Smoking and Mental Health Problems in Treatment-

Seeking University Students

Eric Heiligenstein, M.D.

University of Wisconsin-Madison Health Services

Stevens S. Smith, Ph.D.

University of Wisconsin Center for Tobacco Research and Intervention

Smoking Prevalence in the U.S.

20

25

30

35

40

45

50

55

60

1950 1960 1970 1980 1990 2000

Years

Pe

rce

nta

ge

Women

Men

JAMAJAMA, 1989:261, 1989:261

Association of Smoking and Psychiatric Disorders

General populationo 22-30%

Panic disordero 35%

Alcohol abuseo 43%

Depressiono 49%

Schizophreniao 88%

Smoking Status According to Psychiatric Diagnosis

US Population

Current Smokers, %

Lifetime Smokers, %

Total 100 28.5 47.1

No mental illness

50.7 22.5 39.1

Ever mental illness

49.3 34.8 55.3

Any mental illness in past month

28.3 41.0 59.0

Adapted from Lasser, 2000

Broad Complications of Smoking and Psychiatric

Disorders Additive mortality risks from CV disease

and cancer

Associated with substance abuse and dependence

Poorer HRQOL and functional status

Income diversion Boyd et al., 2001; Bruce et al., 1994; Degenhardt

et al, 2001; Anda et al, 2003; Woolf et al, 1999

Specific Complications of Smoking and Psychiatric Disorders

Higher risk for suicide and suicide attempts

Smokers with PD have more severe symptoms than non-smokers with PD

Smokers with schizophrenia have greater number of hospitalizations than non-smokers with schizophrenia

Miller et al., 2000; Zvolensky et al, 2003; Goff et al., 1992

Smoking Rates Compared to the Number of Lifetime Psychiatric

Diagnoses

0

10

20

30

40

50

60

% Who Are Smokers

0 1 2 3 4 >4

No. of Lifetime Psychiatric Diagnoses

% Heavy Smokers

% Light-ModerateSmokers

Adapted from Lasser, 2000

Methods

Data Sources University of Wisconsin-Madison

o 40,000 undergraduate, graduate, and professional students

o Voluntarily presented for mental health treatment at Counseling Services (9/03-12/03)

Methods

Assessment (retrospective chart review) Basic demographic measures Smoking status

o Nonsmoker/occasionalo Light smoker (at least weekly use)o Heavy smoker (daily smoking, >10 cigarettes per

day) PsyberCare-MH (Polaris Health Directions)

o Standardized and validated computer assessment

PsyberCare-MH In Use

Typical Clinical Setting Process Flow

Real-Time Clinical Report

Patient Self-Report

Assessment(unassisted)

Physician / Treatment Provider

Patient Set Up At

Computer (30 seconds)

Master Database Aggregate

Data Report

Question Presentation

Sample Report Page

Methods

PsyberCare-MH Scales Subjective well-being ( includes SF-

12) Psychiatric symptom severity (DSM

IV) Functional disability (SSI guidelines)

Results

1259 students presented for evaluation

1148 took PsyberCare-MH (91%)

Reviewed random sample of ½ records (n=574)

Smoking status identified in 503 (88%)

Demographic Characteristics According to Smoking Status

Variable Nonsmokersa

(n=384)Light

Smokersb

(n=68)

Heavy Smokersc

(n=51)

Mean SD Mean SD Mean SD

Age 22.4 4.3 22.6 4.0 22.7 5.0

N % N % N %

Male 121 71.6 26 15.4 22 13.0

Female 263 78.7 42 12.6 29 8.7

White 330 75.5 62 14.2 45 10.3

Non-Whited

54 81.8 6 9.1 6 9.1

dHispanic n=11, Black n=10, Asian n=16, International n=23, Other n=6

PsyberCare Scales By Smoking Status

PsyberCareScale

Non-smokers with

percentile scores < 50a

(n=384)

Light smokers

with percentile

scores < 50(n=68)

Heavy smokers with percentile

scores < 50(n=51)

Non-smokers vs Light Smokers

Comparison

Non-Smokers vs. Heavy Smokers

Comparison

Light Smokers vs. Heavy Smokers

Comparison

Depression 32.3% 41.2% 80.4% 2(1)=2.0, p=.15

2(1)=44.2, p<.001

2(1)=18.4, p<.001

Anxiety 38.5% 48.5% 80.4% 2(1)=2.4, p=.12

2(1)=32.1, p<.001

2(1)=12.6, p<.001

SubjectiveWell-being

54.7% 61.8% 96.1% 2(1)=1.2, p=.28

2(1)=32.0, p<.001

2(1)=19.1, p<.001

Personal Functioning

25.0% 35.3% 82.4% 2(1)=3.1, p=.08

2(1)=63.4, p<.001

2(1)=26.1, p<.001

Social Functioning

24.5% 27.9% 54.9% 2(1)=0.4, p=.54

2(1)=20.6, p<.001

2(1)=8.9, p<.004

Vocational Functioning

27.1% 32.4% 68.6% 2(1)=0.8, p=.37

2(1)=35.7, p<.001

2(1)=15.4, p<.001

aPercentile scores <50 indicate poorer functioning.

PsyberCare-MH Scales by Smoking Status

0

20

40

60

80

100

Dep Anx SubjWB

PersFunc

SocFunc

VocFunc

Non-smokers with % scores <50

Light smokers with % scores < 50

Heavy smokers with % scores < 50

Discussion

Heavy smokers compared to light and non-smokers More severe depression and anxiety Poorer overall well-being Greater functional impairment (all p<.008)

No differences between light smokers and non-smokers

Discussion

Results support existing research in general population and medical settings

Smoking is severity of illness multiplier

Understanding the Results

Neuropharmacologic effects of nicotine

Shared genetic and psychosocial factors

Cigarette smoke contains numerous other psychoactive compounds

Methodological Limitations

Cross-sectional data

Limited generalizability

Tobacco use determine by self-report

Psychiatric diagnoses not recorded

Clinical Implications

Systematic identification processes that mesh with a non-medical practice style

Integration of smoking cessation efforts within primary mental health treatments

Evaluation of outcomes of standard mental health treatments in smokers

Address the effects of psychiatric comorbidity on cessation efforts in primary care settings