Deadly link between antipsychotics and cigarettes exposed: A young man on anti-psychotics died because he stopped smoking

Dr Jess discusses the fatal link between anti-psychotics and smoking - and asks why people don’t know about this common interaction

Jack Burton didn’t die from smoking - he died from not smoking for just three days whilst he was on holiday. Read that sentence again.

A 29-year-old man died after stopping smoking. Not because smoking caused lung disease or cancer or pneumonia. Not because nicotine withdrawal harmed him. He died because stopping smoking caused the level of his prescribed antipsychotic medication, Clozapine, to rise to toxic levels. He stopped smoking for three days, and died on the fourth.

The coroner concluded that this was the likely cause of his death. If that fact shocks you, ask yourself another question.

Why didn’t he know? Why didn’t you know about this?

The risk most people have never heard of

For people taking certain so-called ‘antipsychotic medications’ (namely Clozapine and Olanzapine - although there are a few others so please look for up for yourself if you are taking antipsychotics), cigarette smoking is an extremely important risk factor. It completely changes how the medication behaves inside the body.

The chemicals produced by the burning tobacco increase the activity of a liver enzyme responsible for breaking down medications such as clozapine and olanzapine. This means many people who smoke ‘require’ higher doses than people who do not. When someone stops smoking or even reduces smoking temporarily, that effect begins to disappear. The medication is no longer broken down as quickly. Blood levels of toxic antipsychotics can rise dramatically within days causing severe side effects.

In some cases, as the tragic death of Jack Burton demonstrates, those levels can become fatal. He was taking 525mg of Clozapine, stopped smoking for three days due to being on holiday, and then died from the toxicity in his blood.

This is not because of nicotine. It is because of the tobacco smoke itself.

The question we should all be asking

If this interaction can kill someone… why is it not common knowledge? Where are the PSAs?

How many people prescribed clozapine or olanzapine even know that stopping or reducing smoking over a couple of days could rapidly increase the amount of medication in their bloodstream?

How many families know? How many carers know that?

How many people on antipsychotics trying to improve their health by quitting smoking realise they also need an urgent medication review? As in like URGENT.

Because I suspect most members of the public have never heard this before - and I would hazard a guess that many professionals have never heard of this before either.

This raises so many questions for me, as the most common symptoms of the antipsychotic toxicity rising due to reducing tobacco even over a couple of days include:

• dizziness

• confusion

• seizures (especially with clozapine)

• toxicity

• feelings of severe drowsiness or sedation

Conversely, if someone then starts smoking more again a couple of days later, the medication may become ‘less effective’ because the body clears it more quickly - and so the person could be experiencing an absolute rollercoaster of medication side effects purely based on how many cigarettes they have been having recently.

Has anyone actually considered how common that issue probably is?

Even if someone doesn’t die, they could be going through hell on their antipsychotic medication that is being pathologised as their mental health worsening or even as them fabricating illnesses - when in fact it is directly linked to their smoking habits changing and fluctuating.

This information could be HUGE for patients and clinicians.

The coroner’s concerns should concern us all

Following this young man’s death, the coroner issued a Prevention of Future Deaths report. What I found particularly striking was not only the tragedy itself, but the concerns raised afterwards.

The report describes inconsistent accounts from his consultant psychiatrists about their understanding of the relationship between smoking and clozapine, and raises concerns about whether there are sufficiently standardised systems to identify and respond when patients change their smoking habits.

This probably annoyed me the most - that even in the event of a death - the coroner got inconsistent and conflicting accounts from the psychiatrists about their understanding of the impact of smoking on the antipsychotics they prescribe. It speaks volumes.

And then for the coroner to state that there is no national guidance on this, no frameworks and no practice guidance for any of this relationship between smoking and antipsychotic use is absolutely appalling considering how clearly deadly this is.

Because this is not an obscure interaction affecting a handful of people - we cannot argue that this risk is rare. Smoking has long been recognised as being substantially more common among people diagnosed with mental disorders such as ‘psychosis’ and ‘schizophrenia’ than in the general population, with many studies reporting rates of around 60-80% (Leon et al. 2005).

That means a large proportion of people prescribed clozapine are likely to smoke. And many of them will, at some point, try to cut down. Or stop altogether - because there are endless public health campaigns encouraging everyone to stop smoking.

This is also an informed consent issue

Whenever I question psychiatric prescribing, I get into trouble - so let’s simplify this to an issue of informed consent about antipsychotics:

Were people on antipsychotics given enough information to make a genuinely informed decision?

Because informed consent is not simply signing a form or accepting a prescription. It means fully understanding the material risks. If stopping smoking can alter the concentration of a medication enough to become life-threatening within 72 hours, that is not a minor side effect.

That is information every patient deserves to know before they swallow the first tablet. Not buried in a leaflet. Not discovered on social media or a fucking Substack article. Not learned after someone has died in an inquest whilst the psychiatrists submit inconsistent accounts because they don’t really know the links.

We should never need a coroner to teach us pharmacology. This young man’s death should never have become another headline that disappears next week. It should force difficult questions.

How consistently are patients warned about this interaction?

How consistently are clinicians asking about smoking at every review?

Why do we have no guidance or practice around this, when it’s so common?

What happens when someone is admitted to hospital, and suddenly stops smoking?

What happens when someone decides to quit after New Year?

What happens when someone switches from cigarettes to vaping?

And perhaps the biggest question of all…

If the coroner found inconsistencies in professional understanding after a preventable death, how confident should patients be that they have received all the information they needed to give truly informed consent?

For me, that is the real issue. Informed consent only exists when people are given all of the knowledge they need to understand the risks they are taking by starting a medication. This young man never got another opportunity to ask those questions.

And this is just one reason I am writing this article for my followers and readers. Did you know about this link?