The prevalence of smoking is unusually high among patients with SCZ. In light of the negative health, economic, and social consequences of smoking, treatment efforts in this area are imperative. Such efforts rest, in part, on an improved understanding of the underlying causes of smoking within this unique population. For example, several lines of research have indicated that smoking improves specific SCZ-related symptoms (i.e., negative psychotic symptoms, negative affect, cognitive deficits) and that patients may smoke to self-medicate with nicotine. However, the mechanism(s) underlying this effect are unknown. The current proposal posits that improved NI may be one such mechanism. More specifically, NI is conceived as a mediator of the relationship between smoking and symptom improvement. Also, given its proposed mechanistic nature, we believe that nicotine-related changes in NI may predict quit/reduction and/or relapse rates following a smoking cessation program. Additionally, variants of CHRNA7 likely represent the genetic underpinnings of decreased NI, vulnerability to smoking, and smoking treatment resistance among patients with SCZ. These hypotheses are supported by previous experiments that suggest: (1) patients with SCZ have decreased NI (Adler et al., 1998); (2) nicotine administration (via its effects on the alpha-7-nicotinic receptor, which, in turn activates GABAergic interneurons) enhances NI in these patients (Adler et al., 1998); (3) genetic variation in the alpha-7-nicotinic receptor increases risk for smoking among patients with SCZ (Leonard et al., 1996); and, (4) higher levels of NI are associated with fewer negative symptoms, less negative affect, and better cognition (Yee et al., 1998). However, these studies have been hampered by several methodological and conceptual shortcomings including small sample sizes, the presence of confounding variables (e.g., the effects of nicotine withdrawal), and limited testing of relevant symptom domains. Furthermore, previous studies have examined only isolated aspects of the proposed model, leaving many of the central relationships between variables untested and speculative. The current proposal seeks to rectify these methodological issues within the context of a multidisciplinary scientific team. Globally, its objectives are twofold. First, to replicate and extend previous findings that nicotine causes symptom attenuation. Second to investigate the underlying neurophysiological and genetic mechanisms of these effects. The specific objectives and hypotheses addressed in this study are as follows:
1. To acutely administer nicotine versus placebo to smokers with SCZ following transient abstinence from cigarettes, in order to investigate the effect of nicotine on the SCZ symptoms. This objective extends previous research by employing an adequately large sample and simultaneously testing several relevant domains of symptom improvement. Hypothesis: Significantly greater improvements across the domains of negative symptoms, negative affect, and cognitive deficits will be evident among those patients receiving nicotine versus placebo.
2. To acutely administer nicotine versus placebo to nonsmokers with SCZ in order to investigate the effects of nicotine on the symptoms of SCZ, independent of withdrawal. This objective allows for the methodological disambiguation of the direct neural effects of nicotine from the effects of termination of withdrawal symptoms. Additionally, this will provide seminal data regarding the acute treatment benefits of nicotine as a therapeutic agent, delivered without the health risks associated with smoking. Hypothesis: Significantly greater improvements across all symptoms domains will be evident among those patients receiving nicotine versus placebo.
3. To ascertain (using statistical techniques outlined by Kenny and others) (Baron \& Kenny, 1986; Judd \&Kenny, 1981) whether the relationship between acute nicotine administration and symptom reductions is mediated by increased NI (as measured via ERP and TMS paradigms). Hypothesis: NI will meet the statistical criteria for mediating the relationship between nicotine administration and symptom reductions.
4. To ascertain whether nicotine-related changes in NI predict patients' ability to reduce smoking, the amount of nicotine replacement therapy (NRT) required, and rates of quitting and smoking relapse following completion of a smoking cessation program. Hypothesis: NI will operate as a significant and unique predictor of the amount of smoking reduction and NRT use, as well as quit and relapse rates, over and above conventional predictors of smoking reduction from the general population (i.e., age, marital status, coping resources, socioeconomic status, smoking related health problems, the number of cigarettes smoked per day, concomitant alcohol and coffee consumption, treatment compliance, and stage of change) (Matheny \& Weatherman, 1998; Ockene et al., 2000; Oritz et al., 2003).
5. To investigate whether polymorphisms in CHRNA7 are associated with the magnitude of NI deficits, symptom reductions following acute nicotine administration, rates of smoking among patients with SCZ, and/or quit/reduction or relapse rates following smoking cessation treatment. Hypothesis: Significant genetic association will be demonstrated between CHRNA7 polymorphisms and each of the above-listed clinical variables.
