Elsevier

Drug and Alcohol Dependence

Volume 76, Issue 3, 7 December 2004, Pages 287-295
Drug and Alcohol Dependence

Smoking, nicotine dependence and psychiatric comorbidity—a population-based study including smoking cessation after three years

https://doi.org/10.1016/j.drugalcdep.2004.06.004Get rights and content

Abstract

Background: Evidence suggests that nicotine-dependent smokers are at increased risk for psychiatric comorbidity but general population data that included the number of nicotine dependence and withdrawal symptoms according to DSM-IV, the Fagerstrom Test for Nicotine Dependence (FTND), somatoform disorders and the number of psychiatric diagnoses are rare. The goal of the present study was to analyse relationships of smoking and nicotine dependence with psychiatric disease and whether psychiatric disease predicts the sustaining of smoking after three years. Methods: Cohort study with a random adult population sample in a northern German region (N = 4075) including a baseline measurement of ever daily smokers aged 18–64 (n = 2458), a first follow-up of the current smokers at baseline (n = 1552) after 30 months and a second follow-up after 36 months. Measures included DSM-IV diagnoses by the Composite International Diagnostic Interview, FTND, smoking cessation by interview. Results: Current daily smokers showed higher odds of a substance use disorder other than nicotine dependence compared with never smokers (odds ratio, OR, 4.6; confidence interval, CI, 2.9–7.2), affective (OR 1.8; CI 1.4–2.5), anxiety (OR 1.6; CI 1.2–2.0) or somatoform disorder (OR 1.4; CI 1.0–1.8). DSM-IV nicotine dependence and the FTND were positively related with the number of psychiatric diagnoses. Psychiatric comorbidity did not predict the maintenance of smoking or quitting. Conclusions: Findings of increased rates of mental disorders among smokers and nicotine-dependent smokers in the adult general population are supported by this study. The number of nicotine dependence and withdrawal symptoms are related to mental disorders. In addition, somatoform disorders show relationships with smoking similar to relationships with depressive or anxiety disorders. The intention to stop smoking should be proactively supported among these comorbid patients.

Introduction

There is considerable evidence for the cooccurrence of smoking and mental disorders from general population data (Upadhyaya et al., 2002, Rohde et al., 2004). Based on a nationally representative sample in the USA, 44.3% of all cigarette smokers were estimated to have a mental disorder (Lasser et al., 2000). Current smokers compared with never smokers in the adult population of Australia (N = 10,641, aged 18 or older) showed an odds ratio (OR) of 3.4 for alcohol use disorders (confidence interval, CI, 2.6–4.4) according to DSM-IV (Degenhardt and Hall, 2001). In this study, the Composite International Diagnostic Interview (CIDI; World Health Organization, 1990) was used; after controlling for age, gender and education, current tobacco users had an odds ratio of 1.5 (CI 1.2–1.8) for any affective and an odds ratio of 1.7 (CI 1.4–2.0) for any anxiety disorders (Degenhardt et al., 2001). The smoking rate seems to be related also to the number of mental disorders. In the US population, individuals with two or more lifetime psychiatric diagnoses showed higher rates of smoking and more cigarettes per day than those who had one psychiatric diagnosis (Lasser et al., 2000).

Individuals dependent on nicotine had an odds ratio of 12.8 (CI 11.7–14.0) for dependence on alcohol compared with nicotine non-dependent smokers based on data from surveys (N = 39,994), that represent the non-institutionalized US population aged 18 or older. Six DSM-IV criteria for nicotine dependence had been approximated by single questions (Kandel et al., 2001). The rates of those who had a major depressive episode or any anxiety disorder increased from never and former users of cigarettes, non-dependent current smokers, up to dependent current smokers (Kandel et al., 2001). The odds ratios adjusted for sociodemographic variables were 1.8 for non-dependent and 3.1 for dependent current smokers with a major depressive episode and 1.4 for non-dependent and 2.6 for dependent current smokers who had any anxiety disorder compared to never cigarette smokers. Major depression was more prevalent during lifetime among nicotine-dependent daily smokers than among individuals who were not nicotine dependent (OR 3.2; CI 1.7–5.8) in a study that included DSM-III-R diagnoses based on the diagnostic interview schedule (DIS) and a random sample of 1200 members of a health maintenance organization (HMO; 21–30-year-olds; Breslau and Johnson, 2000). The odds for anxiety disorders at baseline were found to be higher in nicotine-dependent than in non-dependent smokers (males: OR 2.2, CI 1.3–3.9; females: OR 2.6, CI 1.8–3.9; Breslau, 1995), and the sex-adjusted odds ratio for dependent smokers versus non-smokers was 2.4 (CI 1.7–3.5; Breslau, 1995). In a random community sample of individuals aged 14–24, nicotine-dependent smokers showed increased odds ratios for lifetime alcohol dependence, abuse of illicit drugs, affective disorders and anxiety disorders (Nelson and Wittchen, 1998).

The number of nicotine dependence and withdrawal symptoms was included in the study of 1200 HMO members. The prevalence rates for any anxiety disorder among the non-dependent smokers or non-smokers was 26.3%, among the mild nicotine dependent subjects 36.8% and among the moderate dependent subjects 62.3% (Breslau et al., 1991). Mild nicotine dependence was defined as the presence of three or four symptoms excluding social, occupational or recreational functioning. Moderate nicotine dependence was defined by five or six dependence symptoms or three or four symptoms when interference in functioning was included. Smokers with an anxiety disorder showed more withdrawal symptoms than smokers without any anxiety disorder (Breslau et al., 1992).

The relationship between smoking or nicotine dependence and mental disorders has been further analysed according to their sequencing. Different reasons for the cooccurrence of smoking and mental disorders may exist. (1) Smoking could be reinforced by a pre-existing mental disorder, and individuals may use nicotine as a form of self-medication (cf. Poirier et al., 2002, Upadhyaya et al., 2002). Among depressive persons, self-medication might function via an MAO inhibiting effect of tobacco smoking (Fowler et al., 1998, Fowler et al., 1996), which seems to be related to the serotonin and dopamine metabolism (cf. Upadhyaya et al., 2002). (2) There may exist common causes such as common genetic predispositions (Breslau et al., 2004b). In a cohort study of an adult general population sample, mental disorders preceded increased smoking a year later (Ismail et al., 2000). Progression to daily smoking was found to be associated with major depression, alcohol and drug use disorders (Rohde et al., 2004). In a cross-sectional study including a representative population sample of 15–54-year-olds, pre-existing major depressive and anxiety disorders predicted an increased risk for the first onset of daily smoking and for nicotine dependence according to DSM (Breslau et al., 2004b). A cohort study of 14–24-year-olds revealed increased odds ratios for nicotine dependence after four years among baseline non-smokers who had social fears and baseline non-dependent smokers who had social fears (Sonntag et al., 2000).

On the other hand, the smoking in adolescence often precedes the onset of mental disorders (Upadhyaya et al., 2002), and we do not know whether smoking and psychiatric comorbidity are independent from each other in this case. In a retrospective analysis of the general population sample of 15–54-year-olds in the USA investigated in the National Comorbidity Survey, mental disorders were predicted by daily smoking, but the lifetime amount smoked was not related to increased odds ratios of mental disorder (Breslau et al., 2004a). Smoking may increase the odds of single anxiety disorders (Johnson et al., 2000), and DSM-IV nicotine dependence may increase the odds of onset of panic disorder and specific phobia. A reason could be that psychiatric symptoms may follow from damage of the upper aerodigestive tract caused by smoking and that this damage leads to the panic attack (Isensee et al., 2003). Taken together, the evidence shows that smoking and mental disorders may reinforce each other; this may be an obstruction to smoking cessation.

Smoking cessation could be impeded by the cooccurrence of mental disorders and smoking because the psychiatric disorder and smoking have developed into a system of mutually supporting conditions. As part of this, smoking may relieve anxiety or may increase mood. Thus, adequate treatment of the mental disorder might support the probability of smoking cessation. However, much less is known about the process of remission, i.e. how the interaction of smoking and nicotine dependence with mental disorders is disentangled, than about how it develops. It is unclear whether a past history of psychiatric disease may predict the inability to stop smoking (Hughes, 1999, Sullivan and Covey, 2002). Among a population-based sample of 2004 females in New Zealand (Romans et al., 1993), a random subsample (n = 314) got a psychiatric interview, the Present State Examination. Women who showed depression or any anxiety disorder were more likely to be smokers in a follow-up 30 months later (63.2%) than women without a psychiatric disorder at baseline (22.7%). Of the 57 cases with a psychiatric disorder, 32 had remitted, and of those remitted, more (50%) smoked 30 months later than among those not remitted (20%). This gives support to the assumption that smoking might be used as a help against mood disorders. Population-based data from the National Health and Nutrition Examination Survey Follow-up Study collected nine years after baseline show that smokers with the higher depression scores (Center for Epidemiological Studies Depression Scale, CES-D) were less likely to have quit nine years later compared to smokers who were non-depressed at baseline (Anda et al., 1990). Among 1224 patients who had received smoking cessation counselling, those who had a current psychiatric diagnosis were less likely to stay quit six months after treatment (Ferguson et al., 2003). Using the National Comorbidity Survey data from the USA, it was shown that persons with a history of mental disorder (depressive, anxiety or substance use disorder (SUD)), particularly those with a mental disorder during the last four weeks, had a higher percentage of current smokers and lower quit rates (Lasser et al., 2000).

Other data reveal that there is no less cessation among comorbid than among non-comorbid smokers. Those with a past history of alcohol dependence had a similar smoking cessation rate as non-alcohol dependent smokers, and abstinence from tobacco did not increase the likelihood of alcohol relapse (Sullivan and Covey, 2002). Major depression did not predict smoking relapse according to clinical as well as general population studies (Hitsman et al., 2003, John et al., 2004). Cross-sectional general population data that included the age of onset for single DSM-IV psychiatric disorders, smoking and nicotine dependence revealed that depressive, anxiety and substance use disorders could not predict the persistence versus cessation of smoking (Breslau et al., 2004b).

Altogether, there is considerable evidence about the cooccurrence of smoking or nicotine dependence with substance use disorders, anxiety disorders and depressive disorders. However, the studies done so far that used DSM-IV diagnoses did not include somatoform disorders, the number of psychiatric diagnoses and detailed information about smoking behaviour and nicotine dependence such as the number of nicotine dependence and withdrawal symptoms, the FTND, quit attempts, the number of years of smoking, the number of cigarettes smoked per day and smoking cessation in adult age until 64.

The goal of the present study was to examine (1) whether there are increased odds ratios of individuals with substance use disorders other than nicotine dependence, with affective, anxiety or somatoform disorders among tobacco smokers; the hypothesis being that smokers have increased odds of psychiatric diagnoses and a higher number of psychiatric diagnoses compared to never smokers, current daily smokers more so than former smokers. (2) It should be examined whether the number of nicotine dependence and nicotine withdrawal symptoms are larger in individuals with a psychiatric diagnosis than in individuals without; the hypothesis being that these variables show increased odds ratios among individuals who have a psychiatric diagnosis and that the odds increase by the number of the diagnoses. (3) We wanted to know whether the number of psychiatric diagnoses, the number of years with smoking, of cigarettes per day, the number of nicotine dependence and withdrawal symptoms predict quit attempts and staying quit after three years; the hypothesis being that the higher the values in these variables, the lower the probability of smoking cessation.

Section snippets

Subjects

Individuals aged 18–64 years living in the northern German 217,000-inhabitant city of Lübeck and 46 surrounding communities were eligible for the present study (Transitions in Alcohol Consumption and Smoking, TACOS; Meyer et al., 2000). A random sample from the communities’ resident registration files, in which the address and further personal data of everybody have to be included, was drawn. Of the eligible subjects, 4093 completed the baseline interview (participation rate: 70.2%), and the

Results

Female current daily smokers showed higher age-adjusted odds of SUD, affective, anxiety and somatoform disorders compared to females who had never smoked (Table 1), and they revealed an odds ratio of 2.7 for having two or more psychiatric diagnoses other than nicotine dependence compared to female never smokers (Table 2). Male former or current daily smokers revealed increased age-adjusted odds ratios of SUD, affective and anxiety, not, however, somatoform disorders. Male current daily smokers

Discussion

The results clearly show that individuals who were current smokers at baseline are more likely to have a substance use disorder, affective, anxiety or a somatoform disorder. Our data confirm hypothesis 1 in part, and they confirm results from former studies that used representative general population samples (Lasser et al., 2000, Breslau et al., 2004b; Degenhardt et al., 2001), findings from more limited samples (Breslau, 1995) and findings from studies more limited in their measurements (

Acknowledgements

Data described in this paper are part of the project “Transitions in Alcohol Consumption and Smoking (TACOS)” which has been funded by the German Federal Ministry of Education, Science, Research, and Technology (grant no. 01 EB 9406).

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