Article
Prevalence of smoking in psychiatric patients

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Abstract

Compelling evidence that tobacco-smoking is a form of drug addiction exists. The aim of this study is to determine the following: (1) prevalence of tobacco-smoking and of nicotine dependence in French psychiatric patients; (2) rates and patterns of tobacco smoking and of nicotine dependence according to diagnosis; (3) relationship between current smoking status and antipsychotic medications; and (4) relationship between cigarette smoking and neurological side effects induced by neuroleptics. A population of 711 psychiatric in- and outpatients was assessed using: (1) a detailed smoking self-questionnaire for smoking history and nicotine dependence; and (2) a questionnaire for staff covering treatments and DSMIII-R diagnoses. Data were analyzed using χ2 analysis of variance (ANOVA) tests (one factor) for quantitative comparisons between groups of patients, and analysis of covariance (ANCOVA) test with age covariate was performed for age-dependent variables. Prevalence of smoking in the population of psychiatric patients was significantly higher than in the French general population. Diagnoses among current smokers were mainly substance-related disorder and schizophrenia. The authors established correlations between prevalence of smoking and age, sex, marital and socioeconomic status, alcohol use, coffee consumption and other psychoactive substance use or abuse. The authors did not find relationship between smoking prevalence and institutionalization. Neuroleptic neurological side effects were significantly fewer among smokers compared to nonsmokers. However, the rate of smokers was significantly higher in psychiatric patients receiving neuroleptic drugs. Nicotine abuse in psychiatric patients, and especially in schizophrenic patients, could support the hypothesis that smoking is consistent with self-medication.

Introduction

The interest in substance abuse in psychiatric patients has received increasing attention. Recently, nicotine dependence has been considered as a drug dependency. Today, evidence that tobacco smoking represents a form of drug addiction to nicotine exists. Moreover, nicotine has even been pointed out as more addictive than alcohol, marijuana and cocaine (Kandel et al., 1997). Nicotine activates the mesolimbic system as well as addictive drugs. More specifically, nicotine has been shown to burst activity in dopamine neurones of the ventral tegmental area that are physiologically associated with basic motivational processes underlying learning and cognitive behaviors. Nicotine into ventral tegmental area produces a long-lasting increase in accumbal dopamine release (Nisell et al., 1995). Psychiatric outpatients have been reported to be more likely smokers than individuals in the general US population, 52% and 33%, respectively. Persons with mental illness are about twice as likely to smoke as others persons (Lasser et al., 2000). Rates of smoking are different according to diagnosis of: schizophrenia 88%; manic disorder 70%; major depressive disorder 49%; anxiety disorder 47%; personality disorder 46%; and adjustment disorder 45% (Hugues et al., 1986). In depression, association of symptoms and smoking has been found out in several studies Anda et al., 1990, Breslau et al., 1991, Zimmerman et al., 1991, Kendler et al., 1993 but not in others (Haines et al., 1980). Published data have shown (Kandel et al., 1997) a greater lifetime prevalence of major depression in smokers compared to nonsmokers with 6.6% and 2.9%, respectively Glassman et al., 1990, Nisell et al., 1995. In addition, smokers with a life history of major depression were less likely to succeed in smoking cessation compared to smokers without such history Glassman et al., 1990, Hall et al., 1991, Covey et al., 1998. Smoking cessation nicotine withdrawal without replacement have been the case reports of exacerbation of dysphoria (Hall et al., 1991) or of schizophrenic symptoms (Dalack and Meador-Woodruff, 1996). Besides, in addition to associated health risks, nicotine may hinder benefits of antipsychotic medications (Goff et al., 1992). Smoking increases the metabolism of neuroleptics by a pharmacokinetic interaction and induces a decrease in blood levels and therapeutic effects of neuroleptics Miller et al., 1990, Vinarova et al., 1992, Dalack and Meador-Woodruff, 1996. Regarding neurological side effects, smokers have been reported to display less neuroleptic-induced extrapyramidal symptoms (Decina et al., 1989), although they are more likely to suffer from tardive dyskinesia (Yassa et al., 1987).

In the French general population from 18 to 75 years old, prevalence of smokers is 33.6%, with males being 40% and females 27% (Comité Français d'Education pour la Santé (CFES), 1995). However, so far, psychiatric based nationally representative data are lacking. We have designed a survey on tobacco smoking in psychiatric patients in a public mental health care hospital's Department of Adult Psychiatry. The purpose of this study is to determine the following: (Kandel et al., 1997) prevalence of tobacco smoking and nicotine dependence in psychiatric patients; (Nisell et al., 1995) rates and patterns of smoking and of nicotine dependence according to psychiatric diagnosis; (Hugues et al., 1986) relationship between current smoking status and antipsychotic medications; and (Anda et al., 1990) relationship between nicotine and neurological side effects induced by antipsychotics.

Section snippets

The patient questionnaire

The authors designed a smoking self-questionnaire, which included two parts: (1) demographic informations (sex, age, education, family situation), current alcohol, coffee and psychoactive substance use or abuse, and other “compulsive–impulsive spectrum disorders” Hollander and Wong, 1995, Nisell et al., 1995; and (2) and a detailed tobacco-smoking history: current smoking status, number of cessation attempts, family history for smoking, and symptoms of nicotine dependence and withdrawal

Demographic characteristics

Patients were: (1) mean aged 41.7 (S.D.=14.7); (2) 379 males, 332 female; and (3) current smokers 59%, never-smokers 35%, former smokers 6%. Smoking referred only to cigarettes. Definitions of tobacco use status were taken from French studies in general population (CFES, 1995), i.e., current smokers smoke daily at least one cigarette per day over the last month or longer, whereas former smokers have stopped their consumption for at least 3 months. Current smokers compared to former and

Discussion

In our study, a psychiatric population of 711 in- and outpatients receiving specialist psychiatric care in a public mental health hospital showed prevalence of tobacco smoking of 58.9%. In 1986, Hugues et al. reported a similar prevalence of smokers (52%) in a population of adult psychiatric outpatients. Our result is consistent with the literature. It confirms the higher prevalence of smoking among psychiatric patients compared to the general population. Smoking prevalence in the French and

Conclusion

This survey shows a higher prevalence of smoking in a population of psychiatric in- and outpatients compared to the French general population. Smokers are younger than nonsmokers and are more likely to be men in both populations. Unemployment do not appear as risk factor of smoking. Smokers are more likely to have a family history of smoking, which does not appear to be associated with nicotine dependence. Prevalence of cigarette smoking in patients with substance-related disorders and with

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