Smokers have lower rates of Parkinson's disease. There has been plenty of science recently examining the link between high rates of smoking in the schizophrenia population and the biological basis for that. I would much prefer to see you explaining nicotine's affect on the brain, gating, etc. than these biased, prejudiced anti-smoking goofy explanations.

Posted by: Judy | November 25, 2007 2:36 PM

Indeed -- smoking is known to be used as self-medication in schizophrenics. Although this is a well known observation the neurochemical mechanisms are not understood. However, the idea seems plausible given the distribution of nicotinic receptors in the brain and our vague understanding about the neural basis of schizophrenia.

Posted by: a | November 25, 2007 10:01 PM

While nicotine is certainly the key compound in tobacco addiction and the nicotine in cigarettes almost certainly plays a role in the "self-medication" often seen in the mentally ill (in fact, a nicotinic acetylcholine receptor mutation is a genetic locus in schizophrenia), other compounds in cigarettes may be involved. Smokers have reduced levels of monoamine oxidase B (Fowler et al., 1996), which is involved in breakdown of catecholamines. This would almost certainly alter regulation of dopamine and norepinephrine.

Posted by: Crusty Dem | November 26, 2007 1:34 AM

tristero: I've known heroin addicts who have told me that cigarettes are far harder to quit. Although I've never tried heroin, I have no reason to disbelieve them.

Likewise: And I got that from a former junkie and current smoker....

Posted by: David Harmon | April 3, 2008 1:33 PM

I'm not going to post this under my usual name because it's not something I'm proud of, but as both a former heroin addict and a former smoker I can tell you over the long haul, quitting smoking is more difficult. It's a bit of a trade-off though.

The initial withdrawal was much more difficult from heroin than nicotine, but the triggers to smoke are constant and everywhere. Think about it. Smokers dose themselves much more frequently than heroin addicts do. I used heroin only once or twice a day most days. But I smoked anywhere from 20 to 60 times a day. That means that the urge to smoke is going to strike you a lot more often than the urge to shoot up is. I want to smoke when I'm happy, when I'm sad, when I'm stressed out, when I'm relaxed. When I drink coffee, when I go out with friends... in short, always.

I just don't really have the emotional triggers with heroin that I do with smoking. Even talking about it now it making me tense! For heroin, the trigger only really happens when I smell something that smells like cooking heroin. It's a very specific and weird smell that one rarely encounters in everyday life, and the urge goes away almost immediately. I don't even want to use it, so I just live with the infrequent Pavlovian responses. At this point my response is largely negative. Not so with cigarettes.

Back to the topic of the OP, I wonder part of it isn't because the mental illness often manifests in the teens and twenties, when most people begin to smoke. As the disease progresses, the person becomes not only less able to control their impulses and addiction, but increasingly alienated from friends and family- the usual support networks, positive influences, etc.

Posted by: Being Secretive | April 3, 2008 9:11 PM

But I wonder if something else is also going on, and that smoking acts as a form of self-medication for people with mental illness.

Absolutely, one hundred percent accurate. I have severe ADHD and was also diagnosed with mild bipolar. I have been smoking for seventeen years (I'm thirty-two). The problem I have had with quitting, is that I get very disassociative without cigarettes. It didn't go away even after six weeks without smoking (the longest I have ever made it).

And then there's the calming effect. (Odd for a stimulant, I know.)

This has less to do with the fact that it's a stimulant and more to do with the nature of addiction. The same it true of methamphetimine. Take a tweaker's speed away and you'll see real agitation. Give them their speed back and you will see instant calm. The two points at which a tweaker will start getting aggressive, is at the point they come down and want more or their system becomes saturated to the point that it isn't getting them high any more. Actually, they will also start to freak, if they've been awake for too long, but that's a bit of a different story.

Posted by: DuWayne | April 3, 2008 10:41 PM

One of the most recent models of depression is that it is characterised by disregulation of the brain reward system, with sufferers experiencing attenuated reward from most stimuli. Could it be that smoking is attractive to depressives (as a sub-set of those with mental illnesses)due to the fairly constant stream of reward that it provides them with?

Posted by: Physis | April 4, 2008 3:49 AM

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