Nicotine dependence and motives for smoking in depression

Journal of Substance Abuse, 6, 67-76 (1994)

Nicotine Dependence and Motives for Smoking in Depression Solange Carton Roland Jouvent Daniel Widl~cher H~pital de la Salp~tri~re, Service de Psychiatrie Pr. Widl~cher, and CNRS EP53, Paris, France.

Smoking variables were assessed in female (n = 48) and male (n = 28) French hospitalized depressed smokers. Nicotine dependence, motives for smoking, and emotional situations in which depressed smokers were likely to smoke were compared with those of female (n = 36) and male (n = 60) nondepressed smokers from the general population. Depressed smokers scored higher than controls on nicotine dependence, and on stimulant and sedative smoking; they also reported that they were more likely to smoke in negative emotional situations. Sedative smoking decreased significantly between admission and discharge. Sedative smoking is a strong reason for smoking among depressed smokers regardless of degree of dependence, whereas stimulant smoking is positively correlated with degree of dependence. Nicotine dependence is also significantly correlated with anhedonia, and its relationship to depression is discussed in regard to nicotine action on hedonic systems.

Over the past several years, considerable research has focused on the relationships between psychopathology and smoking, and especially between depressive disorders and smoking (Anda et al., 1990; Glassman et al., 1990). Numerous investigators have found, in large samples, links among a history of major depressive episode, smoking, and difficulty in maintaining cessation (Breslau, Kilbey, & Andreski, 1991; Covey, Glassman & Stetner, 1990). Hall and colleagues reported that depressive subjects seeking smoking-cessation treatment tended to relapse quickly (Hall, Tunstall, Rugg, Jones, & Benowitz, 1985), and that the rate of major depression in smoking clinic data was higher than average (Hall, Munoz, & Reus, 1991). Once the association among history of depression, smoking, and difficulty quitting was observed, attention turned to the reemergence

Preparation of this manuscript was supported by a grant from the Soci~t~ de Tabacologie, Paris. The authors are grateful to C.S. Pomerleau for editorial assistance. Correspondence and requests for reprints should be sent to Solange Carton or Daniel Widl6cher, H6pital de la Salp~tri~re, Service de Psychiatrie Pr. Widl6cher and CNRS EP53, Pavillion Cl~rambault, 47 bd de l'H6pital, 75651 Paris Cedex, France. 67

S. Carton, R. louvent, and D. Widl6cher

68

of depressive symptoms following cessation. It was noted that among subjects with a history of major depression, those who maintained abstinence became seriously depressed (Flanagan & Maany, 1982). Depressive mood is not used as a smoking withdrawal symptom in the Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised (DSM-III-R). In smokers with no history of depression, it is unusual for such symptoms to appear; when they do, they are generally attenuated (Covey et al., 1990). Other researchers have demonstrated that smokers with a history of depression develop more intense withdrawal symptoms (Hall et al., 1991). Breslau showea that among smokers who failed to quit, those with a history of depression developed dysphoria and experienced more difficulty in concentrating than the subjects without such a history, although these symptoms were not significantly more severe than the other withdrawal symptoms (Breslau, Kilbey, & Andreski, 1992). The self-medication hypothesis (Khantzian, 1985) is very attractive as a way of explaining higher rates of initiation among depressive subjects. Alternatively, it has been suggested that some shared genetic vulnerability leads to increased risk of both depression and smoking (Kendler et al., 1993). Breslau and colleagues, observing a relationship between nicotine dependence and other measures of psychopathology, noted that neuroticism commonly predisposes to both nicotine dependence and major depression (Breslau, Kilbey, & Andreski, 1993). Reasons for smoking reported by smokers range from tension and negative affect reduction to improvement of mood and increase of alertness and cognitive function. If smoking provides such emotional regulation, we postulated that such effects would be stronger in subjects with emotional disorders. The aim of the study presented here was to investigate, in hospitalized depressed subjects, motives for smoking, situations in which smoking is likely to occur, degree of dependence, and their interrelationships. We hypothesized that depressed patients would be more dependent than normal smokers, and that dependence would be strongly related to affect regulation as a motive for smoking. Furthermore, we wanted to explore the relationships between smoking patterns and the nature of anxious and depressive symptomatology. We hypothesized (a) that negative symptomatology--that is, anhedonia, emotional blunting, and motor retardation-would be positively correlated with "stimulant smoking"; and (b) that anxious syrnptomatology would be positively correlated with "sedative smoking."

METHOD Subjects The sample was composed of 76 depressed smokers (48 women and 28 men) meeting the DSM-III-R criteria of major depressive disorder and hospitalized in the Salp~tri~re Hospital (Paris) for a minimum of 3 weeks. A control sample of 96 smokers (36 women and 60 men) was assembled from the general population.

Motives for Smoking in Depression

69

Procedure

Each depressed subject was assessed upon admission before administration of antidepressant treatment and in some instances after a placebo wash-out period. An extensive psychiatric interview was conducted in the morning by an experienced clinician, in order to evaluate intensity and form of symptomatology, following which patients were asked to complete the questionnaires. Thirty-six subjects were reassessed in an identical manner just prior to discharge, when they were j u d g e d as normo-thymic by the clinicians, after approximately 3 weeks of antidepressant treatment. The clinician used the following instruments: (a) Hamilton Depressive Rating Scale (HDRS), 17-item version (Hamilton, 1967); (b) Covi Anxiety Brief Scale (Lipman, 1982); (c) Abrams-Taylor Scale for Emotional Blunting I (Abrams & Taylor, 1978); (d) Widl6cher Depressive Retardation Scale x (Widl6cher, 1983); (e) Jouvent Depressive Mood Scale (Jouvent, Vindreau, Montreuil, Bungener, & Widl6cher, 1988); including five emotional factors: anhedonia/global indifference, subjective hyperemotivity/hypersensitivity to unpleasant events, emotional expressiveness, sadness, anxious hyperattentivity. The patients completed the following questionnaires: (a) The Fagerstr6m Tolerance Questionnaire (FTQ; range of possible scores 0-11) was administered as a measure of nicotine dependence (Fagerstr6m, 1978); (b) The Smoking Motives Questionnaire (SMQ: Russell, Peto, & Patel, 1974), which identifies seven "types" of smoking (stimulation, indulgent, psychosocial, sensorimotor, addictive, automatic, and sedative), was translated into French; a 5-point rating-scale was used (1-5). It was subjected to factor analysis to verify that the original factor structure emerged (Carton, 1992). (c) The Differential Emotions Scale (DES: Izard, 1972) is a self-report composed of 30 emotional adjectives, grouped into 10 fundamental emotion factors (joy, alertness, sadness, disgust, anger, contempt, guilt, fear, shyness, surprise), which was translated into French and validated (Ouss, Carton, Jouvent, & Widl6cher, 1990). The original instructions were modified such that subjects were asked to indicate how likely they were to smoke when experiencing these emotions. Controls recruited from the general population were asked to complete the same questionnaires.

RESULTS

T h e mean age (+SD) was 37.5 years (+9.7 SD) for depressed men, 35.2 years (+-11.0 SD) for depressed women, 39.1 years (+ 10.2 SD) for men, and 28.0 years (+-7.6 SD) for women. A trend toward a significant main effect for depression status, F(I, 168) = 3.59, p = .06, and a significant main effect for gender, F(I, 168) = 21.46, p < .0001, were detected. There was a significant Depression x Gender interaction, F(1, 168) = 7.81, p = .006. Age was included as a covariate in all analyses.

70

S. Carton, R. Jouvent, and D. Widl6cher Table 1. FTQ Scores: Comparison Between Depressed and Control Smokers Depressed Smokers (N = 76)

FTQ Total Intake Nicotine Morning Inhalation 1st cigarette/day Give Up Forbidden Illness

Control Smokers (N = 96)

ANOVA (df = 169)

M

+-SD

M

+-SD

F

p

6.09 1.01 1.11 0.28 1.59 0.41 0.63 0.39 0.67

2.29 0.72 0.70 0.45 0.64 0.49 0.49 0.49 0.47

4.59 0.59 0.98 0.18 1.70 0.16 0.50 0.18 0.31

1.98 0.64 0.72 0.38 0.62 0.36 0.50 0.38 0.47

23.15 15.79 1.38 2.39 0.86 15.92 3.09 11.02 28.25

.000 .000 n.s. n.s. n.s. .000 .081 .001 .000

S m o k i n g D e p e n d e n c e and P a t h o l o g y

Mean F T Q total score for depressed smokers was 6.1 (+2.3 SD). T h e r e was no significant d i f f e r e n c e between w o m e n and men. C o m p a r i s o n with controls showed that d e p r e s s e d subjects o f both genders scored significantly h i g h e r o n the total F T Q . Table 1 presents scores for d i f f e r e n t F T Q items (mean +-SD)and comparisons with control smokers after controlling for age. No significant correlation between d e g r e e o f d e p e n d e n c e and intensities o f depression, anxiety, emotional blunting, and r e t a r d a t i o n was detected. In women, the F T Q total score correlated significantly with the a n h e d o n i a factor o f the Depressive Mood Scale (N = 48, r = .32, p < .05). A t r e n d towards a significant correlation between the SMQ addictive factor and a n h e d o n i a a p p e a r e d in both g e n d e r s (N = 76, r = .20, p = .08) and between automatic smoking and anh e d o n i a (N = 76, r = .24, p = .04). Addictive smoking was correlated with sadness, (N = 76, r = .28, p < .01). M o t i v e s for S m o k i n g a n d E m o t i o n a l S i t u a t i o n s

T h e r e was no significant d i f f e r e n c e between m e n and w o m e n on the SMQ factors. O n the DES, w o m e n scored h i g h e r on the disgust f a c t o r - - t h a t is, they r e p o r t e d m o r e smoking than m e n w h e n experiencing disgust, F(1, 62) = 4.34, p < .05. Depressed subjects scored significantly h i g h e r than controls on several motives for smoking; they also r e p o r t e d m o r e smoking in negative emotional situations (Table 2). W h e n we focused on the relationships between motives for smoking and emotional r e g u l a t i o n - - t h a t is stimulant smoking and sedative smoking, and the f o r m o f emotional p a t h o l o g y - - w e f o u n d that stimulant smoking was positively c o r r e l a t e d with the F T Q total score (N = 76, r = .35, p < .001), but sedative

Motives for Smoking in Depression

71

Table 2. Smoking Motives and Emotional Situations for Smoking: Comparison Between Depressed and Control Smokers Depressed M

SMQ

+SD

M

5.14 3.09 4.08 4.31 3.40 3.23 1.92

16.91 13.06 11.83 13.44 11.43 5.97 7.21

19.03 12.95 13.46 14.12 13.91 7.47 8.17

DES

3.94 3.79 3.74 3.78 3.26 2.98 2.64 3.59 3.26 3.42

6.22 5.34 4.75 4.55 4.73 3.92 3.69 5.97 7.80 8.13

10.28 10.12 7.94 7.58 6.86 5.86 5.00 7.09 9.11 8.42

5.49 2.89 3.83 4.01 3.64 2.49 2.13

N = 96

N = 65

Anger Sadness Disgust Fear Shyness Surprise Contempt Guilt Alertness Joy

+SD

N = 96

N = 76

Stimulant Indulgent Psychosocial Sensorimotor Addictive Automatic Sedative

ANOVA

Control

3.42 2.86 2.36 2.57 2.41 1.66 1.27 2.78 3.11 2.87

F

p

df = 6.50 0.43 7.85 1.31 21.09 11.37 9.54

df = 48.63 86.64 43.73 38.85 23.16 26.69 18.18 4.70 6.23 0.23

169 .012 n.s. .006 n.s. .000 .001 .002 158 .000 .000 .000 .000 .000 .000 .000 .032 .014 n.s.

s m o k i n g was not. T a b l e 3 shows t h e c o r r e l a t i o n c o e f f i c i e n t s o f t h e s t i m u l a n t a n d s e d a t i v e scores with d e p r e s s i v e m o o d scale factors i n all d e p r e s s e d subjects. S e d a t i v e s m o k i n g was positively c o r r e l a t e d with i n t e n s i t y o f d e p r e s s i v e s y m p t o m s ( H D R S , N = 76, r = .35, p < .001) a n d with t h e A b r a m s - T a y l o r a f f e c t i v e f a c t o r (N = 38, r = .32, p < .05). I n w o m e n only, s e d a t i v e s m o k i n g was also p o s i t i v e l y c o r r e l a t e d with t h e a n x i e t y total score (N = 48, r = .34, p < .01) a n d with all o f t h e d e p r e s s i v e m o o d factors e x c e p t e m o t i o n a l h y p e r e x p r e s s i v i t y : a n h e d o n i a (N = 48, r = .34, p < .01), s a d n e s s (N = 48, r = + . 4 2 , p < .001), h y p e r s e n s i t i v i t y (N = 48, r = .30, p < .05), a n x i o u s h y p e r a t t e n t i v i t y (N = 48, r = .27, p = .06). I n m e n , t h e s e d a t i v e f a c t o r o n l y was c o r r e l a t e d with h y p e r s e n s i t i v i t y (N = 28, r = .46, p < .01). I n w o m e n , b u t n o t i n m e n , s t i m u l a n t s m o k i n g was

Table 3. C o r r e l a t i o n s B e t w e e n D e p r e s s i v e M o o d S c a l e Factors a n d S e d a t i v e a n d S t i m u l a n t S m o k i n g ( N = 76)

Sedative Stimulant *p < .05;

Sadness

Hypersensitivity

Hyperesthesia

.25* .08

.37*** .29**

.27* .10

**p < .01;

***p < .001.

72

S. Carton, R. Jouvent, and D. Widl6cher

significantly correlated with hypersensitivity to unpleasant events/hyperemotivity (N = 48, r = .35, p < .01). Differences Between Admission and Discharge Results Prior to discharge, all of the subjects were judged to be normo-thymic by the clinicians, and scores on the clinical scales all were significantly decreased (p < .001). Sedative smoking decreased significantly, and the subjects reported less smoking than at admission in situations involving sadness, anger, disgust, and fear (Table 4). No difference in the FTQ total score or items appeared, demonstrating that the stability of this measure was not affected by acute changes in depressive status (Pomerleau, Carton, Lutzke, Flessland, & Pomerleau, 1994. Differences between admission and discharge scores were calculated for factor scores on each scale. No correlation was detected between improvements in depression and anxiety and changes in any smoking variable. On the depressive mood scale, significant correlations appeared between decreases in hypersensitivity and in sedative smoking (N = 36, r = .48, p < .01), and between increases in emotional expressivity and in psychosocial smoking (N = 36, r = .46, p < .01). DISCUSSION Depressed patients showed a significantly higher degree of nicotine dependence than did control smokers, as measured by the F T Q total score and the Table 4. Comparison Between SMQ and DES Scores Before and After Treatment Day 0

Day 21 Paired t-Test

+-SD

p

17.61 13.75 12.28 12.69 13.47 7.17 7.88

6.09 2.89 2.89 4.09 2.71 3.63 1.8

n.s. n.s. n.s. n.s. n.s. n.s. .02

8.89 8.52 6.52 6.10 6.41 5.83 4.34 6.21 8.38 8.52

4.0 3.2 3.38 2.96 2.58 3.12 1.93 3.18 3.45 2.89

.004 .002 .003 .037 n.s. n.s. n.s. n.s. n.s. n.s.

M

+SD

M

18.06 13.08 12.28 13.28 13.81 7.42 8.55

5.13 3.10 2.94 4.41 3.28 3.43 1.8

10.76 10.21 8.48 7.00 6.65 6.34 4.21 6.38 9.38 8.55

3.57 3.36 3.65 3.07 3.07 2.95 2.08 3.46 3.20 3.64

SMQ (N -- 36) Stimulant

Indulgent Psychosocial Sensorimotor Addictive Automatic Sedative DES (N = 29) Anger

Sadness Disgust Fear

Shyness Surprise Contempt Guilt Alertness Joy

Motives for Smoking in Depression

73

SMQ addictive factor. These subjects, recruited over a period of 2 years, were representative of inpatients hospitalized for depression. Our control sample was likewise representative of the general population, with FTQ scores comparable to that of a normative French sample in 1988, equal to 4.5 -+2.03 SD (K.O. Fagerstr6m, personal communication, April 28, 1993). French norms are lower than the mean of 5 to 6 seen in unselected American smokers (Opinion Research Corp., 1988), probably because public health campaigns and workplace bans have discouraged light or discretionary smokers in the U.S. The FTQ items on which depressed subjects scored significantly higher than did controls were the most representative of nicotine dependence; two of the three items on which depressed people did not differ from the controls (inhalation and nicotine dosage) have been deleted in the new dependence questionnaire (Fagerstr6m Test for Nicotine Dependence [FTND]: Heatherton, Kozlowski, Frecker, & Fagerstr6m, 1991). Likewise, depressed patients of both genders also scored higher than did control smokers on the SMQ addictive and automatic factors. Sedative smoking is linked in both men and women with hypersensitivity/irritability, and with depressive and anxious symptomatology, anhedonia, sadness, and hyperesthesia factors of the Depressive Mood Scale in women. Although there is no difference between men and women on sedative smoking, its relationship to the intensity of overall pathology in women may reflect a stronger relationship between negative affect smoking and intensity of emotional distress in women, who already have been shown in literature to be more likely to smoke in negative emotional situations (Frith, 1971; I kard & Tomkins, 1973; Russell et al., 1974). Depressed subjects scored higher than controls on this motive for smoking, and scores decreased significantly between the first and second evaluation. Depressed subjects of both genders reported that they were more likely than controls to smoke when experiencing negative emotions, although this finding may simply reflect the fact that they spent more time in negative emotional states than did nondepressed smokers. Nevertheless, they also reported that they were more likely than controls to smoke when alert and were not less likely to smoke in joyful states, which tends to undercut such an interpretation and lends credibility to the hypothesis that depressive subjects are more likely to "use" smoking to regulate emotions. In nondepressed subjects, degree of dependence is correlated with both sedative and stimulant smoking (Carton, Jouvent, & Widl/3cher, 1991), whereas in depressed subjects it is correlated only with stimulant smoking. Many subjects report smoking primarily for the arousing properties of nicotine and to increase alertness (Russell et al., 1974; Spielberger, 1986). There is evidence that people regularly monitor their levels of arousal and that they employ mood-enhancing techniques that have been successful in the past (Thayer, 1989). The report of mood enhancement upon smoking is more likely if the smoker is in a low-arousal state, because smoking increases the level of cortical arousal (Edwards, Wesnes, Warburton, & Gale, 1985). In depressed subjects, we failed to observe specific positive relationships between anhedonia, retardation, and stimulant smoking. It is possible that depression masks the usual relationship between stimulant properties of smoking, dependence, and pathology. We are currently conduct-

74

S. Carton, R. Iouvent, and D. Widl6cher

ing longitudinal follow-ups of patients to track their habitual smoking behavior between depressive episodes and the relation of smoking behavior to mood. The sedating effects of nicotine may be sought by all depressed smokers, whereas the particular relationship between stimulant smoking and F T Q score may reflect habitual use of nicotine for improvement of mood and increase of arousal in the more dependent subjects. Furthermore, although we did not observe correlation between anhedonia and stimulant smoking, anhedonia was correlated in women with degree of nicotine dependence (FTQ scores), and a trend toward a significant correlation with the SMQ addictive factor emerged in both genders. The release of dopamine by nicotine--whose role in reward and hedonic pathways is generally acknowledged and which serves as a biological basis for a psychomotor stimulant theory of addiction (Wise & Bozarth, 1987)--was recently emphasized as having favorable effects on the negative symptoms of schizophrenia and recurrent depressions (Glassman, 1993). We have previously shown that some anhedonic depressed subjects were paradoxically high sensation seekers, suggesting that some anhedonic patients might need unusually strong pleasurable stimulation to compensate for their low emotional reactivity (Carton, Jouvent, Bungener, & Widl6cher, 1992). Because of its action on hedonic pathways, nicotine could be particularly appealing to anhedonic depressive patients, and this may explain why depressed female smokers score higher on sensation seeking than do female nonsmokers, both depressed and nondepressed (Carton, Jouvent, & Widl6cher, in press a, 1993). It has been suggested that vulnerability to nicotine dependence is a function of high initial sensitivity to nicotine, which produces reinforcing consequences that lead to chronic use (Pomerleau, Hariharan, Pomerleau, Cameron, & Guthrie, 1993); possibly, some depressive subjects may be very sensitive to nicotine, especially to its stimulant properties, which in these smokers could form the basis for dependence. Further research is needed to determine whether there exists, in some depressed subjects, a particular link between the action of nicotine on reward systems and anhedonia.

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