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Explanations for the lack of an additional cognitive benefit in smokers promoted by the SGA can be a possible ceiling effect of the agonist activity that may be obtained by smoking and/or SGA or the possibility of an etiologically differentiated system with more marked alterations among smokers, which might prevent smokers from benefitting from practice effects, suggesting that smoking may be a marker for more severe illness and/or its neurodevelopmental phenotype, as was suggested by some authors.15,20 Also supporting this hypothesis, although the results of this study indicate that the initial clinical presentation is the same for the two groups, it was found that negative symptoms worsened significantly in smokers.32 With respect to the exploration of the association between smoking and the symptoms and side effects of medication, these study results do not support that FEP patients smoke in order to reduce the side effects of antipsychotic drugs, since smokers did not exhibit fewer extrapyramidal side effects comparative to non-smokers.32 A second study documented that cigarette smoking was consistently associated with higher ratings of psychiatric symptoms and functional impairment, more missed pills and lower ratings of quality of life,33 also encouraging the hypothesis of tobacco being a marker for greater illness severity

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