Comorbid Tobacco Dependence and Psychiatric Disorders

Psychiatric TimesPsychiatric Times Vol 25 No 1
Volume 25
Issue 1

Smokers with co-morbid psychiatric and substance use disorders smoke at a much higher rate and seem to have more difficulty quitting than those in the general population. Tobacco treatment that is integrated into mental health settings may lead to greater success than non-integrated treatment. As a result, mental health care providers can play a critical role by careful assessments of smoking, employment of motivational techniques and increasing access to pharmacological and behavioral treatments.

In the United States,smoking is the leading preventable cause of disease and death and it isestimated that over 440,000 people die from smoking-related causes annually(U.S. Department of Health and Human Services, 2004). Adverse healthconsequences of smoking include lung cancer, cardiovascular disease and stroke.

Although the overall prevalence of smoking has been decreasing to 23% in2000 (Centers for Disease Control and Prevention, 2004), current smokers seemto have more difficulty quitting despite combining U.S. Food and DrugAdministration-approved pharmacological treatments (nicotine replacementtherapies, sustained-release bupropion [Zyban]) with behavioral therapies. A large proportion ofthese difficult-to-treat smokers may have comorbidpsychiatric and substance use disorders (Kalman etal., in press). Determining the usefulness of current smoking cessationtreatments can guide clinicians. Advances in our understanding of biologicalexplanations for the high rates of comorbid nicotineaddiction and mental disorders may lead to the development of more targeted andeffective treatment.


Large population-based studies in the United States report the currentrate of smoking to be approximately 22% to 28% (CDC, 2004; Grant et al., 2004; Lasser et al., 2000). Smokers with current psychiatricdisorders have significantly higher rates of smoking (41% on average), and ithas been estimated that patients with mental illness consume 44.3% of allcigarettes in the United States (Lasser etal., 2000). The highest smoking prevalences werefound for people with bipolar (68.8%), psychotic (49.4%) and substance usedisorders (49.0%) (Lasser et al.,2000).

According to the DSM-IV, nicotinedependence is determined by daily smoking (typically 10 to 40 cigarettes/day),resulting in tolerance and the presence of withdrawal symptoms after smokingcessation. While the general rate of nicotine dependence has been reported at12.8%, much higher rates have been found for smokers with psychiatric disorders(Figure) (Grant et al., 2004).

Rates of dependence in psychotic populations also appear to be high (Dalack et al., 1998; Kalman etal., in press). Smokers with comorbid psychiatric orsubstance use disorders are less likely to attempt quitting (Lasser et al., 2000) and have higher risk of developingsmoking-related illnesses (Hurt et al., 1996; Lichtermannet al., 2001).

There have been several hypotheses to explain the high rates of smokingamong people with psychiatric and substance use disorders. One hypothesis isthat genetic factors influence vulnerability to both smoking and thesedisorders (Kendler et al., 1993). Second, certainenvironmental factors (e.g., stress, poverty) are associated with increasedsmoking and the onset of symptoms of psychiatric disorders. Third, people withpsychiatric or substance use disorders use smoking as a way to self-medicateclinical symptoms, side effects of psychiatric medication or cognitive deficits(Chambers et al., 2001; Sacco et al., 2004).

Biologic and Genetic Contributors

Nicotine stimulates the release of several neurotransmitter systems,including dopamine, norepinephrine,5-hydroxytryptamine (5-HT), glutamate, γ-aminobutyricacid (GABA) and endogenous opioid peptides, and actsas an agonist on presynaptic nicotinic acetylcholinereceptors (nAChRs), which are stimulated endogenouslyby acetylcholine (Mansvelder and McGehee,2002; Picciotto, 2003). Although chronic exposure ofagonists typically produces receptor downregulation,chronic nicotine administration causes a paradoxical upregulationof nAChRs through rapid desensitization followed byreceptor inactivation (Gentry and Lukas, 2002). After a short period ofabstinence (e.g., overnight), nAChRs are resensitized and once again responsive to nicotine. Thismay explain why many smokers tend to report the first cigarette of the morningas their most satisfying.

The dopamine reward system is associated with addiction to drugs of abuse,including nicotine (Volkow et al., 2002). Nicotine isthought to be reinforced by stimulating nAChRs in theventral tegmental area of the midbrain that projectto the nucleus accumbens, an important limbic areathought to be involved in drug reinforcement and reward. Further, these neuronsproject to the prefrontal cortex, which is thought to directly influencecognitive states, such as arousal and cognitive functioning.

Nicotine administration has been shown to improve neurocognitivedeficits observed in neuropsychiatric disorders suchas schizophrenia (George et al., 2002a; Sacco et al.,2005; Smith et al., 2002), attention-deficit/hyperactivity disorder (Conners et al., 1996; Levin et al., 1996) and Alzheimer'sdisease (Newhouse et al., 1988; Potter et al., 1999).This suggests a potentially critical role for nAChRstimulation in mediating cognitive dysfunction in these specific disorders (Sacco et al., 2004). Interestingly these effects are notconsistently observed in healthy smoking controls. A series of studies haveshown that an auditory gating measure (P50) deficit associated withschizophrenia is mediated by nicotine and smoking (Adler et al., 1993; Freedmanet al., 1997; Leonard et al., 2002), and that these effects are related toactivation of one form of nAChR (α7 nAChR [CHNRA7]) and that the expression of this receptorappears to be dysregulated (Leonard et al., 2002).

Our group has found that in schizophrenia, long-term abstinence impairs visuospatial working memory (VSWM) performance (which isdependent on the prefrontal cortex), while improving performance in nonpsychiatric controls (George et al., 2002a). Enhancementof VSWM and other areas of cognitive performance may be dependent on nAChR stimulation (Sacco et al.,2005). Furthermore, patients with schizophrenia who show greater deficits inprefrontal cognitive functioning also have a harder time successfully quittingwith intervention (Dolan et al., 2004). Thus, the cognitive deficits found in neuropsychiatric disorders may be a vulnerability factorpredisposing these patients to initiate and maintain their smoking (Chambers etal., 2001).

Clinical Assessment

An assessment of smokers with psychiatric disorders should include completepsychiatric and substance use evaluations. Assessment of smoking behaviorsshould include self-report of cigarette and other tobacco use over the past 30days and surrogate measures of smoking such as expired breath carbon monoxide(CO) (levels <8 ppm are associated withabstinence) or plasma nicotine levels (levels<15 ng/mlare consistent with abstinence) (Benowitz et al.,2002).

Level of nicotine dependence can be assessed through an empiricallyvalidated measure such as the Fagerstrom Test forNicotine Dependence and the presence of nicotine withdrawal symptoms (e.g.,irritability, cravings) upon smoking abstinence. Finally, it is important todetermine the level of motivation to quit. Motivation can be measured usingscales such as the Contemplation Ladder or through direct questioning aboutinterest to quit in the next month. An approach to treatment of nicotinedependence in patients with comorbid psychiatricdisorders and substance use disorders is given in the Table.


The development of effective strategies for promoting smoking cessation inschizophrenia is of great importance given the high rates of smoking andcessation failure in this patient group. The nicotine transdermalpatch (NTP) is associated with smoking cessation rates of 27% to 42% in smokerswith schizophrenia (Addington et al., 1998; Chou etal., 2004; George et al., 2000). Further, use of the nicotine nasal spray,which produces higher plasma levels of nicotine, is associated with reductionof withdrawal and craving, and smoking cessation in smokers with schizophrenia(Williams et al., 2004).

In controlled trials, pharmacological treatment with sustained-release (SR) bupropion has been efficacious in promoting abstinence inschizophrenia. Treatment-seeking smokers have shown success (with short-termabstinence rates of 11% to 50%) with a combination of bupropionSR and cognitive-behavioral therapy (CBT) at both the 150 mg/day (Evins et al., 2001) and the 300 mg/day doses (Evins et al., 2005; George et al., 2002b). Bupropion treatment also appears to help reduce negativesymptoms.

Patients treated with atypical antipsychotic agents, especially clozapine (Clozaril), smoke less(George et al., 1995; McEvoy et al., 1999, 1995) andhave an easier time quitting (George et al., 2002b, 2000) than those treatedwith typical antipsychotic medications. However, smoking cessation can cause achange in plasma concentrations of psychotropic agents due to a decrease in theinduction of cytochrome P450 1A2. Monitoringmedication side effects may be required within the first month after quitting (Kalman et al., in press; Ziedonisand George, 1997).

Mood Disorders

Major depression.Smokers with depression have a more difficult time quitting (Glassman et al.,1988; Lasser et al., 2000; Niauraet al., 2001) and require more attempts to quit (Glassman et al., 1993, 1990)than smokers without depression. However, a past history of major depressiondoes not appear to influence tobacco treatment outcomes (Hayfordet al., 1999). Although some research has reported that smoking cessation canlead to a reemergence of depressive symptoms (Covey et al., 1997; Glassman etal., 1990), other studies have questioned this relationship (Thorsteinsson et al., 2001; Tsohet al., 2000).

Pharmacotherapies for smoking cessation have notbeen extensively evaluated in patients with current major depression. Oneopen-label trial of bupropion SR (300 mg/day)suggested that this medication was well tolerated in smokers taking selectiveserotonin reuptake inhibitor and enhanced short-term (three-month) cessationsuccess in about one-third of patients (Chengappa etal., 2001). Additional research on smokers with a history of depressionsuggested the usefulness of NTP (Thorsteinsson etal., 2001) and nicotine gum (Kinnunen et al., 1996)for short-term smoking cessation.

In addition, some antidepressant medications appear to be useful agents. Nortriptyline (Aventyl, Pamelor) (Hall et al., 1998) and bupropion(Hayford et al., 1999) have shown promise as smokingcessation aids while SSRIs do not appear to enhancesmoking abstinence (Dalack et al., 1995; Niaura et al., 2002). Behavioral therapies such as CBTshould be strongly considered, as smokers with depression are likely to failwith more minimal interventions (Brown et al., 2001). Improved cessationoutcomes with the addition of CBT have been reported for nortriptylineand nicotine gum (Hall et al., 1998, 1994).

Bipolar disorder.Glassman et al. (1993) found that patients with bipolar disorder (BD) may alsobe at risk for recurrence of depressive symptoms during smoking cessation. Noempirically based treatments have been published for smokers with BD. Our groupis currently conducting a double-blind, placebo-controlled trial of bupropion SR for the treatment of nicotine dependence insmokers with BD.

Anxiety Disorders

Cinciripini and colleagues (1995) found thatsmokers with high levels of trait anxiety taking buspirone(BuSpar) versus placebo were more likely to beabstinent at trial end point but not at follow-up. Aplacebo-controlled study of bupropion SR for smokerswith posttraumatic stress disorder reported that bupropionwas well tolerated and resulted in higher rates of smoking cessation (60%), ascompared to placebo (20%) (Hertzberg et al., 2001).Interestingly, a study by McFall and colleagues(2005) found that smokers who received tobacco treatment integrated with theirpsychiatric care were five times more likely than smokers who received separatetreatment to report abstinence from smoking nine months after the study.

Substance Use Disorders

Concurrent use of alcohol and/or other drugs is a negative predictor ofoutcomes during smoking cessation treatment (Hughes, 1996), and long-term quitrates of smokers in early recovery from substance use disorders (SUDs) are low-approximately 12% (Kalman,1998; Sussman, 2002). However, a past history ofalcoholism does not influence tobacco treatment outcome (Hayfordet al., 1999).

Conditioned effects of substance use with smoking may be an important factorinfluencing both the high rates of comorbidity andtreatment failure, as these behaviors are often concurrent. Studies of pharmacotherapies in substance abusers are few, but thereis some evidence for the utility of nicotine replacement and behavioralapproaches (e.g., contingency management) (Burling et al., 1996; Shoptaw et al., 1996). Controlled studies using bupropion SR in smokers with SUDsare in progress.

There is controversy regarding the timing of smoking cessation treatmentwith substance abusers. Some studies have suggested that concurrent treatmentfor smoking and other drugs is not associated with increased use of alcohol orother drugs (Burling et al., 2001; Kalman et al.,2004, 2001). However, one large, well-controlled study has reported thatdrinking outcomes may be worse for patients who go through concurrent alcoholand nicotine treatment, suggesting that smoking cessation should be delayeduntil after alcohol treatment has been completed (Joseph et al., 2004).


Many studies have shown that the likelihood of smoking cessation is lowerfor smokers with comorbid psychiatric and substanceuse disorders, but that with optimized treatment, reasonable success rates arepossible. Furthermore, there are important medical and psychiatric reasons toimprove smoking cessation in these populations.

As our understanding increases about biological associations between comorbid nicotine addiction and psychiatric disorders, itis clear that biological predispositions associated with the disorders may needto be a focus of treatment. Mental health providers can play a critical role insmoking cessation efforts by identifying smokers; using motivational techniquesto encourage quitting; and increasing accessibility to tobacco treatments. Thismay be most easily achieved in treatment settings that integrate nicotinedependence and mental health treatment (McFall etal., 2005).




Addington J, el-GuebalyN, Campbell W et al. (1998), Smoking cessation treatment for patients withschizophrenia. Am J Psychiatry 155(7):974-976.


Adler LE, Hoffer LD, Wiser A, Freedman R (1993),Normalization of auditory physiology by cigarette smoking in schizophrenicpatients. Am J Psychiatry 150(12):1856-1861.


Benowitz NL, Jacob P III, AhijevichK et al. (2002), Biochemical verification of tobacco use and cessation. Reportfrom the SRNT Subcommittee on Biochemical Verification. Nicotine Tob Res 4(2):149-159 [seecomment].


Brown RA, Kahler CW, NiauraR et al. (2001), Cognitive-behavioral treatment for depression in smokingcessation. J Consult Clin Psychol69(3):471-480.


Burling TA, Burling AS, Latini D(2001), A controlled smoking cessation trial forsubstance-dependent inpatients. J Consult Clin Psychol 69(2):295-304.


Burling TA, Salvio MA, Seidner AL, Ramsey TG (1996), Cigarette smoking in alcoholand cocaine abusers. J Subst Abuse8(4):445-452.


CDC (2004), Cigarette smoking among adults-United States,2002. MMWR 53(20):427-431.


Chambers RA, Krystal JH, Self DW (2001), A neurobiological basis for substance abuse comorbidity in schizophrenia. BiolPsychiatry 50(2):71-83.


Chengappa KN, KambhampatiRK, Perkins K et al. (2001), Bupropionsustained-release as a smoking cessation treatment in remitted depressedpatients maintained on treatment with selective serotonin reuptake inhibitors.J Clin Psychiatry 62(7):503-508.


Chou KR, Chen R, Lee JF et al. (2004), The effectiveness of nicotine-patchtherapy for smoking cessation in patients with schizophrenia. Int J Nurs Stud 41(3):321-330.


Cinciripini PM, LapitskyL, Seay S et al. (1995), Aplacebo-controlled evaluation of the effects of buspironeon smoking cessation: differences between high- and low-anxiety smokers. [Published erratum J Clin Psychopharmacol 15(6):408.] J ClinPsychopharmacol 15(3):182-191.


Conners CK, Levin ED, Sparrow E et al. (1996),Nicotine and attention in adult attention deficit hyperactivity disorder(ADHD). Psychopharmacol Bull 32(1):67-73.


Covey LS, Glassman AH, Stetner F(1997), Major depression following smoking cessation. AmJ Psychiatry 154(2):263-265.


DalackGW, Glassman AH, Rivelli S et al. (1995), Mood, majordepression, and fluoxetine response in cigarettesmokers. Am J Psychiatry 152(3):398-403.


Dalack GW, Healy DJ, Meador-Woodruff JH (1998),Nicotine dependence and schizophrenia: clinical phenomenon and laboratoryfindings. Am J Psychiatry 155(11):1490-1501.


Dolan SL, Sacco KA, TermineA et al. (2004), Neuropsychological deficits may predict smoking cessationtreatment failure in patients with schizophrenia. Schizophrenia Res 70(2-3):263-275.


Evins AE, Cather C, Deckersbach T et al. (2005), A double-blindplacebo-controlled trial of bupropionsustained-release for smoking cessation in schizophrenia. J ClinPsychopharmacol 25(3):218-225.


Evins AE, Mays VK, RigottiNA et al. (2001), A pilot trial of bupropionadded to cognitive behavioral therapy for smoking cessation in schizophrenia.Nicotine Tob Res3(4):397-403.


Freedman R, Coon H, Myles-Worsley M et al. (1997),Linkage of a neurophysiological deficit inschizophrenia to a chromosome 15 locus. Proc Nat AcadSci U S A 94(2):587-592.


Gentry CL, Lukas RJ (2002), Regulation of nicotinicacetylcholine receptor numbers and function by chronic nicotine exposure.Curr Drugs Targets CNS NeurolDisord 1(4):359-385.


George TP, Sernyak MJ, ZiedonisDM, Woods SW (1995), Effects of clozapine on smokingin chronic schizophrenic outpatients. J ClinPsychiatry 56(8):344-346.


George TP, Vessicchio JC, TermineA et al. (2002a), Effects of smoking abstinence on visuospatialworking memory function in schizophrenia. Neuropsychopharmacol26(1):75-85 [see comment].


George TP, Vessicchio JC, TermineA et al. (2002b), A placebo-controlled study of bupropionfor smoking cessation in schizophrenia. BiolPsychiatry 52(1):53-61.


George TP, Zeidonis DM, Feingold A et al. (2000),Nicotine transdermal patch and atypical antipsychoticmedications for smoking cessation in schizophrenia. Am J Psychiatry157(11):1835-1842.


Glassman AH, Covey LS, Dalack GWet al. (1993), Smoking cessation, clonidine, andvulnerability to nicotine among dependent smokers. ClinPharmacol Ther54(6):670-679.


Glassman AH, Helzer JE, Covey LSet al. (1990), Smoking, smoking cessation and major depression. JAMA 264(12):1546-1549[see comment].


Glassman AH, Stetner F, Walsh BTet al. (1988), Heavy smokers, smoking cessation, and clonidine.JAMA 259(19):2863-2866.


Grant BF, Hasin DS, Chou P et al. (2004), Nicotinedependence and psychiatric disorders in the United States. Arch Gen Psychiatry61(11):1107-1115.


Hall SM, Munoz RF, Reus VI (1994),Cognitive-behavioral intervention increases abstinence rates fordepressive-history smokers. J Consult Clin Psychol 62(1):141-146.


Hall SM, Reus VI, Munoz RF et al. (1998), Nortriptyline and cognitive-behavioral therapy in thetreatment of cigarette smoking. Arch Gen Psychiatry 55(8):683-690 [seecomment].


Hayford KE, Patten CA, RummansTA et al. (1999), Efficacy of bupropion for smokingcessation in smokers with a former history of major depression or alcoholism.Br J Psychiatry 174:173-178 [see comment].


Hertzberg MA, Moore SD, Feldman ME, Beckham JC (2001), A preliminary studyof bupropion sustained-release for smoking cessationin patients with chronic posttraumatic stress disorder. J ClinPsychopharmacol 21(1):94-98.


Hughes JR (1996), The future of smoking cessationtherapy in the United States.Addiction 91(12):1797-1802.


Hurt RD, Offord KP, CroghanIT et al. (1996), Mortality following inpatient addictions treatment. Role of tobacco use in a community-based cohort. [Published erratum JAMA 276(10):784.] JAMA 275(14):1097-1103[see comments].


Joseph A, Willenbring M, Nugent S, Nelson D(2004), A randomized trial of concurrent versus delayed smoking interventionfor patients in alcohol dependence treatment. J Stud Alcohol 65(6):681-691.


Kalman D (1998), Smoking cessation treatment forsubstance misusers in early recovery: a review of theliterature and recommendations for practice. SubstUse Misuse 33(10):2021-2047.


Kalman D, Hayes K, Colby SM et al. (2001),Concurrent versus delayed smoking cessation treatment for persons in earlyalcohol recovery. A pilot study. J SubstAbuse Treat 20(3):233-238.


Kalman D, Kahler C, Tirch D et al. (2004), Twelve-week outcomes from aninvestigation of high dose nicotine patch therapy for heavy smokers with a pasthistory of alcohol dependence. Psychol Addict Behav 18(1):78-82.


KalmanD, Morrisette SB, George TP (in press), Co-morbidityof smoking with psychiatric and substance use disorders. Am J Addict.


Kendler KS, NealeMC, MacLean CJ et al. (1993), Smoking and major depression: a causal analysis.Arch Gen Psychiatry 50(1):36-43.


Kinnunen T, Doherty K, MilitelloFS, Garvey AJ (1996), Depression and smoking cessation: characteristics ofdepressed smokers and effects of nicotine replacement. J Consult Clin Psychol 64(4):791-798.


Lasser K, Boyd JW, WoolhanderS et al. (2000), Smoking and mental illness: a population-based prevalencestudy. JAMA 284(20):2606-2610.


Leonard S, Gault J, Hopkins J et al. (2002),Promoter variants in the alpha-7 nicotinic acetylcholine receptor subunit geneare associated with an inhibitory deficit found in schizophrenia. Arch GenPsychiatry 59(12):1085-1096.


Levin ED, Conners CK, Sparrow E et al. (1996),Nicotine effects on adults with attention-deficit hyperactivity disorder.Psychopharmacology 123(1):55-63.


Lichtermann D, EkelundE, Pukkala E et al. (2001), Incidence of cancer amongpersons with schizophrenia and their relatives. Arch Gen Psychiatry58(6):573-578 [see comment].


Mansvelder HD, McGehee DS (2002), Cellular andsynaptic mechanisms of nicotine addiction. J Neurobiol53(4):606-617.


McEvoy J, FreudenreichO, McGee M et al. (1995), Clozapine decreases smokingin patients with chronic schizophrenia. BiolPsychiatry 37(8):550-552.


McEvoyJP, Freudenreich O, Wilson WH (1999), Smoking andtherapeutic response to clozapine in patients withschizophrenia. Biol Psychiatry 46(1):125-129.


McFall M, Saxon AJ, Thompson CE et al. (2005), Improving the rates of quitting smoking for veterans withposttraumatic stress disorder. Am J Psychiatry162(7):1311-1319.


Newhouse PA, Sunderland T, TariotPN et al. (1988), Intravenous nicotine in Alzheimer's disease: a pilot study.Psychopharmacology (Berl) 95(2):171-175.


Niaura R, Borreli B, Hedeker D et al. (2002), Multicentertrial of fluoxetine as an adjunct to behavioralsmoking cessation treatment. J Consult ClinPsychology 70(4):887-896.


Niaura R, Britt DM, ShadelWM et al. (2001), Symptoms of depression and survival experience among threesamples of smokers trying to quit. Psychol Addict Behav 15(1):13-17.


Picciotto MR (2003), Nicotine as a modulator ofbehavior: beyond the inverted U. Trends Pharmacol Sci 24(9):493-499.


Potter A, Corwin J, Lang J et al. (1999), Acute effects of the selectivecholinergic channel activator (nicotinic agonist) ABT-418 in Alzheimer'sdisease. Psychopharmacology (Berl) 142(4):334-342.


Sacco KA, Bannon KL,George TP (2004), Nicotinic receptor mechanisms andcognition in normal states and neuropsychiatricdisorders. J Psychopharmacol 18(4):457-474.


Sacco KA, Termine A, Seyal AA et al. (2005), Effects of cigarette smokingfunction on spatial working memory and attentionalfunction in schizophrenia: involvement of nicotinic receptor mechanisms. ArchGen Psychiatry 62(6):649-659.


Shoptaw S, Jarvik ME,Ling W, Rawson RA (1996), Contingency management for tobacco smoking inmethadone-maintained opiate addicts. Addict Behav21(3):409-412.


Smith RC, Singh A, Infante M et al. (2002), Effectsof cigarette smoking and nicotine nasal spray on psychiatric symptoms andcognition in schizophrenia. Neuropsychopharmacology27(3):479-497.


Sussman S (2002), Smoking cessation among personsin recovery. Subst Use Misuse 37(8-10):1275-1298.


Thorsteinsson HS, GillinJC, Patten CA et al. (2001), The effects of transdermalnicotine therapy for smoking cessation on depressive symptoms in patients withmajor depression. Neuropsychopharmacology24(4):350-358.


Tsoh JY, Humfleet GL,Munoz RF et al. (2000), Development of major depression after treatment forsmoking cessation. Am J Psychiatry 157(3):368-374.


U.S.Department of Health and Human Services (2004), Health Consequences of SmokingCessation: A Report of the Surgeon General. Washington, D.C.:Government Printing Office.


Volkow ND, Fowler JS, Wang GJ (2002),Role of dopamine in drug reinforcement and addiction in humans: results fromimaging studies. Behav Pharmacol13(5-6):355-366 [comment].


Williams JM, Ziedonis DM, FouldsJ (2004), A case series of nicotine nasal spray in the treatment of tobaccodependence among patients with schizophrenia. PsychiatrServ 55(9):1064-1066.


Ziedonis DM, George TP (1997), Schizophrenia andnicotine use: report of a pilot smoking cessation program and review ofneurobiological and clinical issues. Schizophr Bull23(2):247-254.  

Recent Videos
Erin Crown, PA-C, CAQ-Psychiatry, and John M. Kane, MD, experts on schizophrenia
brain depression
nicotine use
brain schizophrenia
© 2024 MJH Life Sciences

All rights reserved.