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Synopsis: This study found that people who smoke cigarettes are approximately twice as likely to have mental illness as people who do not smoke.
Source: Lasser K, et al. JAMA 2000;284:2606-2610.
Lasser and colleagues used data from the National Comorbidity Survey (NCS), a congressionally mandated study of the prevalence of psychiatric disorders in the United States. Data for this paper were gathered from 4411 people aged 15-54 years, and included smoking histories and a modified version of the Composite International Diagnostic Interview, a well-validated structured psychiatric interview. Mental illness was defined 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. Smoking status was broken down into never smokers, "lifetime smokers," (those who had smoked for at least a month in the past, but not currently), and current smokers. Current smokers were further categorized as heavy smokers (> 24 cigarettes/d) or moderate and light smokers. Among the findings of interest are: 1) the prevalence of ever having mental illness by Lasser et al’s definition was 50.7%; 2) those with a history of mental illness were twice as likely to be lifetime smokers as those without (odds ratio [OR] 2.1; confidence interval [CI] 1.9-2.4); 3) those with a history of mental illness were twice as likely to be current smokers as those without (OR 1.9, CI 1.7-2.2); 4) heavy smoking was rare in people with no history of mental illness; only 10% of such persons were heavy smokers; and 5) people with mental illness comprise 44.3% of the U.S. tobacco market.
Comment by Barbara a. Phillips, MD, MSPH
Previous studies1-5 have suggested that smokers are more likely than are nonsmokers to have psychiatric disorders, and many front-line internists undoubtedly suspect this relationship on the basis of their daily experiences. This study is the first to use a structured psychiatric interview and to estimate the proportion of the tobacco market comprised by smokers. Although intuition suggests that mental disturbance predisposes to smoking and there is some evidence to suggest that RJ Reynolds Tobacco Company may have deliberately exploited that tendency,6 the converse may be true. Several studies have suggested that smoking increases the risk of psychiatric disorders, and not vice versa.7-9
Thus, smoking cessation and prevention may prevent not only the well-known causes of more than 400,000 premature deaths per year, but also some of the terrible morbidity and mortality associated with psychiatric illness. We spend a lot of time bemoaning the lack of effect of anti-tobacco educational and awareness programs. In fact, there is some evidence that exposure to anti-tobacco advertisements results in an increased likelihood of adolescent smoking.10 The latest data on intensive, pharmacologically supported smoking cessation are not encouraging, either—at 12 months, a combination of nicotine inhaler and nicotine patch resulted in a 19.5% abstinence rate.11
What does work? Cost, of course. Not only do we know that excise taxes result in reduced teen (and overall) consumption, we have precise data on how many lives are saved by each percentage increase in the price of a pack of cigarettes.10,12 The data on the effectiveness of excise tax increases in reducing tobacco consumption are overwhelming. Physicians need to remember this! I personally believe I can save many more lives (and maybe even reduce the suffering associated with mental illness) by enlightening legislators about this issue than I can working in the intensive care unit.
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