Today is World Tobacco Day. In the special feature, we reach out to those who have been trying to quit smoking or chewing tobacco to help them.
Everyone who smokes knows that smoking is not good for them, yet they do it. There is a reason for this – smoking and mental health are connected. People who smoke or chew tobacco have linkages with anxiety, stress and depression as per research at Purdue, WHO, Hebrew University and Mental Health Foundation UK. And that is why they turn to tobacco for enhanced moods, or simply gaining confidence to be able to face the world
We often associate tobacco with the looming spectre of physical ailments, such as cancer and heart disease. But there is a quieter, insidious battle being fought within the realms of the mind.
The vicious cycle of tobacco use and mental illness
Mental illness makes people twice as likely to use tobacco and, at the same time, tobacco makes people more vulnerable to mental health concerns.
People with mental health problems, including anxiety, depression, or schizophrenia:
- are much more likely to smoke than the general population.
- tend to smoke more heavily.
- die on average 10 to 20 years earlier than those who don’t experience mental health problems – smoking plays a major role in this difference in life expectancy.
- need higher doses of some antipsychotic medicines and antidepressants because smoking interferes with the way these medicines work.
“The connection between nicotine use and mental health is a vicious cycle,” said Lindsay Bloom, health coach at Purdue Fort Wayne. “Statistics show the connection between those living with mental health issues and the use of tobacco (smoking, vaping, etc.). This increase can be linked to individuals wanting to self-medicate to help alleviate symptoms of their mental health issues; however, using tobacco doesn’t really alleviate the symptoms. It negatively impacts mental health. Over time, smoking can lead to lower levels of dopamine production by the brain, which then triggers a need to smoke more to increase the dopamine levels.”
Smoking and mental health
According to the WHO, the relationship between tobacco use and mental health is complex and eye-opening. People with severe mental health conditions die on average 15–20 years prematurely, with tobacco cited as one of the main causes of death.
The impact of tobacco use is not limited to mortality rates but also affects the quality of life and attempts to cope with poor mental health. For example, tobacco reduces the effectiveness of certain medications for mental health. Conversely, quitting tobacco can allow people on certain antipsychotic medications to reduce the dosage by up to 25%.
In 2012, global prevalence rates for tobacco smoking were estimated to be 31% for men and 6% for women. 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, including schizophrenia, mood disorders, anxiety disorders, attention-deficit/hyperactivity disorder (ADHD), binge eating disorder, bulimia, and substance use disorders.
Smoking and anxiety disorders
Smoking has been linked to the development and maintenance of anxiety disorders due to nicotine’s ability to alter fear memory and emotional processing. It has also been proposed that smoking’s effects on the monoaminergic and glutamatergic systems, oxidative stress, as well as inflammatory and neurotrophic processes, may contribute to the neuropathological mechanisms underlying the development of bipolar illness.
Thus, while individuals with mental health issues smoke and use tobacco at higher rates, the effects of the users can also bring about mental health concerns such as:
- Addiction
- Stress
- Depression
- Schizophrenia
Smoking and depression
Research by Hebrew University studied the relationship between health-related quality of life and smoking and strongly observed an association between smoking and poorer physical and mental health components of health-related quality of life (HRQoL). Overall, the study found that having a higher Beck Depression Inventory (BDI) score was associated with smoking. Furthermore, the students who smoked were two to three times more likely to have clinical depression than those who had never smoked.
“A strong association between Beck Depression Inventory (BDI) score Physical composite score (PCS) and Mental composite score (MCS) score was found across all five quantile scores,” explained Professor Levine from the Hebrew University-Hadassah Braun School of Public Health and Community Medicine in Jerusalem, Israel who is also the senior and corresponding author of the study paper. The study appeared in the journal PLoS ONE.
Those who smoked also consistently had more depressive symptoms and poorer mental health, as reflected in the “vitality” and “social functioning” parameters.
“These findings highlight the need for further research on the interaction between smoking, mental health, and quality of life, with implications for prevention, diagnosis, and treatment,” conclude the study authors. Prof. Levine adds, “Our study adds to the growing body of evidence that smoking and depression are closely linked.”
“While it may be too early to say that smoking causes depression, tobacco does appear to have an adverse effect on our mental health,” Prof. Levine added.
Why is smoking so addictive
When a person smokes, nicotine reaches the brain within about ten seconds. At first, nicotine improves mood and concentration, decreases anger and stress, relaxes muscles, and reduces appetite.
Regular doses of nicotine lead to changes in the brain, which then lead to nicotine withdrawal symptoms when the supply of nicotine decreases. Smoking temporarily reduces these withdrawal symptoms and can therefore reinforce the habit. This cycle is how most smokers become nicotine dependent.
Smoking and stress
Some people use smoking as ‘self-medication’ to reduce stress. Smoking, however, has been found to elevate tension and anxiety. People smoke in the mistaken idea that it eases tension and anxiety because nicotine immediately induces a feeling of calm. This sensation is fleeting and quickly gives place to desires that get worse and withdrawal symptoms. Smoking lessens the symptoms of withdrawal, but it has no effect on anxiety or the causes of it.
Smoking and depression
When compared to those without depression, adults with depression are twice as likely to smoke. It’s unclear whether smoking causes depression or whether depression motivates people to start smoking because most smokers begin before exhibiting depressive symptoms. The likelihood of a complicated interaction between the two is high.
According to the Mental Health Foundation, United Kingdom, Nicotine stimulates the release of the chemical dopamine in the brain. Dopamine is involved in triggering positive feelings. It is often found to be low in people with depression, who may then use cigarettes to temporarily increase their dopamine supply. However, smoking encourages the brain to switch off its mechanism for making dopamine, so in the long term, the supply decreases, which in turn prompts people to smoke more.
Another study reiterates the effects of nicotine on changes in neurotransmitter activity that may lead to the development of depression. It has been suggested that numerous chemicals in cigarette smoke interact with high-affinity nicotinic acetylcholine receptors and indirectly stimulate the release of dopamine, enabling, therefore, a sense of reward and positive reinforcement. This effect has also been observed to relieve feelings of depression and positively influence mood swings.
Moreover, people with depression can have difficulty when they try to stop smoking and have more severe withdrawal symptoms.
Smoking and schizophrenia
Smoking is three times more common and more frequent among people with schizophrenia than in the general population. It’s likely that smoking helps persons with schizophrenia manage or control some of their symptoms and lessen some of the negative effects of their medications.
A recent study has shown smoking may increase the risk of developing schizophrenia. However, further research is needed to fully understand how the two are linked.
Impaired mental health with smoking
The presence of depression may increase the smoking rate in youth indirectly by increasing their vulnerability and acceptance of peer norms. Smoking cessation may help to improve mental health and it is suggested that smoking cessation drugs may also have anti-depressive properties. Continuing stress during higher schooling has been suggested to contribute to the development of mental disorders and substance use disorders.
Smoking, a symptom of mental health disorder
Combining the efforts of mental health services and substance abuse specialists could be relevant to enhance the promotion of healthy behavioural patterns and reducing the impact of depression on overall health.
Moreover, smoking might be regarded as a symptom of mental health disorders and a marker of increased risk for depression. Previous studies reported that people who have successfully quit smoking have better emotional and mental health stability and score better in the HRQoL measurements. On the other hand, anti-depressive drugs are used for smoking cessation.
Smoking, psychiatric illness, and the brain
According to an editorial by Patricia Boska, Ph.D., that was published in the Journal of Psychiatry and Neuroscience, smoking is a factor that should regularly be considered as a potential confound in neurobiological studies of psychiatric illnesses. “Smoking can be regarded as playing at least several roles in relation to psychiatric illness — as a causal factor contributing to psychiatric disorders, as an agent causing brain changes on its own that may interact with psychiatric pathophysiology, or as a modulator of effects of psychotropic medications. In each of these roles, smoking may impact the course of psychiatric illness and brain function,” she said.
Smoking and ADHD
“There is strong evidence for an association between smoking and the development or progression of psychiatric disorders at the ends of the developmental timeline — namely, ADHD and Alzheimer’s disease/dementia,” explained Boska in her editorial.
In the case of ADHD, a large body of evidence supports an association between maternal smoking during pregnancy and increased risk for ADHD. However, whether maternal smoking is a causal factor for ADHD remains open to question, with recent research suggesting that the association may be due to a shared familial/genetic susceptibility for both smoking and ADHD.
Nonetheless, children with ADHD born from mothers who smoked during pregnancy have been reported to have more severe behavioural problems than children with ADHD born from non-smoking mothers, with a dose–response relationship between the amount smoked and several cognitive and clinical variables in the children.
At a neurobiological level, maternal smoking during pregnancy has been shown to be associated with grey matter loss and cortical thinning as well as functional alteration in neural circuitry involved in inhibitory control and reward in children.
Smoking, Dementia and Alzheimer’s disease
There is also strong epidemiological evidence that smoking is associated with an increased risk for dementia and the development of Alzheimer’s disease. In a 2-year longitudinal study of 186 healthy elderly individuals, Durazzo, and colleagues found that the rate of atrophy in several brain regions known to be affected by Alzheimer’s disease was greater in those with a history of smoking than in never-smokers.
Although the precise mechanism by which smoking produces central nervous system (CNS) atrophy has not been pinpointed, it is plausible that these effects may be mediated through the burden of cardiovascular impairment caused by smoking and by the cumulative direct cytotoxic effects of some of the thousands of compounds present in cigarette smoke.
Smoking causes brain changes that affect psychiatric symptoms
With regards to neuropsychological function, short-term administration of nicotine has positive effects on aspects of cognition, including learning, memory, and attention in healthy individuals, as well as in patients with schizophrenia, Alzheimer’s disease, or ADHD. In contrast, chronic tobacco smoking has been shown to be associated with deficits in cognitive function, prominently verbal memory, and processing speed, in middle-aged to elderly adults.
“Structural alterations, including decreases in grey matter volume of various brain structures and increased fractional anisotropy in diffusion tensor imaging studies, have been found not only in older smokers but also in smokers younger than 30 years of age,” Baska explained.
“Overall, there is now substantial evidence that tobacco smoking is associated with changes in brain structure and neural circuitry in brain regions and systems clearly implicated in many psychiatric disorders. These findings, together with the high prevalence of smoking in psychiatric populations, highlight the importance of including smoking as a potential confounding variable in studies examining neural mechanisms of psychiatric disorders,” Baska notes.
Smoking as a modulator of the effects of psychotropic medications
Smoking/nicotine may modulate the metabolism of other psychoactive agents. The effects of smoking status on the metabolism of psychoactive drugs may be an additional way in which smoking could influence measures of brain function in some psychiatric populations.
How does smokeless tobacco (snus) impact mental health?
Smokeless tobacco usage, in contrast to cigarette smoking, is linked to a certain subset of psychiatric problems, according to a study published in PLoS One. Different psychiatric illnesses are associated with the type of smokeless tobacco use, such as panic disorder and particular phobia for chewing tobacco users and cannabis use disorder for snuff users.
The study also discovered a previously unreported link between inhalant or solvent use disorder and chewing tobacco exclusivity. All forms of smokeless tobacco usage were discovered to be related to alcohol consumption disorder. The study recommends concentrating prevention and treatment efforts on psychiatric illnesses among users of smokeless tobacco.
Relationship between smokeless tobacco use and psychiatric disorders
A study published in the Society for the Study of Addiction, states that the use of smokeless tobacco has been linked to psychiatric problems. Mania/hypomania and particular personality disorders have both been connected to snuff usage, both exclusively and in combination with chewing tobacco.
According to the study, the use of smokeless tobacco of any kind was linked to antisocial personality disorder and substance use disorders. The use of only chewing tobacco was connected to panic disorder and particular phobia. The study recommends focusing treatment on particular psychiatric illnesses among smokeless tobacco users, such as cannabis use disorder, panic disorder, panic attacks, specific phobias, and alcohol use disorder.
Smoking cessation among individuals with psychiatric illnesses
A meta-analysis found reductions in measures of anxiety and depression after smoking cessation, with an effect size at least as great as that for antidepressant treatments and a similar effect size in both the general population and populations with psychiatric disorders.
Although the reasons for this are undoubtedly complex, a recent systematic review and meta-analysis found that a large proportion of mental professionals hold a negative attitude toward smoking cessation among psychiatric patients, believing that “patients are not interested in quitting” or “quitting smoking is too much for patients to take on,” and indicating a lack of training and time to help patients with their smoking reduction efforts. This is undoubtedly an area that would benefit from further attention.
The mental health benefits of quitting smoking
When people stop smoking, studies show:
- Anxiety, depression, and stress levels are lower.
- Quality of life and positive mood improve.
- The dosage of some medicines used to treat mental health problems can be reduced.
Head to the next article to get expert tips on how to quit smoking
Source: www.nhs.uk, www.mentalhealth.org.uk, www.ncbi.nlm.nih.gov, www.purdue.edu, www.who.int, www.medicalnewstoday.com, www.onlinelibrary.wiley.com
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