There was a time not long ago when psychiatric hospitals doled out cigarettes as rewards for good behavior. Outpatient clinics were thick with smoke, and patients smoked butts down to yellow-stained fingers.
Laws in Maryland and other states banished tobacco from hospitals and health clinics in the late 1990s, but smoking rates among the severely mentally ill - especially those with schizophrenia and bipolar illness - remain two to three times higher than among the general population.
Though surely not the only cause, the smoking rates correspond with similarly high rates of diabetes and heart and lung disease among the mentally ill. People with severe mental afflictions also die about 10 years earlier than others - and suicide accounts for only a fraction of the difference.
Faced with these issues, doctors are slowly abandoning the long-held notion that smoking is not worth addressing among the mentally ill because, as the saying goes, it's the least of their problems.
At the University of Maryland School of Medicine, researchers have begun a study to find out what happens when therapists ask patients who smoke whether they want to quit - and then explore options if the answer is yes.
"We're used to hearing people not wanting to tackle this problem," said Dr. Lisa Dixon, the UM psychiatrist who leads the study, funded by the National Institute on Drug Abuse.
"They say, `These people have such terrible lives. They can't quit anyway.' But to say we shouldn't want to work with them to try is not fair."
Doctors have long thought that schizophrenics smoke to ease some symptoms, including poor concentration and difficulty filtering the barrage of sights, sounds and smells that floods the nervous system. Although studies have shown that nicotine does offer short-term relief, researchers say there is more to the story.
Many patients actually began smoking years before the onset of schizophrenia, which is typically around age 20. One possible explanation is that many future schizophrenics wrestle first with attention deficit disorder, and nicotine helps alleviate those symptoms, too.
"It helps them concentrate," said Dr. Anthony Lehman, chief of psychiatry at Maryland. "Probably with some of these teenagers, smoking may have something to do with some effort to have clearer thinking or feel better."
Researchers have made progress in understanding tobacco's hold on the mentally ill. Dr. Gunvant Thaker, chief of the schizophrenia-related disorders program at the Maryland Psychiatric Research Center, said studies have shown that nicotine helps to mitigate two problems associated with schizophrenia.
The first is faulty sensory "gating," the ability to make sense of stimuli in the environment. People startle the first time they hear a loud noise such as a car alarm - but they're able to ignore it, or at least mute their reaction, when they hear it again and again.
Schizophrenics lack this "gating" capacity, which may explain some of the confusion and fear they feel in seemingly harmless situations.
As it turns out, the deficit is associated with a faulty gene that also happens to be a nicotine receptor gene. "When schizophrenia patients smoke, or are given nicotine gum, this deficit of sensory gating is reduced or normalized," Thaker said.
Nicotine also helps with other cognitive problems related to schizophrenia, Thaker said, including difficulty tracking a moving object and remembering things. With these problems, however, a genetic link is less clear.
Although surveys have yielded varying results, all show considerably higher smoking rates among the mentally ill. Some show smoking rates as high as 80 percent among people with severe mental diseases, compared with 25 percent in the general population.
Using data from a national mental health survey, researchers at Cambridge Hospital in Massachusetts found that people with mental illness were twice as likely to smoke. In that study, however, the authors defined mental illness more broadly, including addictions and milder afflictions.
So defined, the mentally ill accounted for almost half of tobacco sales in the United States. But in a hopeful sign, they also found that "a third of patients with mental illness had quit smoking by the time of the survey."
At Maryland, doctors take heart that patients such as 47-year-old Stephen Finzel, who developed schizophrenia when he was a college senior, are making an effort to stop.
"I cut my smoking in half," Finzel recently said at a medical school's community psychiatry clinic. "I was smoking about two packs a day, and I've cut down to about half a pack."
Finzel, who grew up in Bowie and attended Frostburg State University until his illness forced him to drop out, said he began smoking when he was 13. His habit grew worse after symptoms of schizophrenia set in, and life in a group home - where everyone smoked and cigarettes served as currency - only reinforced it.