Nicotine withdrawal in U.S. smokers with current mood, anxiety, alcohol use, and substance use disorders
Introduction
Adults with current psychiatric disorders are much more likely to smoke than other adults (Centers for Disease Control, 2007, Lasser et al., 2000; see Ziedonis et al., 2008 for review). While approximately 22% of adults in the U.S. general population are current smokers, rates of smoking are significantly higher for adults with current mood disorders (38.2–44.7%), anxiety disorders (31.5–54.6%), alcohol use disorders (AUD; 65.1%), and substance use disorders (SUD; 67.9%) (Lasser et al., 2000). Smokers with psychiatric disorder are also less likely than other smokers to quit smoking (Lasser et al., 2000, Ziedonis et al., 2008). Quit rates for smokers with current mood disorders (22.0–26.0%), anxiety disorders (23.2–32.0%), SUDs (22.4%), and AUDs (16.9%) are approximately half that of U.S. adults with no mental illness (42.5%) (Lasser et al., 2000). It is not clear why smokers with Axis I disorders have a more difficult time with smoking cessation.
Data from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC, Wave 1, 2001–2002, full sample n = 43,093; Grant et al., 2004) showed that rates of nicotine dependence are two to four times higher in adults with current mood disorders (29.2%), anxiety disorders (25.3%), AUDs (34.5%), and SUDs (52.4%) compared to adults in the general population (12.8%). Nicotine dependence is marked by withdrawal symptoms (American Psychiatric Association, 1994) and it has been hypothesized that smokers with Axis I disorders have more trouble quitting smoking due to greater withdrawal (Covey et al., 1990). While there is evidence for an association between Axis I disorders and more severe withdrawal symptoms (e.g., Breslau et al., 1992, Covey et al., 1990, John et al., 2004a, John et al., 2004b, Madden et al., 1997, Marks et al., 1997, Pomerleau et al., 2000, Pomerleau et al., 2005), the majority of these studies examined psychiatric symptoms (e.g., symptoms of depression or anxiety) or a history of disorders (e.g., depression, anxiety, AUDs). Little is known about the experience of withdrawal symptoms in smokers with a current Axis I disorder although two recent studies suggest that smokers with current anxiety disorders endorse a greater number of withdrawal symptoms (Zvolensky et al., 2008) and report more severe withdrawal (Marshall et al., 2008) than non-psychiatric smokers. Additional research using epidemiological datasets such as the NESARC is needed to learn more about the experience of withdrawal in smokers with anxiety and other current Axis I disorders.
Recent analyses of the NESARC data have found high rates of co-morbidity between psychiatric disorders (i.e., mood and anxiety disorders) and AUD/SUDs (e.g., Grant et al., 2005, Hasin et al., 2005, Hasin et al., 2007). Most treatment research has focused on the efficacy of interventions for smokers who have either a psychiatric disorder or an AUD/SUD and not smokers with concurrent disorders (see Hall, 2007 for a review). Two studies of smoking cessation outcomes for smokers with co-morbid depression and AUDs found mixed results. Data from Project MATCH (n = 1193) suggested that higher levels of depression symptoms were related to a decreased likelihood of smoking abstinence (Friend and Pagano, 2007) while symptoms of depression were not related to smoking abstinence in the Timing of Alcohol and Smoking Cessation Study (n = 462; Kodi et al., 2008). It is not clear whether having both a psychiatric disorder and an AUD/SUD would synergistically increase the experience of withdrawal-related symptoms.
The purpose of this study was to examine the experience of withdrawal in U.S. adult smokers with current depression, anxiety, AUD, and SUD using data from Wave 1 of the NESARC study. The first aim of the study was to compare smokers with and without a current Axis I disorder (e.g., smokers with current depression versus smokers without current depression) on aspects of tobacco withdrawal. It was predicted that smokers with a current psychiatric disorder or AUD/SUD would (1) endorse more symptoms of tobacco withdrawal, (2) be more likely to report discomfort related to withdrawal, and (3) be more likely to smoke to avoid withdrawal than smokers without a current disorder. The second aim of the study was to compare the experience of withdrawal in smokers with co-morbid psychiatric disorders with AUD/SUD to smokers with a single psychiatric disorder or AUD/SUD (e.g., smokers with depression and an alcohol use disorder compared to smokers with depression alone). It was predicted that smokers with current co-morbid disorders would (1) endorse more symptoms of tobacco withdrawal, (2) be more likely to report withdrawal-related discomfort, and (3) be more likely to report withdrawal-related relapse than smokers with a diagnosis of a psychiatric disorder alone.
Section snippets
Participants and procedures
Data for these analyses were taken from the National Institute on Alcohol Abuse and Alcoholism's NESARC study (Wave 1, 2001–2002). Face-to-face personal interviews were conducted with 43,093 non-institutionalized civilians aged 18 and older. The response rate was 81% and African-Americans, Hispanics, and young adults (age = 18–24) were over-sampled. See Grant et al. (2003a) for more details about the sampling, purpose, and weight procedures for the NESARC. The current analyses were conducted for
Demographics, smoking characteristics, and rates of psychiatric and substance use disorders by diagnosis (Table 1)
See Table 1 for demographic characteristics of the overall sample (n = 8213 current daily smokers) and by the presence of a current mood disorder, anxiety disorder, AUD, and SUD. The participants in this sample were primarily Caucasian (64%; 52% female). Participants with current disorders tended to be younger and less likely to be married. Women were more likely to report current mood and anxiety disorders and less likely to report current AUDs and SUDs than men. Education was not significantly
Discussion
Consistent with our prediction, smokers with a current diagnosis of a mood disorder, anxiety disorder, SUD, or AUD reported a greater number of tobacco withdrawal symptoms than smokers without a current diagnosis of the respective disorder. This finding is consistent with previous work reporting greater levels of nicotine withdrawal for smokers with psychiatric symptoms or a lifetime Axis I diagnosis (e.g., Breslau et al., 1992, Covey et al., 1990, Madden et al., 1997, Marks et al., 1997,
Conclusions
Smokers with current Axis I disorders may have a more difficult time quitting smoking due to a greater number of withdrawal symptoms and a greater experience of withdrawal-related discomfort. As a result, smokers with Axis I disorders would benefit from treatments that are more intensive and of longer duration. Intensive pharmacotherapy may aid participants by relieving withdrawal symptoms while behavioral therapies can teach smokers how to manage withdrawal symptoms and discomfort and how to
Role of funding source
This work was supported in part by the National Institutes on Health (NIH) grants AA016267 (to Dr. McKee) and K12-DA000167 (to Dr. Weinberger). The NIH had no further role in study design; in the collection, analysis and interpretation of data; in the writing of the report; or in the decision to submit the paper for publication.
Contributors
Dr. Weinberger helped to design the study, managed the literature searches and summaries of previous work, and wrote the first draft of the manuscript. Dr. Desai undertook the statistical analysis. Dr. McKee helped to design the study and provided feedback on all drafts of the paper. All authors contributed to and approved the final manuscript.
Conflict of interest
Drs. Weinberger, Desai, and McKee have no conflicts of interest to report.
Acknowledgements
The authors wish to thank Erin Reutenauer and Monica Solorzano for their assistance with this work. These analyses were conducted in the Department of Psychiatry, Yale University School of Medicine.
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