Probing the smoking-suicide association: do smoking policy interventions affect suicide risk?

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.

Sex difference in association between suicide attempts and lipid profile in first-episode and drug naive patients with major depressive disorder

BACKGROUND

The relationship between suicide attempts and lipid profiles in patients with major depressive disorder (MDD) remains uncertain. The purpose of this study was to investigate sex differences in the relationship between suicide attempts and plasma lipid profiles in a large sample of first-episode and drug naive (FEDN) MDD patients.

METHODS

We recruited 1718 FEDN MDD patients and gathered demographic, clinical, and blood lipid data. The Hamilton Depression Rating Scale, Hamilton Anxiety Rating Scale and the Positive and Negative Syndrome Scale were used to assess the symptoms of patients.

RESULTS

There was no significant difference in the prevalence of suicide attempts between male and female MDD patients. The suicide attempt group had higher levels of depression, anxiety, psychotic symptoms, total cholesterol (TC), and low-density lipoprotein cholesterol (LDL-C), but lower levels of high-density lipoprotein cholesterol (HDL-C) levels than the non-suicide attempt group. Binary logistic regression showed that TC levels were significantly correlated with suicidal attempts in both male and female patients. Correlation analysis revealed that the levels of TC, HDL-C and LDL-C were significantly associated with the number of suicide attempts in both male and female patients. Further multiple linear regression revealed that TC levels were significantly associated with the number of suicide attempts in male patients only.

CONCLUSIONS

Lipid biomarkers, particularly high TC levels, are associated with suicide attempts in both male and female MDD patients. However, there is gender difference in association between lipid biomarkers, especially TC levels, and the number of suicide attempts in MDD patients.

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.

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.

Characteristics associated with later self-harm hospitalization and/or suicide: A follow-up study of the HUNT-2 cohort, Norway

BACKGROUND

To improve suicide and self-harm prevention in adults, better knowledge on preexisting characteristics and risk factors is of great importance.

METHODS

This is a population-based case-control study; baseline measures were collected in the second wave of the North-Trøndelag Health Study (HUNT-2, 1995-1997) in Norway, and outcomes were observed for up to 19 years. Average follow up time was 4.9 years for self-harm and 6.8 years for suicides. Out of 93,898 eligible adult inhabitants aged 20 and above, a total of 65,229 (70%) participated in the study. The data were linked to the National Mortality Registry and hospital patient records in the three hospitals covering the HUNT-2 catchment area.

RESULTS

Among the participants, 332 patients (68% women) were hospitalized because of self-harm (HSH), and 91 patients (32% women) were died by suicide (SU). A total of 10% of those who died by SU had previously been HSH. People in the HSH and SU groups were younger, reported more depression and anxiety symptoms, sleeping problems, higher use of alcohol and tobacco, poorer social network and more economic problems, compared to the rest of the HUNT-2 population. In addition, the HSH group reported more somatic health problems, higher use of health services, higher sick leave, and lower work participation than the SU group.

LIMITATIONS

Younger adults (20-40 years) were under-represented in HUNT-2. Younger adults (20-40 years) were constituted 31.7% in HUNT-2, 50% in HSH and 33% in SU. Further, we did not identify less severe self-harm, not requiring hospitalization. Life changes, adverse events, and other possible triggers to self-harming behavior were not recorded.

CONCLUSION

Psychological problems were long-term predictors of both HSH and SU. Somatic health problems and lower functional performance were more present in HSH-group compared to the SU-group.

Integrating local health departments to reduce suicide-related emergency department visits among people with substance use disorders - Evidence from the state of Maryland

Individuals with a substance use disorder (SUD) are six times as likely than those without a SUD to attempt suicide, however just 18% of the SUD population has received treatment. One of the barriers to treatment is appropriate and timely mental health services. This resulted in a substantial increase in emergency department (ED) visits related to SUD and suicide. This study sought to determine if the number of suicide-related ED visits for patients with SUD is associated with the types of mental health activities provided by their local health department (LHD). Specifically, we examined whether patients with a SUD aged 18-64 experienced reductions in suicide-related ED visits when their LHD directly engaged in mental health activities, such as (1) primary prevention for mental illness or (2) mental health services. Using linked datasets for 2012 from the National Profile of Local Health Departments, U.S. Census data, Area Health Resource File, and Maryland's State Emergency Department Databases (SEDD), we employed multivariable logistic regressions and instrumental variable models to examine this association. After adjusting for the endogeneity of LHDs' activity measures and controlling for individual-, hospital-, LHD-, and county-level characteristics, results demonstrated patients with a SUD experienced a 6% and 5% reduction in suicide-related ED visits when their LHD directly provided primary prevention for mental illness and mental health services, respectively. The results are small but significant, with robust standard errors. This study suggests LHDs may be key players in preventing suicide-related ED visits among the SUD population.

Tobacco smoking and other substance use disorders associated with recurrent suicide attempts in bipolar disorder

BACKGROUND

Suicide attempts (SA) are more frequent in bipolar disorder (BD) than in most other mental disorders. Prevention strategies would benefit from identifying the risk factors of SA recurrence in BD. Substance use disorders (SUD) (including tobacco-related) are strongly associated with both BD and SA, however, their specific role for the recurrence of SA in BD remains inadequately investigated. Thus, we tested if tobacco smoking - with or without other SUDs - was independently associated with recurrent SA in BD.

METHODS

916 patients from France and Norway with ascertained diagnoses of BD and reliable data about SA and SUD were classified as having no, single, or recurrent (≥2) SA. Five SUD groups were built according to the presence/absence/combination of tobacco, alcohol (AUD) and cannabis use disorders. Multinomial logistic regression was used to identify the correlates of SA recurrence.

RESULTS

338 (37%) individuals reported at least one SA, half of whom (173, 51%) reported recurrence. SUD comorbidity was: tobacco smoking only, 397 (43%), tobacco smoking with at least another SUD, 179 (20%). Regression analysis showed that tobacco smoking, both alone and comorbid with AUD, depressive polarity of BD onset and female gender were independently associated with recurrent SA.

LIMITATIONS

Lack of data regarding the relative courses of SA and SUD and cross-national differences in main variables.

CONCLUSION

Tobacco smoking with- or without additional SUD can be important risk factors of SA recurrence in BD, which is likely to inform both research and prevention strategies.

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.

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.

Burden associated with smoking as a suicidal risk factor in an Australian sample of patients with psychosis

OBJECTIVE

We aim to describe the burden associated with smoking as a risk factor for suicidal behaviors among patients with psychosis.

METHOD

We calculated the Population Attributable Risk (PAR) associated with smoking and other known modifiable risk factors for suicidal behaviors for participants (N=1812) who took part in the Australian Survey of High Impact Psychosis (SHIP). A combined PAR for the seven identified modifiable risk factors was calculated.

RESULTS

Smoking contributed to 21% of the suicidal behaviors in this sample; together, the seven factors contributed to 86% of all attempted suicide in this cohort.

CONCLUSIONS

Smoking may exert a role either directly or indirectly. Evidence indicates that smoking is associated with psychological, biochemical and neurobiological changes that are in turn implicated in smoking. Suicidal behaviors are nevertheless complex behaviors needing multi-faceted approach.

Reducing smoking reduces suicidality among individuals with psychosis: Complementary outcomes from a Healthy Lifestyles intervention study

This study sought to explore the impact of smoking reduction on suicidality (suicide ideation and behaviour) among people with a psychotic disorder (n=235) who participated in a randomized trial of a healthy lifestyle intervention trial. Suicidality, measured by item -4 of the Brief Psychiatric Rating Scale (BPRS) was the main variable of interest. Measures were collected by research assistants blind to treatment allocation at baseline, at 15 weeks (mid-intervention) and 12 months after baseline. Mediation analysis, adjusted for confounders, was used to determine the relationship between smoking reduction and suicidality and to explore whether this was mediated through depression. At 12 months, smoking reduction was found to be significantly associated with suicidality change; an association was also seen between smoking reduction and depression and depression and suicidality. After adjusting for depression, the association between smoking reduction and suicidality was attenuated but remained statistically significant; the proportion of the total effect that was mediated through depression was 30%. There was no significant association between suicidality and treatment group (vs. controls) over time. Our study suggests that smoking interventions may have benefits over and above those for improved physical health, by reducing suicidal ideation in people with psychosis.

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.

Serum lipid levels and suicidality: a meta-analysis of 65 epidemiological studies

BACKGROUND

We conducted a systematic review and meta-analysis to determine the association between serum lipid levels and suicidality, as evidence from previous studies has been inconsistent.

METHODS

We identified relevant studies by searching Medline, Web of Science, EMBASE, and the Cochrane Database of Systematic Reviews (1980 to Dec. 5, 2014). Studies assessing the association between serum total cholesterol (TC), high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C) and/or triglycerides (TG) levels and suicidality were included. We used a random-effects model to take into account heterogeneity among studies.

RESULTS

We included 65 studies with a total of 510 392 participants in our analysis. Compared with the nonsuicidal patients, suicidal patients had significantly lower serum TC (weighted mean difference [WMD] -22.35, 95% confidence interval [CI] -27.95 to -16.75), LDL-C (WMD -19.56, 95% CI -26.13 to -12.99) and TG (WMD -23.40, 95% CI -32.38 to -14.42) levels, while compared with the healthy controls, suicidal patients had significantly lower TC (WMD -24.75, 95% CI -27.71 to -21.78), HDL-C (WMD -1.75, 95% CI -3.01 to -0.48) and LDL-C (WMD -3.85, 95% CI -7.45 to -0.26) levels. Furthermore, compared with the highest serum TC level category, a lower serum TC level was associated with a 112% (95% CI 40%-220%) higher risk of suicidality, including a 123% (95% CI 24%-302%) higher risk of suicide attempt and an 85% (95 CI 7%-221%) higher risk of suicide completion. The cut-off values for low and high serum TC level were in compliance with the categories reported in the original studies.

LIMITATIONS

A major limitation of our study is the potential heterogeneity in most of the analyses. In addition, the suicidal behaviour was examined using different scales or methods across studies, which may further explain heterogeneity among the studies.

CONCLUSION

We identified an inverse association between serum lipid levels and suicidality. More mechanistic studies are needed to further explain this association.

A reexamination of medical marijuana policies in relation to suicide risk

OBJECTIVES

Previous research has suggested that medical marijuana policies lead to reductions in suicide rates. In this study, we further investigate the association between these policies and within-state changes in suicide risk.

METHODS

Data on suicide deaths (n=662,993) from the National Vital Statistics System Multiple Cause of Death files were combined with living population data. Fixed-effects regression methods were employed to control for state differences in suicide rates and national and state secular trends. Analyses extended prior research that suggested a protective effect of medical marijuana policies by incorporating newer data and additional covariates.

RESULTS

After adjustment for race/ethnicity, tobacco control policies, and other covariates, we found no association between medical marijuana policy and suicide risk in the population ages 15 and older (OR=1.000; 95% CI: 0.956, 1.045; p=0.98), among men overall (OR=0.996; 95% CI: 0.951, 1.043; p=0.87) or for any other age-by-sex groups.

CONCLUSION

We find no statistically significant association between medical marijuana policy and suicide risk. These results contradict prior analyses which did not control for race/ethnicity and certain state characteristics such as tobacco control policies. Failure to control for these factors in future analyses would likely bias estimates of the associations between medical marijuana policy and health outcomes.

Characterizing Social Interaction in Tobacco-Oriented Social Networks: An Empirical Analysis

Social media is becoming a new battlefield for tobacco "wars". Evaluating the current situation is very crucial for the advocacy of tobacco control in the age of social media. To reveal the impact of tobacco-related user-generated content, this paper characterizes user interaction and social influence utilizing social network analysis and information theoretic approaches. Our empirical studies demonstrate that the exploding pro-tobacco content has long-lasting effects with more active users and broader influence, and reveal the shortage of social media resources in global tobacco control. It is found that the user interaction in the pro-tobacco group is more active, and user-generated content for tobacco promotion is more successful in obtaining user attention. Furthermore, we construct three tobacco-related social networks and investigate the topological patterns of these tobacco-related social networks. We find that the size of the pro-tobacco network overwhelms the others, which suggests a huge number of users are exposed to the pro-tobacco content. These results indicate that the gap between tobacco promotion and tobacco control is widening and tobacco control may be losing ground to tobacco promotion in social media.

Suicide Prevention Referrals in a Mobile Health Smoking Cessation Intervention

Automated mobile health (mHealth) programs deliver effective smoking cessation interventions through text message platforms. Smoking is an independent risk factor for suicide, so the Department of Veterans Affairs incorporated information about the Veterans Crisis Line into its SmokefreeVET smoking cessation text messaging program. Almost 7% of all SmokefreeVET enrollees have accessed this information. Because of the reach and automated nature of this and similar programs, we recommend including a referral to a suicide prevention hotline for all smoking cessation mHealth interventions.

Tobacco use and suicide attempt: longitudinal analysis with retrospective reports

Background

Suicide has been associated with smoking/tobacco use but its association of and change in smoking/tobacco use status with suicide attempt (SA) is not well established.

Methods

We investigated whether persistent, former tobacco use, initiation, quitting tobacco use, relapse to tobacco use, and DSM-IV nicotine dependence predict independently SA using Wave 1 and 2 data of the National Epidemiologic Survey of Alcohol and Related Conditions. Data from 34,653 US adults interviewed at Wave 1 (2001-02) and Wave 2 (2004-05) were analyzed. The main outcome measure was SA between Wave 1 and Wave 2 as reported at Wave 2.

Results

Among the 1,673 respondents reporting lifetime SA at Wave 2, 328 individuals reported SA between Wave 1 and Wave 2. Current and former tobacco use at Wave 1 predicted Wave 2 SA independently of socio-demographic characteristics, psychiatric history, and prior SA (Adjusted Odds Ratio (AOR): 1.49; 95% CI: 1.13-1.95, AOR: 1.31; 95% CI:1.01-1.69, respectively versus never tobacco users). The strongest association with SA was observed among former tobacco users who relapsed after Wave 1 (AOR: 4.66; 95% CI: 3.49-6.24) and among tobacco use initiators after Wave 1 (AOR: 3.16; 95% CI: 2.23-4.49). Persistent tobacco use (current tobacco use at both Wave 1 and Wave 2) also had an increased risk of SA (AOR: 1.89; 95% CI: 1.47-2.42). However, former tobacco users in both Waves 1 and 2 did not show a significantly elevated risk for SA in Wave 2 (AOR:1.09, 95% CI: 0.78-1.52) suggesting that the risk resided mainly in Wave 1 former tobacco users who relapsed to tobacco use by Wave 2. DSM-IV nicotine dependence did not predict SA at Wave 2.

Conclusion

In a representative sample of US adults, relapse, tobacco use initiation, and persistent tobacco use, which are amenable to intervention, were associated with risk of SA.