schizophrenics who smoke and drink a lot

Schizophrenia does not make smoking or heavy drinking safe. But the numbers are stark, and the standard explanation—that patients are just self-medicating—is too simple.

Smoking rates in schizophrenia are about double the general population. A 2013 study of male patients in Singapore found that roughly 38–42% were current smokers versus 17% of healthy controls [2]. A 2009 Maryland cohort of 1,213 patients reported a 55% smoking rate [1]. Heavy drinking is also high: a 2021 Nordic registry study of 45,476 schizophrenia patients found alcohol use disorders in 10–25% of the sample, depending on the country [5].

Why so much? Part of it is the biological vulnerability of the disorder itself. People with schizophrenia have abnormal dopamine, opioid, and glutamate signaling—the exact systems that nicotine and alcohol hit [7, 6]. Smoking briefly improves attention and reduces some negative symptoms (the blankness, the lack of drive). Small studies find that patients who smoke report slightly fewer negative symptoms on rating scales [2]. This is the self-medication hook.

But the cost is huge. The Maryland cohort followed patients for 4–10 years and found that smokers aged 35–54 had more than twice the death rate of nonsmokers in the same age range (14.2% vs 10.0% at 10 years) and that smokers were vastly more likely to die of heart disease (43% of deaths vs 19%) [1]. A 2021 Nordic registry study found that having any substance use disorder roughly doubled the risk of dying, with most of the excess coming from suicide and accidents, not natural causes [5]. The same study found that substance use disorders raised the risk of psychiatric hospitalization by 50–80% [5].

A 2011 baseline study of 43 smokers with psychosis found they averaged 31 cigarettes per day, ate too few vegetables, exercised rarely, and scored at the 74th percentile for heart disease risk—meaning three-quarters of the general population their age had a lower risk [4]. They were motivated to change but had very low confidence they could [4].

The standard clinical response is to add a patch or a pill. A 2015 randomized trial of a healthy-lifestyle program plus nicotine patches showed that most people relapsed: at 12 months, only about 6 in 100 were still abstinent [3]. The dropout rate was 41%. That is not a treatment failure—it is a reflection of how deep the dependency runs and how little the system invests in the underlying causes.

The literature is also silent on an important question: how much of the excess risk is the substance itself, and how much is the interaction with antipsychotic drugs? Antipsychotics make people metabolically fragile—they cause weight gain, insulin resistance, and high triglycerides [8, 9]. Adding heavy smoking and alcohol to that foundation may be especially toxic. Standard research rarely separates these factors, and the safest comparison group—unmedicated patients who do not smoke or drink—is almost never studied.

My call: both smoking and heavy drinking are more common in schizophrenia, driven by real but temporary symptom relief and by the biology of the illness, while the long-term cost includes dramatically higher death rates from heart disease, suicide, and accidents, and standard cessation programs fail most patients. Confidence: high that these patterns and risks are real; moderate that the specific causes are well-understood, because the role of antipsychotic interaction is understudied.