Schizophrenia Bulletin vol. 36 no. 1 pp.
173–181, 2010
doi:10.1093/schbul/sbn066
Advance Access publication on June 17, 2008
Smoking in Schizophrenia: Diagnostic Specificity, Symptom Correlates, and Illness
Severity
Roman Kotov1,2, Lin T. Guey2, Evelyn J. Bromet2, and
Joseph E. Schwartz2
2
Department of Psychiatry and Behavioral Sciences, Stony
Brook University, Putnam Hall-South Campus, Stony Brook,
NY 11794-8790
Background: Cigarette smoking was consistently found to
be more prevalent in individuals with schizophrenia than in
other psychiatric groups and the general population. These
findings have been interpreted as evidence of a specific as-
sociation between schizophrenia and smoking. However,
the supporting data come primarily from cross-sectional
studies, which are susceptible to confounding. Our aim
was to test specificity of this link longitudinally in an ep-
idemiologic sample. Methods: A cohort of 542 inpatients
with psychosis was followed for 10 years after first hospi-
talization, completing 5 face-to-face interviews. Assess-
ments included ratings of specific symptoms (psychotic,
negative, disorganized, and depressive), Global Assessment
of Functioning, and a categorical measure of cigarette con-
sumption. All participants were assigned longitudinal con-
sensus diagnoses by study psychiatrists, and 229 were
diagnosed with schizophrenia spectrum disorders (SZ).
Results: At baseline, 52.4% of participants were current
smokers and 69.3% were lifetime smokers. Smoking rates
did not differ among the diagnostic groups (schizophrenia
spectrum, major depressive, bipolar, or other psychotic dis-
order) at any assessment point. Smokers were more se-
verely ill than nonsmokers but did not differ in specific
symptoms either cross-sectionally or longitudinally.
Among smokers, changes in cigarette consumption were
linked only with changes in depression (b = .16,
P < .001). Conclusions: Rates of smoking were elevated
in subjects with schizophrenia but were just as high with
other psychotic disorders. Smoking was not associated
with psychotic symptoms, but cigarette consumption
covaried with depression over time. Given the devastating
health consequences of cigarette use, smoking cessation
interventions are urgently needed in this population and
should specifically address depression.
1
To whom correspondence should be addressed; tel: 631-632-
7763, fax: 631-632-9433, e-mail: roman.kotov@stonybrook.edu.
Ó The Author 2008. Published by Oxford University Press on behalf of the Maryland Psychiatric Research Center. All rights reserved.
For permissions, please email: journals.permissions@oxfordjournals.org.
173
Key words: depression/psychosis/severe mental illness/
epidemiology
Introduction
Smoking is the leading cause of preventable mortality in
developed countries, and it remains highly prevalent
among patients with schizophrenia despite a steep decline
in the general US population.1–5 A quantitative review of
42 studies from 20 countries reported a 62% pooled rate
of smoking in patients with schizophrenia, which was sig-
nificantly elevated relative to general population and psy-
chiatric comparison groups.2 These data have been
interpreted as evidence of a specific link between smoking
and schizophrenia. It was hypothesized that schizo-
phrenia leads to smoking, presumably, because nicotine
reduces symptoms of the illness (ie, self-medication),6
that smoking may contribute to development of the dis-
order by altering neurochemical systems in the brain,7
and that both conditions could arise from a common
genetic vulnerability.2
However, these hypotheses are based primarily on
cross-sectional comparisons of smoking rates in schizo-
phrenia and various other psychiatric disorders.2 Elevated
rates found in such studies may be due to confounders,
such as illness severity or impoverished environment.4,8,9
Several investigations attempted to control for potential
confounders statistically, but the selection of variables var-
ied widely. Typically, adjustments were made for age and
gender, but some studies also controlled for socioeco-
nomic status (SES), low IQ, education, marital status,
comorbid diagnoses, and several other characteris-
tics.4,10–13 The effect almost invariably persisted after cor-
rections. However, no study controlled for illness severity.
Prospective investigations can provide more direct evi-
dence of the connection, but 2 studies conducted to
date produced contradictory results. Weiser et al12 found
that smokers were at an increased risk for developing the
illness, whereas Zammit et al13 reported that smoking had
a protective effect. Moreover, investigations of associa-
tions between smoking and severity of schizophrenia
symptoms have also produced inconsistent results. One
study reported a link to both negative and positive
R. Kotov et al.
Baseline Interview
N = 675
Analysis Sample
N = 542
Intermediate
6 months N = 423
2 years N = 387
4 years N = 319
Year 10 Interview
N = 357
Fig. 1. Derivation of the Sample and Its Retention by the 10-Year Follow-up.
symptoms,14 4 found associations with one type of symp-
toms but not the others,11,15–17 and another 4 did not find
any significant relations.18–21 In contrast, the link between
smoking and depression is well established both cross-
sectionally22 and prospectively.23–27 In fact, it was sug-
gested that depression may contribute to the high rates
of smoking in patients with schizophrenia,14,17 but this
hypothesis has not been directly tested.
The objective of this study was to test the belief that
schizophrenia has a specific connection to smoking. First,
we examined the specificity of elevated smoking rates to
schizophrenia by comparing it to disorders of similar se-
verity (eg, mood disorders with psychosis). Second, we
tested associations of smoking with schizophrenia and de-
pression symptoms both cross-sectionally and longitudi-
nally. Third, we evaluated links between changes in
these symptoms and fluctuations in cigarette consump-
tion over time among smokers.
Methods
Sample and Procedure
Data for this study came from a first-admission cohort
described in detail elsewhere.28–31 The patients were
recruited from all 12 psychiatric inpatient units of Suffolk
County, NY, between 1989 and 1995. The units included
state, community, and university facilities. At the begin-
ning of the study, all facilities permitted smoking, but in
late 1991 and early 1992, policies changed to prohibit
smoking on the units. Instead, patients were regularly
taken outside to smoke. They were also offered nicotine
replacement (gum or patch). Despite these changes, the
174
Excluded
31 ineligible
55 insufficient longitudinal data
47 substance-induced or
organic psychosis
Incomplete Data
28 Died
29 Lost
47 Refused
8 Unable to consent
73 Contacted but insufficient data
rate of current smoking remained stable across the
6-year enrollment period (b = .01, P = .83).
The purpose of the parent study was to investigate the
course of schizophrenia longitudinally in an epidemio-
logic sample of first-admission cases. To obtain a repre-
sentative sample, all new patients with psychosis were
enrolled, and thus, a variety of psychotic disorders are
present in this cohort. The inclusion criteria were aged
15–60, first admission either concurrent or during the
6 months prior to the index admission, clinical evidence
of psychosis, ability to understanding the assessment pro-
cedures in English, and capacity to provide written in-
formed consent. The procedures for obtaining
informed consent were approved annually by the Institu-
tional Review Boards at Stony Brook University and all
hospitals where respondents were recruited. For partici-
pants aged 15–17, written consent of parents was also re-
quired. The response rate was 72%. Overall, 675
individuals met the inclusion criteria and were inter-
viewed at the baseline. Of those, 31 were later found
to be ineligible, primarily because it became clear that
they never suffered from psychosis. Another 55 partici-
pants were excluded because of insufficient follow-up in-
formation to permit a longitudinal diagnosis (15 of them
died in the first 24 months of the study), and 47 were re-
moved because they had a substance-induced or organic
psychosis. Hence, the analysis sample is composed of 542
participants (figure 1).
In addition to baseline, face-to-face interviews were
performed at month 6 and years 2, 4, and 10 by trained
master’s level mental health professionals. Study psychia-
trists formulated longitudinal consensus Diagnostic and
Statistical Manual of Mental Disorders, Fourth Edition,

55
50
45
GAF
40
35
abstaining
30 fluctuating
persisting
25
0 2 4 6 8 10
Years
Fig. 2. Trajectory of Illness Severity (GAF) in the 3 Smoking Pattern
Groups of the Total Sample: Abstaining (N 5 191), Fluctuating
(N 5 127), and Persisting (N 5 224).
research diagnoses after the year 2 assessment. The rat-
ings were made independently by at least 2 psychiatrists
and were discussed by the whole team. The raters based
diagnoses on all available information from structured
clinical interviews, medical records, and significant
others collected at baseline, month 6, and year 2.30
The diagnoses were grouped as schizophrenia spectrum
(SZ; schizoaffective disorder, and schizophreniform
disorder; N = 229), bipolar disorder with psychosis
(N = 148), major depressive disorder with psychosis
(N = 104), and other psychotic disorders (delusional dis-
order, brief psychotic reaction, and psychotic disorder
not otherwise specified; N = 61). The SZ group is the fo-
cus of the present study.
With extensive efforts to track the sample and keep
respondents invested in the study, we were able to main-
tain contact with the vast majority of participants. By the
10-year point, 28 respondents had died, 29 were lost to the
study, 47 refused to be interviewed, and 8 were too ill to
give informed consent. Half of the 28 participants died of
medical illnesses (most commonly cardiovascular disease,
various forms of cancer, and liver failure), but only one of
them died of lung cancer. Due to relatively low mortality
and absence of a clear connection to tobacco use, we do
not expect that mortality biased our findings. Of 430 con-
tacted respondents, 73 provided limited data and could not
be analyzed. Thus, all necessary information at year 10
was available for 357 respondents (completers), and 147
of them had an SZ diagnosis. We compared excluded par-
ticipants (N = 185) with completers on all variables used
in this study and found no significant differences (all
P > .10), which suggests that attrition had little systematic
impact on the results. For instance, the prevalence of cur-
rent smoking at baseline was 51.6% among noncomplet-
ers, as compared with 52.8% among completers
(v2(1) = .07, P = .80). Missing data were handled with
maximum likelihood methods, and thus, all available
data were utilized without deleting any records.
Smoking in Schizophrenia
Measures
Smoking was assessed with items adapted from the Na-
tional Household Survey on Drug Abuse interview.32 All
participants were asked how much they smoked per day
in the past 30 days (past 6 months at waves 2, 3, and 4) on
the following scale: none, <1 cigarette, 1–5 cigarettes,
½ a pack, 1 pack, 1½ packs, and 2 or more packs. A par-
ticipant reporting any usage was considered a smoker at
that wave. At baseline, participants were also asked
whether they ever smoked on a regular basis. Those
who responded yes or reported cigarette usage at baseline
were considered lifetime smokers. Responses were
recoded as the number of cigarettes consumed on an
average day using the mid-point of the corresponding in-
terval except for the highest level, which was coded as 40.
Symptoms of schizophrenia in the 4-week period pre-
ceding the interview were measured with the Scale for the
Assessment of Positive Symptoms (SAPS)33 and the Scale
for the Assessment of Negative Symptoms (SANS).34 The
SAPS consists of 31 items tapping 4 symptom domains
and a global rating for each domain. The SANS is com-
posed of 19 items measuring 5 domains as well as the
global ratings. SAPS and SANS items are rated on
a 6-point scale (0 = none, 5 = severe). The validity of
these measures is well established.35–37 Specifically, the
SANS is unidimensional, whereas the SAPS taps 2 fac-
tors: psychotic symptoms (hallucinations and delusions)
and disorganized symptoms (bizarre behavior and formal
thought disorder). Consistent with prior studies, we used
individual items but not the global items.38–40 Common
factor analysis supported the established structure in the
present data. We removed 3 items that had consistently
poor loadings in these analyses: SANS item 13 (inatten-
tiveness during mental status testing), SAPS item 9 (per-
secutory delusions), and SAPS item 10 (delusions of
jealousy). Thus, the final SANS composite consisted of
18 items (internal consistency reliability ranged
a = .88–.90 over the 5 waves), SAPS psychotic of 16 items
(a = .79–.85), and SAPS disorganized of 13 items
(a = .71–.76). The interrater reliability of these ratings
was very good (average interrater r = .72).41
Symptoms of depression in the month preceding
the interview were assessed with the Structured Clinical
Interview for DSM-III-R (SCID)42 depression module
administered without skip-outs. Depression was opera-
tionalized as a composite of the 9 DSM criterion symp-
toms. Items were rated on a 3-point scale: 1 = not
present, 2 = questionable, and 3 = definite. Internal
consistency reliability of the composite ranged from
.83 to .86, and the interrater reliability was very
good.28 The composite correlated .74–.80 with the Ham-
ilton Rating Scale for Depression (HAM-D)43 across dif-
ferent waves. The HAM-D was not administered at year
4, and hence, depression was assessed with the SCID-
based scale. However, we repeated all analyses with the
175
R. Kotov et al.
HAM-D (without the year 4 data), and none of our find-
ings changed.
Illness severity was operationalized as psychiatrists’
consensus Global Assessment of Functioning (GAF) rat-
ing for the worst week in the past month. This score had
little variability at baseline because all participants were
hospitalized. Thus, we also report on baseline GAF for
the best month (GAF Best) in the year prior to hospital-
ization in some analyses.
GAF correlated strongly with the SANS (average con-
current r = .61) but had only moderate associations
with the other symptom scales (average r = .33). The
concurrent correlations among the symptom scales
were low to moderate (average r = .19), which is consis-
tent with the literature.35–37
We examined 3 demographic variables: sex, age at
baseline, and SES of the head of the household. SES
was assessed at baseline using the 7-point occupational
scale of the Hollingshead Four Factor Index of Social Po-
sition.44 It refers to the participant unless he or she is sup-
ported by someone else.
Data Analysis
Cross-sectional comparisons were made with t tests and
chi-square tests. Adjustment for covariates was per-
formed with logistic regression. Stability of smoking sta-
tus was evaluated with tetrachoric correlations, estimated
in Mplus version 4.1.45 Tetrachoric correlations quantify
associations between dichotomous variables on the met-
ric of Pearson r while correcting for biasing effects of low
base rates. Longitudinal associations between smoking
status and symptom/illness severity were examined
with repeated-measures analysis of variance in SAS
PROC MIXED.46 Changes in cigarette consumption
over time and their correlates were evaluated with mul-
tilevel growth curve analysis,47 estimated in PROC
MIXED. Specifically, cigarette consumption was modeled
on 2 levels as repeated observations (level 1) nested within
individuals (level 2). In level 1 (within subjects), cigarette
consumption was evaluated as a function of time, symp-
toms, and illness severity, whereas level 2 (between sub-
jects) modeled the mean and variance of the level 1
intercept as a function of demographic variables. Longi-
tudinal trends in cigarette consumption were evaluated
with a modified model. We removed all clinical and de-
mographic covariates, so that level 1 described cigarette
consumption as a linear function of time alone, and level
2 included only mean and variance of the intercept. All
variables except time were standardized with respect to
their grand means and SDs (across all subjects and
waves) to facilitate interpretation. In both PROC
MIXED analyses, the random-effects covariance struc-
ture was specified as an unstructured covariance matrix
because it imposed the fewest assumptions and provided
a better fit than various constrained covariance matrices.
176
Although the SZ group was the focus of the study, all
analyses were also repeated for the total sample.
Results
Prevalence of Smoking Across Diagnoses
In the total sample, the lifetime prevalence of smoking
was 69.3%. It did not differ by diagnosis, although the
SZ group had the lowest rate (67.4%; table 1). Current
prevalence of smoking at baseline was 52.4% and was
similar across the diagnoses. In fact, there were no diag-
nostic differences in rates of current smoking at any of the
follow-up assessments. Adjusting these comparisons for
age, sex, and SES did not change the findings, except that
at year 4 the SZ group had a significantly lower rate of
smoking that the ‘‘other psychoses’’ group (adjusted
odds ratio = .32, confidence interval = .12–.86). We also
stratified the sample by age (15–18, 19–25, 26–44, and
45–58 years) and repeated the analyses but observed no
diagnostic differences in either of these strata (table 1).
Smoking Status in the SZ Sample
Smoking status was very stable over the 10 years with tet-
rachoric correlations between waves ranging .80–.97
(table 2; top half). Indeed, 80% of baseline smokers, as
compared with 21% of baseline nonsmokers, smoked
at year 10. Of the 229 participants with SZ diagnoses,
147 smoked at one or more waves and constitute the
smokers subsample.
Lifetime smokers did not differ from nonsmokers with
respect to sex, age, and SES (table 1). Moreover, smoking
status was not related to symptom and illness severity at
any assessments point, except for one significant finding
for the GAF and one for the SANS (table 3). We also
examined these relationships longitudinally. Given the
high stability of smoking status, participants were classi-
fied according to their pattern of smoking across all avail-
able assessments as abstaining (never smoked during the
study, N = 82), fluctuating (had a change in smoking sta-
tus, N = 51), or persisting (always smoked, N = 96). The
groups did not differ on diagnosis, gender, or SES, but
the fluctuating group was 5.0 years younger than the
rest of the sample (P < .001). The groups also did not
differ in their trajectories of symptom and illness severity.
Controlling for sex, age, and SES did not change the
findings.
Cigarette Consumption Among SZ Smokers
In the smokers subsample (N = 147), individual cigarette
consumption varied considerably over time, with Pearson
correlations across waves ranging .33–.64 (table 2; bot-
tom half). These results indicate that some participants
increased their use while other decreased it. However,
the group’s average daily cigarette consumption did
 Smoking in Schizophrenia

Table 1. Demographic Characteristics of Lifetime Smokers

Odds Ratio
N Nonsmoker (%) Smoker (%) (confidence interval)

Total sample
Diagnosis
Schizophrenia spectrum 229 32.6 67.4 —
Bipolar disorder 148 30.8 69.2 1.09 (.69–1.70)
Major depression 104 26.9 73.1 1.31 (.79–2.20)
Other psychoses 61 29.5 70.5 1.16 (.62–2.14)
Sex
Male 302 31.1 68.9 —
Female 240 30.1 69.9 1.05 (.72–1.52)
Age
15–18 52 34.6 65.4 —
19–25 170 35.7 64.3 0.95 (.50–1.83)
26–44 272 28.5 71.5 1.33 (.71–2.49)
45–58 48 20.8 79.2 2.01 (.82–4.95)
SES
Blue collar or less 245 29.2 70.8 —
Above blue collar 297 31.9 68.1 0.88 (.61–1.28)
Schizophrenia spectrum group
Sex
Male 149 34.7 65.3 —
Female 80 28.8 71.3 1.32 (.73–2.38)
Age
15–18 20 40.0 60.0 —
19–25 88 33.0 67.0 1.36 (.50–3.68)
26–44 109 32.7 67.3 1.37 (.51–3.66)
45–58 12 16.7 83.3 3.33 (.57–19.41)
SES
Blue collar or less 121 29.4 70.6 —
Above blue collar 108 36.1 63.9 .74 (.42–1.29)

Note: SES, socioeconomic status. N = 542 (229 for the schizophrenia spectrum group). Dashes indicate reference category.

not change. It was 16.1 cigarettes a day at baseline and
showed no significant upward or downward trend over
the 10-year follow-up.
Cross-sectional analyses did not reveal any consistent
associations between cigarette consumption and clinical
variables (Appendix), including GAF Best at baseline
(r = .04). In the longitudinal analysis, we related
changes in cigarette consumption to changes in symptom
and illness severity over time. Each association was
adjusted for demographic characteristics and influence
of the other variables. Only depression severity showed
a significant effect (b = .16, P < .001), which corre-
sponds to consuming an extra cigarette a day for each
additional DSM depression symptom (table 4).
Analyses in the Total Sample
Given that the rates of smoking did not differ among the
diagnostic groups, we repeated all analyses in the total
sample. We thus increased power and enhanced general-
izability of the analyses. Smoking status was very stable
in this sample (table 2), and 351 of the 542 participants
smoked at least at one point during the study. In this
group, cigarette consumption varied considerably over
time (table 2). Average consumption at baseline was
18.1 cigarettes a day and declined at the rate of 0.36 cig-
arettes a year (P < .001) over the 10-year follow-up.
Lifetime smokers did not differ from nonsmokers with
respect to sex, age, and SES (table 1). On the other hand,
smokers had consistently lower GAF scores, with com-
parisons being significant at each wave except lifetime
and baseline (table 3). However, lifetime and baseline
smokers had significantly lower GAF Best scores (d =
0.23, P < .05 for both). Depression scores were consis-
tently elevated in smokers and the difference reached sig-
nificance at 3 time points. The SANS was also
significantly elevated at years 4 and 10 (table 3). Control-
ling for sex, age, and SES did not change the findings,
except for the effect of year 2 GAF in the total sample,
whose significance changed from P = .030 to .081. Al-
though more associations were statistically significant
in the total sample than in the SZ subgroup, the effect
sizes remained essentially the same (see mean effects in
table 3). Thus, the apparent difference in findings like-
ly reflects greater statistical power of the total sample.
To appreciate the magnitude of association between
177
R. Kotov et al.

Table 2. Stability of Smoking in the Schizophrenia Spectrum Results for cigarette consumption paralleled findings
Group (N = 229, above diagonal) and the Total Sample (N = 542, in the SZ group. Cross-sectional analyses did not reveal
below diagonal)
any consistent associations between cigarette consump-
tion and clinical variables because no links were repli-
Baseline Month 6 Year 2 Year 4 Year 10
cated across more than 2 waves (Appendix). In the
Smoking statusa longitudinal analysis, only depression severity had a sig-
Baseline — 0.95 0.94 0.88 0.80 nificant association with the amount of smoking while
6 mo 0.95 — 0.97 0.95 0.91 adjusting for other clinical variables and demographic
2y 0.94 0.96 — 0.97 0.97 characteristics (table 4).
4y 0.91 0.94 0.97 — 0.91
10 y 0.79 0.87 0.91 0.88 —
Additional Analyses
Consumptionb
Baseline — 0.62 0.47 0.36 0.33 All analyses were repeated in the completers subsample.
6 mo 0.64 — 0.61 0.55 0.42 The results were unchanged, except that a few cross-
2y 0.51 0.65 — 0.64 0.45 sectional comparisons became nonsignificant due to
4y 0.41 0.54 0.65 — 0.38
10 y 0.30 0.41 0.41 0.47 —
reduced power and without an appreciable change in
magnitude.
a
Top block = tetrachoric correlations among smoking status
variables (smoker/nonsmoker).
b Discussion
Bottom block = Pearson correlations of cigarette consumption
in the smokers subsample. Consistent with previous reports, the point prevalence
of smoking in the schizophrenia group of our epidemio-
logic first-admission sample (51.0% at year 10) was 2.5-
smoking and GAF, we compared prevalence of severe fold greater than in the US population (20.9% in 2005).1
illness (GAF  50) at year 10 between smokers and non- However, rates of smoking were just as high in the other
smokers. Many more smokers were severely ill (64.5% vs diagnostic groups. The present findings underscore the
45.1%, P < .001). significance of smoking as a public health problem
Longitudinal analyses also confirmed the association that cuts across psychotic disorders and possibly all se-
between smoking status and illness severity. Smoking vere mental illnesses. There was little change in smoking
pattern (abstaining, fluctuating, or persisting) had no as- status among participants with schizophrenia over the
sociation with symptom trajectories, but the persisting 10-year follow-up, and the average cigarette consump-
group had consistently lower GAF scores than the tion remained stable, although for individual smokers
abstaining (P < .01), with the fluctuating falling in be- the amount of consumption fluctuated notably over
tween (figure 1). Controlling for sex, age, and SES did time. Neither smoking status nor amount of consump-
not change the findings. tion was associated with schizophrenia symptoms.

Table 3. Cross-sectional Comparisons of Smokers and Nonsmokers in Symptom and Illness Severity (Cohen d)

Lifetime Baseline Month 6 Year 2 Year 4 Year 10 Meana

Schizophrenia spectrum group

N 227 229 183 168 140 147
GAF 0.14 0.01 0.31* 0.10 0.29 0.22 0.16
Depression scale 0.22 0.11 0.27 0.13 0.34 0.03 0.18
SAPS psychotic 0.25 0.13 0.17 0.08 0.07 0.25 0.14
SAPS disorganized 0.11 0.02 0.12 0.16 0.00 0.03 0.01
SANS 0.13 0.08 0.16 0.26 0.26 0.34* 0.10
Total sample
N 540 542 423 387 319 357
GAF 0.07 0.03 0.28** 0.22* 0.32** 0.45*** 0.16
Depression scale 0.19* 0.15 0.20* 0.15 0.25* 0.10 0.17
SAPS psychotic 0.12 0.07 0.15 0.07 0.13 0.21 0.12
SAPS disorganized 0.01 0.02 0.04 0.03 0.02 0.10 0.01
SANS 0.05 0.05 0.14 0.18 0.25* 0.35* 0.11

Note: GAF, Global Assessment of Functioning; SAPS, Scale for the Assessment of Positive Symptoms; SANS, Scale for the
Assessment of Negative Symptoms.
a
Mean = sample size weighted mean of the 6 columns.
*P < .05, **P < .01, ***P < .001.

178

Table 4. Correlates of Cigarette Consumption Over Time in
Smokers: Multilevel Growth Curve Analysisa
Schizophrenia
Spectrum Total Sample
GAF 0.01 0.02
Depression scale 0.16*** 0.11***
SAPS psychotic 0.01 0.02
SAPS disorganized 0.03 0.04
SANS 0.01 0.01
Note: GAF, Global Assessment of Functioning; SAPS, Scale for
the Assessment of Positive Symptoms; SANS, Scale for the
Assessment of Negative Symptoms.
a
All values are standardized b-weights and represent
independent contributions of each predictor. Associations are
also adjusted for age, sex, socioeconomic status, and time
(nominal variable).
*P < .05, **P < .01, ***P < .001.
However, changes in the letter were linked with changes
in depression symptoms.
We did not find evidence of specificity of smoking to
schizophrenia relative to other psychotic disorders at any
point during the follow-up, although our study had the
power of .93 to detect the level of difference reported
in a recent meta-analysis that compared schizophrenia
with other psychiatric disorders.2 Further examination
of smokers suggested that they were not different from
nonsmokers in severity of specific symptoms but were
more severely ill overall. For instance, at the end of
the follow-up, smokers were 43% more likely to be se-
verely ill than nonsmokers. Thus, it appears that reports
of elevated smoking rates in schizophrenia may have con-
founded diagnosis with illness severity. In support of this
interpretation, smoking did not show specificity to non-
affective psychosis in a nationally representative study of
mental illness in the United States.48 Furthermore, as
mentioned in the Introduction, prospective investigations
of relations between smoking and schizophrenia pro-
duced contradictory results, and cross-sectional studies
failed to find consistent associations between smoking
and severity of schizophrenia symptoms. On the other
hand, smoking status has been linked to illness severity
in general psychiatric samples, albeit assessed with proxy
measures.4,8,49 For instance, Aguilar et al49 found no
clear links between nicotine dependence and schizophre-
nia symptoms but observed an association between
smoking and frequent hospitalizations, an indirect mea-
sure of illness severity.
Examination of cigarette consumption among smokers
did not support the self-medication hypothesis with
regard to schizophrenia symptoms. However, we found
that increases in depression were associated with heavier
smoking. This observation is consistent with the exten-
Smoking in Schizophrenia
sive literature documenting cross-sectional and longitudi-
nal correlations between smoking and depression in other
populations.22 It appears that depression may have an
etiologic connection with smoking behavior, and mech-
anisms for this association have been proposed.22,50–52
These data highlight the importance of addressing de-
pression in smoking cessation interventions.
We did not find differences between smokers and
nonsmokers in SES and gender composition, although
in the general population smoking is more prevalent
among men and in lower socioeconomic strata.1 The
gender difference was also observed in schizophrenia
samples.2 However, the patients in these studies have
typically been ill for a long time. In contrast, our cohort
was assessed at the time of the first admission and was
followed through the early stages of the illness. We ex-
pect that gender and SES differences will emerge in our
sample with time.
A notable caveat of this study is that the findings
should not be generalized to patients who have never
suffered from psychosis. With regard to our diagnostic
comparisons, it is important to note that the majority
of mood disorder patients did not have any psychotic
symptoms at the follow-up assessments, yet no diagnos-
tic differences were observed. Furthermore, severity
of psychotic symptoms was associated neither with
smoking status nor with cigarette consumption. Never-
theless, our conclusions should also be tested in nonpsy-
chotic severely ill patients. The present findings do show
that smoking is highly prevalent across psychotic
disorders rather than being specific to schizophrenia.
Another limitation of the study is that anxiety was
not assessed, despite growing evidence of its links to
smoking.5,48,53 Cigarette consumption is also associated
with substance use. Evaluation of this relationship was
beyond the scope of the present study, but it would be
very informative to examine the links between substance
abuse and smoking over time. Finally, smoking was
measured with a single item and was rated on an ordinal
scale rather that continuously. This likely limited reli-
ability of the score and probably led to underestimation
of the effect sizes.
Despite these limitations, our findings suggest that
smoking is especially prevalent among those with severe
mental illness, and special intervention efforts should be
directed toward this group. It appears that factors con-
tributing to high rates of smoking are likely to be consis-
tent across the diagnostic groups studied here. One factor
with potential etiological significance is depression, and it
should be addressed specifically in smoking cessation
protocols. Importantly, emerging evidence suggests
that smoking cessation interventions can be successfully
employed in psychiatric populations,54,55 and quitting
does not seem to impede recovery from mental illness.56
Hence, provision of these services to severely mentally ill
is an imperative.
179
R. Kotov et al.

Appendix Cross-sectional Correlations (Pearson r) Between Cigarette Consumption and Clinical Variables in Smokers Subsample

Baseline Month 6 Year 2 Year 4 Year 10 Meana

Schizophrenia spectrum group

N 147 119 109 96 97
GAF 0.05 0.14 0.18 0.03 0.05 0.05
Depression scale 0.12 0.14 0.10 0.09 0.08 0.11
SAPS psychotic 0.10 0.06 0.04 0.14 0.04 0.04
SAPS disorganized 0.17* 0.04 0.02 0.21* 0.05 0.10
SANS 0.03 0.11 0.29** 0.01 0.13 0.11
Total sample
N 349 279 253 219 235
GAF 0.10 0.05 0.17** 0.10 0.23** 0.07
Depression scale 0.08 0.15** 0.19** 0.07 0.06 0.11
SAPS psychotic 0.03 .01 0.00 0.04 0.10 0.00
SAPS disorganized 0.12* 0.08 0.03 0.12 0.03 0.06
SANS 0.05 0.09 0.18** 0.13 0.24** 0.10

Note: GAF, Global Assessment of Functioning; SAPS, Scale for the Assessment of Positive Symptoms; SANS, Scale for the
Assessment of Negative Symptoms.
a
Mean = sample size weighted mean of the 5 columns.
*P < .05, **P < .01, ***P < .001.

Supplementary Material 7. Kelly C, McCreadie RG. Smoking habits, current symptoms,

Supplementary table is available at http://
schizophreniabulletin.oxfordjournals.org.
Funding
National Institutes of Health (MH-44801 to E.B.).
Acknowledgments
The authors thank the mental health professionals in
Suffolk County, the mental health project psychiatrists
and staff, and most of all, the study participants and
their families and friends. Special thanks to Elizabeth
Persons for help in preparation of the manuscript.
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