PSYCHIATRIC COFACTORS FOR SMOKING

As intensifying public health campaigns and workplace smoking restrictions have led many casual or "discretionary" smokers to stop smoking, evidence is mounting that individuals who continue to smoke are more likely than nonsmokers to have subclinical or diagnosable psychopathology, or even a history of psychopathology, that may make smoking more rewarding or increase the difficulty of quitting (Glassman, 1993; Pomerleau, 1997). Significantly higher smoking rates were reported by Hughes and colleagues (1986) in a sample of 217 psychiatric outpatients in comparison with controls, a finding that has subsequently been replicated in numerous reports. The best documented of these smoking-linked co-morbid conditions is depression, an association that persists even after alcoholism and anxiety disorders are factored out (Glassman, 1993). Other conditions known or suspected to be over-represented in smokers, and vice versa, include bulimia, binge eating, and body image disturbances (Weiss & Ebert, 1983; Killen et al., 1986; Bulik et al., 1992; Krahn et al., 1992; Pomerleau & Krahn, 1993), anxiety (Breslau et al., 1991), attention deficit-hyperactivity disorder (Borland & Heckman, 1976; Hartsough & Lambert, 1987; Barkley,1990; Pomerleau et al., 1995), and schizophrenia (O'Farrell et al. 1983; Masterson & O'Shea, 1984; Goff et al., 1992), as well as alcohol and other drug use (Istvan & Matarazzo, 1984; Bobo, 1989; Breslau et al., 1991). These conditions constitute major public health problems in their own right, taking a large toll in terms of lost productivity and diminished quality of life. To the extent that they are associated with an increased likelihood of smoking or greater difficulty in quitting, their health consequences are magnified.

Summary

1) Considerable evidence has been accumulated documenting the overrepresentation of diagnosable or sub-clinical psychiatric disorders among smokers, and vice versa. The best documented of these cofactors is depression. Others include anxiety disorders, eating disorders such as binge-eating disorder and bulimia nervosa, attention deficit disorder, schizophrenia, and alcoholism. As the prevalence of smoking declines, the association of smoking and psychiatric disorders is likely to become even stronger.

2) Although the epidemiological association of smoking with several psychiatric disorders has been well documented, the mechanisms underlying this association are not fully understood. It is possible that in people with a history of relevant psychiatric disorders, smoking cessation "unmasks" behavioral or cognitive deficits that, once expressed, are sustained well beyond the usual manifestations of nicotine withdrawal. Thus, dosing with nicotine in such individuals would be expected to relieve both nicotine withdrawal and psychiatric symptomatology. Alternatively, smoking may predispose to psychiatric disorders; or the relationship between smoking and other drug use may represent common addictive processes and/or drug interactions that are pleasurable or reinforcing. Since depression is frequently co-morbid with all of the other conditions described, the possible mediating role of depression in the link between these conditions and smoking must also be considered.

3) Although treating the cofactor in conjunction with or prior to smoking cessation has face validity, it is not known whether such a strategy will facilitate smoking cessation, nor what sequence of interventions is most likely to produce favorable results.

4) Smoking may enable people who might otherwise require psychiatric intervention to manage symptomatology or suboptimal functioning successfully. Research is therefore needed to help in identifying individuals who, though not symptomatic while smoking, may be vulnerable to the emergence of depressive episodes, disordered eating, or other psychopathology following cessation.

References

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