Elsevier

Drug and Alcohol Dependence

Volume 194, 1 January 2019, Pages 128-135
Drug and Alcohol Dependence

Full length article
The relationship between smoking cessation and binge drinking, depression, and anxiety symptoms among smokers with serious mental illness

https://doi.org/10.1016/j.drugalcdep.2018.08.043Get rights and content

Highlights

  • A study of smoking cessation, drinking, and mental health among smokers with SMI.

  • Smoking cessation did not heighten binge drinking or depression/anxiety symptoms.

  • Healthcare providers should facilitate use of cessation tools for smokers with SMI.

Abstract

Introduction

Concerns about the adverse effects of smoking cessation on alcohol use and mental health are a barrier to cessation for smokers with serious mental illness (SMI). The purpose of this study is to examine how incident smoking cessation affects binge drinking and symptoms of depression and anxiety among smokers with SMI.

Methods

The present study is a secondary analysis of the OPTIN trial, which demonstrated the effectiveness of proactive outreach for smoking cessation among Minnesota Health Care Programs enrollees. Participants with ICD-9 codes indicating schizophrenia spectrum disorders, psychotic disorders, bipolar disorders, or severe/recurrent major depressive disorder were categorized as having SMI (n = 939); remaining smokers were categorized as non-SMI (n = 1382). Multivariable regressions modeled the association between incident smoking cessation and binge drinking, PHQ-2 depression scores, and PROMIS anxiety scores in the two groups.

Results

Quitting smoking was not associated with binge drinking among those with SMI, but was associated with less binge drinking among those without SMI (p = 0.033). Quitting smoking was not associated with PHQ-2 depression scores among those with or without SMI. However, quitting smoking was associated with lower mean PROMIS anxiety scores for those with SMI (p = 0.031), but not those without SMI.

Conclusion

Quitting smoking was not associated with heightened binge drinking or symptoms of depression and anxiety among smokers with SMI. These findings suggest that quitting smoking is not detrimental for these patients, and provide evidential support for facilitating access to cessation resources for patients with serious mental illness who smoke.

Introduction

The prevalence of smoking among those with mental health disorders is two to three times higher than that of the general US population, depending on clinical diagnosis (Gfroerer et al., 2013). Those with diagnoses consistent with serious mental illness (SMI) like major depressive disorder (Crum et al., 2013; Grant and Harford, 1995) and schizophrenia (Drake and Mueser, 2002) are also more likely to engage in alcohol abuse behaviors. Furthermore, evidence suggests that there is a high prevalence of concurrent smoking and alcohol dependence; nicotine-dependent smokers have nearly 3-times higher risk of becoming alcohol dependent compared to nonsmokers (Breslau, 1995). The high co-occurrence of smoking and alcohol dependence among those with SMI is a grave public health concern. In addition to the independent risks associated with these behaviors (National Center for Chronic Disease Prevention and Health Promotion (US) Office on Smoking and Health, 2014; Rocco et al., 2014), combined use is associated with a multiplicative increase in the risk for some cancers, including head and neck and esophageal cancer (Blot et al., 1988). The increased prevalence of these deleterious health behaviors contributes to the heightened mortality rate observed in this population, and individuals with SMI die an average of 25 years earlier than those in the general population (Parks et al., 2006).

Many smokers with alcohol dependence report using smoking as a way to cope with urges to drink (Monti et al., 1995) making the prospect of quitting seem overwhelming and unattainable. Furthermore, there is concern that nicotine withdrawal symptoms may threaten sobriety from alcohol, contributing to a reluctance to treat these conditions simultaneously (Berg et al., 2015; Kozlowski et al., 1989; Romberger and Grant, 2004). Some research partially validates the concern that smoking cessation exacerbates alcohol use, as several studies have demonstrated an association between smoking cessation and increased alcohol use (Carmelli et al., 1993; Perkins et al., 1990). One trial of smokers with alcohol dependence who were randomized to either concurrent smoking cessation treatment or delayed smoking cessation treatment found that participants in the concurrent treatment condition reported lower rates of abstinence from alcohol than those in the delayed condition (Joseph et al., 2004). However, a similar trial conducted among alcohol-dependent smokers found that alcohol use did not differ significantly between participants receiving concurrent versus delayed smoking cessation treatment (Cooney et al., 2015). Furthermore, several more recent studies have shown that alcohol use does not substantially change following smoking cessation (Kahler et al., 2010) or is reduced (Berg et al., 2015). It has been suggested that methodological problems including small sample size (Perkins et al., 1990) and an inability to establish temporal ordering (Carmelli et al., 1993) may account for these inconsistent findings (Berg et al., 2015).

Another key barrier to smoking cessation among patients with SMI is the perception that quitting smoking may exacerbate mental health symptoms. Evidence suggests that smokers with SMI may use nicotine as a form of self-medication to help reduce the experience of negative affect and anxiety associated with their condition(s) (Glassman, 1993; Thornton et al., 2012) and qualitative work has shown that these smokers expect that their mental health will deteriorate following a quit attempt (Kerr et al., 2013). This is also a concern among healthcare providers, some of whom believe quitting smoking may increase depressive symptoms among their patients (Hall and Prochaska, 2009; Hitsman et al., 2009).

Despite the concerns of both smokers and healthcare providers regarding the potentially deleterious mental health consequences associated with smoking cessation, a growing body of evidence suggests that quitting smoking may lead to improvements in mental health symptoms among the general population (Kahler et al., 2011; Taylor et al., 2015, 2014). Other research has shown similarly beneficial effects of smoking cessation on mental health symptoms among smokers with diagnoses of mood and/or anxiety disorders (Cavazos-Rehg et al., 2014).

The inconsistent findings regarding the association between smoking cessation and alcohol use highlight the need for continued research exploring this issue. As such, the first aim of the present study is to assess the association between smoking cessation and binge drinking among socioeconomically disadvantaged smokers enrolled in Minnesota Health Care Programs (MHCP). We focused on binge drinking because of the pronounced deleterious health risks associated with drinking to excess (Gupta et al., 2010; Llerena et al., 2015; Samokhvalov et al., 2010) and because binge drinking is a predictor of alcohol dependence (Bonomo et al., 2004). There is also a lack of research exploring whether the association between smoking cessation and alcohol use differs by SMI status; an important clinical consideration when approaching the treatment of smoking for those with mental health disorders due to the high co-morbidity of these conditions (Grant et al., 2004; Grant and Harford, 1995). We address this gap in the literature by examining the association between smoking cessation and binge drinking among those with SMI and without SMI, respectively.

The second aim of this study is to explore the association between smoking cessation and mental health symptoms among our low-income sample. Continued research in this area is essential in order to better inform both smokers and physicians on what to expect when approaching cessation, an issue of particular importance for smokers with SMI. We address this issue by examining the association between smoking cessation and symptoms of depression and anxiety among smokers with SMI and without SMI.

Section snippets

Study design

This is a secondary analysis of data from the “Proactive Smoking Cessation Treatment for Minnesota Priority Populations” (OPTIN) study (N = 2406) (Fu et al., 2014). This study was a two-arm randomized controlled trial conducted among a sample of smokers enrolled in Minnesota Health Care Programs (MHCP), which is a state-funded health insurance plan for low-income persons. As described previously, this study demonstrated the effectiveness of proactive outreach relative to usual care for boosting

Baseline characteristics

Compared to non-SMI smokers (n = 1382), those with SMI (n = 939) were more likely to be enrolled in Medicaid, were older, and more likely to be female. Smokers with SMI also tended to have lower levels of education and income and were less likely to be currently employed (see Table 1). Smokers with SMI had significantly more symptoms of depression and anxiety at baseline and were more likely to have a diagnosis of alcohol dependence (21.0% vs. 3.9%), but had lower levels of current binge

Discussion

Quitting smoking was not associated with a significant difference in the odds of past month binge drinking compared to continuing smoking for those with SMI, and quitting was associated with reduced odds of binge drinking for those without SMI. In addition, quitting smoking was not associated with differences in depression scores in either group. Quitting smoking was associated with significant reductions in anxiety scores for those with SMI but was not associated with differences in anxiety

Role of funding source

Primary funding provided by NCI Grant R01CA141527-01. Additional support provided by NCI Grant 2T32CA163184 and the Center for Chronic Disease Outcomes Research, VA, Minneapolis, MN. The contents of this article do not represent the views of the U.S. Department of Veterans Affairs or the United States government. Funding sources had no role in the collection, analysis or interpretation of data, the writing of the report, or the decision to submit the article for publication.

Contributors

Concept and design (PJH, SSF, HAL, RW, DJE, BCT); acquisition of data (PJH, BC); analysis and interpretation of data (PJH, SSF, HAL, RW, DJE, BCT); drafting of the manuscript (PJH); critical revision of the manuscript for important intellectual content (PJH, SSF, HAL, BCT, RW, DJE, AMJ); statistical analysis (PJH, DJE, BCT, BC) provision of patients or study materials (SSF, AMJ); obtaining funding (SSF, AMJ). All authors have read and approve the final manuscript.

Conflicts of interest

No conflict declared.

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