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ISSN: 2155-6105
Journal of
Addiction Research & Therapy
de Oliveira et al., J Addict Res Ther 2015, 6:2
DOI: 10.4172/2155-6105.1000231
Open Access
Research Article
Factors Associated With Tobacco Dependence in People with Mental
Disorders
Renata Marques de Oliveira1*, Jair Lício Ferreira Santos2 and Antonia Regina Ferreira Furegato1
1
2
Department of Psychiatric Nursing and Human Sciences at Ribeirão Preto College of Nursing, University of São Paulo. Ribeirão Preto, São Paulo, Brazil
Department of Social Medicine of the Ribeirão Preto Faculty of Medicine, University of São Paulo. Ribeirão Preto, São Paulo, Brazil
Abstract
This study’s objective was to identify socio-demographic and clinical factors associated with the degree of tobacco
dependence in those with mental disorders, hospitalized in the psychiatric unit of a general hospital. An exploratory study
with the participation of 96 smokers, who have mental disorders, hospitalized in the psychiatric unit of a general public
hospital between August 2010 – February 2012. Individual interviews were held using the Fagerstrom Test for Nicotine
Dependence (FTND). A questionnaire was administered for raising socio-demographic and clinical variables. Bivariate and
multivariate analysis was undertaken. Of the 96 smokers, 53.2% had a high or very high degree of tobacco dependence.
Those who had previously been hospitalized in a psychiatric unit (OR= 3.59) or who had somatic comorbidities (OR= 2.50)
have greater chances of being classified as highly dependent on tobacco than do the other subjects. The variables of
psychiatric hospitalization and somatic comorbidities are risk factors for a high degree of tobacco dependence. Knowing
the factors involved in tobacco dependence can help in planning the care for the mentally ill.
Keywords: Tobacco; Mental disorders; Socio-demographic; Smoking
Introduction
There are currently over one billion users of tobacco worldwide. It
is calculated that half will die prematurely as a result of illnesses related
to its use, making smoking one of the main causes of preventable death
[1]. Tobacco is responsible for one in every 10 deaths among adults [1].
As the somatic complications appear only one to three decades after
smoking is initiated [2], by the end of the 21st century, the death rate
could be ten times higher than that found in the previous century [1].
The information on morbidity/mortality is concerning not only because
of the number of users of tobacco, but also because of these subjects’
degree of tobacco dependence.
Tobacco is one of the principal risk factors for developing chronic
physical diseases, especially cardiorespiratory diseases, contributing
to reducing survival of those with mental disorders [3]. Tobacco
dependence has an important role in this context, given that higher
degrees of dependence are found among psychiatric patients than
among the other groups of the population [4-6]. It is recognized that
tobacco dependence is associated with the presence of depressive and
anxious symptoms [7,8]. In addition to the physical harm, the mental
health of the psychiatric population is severely compromised through
tobacco use [9]. It is accepted that smoking is associated with the
seriousness of the psychiatric symptoms [10,11], the occurrence of
suicide attempts [12,13] and the need for hospitalization [10].
On the other hand, those with mental disorders find social
and psychological benefits in tobacco [14]. It has been noticed
within psychiatric services that many patients and professionals
smoke cigarettes as a manner to approaching each other [16-18].
The increased social interaction helps to alleviate the stress and the
solitude [18,19]. The social and psychological benefits motivate those
with mental disorders to increase the daily quantity of cigarettes,
worsening the tobacco dependence and the threats to the physical
and mental health (dose-response effect), which justifies the need to
identify possible factors involved in this issue. This study is important
due to the scarcity of publications that approach this topic within
the Brazilian psychiatric population. From what we have seen this is
the first Brazilian study which investigates the topic by performing a
multivariate analysis.
J Addict Res Ther
ISSN:2155-6105 JART an open access journal
We hypothesized that the degree of tobacco dependence is
associated with physical harm and with the history of psychiatric
inpatient treatment.
This study’s objective was to identify socio-demographic and
clinical factors associated with the degree of tobacco dependence in
those with mental disorders, hospitalized in the psychiatric unit of a
general hospital.
Material and Methods
An exploratory study with persons with mental disorders,
hospitalized in the psychiatric unit of a state general hospital in a city in
the non-metropolitan region of the state of São Paulo, Brazil. The unit
has 18 beds for psychiatric inpatient treatment, with a bed occupancy
rate of 83.3%. The mean duration of hospitalization for the subjects is
14.5 days.
Cigarette smoking in the Brazilian health services is in line with
Brazilian legislation, which permits smoking as long as there is
authorization from the medical team [20]. As a result, each hospital
has the freedom to implement its own rules. In the psychiatric ward
of this study, the patients who were smokers prior to being admitted
are allowed eight cigarettes per day at the following times: 07:30 (two
cigarettes); 09:30 (one cigarette); 12:00 (one cigarette); 14:30 (one
cigarette); 16:30 (one cigarette); and 18:30 (two cigarettes). Smoking
takes place in an open area outside the ward.
A simple random probabilistic sample was selected (95% confidence
*Corresponding author: Renata Marques de Oliveira, Department of Psychiatric
Nursing and Human Sciences at Ribeirão Preto College of Nursing, University
of São Paulo. Ribeirão Preto, São Paulo, Brazil, Tel: 551 499 703 8876; E-mail:
renatamarques@ymail.com
Received May 10, 2015; Accepted June 15, 2015; Published June 21, 2015
Citation: de Oliveira RM, Santos JLF, Furegato ARF (2015) Factors Associated
With Tobacco Dependence in People with Mental Disorders. J Addict Res Ther 6:
231. doi: 10.4172/2155-6105.1000231
Copyright: © 2015 de Oliveira RM, et al. This is an open-access article distributed
under the terms of the Creative Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in any medium, provided the
original author and source are credited.
Volume 6 • Issue 2 • 1000231
Citation: de Oliveira RM, Santos JLF, Furegato ARF (2015) Factors Associated With Tobacco Dependence in People with Mental Disorders. J Addict
Res Ther 6: 231. doi: 10.4172/2155-6105.1000231
Page 2 of 5
and maximum error of 10%), made up of 96 patients hospitalized in a
ward. Inclusion criteria: to be a smoker and to accept to participate in
the study. Exclusion criteria: to be below 15 years of age, persons with
mental retardation, and those with difficulty in answering the interview
questions. The investigation of psychiatric patients was chosen due to
the knowledge, gained from the scientific literature, that psychiatric
hospitalization is one of the factors which influences this population
to smoke cigarretes. Data collection started in August 2010 and was
terminated in August 2012 when the number of smokers stipulated by
the sample calculation was obtained (n= 96).
The study was approved by the Ethics Committee of Ribeirão
Preto College of Nursing, University of São Paulo (1173/2010). This
Committee approved the consent procedures. The subjects provided
written informed consent to participate in the study. The patients
below 18 years old signed the consent, but we also obtained their
legal guardian’s signature. In case an impairment in the individual’s
capacity to consent was perceived, we also obtained the legal guardian’s
signature. Criteria for establishing whether the patients could give
written consent without the guardian’s signature: psychiatric symptoms
controlled; intact cognitive functions; agree to participate voluntarily;
be able to understand the study’s information.
The smokers were interviewed individually by one of the researchers
in the psychiatric unit.
The degree of tobacco dependence was obtained through the
Fagerstrom Test for Nicotine Dependence (FTND) (test-retest of 0.91
and Cronbach 0.64), which classifies the degree of dependence as very
low (0-2 points), low (3-4 points), medium (5 points), high (6-7 points)
and very high (8-10 points) [21].
For surveying the socio-demographic and clinical variables,
a questionnaire was administered (Instrument for Identification
of Smokers in a Psychiatric Unit of a general hospital (ISPI). The
questionnaire was developed for this study, and was made up of the
variables: sex; age; educational level; place of current residence;
main psychiatric diagnosis; time since diagnosis; therapies received;
medications currently being used; previous psychiatric hospitalizations;
somatic comorbidities (cardiovascular, digestive, endocrine and
respiratory); age at which smoking was initiated; and attempts at
quitting smoking.
somatic comorbidities; age when smoking initiated; attempted to quit
smoking.
A dependent variable is the degree of tobacco dependence
dichotomized in the categories Low/Medium dependence and High
dependence, to facilitate the interpretation of the results. The class
of Low/Medium dependence was chosen as a reference for the other
class. The value of the mean, standard deviation, and minimum and
maximum of the amount of tobacco used in each of these categories can
be observed in Table 1.
A backward stepwise logistic regression was adjusted [22]. The
model is initiated with all the variables present, and the process
eliminates each variable which, in the presence of the others, does not
contribute significantly to the explanation of the dependent variable.
The level of significance was fixed at 5%. The Odds Ratio (OR) was used
as the comparator.
Results
Figure 1 illustrates the total number of patients receiving inpatient
treatment during the data collection period (Figure 1).
Characterization of the subjects
The majority of the 96 smokers was female (61.5%), had studied
only up to junior high school level (53.1%), lived in an urban region
(91.7%) and had an occupation (61.5%). The subjects’ mean age was
38.2 years old (15 – 69 years old). The majority of the diagnoses (80.2%)
were for severe mental disorders (33.3% schizophrenia, 34.4% mood
disorders and 12.5% personality disorders). The mean time since
diagnosis was four years. 44.8% had received only clinical therapies,
58.3% had a history of psychiatric hospitalization and 52.1% had
somatic comorbidities.
Classification of degree of tobacco dependence of the 96 smokers:
very low (n= 14, 14.6%); low (n= 18, 18.8%); medium (n= 13, 13.5%);
high (n= 28, 29.2%) and very high (n= 23, 24%).
The main psychiatric diagnosis and the medications being used at
the time of the beginning of inpatient treatment were obtained from
the subjects’ medical records. The responses for the other variables
were self-reported. The interviews lasted an average of 43 minutes.
The bivariate analysis was accomplished using Fisher’s Exact Test.
Possible relationships were investigated between the variables, through
multivariate statistical analysis, controlling the results by age and sex,
among the smokers. The statistical treatment was undertaken using
Stata. The discussion of the results was based on the scientific literature.
The variables selected for analysis of their relationship with
tobacco dependence: sex; current age; educational level; place of
residence; time since psychiatric diagnosis; diagnosis of schizophrenia;
therapies received; previous psychiatric hospitalization; use of 1st
generation antipsychotics; use of 2nd generation antipsychotics;
Figure 1: Description of the patients hospitalized during the data collection
period.
Degree of tobacco dependence
N
Mean
Standard deviation
Minimum
Medium/Low
45
12.1
7.5
1.0
Maximum
20.0
High
51
34.8
19.8
7.0
100.0
Total
96
24.2
19.0
1.0
100.0
Table 1: Number of cigarettes smoked daily, by degree of tobacco dependence (dependent variable).
J Addict Res Ther
ISSN:2155-6105 JART an open access journal
Volume 6 • Issue 2 • 1000231
Citation: de Oliveira RM, Santos JLF, Furegato ARF (2015) Factors Associated With Tobacco Dependence in People with Mental Disorders. J Addict
Res Ther 6: 231. doi: 10.4172/2155-6105.1000231
Page 3 of 5
Bivariate analysis
increases the chance of having high dependence by 2.5.
Table 2 presents the results of the comparison of the degree of
tobacco dependence with the independent variables. The smokers
who have received inpatient psychiatric treatment previously have
a probability of being classified as having high tobacco dependence
which is 3.62 times higher than that of those without a previous history
of inpatient treatment (Table 2).
Collinearity and interactions
The possible existence of collinearity between the variables was
investigated, the Variance Inflation Factor (VIF) being evaluated [23].
Logistic regression
The study showed that the variable “Place of residence” with the
categories ‘Urban’ and ‘Rural’ had a VIF of over 10, for which reason
it was eliminated from the study. After its elimination, all the variables
remained with VIF below 10 and with a mean of 3.55.
The binomial logistic regression, with retroselection of the variables,
after elimination of the variables which did not present significant
contributions, allows one to emphasize and analyze the results (Table
3). It may be observed that previous hospitalization increases the chance
of being classified as highly dependent by 3.59. Having comorbidities
Also investigated were the possible interactions between age and
the number of hospitalizations, given that the original variables had a
correlation coefficient which was small (0.24), although significant. The
interaction was not significant, with the likelihood ratio test between
the models – with and without interaction – indicating a value of 0.114.
Tobacco dependence
Medium/
Low
n(%)
High
n(%)
Fisher’s test
Unadjusted Odds
Ratio
Confidence interval
95%
25(42.4)
34(57.6)
0.182
0.62
0.27-1.43
20(54)
17(46)
Mean
35.8
40.4
0.087b
1.03
1.00-1.06
Standard Deviation
14.6
11.5
0.257
1.42
0.63-3.19
0.097
0.27
0.05-1.39
0.074
1.98
0.88-4.46
0.258
1.46
0.62-3.45
0.137
0.58
0.26-1.32
0.002
3.62
1.54-8.49
0.387
1.23
0.54-2.79
0.089
1.92
0.84-4.40
0.053
2.15
0.94-4.90
0.362
1.27
0.56-2.90
0.395
0.74
0.24-2.22
Independent variables
Sex
Femalea
Male
Current age
Education
Up to Junior Higha
26(51)
25(49)
Above Junior High
19(42.2)
26(57.8)
39(44.3)
49(55.7)
6(75)
2(25)
Up to 4 yearsa
27(55.1)
22(44.9)
4 years and over
18(38.3)
29(61.7)
Place of residence
Urbana
Rural
Time since diagnosis
Schizophrenia
Noa
32(50)
32(50)
Yes
13(40.6)
19(59.4)
Only clinicala
17(39.5)
26(60.5)
Other types
28(52.8)
25(47.2)
Therapies received
Previous hospitalization
Noa
26(65)
14(35)
Yes
19(33.9)
37(66.1)
1st generation antipsychotics
Noa
19(50)
19(50)
Yes
26(44.8)
32(55.2)
Noa
30(53.6)
26(46.4)
Yes
15(37.5)
25(62.5)
Noa
25(56.8)
19(43.2)
Yes
19(38)
31(62)
Up to 15 yearsa
29(49.2)
30(50.8)
16 years and over
16(43.2)
21(56.8)
Yesa
37(45.7)
44(54.3)
No
8(53.3)
7(46.7)
2nd generation antipsychotics
Somatic comorbidities
Age when smoking initiated
Attempted to quit smoking
a
b
Reference category
t test for equality of means
Table 2: Degree of tobacco dependence in relation to each one of the independent variables.
J Addict Res Ther
ISSN:2155-6105 JART an open access journal
Volume 6 • Issue 2 • 1000231
Citation: de Oliveira RM, Santos JLF, Furegato ARF (2015) Factors Associated With Tobacco Dependence in People with Mental Disorders. J Addict
Res Ther 6: 231. doi: 10.4172/2155-6105.1000231
Page 4 of 5
Degree of tobacco dependence
Previous hospitalization
Somatic comorbidity
Odds Ratio
Standard Error
Z
P>|z|
Confidence Interval 95%
No
1
1.65
2.78
0.006
1.46-8.86
Yes
3.59
1.15
1.99
0.047
1.01-6.16
No
1
Yes
2.5
Table 3: Results of the logistic regression for the dependent variable of tobacco dependence.
Discussion
Our investigation shows that the majority of those with mental
disorders who smoked were highly dependent on tobacco (high and
very high degree). After control of the potential confounding variables,
it was identified in this study that the subjects who had previously been
hospitalized in psychiatric units and who had somatic comorbidities
have a higher chance of being classified more highly dependent on
tobacco than the other subjects.
The high degree of tobacco dependence found in the present study
is consistent with the Brazilian and international scientific literature.
Research undertaken in Australia with persons with psychotic disorders
(n= 1,812) revealed a mean score of 5.9 (high degree of dependence) in
the Fagerstrom Test for Nicotine Dependence (FTND) [10]. A Brazilian
study observed that 56.3% of schizophrenics attended in psychiatric
units (n= 83) were heavy smokers (≥ 8 points in the previous version
of the FTND) [24].
Another study undertaken in Brazil, in a psychiatric inpatient
treatment unit evaluated the degree of tobacco dependence of 103
patients, hospitalized in three distinct periods. The mean scores
obtained on the FTND revealed that the subjects were heavy smokers
(≥ 6 points): 1st census (6.71), 2nd census (7.44) and 3rd census (7.57)
[25].
In Turkey, a statistical difference was evidenced in comparing the
degree of tobacco dependence of 80 persons with mental disorders
(hospitalized in a psychiatric unit) with 80 controls (general
population). Among those with mental disorders, there was a greater
frequency of high/very high degree of dependence (26.8%) than among
the controls (9.1%) [7].
The multivariate analysis undertaken in the present study revealed
that the psychiatric hospitalizations stand out as the principal risk
factor for the higher degrees of tobacco dependence.
The culture of smoking in psychiatric institutions may be indirectly
related to the higher degree of dependence, as the incentive to smoke
leads to the use of a large quantity of cigarettes (many times greater than
was smoked prior to the inpatient treatment) and to the development of
tolerance to the effects of the tobacco, characterizing an increase in the
degree of dependence.
After controlling for the confounding variables, the present study
identified that the presence of somatic comorbidities is also a risk factor
for a high degree of tobacco dependence.
The association between tobacco dependence and somatic
comorbidities found in the present study may be understood based on
the recognition of the influence of tobacco on the organism, given that
the greater the degree of tobacco dependence, the higher the number of
cigarettes smoked and, as a consequence, the greater the occurrence of
morbidities (dose-response effect).
In an analysis of 1,812 Australian outpatients with a psychotic
disorder, greater occurrence of medical complications was identified
among the smokers than among the non-smokers over their lifetimes.
In addition, the smokers had a worse perception of their physical health
than the other subjects [10]. A study with 34,653 Americans showed
that those who met the DSM-IV criteria for tobacco dependence
presented greater harm to their physical and mental quality of life, in
comparison with ex-smokers [9].
A retrospective cohort investigation in the medical records and
death certificates of 591,266 Americans who were hospitalized in
psychiatric hospitals between 1990 and 2005 identified that a significant
proportion of the deaths (schizophrenia - 53%, bipolarity - 48% and
depressives - 50%) was due to illnesses related to tobacco (cancers, and
cardiovascular and respiratory diseases) [3].
Similarly, 1,848 persons with mood disorders, in three Primary
Healthcare Centers in Pelotas, Brazil, who had received psychiatric
inpatient treatment in the previous year, had an increased risk of being
a tobacco user, although the association with the degree of tobacco
dependence was not investigated [26].
The present study fills a gap in the Brazilian scientific literature
through investigating, based on a multivariate analysis, the factors
associated with tobacco dependence among those with mental
disorders. The knowledge of these factors brings important
contributions for psychiatric professionals, bearing in mind that
tobacco is currently prohibited in collective environments, including
the some environments of psychiatric inpatient treatment.
In a psychiatric hospital in England, an ethnographic case study
identified that tobacco is considered important for ensuring mental
well-being and promoting social interactions during inpatient
treatment [18]. One study undertaken in a Brazilian psychiatric ward
revealed that cigarettes are used during inpatient treatment to cope
with the difficulty of coexisting with the other patients and with the
lack of activities [27].
Finally, the association of degree of tobacco dependence with the
occurrence of episodes of psychiatric inpatient treatment and with the
presence of somatic comorbidity reveals two essential perspectives on
this issue: the encouragement to use tobacco in psychiatric institutions
(the smoking culture) and the harm caused by this practice to the
physical health of those with mental disorders, making the need for
intervention clear.
In two psychiatric wards in Norway, participant observation and
interviews were undertaken with the professionals (n= 23) and patients
(n= 15). The rooms set aside for smoking cigarettes on the wards were
seen by the patients as “sanctuaries”, that is, places where they could
converse about subjects which would be prohibited in the presence of
the professionals, showing the strength of the culture of smoking in the
mental health institutions [16].
The present study provides health professionals with valuable
information regarding the factors involved in the degree of tobacco
dependence of persons with mental disorders. In emphasizing
smoking’s risk to health and indicating that the culture of psychiatric
hospitals reinforces the behavior of smoking cigarettes, it is hoped that
this study may help health professionals to reflect on their professional
practice. The next studies must address this same issue, comparing the
J Addict Res Ther
ISSN:2155-6105 JART an open access journal
Volume 6 • Issue 2 • 1000231
Citation: de Oliveira RM, Santos JLF, Furegato ARF (2015) Factors Associated With Tobacco Dependence in People with Mental Disorders. J Addict
Res Ther 6: 231. doi: 10.4172/2155-6105.1000231
Page 5 of 5
results found with the general Brazilian population. Furthermore, other
variables must be investigated so as to extend knowledge on the topic.
Limitations of the study: 1) as the variable of the psychiatric
hospitalization was used dichotomously (yes/no), it was not possible
to assess the dose-response relationship – whether the increase in
exposure (number of hospitalizations) is associated with the increase
in the outcome (degree of tobacco dependence); 2) the study design
does not permit one to establish the time relationship between the
independent and dependent variables; 3) some important variables
with the potential to confound were not included in the regression
model (severity of the psychiatric symptoms, use of alcohol and illicit
substances, interest in quitting, and provision of clinical support to
quit).
Conclusions
The majority of those with mental disorders who were hospitalized
in the psychiatric unit had high and very high degree of tobacco
dependence. The variables of hospitalization in a psychiatric ward and
somatic comorbidities are associated with tobacco dependence.
The knowledge of the factors involved in tobacco dependence could
help the health professionals in planning interventions geared towards
the psychiatric population, contributing to these individuals’ physical
and mental health.
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J Addict Res Ther
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Volume 6 • Issue 2 • 1000231