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Original Article

PREVALENCE OF NICOTINE DEPENDENCE SYNDROME IN PSYCHOTIC DISORDERS, MOOD DISORDERS AND ALCOHOL DEPENDENCE SYNDROME

 Priya nayak k1., Chandini2,  Safeekh a.t.3

1Resident, Dept. of Psychiatry. Fr. Muller Medical College. Mangalore 575002

2Senior Resident, Dept. of Psychiatry. Fr. Muller Medical College. Mangalore 575002

3Professor, Dept. of Psychiatry. Fr. Muller Medical College. Mangalore 575002

 

Abstract

Backrround: Tobacco smoking is the leading cause of preventable death and is the single most important avoidable cause of morbidity and premature mortality worldwide. It is the most prevalent form of drug dependence in the world and is regarded as the purest pharmacological dependence. Approximately 20% of the population continues to smoke in United States despite the public health efforts to reduce tobacco use. Smoking is significantly associated with morbidity and mortality. The prevalence of Nicotine Dependence Syndrome (NDS) is increasing in most developing countries, whereas it is decreasing in most industrialized countries. Prevalence of smoking in psychiatric patients in the United States was about 50 percent, including those with other substance use disorders was about 80 percent.

Objectives: tobacco smoking continues to be a serious public health problem. Tobacco use is highly prevalent and is more intense in patients with psychiatric disorders. The aim of this study is to evaluate the prevalence and severity of nicotine dependence syndrome in patients with psychotic disorders, mood disorders and alcohol dependence syndrome and also to study the relationship between the prevalence of nicotine dependence syndrome with socio-demographic and clinical variables.

Materials and methods: this is an observational, descriptive, cross sectional clinical study conducted on 30 consecutive patients with the icd 10 dcr diagnosis of alcohol dependence syndrome and 30 consecutive patients with psychotic disorders and 30 consecutive patients with mood disorders from outpatient and inpatient facilities of psychiatry department of father muller medical college, mangalore. All patients were administered with Fagerstrom test for nicotine dependence to determine the severity of nicotine dependence. The prevalence and severity of the dependence is compared in all three groups of patients using appropriate statistical methods.

Results: in the present study, 66.7% patients had nicotine dependence syndrome. The co morbidity of nicotine dependence syndrome in alcohol dependence syndrome is 80%, psychotic disorders are 56.7% and in mood disorders is 63.3%.

Conclusion: the prevalence of nicotine dependence syndrome is found to be much higher in patients with psychiatric disorders. Prevalence of nicotine dependence syndrome is higher among patients with alcohol dependence syndrome compared to psychotic disorders and mood disorders.

Key words: nicotine dependence syndrome, alcohol dependence syndrome, psychotic disorders, mood disorders.

Introduction

Tobacco smoking is the leading cause of preventable death and is the single most important avoidable cause of morbidity and premature mortality worldwide. It is the most prevalent form of drug dependence in the world and is regarded as the purest pharmacological dependence. Approximately 20% of the population continues to smoke in United States despite the public health efforts to reduce tobacco use. Smoking is significantly associated with morbidity and mortality.1 Tobacco is addictive in all forms; smoking or smokeless forms. It increases the risk of cancer, cardiovascular disease, stroke, peripheral vascular disease, osteoporosis, chronic obstructive pulmonary disease, diabetes and adverse reproductive outcomes. It can be associated with other substance use disorders, mood disorders, psychotic disorders or anxiety disorders. Smoking is often viewed as a form of self-medication to cope with stress, but there is little evidence that nicotine possesses any anxiolytic or antidepressant properties. There has been a growing interest for association of cigarette smoking with various psychiatric disorders.2

The prevalence of Nicotine Dependence Syndrome (NDS) is increasing in most developing countries, whereas it is decreasing in most industrialized countries. Prevalence of smoking in psychiatric patients in the United States was about 50 percent, including those with other substance use disorders was about 80 percent.3,4 In India prevalence of nicotine use is about 18.4% for tobacco smoking and  21% for tobacco chewing.5 A study in India reported that the prevalence of smoking was 38% among patients with schizophrenia, 24% among patients with mood disorders, and 23% among those with a non-psychotic disorder.6 In another study in South India on prevalence and correlates of tobacco use and nicotine dependence among psychiatric patients, 36% of patients reported tobacco use in at least one form and 39% among them used more than one form of tobacco. Nicotine use in women were more in the form of smokeless tobacco when compared to men who were more likely to smoke.7

In a NESARC study on prevalence of nicotine dependence and psychiatric disorders in the United States, it was reported that among the patients with current nicotine dependence syndrome, most common co morbidity was Alcohol Dependence Syndrome (ADS) and it was more when compared to any other substance use in the population.8 A study on prevalence of substance use disorders in various psychiatric disorders had a significant result for increased prevalence for cigarette smoking in schizophrenia when compared to other psychiatric disorders and with relation to other substance use.9 A 16 year old cohort study with co morbidity of nicotine dependence and depressive disorder showed that a moderate to strong co morbidity with  teenagers with a depressive disorder had odds of nicotine dependence that were 4.6 times those of teenagers without depressive disorder.10

Little is known about co morbid nicotine dependence and psychiatric disorders in adult population. The most extensive data are available from the Western studies and the present authors have come across only few studies in Indian population. The aims of the present study is to evaluate the prevalence and severity  of nicotine dependence syndrome in patients with  psychotic  disorders, mood  disorders , alcohol dependence syndrome  and  also to study the relationship between the prevalence of nicotine dependence syndrome with                        socio-demographic and clinical variables among the above mentioned three groups.

Materials and methods

This is an observational, descriptive, cross sectional clinical study that was conducted in patients during the period between July 2013 and December 2013. The clinical study was conducted in both inpatient and outpatient facilities of the department of psychiatry in Father Muller Medical College, Mangalore. The study was approved by Institutional Ethics committee and a written informed consent was obtained from the participants of the study.

90 consecutive patients who satisfied the inclusion and exclusion criteria were selected as sample for the study. The study consisted of 30 consecutive patients with the diagnosis of alcohol dependence syndrome and 30 consecutive patients with diagnosis of psychotic disorders and 30 consecutive patients with diagnosis of mood disorders who were admitted in psychiatry ward or attending the psychiatry outpatient department of Father Muller Medical College. Inclusion criteria were patients with ICD-10 Diagnostic Criteria for Research (DCR-10) diagnosis of alcohol dependence syndrome, psychotic disorders, mood disorders; male patients, and age group between 18 and 65years. Female patients, patients with mental retardation and cognitive deficits were excluded from the study. The tools used for the investigation were (1) semi-structured proforma to collect and document the socio-demographic and clinical data (2) The Socioeconomic Status Schedule (SESS) to assess the socioeconomic status of the patients [Sodhi and Sharma 1986]. (3) Fagerstrom test to assess severity of nicotine dependence

The design and nature of the clinical study was explained to the patients and to the significant relatives of patients. A written informed consent was obtained from the subjects. All the patients were subjected to a thorough clinical examination which included physical and mental status examination. The socio-demographic and clinical data were collected using the semi- structured proforma. Socioeconomic class was assessed using Socioeconomic Status Schedule. The diagnosis of nicotine dependence syndrome was made according to ICD-10 Diagnostic Criteria for Research (DCR-10). All the patients were administered with Fagerstrom test to assess severity of Nicotine Dependence Syndrome. The prevalence and severity of the dependence is compared in all three groups of patients. The collected data was analyzed by frequency, percentage, mean, standard deviations and chi square test.

Results

Of the total 90 patients, the maximum number of subjects were in the age group        of 26 -35 years, 73% of the subjects belonged to Hindu religion. Majority of the patients were from rural area and nuclear family. About 71.1 % of the patients had an education of high school certificate and above. About 44.4% of the patients belonged to category 4 of socio-economic status scale. [Table 1]

The overall prevalence of nicotine dependence syndrome in the three groups is     66.67 %. The prevalence of nicotine dependence syndrome is highest in patients with alcohol dependence syndrome with 80%. The prevalence in mood and psychotic disorders is 63.3% and 56.7% respectively.  In the study the difference of prevalence of nicotine dependence in the three groups is not statistically significant. (P = 0.142) [Table 2, Figure 1]

The mode of nicotine use was analysed for the patients with nicotine dependence syndrome in the three groups. Of the 24 subjects with alcohol dependence syndrome 43.3 % were smoking nicotine, whereas 23.3% and 36.7% of the individuals with psychotic disorders and mood disorders were smoking nicotine. There was no significant association between psychiatric disorders and the mode of nicotine use. (P = 0.188) [Table 3, Figure 2]

The severity of nicotine dependence syndrome is assessed according to score obtained from Fagerstrom test for nicotine dependence. 24 patients out of 60 had low nicotine dependence syndrome, 18 patients had very low nicotine dependence syndrome, both of which accounts to about 70% of the patients with nicotine dependence syndrome. [Table 4, Figure 3]

Table 1: Nicotine Dependence Syndrome and  Socio-Demographic Data

 

 

ADS

Psychotic Disorders

Mood Disorders

 

AGE 

18-25

26-35

36-45                      

46-55

56-65

 

3

11

8

5

3

 

6

15

6

2

1

 

4

8

11

4

3

 

RELIGION

Hindu

Muslim

Christian

Others

 

19

3

8

0

 

17

7

6

0

 

17

8

5

0

 

DOMICILE

Urban

Rural

Others

 

9

15

6

 

8

21

1

 

6

23

1

 

FAMILY

Nuclear

Joint

Extended

Joint Extended

 

22

7

1

0

 

15

15

0

0

 

20

9

1

0

 

EDUCATION

Profession or Honours

Graduate or post graduate

Intermediate or post high school

High school certificate

Middle school certificate

Primary school certificate

Illiterate

 

1

5

6

10

2

4

2

 

0

3

3

14

8

1

1

 

1

4

8

9

6

1

1

 

OCCUPATION

Profession

Semi- profession

Clerical, Shop-owner, Farmer

Skilled worker

Semi-skilled worker

Unskilled worker

Unemployed

 

1

3

9

10

4

3

0

 

0

1

5

6

9

5

4

 

1

5

5

9

5

5

0

 

SESS CATEGORY

I

II

III

IV

V

 

0

10

10

10

0

 

0

1

10

19

0

 

0

8

11

11

0

 

TOTAL

30

30

30

 

 

 

Table 2 : Prevalence of Nicotine Dependence Syndrome

 

Present

Percentage

Absent

Percentage

ADS

24

80

6

20

Psychotic Disorders

17

56.7

13

43.3

Mood Disorders

19

63.3

11

36.7

 

 

 

 

 

 

 

 

Table 3 : Mode of Nicotine Use

Variable

Smoking

Smokeless

Both

None

Total

Ads

13

9

2

6

30

Psychotic Disorder

7

7

3

13

30

Mood Disorder

11

3

5

11

30

 

 

 

Table 4: Severity of Nicotine Dependence Syndrome

Variable

ADS

Psychotic Disorders

Very Low dependence

5

7

Low dependence

11

7

Medium dependence

4

1

High dependence

3

1

Very High dependence

1

1

TOTAL

24

17

 

Figure1: Prevalence of Nicotine Dependence Syndrome                                            

Discussion

In the present study 66.67% (60/90) patients had nicotine dependence syndrome and the prevalence of 80% is seen in patients with alcohol dependence syndrome. Prevalence of smoking in psychiatric patients in the United States is about 50 percent, including those with other substance use disorders is about 80 percent, which is similar to our study.3,4

In a NESARC study it is reported that among the patients with current nicotine dependence syndrome, most common co morbidity is alcohol dependence syndrome and it is more when compared to any other substance use in the population which is  similar to our study.8 When compared between mood disorders and psychotic disorders, nicotine dependence syndrome is more common in patients with mood disorder.7 This is in contrast to other studies were nicotine dependence syndrome is associated with psychotic disorders. When compared among the mood disorders, it is more commonly associated with depressive disorder, BPAD with psychotic symptoms.11,12,13

In the current study about 51% of the patients used tobacco in the form of smoking, 32% used in the form of smokeless tobacco use and 17% used more than one form.This is contrary to another study in South India in which 36% of patients reported tobacco use in at least one form and 39% among them used more than one form of tobacco.7 About 70% of the patients in the present study had very low to low nicotine dependence syndrome. Severity of nicotine dependence syndrome in psychotic disorder is expected to be high, 13 but in the present study most of the patients had low nicotine dependence syndrome. This could be because the patients with psychotic disorder had used tobacco more in smokeless form than smoking. The scales used for assessment was for tobacco in the form of smoking. The modified form for smokeless tobacco was not used which could be one of the limitations of the present study.

Patients with mood disorder had low nicotine dependence even though most of them use tobacco in the form of smoking. This could be because the patients with mood disorder were mostly in remission or on medication with no active mood symptoms. The prevalence of nicotine dependence syndrome is found to be much higher in patients with psychiatric disorders 66.7% compared to the reported prevalence in Indian general population - 31.6%,6 33%,3 45%.13 The present investigation findings are similar to the studies done in western countries.14

This is an observational, descriptive, cross sectional clinical study. This study has certain merits and limitations. Although selection bias is avoided the sample is not representative of the general population of such patients. The sample size is inadequate. Scales to assess severity of smokeless tobacco use could have been used. Further studies with much larger representative sample are required to draw definite conclusions.

Conclusion

The prevalence of nicotine dependence syndrome is higher among patients with psychiatric disorders. Smoking nicotine is the commonest mode of nicotine use. Prevalence of nicotine dependence syndrome is higher among patients with alcohol dependence syndrome compared to psychotic disorders and mood disorders. When compared between mood disorders and psychotic disorders, nicotine dependence syndrome is more common in patients with mood disorders. Severity of nicotine dependence ranged from very low to low nicotine dependence syndrome.

References:

1.        CDC. Cigarette smoking among adults and trends in smoking cessation – United States, 2008. MMWR 2009; 58:1227–1232.

2.        Gupta PC, Hamner JE. Tobacco habits in India. In: Bhonsle RB, Murti PR, Gupta PC, editors. Control of tobacco related cancers and other diseases. International Symposium, 1990. Bombay: Oxford University; 992: 25–46.

3.        Hughes JR. Nicotine Related disorders. Kaplan and Sadock’s Comprehensive Text Book of Psychiatry. 9th Ed. Volume 1.(Ed). Sadock BJ. Sadock VA. Ruiz P.NewYork :Lippincott Williams and Wilkins;2009:1353-1360

4.        Glassman AH, Helzer JE, Covey LS, Cottler LB, Stetner F, Tipp JE, Johnson J. Smoking, smoking cessation, and major depression. Journal of American Medical Association. 1990; 264:1546–1549.

5.        Subramanian SV, Nandy S, Kelly M, Gordon D, Smith GD. Patterns and distribution of tobacco consumption in India: Cross sectional multilevel evidence from the 1998–9 national family health survey. British Medical Journal. 2004; 328:801–806.

6.        Srinivasan TN, Thara R. Smoking in schizophrenia—All is not biological. Schizophrenia Research. 2002; 56:67–74.

7.        Chandra PS, Carey MP, Carey KB, Jairam KR, Girish NS, Rudresh HP. Prevalence and Correlates of Tobacco Use and Nicotine Dependence among Psychiatric Patients in India. Addict Behav. 2005 August; 30(7): 1290–1299.

8.        Grant BF, Hasin DS, Chou SP, Stinson FS, Dawson DA. Nicotine Dependence and Psychiatric Disorders in the United States. Arch Gen Psychiatry. 2004;61(11):1107-1115

9.        Diwan A, Castain M, Pomerleau CS Meador Woodoff JH, Dalace GW. Differential prevalence of cigarette smoking in patients with schizophrenic vs mood disorders. Schizophrenic research1998;33(1-2):113–118.

10.     Fergusson DM, Lynskey MT, Horwood LJ. Comorbidity between Depressive Disorders and Nicotine Dependence in a Cohort of 16-Year-Olds. Arch Gen Psychiatry.1996; 53(11):1043-1047.

11.     Breslau N. Psychiatric comorbidity of smoking and nicotine dependence. Behavior Genetics. 1995; 25:95–101.

12.     Glassman A, Covey L. Smoking and affective disorder. American Journal of Health Behavior. 1996; 20:279–285.

13.     Corvin A, O'Mahony E, O'Regan M, Comerford C, O'Connel R, Craddock N, Gill M. Cigarette smoking and psychotic symptoms in bipolar affective disorder. British Journal of Psychiatry. 2001; 179:35–38.

14.     Vanable PA, Carey MP, Carey KB, Maisto SA. Smoking among psychiatric outpatients: Relationship to substance use, diagnosis, and illness severity. Psychology of Addictive Behaviors. 2003; 17:259–265.

 

 

 

 

 

 

 

Table 3 : Mode of Nicotine Use

Variable

Smoking

Smokeless

Both

None

Total

ADS

13

9

2

6

30

PSYCHOTIC DISORDER

7

7

3

13

30

MOOD DISORDER

11

3

5

11

30