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Smoking in psychiatric inpatients: Association with working status, diagnosis, comorbid substance abuse and history of suicide attempts
Addictive Behaviors 34 (2009) 815–820
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Addictive Behaviors
Smoking in psychiatric inpatients: Association with working status, diagnosis, comorbid substance abuse and history of suicide attempts Ineke Keizer ⁎, Marianne Gex-Fabry, Ariel Eytan, Gilles Bertschy Division of Adult Psychiatry, Department of Psychiatry, HUG-University Hospitals of Geneva, Site de Belle-Idée, Les Voirons, Ch. du Petit Bel-Air 2, CH-1225 Chêne-Bourg, Switzerland
a r t i c l e Keywords: Psychiatric inpatients Health beliefs Suicide attempt Psychiatric diagnosis Comorbidity Smoking
i n f o
a b s t r a c t The present cross-sectional study investigates the association between smoking and psychopathology (ICD10 diagnosis), history of suicide attempts and socio-demographic characteristics in a sample of 180 adult hospitalized patients. Results confirmed a high frequency of current smokers (63.3%) and heavy smokers with ≥ 20 cigarettes/day (47.4%). Smoking was significantly associated with being on invalid pension, social welfare or unemployed (N 70% of smokers, p = 0.008), a history of suicide attempts (73.2%, p = 0.04) and the primary mental health diagnosis (p = 0.004). A majority of patients (57.8%) presented at least one comorbid condition. Multivariate logistic regression indicated that disorders due to psychoactive substances, either as a primary diagnosis or as a comorbid condition, were significantly associated with smoking, in addition to significant effects of age group, financial resources and history of suicide attempts. Investigation of health beliefs showed that psychopathology did not compromise a realistic appreciation of smoke-related health risks. These results underline the importance of taking into account socio-demographic factors and substance use comorbidity in designing targeted interventions to reduce smoking in psychiatric patients. © 2009 Elsevier Ltd. All rights reserved.
1. Introduction Cigarette smoking is a particularly complex behaviour and its association with mental health has been largely documented. According to large epidemiological studies, smoking frequency in psychiatric patients is about two to three-fold higher than in the general population (Lasser et al., 2000). Furthermore, people with mental illness tend to be heavy smokers (Araya, Gaete, Rojas, Fritsch, & Lewis, 2007; Xian et al., 2007). Whereas approximately 13% of the US population is nicotine-dependent, individuals with a comorbid psychiatric disorder make up 7% of the population yet consume 34% of all cigarettes smoked in the United States (Grant, Hasin, Chou, Stinson, & Dawson, 2004). The reasons for the strong association between smoking and mental health remain unclear. Diverse explanations related to mechanisms inherent to psychopathology have been proposed (e.g. the self-medication hypothesis) and theories about smoking and mood regulating processes have been developed (Carmody, 1992). One hypothesis particularly relevant in patients with mental disorders is that cigarette smoking might alleviate negative mood states such as anxiety and depression (Gregor, Zvolensky, Bernstein, Marshall, & Yartz, 2007). Much research has concentrated on the associations between smoking and psychopathology, and depression in particular. It has ⁎ Corresponding author. Tel.: +41 22 305 47 62; fax: +41 22 305 57 99. E-mail addresses: [email protected] (I. Keizer), [email protected] (M. Gex-Fabry), [email protected] (A. Eytan), [email protected] (G. Bertschy). 0306-4603/$ – see front matter © 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.addbeh.2009.03.018
been shown that the risk for depression increases with the severity of nicotine dependence (John, Meyer, Rumpf, & Hapke, 2004), that smoking in teenagers is a risk factor for the onset of later depressive pathology (Choi, Patten, Gillin, Kaplan, & Pierce, 1997; Horn et al., 2004; Patten, Choi, Vickers, & Pierce, 2001), and that the association between depressive symptoms and smoking can be generalized across diverse ethnic groups (Nezami et al., 2005). Elevated risk for smoking has been reported in patients with schizophrenia (Dervaux & Laqueille, 2008), bipolar disorders (Wilens et al., 2008), alcohol or substance use, and anxiety disorders (Cuijpers, Smit, ten Have, & de Graaf, 2007; Morissette, Tull, Gulliver, Kamholz, & Zimering, 2007). Smoking is also associated with sleep disorders and suicidality. Smoking and suicides or suicide attempts were associated in many studies, both in community samples (Breslau, Schultz, Johnson, Peterson, & Davis, 2005) and psychiatric populations (Malone et al., 2003; Ostacher et al., 2006). Smokers obviously do not all present psychopathology, and other risk factors have been investigated, such as socio-demographic status (Agrawal, Sartor, Pergadia, Huizink, & Lynskey, 2008), biological and genetic factors (Bierut et al., 2007), social influences (Killen et al., 2004), personality factors (Cloninger, Svrakic, & Przybeck, 1993; Enns & Cox, 1997; Zuckerman, Ball, & Black, 1990), coping mechanisms (Chorpita & Barlow, 1998; Siqueira, Rolnitzky, & Rickert, 2001; Vickers et al., 2003) and health risk perception (Murphy-Hoefer, Alder, & Higbee, 2004). The general objective of the present study was to investigate tobacco consumption in a sample of psychiatric inpatients in relation with recently introduced smoking restrictions, as reported in an
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earlier publication (Keizer, Descloux, & Eytan, 2009). The present article focuses on the relevance of different factors known to influence smoking behaviour, such as socio-demographic characteristics (gender, age and socio-economic status), psychopathology (main diagnosis, comorbidity and lifetime suicide attempts) and negative affects (anxiety and hopelessness levels). As reality perception can be altered in mental health patients, we also investigated health-related beliefs about smoking, such as risk perception and sense of personal vulnerability (Rodriguez, Romer, & Audrain-McGovern, 2007). Given the burden of smoking in psychiatric patients, it is crucial to gain understanding of the most important factors influencing cigarette consumption. If socio-economic status showed to be a significant factor, strategies reinforcing socio-education might be used in the first place; whereas if negative affects were preponderant, reduction of these symptoms might be most important to begin with. 2. Methods 2.1. Setting and procedure The present cross-sectional study took place between October 2005 and January 2006 in a public psychiatric university hospital in Geneva, Switzerland which provides care to patients aged 18–65 with acute psychopathology. All newly admitted inpatients were approached individually by a member of the research team and invited to participate if compatible with clinical status, as evaluated by the patient's principal caregivers (physician and nurse). The research protocol was approved by the Ethics Committee of the Department of Psychiatry. All participants provided written informed consent before being enrolled. Sociodemographic and clinical data, as well as smoking characteristics were collected during a single interview. Patients were then administered several self-rated instruments that they filled in the presence of a research team member not involved in patient therapy, and who could assist participants in case they encountered difficulties with the questionnaires. Of 183 consecutively admitted patients who agreed to participate, 3 subjects were excluded because of missing sociodemographic and smoking-related data. Analyzed sample thus included 180 patients. 2.2. Measures
Comorbid disorder due to psychoactive substance use was considered present if patients had at least one diagnosis related to either alcohol or other substances, except tobacco. 2.2.3. Negative affects Negative affects were assessed using the State and Trait Anxiety Inventory (STAI, Spielberger, 1983) and the Beck Hopelessness Scale (Beck, Weissman, Lester, & Trexler, 1974), French version (Bouvard, Charles, Guerin, Aimard, & Cottraux, 1992). 2.3. Data analysis Associations between smoking status (current smoker yes vs. no) and sociodemographic and clinical variables were first examined using chi-square tests for proportions. Group comparison proceeded with the Mann–Whitney U-test and the Kruskal–Wallis test for ordinal scores. A multivariate logistic regression model was then used to investigate the combined influence of different factors on current smoking (10 occasional smokers were excluded). Adjusted odds ratios (OR) and 95% confidence intervals (95% CI) were reported for all independent variables, that entered the model simultaneously. Statistical significance was set at 0.05. Analysis was performed using SPSS, version 15 (SPSS Inc., Chicago IL, USA). 3. Results 3.1. Tobacco use Distribution of patients (n = 180) according to nicotine use was as follows: 63.3% (n = 114) were current smokers, 5.6% (n = 10) occasional smokers, 20.6% (n = 37) never-smokers and 10.6% (n = 19) former smokers. Heavy smokers were 47.4% (n = 54). 3.2. Sociodemographics and smoking status Sociodemographic characteristics are summarized in Table 1. The proportion of current smokers did not significantly differ according to Table 1 Sociodemographic characteristics and smoking status in a Swiss sample of psychiatric inpatients (n = 180). Current smokers
2.2.1. Tobacco use and smoking-related health beliefs Smoking intensity was defined as the mean number of cigarettes/ day during the week before hospitalisation. Smoking status was defined as follows: never smoker (b100 cigarettes in a lifetime), current smoker (smoking during the survey and at least 1 cigarette/day during 6 months), former smoker (not smoking during the survey, at least 100 cigarettes in a lifetime and at least 1 cigarette/day during 6 months), present and former occasional smokers (at least 100 cigarettes in a lifetime and never smoked every day for 6 months or more). Smokers consuming N20 cigarettes daily were considered as heavy smokers. Smoking-related health beliefs were investigated with the following questions, rated on a 5-point Likert scale: “Do you think that exposure to smoke is dangerous for health?” (risk perception, 1 = definitely dangerous to 5 = not dangerous at all); “Do you think that during your lifetime you might develop an illness due to the effects of smoke/tobacco?” (personal vulnerability, 1 = yes, absolutely to 5 = no, definitely not). 2.2.2. Diagnosis and suicide attempts During the research interview, a question about lifetime suicide attempts was included: “In your whole life, how many suicide attempts have you made?” Main psychiatric diagnosis according to ICD-10 criteria (World Health Organization, 1992) and comorbidity were recorded from the medical charts (discharge summary).
Gender Female Male Age ≤ 30 31–50 N 50 Education Compulsory basic or less Some secondary or professional education Secondary or professional degree University or similar degree Financial resources Work Family Invalid pension Unemployment or social aid History of suicide attempta No Yes Primary diagnosis Disorders due to psychoactive substances Schizophrenia and psychotic disorders Mood disorders: bipolar and mania Mood disorders: unipolar depression Other diagnoses a
Missing data for 7 patients (n = 173).
N
%
%
83 97
46.1 53.9
61.4 64.9
41 97 42
22.8 53.9 23.3
63.4 67.0 54.8
73 57 32 18
40.6 31.7 17.8 10.0
65.8 63.2 68.8 44.4
40 19 69 52
22.2 10.6 38.3 28.9
47.5 42.1 71.0 73.1
91 82
52.6 47.4
57.1 73.2
33 54 29 44 20
18.3 30.0 16.1 24.5 11.1
87.9 51.9 65.5 52.3 75.0
p-value 0.65
0.39
0.34
0.008
0.04
0.004
I. Keizer et al. / Addictive Behaviors 34 (2009) 815–820
gender and age group. No significant difference was found with respect to education, despite a lower proportion of smokers among a minority of patients with university or similar degrees. Financial resources and working status were strongly and significantly associated with nicotine use, with higher proportions of smokers among patients with invalid pension (71.0%) and unemployment or social aid (73.1%) than in patients working (47.5%) or depending on family resources (42.1%). 3.3. Psychopathology and smoking status Distribution of primary diagnoses is provided in Table 1. Substance use disorders included diagnoses related to alcohol (n = 20, 60.6%) and other substances (n = 13, 39.4%). No tobacco-related diagnosis was reported in the discharge summaries. The category “other diagnoses” included stress-related disorders, personality and behavioural disorders, as well as other infrequent diagnoses. The proportion of smokers significantly differed across diagnostic categories, with substance use disorders characterized by the highest (87.9%) and psychotic disorders by the lowest proportions of smokers (51.9%). Nearly half the sample (47.4%) reported at least one lifetime suicide attempt, and the proportion of smokers was significantly higher in these patients than in those without any history of suicide attempt (Table 1). Comorbidity was frequent since 57.8% (n = 104) of the sample presented more than one psychiatric diagnoses. Of these, patients with substances as main diagnoses formed 20.2% (n = 21), those with other main diagnoses and presenting substance-related comorbidity represented 47.1% (n = 49) and finally patients with psychiatric comorbidity but no substance-related diagnosis were 32.7% (n = 34). The association between smoking status and substance use disorders was analyzed by comparing patients with a primary diagnosis of substance-related disorders (n = 33, 18.3%), with substance-related comorbidity (n = 49, 27.2%) and without any substance-related disorder (n = 98, 54.4%). Proportions of current smokers were 87.9%, 83.7% and 44.9%, respectively (chi-square test, df = 2, p b 0.001). 3.4. Anxiety, hopelessness and smoking status Smoking status was not significantly associated with negative affects, as measured with the STAI and BHS rating scales during hospital stay (median STAI scores 47 in current smokers and 41 in non-smokers, Mann–Whitney U-test p = 0.49; median BHS scores 6 and 5, p = 0.59). 3.5. Factors associated with smoking: logistic regression model Factors associated with current smoking were further investigated by entering them simultaneously into a logistic regression model (Table 2). Sociodemographic variables significantly associated with smoking included being younger than 50 years old and on any form of financial aid. In addition, substance-related disorder, either as a primary diagnosis (OR = 41.7, p b 0.0001) or as a comorbid condition (OR = 11.8, p b 0.0001), was a major factor associated with smoking. A significantly elevated proportion of smokers was also observed in bipolar disorders when compared with schizophrenia and other psychotic disorders, considered as the reference diagnostic category (OR = 4.9, p = 0.02). Interestingly, patients who reported at least one lifetime suicide attempt displayed an increased risk of being current smokers, even after taking into account sociodemographic and diagnostic variables (OR = 4.0, p = 0.005). Including STAI and BHS scores did not improve the model further (not shown). 3.6. Smoking-related health beliefs and tobacco use Most patients (84.2%, n = 149 of 177 valid answers) rated danger of exposure to smoke at the 2 highest levels: definitely dangerous (68.4%,
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Table 2 Factors associated with current smoking in a Swiss sample of psychiatric inpatients (n = 163a): multivariate logistic regression model. Adjusted ORb 95% CI Gender Female 0.9 Male 1 Age ≤ 30 3.6 31–50 4.2 N 50 1 Education Compulsory basic or less 1.9 Some secondary or professional education 3.4 Secondary or professional degree 2.3 University or similar degree 1 Financial resources Work or family 1 Invalid pension, unemployment or social aid 3.0 History of suicide attempt No 1 Yes 4.0 Primary diagnosis Disorders due to psychoactive substances 41.7 Schizophrenia and psychotic disorders 1 Mood disorders: bipolar and mania 4.9 Mood disorders: unipolar depression 1.5 Other diagnoses 1.2 Comorbid disorders due to psychoactive substancesc No 1 Yes 11.8
p-value
(0.4–2.3)
0.90
(0.8–15.6) (1.4–12.7)
0.09 0.01
(0.4–9.3) (0.7–16.3) (0.5–12.1)
0.45 0.13 0.32
(1.2–7.6)
0.02
(1.5–10.3)
0.005
(7.9–220.7) b0.0001 (1.3–19.3) (0.5–4.7) (0.2–5.9)
0.02 0.50 0.86
(3.6–39.2)
b0.0001
a
From the total sample (n = 180), 17 patients were excluded (10 occasional smokers and 7 patients with missing data about suicide attempts). b An odds ratio (OR) of 1 indicates the reference category. c At least one diagnosis related to alcohol or other substances (except tobacco), in addition to a primary diagnosis not related to substance use.
n = 121) or very probably dangerous (15.8%, n = 28). Perceived risk of personally developing an illness due to tobacco was more uniformly distributed along the 5 levels (n = 176 valid answers). Fig. 1 illustrates the comparison between current smokers and non smokers (10 occasional smokers were excluded). Groups did not significantly differ with respect to the perceived danger of smoke exposure. However, the risk of developing a smoke-related illness was perceived as significantly higher in smokers than in non-smokers (Mann–Whitney test, p b 0.0001). When taking smokers and non-smokers together, perceived danger of exposure to smoke did not differ between the 5 diagnostic groups, whereas perceived personal vulnerability was lowest among psychotic/schizophrenic patients (Kruskal–Wallis test, p = 0.05). Among smokers, danger associated with smoke was rated the lowest by psychotic/schizophrenic patients and the highest by substance abuse patients, but the difference across diagnostic categories did not reach statistical significance (Kruskal–Wallis test, p = 0.07). As for the risk of personally developing a tobacco-related illness, it did not significantly differ across groups, although psychotic/schizophrenic patients rated such a risk the lowest. 4. Discussion The present study confirmed the very high proportion of smokers among persons with mental illness. Percentages of smokers in different diagnostic categories were in line with published prevalence estimates of tobacco use in psychiatric patients. The proportion of smokers was highest in substance use disorders in our Swiss study (88%) as well as the US study by Morris et al (61–66%) (Morris, Giese, Turnbull, Dickinson, & Johnson-Nagel, 2006) and the data reported by Schneider et al (75%–90%) (Schneider et al., 2005). Smoking has frequently been reported as more prevalent among schizophrenic patients than in mood disorders (Diwan, Castine, Pomerleau, MeadorWoodruff, & Dalack, 1998), but this was not the case in the present
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Fig. 1. Smoking-related health beliefs in a Swiss sample of psychiatric inpatients. Perceived danger of smoke exposure (Part a, n = 177) and risk of personally developing a smokerelated illness (Part b, n = 176) are displayed for current smokers (light grey) and non-smokers (dark grey).
study, where manic and bipolar mood disorders had the second highest proportion of smokers, which was 66% as compared with 51% in the US study (Morris et al., 2006). In schizophrenia and other psychotic disorders, as well as in depressive mood disorders, 52% of Geneva patients were smokers, in contrast with rates of 57–62% for schizophrenia and 36% for depression in Morris et al. (Morris et al., 2006). Differences between studies may be due to numerous methodological factors, such as definition of smoking and diagnosis type, e.g. structured diagnostic interview vs. clinical diagnosis. Furthermore, sociodemographic and clinical characteristics of the samples may be invoked. In particular, the sample in Morris et al. was drawn from a large administrative database of the population accessing the public mental health care system in Colorado, whilst patients in the present study had been recently admitted in a Swiss public university hospital, and thus were likely to suffer from more severe, acute and complex forms of psychiatric disorders. Multivariate analysis showed that disorders due to psychoactive substance use, either as a primary diagnosis or as a comorbid condition, were strongly associated with smoking. This is consistent with earlier studies showing that nicotine consumption and use of other substances are frequently observed together (Kalman, Morissette, & George, 2005). A large study reported that alcohol and cocaine dependence clearly influenced the relationship between smoking and psychiatric condition (Wiesbeck et al., 2008). The present study in patients hospitalized with severe psychiatric conditions and frequent comorbidity emphasized that taking into account primary diagnosis, without controlling for comorbid substance use, might be misleading with respect to the relationship between psychopathology and smoking habits. The strong association between smoking and other substance-related disorders might involve similar mechanisms of dependence, as postulated in positive reinforcement models (Glautier, 2004). In the present study, smoking was also associated with manic and bipolar mood disorders. A possible explanation might involve the general activation and behavioural lack of control,
present in severe conditions such as those encountered in hospital settings. Anxiety and hopelessness, as measured with the STAI and BHS scores, were not associated with smoking in the present inpatient sample. The hypothesis of smoking as a mean to regulate negative affects does not seem to be supported here, and this raises the question of the use of these scales or other self-reports such as questionnaires about personality traits to study associations with smoking. These have frequently been performed on non-clinical samples and our results are a reminder of the fact that research in non-clinical populations cannot simply be generalized to patients. Non-clinical samples and psychiatric outpatients might smoke for different reasons than inpatients. The burden of psychopathology and its correlates might also be an important determinant of smoking behaviour in psychiatric inpatients, in contrast with non-clinical samples. The present study indicated that history of suicide attempts was associated with smoking, even after controlling for sociodemographic and diagnostic characteristics. Although this association has been documented in many studies, no clear explanation has yet emerged for the relationship between these two complex behaviours. Hypotheses have been raised with respect to genetic vulnerability and biological factors, specific interactions between smoking and depression, common underlying factors such as personality or family environment, and interactions between risk factors predisposing to suicidality (Bronisch, Hofler, & Lieb, 2008). Debate is ongoing about the role of mental disorders in the association between smoking and suicidal behaviours. A possible model postulates that mental disorders might mediate the effect of smoking on suicidal behaviour, another hypothesis being that smoking and suicidality are both consequences of psychopathology or more remote influencing factors (Kessler et al., 2007). In many studies, lower socioeconomic status has been associated with higher cigarette consumption (Dixon et al., 2007). However, socioeconomic condition is also a confounding factor when studying
I. Keizer et al. / Addictive Behaviors 34 (2009) 815–820
smoking in different populations, because it might play a major part in differences between general and psychiatric subjects. It is a complex variable that encompasses education, occupation, working status and financial resources, among other aspects. In the present study, education was not associated with smoking, whereas patients relying on invalid pension, unemployment benefit or social aid displayed significantly higher proportions of smokers. This issue is important in mental health services that care for patients with psychiatric disorders, who often face unemployment. Working and non-working persons might differ in many aspects that include psychological functioning and distress, as well as relational and social support. Smoking restrictions at the workplace might also contribute to lower the frequency of smoking in occupationally active persons when compared with non-working people (Farkas, Gilpin, White, & Pierce, 2000), and this is not specific to mental illness. In the present sample of hospitalized patients, the general risk related to smoke exposure was similarly perceived in smokers and non-smokers, whereas the risk of personally developing a smokerelated illness was estimated as significantly higher in smokers. These results suggest that psychopathology does not compromise a realistic appreciation of smoking-related health risks, and that patients can be receptive to health-related information and recommendations. Incidentally, these risks might not be fully addressed by mental health professionals since nicotine dependence was never recorded as such in discharge summaries, despite being clearly recognized as a diagnostic category in the ICD-10 classification of mental disorders. Although general restrictive smoking policies have been implemented, the individual problem of the nicotine-dependent patient remains a neglected issue at the psychiatric hospital. Reasons for the present unsatisfactory situation need to be further investigated: is smoking not perceived as a priority when compared with acute psychiatric symptoms; does it seem too difficult to address smoking behaviours during hospitalisation for acute episodes; is it excessively timeconsuming; are there too few professionals with sufficient expertise; are institutional recommendations lacking about the ways to address these issues during hospital stay or at discharge? There ought to be some place for introducing minimal recommendations concerning reduction of tobacco use on the long term and informing about specialized outpatient services. Study limitations are related with sample selection, instruments and cross-sectional design. Firstly, results refer to inpatients interviewed during a severe episode and might not be generalized to less severe psychiatric patients, e.g. patients attending public outpatient services, or to other subgroups in the general population. Secondly, self-reports addressing smoking behaviour might not provide an exact picture in some psychiatric patients, although they have been shown to be sufficiently valid measures of nicotine dependence for example in male drug/alcohol-dependent individuals (Burling & Burling, 2003). Furthermore, we considered current smoking as the main dichotomous dependent variable in the present study, whereas light and heavy smokers might need to be distinguished. Some authors even classified current smokers into 8 subtypes (Furberg et al., 2005). The question about suicide attempts also relied on self-report and might have been perceived as intrusive by some patients. However, it was included among several other questions about psychopathology and many hospital admissions were related with suicidal behaviour or ideation, so that the question was generally well-accepted and bias was unlikely. Clinical diagnoses were retrospectively taken from hospital discharge reports rather than established according to semistructured research interviews, which were incompatible with naturalistic study conditions. Finally, the present cross-sectional study allowed investigating factors associated with smoking but cannot be interpreted with respect to causal relationships between smoking, psychopathology and suicide attempts. In addition, non-observed factors, e.g. life events, might play a major role with respect to cigarette smoking (Boden, Fergusson, & Horwood, 2008).
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5. Conclusion By documenting factors associated with smoking, such as unemployment, concomitant substance-related disorders and history of suicide attempts, the present study in patients hospitalized with severe psychiatric disorders emphasizes that initiatives aimed at smoke reduction in psychiatry need to consider socio-demographic aspects as well as clinical factors. Health risk perceptions appeared largely similar to those in the general population, suggesting that similar interventions might be effective, despite additional complexity associated with specific mental health issues. Hospitalization might provide an opportunity for informing and enhancing motivation to quit smoking. Discharge summaries should include concern about cigarette consumption, information about specialized services and recommendations for outpatient follow-up.
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Addictive Behaviors
Smoking in psychiatric inpatients: Association with working status, diagnosis, comorbid substance abuse and history of suicide attempts Ineke Keizer ⁎, Marianne Gex-Fabry, Ariel Eytan, Gilles Bertschy Division of Adult Psychiatry, Department of Psychiatry, HUG-University Hospitals of Geneva, Site de Belle-Idée, Les Voirons, Ch. du Petit Bel-Air 2, CH-1225 Chêne-Bourg, Switzerland
a r t i c l e Keywords: Psychiatric inpatients Health beliefs Suicide attempt Psychiatric diagnosis Comorbidity Smoking
i n f o
a b s t r a c t The present cross-sectional study investigates the association between smoking and psychopathology (ICD10 diagnosis), history of suicide attempts and socio-demographic characteristics in a sample of 180 adult hospitalized patients. Results confirmed a high frequency of current smokers (63.3%) and heavy smokers with ≥ 20 cigarettes/day (47.4%). Smoking was significantly associated with being on invalid pension, social welfare or unemployed (N 70% of smokers, p = 0.008), a history of suicide attempts (73.2%, p = 0.04) and the primary mental health diagnosis (p = 0.004). A majority of patients (57.8%) presented at least one comorbid condition. Multivariate logistic regression indicated that disorders due to psychoactive substances, either as a primary diagnosis or as a comorbid condition, were significantly associated with smoking, in addition to significant effects of age group, financial resources and history of suicide attempts. Investigation of health beliefs showed that psychopathology did not compromise a realistic appreciation of smoke-related health risks. These results underline the importance of taking into account socio-demographic factors and substance use comorbidity in designing targeted interventions to reduce smoking in psychiatric patients. © 2009 Elsevier Ltd. All rights reserved.
1. Introduction Cigarette smoking is a particularly complex behaviour and its association with mental health has been largely documented. According to large epidemiological studies, smoking frequency in psychiatric patients is about two to three-fold higher than in the general population (Lasser et al., 2000). Furthermore, people with mental illness tend to be heavy smokers (Araya, Gaete, Rojas, Fritsch, & Lewis, 2007; Xian et al., 2007). Whereas approximately 13% of the US population is nicotine-dependent, individuals with a comorbid psychiatric disorder make up 7% of the population yet consume 34% of all cigarettes smoked in the United States (Grant, Hasin, Chou, Stinson, & Dawson, 2004). The reasons for the strong association between smoking and mental health remain unclear. Diverse explanations related to mechanisms inherent to psychopathology have been proposed (e.g. the self-medication hypothesis) and theories about smoking and mood regulating processes have been developed (Carmody, 1992). One hypothesis particularly relevant in patients with mental disorders is that cigarette smoking might alleviate negative mood states such as anxiety and depression (Gregor, Zvolensky, Bernstein, Marshall, & Yartz, 2007). Much research has concentrated on the associations between smoking and psychopathology, and depression in particular. It has ⁎ Corresponding author. Tel.: +41 22 305 47 62; fax: +41 22 305 57 99. E-mail addresses: [email protected] (I. Keizer), [email protected] (M. Gex-Fabry), [email protected] (A. Eytan), [email protected] (G. Bertschy). 0306-4603/$ – see front matter © 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.addbeh.2009.03.018
been shown that the risk for depression increases with the severity of nicotine dependence (John, Meyer, Rumpf, & Hapke, 2004), that smoking in teenagers is a risk factor for the onset of later depressive pathology (Choi, Patten, Gillin, Kaplan, & Pierce, 1997; Horn et al., 2004; Patten, Choi, Vickers, & Pierce, 2001), and that the association between depressive symptoms and smoking can be generalized across diverse ethnic groups (Nezami et al., 2005). Elevated risk for smoking has been reported in patients with schizophrenia (Dervaux & Laqueille, 2008), bipolar disorders (Wilens et al., 2008), alcohol or substance use, and anxiety disorders (Cuijpers, Smit, ten Have, & de Graaf, 2007; Morissette, Tull, Gulliver, Kamholz, & Zimering, 2007). Smoking is also associated with sleep disorders and suicidality. Smoking and suicides or suicide attempts were associated in many studies, both in community samples (Breslau, Schultz, Johnson, Peterson, & Davis, 2005) and psychiatric populations (Malone et al., 2003; Ostacher et al., 2006). Smokers obviously do not all present psychopathology, and other risk factors have been investigated, such as socio-demographic status (Agrawal, Sartor, Pergadia, Huizink, & Lynskey, 2008), biological and genetic factors (Bierut et al., 2007), social influences (Killen et al., 2004), personality factors (Cloninger, Svrakic, & Przybeck, 1993; Enns & Cox, 1997; Zuckerman, Ball, & Black, 1990), coping mechanisms (Chorpita & Barlow, 1998; Siqueira, Rolnitzky, & Rickert, 2001; Vickers et al., 2003) and health risk perception (Murphy-Hoefer, Alder, & Higbee, 2004). The general objective of the present study was to investigate tobacco consumption in a sample of psychiatric inpatients in relation with recently introduced smoking restrictions, as reported in an
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earlier publication (Keizer, Descloux, & Eytan, 2009). The present article focuses on the relevance of different factors known to influence smoking behaviour, such as socio-demographic characteristics (gender, age and socio-economic status), psychopathology (main diagnosis, comorbidity and lifetime suicide attempts) and negative affects (anxiety and hopelessness levels). As reality perception can be altered in mental health patients, we also investigated health-related beliefs about smoking, such as risk perception and sense of personal vulnerability (Rodriguez, Romer, & Audrain-McGovern, 2007). Given the burden of smoking in psychiatric patients, it is crucial to gain understanding of the most important factors influencing cigarette consumption. If socio-economic status showed to be a significant factor, strategies reinforcing socio-education might be used in the first place; whereas if negative affects were preponderant, reduction of these symptoms might be most important to begin with. 2. Methods 2.1. Setting and procedure The present cross-sectional study took place between October 2005 and January 2006 in a public psychiatric university hospital in Geneva, Switzerland which provides care to patients aged 18–65 with acute psychopathology. All newly admitted inpatients were approached individually by a member of the research team and invited to participate if compatible with clinical status, as evaluated by the patient's principal caregivers (physician and nurse). The research protocol was approved by the Ethics Committee of the Department of Psychiatry. All participants provided written informed consent before being enrolled. Sociodemographic and clinical data, as well as smoking characteristics were collected during a single interview. Patients were then administered several self-rated instruments that they filled in the presence of a research team member not involved in patient therapy, and who could assist participants in case they encountered difficulties with the questionnaires. Of 183 consecutively admitted patients who agreed to participate, 3 subjects were excluded because of missing sociodemographic and smoking-related data. Analyzed sample thus included 180 patients. 2.2. Measures
Comorbid disorder due to psychoactive substance use was considered present if patients had at least one diagnosis related to either alcohol or other substances, except tobacco. 2.2.3. Negative affects Negative affects were assessed using the State and Trait Anxiety Inventory (STAI, Spielberger, 1983) and the Beck Hopelessness Scale (Beck, Weissman, Lester, & Trexler, 1974), French version (Bouvard, Charles, Guerin, Aimard, & Cottraux, 1992). 2.3. Data analysis Associations between smoking status (current smoker yes vs. no) and sociodemographic and clinical variables were first examined using chi-square tests for proportions. Group comparison proceeded with the Mann–Whitney U-test and the Kruskal–Wallis test for ordinal scores. A multivariate logistic regression model was then used to investigate the combined influence of different factors on current smoking (10 occasional smokers were excluded). Adjusted odds ratios (OR) and 95% confidence intervals (95% CI) were reported for all independent variables, that entered the model simultaneously. Statistical significance was set at 0.05. Analysis was performed using SPSS, version 15 (SPSS Inc., Chicago IL, USA). 3. Results 3.1. Tobacco use Distribution of patients (n = 180) according to nicotine use was as follows: 63.3% (n = 114) were current smokers, 5.6% (n = 10) occasional smokers, 20.6% (n = 37) never-smokers and 10.6% (n = 19) former smokers. Heavy smokers were 47.4% (n = 54). 3.2. Sociodemographics and smoking status Sociodemographic characteristics are summarized in Table 1. The proportion of current smokers did not significantly differ according to Table 1 Sociodemographic characteristics and smoking status in a Swiss sample of psychiatric inpatients (n = 180). Current smokers
2.2.1. Tobacco use and smoking-related health beliefs Smoking intensity was defined as the mean number of cigarettes/ day during the week before hospitalisation. Smoking status was defined as follows: never smoker (b100 cigarettes in a lifetime), current smoker (smoking during the survey and at least 1 cigarette/day during 6 months), former smoker (not smoking during the survey, at least 100 cigarettes in a lifetime and at least 1 cigarette/day during 6 months), present and former occasional smokers (at least 100 cigarettes in a lifetime and never smoked every day for 6 months or more). Smokers consuming N20 cigarettes daily were considered as heavy smokers. Smoking-related health beliefs were investigated with the following questions, rated on a 5-point Likert scale: “Do you think that exposure to smoke is dangerous for health?” (risk perception, 1 = definitely dangerous to 5 = not dangerous at all); “Do you think that during your lifetime you might develop an illness due to the effects of smoke/tobacco?” (personal vulnerability, 1 = yes, absolutely to 5 = no, definitely not). 2.2.2. Diagnosis and suicide attempts During the research interview, a question about lifetime suicide attempts was included: “In your whole life, how many suicide attempts have you made?” Main psychiatric diagnosis according to ICD-10 criteria (World Health Organization, 1992) and comorbidity were recorded from the medical charts (discharge summary).
Gender Female Male Age ≤ 30 31–50 N 50 Education Compulsory basic or less Some secondary or professional education Secondary or professional degree University or similar degree Financial resources Work Family Invalid pension Unemployment or social aid History of suicide attempta No Yes Primary diagnosis Disorders due to psychoactive substances Schizophrenia and psychotic disorders Mood disorders: bipolar and mania Mood disorders: unipolar depression Other diagnoses a
Missing data for 7 patients (n = 173).
N
%
%
83 97
46.1 53.9
61.4 64.9
41 97 42
22.8 53.9 23.3
63.4 67.0 54.8
73 57 32 18
40.6 31.7 17.8 10.0
65.8 63.2 68.8 44.4
40 19 69 52
22.2 10.6 38.3 28.9
47.5 42.1 71.0 73.1
91 82
52.6 47.4
57.1 73.2
33 54 29 44 20
18.3 30.0 16.1 24.5 11.1
87.9 51.9 65.5 52.3 75.0
p-value 0.65
0.39
0.34
0.008
0.04
0.004
I. Keizer et al. / Addictive Behaviors 34 (2009) 815–820
gender and age group. No significant difference was found with respect to education, despite a lower proportion of smokers among a minority of patients with university or similar degrees. Financial resources and working status were strongly and significantly associated with nicotine use, with higher proportions of smokers among patients with invalid pension (71.0%) and unemployment or social aid (73.1%) than in patients working (47.5%) or depending on family resources (42.1%). 3.3. Psychopathology and smoking status Distribution of primary diagnoses is provided in Table 1. Substance use disorders included diagnoses related to alcohol (n = 20, 60.6%) and other substances (n = 13, 39.4%). No tobacco-related diagnosis was reported in the discharge summaries. The category “other diagnoses” included stress-related disorders, personality and behavioural disorders, as well as other infrequent diagnoses. The proportion of smokers significantly differed across diagnostic categories, with substance use disorders characterized by the highest (87.9%) and psychotic disorders by the lowest proportions of smokers (51.9%). Nearly half the sample (47.4%) reported at least one lifetime suicide attempt, and the proportion of smokers was significantly higher in these patients than in those without any history of suicide attempt (Table 1). Comorbidity was frequent since 57.8% (n = 104) of the sample presented more than one psychiatric diagnoses. Of these, patients with substances as main diagnoses formed 20.2% (n = 21), those with other main diagnoses and presenting substance-related comorbidity represented 47.1% (n = 49) and finally patients with psychiatric comorbidity but no substance-related diagnosis were 32.7% (n = 34). The association between smoking status and substance use disorders was analyzed by comparing patients with a primary diagnosis of substance-related disorders (n = 33, 18.3%), with substance-related comorbidity (n = 49, 27.2%) and without any substance-related disorder (n = 98, 54.4%). Proportions of current smokers were 87.9%, 83.7% and 44.9%, respectively (chi-square test, df = 2, p b 0.001). 3.4. Anxiety, hopelessness and smoking status Smoking status was not significantly associated with negative affects, as measured with the STAI and BHS rating scales during hospital stay (median STAI scores 47 in current smokers and 41 in non-smokers, Mann–Whitney U-test p = 0.49; median BHS scores 6 and 5, p = 0.59). 3.5. Factors associated with smoking: logistic regression model Factors associated with current smoking were further investigated by entering them simultaneously into a logistic regression model (Table 2). Sociodemographic variables significantly associated with smoking included being younger than 50 years old and on any form of financial aid. In addition, substance-related disorder, either as a primary diagnosis (OR = 41.7, p b 0.0001) or as a comorbid condition (OR = 11.8, p b 0.0001), was a major factor associated with smoking. A significantly elevated proportion of smokers was also observed in bipolar disorders when compared with schizophrenia and other psychotic disorders, considered as the reference diagnostic category (OR = 4.9, p = 0.02). Interestingly, patients who reported at least one lifetime suicide attempt displayed an increased risk of being current smokers, even after taking into account sociodemographic and diagnostic variables (OR = 4.0, p = 0.005). Including STAI and BHS scores did not improve the model further (not shown). 3.6. Smoking-related health beliefs and tobacco use Most patients (84.2%, n = 149 of 177 valid answers) rated danger of exposure to smoke at the 2 highest levels: definitely dangerous (68.4%,
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Table 2 Factors associated with current smoking in a Swiss sample of psychiatric inpatients (n = 163a): multivariate logistic regression model. Adjusted ORb 95% CI Gender Female 0.9 Male 1 Age ≤ 30 3.6 31–50 4.2 N 50 1 Education Compulsory basic or less 1.9 Some secondary or professional education 3.4 Secondary or professional degree 2.3 University or similar degree 1 Financial resources Work or family 1 Invalid pension, unemployment or social aid 3.0 History of suicide attempt No 1 Yes 4.0 Primary diagnosis Disorders due to psychoactive substances 41.7 Schizophrenia and psychotic disorders 1 Mood disorders: bipolar and mania 4.9 Mood disorders: unipolar depression 1.5 Other diagnoses 1.2 Comorbid disorders due to psychoactive substancesc No 1 Yes 11.8
p-value
(0.4–2.3)
0.90
(0.8–15.6) (1.4–12.7)
0.09 0.01
(0.4–9.3) (0.7–16.3) (0.5–12.1)
0.45 0.13 0.32
(1.2–7.6)
0.02
(1.5–10.3)
0.005
(7.9–220.7) b0.0001 (1.3–19.3) (0.5–4.7) (0.2–5.9)
0.02 0.50 0.86
(3.6–39.2)
b0.0001
a
From the total sample (n = 180), 17 patients were excluded (10 occasional smokers and 7 patients with missing data about suicide attempts). b An odds ratio (OR) of 1 indicates the reference category. c At least one diagnosis related to alcohol or other substances (except tobacco), in addition to a primary diagnosis not related to substance use.
n = 121) or very probably dangerous (15.8%, n = 28). Perceived risk of personally developing an illness due to tobacco was more uniformly distributed along the 5 levels (n = 176 valid answers). Fig. 1 illustrates the comparison between current smokers and non smokers (10 occasional smokers were excluded). Groups did not significantly differ with respect to the perceived danger of smoke exposure. However, the risk of developing a smoke-related illness was perceived as significantly higher in smokers than in non-smokers (Mann–Whitney test, p b 0.0001). When taking smokers and non-smokers together, perceived danger of exposure to smoke did not differ between the 5 diagnostic groups, whereas perceived personal vulnerability was lowest among psychotic/schizophrenic patients (Kruskal–Wallis test, p = 0.05). Among smokers, danger associated with smoke was rated the lowest by psychotic/schizophrenic patients and the highest by substance abuse patients, but the difference across diagnostic categories did not reach statistical significance (Kruskal–Wallis test, p = 0.07). As for the risk of personally developing a tobacco-related illness, it did not significantly differ across groups, although psychotic/schizophrenic patients rated such a risk the lowest. 4. Discussion The present study confirmed the very high proportion of smokers among persons with mental illness. Percentages of smokers in different diagnostic categories were in line with published prevalence estimates of tobacco use in psychiatric patients. The proportion of smokers was highest in substance use disorders in our Swiss study (88%) as well as the US study by Morris et al (61–66%) (Morris, Giese, Turnbull, Dickinson, & Johnson-Nagel, 2006) and the data reported by Schneider et al (75%–90%) (Schneider et al., 2005). Smoking has frequently been reported as more prevalent among schizophrenic patients than in mood disorders (Diwan, Castine, Pomerleau, MeadorWoodruff, & Dalack, 1998), but this was not the case in the present
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Fig. 1. Smoking-related health beliefs in a Swiss sample of psychiatric inpatients. Perceived danger of smoke exposure (Part a, n = 177) and risk of personally developing a smokerelated illness (Part b, n = 176) are displayed for current smokers (light grey) and non-smokers (dark grey).
study, where manic and bipolar mood disorders had the second highest proportion of smokers, which was 66% as compared with 51% in the US study (Morris et al., 2006). In schizophrenia and other psychotic disorders, as well as in depressive mood disorders, 52% of Geneva patients were smokers, in contrast with rates of 57–62% for schizophrenia and 36% for depression in Morris et al. (Morris et al., 2006). Differences between studies may be due to numerous methodological factors, such as definition of smoking and diagnosis type, e.g. structured diagnostic interview vs. clinical diagnosis. Furthermore, sociodemographic and clinical characteristics of the samples may be invoked. In particular, the sample in Morris et al. was drawn from a large administrative database of the population accessing the public mental health care system in Colorado, whilst patients in the present study had been recently admitted in a Swiss public university hospital, and thus were likely to suffer from more severe, acute and complex forms of psychiatric disorders. Multivariate analysis showed that disorders due to psychoactive substance use, either as a primary diagnosis or as a comorbid condition, were strongly associated with smoking. This is consistent with earlier studies showing that nicotine consumption and use of other substances are frequently observed together (Kalman, Morissette, & George, 2005). A large study reported that alcohol and cocaine dependence clearly influenced the relationship between smoking and psychiatric condition (Wiesbeck et al., 2008). The present study in patients hospitalized with severe psychiatric conditions and frequent comorbidity emphasized that taking into account primary diagnosis, without controlling for comorbid substance use, might be misleading with respect to the relationship between psychopathology and smoking habits. The strong association between smoking and other substance-related disorders might involve similar mechanisms of dependence, as postulated in positive reinforcement models (Glautier, 2004). In the present study, smoking was also associated with manic and bipolar mood disorders. A possible explanation might involve the general activation and behavioural lack of control,
present in severe conditions such as those encountered in hospital settings. Anxiety and hopelessness, as measured with the STAI and BHS scores, were not associated with smoking in the present inpatient sample. The hypothesis of smoking as a mean to regulate negative affects does not seem to be supported here, and this raises the question of the use of these scales or other self-reports such as questionnaires about personality traits to study associations with smoking. These have frequently been performed on non-clinical samples and our results are a reminder of the fact that research in non-clinical populations cannot simply be generalized to patients. Non-clinical samples and psychiatric outpatients might smoke for different reasons than inpatients. The burden of psychopathology and its correlates might also be an important determinant of smoking behaviour in psychiatric inpatients, in contrast with non-clinical samples. The present study indicated that history of suicide attempts was associated with smoking, even after controlling for sociodemographic and diagnostic characteristics. Although this association has been documented in many studies, no clear explanation has yet emerged for the relationship between these two complex behaviours. Hypotheses have been raised with respect to genetic vulnerability and biological factors, specific interactions between smoking and depression, common underlying factors such as personality or family environment, and interactions between risk factors predisposing to suicidality (Bronisch, Hofler, & Lieb, 2008). Debate is ongoing about the role of mental disorders in the association between smoking and suicidal behaviours. A possible model postulates that mental disorders might mediate the effect of smoking on suicidal behaviour, another hypothesis being that smoking and suicidality are both consequences of psychopathology or more remote influencing factors (Kessler et al., 2007). In many studies, lower socioeconomic status has been associated with higher cigarette consumption (Dixon et al., 2007). However, socioeconomic condition is also a confounding factor when studying
I. Keizer et al. / Addictive Behaviors 34 (2009) 815–820
smoking in different populations, because it might play a major part in differences between general and psychiatric subjects. It is a complex variable that encompasses education, occupation, working status and financial resources, among other aspects. In the present study, education was not associated with smoking, whereas patients relying on invalid pension, unemployment benefit or social aid displayed significantly higher proportions of smokers. This issue is important in mental health services that care for patients with psychiatric disorders, who often face unemployment. Working and non-working persons might differ in many aspects that include psychological functioning and distress, as well as relational and social support. Smoking restrictions at the workplace might also contribute to lower the frequency of smoking in occupationally active persons when compared with non-working people (Farkas, Gilpin, White, & Pierce, 2000), and this is not specific to mental illness. In the present sample of hospitalized patients, the general risk related to smoke exposure was similarly perceived in smokers and non-smokers, whereas the risk of personally developing a smokerelated illness was estimated as significantly higher in smokers. These results suggest that psychopathology does not compromise a realistic appreciation of smoking-related health risks, and that patients can be receptive to health-related information and recommendations. Incidentally, these risks might not be fully addressed by mental health professionals since nicotine dependence was never recorded as such in discharge summaries, despite being clearly recognized as a diagnostic category in the ICD-10 classification of mental disorders. Although general restrictive smoking policies have been implemented, the individual problem of the nicotine-dependent patient remains a neglected issue at the psychiatric hospital. Reasons for the present unsatisfactory situation need to be further investigated: is smoking not perceived as a priority when compared with acute psychiatric symptoms; does it seem too difficult to address smoking behaviours during hospitalisation for acute episodes; is it excessively timeconsuming; are there too few professionals with sufficient expertise; are institutional recommendations lacking about the ways to address these issues during hospital stay or at discharge? There ought to be some place for introducing minimal recommendations concerning reduction of tobacco use on the long term and informing about specialized outpatient services. Study limitations are related with sample selection, instruments and cross-sectional design. Firstly, results refer to inpatients interviewed during a severe episode and might not be generalized to less severe psychiatric patients, e.g. patients attending public outpatient services, or to other subgroups in the general population. Secondly, self-reports addressing smoking behaviour might not provide an exact picture in some psychiatric patients, although they have been shown to be sufficiently valid measures of nicotine dependence for example in male drug/alcohol-dependent individuals (Burling & Burling, 2003). Furthermore, we considered current smoking as the main dichotomous dependent variable in the present study, whereas light and heavy smokers might need to be distinguished. Some authors even classified current smokers into 8 subtypes (Furberg et al., 2005). The question about suicide attempts also relied on self-report and might have been perceived as intrusive by some patients. However, it was included among several other questions about psychopathology and many hospital admissions were related with suicidal behaviour or ideation, so that the question was generally well-accepted and bias was unlikely. Clinical diagnoses were retrospectively taken from hospital discharge reports rather than established according to semistructured research interviews, which were incompatible with naturalistic study conditions. Finally, the present cross-sectional study allowed investigating factors associated with smoking but cannot be interpreted with respect to causal relationships between smoking, psychopathology and suicide attempts. In addition, non-observed factors, e.g. life events, might play a major role with respect to cigarette smoking (Boden, Fergusson, & Horwood, 2008).
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5. Conclusion By documenting factors associated with smoking, such as unemployment, concomitant substance-related disorders and history of suicide attempts, the present study in patients hospitalized with severe psychiatric disorders emphasizes that initiatives aimed at smoke reduction in psychiatry need to consider socio-demographic aspects as well as clinical factors. Health risk perceptions appeared largely similar to those in the general population, suggesting that similar interventions might be effective, despite additional complexity associated with specific mental health issues. Hospitalization might provide an opportunity for informing and enhancing motivation to quit smoking. Discharge summaries should include concern about cigarette consumption, information about specialized services and recommendations for outpatient follow-up.
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