Abstracts

Introduction

Tobacco smoking remains a serious public health problem worldwide and, although its magnitude and relative impact vary among different populations, it is considered the main avoidable cause of death in a number of countries ¹1 . World Health Organization. WHO report on the global tobacco epidemic, 2009: implementing smoke-free environments. Geneva: World Health Organization; 2009.. Smoking is a major contributing factor to excess mortality and morbidity from cardiovascular diseases among patients with severe mental illness ²2 . Brown S, Inskip H, Barraclough B. Causes of the excess mortality of schizophrenia. Br J Psychiatry 2000; 177:212-7.^,33 . Hennekens CH, Hennekens AR, Hollar D, Casey DE. Schizophrenia and increased risk of cardiovascular disease. Am Heart J 2005; 150:1115-21.. Excess mortality due to smoking has also been shown among patients with other diseases, such as HIV. A study in Denmark indicated that mortality due to smoking is greater than mortality attributable to HIV among people with HIV/AIDS, showing that the number of life years lost due HIV was 5.1, compared to 12.3 because of smoking ⁴4 . Helleberg M, Afzal S, Kronborg G, Larsen CS, Pedersen G, Pedersen C, et al. Mortality attributable to smoking among HIV-1-infected individuals: a nationwide, population-based cohort study. Clin Infect Dis 2013; 56:727-34..

It has been repeatedly shown that smoking prevalence among psychiatric populations is higher than among the general population. The prevalence of current smoking among people with mental illness is higher than in the general population in the USA (34.8% and 28.5%, respectively) ⁵5 . Lasser K, Boyd JW, Woolhandler S, Himmelstein DU, McCormick D, Bor DH. Smoking and mental illness: a population-based prevalence study. JAMA 2000; 284:2606-10., Canada (46.8% and 14%, respectively) ⁶6 . Johnson JL, Ratner PA, Malchy LA, Okoli CTC, Procyshyn RM, Bottorff JL, et al. Gender-specific profiles of tobacco use among non-institutionalized people with serious mental illness. BMC Psychiatry 2010; 10:101., and Australia (31.2% and 18.7%, respectively) ⁷7 . Bowden JA, Miller CL, Hiller JE. Smoking and mental illness: a population study in South Australia. Aust N Z J Psychiat 2011; 45:325-31.. In Australia, a study showed that prevalence is higher among patients with severe mental illness than in people with general mental illness (51.2% and 26.4%, respectively) ⁷7 . Bowden JA, Miller CL, Hiller JE. Smoking and mental illness: a population study in South Australia. Aust N Z J Psychiat 2011; 45:325-31., while in Canada smoking prevalence was 51.8% in patients with schizophrenia compared to 39.2% among those with mood disorder or anxiety ⁶6 . Johnson JL, Ratner PA, Malchy LA, Okoli CTC, Procyshyn RM, Bottorff JL, et al. Gender-specific profiles of tobacco use among non-institutionalized people with serious mental illness. BMC Psychiatry 2010; 10:101.. A more recent study of a nationally representative probability sample of 9,282 people in the USA showed that adults affected by a mental disorder in the past 12 months smoked almost twice as much as adults without mental disorders ⁸8 . Lawrence D, Mitrou F, Zubrick SR. Smoking and mental illness: results from population surveys in Australia and the United States. BMC Public Health 2009; 9:285..

A dose-response relationship has been observed between the number of psychiatric diagnoses and smoking ⁵5 . Lasser K, Boyd JW, Woolhandler S, Himmelstein DU, McCormick D, Bor DH. Smoking and mental illness: a population-based prevalence study. JAMA 2000; 284:2606-10., showing that prevalence is highest among individuals with four or more psychiatric diagnoses. Also, smokers in the USA that experienced high levels of psychological distress smoked more cigarettes per day and smoking rates varied according to type of mental disorder. Smoking prevalence was 21.3% among those with no mental disorder compared to 37.8% in people with anxiety disorders, 45.1% in those with mood disorders, and 63.6% among adults with substance use disorders ⁸8 . Lawrence D, Mitrou F, Zubrick SR. Smoking and mental illness: results from population surveys in Australia and the United States. BMC Public Health 2009; 9:285..

Although there are few publications on smoking among patients with mental illness in Brazil, evidence suggests that smoking prevalence is higher among this group than in the general population: population based studies show that smoking prevalence was 21% in Pelotas (State of Rio Grande do Sul) ⁹9 . Dias-Damé JL, Cesar JA, Silva SM. Tendência temporal de tabagismo em população urbana: um estudo de base populacional no Sul do Brasil. Cad Saúde Pública 2011; 27:2166-74. and 19% in Campinas (State of São Paulo) ¹⁰10 . Francisco PMSB, Barros MBA, Segri NJ, Alves MCGP. Comparação de estimativas de inquéritos de base populacional. Rev Saúde Pública 2013; 47:60-8., while among patients with severe psychiatric illness in São Paulo it was 59% ¹¹11 . Ratto LRC, Menezes PR, Gulinelli A. Prevalence of tobacco use in individuals with severe mental illnesses, São Paulo, Brazil. Rev Saúde Pública 2007; 41:510-6., almost three times higher.

The intricate relationship between explanatory variables, including clinical, behavioral and sociodemographic factors, associated with higher smoking prevalence among patients with mental illness is still the subject of much research. An association has been found between smoking and severe mental illness (schizophrenia, bipolar disorders and other psychoses), markers for clinical severity (e.g. previous hospitalization) and substance use disorders ¹¹11 . Ratto LRC, Menezes PR, Gulinelli A. Prevalence of tobacco use in individuals with severe mental illnesses, São Paulo, Brazil. Rev Saúde Pública 2007; 41:510-6.^,1212 . de Leon J, Susce MT, Diaz FJ, Rendon DM, Velásquez D. Variables associated with alcohol, drug, and daily smoking cessation in patients with severe mental illnesses. J Clin Psychiatry 2005; 66:1447-55.^,1313 . Keizer I, Gex-Fabry M, Eytan A, Bertschy G. Smoking in psychiatric inpatients: association with working status, diagnosis, comorbid substance abuse and history of suicide attempts. Addict Behav 2009; 34:815-20.^,1414 . Morris CD, Giese AA, Turnbull JJ, Dickinson M, Johnson-Nagel N. Predictors of tobacco use among persons with mental illnesses in a statewide population. Psychiatr Serv 2006; 57:1035-8.^,1515 . Vanable PA, Carey MP, Maisto SA. Smoking among psychiatric outpatients: relationship to substance use, diagnosis, and illness severity. Psychol Addict Behav 2003; 17:259-65.. However, the nature of these associations is not always clear. Sociodemographic factors such as male gender, older age, lower education, and not being married have also been identified. On the other hand, female and younger smokers had higher rates of mental disorders than male or older smokers, respectively ⁸8 . Lawrence D, Mitrou F, Zubrick SR. Smoking and mental illness: results from population surveys in Australia and the United States. BMC Public Health 2009; 9:285.. Behavioral correlates of smoking, including alcohol and illicit drug use, are also more common among psychiatric patients ⁶6 . Johnson JL, Ratner PA, Malchy LA, Okoli CTC, Procyshyn RM, Bottorff JL, et al. Gender-specific profiles of tobacco use among non-institutionalized people with serious mental illness. BMC Psychiatry 2010; 10:101.^,1212 . de Leon J, Susce MT, Diaz FJ, Rendon DM, Velásquez D. Variables associated with alcohol, drug, and daily smoking cessation in patients with severe mental illnesses. J Clin Psychiatry 2005; 66:1447-55.^,1313 . Keizer I, Gex-Fabry M, Eytan A, Bertschy G. Smoking in psychiatric inpatients: association with working status, diagnosis, comorbid substance abuse and history of suicide attempts. Addict Behav 2009; 34:815-20.^,1414 . Morris CD, Giese AA, Turnbull JJ, Dickinson M, Johnson-Nagel N. Predictors of tobacco use among persons with mental illnesses in a statewide population. Psychiatr Serv 2006; 57:1035-8.^,1515 . Vanable PA, Carey MP, Maisto SA. Smoking among psychiatric outpatients: relationship to substance use, diagnosis, and illness severity. Psychol Addict Behav 2003; 17:259-65.^,1616 . Hou YZ, Xiang YT, Yan F, Ungvari GS, Dickerson F, Chiu HFK, et al. Cigarette smoking in community-dwelling patients with schizophrenia in China. J Psychiatr Res 2011; 45:1551-6..

Several studies indicate that psychiatric patients often “self-medicate” smoking as a form of relaxation and also to reduce anxiety and relieve some of the symptoms of the illness and the side effects of antipsychotic drugs ¹⁷17 . McCloughen A. The association between schizophrenia and cigarette smoking: a review of the literature and implications for mental health nursing practice. Int J Ment Health Nurs 2003; 12:119-29.^,1818 . Patkar AA, Gopalakrishnan R, Lundy A, Leone FT, Certa KM, Weinstein SP. Relationship between tobacco smoking and positive and negative symptoms in schizophrenia. J Nerv Ment Dis 2002; 190:604-10.. All these effects are directly associated with nicotine and the dependence on this drug has been shown to be more intense among psychiatric patients than in the general population ¹⁹19 . de Leon J, Diaz FJ. A meta-analysis of worldwide studies demonstrates an association between schizophrenia and tobacco smoking behaviors. Schizophr Res 2005; 76:135-57.. Despite evidence of the benefits of supporting the smoking cessation efforts of people with serious mental illness during hospital stays and beyond, quit rates are low and recurrence is high. Understanding the potential reasons for this situation is essential to improving the effectiveness of smoking cessation programs in psychiatric settings ²⁰20 . Prochaska JJ, Hall SE, Delucchi K, Hall SM. Efficacy of initiating tobacco dependence treatment in inpatient psychiatry: a randomized controlled trial. Am J Public Health 2013. [Epub ahead of print]..

Most studies about smoking in psychiatric populations have been conducted in high income countries. In Brazil, the few studies that exist on smoking among psychiatric patients use small samples and are limited to one service or to patients with severe mental illness ¹¹11 . Ratto LRC, Menezes PR, Gulinelli A. Prevalence of tobacco use in individuals with severe mental illnesses, São Paulo, Brazil. Rev Saúde Pública 2007; 41:510-6.^,2121 . Munaretti CL, Terra MB. Transtornos de ansiedade: um estudo de prevalência e comorbidade com tabagismo em um ambulatório de psiquiatria. J Bras Psiquiatr 2007; 56:108-15.^,2222 . Pillon SC, Jora NP, Amorim GP, Domingos JBC, Santos RA. Tabagismo em usuários de um centro de atenção psicossocial álcool e drogas: um estudo piloto. Acta Paul Enferm 2011; 24:313-9.. Thus, the aims of the present study were to estimate the prevalence of current and past tobacco smoking and assess associated factors among each group of a national representative sample of patients with chronic mental illness in public psychiatric facilities in Brazil. This study also assessed the association between severe mental illness and past and current smoking, adjusted for clinical, sociodemographic and behavioral factors.

Methods

Study sample

The sample was drawn from a national cross-sectional multicenter study conducted in Brazil in 2006 called the PESSOAS Project which examined 2,475 patients for HIV/AIDS risk behaviors and the prevalence of HIV and syphilis ²³23 . Guimarães MDC, Campos LN, Melo APS, Carmo RA, Machado CJ, Acúrcio FA. Prevalence of HIV, syphilis, hepatitis B and C among adults with mental illness: a multicenter study in Brazil. Rev Bras Psiquiatr 2009; 31:43-7.. Adults receiving treatment in public psychiatric hospitals or public mental health outpatient clinics, known as Psychosocial Care Centers (CAPS, acronym in Portuguese), who were capable of providing written informed consent, and able to respond a face-to-face questionnaire were considered eligible for inclusion in the sample. CAPS that exclusively treated substance use disorders were excluded in order to avoid overrepresentation of selected risk behaviors and/or prevalence rates. Patients’ capability to answer the questionnaire was assessed using a preliminary evaluation adapted from the Mini Mental State Examination (MMSE). A random selection of 11 hospitals and 15 CAPS was made which was proportional to the type of care, the five geographical regions of Brazil, and the distribution of reported AIDS cases at the time of data collection. A two-stage probability sampling frame was used. First, a random sample of facilities was taken which was proportional to the number of beds in the hospital stratum and number of registered patients in the CAPS stratum for each region. In the second stage, patients were selected using simple random sampling for each chosen facility ²³23 . Guimarães MDC, Campos LN, Melo APS, Carmo RA, Machado CJ, Acúrcio FA. Prevalence of HIV, syphilis, hepatitis B and C among adults with mental illness: a multicenter study in Brazil. Rev Bras Psiquiatr 2009; 31:43-7.. Patients were included only if information on tobacco use was available (n = 2,461).

The project was approved by the Ethics Research Committee of the Federal University of Minas Gerais (COEP/UFMG, Etic 125/03) and the National Ethics Research Committee (CONEP 592/2006). Participation was voluntary and written informed consent was obtained.

Exposure and event measurements

Sociodemographic, clinical and behavioral data was obtained through face-to-face interviews using a semi-structured questionnaire, while psychiatric diagnoses were obtained from medical records. Questionnaires were previously tested for reliability and validity ²⁴24 . Guimarães MDC, Oliveira HN, Campos LN, Santos CA, Gomes CER, Oliveira SB, et al. Reliability and validity of a questionnaire on vulnerability to sexually transmitted infections among adults with chronic mental illness – PESSOAS Project. Rev Bras Psiquiatr 2008; 30:55-9..

The dependent variable was tobacco smoking divided in three categories: current smokers, ex-smokers, and non-smokers. Current smokers were defined as those who reported smoking at least one regular or hand-rolled cigarette per day at the time of the interview. Ex-smokers were defined as those who used to smoke at least one regular or hand-rolled cigarette per day, but were not smokers at the time of the interview, regardless of the length of smoking period. Finally, non-smokers were individuals who had never smoked during their lifetime. Smoking behavior was analyzed using variables such as the age the individual began smoking, number of cigarettes smoked per day (overall and by psychiatric diagnoses), and smoking inside service settings.

The explanatory variables included in this analysis were divided into three categories: (a) sociodemographic (gender, age, skin color, schooling, family income in the last month, marital status, history of homelessness, and the practice of a religion); (b) clinical (treatment settings, main psychiatric diagnosis, previous psychiatric hospitalization, and other self-reported medical conditions); and, (c) behavioral (lifetime alcohol or illicit drug use, lifetime unsafe sex, having received or offered money or drugs for sex, lifetime physical and sexual violence). The cutoff point for family income was based on the Brazilian minimum wage at the time of the study (US$200). Those individuals who reported that they were single, separated, divorced and widowed were grouped as “unmarried”. History of homelessness was defined as having lived on the street, in parks, or outdoor public spaces. Psychiatric diagnoses were undertaken by a psychiatrist and classified according to the International Classification of Diseases, 10^th revision (ICD-10), a standard system adopted by the public health system in Brazil. Up to three main psychiatric diagnoses were recorded, and hierarchically categorized according to severity as follows: (1) psychotic disorders and depression with psychotic symptoms; (2) bipolar disorder; (3) depression; (4) anxiety; (5) substance use disorders; (6) others. Diagnoses of tobacco use were not recorded in the substance use disorder category. Other medical conditions were self-reported and were defined as having been diagnosed by a nonpsychiatric health professional. Lifetime alcohol or illicit drug use was defined as use of alcohol or any illicit drug, such as marijuana, cocaine, crack, hallucinogens, amphetamines, opiates, solvents. Lifetime unsafe sex was defined as not always using condoms in all practices. Lifetime physical and sexual violence were defined as having suffered any type of physical or sexual aggression, i.e., being forced to maintain an undesired sexual relationship, or having suffered sexual abuse.

Statistical analysis

Current smoking prevalence was estimated by dividing the number of participants who reported current smoking by the total number of participants and past smoking prevalence was defined as the number of participants who used to smoke but were not current smokers, divided by the total number of participants.

Pearson’s chi-square statistic and Student’s t-statistic were used to assess statistical differences between proportions and means. The magnitude of association between the potential explanatory variables and smoking was estimated using the odds ratio (OR) with a 95% confidence interval (95%CI) and significance level of 0.05 for both the univariate and multivariate analyses. A multiple logistic regression was carried out to assess the independent effect of the explanatory factors on tobacco smoking separately comparing current smokers and ex-smokers to nonsmokers. Multivariate modeling was carried out starting with a full model which included variables with a p-value of less than 0.20 in the univariate analysis and those with epidemiological relevance. Variables with a p-value of less than 0.05 were maintained in the final model. Model fit was assessed using the Hosmer-Lemeshow test. The software programs used were Paradox (Corel Corp., Ottawa, Canada) and SAS 9.0 (SAS Inst., Cary, USA).

Results

Descriptive characteristics

A total of 2,475 participants from the final sample of 2,763 patients, (90%) were interviewed. Ten percent of the sample (288) did not participate due to the following reasons: refusal (52%), patient was not located (19%), patient did not show up for interview (8%), not eligible (4%), and death (0.7%). No statistically significant difference was found between participants and non-participants with regard to age, sex, schooling and psychiatric diagnoses. Among the 2,475 participants initially interviewed, 14 did not answer the questions about smoking, resulting in a final analysis of 2,461 patients.

Table 1 presents demographic, clinical and behavioral characteristics. Most patients were female, aged 40 years or over, white, had a low education level, were unmarried, and practiced some type of religion. Eighteen percent of patients had a history of homelessness and 35.4% were from low income families (< US$ 200). More than half of the sample population were receiving treatment at a CAPS facility at the time of the interview, had a severe mental illness (psychoses and bipolar disorders), and a history of previous hospitalizations. At least 65% of substance use disorders were related to alcohol use. Similarly, most participants consumed alcohol, practiced unsafe sex, and had suffered physical violence. Forty-five percent reported at least one other medical condition: circulatory disorders (25%), digestive disorders (14%), respiratory disorders (14%), and endocrine system disorders (11%). Almost 30% received or offered money or drugs for sex, and 20% reported having suffered from sexual violence.

Current smokers comprised 52.7% (95%CI: 50.8-54.7) of the sample and 18.9% (95%CI: 17.4-20.4) were ex-smokers (Table 2). The average number of cigarettes smoked per day was higher among current smokers (mean = 15.6) than among ex-smokers (mean = 10.8) (t-test = 7.01; p < 0.001). With respect to current smokers, the average number of cigarettes smoked per day was higher among patients with substance use disorders (mean = 17.0) (F-statistic = 3.66; p = 0.03), however the same variation was not observed among ex-smokers (F-statistic = 1.15; p = 0.32). Finally, current smokers started smoking earlier (mean age = 15.9 years old) than ex-smokers (mean age = 17.3 years old) (t-test = -3.66; p < 0.001), and a high proportion of current smokers (80%) reported that they smoked inside the mental health facilities.

Univariate and multivariate analysis

Smoking prevalence was significantly higher (p < 0.05) among nonwhite, unmarried male participants, aged 40 years or over, with a low education level (≤ 8 years of schooling) and a history of homelessness. A significant negative association was found between smoking and practicing a religion (OR = 0.56). The prevalence of smoking was higher (p < 0.05) among hospitalized participants (OR = 2.75) with a more severe mental illness (psychoses and bipolar disorder) or substance use disorders, and among those individuals previously admitted to hospital for psychiatric treatment (OR = 2.56). Prevalence of current smoking was higher among individuals who used alcohol or illicit drugs, did not practice safe sex, had received/offered money/drugs for sex, and had suffered physical violence (Table 3).

The likelihood of being an ex-smoker was higher (p < 0.05) among nonwhite men, aged 40 years or over, with a low education level and history of homelessness. Univariate analysis showed a statistically significant association between past smoking and the following clinical and behavioral variables: previous psychiatric hospitalizations, other medical conditions, alcohol or illicit drug use, unsafe sex, exchange of money/drugs for sex and having suffered physical violence (Table 3).

Multivariate analysis (Table 4) showed a statistically significant independent association between current smoking and being male, being aged 40 years or over, having a low education level and history of homelessness, and not practicing a religion (p < 0.05). In addition, the likelihood of being a current smoker was higher with the presence of the clinical variables current and previous psychiatric hospitalization (OR = 1.63 and OR = 1.59, respectively), and when the main psychiatric diagnosis was substance use disorders (OR = 4.48). Finally, an independent association was found between current smoking and lifetime alcohol and illicit drug use, unsafe sex, and physical violence (p < 0.05). An independent association was found between past smoking (p < 0.05) and being male, being aged 40 years or over, lifetime alcohol and illicit drug use, unsafe sex and physical violence.

Discussion

Current smoking prevalence among the sample was high (53%). This rate is much higher than the rate among the general population of Brazil which in 1989 was 35%. This rate decreased in 2003 to 22%, followed by further decreases in 2008 and 2011 to 18% ²⁵25 . Instituto Nacional de Câncer; Organização Pan-Americana da Saúde. Pesquisa Especial de Tabagismo – PETab: relatório Brasil. Rio de Janeiro: Instituto Nacional de Câncer; 2011.^,2626 . Monteiro CA, Cavalcante TM, Moura EC, Claro RM, Szwarcwald CL. Population-based evidence of a strong decline in the prevalence of smokers in Brazil (1989-2003). Bull World Health Organ 2007; 85:527-34. and 15%, respectively ²⁷27 . Secretaria de Vigilância em Saúde, Ministério da Saúde. Vigitel Brasil 2011: Vigilância de Fatores de Risco e Proteção para Doenças Crônicas por Inquérito Telefônico. Brasília: Ministério da Saúde; 2012. (Série G. Estatística e Informação em Saúde).. It is probable that this clear downward trend in smoking prevalence is attributed to the recent implementation of stricter public smoking policies by the Brazilian government ²⁸28 . Wünsch-Filho V, Mirra AP, López RVM, Antunes LF. Tabagismo e câncer no Brasil: evidências e perspectivas. Rev Bras Epidemiol 2010; 13:175-87., including advertising restrictions, warning labels printed on cigarette packs, and prohibition of indoor smoking in all public places ²⁹29 . Instituto Nacional de Câncer. A situação do tabagismo no Brasil: dados dos inquéritos do Sistema Internacional de Vigilância, da Organização Mundial da Saúde, realizados no Brasil, entre 2002 e 2009. Rio de Janeiro: Instituto Nacional de Câncer; 2011.. In addition, the relatively high price of cigarettes in Brazil, considered the highest in the world, may also have contributed to this reduction ³⁰30 . Levy D, Almeida LM, Szklo A. The Brazil SimSmoke policy simulation model: the effect of strong tobacco control policies on smoking prevalence and smoking-attributable deaths in a middle income nation. PLoS Med 2012; 9:e1001336.. Our results are corroborated by the findings of studies in high income countries that observed a higher rate of current smoking prevalence among patients with mental illnesses than in the general population ⁵5 . Lasser K, Boyd JW, Woolhandler S, Himmelstein DU, McCormick D, Bor DH. Smoking and mental illness: a population-based prevalence study. JAMA 2000; 284:2606-10.^,66 . Johnson JL, Ratner PA, Malchy LA, Okoli CTC, Procyshyn RM, Bottorff JL, et al. Gender-specific profiles of tobacco use among non-institutionalized people with serious mental illness. BMC Psychiatry 2010; 10:101.^,77 . Bowden JA, Miller CL, Hiller JE. Smoking and mental illness: a population study in South Australia. Aust N Z J Psychiat 2011; 45:325-31..

However, it is important to note that the psychiatric patients from our sample did not start smoking earlier (mean age = 16 years) than the general population (13 to 15 years of age) ²⁹29 . Instituto Nacional de Câncer. A situação do tabagismo no Brasil: dados dos inquéritos do Sistema Internacional de Vigilância, da Organização Mundial da Saúde, realizados no Brasil, entre 2002 e 2009. Rio de Janeiro: Instituto Nacional de Câncer; 2011.. Also, current smokers in our study reported smoking an average of 15.6 cigarettes per day, which is slightly higher than in the general population (mean = 13.3) ³¹31 . Giovino GA, Mirza SA, Samet JM, Gupta PC, Jarvis MJ, Bhala N, et al. Tobacco use in 3 billion individuals from 16 countries: an analysis of nationally representative cross-sectional household surveys. Lancet 2012; 380:668-79.. This number is lower than in developed countries, such as Australia (17.0 cigarettes per day among individuals with a general mental illness and 21.4 per day in people with a severe mental illness) ⁷7 . Bowden JA, Miller CL, Hiller JE. Smoking and mental illness: a population study in South Australia. Aust N Z J Psychiat 2011; 45:325-31. and the USA (26.2 cigarettes per day among people with mental illness and 22.6 per day among the general population) ⁵5 . Lasser K, Boyd JW, Woolhandler S, Himmelstein DU, McCormick D, Bor DH. Smoking and mental illness: a population-based prevalence study. JAMA 2000; 284:2606-10.. Studies in Beijing (China) and Syracuse (USA) showed cigarette consumption rates of 20.1 and 21.6 cigarettes per day, respectively ¹⁵15 . Vanable PA, Carey MP, Maisto SA. Smoking among psychiatric outpatients: relationship to substance use, diagnosis, and illness severity. Psychol Addict Behav 2003; 17:259-65.^,1616 . Hou YZ, Xiang YT, Yan F, Ungvari GS, Dickerson F, Chiu HFK, et al. Cigarette smoking in community-dwelling patients with schizophrenia in China. J Psychiatr Res 2011; 45:1551-6..

Several studies have found an association between smoking and the level of severity of mental illness ⁵5 . Lasser K, Boyd JW, Woolhandler S, Himmelstein DU, McCormick D, Bor DH. Smoking and mental illness: a population-based prevalence study. JAMA 2000; 284:2606-10.^,66 . Johnson JL, Ratner PA, Malchy LA, Okoli CTC, Procyshyn RM, Bottorff JL, et al. Gender-specific profiles of tobacco use among non-institutionalized people with serious mental illness. BMC Psychiatry 2010; 10:101.^,77 . Bowden JA, Miller CL, Hiller JE. Smoking and mental illness: a population study in South Australia. Aust N Z J Psychiat 2011; 45:325-31.^,88 . Lawrence D, Mitrou F, Zubrick SR. Smoking and mental illness: results from population surveys in Australia and the United States. BMC Public Health 2009; 9:285.^,1919 . de Leon J, Diaz FJ. A meta-analysis of worldwide studies demonstrates an association between schizophrenia and tobacco smoking behaviors. Schizophr Res 2005; 76:135-57.. Although no independent association was observed between smoking and more severe psychiatric diagnoses (psychoses and bipolar disorders), we found a strong independent association between smoking and substance use disorders. A similar association was found in a study of Swiss psychiatric inpatients ¹³13 . Keizer I, Gex-Fabry M, Eytan A, Bertschy G. Smoking in psychiatric inpatients: association with working status, diagnosis, comorbid substance abuse and history of suicide attempts. Addict Behav 2009; 34:815-20..

The most likely explanation for the association between tobacco smoking and mental illness is that smoking follows the same pattern as other substance use disorders which are more common among people with a mental illness than in the general population. Suggested explanations for these associations include a common underlying vulnerability to both types of disorders, “self-medication” of substances to alleviate the side-effects of psychotropic medications, and the possibility that smoking increases the vulnerability to developing other mental disorders. Furthermore, one of the potential barriers to treating tobacco smoking among patients with a mental illness is the strong correlation between smoking and the psychiatric diagnosis of substance use disorders, including the use of alcohol and illicit drugs.

Our study found an association between smoking and being currently hospitalized and having a history of previous psychiatric hospitalization, indicators of more severe forms of mental illness. A possible contributing factor to this situation is that smoking is still accepted in some psychiatric hospitals and professionals, who are often smokers themselves, allow patients to smoke inside the institution ³²32 . Williams JM. Eliminating tobacco use in mental health facilities – patient’s right, public health, and policy issues. JAMA 2008; 299:571-3. and our study found that a high proportion of patients smoked inside the mental health facility. Although Brazilian legislation does not specifically mention psychiatric institutions current laws restrict exposure to tobacco smoke in public places, including hospitals in general ³³33 . Presidência da República. Lei no 9.294, de 15 de julho de 1996. Dispõe sobre as restrições ao uso e à propaganda de produtos fumígeros, bebidas alcoólicas, medicamentos, terapias e defensivos agrícolas, nos termos do § 4o do art. 220 da Constituição Federal. Diário Oficial da União 1996; 16 Dez.. Smoking policies differ from country to country, and although Brazilian government strategies to combat smoking have advanced in recent years ³⁴34 . Cavalcante TM. O controle do tabagismo no Brasil: avanços e desafios. Rev Psiq Clín 2005; 32:283-300., the country’s laws are less comprehensive than in other countries such as Spain ³⁵35 . Ballbè M, Nieva G, Mondon S, Pinet C, Bruguera E, Saltó E, et al. Smoke-free policies in psychiatric services: identification of unmet needs. Tob Control 2012; 21:549-54.^,3636 . Gruer L, d’Espaignet ET, Haw S, Fernández E, Mackay J. Smoke-free legislation: global reach, impact and remaining challenges. Public Health 2012; 126:227-9.. Mental health professionals’ tolerance of patient smoking may contribute to the high rate of smoking in facilities, since smoking may serve as a tool for reducing anxiety, or a tradeoff for better adherence to treatment and less aggressive behavior ³⁷37 . Olivier D, Lubman DI, Fraser R. Tobacco smoking within psychiatric inpatient settings: a biopsychosocial perspective. Aust N Z J Psychiatry 2007; 41:572-80.^,3838 . Ratschen E, Britton J, McNeill A. The smoking culture in psychiatry: time for change. Br J Psychiatry 2011; 198:6-7.^,3939 . Williams JM, Ziedonis D. Addressing tobacco among individuals with a mental illness or an addiction. Addict Behav 2004; 29:1067-83.. In addition, smoking cessation programs are not part of psychiatric care in many services, despite evidence that the use of smoking cessation medications is safe for psychiatric populations.

As in other studies, an association was found between current smoking and several sociodemographic characteristics, including being male, older age, low education level ⁶6 . Johnson JL, Ratner PA, Malchy LA, Okoli CTC, Procyshyn RM, Bottorff JL, et al. Gender-specific profiles of tobacco use among non-institutionalized people with serious mental illness. BMC Psychiatry 2010; 10:101.^,1111 . Ratto LRC, Menezes PR, Gulinelli A. Prevalence of tobacco use in individuals with severe mental illnesses, São Paulo, Brazil. Rev Saúde Pública 2007; 41:510-6.^,1313 . Keizer I, Gex-Fabry M, Eytan A, Bertschy G. Smoking in psychiatric inpatients: association with working status, diagnosis, comorbid substance abuse and history of suicide attempts. Addict Behav 2009; 34:815-20.^,1414 . Morris CD, Giese AA, Turnbull JJ, Dickinson M, Johnson-Nagel N. Predictors of tobacco use among persons with mental illnesses in a statewide population. Psychiatr Serv 2006; 57:1035-8.^,1616 . Hou YZ, Xiang YT, Yan F, Ungvari GS, Dickerson F, Chiu HFK, et al. Cigarette smoking in community-dwelling patients with schizophrenia in China. J Psychiatr Res 2011; 45:1551-6., and history of homelessness ⁴⁰40 . Baggett TP, Rigotti NA. Cigarette smoking and advice to quit in a national sample of homeless adults. Am J Prev Med 2010; 39:164-72.^,4141 . Torchalla I, Strehlau V, Okoli CTC, Li K, Schuetz C, Krausz M. Smoking and predictors of nicotine dependence in a homeless population. Nicotine Tob Res 2011; 13:934-42., while a negative association was found between smoking and practicing a religion ⁴²42 . Lucchetti G, Peres MFP, Lucchetti ALG, Koenig HG. Religiosity and tobacco and alcohol use in a Brazilian shantytown. Subst Use Misuse 2012; 47:837-46.^,4343 . Wray-Lake L, Maggs JL, Johnston LD, Bachman JG, O’Malley PM, Schulenberg JE. Associations between community attachments and adolescent substance use in nationally representative samples. J Adolesc Health 2012; 51:325-31.. A low level of education may be considered a marker for low access to knowledge and understanding of the harmful effects of tobacco ¹⁶16 . Hou YZ, Xiang YT, Yan F, Ungvari GS, Dickerson F, Chiu HFK, et al. Cigarette smoking in community-dwelling patients with schizophrenia in China. J Psychiatr Res 2011; 45:1551-6.. Practicing a religion may act as a protective factor for substance use ⁴⁴44 . Yeung JW, Chan YC, Lee BL. Youth religiosity and substance use: a meta-analysis from 1995 to 2007. Psychol Rep 2009; 105:255-66. since it represents a potential social safety net that establishes values, restrictions or impositions on certain behaviors ⁴²42 . Lucchetti G, Peres MFP, Lucchetti ALG, Koenig HG. Religiosity and tobacco and alcohol use in a Brazilian shantytown. Subst Use Misuse 2012; 47:837-46.^,4343 . Wray-Lake L, Maggs JL, Johnston LD, Bachman JG, O’Malley PM, Schulenberg JE. Associations between community attachments and adolescent substance use in nationally representative samples. J Adolesc Health 2012; 51:325-31.. On the other hand, increased social vulnerability and the high prevalence of co-occurring substance use among homeless people with mental health disorders place this population at a higher risk of smoking. Excess mortality rates are higher among homeless people for all causes of death, especially cardiovascular, pulmonary and other smoking-related causes ⁴⁰40 . Baggett TP, Rigotti NA. Cigarette smoking and advice to quit in a national sample of homeless adults. Am J Prev Med 2010; 39:164-72.^,4141 . Torchalla I, Strehlau V, Okoli CTC, Li K, Schuetz C, Krausz M. Smoking and predictors of nicotine dependence in a homeless population. Nicotine Tob Res 2011; 13:934-42..

The associations between current and past smoking and behavioral characteristics, such as alcohol and drug use, unsafe sex, and lifetime physical violence, are consistent with findings of other studies ⁸8 . Lawrence D, Mitrou F, Zubrick SR. Smoking and mental illness: results from population surveys in Australia and the United States. BMC Public Health 2009; 9:285.^,1212 . de Leon J, Susce MT, Diaz FJ, Rendon DM, Velásquez D. Variables associated with alcohol, drug, and daily smoking cessation in patients with severe mental illnesses. J Clin Psychiatry 2005; 66:1447-55.^,3939 . Williams JM, Ziedonis D. Addressing tobacco among individuals with a mental illness or an addiction. Addict Behav 2004; 29:1067-83. and are of particular concern. Unsafe sex and lifetime physical violence reflect the vulnerability context of this population which can also influence substance use ⁴⁵45 . McFarlane A, Schrader G, Bookless C, Browne D. Prevalence of victimization, posttraumatic stress disorder and violent behaviour in the seriously mentally ill. Aust N Z J Psychiatry 2006; 40:1010-5.^,4646 . Pechansky F. Modelo teórico de exposição a risco para transmissão do vírus HIV em usuários de drogas. Rev Bras Psiquiatr 2001; 23:41-7.. As pointed out by Chartier et al. ⁴⁷47 . Chartier MJ, Walker JR, Naimark B. Health risk behaviors and mental health problems as mediators of the relationship between childhood abuse and adult health. Am J Public Health 2009; 99:847-54., smoking and other health risk behaviors, such as alcohol use and number of sexual partners, may be mediator factors related to childhood physical abuse and mental health problems. A more recent study also found that childhood physical abuse was associated with ever smoking among both males and females ⁴⁸48 . Fuller-Thomson E, Filippelli J, Lue-Crisostomo CA. Gender-specific association between childhood adversities and smoking in adulthood: findings from a population-based study. Public Health 2013; 127:449-60.. Anda et al. ⁴⁹49 . Anda RF, Croft JB, Felitti VJ, Nordenberg D, Giles WH, Williamson DF, et al. Adverse childhood experiences and smoking during adolescence and adulthood. JAMA 1999; 282:1652-8. suggest that smokers use nicotine’s psychoactive effects to cope with the negative emotional, neurobiological and social effects of adverse experiences. They also note that individuals with adverse childhood experiences suffer from problems with affection, socialization and self-esteem. These problems may increase their susceptibility to peer pressure and tobacco marketing ⁴⁹49 . Anda RF, Croft JB, Felitti VJ, Nordenberg D, Giles WH, Williamson DF, et al. Adverse childhood experiences and smoking during adolescence and adulthood. JAMA 1999; 282:1652-8.^,5050 . Ford ES, Anda RF, Edwards VJ, Perry GS, Zhao G, Li C, et al. Adverse childhood experiences and smoking status in five states. Prev Med 2011; 53:188-93.. These associations suggest the need to incorporate approaches to treating alcohol/drug use and strategies for promoting safer sexual behavior and preventing violence into mental health care ¹²12 . de Leon J, Susce MT, Diaz FJ, Rendon DM, Velásquez D. Variables associated with alcohol, drug, and daily smoking cessation in patients with severe mental illnesses. J Clin Psychiatry 2005; 66:1447-55..

The risk profiles of current smokers and ex-smokers produced by our analysis contain factors that were statistically associated by both models, in the same direction and magnitude, including: being male, older age, alcohol or illicit drug use, having suffered physical violence, and the practice of unsafe sex. However, the psychiatric variables current and previous hospitalization and substance use disorders, and low education level, history of homelessness and not practicing a religion were associated only with current smoking. Although these associations are complex, these factors may act as barriers to stopping smoking or triggers of smoking initiation. The high rate of smoking prevalence and the correlates found in our study are consonant with stigma, discrimination, and the increased social and behavioral vulnerabilities of psychiatric patients. In addition, the lack of smoking cessation programs and tolerance of smoking in mental health facilities potentially reinforce smoking behavior.

The cross-sectional design of this study limits its capacity to establish direct causality and, although they are consistent with the literature, the associations observed are only indicators of potential direct causal effect. Data was limited to the psychiatric diagnoses registered in medical records and no direct information was available on psychiatric symptoms. In addition, the exclusion of patients unable to answer the questionnaires and outpatient services which exclusively treated alcohol and substance addiction may have led to an underestimation of prevalence and correlates.

Furthermore, the large confidence interval for substance use disorders may be due to the small number of subjects in this category.

Finally, our definition of the variable ex-smoker may have caused overlaps with the current smoker group, leading to a potential underestimation of associations. However, there is no reason to believe that estimates are in anyway biased. It is also important to emphasize the reasonable to good reliability of the data and the fact that this investigation is unique, since it is the only study to date to use a nationally representative sample of psychiatric populations attended in care facilities in Brazil. Nevertheless, future studies should be conducted in order to address these limitations.

In conclusion, intervention measures, such as screening, treatment and tobacco smoking prevention programs should be urgently incorporated into mental health services on a routine basis. It is also essential to develop actions that focus on the training and education of mental health professionals involved with direct care and implement comprehensive smoke-free policies in care facilities. More research, including qualitative studies, is needed to better understand the determinants of smoking and explore possible interventions to facilitate and maintain smoking cessation among psychiatric patients attended in care facilities in Brazil.

Acknowledgments

This work was carried out by the Federal University of Minas Gerais with technical and financial support provided by the Health Surveillance Secretariat/Department of STDs, AIDS and Viral Hepatitis of the Ministry of Health through the International Technical Cooperation Agreement 914/BRA/1101 between the Brazilian Government and the United Nations Educational, Scientific and Cultural Organization (UNESCO).

References

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