INTRODUCTION:

Tobacco use is an example of modern epidemic and also known as “the brown plague”. ¹ According to the estimation of the WHO, tobacco use will cease one billion lives in the 21st century and 80% of that will occur in developing countries. The WHO predicted that the tobacco deaths in India may exceed 1.5 million annually by 2020. ² Rates of smoking are markedly higher among people with psychiatric illness than in the general population, estimated at being 2–5 times higher in patients with several disorders. ^{3, 4} Lasser et al. found that 41% with psychiatric diagnosis are nicotine addicted, which indicate two–fold of greater prevalence than general population. ⁵

Nicotine is the chief component of tobacco, which causes dependence both physically and psychologically. It causes temporarily pleasing effect in brain predominantly by altering the mesolimbic pathway that project to the nucleus accumbens causing dopamine hike. ⁶ Young age group who are usually quite explorative and experimental starts initially with cigarette smoking to get that pleasing effect which eventually may lead to addiction. Even the studies reveal that the average age of onset of smoking is 14.5years and the average age for smoking daily is 17.7 years. ⁷ They explore nicotine in different smoke and smokeless forms. Out of which beedi smoking constitute 40%, cigarette smoking 20% and smokeless form 40%. ⁸

Socioeconomic status (SES) which is most frequently measured by education level, income and occupation has a clear relationship with poor health, morbidity and mortality. ^{9, 10} The people belonging to low SES usually have an early exposure to substance use, and they are more likely to smoke for longer periods of time, have more trouble to quit smoking and are more likely to suffer from smoking-related diseases. ^{10, 11} The neuroimaging studies have revealed that smoking activates the reward pathways more among men than women. ¹²

It was found that prevalence of smoking is especially high in patients with schizophrenia (70-90%), affective disorder (42-70%), alcohol dependence (60-90%), and other substance use disorders (70-95%). About 75% of subjects with nicotine use and history of major depressive disorder developed depressed mood during the first week of withdrawal versus only 30% of those with no depressive history. ¹³

Henceforth, there is an ongoing debate over which comes first; nicotine use or the symptoms of mental illness but both tend to manifest in adolescence and early adulthood and believe that the relationship is cyclical. Studies about nicotine consumption in psychiatric patients are few from developing countries where social and familial factors influence smoking behavior. To address this issue, the current study was designed to estimate the prevalence of tobacco use in both smoking and smokeless forms among male and female psychiatric patients in India. In addition, we sought to identify socio-demographic and diagnostic correlates of tobacco use and nicotine dependence.

MATERIAL AND METHODS :

It is a cross-sectional study conducted at Prathima Institute of Medical Sciences, Karimnagar. Every tenth patient attending the psychiatric out patient with nicotine use along with co-morbid psychiatric illness and have given their informed consent during 2014 – 2016 were included in the study.

Description of Tool:A total of 101 subjects with nicotine use and age above 18years of both the genders who have given their informed consent were included in this study. Patients who were not willing to participate and those below 18 years of age were excluded from the study. All the participants were administered a semi structured questionnaire including socio-demographic data, Nicotine use age of onset, severity of dependence, coping mechanisms, quitting and relapse history, Co morbid psychiatric illness. Along with the semi structured questionnaire following scales for assessing nicotine dependence were administered.

Fagerstrom Test for Nicotine Dependence (FTND)

Fagerstrom began constructing a scale with the specific objective to estimate the degree of pharmacologically determined dependence. This work resulted in the 8 item Fagerstrom tolerance questionnaire (FTQ) in 1978. FTQ is multi factorial with only two items limited to cigarette use. So, Lynn kozlowski & Todd Heatherton revised Fagerstrom tolerance questionnaire in 1991 by excluding those two items and resulted into a new version known as Fagerstrom test for nicotine dependence (FTND). It is a six item scale and scores obtained on the test permit the classification of nicotine dependence into five levels, very low (0-2), low (3-4), moderate (5 points), high (6-7 points) & very high (8-10 points). FTND is a widely used and researched scale with a Cronbach’s alpha value of 0.56. ¹⁴

Nicotine Dependence syndrome scale ( NDSS):

It is a 19 item multi dimensional measure consisting of five factors drive, priority, continuity, stereotypy & tolerance and it assesses nicotine dependence using Edward’s theory of the dependence syndrome. Drive measures craving and withdrawal symptoms, while tolerance assesses reduced sensitivity to tobacco products. Priority assesses the preference for smoking over other reinforces, continuity assesses the regularity of smoking while stereotypy measures the sameness of smoking contexts. Items were rated on a scale from one (not at all true) to five (extremely true). The total score & five factor scores were computed using the regression based algorithms as described in appendix, the total scores and most factors demonstrated acceptable reliability (Cronbach’s alpha = 0.823-0.945). ¹⁵

The data was collected on a daily basis. Verbal consent was taken from each subject prior to data collection. A total of 101 subjects were enrolled in this study. The data collected was entered into the data collection form designed for the recording of only those parameters essential to establish the objectives of the study. Data was analyzed using software Epi info version 7.0. Data collected is thereby subjected to statistical analysis, which included Chi-square and Fischer Exact test, post-hoc analysis.

OBSERVATION AND RESULTS

A total number of 101 psychiatric patients with nicotine use were enrolled during the study period.

The study was conducted among the age group 20 to 61 and above, higher percentage of nicotine abuse (34.7%) seen between the age group of 31-40 years followed by the age group between 41-50 years (19.8%). The least percentage was found to be in 61 and above age group (11.9%).There is statistical significance between age group of psychiatric patients and nicotine abuse with p value 0.035 Out of 90 male respondents and 11 female respondents, male subjects (89.1%) showed the higher percentage. There is no statistical association between gender and nicotine abuse with a p value of 0.0717. Majority of the subjects 77(76.2%) hailed from rural background with 24 (23.8%) from urban area and p value was 0.655 implying no significant difference. Table 1

Self employed (35.6%) subjects found to have higher percentage of nicotine use followed by daily wager (24.8%), unemployed (22.8%) and employed (15.85%). Interestingly students have been reported with 1%. However, the P value was 0.466 with no significant difference. Nicotine use was found to be high among the subjects belonging to Low SES (58.4%) followed by medium SES (33.7%) and high SES (7.7%). The p value was found to be 0.435 showing no statistical association between socio economic status and nicotine use. Among the subjects 87(86.1%) were found to be married who are showing higher FTND values of about 97.5% and with statistically significant p value of 0.003.

Nicotine abuse in the subjects living with the spouse was 83.2%, 12.9% in the subjects living with parents and 4% in the subjects living alone. The p value was 0.036 showing a statistical significance with the social support.

It was found 50.5% of subjects were consuming smokeless form of tobacco followed by 42.6% of subjects smoke form. The high and medium FTND scores were seen consuming chew able form of tobacco. The p value was found to be 0.724 and this clearly states that there is no significant association.

As per the data, the prevalent disease was found to be alcohol dependence(30.7%), followed by depression(23.8%), bipolar affective disorder(11.9%), schizophrenia(10.9%), panic attack(6.9%), mixed anxiety depression(4%), generalized anxiety disorder(4%), somatization disorder(4%), sexual dysfunction(2%), and phobia, PTSD with 1%. The p–value was 0.029 which implies statistically significant.Table 2

The data collected from the subjects show that 91.1% had an exposure to nicotine before the onset of mental illness with a p value of 0.47 which was not significant.

The table reflects the results of a semi structured questionnaire administered by the examiner about the perceived effect of consumption on the subjects. 53.5% subjects said that the tobacco gives energy on consumption.78.2% subjects stated that it calms their mind whenever they are nervous. According to 57.4% of subjects, consumption of nicotine increases their concentration at work. About 86.1% consume nicotine to relieve their stress and 51.5% subjects accepted that the tobacco consumption improves their mood. The p value was statistically not significant for all the components.Table 3

This table reflects that 51.5% subjects never tried to quit tobacco consumption. The value of high FTND was higher over the negative side response with a significant p value of 0.007. The subjects who tried to quit the tobacco consumption, were asked the reason to quit the tobacco and predominantly 42% said healthy well-being as the reason which was followed by money and health (34%) as their reason. Many of the subjects (51.5%) have never tried to quit, however few subjects gave a chance of quitting by 2 attempts which constitutes around 18.8% followed by 14.9% with 1 attempt.Table 4

This table shows 5 domains of NDSS and overall score of study subjects compared by using one way ANOVA with post-hoc(LSD) tests. Drive domain p value was 0.0001 which was significant. The mean drive score was more in high FTND compared to the other groups. P value of Stereotypy and continuity domains were 0.010 and 0.009 which was significant. The mean scores of stereotypy and continuity scores were more in low FTND group compared to other groups. Priority domain score p value is 0.001 which was significant the mean score of high FTND group was more than other groups and coming to tolerance domain p value is 0.716 which was not significant with no difference between groups. Lastly, overall score p value 0.0001 which was significant. The overall mean score in high FTND group was more compared to the other groups.Table 5

DISCUSSION

The current study conducted on psychiatric patients with nicotine abuse, the age group between 31 and 40 had shown the higher percentage of prevalence with a significant association and the similar findings were reported by S Prasannalatha et al. ¹⁶ A contrast results were noticed in the studies conducted outside India. ^{17, 18}

Review articles had shown different results regarding the gender and nicotine dependence. ^{19, 20} The current study sample portrayed male predominance. This could have been due to a bias because of the cultural factors where the females were not more outspoken about their habits.

A household survey inquiring about the form and frequency of nicotine use in their family was done on a sample representative of Indian population. According to that survey there was no statistical difference in over all current tobacco use among rural and urban students and same findings were replicated in our study done on psychiatric patients. It was also observed in our study that consumption of nicotine was mostly smokeless form and the same findings were reported in this survey. ²¹ A study done by S Prasannalatha et al. had found a correlation between occupation and socioeconomic status with nicotine dependence but our study depicted a contrast results. ¹⁶

Few studies stated that, the prevalence of nicotine dependence was higher among the married subjects and more so among women living in a joint family. ^{22, 23} Our study was also showing similar results where the married subjects with spouse being a social support showed higher prevalence with significant p value. This may be because their increased responsibilities after marriage and unable to cope up their stress which may compel them to choose an alternate method like nicotine use to decrease their stress load.

Colin Depp et al. highlighted in his study that patients with schizophrenia had double rate of smoking compared to patients with bipolar disorder. ²⁴ However,our study depicted that the patients with alcohol dependence did have higher prevalence of nicotine abuse(30.7%) followed by depression(23.8%) though, 91.1% subjects were exposed to nicotine before the onset of their illness. This may be because of the additive releases of dopamine in reward pathway and increased sensitivity of nicotine receptors when alcohol and nicotine were consumed together. Hence, increase the pleasurable effects of nicotine. Alcohol and nicotine co morbidity can also be explained by their counteracting mechanism wherein nicotine alleviates cognitive impairment caused by alcohol. ²⁵

Many subjects in our study stated that nicotine consumption calms their mind, decrease the stress and increase their concentration at work. A study done by Knott V et al. depicted that nicotine induces pleasure and reduces stress and anxiety and also stated that stress significantly increased craving but not increased smoking. ²⁶ It was also evident that females have same difficulties in quitting smoking as males and the same findings were replicated in our study. ²⁷

CONCLUSION

Nicotine is a commonly abused substance in psychiatric patients without a clear demarcation about the cause effect relationship. The existing study gives few insights into reasons for nicotine intake which was more so among the productive age group. Hence, there is a need for further research about psychotropic drug interactions with nicotine use and focus on integration of nicotine cessation into treatment of other psychiatric disorders rather than separate deaddiction clinics to alleviate the illness burden.