Nicotine dependence vs. daily smoking as a meaningful variable: implications for clinical and epidemiological psychiatric studies

Psychometric properties and factor structure of the brief Wisconsin Inventory of Smoking Dependence Motives among Spanish smokers from the general population

INTRODUCTION

The brief version of the Wisconsin Inventory of Smoking Dependence Motives (B-WISDM) is a well-established instrument to measure the multidimensional nature of nicotine dependence. However, no previous research has assessed its psychometric properties in the Spanish context. The aim of the present study was to analyze the factor structure and measurement invariance across gender of this instrument among Spanish smokers from the general population.

METHODS

This cross-sectional study assessed 480 smokers through an online questionnaire including information on tobacco use and several nicotine dependence measures. Confirmatory Factor Analysis was used to assess the factorial structure of the Spanish B-WISDM, its internal consistency, measurement invariance across gender and convergent validity with the Fagerström Test for Nicotine Dependence (FTND) and the Glover-Nilsson Smoking Behavioral Questionnaire (GN-SBQ) scores.

RESULTS

Results indicate that the eleven correlated factors solution had a better fit when compared to the other tested models (two correlated factors and two second-order factors with eleven first-order correlated factors solution), remaining such structure invariant across gender. Internal consistency of the scale was high (α = 0.950; dimension α values ranged between 0.657 and 0.921). Overall scores and dimensions of the scale significantly and positively correlated with other nicotine dependence measures (except for Social/Environmental Goads and FTND).

CONCLUSIONS

This is the first version of the B-WISDM validated to assess nicotine dependence with a multidimensional perspective within the Spanish culture. Results show adequate psychometric properties regarding its factor structure and measurement invariance across gender, supporting its utility to evaluate the motives driving tobacco use among Spanish smokers from the general population.

Associations between unhealthy lifestyle and depression: Cross-sectional results from the Spanish National Health Survey

INTRODUCTION

Depression usually worsens lifestyle habits, but previous evidence also suggests that an unhealthy lifestyle (UL) increases the risk of depression. Many studies have analyzed the association between lifestyle and depression in several nationally representative samples, but none have done so in the Spanish adult population. Our aim was to examine the associations between UL habits and depression in Spain.

MATERIALS AND METHODS

Analysis of cross-sectional data from the latest National Health Survey published in 2018 (N=23,089). Data on depression and 4 lifestyle factors (diet, physical exercise, smoking, and alcohol consumption) were used. These factors were combined into an UL index ranging from 0 (healthiest lifestyle) to 4 (unhealthiest lifestyle). The prevalence of depression at different levels of the UL index, and the association between depression and both the cumulative UL index and the 4 UL factors was analyzed using parametric and non-parametric tests.

RESULTS

Sedentarism was the most prevalent UL factor, followed by unhealthy diet, smoking and high-risk alcohol consumption. Having ≥1 UL factors was associated with a higher prevalence of depression compared to having 0 UL factors (2.5% vs. ≥5.2%), regardless of the cumulative number UL factors (1, 2, 3 or 4). Being physically inactive (OR=1.6) and a smoker (OR=1.3) increased the likelihood of depression. Being a high-risk wine drinker (OR=0.26) decreased the likelihood of depression. Dietary intake was not significant.

CONCLUSIONS

The prevalence of depression changes depending on several modifiable lifestyle factors. Policy makers should therefore spare no resources in promoting strategies to encourage healthy lifestyles and prevent the acquisition of UL habits.

Illness Insight and Medication Adherence Among Patients With Bipolar Disorder

The aim of this study was to investigate the factors associated with illness insight and medication adherence in bipolar disorder (BD). This is a cross-sectional study (with a retrospective evaluation of longitudinal variables) and a secondary analysis of a BD database. The insight of 108 outpatients (age, 48.2 ± 14.1 years, 69% women, 33% euthymic) was measured with three items of the Association of Methodology and Documentation in Psychiatry scale. Their adherence was assessed through patients' and caregivers' reports, plus serum levels. We performed multivariate logistic regression analyses. Full insight was independently and directly associated with adherence, a social support score, and depressive symptoms and inversely associated with intensity of manic symptoms, problems ever with alcohol, and age at onset of the first symptoms. Medication adherence was independently and directly associated with insight, being married, and having had a psychiatric hospitalization and inversely with having suffered a high number of depressive episodes, intensity of manic symptoms, and heavy tobacco smoking.

Temperament traits and remission of depression: A naturalistic six-month longitudinal study

BACKGROUND

The aim of this naturalistic longitudinal study was to add evidence regarding the potential of Cloninger's temperament traits (novelty seeking, harm avoidance, reward dependence and persistence) for predicting the effect of pharmacological treatment on the rates of therapeutic response and remission.

METHODS

The study was based on 200 outpatients with unipolar depressive disorders of different severity and course of illness, and extended up to 6 months of follow-up. Patients were assessed in their temperament with the Tridimensional Personality Questionnaire (TPQ) and their condition was classified (in course and severity) according to the International Classification of Diseases, Tenth revision (ICD-10) diagnostic criteria for research. Patients were blindly rated (concerning other predicting variables) on the improved Clinical Global Impression-Severity scale for depression (iCGI-S) at baseline, 6 weeks, 3 months and 6 months. Outcome measures at the last observation carried forward were therapeutic response (reduction of ≥50% in the last iCGI-S) and remission (last iCGI-S = 0), which were available for 187 patients.

RESULTS

Remission was independently and directly associated with length of follow-up, and inversely with the baseline iCGI-S score and harm avoidance (patients in the high tertile had a 2.7 likelihood of non-remission in comparison with those in the low tertile); persistence was found to have a complex, V-shape relationship with remission. Within a sub-sample of more severe cases (n = 118), having higher harm avoidance scores, a more favorable outcome was associated with higher reward dependence and the non-smoking condition.

LIMITATIONS

With a naturalistic, non-experimental design, the sample may not be representative of the general population.

CONCLUSIONS

Temperament traits may help predict outcome in patients treated for depression.

Temporal sequencing of nicotine dependence and major depressive disorder: A U.S. national study

Major Depressive Disorder (MDD) and Nicotine dependence (ND) often co-occur. However, little attention has been given to the temporal order between the two disorders. We compared the sociodemographic and clinical characteristics of individuals whose onset of ND preceded (ND-prior) or followed the onset of MDD (MDD-prior). Binary logistic regression models were computed to compare ND-prior (n=546) and MDD-prior (n=801) individuals from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC, n=43,093). We found that MDD-prior were more likely to have a history of suicide attempts and a family history of both depression and antisocial behavior, to have had psychiatric hospitalization, and to have an earlier age of onset of the first depressive episode; but a later age of onset for both daily smoking and ND. On average, MDD-prior individuals showed a significantly longer transition time from daily smoking to ND (15.6±0.6 vs. 6.9±0.4 years, P<0.001). In contrast, ND-prior subjects had a significantly greater proportion of withdrawal symptoms, and of lifetime alcohol use or alcohol use disorder. We conclude that the phenomenology and course of ND and MDD vary significantly, depending on which disorder had earlier onset.

A combined analysis of worldwide studies demonstrates an association between bipolar disorder and tobacco smoking behaviors in adults

OBJECTIVES

Worldwide studies were combined to examine two hypotheses: (i) bipolar disorder is associated with smoking behaviors, compared with the general population; and (ii) smoking behavior prevalences in bipolar disorder are intermediate between those in major depressive disorder and those in schizophrenia.

METHODS

Combined analyses used 56 articles on adults obtained from a PubMed search or the senior author's article collection. Odds ratios (ORs) and their 95% confidence intervals (CIs) compared current smoking, heavy smoking among current smokers, smoking cessation in ever smokers, and ever smoking in bipolar disorder versus control groups.

RESULTS

The combined OR was 3.5 (CI: 3.39-3.54) in 51 current smoking studies of bipolar disorder versus the general population from 16 countries. More limited data provided an OR = 0.34 (CI: 0.31-0.37) for smoking cessation and an OR = 3.6 (CI: 3.30-3.80) for ever smoking. The combined OR was 0.76 (CI: 0.74-0.79) for current smoking in bipolar disorder versus schizophrenia in 20 studies from ten countries. Ever smoking may be lower in bipolar disorder than in schizophrenia (OR = 0.83, CI: 0.75-0.91). The OR was 2.05 (CI: 2.00-2.10) for current smoking in bipolar disorder versus major depression in 18 studies from seven countries. Ever smoking may be higher (OR = 1.5, CI: 1.40-1.70) and smoking cessation lower (OR = 0.51, CI: 0.45-0.59) in bipolar disorder than in major depression.

CONCLUSIONS

Increased current smoking in bipolar disorder versus the general population reflected increased ever smoking (initiation) and decreased smoking cessation. Smoking behavior frequencies in bipolar disorder may be between those in depressive disorder and schizophrenia, with schizophrenia showing the highest severity level.

The effect of nicotine dependence on psychopathology in patients with schizophrenia

Introduction. Our study aims to determine the prevalence of nicotine dependence and investigate the effect of nicotine dependence on psychopathology among schizophrenia patients. Methods. A cross-sectional study was carried out in an outpatient psychiatric clinic at a general hospital in Malaysia. 180 recruited subjects were administered the Malay version of Mini International Neuropsychiatric Interview (MINI), the Positive and Negative Symptom Scale (PANSS), and the Malay version of Fagerstrom Test for Nicotine Dependence (FTND-M) questionnaires. Results. The prevalence of nicotine dependence among the subjects was 38.1% (n = 69) and they were mainly composed of male gender, Malay ethnicity, being treated with atypical antipsychotics, and taking other illicit drugs or alcohol. Subjects with severe nicotine dependence scored less in the negative subscale of PANSS compared with the nonsmokers (P = 0.011). On performing the hierarchy multiple regressions, dependence status still significantly predicted negative scores after adjusting the confounders (t = −2.87, P = 0.005). Conclusion. The rate of nicotine use disorder among schizophrenia patients in this study is higher than that of the general population in Malaysia. The significant association between nicotine dependence and negative psychopathology symptoms will help the healthcare practitioners in their management of nicotine dependence among schizophrenia patients.

Tobacco use and cessation for cancer survivors: an overview for clinicians

Approximately 30% of all cancer deaths in the United States are caused by tobacco use and smoking. Cancers of eighteen sites have been causally linked to smoking, the most common of which are the lung, head and neck, bladder, and esophagus. While quit rates and quit attempt rates are relatively high shortly after a cancer diagnosis, the recidivism rates are also high. Therefore, screening, treating, and preventing relapse to tobacco use is imperative among patients with and survivors of cancer. To date, research has consistently shown that a combination of pharmacologic and behavioral interventions is needed to achieve the highest smoking cessation rates, with a recent emphasis on individualized treatment as a most promising approach. Challenges in health care systems, including the lack of appropriate resources and provider training, have slowed the progress in addition to important clinical considerations relevant to the treatment of tobacco dependence (eg, a high degree of comorbidity with psychiatric disorders and other substance use disorders). However, continued tobacco use has been shown to limit the effectiveness of major cancer treatments and to increase the risk of complications and of developing secondary cancers. The authors recommend that oncology providers screen all patients for tobacco use and refer users to specialized treatment when available. Alternatively, oncology clinicians can provide basic advice on tobacco use cessation and pharmacotherapy and/or referral to outside resources (eg, quitlines). Herein, the authors summarize the current knowledge on tobacco use and its treatment, with a focus on the related available evidence for patients with and survivors of cancer.

Smoking and psychopathology increasingly associated in recent birth cohorts

BACKGROUND

In recent decades, smoking has become an increasingly non-normative behavior. Because deviant behaviors are associated with greater clinical and genetic risks, current-generation smokers may have greater concentrations of psychiatric comorbidity than previous generations. We examined this question empirically by testing whether associations between measures of smoking, psychiatric diagnoses, and risk-associated personality traits, increased across seven birth-cohorts of the 20th century.

METHOD

4326 subjects from a cross-sectional NIMH control sample were categorized into one of seven groups based on birth (born before 1930, and 1930s-80s) and one of three smoking levels (lifetime dependent smoker, never dependent smoker, never smoker). Smoking and ND were assessed using the Fagerstrom Test for Nicotine Dependence; psychiatric diagnoses (drug and alcohol dependence, major depression, and generalized anxiety disorder) using the Composite International Diagnostic Interview-Short Form, and personality traits (neuroticism and extraversion) with the Eysenck Personality Questionnaire.

RESULT

Lifetime prevalence of smoking decreased across the seven cohorts. Associations between smoking and drug dependence, generalized anxiety, and neuroticism, as well as total psychiatric comorbidity, were greater in more recent cohorts [smoking-by-cohort interaction: p<0.01], with greatest increases contributed by nicotine-dependent smokers. Smoking was also independently associated with alcohol dependence and depression, but these associations did not significantly vary across cohorts.

CONCLUSIONS

More recent generations included fewer persons who smoked, but their smoking was associated with greater psychiatric morbidity. Failure to account for systematic variation in comorbidity across smoking cohorts may lead to unwanted heterogeneity in clinical, and possibly genetic, studies of nicotine dependence.

Overweight and obesity in patients with bipolar disorder or schizophrenia compared with a non-psychiatric sample

OBJECTIVE

Multiple studies suggest an association of overweight and obesity with bipolar disorder (BD) and schizophrenia. The goal of this paper was to determine the magnitude of this association and its relationship with previous course-of-illness and other variables of clinical interest.

METHODS

The prevalence of overweight and obesity was compared among patients with BD (n=108), patients with schizophrenia (n=250) and a non-psychiatric control group (n=290). Moreover, within each group we analyzed the variables associated with overweight [including obesity, i.e., body mass index (BMI) ≥25] and obesity (BMI≥30) adjusting for a possible confounding effect of sex, age and educational level by logistic regression.

RESULTS

In comparison with the non-psychiatric sample, a strong association of both BMI≥25 and obesity was observed with BD and schizophrenia (adjusted odds ratios between 3.4 and 4.6; P-values <0.001). Overweight was significantly associated with male sex and increasing age in both control and BD groups; and with female sex among schizophrenia patients. Moreover, for BD patients, earlier onset of first BD symptoms, presence of a non-psychiatric illness, current use of mood-stabilizing medication, and being a non-smoker were significantly associated with overweight; and male sex and the presence of a non-psychiatric illness, with obesity. Within the schizophrenia patients, obesity was significantly associated with female sex, intermediate age range and lower PANSS score.

CONCLUSIONS

Among patients with BD or schizophrenia, the chronic course of their illness and their current treatment with psychotropic medication might be more relevant for becoming overweight or obese than the specific psychiatric illness.

Factors associated with work, social life and family life disability in bipolar disorder patients

We analyzed the presence of work, social life and family life disability in 108 outpatients with a Diagnostic and Statistical Manual of Mental Disorders IV (DSM-IV) diagnosis of bipolar disorder and their association with previous course-of-illness variables and current psychopathology. Work disability was pragmatically defined as being on a disability pension or in the process of obtaining it; social life or family life disability was defined by a score ≥ 7 in the respective subscales of the Sheehan Disability Scale. At least one type of disability (for work, social life or family life) affected 52-54% of the patients; and two types, 37%. By logistic regression and multiple linear regression analyses we determined the variables independently associated with each type of disability: 1) Work disability was significantly associated with previous repeated manic episodes, three or more hospitalizations, with current depressive symptoms and inversely with the educational attainment. 2) Social life disability significantly increased with the number of hospitalizations and was associated with previous repeated depressive episodes and current depressive symptoms. In alternative models, nicotine dependence and lack of social support were significantly associated with work and social life disability respectively. And 3) family life disability significantly increased with number of hospitalizations, CAGE questionnaire score and age; and was associated with previous repeated manic episodes and current depressive symptoms. In conclusion, previous course-of-illness variables, particularly a high number of manic episodes, and current psychopathology - as indicated by the presence of nicotine dependence or depressive symptoms - may be indicators of disability; previous manic episodes appear to affect disability at work or at family life whereas previous depressive episodes seem to be related with social life disability.

Temporal relationship of first-episode non-affective psychosis with cannabis use: a clinical verification of an epidemiological hypothesis

BACKGROUND

We analyzed the association of age at onset of psychosis treatment (AOPT) with having a history of cannabis use in patients with a first episode of non-affective psychosis. We also investigated the impact on the AOPT of exposure to cannabis in adolescence, compared with young adulthood, and of the additional exposure to cocaine.

METHOD

We recruited 112 consecutive patients (66 men and 46 women; age range, 18-57years) with a first psychotic episode. The composite international diagnostic interview (CIDI) was used to assess drug use and to define the age at onset of heaviest use (AOHU) of a drug, defined as the age when drug was used the most for each patient. The effect of cannabis and cocaine AOHU on AOPT was explored through Kruskal-Wallis and Mann-Whitney tests, and logistic regression. Sex-adjusted cumulative hazard curves and Cox regression models were used to compare the AOPT of patients with and without a history of cannabis use, or associated cocaine use.

RESULTS

We found that the AOPT was significantly associated with the use of cannabis, independently of sex, use of cocaine, tobacco smoking or excessive alcohol consumption. There was a dose-response relationship between cannabis AOHU and AOPT: the earlier the AOHU the earlier the AOPT. Hazard curves showed that patients with a history of cannabis use had a higher hazard of having a first-episode psychosis than the rest of the patients (sex-adjusted log-rank chi(2)=23.43, df=1, p<0.001). Their respective median AOPT (25th, 75th percentiles) were 23.5 (21, 28) and 33.5years (27, 45) (for log-transformed AOPT, t=5.6, df=110, p<0.001). The sex-adjusted hazard ratio of psychosis onset comparing both groups was 2.66 (95% CI, 1.74-4.05).

CONCLUSIONS

Our results are in favor of a catalytic role for cannabis use in the onset of psychosis.