Smoking, But Not Smokeless Tobacco, Associated with Past-Year Psychiatric Disorders

Compared with the general population, smokers have elevated rates of psychiatric problems, and affected smokers tend to consume more cigarettes, inhale more deeply and quit less often (evidence here, here and here).  A new study confirming this link concludes that “smokeless tobacco is not significantly associated with psychiatric morbidity…”

The principal investigator of the study, which was published in Social Psychiatry and Psychiatric Epidemiology (abstract here), is Nicholas Peiper, a doctoral student in epidemiology at the University of Louisville; I am honored to be a co-author. 

Peiper analyzed data from the 2005 to 2008 National Survey on Drug Use and Health (NSDUH).  In addition to detailed information on tobacco use, the survey also measures past-year serious psychological distress and major depressive episodes using clinically validated instruments, and past-year anxiety disorder with proxy items.  Results were adjusted for other potential factors for these disorders, including age, race/ethnicity, education, income, marital status, diabetes and other illnesses, substance/alcohol abuse and pregnancy. 

Odds Ratios For Serious Pyschological Distress (SPD), Major Depressive Episode (MDE) and Anxiety Disorder (AD) Among Current Smokers, Smokeless Tobacco Users and Dual Users, NSDUH 2005-2008
Men
	Smokers	Smokeless Users	Dual Users
SPD	1.14 (0.99 – 1.31)	0.71 (0.55 – 0.91)	0.86 (0.65 – 1.14)
MDE	1.21 (0.99 – 1.48)	0.88 (0.66 – 1.19)	1.15 (0.82 – 1.63)
AD	1.53 (1.17 – 2.00)	1.21 (0.79 – 1.87)	1.73 (1.13 – 2.65)
Women
SPD	1.60 (1.45 – 1.77)	0.95 (0.51 – 1.77)	2.24 (1.10 – 4.58)
MDE	1.43 (1.26 – 1.63)	0.38 (0.13 – 1.10)	1.68 (0.71 – 3.98)
AD	1.83 (1.56 – 2.14)	0.99 (0.35 – 2.81)	2.76 (1.09 – 7.00)

Both male and female smokers were more likely than never tobacco users to have experienced past-year serious psychological distress, major depressive episodes or anxiety disorders.  Smokeless users were less likely to experience psychological distress (statistically significant in men) and depressive episodes.  Female and male dual users were significantly more likely to experience anxiety; female dual users also experienced more psychological distress.

It is evident that tobacco harm reduction can be an effective adjunct to the management of patients with psychological problems.  We conclude: “considerable efforts should focus on addressing differential tobacco risks in treatment settings, as those with psychiatric morbidity suffer a disproportionate share of smoking-attributable morbidity and mortality.” 

Smoking Cessation Medicines Trigger Suicidal Behavior and Depression

Anti-tobacco extremists say that safer tobacco products aren’t necessary because FDA-approved medicines are effective. They ignore scientific evidence of those medicines’ paltry success rate (pharmaceutical nicotine works for only 7% of smokers), and of their significant side effects. For example, varenicline (Chantix) and bupropion (Zyban) carry FDA black-box warnings concerning depression and suicidal or self-injurious behavior.

A study published in PLoS One (here) concludes that “Varenicline shows a substantial, statistically significant increased risk of reported depression and suicidal/self-injurious behavior. Bupropion for smoking cessation had smaller increased risks.” The study’s first author is Thomas Moore from the Institute for Safe Medication Practices; his coauthors are from medical schools at Wake Forest, Harvard and Johns Hopkins Universities.

Moore et al. looked at cases of depression or suicidal/self-injurious behavior in the FDA Adverse Event Reporting System from 1998 to 2010. As a negative control for short-term medication, they compared behavioral episodes during varenicline and bupropion use to those during use of three common antibiotics. Because quitting smoking has also been associated with behavioral problems, Moore also used pharmaceutical nicotine as a “cessation” control.

Compared with antibiotic use, varenicline users were 37 times more likely to experience depression or suicidal/self-injurious behavior (odds ratio, OR = 37, confidence interval, CI = 28-49). The OR for bupropion was 13 (CI = 9-17), and the OR for nicotine was 4.3 (CI = 3.1-6.2).

Compared with nicotine (which controlled for behavioral problems due to quitting smoking), the OR for varenicline was 8.4 (CI = 6.8-10.4) and the OR for bupropion was 2.9 (CI = 2.3-3.7).

Moore also discussed other safety concerns: “While suicidal/self-injurious behavior and depression appear to be prominent side effects of varenicline, they are by no means the only safety issues. Varenicline has been associated with aggression and violence in three studies and carries a warning about this behavior. Its effect on vision, cognition, and motor control and other risks have led to its being banned for airline pilots, air controllers, military pilots and missile crews, and restricted for truck drivers. Varenicline is also associated with an increase in the risk of serious cardiovascular events. In addition, it is associated with hypersensitivity, angioedema and potentially life-threatening severe cutaneous adverse events [references omitted].”

Moore warns doctors prescribing varenicline about “…the value judgment of how to weigh the possible benefits of 52 weeks of smoking abstinence for 1 or 2 out of every 10 patients treated against the risk of less frequent adverse events such as violent and suicidal behavior that can have immediate, catastrophic and irreversible effects on self, family, and career. In the meantime, safer alternatives now exist and should be preferred.”

Unwritten is that one of those safer alternatives is smoke-free tobacco. While no tobacco product is absolutely safe, smoke-free alternatives deliver satisfying doses of nicotine, which is an important modulator of mood, well-being, and other behavioral performance measures.