Smoking cessation in schizophrenia: it's harder, and it's worth it

Tobacco is the single largest preventable cause of premature death in schizophrenia — eclipsing alcohol, illicit drugs, and even suicide. Roughly 60% of people with schizophrenia smoke, often heavily, and the rate has barely budged in decades while the general population's smoking rate has fallen sharply. The good news, frequently buried beneath outdated assumptions, is that people with schizophrenia can quit successfully — and modern treatments are both safe and effective.

Why smoking rates are so high

Self-medication

Nicotine acts on cholinergic receptors that influence attention, working memory, and processing speed — all areas where schizophrenia produces deficits. Many smokers report that cigarettes "clear my head" or help them think. This is a real pharmacological effect, not a rationalisation.

Reward and stress

Nicotine briefly relieves negative symptoms and stress. Combined with limited access to other rewarding activities, this makes smoking unusually entrenched.

Institutional culture

For much of the 20th century, psychiatric wards encouraged or even rewarded smoking. Generations of patients began smoking inside hospitals, and the culture has been slow to change.

Pharmacological reinforcement

Tobacco smoke induces the cytochrome P450 1A2 enzyme, which metabolises clozapine, olanzapine, and several other antipsychotics. Smokers need higher doses of these drugs to achieve the same blood levels — meaning quitting can raise drug levels significantly and produce side effects unless the dose is adjusted.

Why quitting matters

• Smoking is the single biggest contributor to the cardiovascular mortality gap in schizophrenia
• Increases risk of lung cancer, COPD, stroke, and heart disease
• Worsens insulin resistance and metabolic syndrome
• Adds substantially to financial strain
• Quitting at any age extends life expectancy meaningfully

Outdated concerns about quitting

Three myths used to discourage cessation efforts:

1. "Quitting smoking destabilises mental illness." Modern evidence consistently shows the opposite — cessation is associated with reduced anxiety and depression and no increase in psychotic symptoms when properly supported.
2. "Smoking helps cognition, so quitting will worsen it." Cognitive effects of nicotine are short-lived; long-term smokers show worse cognition than non-smokers, and quitting tends to improve it over months.
3. "Cessation medications are dangerous in schizophrenia." Both varenicline and bupropion have been studied extensively in this population and are generally safe.

What actually works

Varenicline

Varenicline (Chantix) is the most effective single agent for cessation in the general population, and the EAGLES trial — a large international RCT including patients with serious mental illness, published in The Lancet in 2016 — found it was both effective and safe in schizophrenia, with no signal of worsened psychiatric symptoms compared with placebo. It is now considered first-line for cessation in this population.

Nicotine replacement therapy

Patches, gum, lozenges, inhalers, and nasal spray all have evidence. Combination therapy (a long-acting patch plus a short-acting form for cravings) is more effective than single-agent. Higher-dose patches are often appropriate for heavy smokers — your prescriber or pharmacist can advise.

Bupropion

Bupropion (Zyban / Wellbutrin) is also evidence-based and safe in schizophrenia. It carries a small seizure risk that is dose-dependent, and shouldn't be used in people with active eating disorders or recent alcohol withdrawal.

Combinations

Combining varenicline or bupropion with NRT often improves outcomes for heavy smokers, and is increasingly standard.

Behavioural support

Counselling, group programs, and digital tools all roughly double quit rates compared with medication alone. Programs tailored for serious mental illness — such as those described in the smokefree.gov resources — exist in most US states.

The clozapine and olanzapine wrinkle

Vaping

The role of e-cigarettes in cessation remains contested. Recent evidence suggests they can help some smokers quit, but they carry their own health risks and dependence risk. They are best viewed as a stepping-stone to full cessation rather than a permanent substitute. Discuss with the prescriber.

What helps long-term success

• Setting a specific quit date and preparing for it
• Medication started before the quit date (varenicline 1 week before, NRT can start at quit)
• Removing tobacco products and triggers from the environment
• Identifying replacement activities for the routines that cued smoking
• Behavioural support — even brief, repeated check-ins help
• Treating sleep, anxiety, and depression — they get worse temporarily during cessation and need active management
• Planning for slips: a slip is not a failure, it's information

What to expect in the first weeks

The first 1–2 weeks are usually hardest: irritability, anxiety, sleep disturbance, intense cravings. These typically peak in the first week and substantially diminish by week 4. Cardiovascular benefits begin within days; lung function improves over weeks to months; major reductions in cancer and heart disease risk accumulate over years.

The takeaway

Quitting smoking in schizophrenia is not a "nice to have." It is one of the highest-impact things anyone can do for their long-term physical health, and it is achievable with the right tools. If smoking is part of your picture, raise the question with the clinician explicitly. Ask about varenicline. Ask about behavioural support. Plan it. Then plan it again. Many people quit only after multiple attempts — and each attempt is a step forward.

This article is for educational purposes only and is not medical advice, diagnosis, or treatment. Always consult a qualified mental health professional. If you or someone you know is in crisis, call or text 988 in the US, or your local emergency number.