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Am Fam Physician. 2005;72(5):900-904

Smoking is a major cause of preventable and premature deaths in the United States and worldwide, and is the source of significant avoidable morbidity. Multiple studies have demonstrated a connection between smoking and psychiatric disorders, but none has examined the issue of nicotine dependence. The Diagnostic and Statistic Manual of Mental Disorders, 4th ed. (DSM-IV), defines dependence on psychoactive substances as repeated or chronic self-administration of a substance that results in compulsive substance-taking behavior, and the continuation of that behavior despite serious consequences. Several regional U.S. studies and one German study have shown a connection between nicotine dependence and psychiatric disorders. However, no U.S. study has examined this association in a representative sample of the population. Without accurate national data on nicotine dependence and psychiatric disorders, treatment needs and intervention strategies cannot be fully understood. Grant and colleagues evaluated the co-occurrence of current nicotine dependence and other psychiatric disorders in a national sample.

The study was performed on a representative sample of the U.S. population targeting the civilian, noninstitutionalized population 18 years and older. The response rate for the survey was 81 percent, and blacks, Hispanics, and young adults (18 to 24 years of age) were oversampled. A face-to-face interview to identify nicotine dependence and psychiatric disorders was conducted by trained individuals using the Alcohol Use Disorder and Associated Disabilities Interview Schedule—DSM-IV version. This survey assesses dependence on multiple substances and the presence of a broad range of psychiatric disorders based on DSM-IV criteria. Nicotine dependence was established by responses to questions about symptoms drawn from four criteria. The first, “using nicotine to relieve or avoid withdrawal symptoms,” was measured by 1) the use of nicotine upon wakening, 2) the use of nicotine after being restricted from its use, 3) the use of nicotine to avoid nicotine withdrawal symptoms, and 4) waking up in the middle of the night to use tobacco. Other criteria were “giving up or cutting down on activities in favor of nicotine use,” “great deal of time spent using tobacco,” and “using tobacco more than intended.” Information about current and past smoking habits also was obtained during the interview.

A total of 43,093 adults participated in the study; 28.4 percent were current users of tobacco products, and 12.8 percent of the total responders were dependent on nicotine. There was a significant correlation between nicotine dependence and specific Axis I and II disorders in the total population and between men and women. Although nicotine-dependent individuals made up only 12.8 percent of the study population, they were responsible for 57.5 percent of the cigarettes smoked. Nicotine dependence was strongly associated with disorders relating to drug or alcohol use. The most common mood disorders in individuals with nicotine dependence were major depression and specific phobia. Obsessive-compulsive, antisocial, and paranoid personality disorders were the most common Axis II disorders in nicotine-dependent individuals.

The authors conclude that individuals with nicotine dependence, psychiatric disorders, or both consume the majority of cigarettes in the United States. Smoking cessation strategies need to focus on these vulnerable individuals, who may be more susceptible to advertising.

editor’s note: The presence of comorbid psychiatric disorders and alcohol dependence has proved detrimental to smoking cessation, and treatment strategies that address these underlying issues need to be developed.1 The study by Grant and colleagues2 indicates a high prevalence of psychiatric disorders among individuals who are nicotine dependent. Although further studies are needed to determine the efficacy of concurrent treatment, this study2 should at least heighten our awareness of the potential correlation. Treating nicotine dependence without addressing comorbid psychiatric disorders may undermine efforts to increase smoking cessation success rates.—k.e.m.

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