Context Studies of selected groups of persons with mental illness, such as those
who are institutionalized or seen in mental health clinics, have reported
rates of smoking to be higher than in persons without mental illness. However,
recent population-based, nationally representative data are lacking.
Objective To assess rates of smoking and tobacco cessation in adults, with and
without mental illness.
Design, Setting, and Participants Analysis of data on 4411 respondents aged 15 to 54 years from the National
Comorbidity Survey, a nationally representative multistage probability survey
conducted from 1991 to 1992.
Main Outcome Measures Rates of smoking and tobacco cessation according to the number and type
of psychiatric diagnoses, assessed by a modified version of the Composite
International Diagnostic Interview.
Results Current smoking rates for respondents with no mental illness, lifetime
mental illness, and past-month mental illness were 22.5%, 34.8%, and 41.0%,
respectively. Lifetime smoking rates were 39.1%, 55.3%, and 59.0%, respectively
(P<.001 for all comparisons). Smokers with any
history of mental illness had a self-reported quit rate of 37.1% (P = .04), and smokers with past-month mental illness had a self-reported
quit rate of 30.5% (P<.001) compared with smokers
without mental illness (42.5%). Odds ratios for current and lifetime smoking
in respondents with mental illness in the past month vs respondents without
mental illness, adjusted for age, sex, and region of the country, were 2.7
(95% confidence interval [CI], 2.3-3.1) and 2.7 (95% CI, 2.4-3.2), respectively.
Persons with a mental disorder in the past month consumed approximately 44.3%
of cigarettes smoked by this nationally representative sample.
Conclusions Persons with mental illness are about twice as likely to smoke as other
persons but have substantial quit rates.
Smoking is the leading preventable cause of death in the United States.1 In an effort to target public health interventions,
recent studies have focused on smoking in distinct populations, such as pregnant
women2 and adolescents.3
We believe those with mental illness are another group that merits special
attention.
Previous studies have found high smoking rates among selected populations
of persons with mental illness, such as psychiatric outpatients4
and patients in a state mental hospital.5 Others
have found elevated smoking rates among patients with specific diagnoses,
such as bipolar illness, depression, schizophrenia, and panic disorder.6-11
Persons with mental illness may encounter greater difficulty with tobacco
cessation.4,12,13
However, no recent study has analyzed rates of smoking and quit rates across
the spectrum of psychiatric diagnoses in a nationally representative sample.
We hypothesized that persons with mental illness smoke at higher rates than
persons without mental illness, have lower quit rates, and comprise a large
proportion of the US tobacco market.
We used population-based data from the National Comorbidity Survey14 (NCS) to examine the association between type and
severity of mental illness and the likelihood of smoking and subsequent cessation.
The NCS differed from previous studies because it was the first to administer
a structured psychiatric interview to a nationally representative sample.15 Furthermore, the NCS was specifically designed to
examine both substance-use and nonsubstance-use psychiatric disorders.
The NCS was a congressionally mandated study of the prevalence of psychiatric
disorders in the United States.15 Administered
between September 1990 and February 1992, the survey used a stratified, multistage
probability sample of persons aged 15 to 54 years in the noninstitutionalized
civilian population. The data were released for public use in 1998. The study
design allowed for estimation of the national prevalence of mental illness
as defined by the Diagnostic and Statistical Manual of Mental
Disorders, Third Edition, Revised (DSM-III-R).16
The NCS surveyed 8098 persons. Questions regarding tobacco use were
asked of the 4411 respondents interviewed during the latter half of the survey
(1991-1992). Specially trained staff from the Survey Research Center at the
University of Michigan administered a modified version of the Composite International
Diagnostic Interview (CIDI).17 The CIDI is
a well-validated, structured diagnostic interview based on the Diagnostic
Interview Schedule (DIS), which was used in the Epidemiologic Catchment Area
Study.18 In the NCS, the overall response rate
was 82.4%; nonrespondents resembled respondents in age and sex, which are
the only demographic variables available for all nonrespondents. A supplemental
survey was administered to a random sample of nonrespondents, who were found
to have elevated rates of both lifetime and current psychiatric disorders.
The data were weighted to account for sample design (ie, probabilities of
selection among households) and for nonresponse using information from the
supplemental survey. An additional weight was used to extrapolate the data
to the national population by age, sex, race or ethnicity, marital status,
educational level, living arrangements, region, and urbanicity (Table 1).
Definitions of Mental Illness and Tobacco Use
We defined respondents as lifetime smokers if they answered affirmatively
to the question, "Have you ever smoked daily for a month or more?" We defined
current smokers as those who responded, "in the past month" when they were
asked, "When was the last time you smoked fairly regularly—in the past
month, past six months, past year, or more than a year ago?" We defined the
quit rate as the proportion of lifetime smokers who were not current smokers.
Because this definition of quit rate differs from that used in other studies,
we also analyzed the data with a more conservative definition of quit rate:
the proportion of lifetime smokers who had stopped smoking for more than a
year. This analysis did not significantly change our findings; hence, we used
the former definition of quit rate. The NCS did not ascertain the total lifetime
consumption of tobacco or the current number of cigarettes smoked. However,
respondents were asked, "How many cigarettes did you smoke per day during
the period when you were smoking most?" We defined this number as peak consumption. We considered persons whose peak consumption exceeded
24 cigarettes per day to be heavy smokers. We defined moderate and light smokers
as those whose peak consumption was 24 cigarettes per day or less. We did
not analyze cigar or pipe smoking.
We defined mental illness as major depression, bipolar disorder, dysthymia,
panic disorder, agoraphobia, social phobia, simple phobia, generalized anxiety
disorder, alcohol abuse, alcohol dependence, drug abuse, drug dependence,
antisocial personality, conduct disorder, or nonaffective psychosis. The latter
includes schizophrenia, schizophreniform disorder, schizoaffective disorder,
delusional disorder, and atypical psychosis.
We analyzed persons with and without any mental illness at any time
in their lives (lifetime mental illness), persons with active mental illness
in the past month (whom we define as "the mentally ill"), and persons with
each of the individual DSM-III-R diagnoses and with
multiple DSM-III-R diagnoses. In addition, we compared
smoking rates in respondents with current alcohol and drug use to those of
respondents who had been abstinent for at least 1 year.
We also estimated the proportion of all cigarettes smoked in the United
States that were consumed by persons with mental illness via the following
calculation: (M) (C1) / {(N) (C2) + (M) (C1)},
where M = the number of current smokers with mental illness in the past month;
C1= the mean peak consumption of cigarettes per day by current
smokers with mental illness in the past month; N = the number of current smokers
without mental illness in the past month, which includes persons with and
without lifetime mental illness; and C2= the mean peak consumption
of cigarettes per day by current smokers without mental illness in the past
month. For both persons with and without mental illness, we assumed that the
peak number of cigarettes consumed correlated with the current number of cigarettes
consumed.
We used the SAS computer statistical package (Version 7; SAS Institute,
Cary, NC). We used the χ2 test to compare differences between
groups in the proportion of persons who smoked, and the Mantel Haenszel χ2 test for trend to compare smoking rates with the number of lifetime DSM-III-R diagnoses. We used logistic regression to analyze
mental illness as a predictor of smoking, while controlling for sex, age,
and region of the United States.
The demographic characteristics of persons with a lifetime history of
mental illness and persons with mental illness in the past month are shown
in Table 1. The population prevalence
of current smoking was 28.5%, while the lifetime prevalence was 47.1%. Forty-one
percent of persons who reported having mental illness in the past month were
current smokers and represented 40.6% of all current smokers in the United
States. Respondents with a history of mental illness had elevated smoking
rates, and smoking rates increased further in respondents with mental illness
in the past month (Table 2). Current
smokers without mental illness in the past month (n = 746) had a mean peak
consumption of 22.6 cigarettes per day vs 26.2 in those with mental illness
in the past month (n = 511). We estimated that persons with mental illness
comprised 44.3% of the US tobacco market.
The relationship between smoking and mental illness persisted when we
controlled for age, sex, and geographic region using logistic regression (details
available on request). Compared with respondents without mental illness, those
with any history of mental illness were significantly more likely to be lifetime
smokers (odds ratio [OR], 2.1; 95% confidence interval [CI], 1.9-2.4) or current
smokers (OR, 1.9; 95% CI, 1.7-2.2). This relationship was stronger among respondents
with mental illness in the past month (OR, 2.7; 95% CI, 2.3-3.1 for current
smokers; OR, 2.7; 95% CI, 2.4-3.2 for lifetime smokers).
Persons with multiple lifetime psychiatric diagnoses had higher rates
of smoking and smoked more heavily than persons with only 1 DSM-III-R diagnosis (P<.001, Figure 1). Heavy smoking was rare in persons with no history of
mental illness; only 10% of such persons were heavy smokers. We observed a
dose-response relationship between the number of lifetime psychiatric diagnoses
and smoking rates. Quit rates were lower in smokers with mental illness in
the past month (30.5%, P<.0001) and in smokers
with any lifetime history of mental illness (37.1%, P
= .04) compared with smokers without mental illness (42.5%).
Table 3 and Table 4 show smoking rates according to psychiatric diagnosis (lifetime
and in the past month), as well as the corresponding quit rates. The quit
rates of respondents who were abstinent from alcohol (41.5%) or drugs (39.0%)
were similar to the quit rate of persons with no mental illness history (42.5%).
Due to small numbers in some diagnostic categories, differences between individual
diagnoses should be interpreted cautiously.
We found that persons with mental illness are about twice as likely
to smoke as other persons, a finding consistent with previous studies.4,6,19,20 Population-based
data collected in the early 1980s by the Epidemiologic Catchment Area Study
showed that persons with major depression, dysthymia, agoraphobia, and alcoholism
were 1.6 to 4.7 times more likely to have ever smoked than subjects without
mental illness.6 However, we observed that
more than a third of patients with a history of mental illness had quit smoking
by the time of the survey. The quit rate in the Epidemiologic Catchment Area
Study was lower than this and was only determined for persons with major depression.
Our finding that persons abstinent from alcohol had quit rates equal to those
of persons without mental illness confirms previous findings.21
However, our finding that persons abstinent from drugs also had quit rates
equal to those of persons without mental illness is a novel one.
Our study is based on data collected from 1991 to 1992 and released
for public use in 1998, the most recent national data available on mental
illness and smoking. Given the minimal decline in the prevalence of smoking
in the United States over the past decade, from 26.5% in 1992 to 24.7% in
1997,22 our findings are still pertinent. Similarly,
we doubt that the prevalence of mental illness has decreased dramatically
since 1992. In the NCS, almost half of the respondents had experienced a DSM-III-R–defined mental illness in their lifetime,
and 28% had experienced mental illness in the past month. These numbers appear
high because the definition of mental illness in the NCS (the standard definition
used by most psychiatrists in the United States) encompassed a broad spectrum
of severity, from simple phobia to schizophrenia.
Mentally-ill cigarette smokers, like other smokers, are at high risk
of smoking-related deaths. Persons with major depression, alcohol disorders,
and schizophrenia have high mortality rates from vascular disease and cancer.23 Smoking also complicates the treatment of some mental
disorders by decreasing blood levels of neuroleptics.24
Thus, smokers may require larger doses to achieve therapeutic effect, and
thereby run an increased risk of adverse effects.13,25,26
Some26,27 but not all28,29 studies have found that smokers experience
more tardive dyskinesia than nonsmokers.
Why do the mentally ill smoke more? Some have suggested that such persons
use cigarettes as a means of self-medication of psychiatric symptoms.13,30 This theory implicitly assumes that
mental illness causes smoking. However, recent findings9,10,31
raise questions about the direction of causality. In a study of childhood
and adolescent depression,31 antecedent smoking
was associated with an increased risk of depression, but not vice-versa. Similarly,
current smokers have an elevated risk of first-time occurrence of panic attacks
relative to nonsmokers or former smokers,10
and smoking may increase the risk of certain anxiety disorders during late
adolescence and early adulthood.32 Lastly,
a recent study9 found that smoking preceded
the onset of schizophrenia in the majority of persons with schizophrenia who
smoked.
Internal documents from the tobacco industry suggest that the industry
has identified psychologically vulnerable persons as a part of their tobacco
market. In the 1981 Segmentation Study,33 market
researchers at R. J. Reynolds Tobacco Co described smokers who smoked for
"mood enhancement" and "positive stimulation." This marketing study implied
that smokers used nicotine for depressive symptoms, stating that smoking "helps
perk you up" and "helps you think out problems." The authors also identified
the role of smoking in "anxiety relief," stating that smoking helped people
"gain self-control," "calm down," and "cope with stress." While studies have
shown that cigarette advertising and promotion influence smoking in adolescents,34 no studies have examined the effect of cigarette
advertising on the mentally ill.
Extrapolating our results to the US population, we estimate that persons
with a diagnosable mental disorder in the past month consume nearly half of
all cigarettes smoked in the United States. Our findings emphasize the importance
of focusing smoking prevention and cessation efforts on the mentally ill.
Individual clinicians' efforts in this regard need to be coupled with broader
public policy interventions. Increases in tobacco taxes and antismoking media
campaigns have been shown to reduce cigarette sales and consumption,35-38 particularly
in lower-income smokers.37 While data are not
available on the impact of tobacco taxation on the subpopulation of smokers
with mental illness, we believe that taxation might be an effective smoking
deterrent in this group, which tends to be at a low-income level. Tax revenues
could then be used to fund smoking cessation and other programs for persons
with mental illness and to support counter-advertising campaigns.
Mental illness carries a unique burden of suffering—an "inexplicable
agony"—according to one eloquent victim.39
The mentally ill also carry the burden of nearly half of all US tobacco consumption.
However, the fact that smokers with mental illness are able to quit should
offer hope.
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