Cigarette smoking and completed suicide: results from 3 prospective cohorts of American adults

Suicide Mortality Among Nurses in the United States: Incidence, Factors Associated with Suicide, Circumstances Preceding Suicide, and Methods of Suicide

The aim of this review was to identify and integrate evidence on suicide mortality among U.S. nurses. To the best of our knowledge, this represents the first review to focus exclusively on suicide among U.S. nurses. Electronic medical databases, reference lists, and supplementary files were searched to identify studies that examined suicide mortality among U.S. nurses. In total, n = 28 studies were included: n = 14 were cohort, n = 10 were epidemiological, and n = 4 utilized mixed methods. Many studies had unique aims, included different nurse groups and referent populations, and utilized a variety of statistical procedures. However, when taken together, four categories were assessed across these n = 28 cumulative studies: incidence of suicide, factors associated with suicide, circumstances preceding suicide, and methods of suicide among U.S. nurses. Taken together, continued surveillance of suicide incidence among U.S. nurses is important, as evidence largely suggests nurses experience elevated suicide incidence when compared to select referent groups. Additional research on factors associated with suicide and circumstances preceding suicide are also needed, particularly among male nurses. Finally, additional research regarding the leading method of suicide, leading substance implicated in self-poisoning, and sex-differentiated suicide methods are also important. Collectively, these data are needed to inform intervention and surveillance strategies.

Suicide mortality following the implementation of tobacco packaging and pricing policies in Korea: an interrupted time-series analysis

BACKGROUND

To prevent tobacco use in Korea, the national quitline number was added to tobacco packages in December 2012, tobacco prices were raised by 80% in January 2015, and graphic health warning labels were placed on tobacco packages in December 2016. This study evaluated the association of these tobacco packaging and pricing policies with suicide mortality in Korea.

METHODS

Monthly mortality from suicide was obtained from Cause-of-Death Statistics in Korea from December 2007 to December 2019. Interrupted time-series analysis was performed using segmented Poisson regression models. Relative risks (RRs) and 95% confidence intervals (CIs) were calculated adjusted for suicide prevention strategies.

RESULTS

Suicide mortality was 20 per 1,000,000 in December 2007 and showed a downward trend over the study period. After the implementation of tobacco packaging and pricing policies, suicide mortality immediately declined by - 0.09 percent points (95% CI =  - 0.19 to 0.01; P > 0.05) for the national quitline number, - 0.22 percent points (95% CI =  - 0.35 to - 0.09; P < 0.01) for tobacco prices, and - 0.30 percent points (95% CI =  - 0.49 to - 0.11; P < 0.01) for graphic health warning labels. The corresponding RRs for these post-implementation changes compared with the pre-implementation level were 0.91 (95% CI = 0.83 to 1.00), 0.80 (95% CI = 0.70 to 0.91), and 0.74 (95% CI = 0.61 to 0.90), respectively. Significant associations between tobacco control policies and suicide mortality were observed even when stratified by sex and region.

CONCLUSIONS

The findings of this study provide new evidence for an association between tobacco control policies and deaths by suicide. An array of effective tobacco control policies should be considered for prevention programs targeting suicide.

Use of Tobacco Products and Suicide Attempts Among Elementary School-Aged Children

Importance

The use of tobacco products, including e-cigarettes and vaping, has rapidly increased among children. However, despite consistent associations found between smoking cigarettes and suicidal behaviors among adolescents and adults, there are limited data on associations between emerging tobacco products and suicidal behaviors, especially among preadolescent children.

Objective

To examine whether the use of tobacco products is associated with nonsuicidal self-injury (NSSI), suicidal ideation (SI), and suicide attempts (SAs) among preadolescent children.

Design, Setting, and Participants

This cohort study, conducted from September 1, 2022, to September 5, 2023, included participants in the Adolescent Brain Cognitive Development study, a population-based cohort of 11 868 US children enrolled at 9 and 10 years of age. The cross-sectional investigation focused on 3-year periods starting from the baseline to year 2 of follow-up. Statistical analysis was performed from October 1, 2022, to June 30, 2023.

Main Outcomes and Measures

Children's use of tobacco products was assessed based on youth reports, including lifetime experiences of various nicotine-related products, supplemented with hair toxicologic tests. Main outcomes were children's lifetime experiences of NSSI, SI, and SAs, assessed using the K-SADS-5 (Kiddie Schedule for Affective Disorders and Schizophrenia for the DSM-5). Multivariate logistic regression was conducted to examine the associations of the use of tobacco products with NSSI, SI, and SAs among the study participants. Sociodemographic, familial, and children's behavioral, temperamental, and clinical outcomes were adjusted in the analyses.

Results

Of 8988 unrelated study participants (median age, 9.8 years [range, 8.9-11.0 years]; 4301 girls [47.9%]), 101 children (1.1%) and 151 children (1.7%) acknowledged lifetime use of tobacco products at baseline and at 18-month follow-up, respectively. After accounting for various suicide risk factors and potential confounders, children reporting use of tobacco products were at a 3 to 5 times increased risk of SAs (baseline: n = 153 [adjusted odds ratio (OR), 4.67; 95% CI, 2.35-9.28; false discovery rate (FDR)-corrected P < .001]; year 1: n = 227 [adjusted OR, 4.25; 95% CI, 2.33-7.74; FDR-corrected P < .001]; and year 2: n = 321 [adjusted OR, 2.85; 95% CI, 1.58-5.13; FDR-corrected P = .001]). Of all facets of impulsivity measures that were significant correlates of use of tobacco products, negative urgency was the only independent risk factor for SAs (adjusted OR, 1.52 [95% CI, 1.31-1.78]; FDR-corrected P < .001). In contrast, children's alcohol, cannabis, and prescription drug use were not associated with SAs.

Conclusions and Relevance

This study of US children suggests that the increased risk of SAs, consistently reported for adolescents and adults who smoke cigarettes, extends to a range of emerging tobacco products and manifests among elementary school-aged children. Further investigations are imperative to clarify the underlying mechanisms and to implement effective preventive policies for children.

Suicide, self-harm, and suicide ideation in nurses and midwives: A systematic review of prevalence, contributory factors, and interventions

BACKGROUND

Nurses have been identified as an occupational group at increased risk of suicide. This systematic review examines the prevalence of, and factors influencing, suicide and related behaviours among nurses and midwives (PROSPERO pre-registration CRD42021270297).

METHODS

MEDLINE, PsycINFO, and CINAHL were searched. Articles published from 1996 onwards exploring suicidal thoughts and behaviours among nurses and midwives were included. Quality of included studies was assessed. Articles were subjected to narrative synthesis informed by suicide data examined, study design, and quality. PRISMA guidelines were followed.

RESULTS

A total of 100 studies were eligible for inclusion in the review. Articles examining suicide exclusively among midwives were absent from the literature. Several studies confirmed that nursing professionals, especially female, are at increased risk of suicide, particularly by self-poisoning. Factors contributing to risk include psychiatric disorders, alcohol and substance misuse, physical health problems, and occupational and interpersonal difficulties. In studies of non-fatal suicidal behaviours, including during the COVID-19 pandemic, psychiatric, psychological, physical and occupational factors were contributory. There has been little investigation of interventions for prevention of suicide in nurses.

LIMITATIONS

Only articles published in English language were reviewed.

CONCLUSIONS

The findings highlight the risk of suicide in nurses. They also show a combination of factors contribute to suicide and non-fatal suicidal behaviour in nurses, with psychiatric, psychological, physical health, occupational and substance misuse (especially alcohol) problems being particularly important. The limited evidence regarding prevention measures indicates a major need to develop primary and secondary interventions for this at-risk occupational group, for example, education regarding enhancing wellbeing and safe alcohol use, alongside accessible psychological support.

Identifying long-term and imminent suicide predictors in a general population and a clinical sample with machine learning

BACKGROUND

Machine learning (ML) is increasingly used to predict suicide deaths but their value for suicide prevention has not been established. Our first objective was to identify risk and protective factors in a general population. Our second objective was to identify factors indicating imminent suicide risk.

METHODS

We used survival and ML models to identify lifetime predictors using the Cohort of Norway (n=173,275) and hospital diagnoses in a Saskatoon clinical sample (n=12,614). The mean follow-up times were 17 years and 3 years for the Cohort of Norway and Saskatoon respectively. People in the clinical sample had a longitudinal record of hospital visits grouped in six-month intervals. We developed models in a training set and these models predicted survival probabilities in held-out test data.

RESULTS

In the general population, we found that a higher proportion of low-income residents in a county, mood symptoms, and daily smoking increased the risk of dying from suicide in both genders. In the clinical sample, the only predictors identified were male gender and older age.

CONCLUSION

Suicide prevention probably requires individual actions with governmental incentives. The prediction of imminent suicide remains highly challenging, but machine learning can identify early prevention targets.

Smoking and suicidal ideation among college students: Smoking expectancies as potential moderators

Objective: In the present study, we sought to establish a link between suicidal ideation (SI) and smoking in college students, determine whether psychopathology accounted for the association, and determine whether smoking expectancies were moderators. Participants: Participants (N = 607) were identified as nonsmokers, exsmokers, infrequent smokers, or daily smokers. Methods: Participants were assessed for smoking patterns, smoking expectancies, psychopathology, SI, and past suicide attempts. Results: Daily smokers had the highest level of SI. There was a dose-response relationship between smoking and SI, such that the higher the daily smoking rate, the greater the SI, even when controlling for depression, alcohol use, and drug use. Trend-level results indicated that at lower smoking rates, elevated smoking-related negative affect reduction (NAR) expectancies were associated with lower SI, while elevated NAR expectancies in combination with higher smoking rates were associated with greater SI. Conclusion: Smoking cessation programs for college students should screen for SI.

The chiropractor's role in primary, secondary, and tertiary prevention of suicide: a clinical guide

OBJECTIVE

To provide the practicing chiropractor foundational knowledge to enhance the understanding of relevant primary, secondary, and tertiary public health measures for suicide prevention.

METHODS

A descriptive literature review was performed using keywords low back pain, neck pain, psychosocial, pain, public health, suicide, suicide risk factors, and suicide prevention. English language articles pertaining to suicide prevention and the chiropractic profession were retrieved and evaluated for relevance. Additional documents from the Centers for Disease Control, Veterans Health Administration, and the World Health Organization were reviewed. Key literature from the clinical social work and clinical psychology fields were provided by authorship team subject matter experts.

CONCLUSION

No articles reported a position statement regarding suicide prevention specific to the chiropractic profession. Risk, modifiable, and protective factors associated with self-directed violence are important clinical considerations. A proactive approach to managing patients at-risk includes developing interprofessional and collaborative relationships with mental health care professionals.

Smoking and Neuropsychiatric Disease-Associations and Underlying Mechanisms

Despite extensive efforts to combat cigarette smoking/tobacco use, it still remains a leading cause of global morbidity and mortality, killing more than eight million people each year. While tobacco smoking is a major risk factor for non-communicable diseases related to the four main groups—cardiovascular disease, cancer, chronic lung disease, and diabetes—its impact on neuropsychiatric risk is rather elusive. The aim of this review article is to emphasize the importance of smoking as a potential risk factor for neuropsychiatric disease and to identify central pathophysiological mechanisms that may contribute to this relationship. There is strong evidence from epidemiological and experimental studies indicating that smoking may increase the risk of various neuropsychiatric diseases, such as dementia/cognitive decline, schizophrenia/psychosis, depression, anxiety disorder, and suicidal behavior induced by structural and functional alterations of the central nervous system, mainly centered on inflammatory and oxidative stress pathways. From a public health perspective, preventive measures and policies designed to counteract the global epidemic of smoking should necessarily include warnings and actions that address the risk of neuropsychiatric disease.

Nicotine Inhalation and Suicide: Clinical Correlates and Behavioral Mechanisms

BACKGROUND AND OBJECTIVES

Extensive evidence links smoking and suicide independently of psychiatric diagnoses, but there are questions about the pathophysiology and specificity of this relationship. We examined characteristics of this linkage to identify potential transdiagnostic mechanisms in suicide and its prevention.

METHODS

We reviewed literature that associated suicide with smoking and e-cigarettes, including the temporal sequence of smoking and suicide risk and their shared behavioral risk factors of sensitization and impulsivity.

RESULTS

Smoking is associated with increased suicide across psychiatric diagnoses and in the general population, proportionately to the number of cigarettes smoked per day. Rapid nicotine uptake into the brain through inhalation of conventional cigarettes, electronic cigarettes (e-cigarette), or even second-hand smoke can facilitate long-term sensitization and short-term impulsivity. Both impair action regulation and predispose to negative affect, continued smoking, and suicidal behavior. Intermittent hypoxia, induced by cigarettes or e-cigarettes, synergistically promotes impulsivity and sensitization, exacerbating suicidality. Two other shared behavioral risks also develop negative urgency (combined impulsivity and negative affect) and cross-sensitization to stressors or to other addictive stimuli. Finally, early smoking onset, promoted by e-cigarettes in never-smokers, increases subsequent suicide risk.

CONCLUSION AND SCIENTIFIC SIGNIFICANCE

Prevention or cessation of nicotine inhalation can strategically prevent suicidality and other potentially lethal behavior regardless of psychiatric diagnoses. Medications for reducing smoking and suicidality, especially in younger smokers, should consider the neurobehavioral mechanisms for acute impulsivity and longer-term sensitization, potentially modulated more effectively through glutamate antagonism rather than nicotine substitution. (Am J Addict 2021;30:316-329).

Proposal for the Inclusion of Tobacco Use in Suicide Risk Scales: Results of a Meta-Analysis

There is an association between smoking and suicide, even though the direction and nature of this relationship remains controversial. This meta-analysis aimed to evaluate the association between smoking and suicidal behaviours (ideation, planning, suicide attempts, and death by suicide). On 24 August 2020, we searched the PubMed, Cochrane library, Scopus, Web of Science, TRIP, and SCIENCE DIRECT databases for relevant articles on this topic. Twenty prospective cohort studies involving 2,457,864 participants were included in this meta-analysis. Compared with never smokers, former and current smokers had an increased risk of death by suicide (relative risk [RR] = 1.31; 95% CI [1.13, 1.52] and RR = 2.41; 95% CI [2.08, 2.80], respectively), ideation (RR = 1.35; 95% CI [1.31, 1.39] and RR = 1.84; 95% CI [1.21, 2.78]), and attempted suicide (RR = 1.27; 95% CI [0.56, 2.87] and RR = 1.71; 95% CI [0.73, 3.97]). Moreover, compared to never smokers, current smoker women (RR = 2.51; 95% CI [2.06–3.04] had an increased risk of taking their own life (Q = 13,591.53; p < 0.001) than current smoker men (RR = 2.06; 95% CI [1.62–2.62]. Furthermore, smoking exposure (former and current smokers) was associated with a 1.74-fold increased risk (95% CI [1.54, 1.96]) of suicidal behaviour (death by suicide, ideation, planning, or attempts). Thus, because of the prospective relationship between smoking and suicidal behaviours, smoking should be included in suicide risk scales as a useful and easy item to evaluate suicide risk.

Examining the effect of smoking on suicidal ideation and attempts: triangulation of epidemiological approaches

BACKGROUND

Previous literature has demonstrated a strong association between cigarette smoking, suicidal ideation and suicide attempts. This association has not previously been examined in a causal inference framework and could have important implications for suicide prevention strategies.

AIMS

We aimed to examine the evidence for an association between smoking behaviours (initiation, smoking status, heaviness, lifetime smoking) and suicidal thoughts or attempts by triangulating across observational and Mendelian randomisation analyses.

METHOD

First, in the UK Biobank, we calculated observed associations between smoking behaviours and suicidal thoughts or attempts. Second, we used Mendelian randomisation to explore the relationship between smoking and suicide attempts and ideation, using genetic variants as instruments to reduce bias from residual confounding and reverse causation.

RESULTS

Our observational analysis showed a relationship between smoking behaviour, suicidal ideation and attempts, particularly between smoking initiation and suicide attempts (odds ratio, 2.07; 95% CI 1.91-2.26; P < 0.001). The Mendelian randomisation analysis and single-nucleotide polymorphism analysis, however, did not support this (odds ratio for lifetime smoking on suicidal ideation, 0.050; 95% CI -0.027 to 0.127; odds ratio on suicide attempts, 0.053; 95% CI, -0.003 to 0.110). Despite past literature showing a positive dose-response relationship, our results showed no clear evidence for a causal effect of smoking on suicidal ideation or attempts.

CONCLUSIONS

This was the first Mendelian randomisation study to explore the effect of smoking on suicidal ideation and attempts. Our results suggest that, despite observed associations, there is no clear evidence for a causal effect.

Prevalence and smokers' profile: comparisons between the psychiatric population and the general population

Objectives:

to identify the prevalence of smokers between the psychiatric population and the general population; to compare the personal, socio-demographic and clinical profile of smokers and non-smokers in the psychiatric population and the general population; to compare the reasons for smoking of these two population groups.

Method:

this is a cross-sectional descriptive-analytical epidemiological study with 378 patients from three services: Ambulatory Mental Health, Psychiatric Hospital, and Basic Health Unit. Interviews were conducted with three questionnaires. The Chi-square and Kruskal-Wallis tests were applied.

Results:

in the total of the 378 participants, 67% were women and 69% were over 40 years old. There was a higher prevalence of smokers among men, young people, illiterates, singles and with more than one government benefit. Smokers prevailed among schizophrenics, chronic patients, who used ≥ 3 psychotropic drugs and had a history of ≥ 4 psychiatric hospitalizations and/or suicide attempts. The main reason for smoking was the improvement of negative feelings.

Conclusion:

the prevalence of smokers is higher in the psychiatric population (especially among severely ill patients) and among men, young people, unmarried and with socioeconomic losses. The main reason for smoking is tension/relaxation relief. This study provides nurses and other professionals with knowledge capable of subsidizing the planning of smoking interventions in the Brazilian population.

Nicotine Dependence and Pre-Enlistment Suicidal Behavior Among U.S. Army Soldiers

INTRODUCTION

Identification of modifiable risk factors for suicidal behaviors is a priority for the U.S. Army. This study investigated associations of nicotine dependence with suicidal behaviors among incoming soldiers.

METHODS

Lifetime DSM-IV nicotine dependence, mental disorders, suicidal behaviors, and their ages of onset were retrospectively assessed in the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) New Soldier Study. Discrete-time survival analysis of person-year data from 30,436 soldiers was performed to evaluate associations of nicotine dependence with subsequent suicidal ideation, plans, and attempts. Among respondents with lifetime ideation (n=4,060), models tested associations of nicotine dependence with progression from ideation to first onset of plan, from plan to first attempt, and, among ideators without plans, from ideation to first unplanned attempt. A hierarchy of models incorporated increasing controls for other risk factors. Data were collected in 2011-2012 and analyzed in 2017-2018.

RESULTS

In models controlling for sociodemographic characteristics, nicotine dependence was associated with onset of all suicidal behaviors (AORs, 2.07-4.08, p<0.001) and with each type of progression of suicidal behavior (AORs, 1.48-2.44, p<0.005). After adjusting for childhood adversities and mental disorders, nicotine dependence remained associated with onset of ideation (AOR=1.27, 95% CI=1.10, 1.46, p=0.001) and attempt (AOR=1.83, 95% CI=1.41, 2.37, p<0.001); and with progression from ideation to unplanned attempt (AOR=2.03, 95% CI=1.17, 1.74, p<0.001).

CONCLUSIONS

Nicotine dependence exhibited associations with onset of suicidal ideation and suicide attempt-and with progression from ideation to unplanned attempt-that were independent of other measured risk factors. Awareness of associations of nicotine dependence with suicidal behaviors may inform risk assessment, facilitate targeting of prevention efforts, and provide further impetus for reducing nicotine dependence.

Genetic Interaction Between Two VNTRs in the SLC6A4 Gene Regulates Nicotine Dependence in Vietnamese Men

Nicotine dependence is an addiction to tobacco products and a global public health concern. Association between the SLC6A4 polymorphisms and nicotine dependence is controversial. Two variable number tandem repeat (VNTR) domains, termed HTTLPR and STin2, in the SLC6A4 gene are well characterized transcriptional regulatory elements. Their polymorphism in the copy number of the repeat correlates with the particular personality and psychiatric traits. We analyzed nicotine dependence in 1,804 participants from Central Vietnam. The Fagerström Test (FTND) was used to evaluate the nicotine dependence and PCR was used to determine the SLC6A4 HTTLPR and STin2 VNTRs. The HTTLPR VNTR was associated with difficulties to refrain from smoking in a prohibiting environment. The STIn2 10/10 genotype was associated with (1) years of smoking, (2) difficulties to quit the first cigarette, and (3) higher number of cigarettes smoked per day (CPD). Stratification analysis was used to find the genetic interaction between these two VNTRs in nicotine dependence as they may synergistically regulate the SLC6A4 expression. Smokers with the S/S HTTLPR genotypes showed a much stronger association between STin2 10/10 variant and CPD. This finding is consistent with the molecular evidence for the functional interaction between HTTLPR and STin2 in cell line models, where STin2 has described as a stronger expressional regulator. Similarly, we found that STin2 is a much stronger modifier of smoking with 10/10 genotype related to higher nicotine dependence. The present study supports genetic interaction between HTTLPR and STin2 VNTRs in the regulation of nicotine dependence with the dominance of the STin2 effects. This finding could be explained by their differential effect on the SLC6A4 expression.

Gender-specific study of recurrent suicide attempts in outpatients with multiple substance use disorders

BACKGROUND

people suffering from substance use disorders (SUD) often die by suicide, so that the prevention of suicide attempts (SA) remains a top priority in this population. SA recurrence is common and is associated with suicide death, but this phenotype has been overlooked in SUD populations. Thus, we aimed at identifying the risk factors of SA recurrence in SUD, controlling for both gender and levels of exposure to addictive substances, including tobacco.

METHODS

we consecutively recruited 433 treatment-seeking outpatients with either opiate or cocaine use disorder and assessed their lifetime history of addictive and suicidal symptoms by standardized questionnaires. They were reliably classified as never, single or recurrent (≥ 2) suicide attempters, whose characteristics were identified by multinomial regression, stratified by gender; and compared to our previous work on serious SA in order to identify common or different risk profiles.

RESULTS

86/140 (61%) suicide attempters reported recurrence. The mean number of SA was 3.1. Recurrence was independently associated with psychiatric hospitalization in both genders, with nicotine dependence in men and with sedative use disorders in women.

LIMITATIONS

psychiatric diagnoses were derived from the current medication regimen.

CONCLUSION

specific and possibly avoidable/treatable risk factors for the recurrence of SA in SUD have been identified for the first time, opening new avenues for research and prevention in this high-risk population. Apart from nicotine dependence, these risk factors were very similar to those of serious SA. Although this comparison is indirect for now, it suggests a common liability towards suicidal behavior.

Association between dry eye symptoms and suicidal ideation in a Korean adult population

Purpose

This study assessed the association of dry eyes with depression and suicidal ideation in a Korean adult population.

Methods

Data from 16408 participants (6972 men and 9436 women) aged ≥ 19 years included in the fifth Korea National Health and Nutrition Examination Survey, conducted from 2010–2012, were analyzed. For dry eyes, surveys of previous diagnosis of dry eye disease (DED) by an ophthalmologist and experience of subjective dry eye symptoms were separately used. Diagnosis of depression and suicidal ideation were obtained via responses to an interviewer-assisted questionnaire, and questions were asked in a closed-ended response format. Logistic regression was used to examine the associations between dry eyes, depression, and suicidal ideation.

Results

DED diagnosis exhibited an odds ratio (OR) of 1.32 (95% confidence interval [CI] 1.11–1.57) for depression and 1.24 (95% CI 1.05–1.48) for suicidal ideation compared to those without DED, after adjusting for sex, age, education, occupation, household income, body mass index, smoking behavior, alcohol consumption, physical activity, hypertension, diabetes, dyslipidemia, thyroid diseases, major cardiovascular disease, and cancer. Similarly, the adjusted OR (95% CI) of dry eye symptoms was 1.50 (95% CI 1.30–1.73) for depression and 1.47 (95% CI 1.27–1.70) for suicidal ideation.

Conclusion

Our findings suggest that dry eyes (either DED diagnosis or dry eye symptoms) may be associated with the prevalence of depression and suicidal ideation in the Korean adult population.

Tobacco addiction in the psychiatric population and in the general population

Objective:

To estimate the degree of tobacco addiction and identify independently associated factors by comparing the psychiatric population of secondary and tertiary care with the general population of the primary healthcare network.

Method:

This is a cross-sectional epidemiological study, conducted in a municipality of São Paulo, with 134 smokers of a Mental Health Outpatient Unit (MHOU), a Psychiatric Hospital (PH), and a Primary Healthcare Unit (PHU). Data were collected by means of individual interviews, recorded on a mobile device. Data were statistically processed using Stata/12

Results:

Of the 134 participants, 54.5% were women. While 49.1% of the psychiatric population (MHOU/PH) had medium/high nicotine addiction, 58.3% of smokers of the general population had very low/low dependency. The Poisson regression model indicated a higher prevalence of smokers with high dependence among men (PR = 1.41), people aged 49 years or less (15 - 29 years, PR = 4.06, 30 - 39 PR = 2.96 years, 40 - 49 years PR = 1.84), with severe mental disorders (PR = 3.05), with anxiety disorders/other (PR = 3.98), and with high suicide risk (PR = 1.55).

Conclusion:

Nicotine dependence was greater in the psychiatric population than in the general population. The independent factors associated with severe dependence were sex, age group, diagnosis, and current risk of suicide. These results trigger reflection among nurses on the need to focus more attention on a neglected subject in mental health services.

Prospective association between tobacco smoking and death by suicide: a competing risks hazard analysis in a large twin cohort with 35-year follow-up

BACKGROUND

The relationship between smoking and suicide remains controversial.

METHOD

A total of 16 282 twin pairs born before 1958 in Finland and alive in 1974 were queried with detailed health and smoking questionnaires in 1975 and 1981, with response rates of 89% and 84%. Smoking status and dose, marital, employment, and socio-economic status, and indicators of psychiatric and somatic illness were assessed at both time points. Emergent psychiatric and medical illness and vital status, including suicide determined by forensic autopsy, were evaluated over 35-year follow-up through government registries. The association between smoking and suicide was determined in competing risks hazard models. In twin pairs discordant for smoking and suicide, the prospective association between smoking and suicide was determined using a matched case-control design.

RESULTS

Smokers had a higher cumulative suicide incidence than former or never smokers. Heavy smokers had significantly higher suicide risk [hazard ratio (HR) 3.47, 95% confidence interval (CI) 2.31-5.22] than light smokers (HR 2.30, 95% CI 1.61-3.23) (p = 0.017). Compared with never smokers, smokers, but not former smokers, had increased suicide risk (HR 2.56, 95% CI 1.43-4.59), adjusting for depressive symptoms, alcohol and sedative-hypnotic use, and excluding those who developed serious somatic or psychiatric illness. In twin pairs discordant for smoking and suicide, suicide was more likely in smokers [odds ratio (OR) 6.0, 95% CI 2.06-23.8].

CONCLUSIONS

Adults who smoked tobacco were more likely to die by suicide, with a large, dose-dependent effect. This effect remained after consideration of many known predictors of suicide and shared familial effects, consistent with the hypothesis that exposure to tobacco smoke increases the risk of suicide.

Reciprocal relationships between substance use and disorders and suicidal ideation and suicide attempts in the Collaborative Study of the Genetics of Alcoholism

BACKGROUND

Substance use and misuse and suicidal thoughts and behaviors tend to co-occur. The purpose of this study was to examine whether (a) suicidal ideation and attempt are related to onset of alcohol, nicotine and cannabis use and dependence; (b) early use of alcohol, nicotine and cannabis is associated with onset of suicidal ideation and attempt; and (c) whether these associations persist while controlling for covariates, such as family history of alcohol problems, major depression and other internalizing and externalizing disorders.

METHODS

The prospective cohort of the Collaborative Study of the Genetics of Alcoholism (COGA; N=3277) was used. Cross-sectional and discrete time logistic regression (i.e. survival) analyses examined associations between suicidal ideation and attempt and onset of alcohol, nicotine and cannabis use and dependence. Survival models also examined whether individual early substance use was related to onset of ideation and attempt.

RESULTS

Ideation was related to 0.71-0.77 odds of onset of subsequent alcohol, nicotine and cannabis use. Attempt was associated with 1.44-1.61 odds of later alcohol, nicotine and cannabis dependence, even after accounting for covariates. Evidence for early substance use being related to subsequent onset of ideation or attempt was limited. Several sex and race differences emerged.

LIMITATIONS

The sample was ascertained for family history of alcoholism; not all participants had been followed up allowing for censored observations; reporting bias.

CONCLUSION

Suicide attempts are associated with increased likelihood of onset of substance dependence.

Suicide risk in a representative sample of people receiving HIV care: Time to target most-at-risk populations (ANRS VESPA2 French national survey)

BACKGROUND

Suicide risk is high among people living with HIV (PLHIV). This study aimed to identify major correlates of suicide risk in a representative sample of PLHIV in France, in order to help target individuals who would benefit from suicide risk screening and psychiatric care.

METHODS

The ANRS VESPA2 cross-sectional survey (April 2011-January 2012) collected socio-demographic, medical and behavioral data from 3,022 PLHIV recruited in 73 French HIV hospital departments. The study sample comprised the 2,973 participants with available self-reported data on suicide risk (defined as having either thought about and planned to commit suicide during the previous 12 months or attempted suicide during the same period of time) and medical data on comorbidities. Weighted Poisson models adjusted for HCV co-infection and significant clinical variables were used to estimate the relationship between suicide risk and HIV transmission groups, experience with HIV disease and other psychosocial factors.

RESULTS

Suicide risk was reported by 6.3% of PLHIV in the study sample. After adjustment for HIV immunological status and HCV co-infection, women (IRR [95%CI]:1.93 [1.17; 3.19]) and men who have sex with men (MSM) (1.97 [1.22; 3.19]) had a higher suicide risk than the rest of the sample. Moreover, the number of discrimination-related social contexts reported (1.39 [1.19; 1.61]), homelessness (4.87 [1.82; 13.02]), and reporting a feeling of loneliness (4.62 [3.06; 6.97]) were major predictors of suicide risk.

CONCLUSIONS

Reducing the burden of precarious social conditions and discrimination is an important lever for preventing suicide risk among PLHIV in France. Comprehensive care models involving peer/community social interventions targeted at women and MSM need to be implemented to lower the risk of suicide in these specific subgroups of PLHIV.

Smoking and Suicide: A Meta-Analysis

BACKGROUND

Many studies have reported a positive association between smoking and suicide, but the results are inconsistent. This meta-analysis was carried out to estimate the association between smoking and suicidal ideation, suicide plan, suicide attempt, and suicide death.

METHODS

Major electronic databases including PubMed, Web of Science, Scopus, and ScienceDirect were searched until May 2015. The reference lists of included studies were screened too. Epidemiological studies addressing the association between smoking and suicidal behaviors were enrolled. The heterogeneity across studies was explored by Q-test and I2 statistic. The possibility of publication bias was assessed using Begg's and Egger's tests and Trim & Fill analysis. The results were reported based on risk ratio (RR) and odds ratio (OR) with 95% confidence intervals (CI) using a random-effects model.

RESULTS

We identified a total of 8062 references and included 63 studies with 8,063,634 participants. Compared to nonsmokers, the current smokers were at higher risk of suicidal ideation (OR = 2.05; 95% CI: 1.53, 2.58; 8 studies; I2 = 80.8%; P<0.001), suicide plan (OR = 2.36; 95% CI: 1.69, 3.02; 6 studies; I2 = 85.2%; P<0.001), suicide attempt (OR = 2.84; 95% CI: 1.49, 4.19; 5 studies; I2 = 89.6%; (P<0.001), and suicide death (RR = 1.83; 95% CI: 1.64, 2.02; 14 studies; I2 = 49.7%; P = 0.018).

CONCLUSIONS

There is sufficient evidence that smoking is associated with an increased risk of suicidal behaviors. Therefore, smoking is a contributing factor for suicide. Although this association does not imply causation, however, smoking prevention and cessation should be the target of suicide prevention programs.

Tobacco Use and 12-Month Suicidality Among Adults in the United States

INTRODUCTION

To examine how 12-month prevalences of suicidality vary by tobacco use.

METHODS

Data were from 325 800 adults who participated in the 2008-2014 National Survey on Drug Use and Health. Descriptive analyses and multivariable multinomial logistic regression models were applied.

RESULTS

Among adults aged 18 or older in the United States during 2008-2014, 27.4% (annual average, standard error [SE] = 0.14%) were never tobacco users, 38.8% (SE = 0.17%) were former tobacco users, 5.9% (SE = 0.07%) were past-year users of other types of tobacco (non-cigarette), 20.2% (SE = 0.13%) were past-year cigarette-only users, and 7.7% (SE = 0.07%) were past-year users of cigarettes plus other types of tobacco; 2.6% (SE = 0.04%) had suicidal ideation only, 0.7% (SE = 0.02%) had suicidal ideation and suicide plan only, and 0.5% (SE = 0.02%) attempted suicide. After controlling for covariates, compared with never tobacco users, past-year users of cigarettes plus other types of tobacco were at elevated risk of all examined suicidality outcomes (adjusted relative risks [ARRs] = 1.2-1.7), and past-year cigarette-only users were at higher risk of suicide attempt (ARR = 1.4). Early age of first tobacco use was associated with higher risk of suicidal ideation and suicide plan among former tobacco users, past-year tobacco users, and past-year cigarette users (ARRs = 1.2-1.6). Among past-year tobacco users, frequencies of cigarette and cigar use were associated with suicide attempt (ARRs = 1.4-1.7). Nicotine dependence was associated with suicide attempt among past-year cigarette users (ARR = 1.2).

CONCLUSIONS

Tobacco use is associated with 12-month suicidality among adults. Patients who use tobacco should be assessed further for mental health status and suicide risk.

IMPLICATIONS

Our results revealed that tobacco use is independently associated with the 12-month suicidality outcomes among adults and identified how the prevalences of 12-month suicidality outcomes vary by tobacco use status and use characteristics among adults. These results have important clinical implications. Future research should assess the effectiveness of tobacco use questions as simple screeners for more extensive assessment of mental health status and suicide risk.

Are Smoking Cessation Treatments Associated with Suicidality Risk? An Overview

Risk of suicidality during smoking cessation treatment is an important, but often overlooked, aspect of nicotine addiction research and treatment. We explore the relationship between smoking cessation interventions and suicidality and explore common treatments, their associated risks, and effectiveness in promoting smoking reduction and abstinence. Although active smokers have been reported to have twofold to threefold increased risk of suicidality when compared to nonsmokers,1–4 research regarding the safest way to stop smoking does not always provide clear guidelines for practitioners wishing to advise their patients regarding smoking cessation strategies. In this article, we review pharmacological and cognitive behavioral therapy (CBT) options that are available for people seeking to quit smoking, focusing on the relationship between the ability of these therapies to reduce smoking behavior and promote abstinence and suicidality risks as assessed by reported suicidality on validated measures, reports of suicidal ideation, behaviors, actual attempts, or completed suicides. Pharmacotherapies such as varenicline, bupropion, and nicotine replacement, and CBTs, including contextual CBT interventions, have been found to help reduce smoking rates and promote and maintain abstinence. Suicidality risks, while present when trying to quit smoking, do not appear to demonstrate a consistent or significant rise associated with use of any particular smoking cessation pharmacotherapy or CBT/contextual CBT intervention reviewed.

Heavy tobacco dependence in suicide attempters making recurrent and medically serious attempts

AIMS

Tobacco dependence and suicidal behaviors have been repeatedly associated in several studies but their relationship is still unclear. We aim to investigate, specifically, the association between the level of tobacco dependence and the severity of suicidal outcomes among suicide attempters, as well as the relationship of impulsivity with both conditions.

METHODS

We examined a cross-sectional sample of 542 adult suicide attempters to compare the characteristics of the attempts depending on the level of tobacco dependence, which was assessed with the Fagerstrom test.

RESULTS

Smokers with heavy dependence (Fagerstrom ≥7) made more attempts and reached higher medical lethality compared to non-smokers. Smokers with moderate dependence were not associated with features of severity in the suicide attempts. The combination of high impulsivity and heavy tobacco dependence showed an additive effect on the number of suicide attempts.

CONCLUSIONS

A high or very high level of tobacco dependence could indicate a specific vulnerability leading to more severe suicide attempts. Impulsive attempters with heavy tobacco dependence were particularly at risk.

Association Between Social Integration and Suicide Among Women in the United States

IMPORTANCE

Suicide is one of the top 10 leading causes of mortality among middle-aged women. Most work in the field emphasizes the psychiatric, psychological, or biological determinants of suicide.

OBJECTIVE

To estimate the association between social integration and suicide.

DESIGN, SETTING, AND PARTICIPANTS

We used data from the Nurses' Health Study, an ongoing nationwide prospective cohort study of nurses in the United States. Beginning in 1992, a population-based sample of 72 607 nurses 46 to 71 years of age were surveyed about their social relationships. The vital status of study participants was ascertained through June 1, 2010.

EXPOSURES

Social integration was measured with a 7-item index that included marital status, social network size, frequency of contact with social ties, and participation in religious or other social groups.

MAIN OUTCOMES AND MEASURES

The primary outcome of interest was suicide, defined as deaths classified using the codes E950 to E959 from the International Classification of Diseases, Eighth Revision.

RESULTS

During more than 1.2 million person-years of follow-up (1992-2010), there were 43 suicide events. The incidence of suicide decreased with increasing social integration. In a multivariable Cox proportional hazards regression model, the relative hazard of suicide was lowest among participants in the highest category of social integration (adjusted hazard ratio, 0.23 [95% CI, 0.09-0.58]) and second-highest category of social integration (adjusted hazard ratio, 0.26 [95% CI, 0.09-0.74]). Increasing or consistently high levels of social integration were associated with a lower risk of suicide. These findings were robust to sensitivity analyses that accounted for poor mental health and serious physical illness.

CONCLUSIONS AND RELEVANCE

Women who were socially well integrated had a more than 3-fold lower risk for suicide over 18 years of follow-up.

Exploring the Determinants of Suicidal Behavior: Conventional and Emergent Risk (DISCOVER): a feasibility study

BACKGROUND

Suicidal behavior is a growing public health concern resulting in morbidity and premature death. Although certain factors such as age, sex, and psychiatric disorders have been consistently reported to be associated with suicidal behavior, other factors including biological markers, diet, and physical activity may also influence suicidal behavior. The purpose of this pilot study was to evaluate the feasibility of conducting a full-scale study to identify the conventional and novel risk factors of suicidal behavior in individuals who made a recent suicide attempt.

METHODS

This pilot study was a case-control study of participants with recent (within 1 month of admission) suicide attempts admitted to hospital and compared to two control groups: 1) psychiatric inpatient participants without a history of suicide attempts and 2) community-based controls. We collected information on demographic variables, circumstances of suicide attempts (for cases), medical and psychiatric diagnoses, behavioral patterns, physical measurements, and social factors. Blood and urine samples were also collected for biological markers. Feasibility outcomes are as follows: 1) 50 % of all eligible cases will consent to participate, 2) 50 cases and 100 controls per year can be recruited, and 3) at least 80 % of the participants will provide blood samples for DNA and biological markers.

RESULTS

We recruited 179 participants in total; 51 cases, 57 psychiatric controls without suicide attempt, and 71 non-psychiatric controls in Hamilton, Ontario. Recruitment rate was 70 % (213/304), and we obtained urine and blood specimens from 90 % (191/213) of participants. Questionnaire completion rates were high, and data quality was very good with few data-related queries to resolve. We learned that cases tended to be hospitalized for long periods of time and the suicide attempt occurred more than a month ago in many of the cases; therefore, we expanded our inclusion criterion related to timing of suicide attempt to 3 months instead of 1 month.

CONCLUSIONS

The study procedures needed certain modifications including extending the time between suicide attempt and date of recruitment, and more detailed questionnaires related to diet were necessary while other questionnaires such as social support needed to be shortened. Overall, this study showed that it is feasible to conduct a larger-scale study.

Manner Determination in Forensic Pathology

A traditional function of forensic pathologists in the United States is the determination of cause and manner of death. The formal certification of manner of death is an American innovation of the early 20th century. Many countries do not follow this tradition. While originally established for vital statistics and public health purposes, the use of manner has grown to include increased legal, social, and business functions. The expanded role of manner determination has led to controversy regarding its true function, who should do it, and if it should be done at all. Much of the controversy regarding manner determination is due to inherent ambiguities that arise primarily from the limited number of categories and fundamental epistemic issues. Much of the heterogeneity in manner determination is structural and not a matter of error. Other criticisms come from those who focus on the legal implications of manner determination. Some have claimed that the use of circumstantial information in manner determination constitutes cognitive bias. Others suggest that manner determination is not a medical issue at all. A response is that the integration of circumstances and history with physical examination and laboratory findings represents the classic paradigm of medical diagnosis, and reinforces rather than opposes recognition that this is the practice of medicine. Transferring the task of manner determination to another agency would do nothing to improve accuracy, timeliness, or function. Other candidates to perform this function would be successful only to the degree that they were trained and function as forensic pathologists.