Smoking, posttraumatic stress disorder, and alcohol use disorders in a nationally representative sample of Australian men and women
Introduction
Tobacco use in the form of cigarette smoking is a leading cause of preventable disease, morbidity, and mortality worldwide (US Department of Health and Human Services USDHHS, 2004, World Health Organization, 2008) and remains a serious health problem despite recent declines in prevalence (King et al., 2012, National Center for Health Statistics, 2007). Approximately 18 per cent of U.S. adults (Centers for Disease Control and Prevention, 2009) and more than 3.5 million Australians smoke (Lawrence et al., 2009). Individuals who smoke incur substantially increased risk for a host of problems including cancer, stroke, heart disease, arthritis, and blindness, among others (DHHS, 2014). Thus, the importance of understanding correlates of smoking behaviours, and their interrelationships, cannot be overstated (Moodie et al., 2008).
Mental health and substance use disorders are among the most salient predictors of smoking and tobacco use disorders (Anthony and Echeagaray-Wagner, 2000, Degenhardt and Hall, 2001, Hitsman et al., 2009). For example, individuals who meet diagnostic criteria for a mental health disorder smoke at nearly twice the rate of those who do not (Lawrence et al., 2009). Lawrence and colleagues (2009) also found that among adult smokers, approximately one third have a past year mental health diagnosis and those with greater psychological distress smoke a greater number of cigarettes per day. Furthermore, the prevalence of smoking is approximately three to four times higher among individuals with a substance use disorder (SUD) compared to the general population (Grant et al., 2004, Sobell et al., 2002). Collectively, this literature suggests that understanding the association between specific mental health and substance use disorders and smoking is critical to identifying pathways to smoking cessation treatment (Prochaska, 2011).
Among mental health disorders, posttraumatic stress disorder (PTSD) has been identified as a particularly salient predictor of smoking (Feldner et al., 2007, Fu et al., 2007, Lawrence et al., 2010). Recent analysis of the 2007 National Survey of Mental Health and Wellbeing (NSMHWB) revealed that 7% of the Australian general population met DSM-IV criteria for a lifetime diagnosis of PTSD and 4% met criteria for current (12-month) PTSD (Chapman et al., 2012). Approximately half of individuals with PTSD have been found to report daily smoking (Feldner et al., 2007), making smoking twice as prevalent among individuals with PTSD compared to the general population (Acierno et al., 2000, Hapke et al., 2005, Lasser et al., 2000). Individuals with PTSD also incur a greatly increased risk of smoking relapse following a quit attempt (Zvolensky et al., 2008). Indeed, this co-occurrence is so common that integrated treatments are being developed and implemented to mitigate PTSD and smoking concurrently (Feldner et al., 2013).
Abundant literature also indicates that alcohol use disorders (AUDs) and smoking are strongly related. Compared to non-smokers, smokers are more than three times as likely to meet diagnostic criteria for an AUD (McKee et al., 2007). Alcohol consumption is known to increase rates of smoking (McKee et al., 2006), and smoking is known to increase alcohol consumption (Barrett et al., 2006). Approximately 35% of individuals with an AUD also meet criteria for tobacco use disorder (Grant et al., 2004). That prevalence rises to approximately 80% among individuals seeking treatment for AUDs (Kalman et al., 2010). The combination of smoking and AUDs is particularly malignant, as morbidity and mortality associated with co-occurrence versus singular use of alcohol and tobacco use disorders is substantially higher (Marrero et al., 2005, Pelucchi et al., 2006).
Of significant concern is the growing literature demonstrating the common co-occurrence of PTSD and AUD, and the increased risk of smoking and other harms associated with this comorbidity. An examination of the Australian general population revealed that individuals with PTSD are 5 times more likely to be suffering from co-occurring AUDs compared to those without PTSD (Mills et al., 2006). The self-medication hypothesis has been used to explain this common co-occurrence, asserting that individuals may use substances to mitigate negative thoughts and emotions typically associated with their PTSD symptoms (Feldner et al., 2007, Khantzian, 1997, Morissette et al., 2007, Sher and Grekin, 2007). Studies illustrate that PTSD typically precedes AUDs among individuals with comorbidity, and that trauma exposure and PTSD typically precede smoking onset (Breslau et al., 2004, Hanna and Grant, 1999, Jamal et al., 2011). In addition, individuals with PTSD commonly self-report using substances to relieve their PTSD symptoms (Leeies et al., 2010). Smoking is prominently noted in the literature as one such substance: studies have documented proximal associations such that trauma cues can elicit smoking withdrawal symptoms (Beckham et al., 1996) and that a reduction in PTSD-related distress follows tobacco use (Beckham et al., 2008).
Given the independent associations between smoking, PTSD, and AUDs, and the common co-occurrence of PTSD and AUDs, it is likely that this comorbidity is associated with an increased risk of smoking and related harms. Indeed, some studies among U.S. samples indicate increased smoking behaviours and smoking onset among individuals with psychiatric disorders such as PTSD and AUDs (Vlahov et al., 2002). However, to our knowledge no study has examined the co-occurrence of smoking, PTSD, and AUDs in a nationally representative Australian sample, or the impact of this co-occurrence on adverse health consequences and impairment. Doing so is critical because comorbidities such as those between mental health and substance use disorders are known to result in more negative health and treatment outcomes compared to single diagnoses (Back et al., 2000, Mills et al., 2006, Petrakis et al., 2011, Teesson et al., 2010). It remains unknown if more complex comorbidities, particularly among multiple disorders known to have negative health outcomes independently, result in worse health outcomes. The present study aims to address this gap in the literature. Specifically, the aims of this study are to examine: (1) the prevalence and demographic correlates of co-occurring daily smoking, PTSD, and AUD; (2) the order of onset of daily smoking and self-reported problems with alcohol in relation to trauma exposure; and (3) the associations between daily smoking, PTSD, and AUD diagnoses on general mental and physical health status and associated disability.
Section snippets
Participants
The 2007 NSMHWB was a national face-to-face survey conducted by the Australian Bureau of Statistics (Australian Bureau of Statistics, 2007) and commissioned by the Australian Government Department of Health and Ageing. As detailed in Slade and colleagues’ (2009) summary of the survey, 14,805 participants aged between 16 and 85 years were randomly selected using a stratified, multi-stage probability design to represent the Australian population. The present study includes the full sample of 8841
Prevalence and co-occurrence of PTSD, AUD, and smoking
Table 1 shows weighted prevalence estimates and standard errors of daily smoking, AUDs, and PTSD. Daily smoking was the most prevalent pathology, followed by PTSD and AUDs, respectively. The rates of co-occurrence were consistently higher than chance. For example, daily smoking, AUDs and PTSD co-occur in 0.3% of the population (representing an estimated 43,813 Australians), which is ten times higher than chance. Overall, 29.3% of people with PTSD were daily smokers and 11.7% had a concurrent
Discussion
Taken together, the results of the present study show a pattern of systematic comorbidity among daily smoking, PTSD, and AUDs that negatively impacts mental and physical health and functioning. The paired comorbidity rates among smoking, PTSD, and AUDs were consistent with other population studies (Acierno et al., 2000, Grant et al., 2004, McKee et al., 2007, Mills et al., 2006), although groups including smokers tended to be smaller than previous studies have found (e.g., Feldner et al., 2007
Role of Funding Source
Nothing declared.
Contributors
JF, EC, and AB collaboratively conceived of the research question. JF wrote the first draft of the Introduction. EC wrote the first draft of the Method. MF and AB designed the statistical analytic approach. MF ran the data analyses and wrote the Data Analysis and Results section, as well as early notes for the Discussion. EB wrote the first draft of the Discussion. KM and MT were on the Expert Advisory Panel for the 2007 National Survey of Mental Health and Wellbeing. KM and MT gave feedback on
Conflict of Interest
Nothing declared.
Acknowledgements
Macquarie University, Faculty of Human Science Visiting International Research Fellowship for supporting collaboration within this team. The National Survey of Mental Health and Well Being was funded by the National Health Branch of the Commonwealth Department of Health and Aged Care, Under the National Mental Health Strategy. It was conducted by the Australian Bureau of Statistics.
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