Article

Cigarette Smoking and Serious Psychological Distress: A Population-Based Study of California Adults

Institute for Health & Aging, School of Nursing, University of California at San Francisco, 3333 California Street, Suite 340, San Francisco, CA 94118, USA.
Nicotine & Tobacco Research (Impact Factor: 3.3). 08/2011; 13(12):1183-92. DOI: 10.1093/ntr/ntr148
Source: PubMed
ABSTRACT
This study examines differences in smoking behaviors between adults with and without serious psychological distress (SPD) in California, which has the longest running comprehensive tobacco control program in the world.
Cross-sectional data from the 2007 California Health Interview Survey on 50,880 noninstitutionalized adults were used to analyze smoking prevalence, cigarette consumption, and quit ratio. Persons with SPD were identified using the K6 scale, a clinically validated psychological screening instrument.
About 3.8% of California adults screened positive for SPD in the past 30 days (acute SPD) and an additional 4.8% screened positive for SPD in the past 2-12 months (recent SPD). Persons with SPD were more likely to be current smokers than those without SPD (adjusted odds ratios [AOR] = 2.54, 95% CI = 2.02-3.19 for acute SPD and AOR = 2.20, 95% CI = 1.79-2.71 for recent SPD). Current smokers with acute SPD were more likely to smoke ≥20 cigarettes daily than those without SPD (AOR = 1.59, 95% CI = 1.06-2.39). The quit rate was lower among ever-smokers with acute (AOR = 0.46, 95% CI = 0.35-0.62) or recent SPD (AOR = 0.55, 95% CI = 0.42-0.71) than those without SPD. While persons with acute or recent SPD comprised 8.6% of adults, they consumed 19.2% of all cigarettes in California.
In California, adults with SPD were more likely to be current smokers and to smoke heavily and less likely to quit than those without SPD. The findings underscore the need for effective smoking cessation strategies targeting this group.

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premature deaths per year and leading to substantial health care
costs and lost productivity (Centers for Disease Control and
Prevention, 2008; V. P. Miller, Ernst, & Collin, 1999; L. S. Miller,
Zhang, Rice, & Max, 1998). Although cigarette smoking preva-
lence in the United States declined dramatically from 42% in
1965 to 26% in 1991, the decline has stalled in the past five years
from 20.9% in 2004 to 20.6% in 2009 (Centers for Disease
Control and Prevention, 1994, 2010). To achieve the Healthy
People 2020 national goal of reducing the adult smoking rate to
less than 12% by 2020 (U.S. Department of Health and Human
Services, 2010), innovative tobacco control efforts need to target
subgroups that smoke at high rates.
Persons with mental illness comprise one of the largest and
most vulnerable subgroup of smokers. Research that examines
the association between smoking and mental illness emerged in
the late 1980s. Early studies mainly focused on mental health
patients selected from specific clinic settings, such as outpatient
psychiatric clinics (Acton, Prochaska, Kaplan, Small, & Hall,
2001; Hughes, Hatsukami, Mitchell, & Dahlgren, 1986; Itkin,
Nemets, & Einat, 2001; Vanable, Carey, Carey, & Maisto, 2003)
and mental hospitals (de Leon et al., 1995; Prochaska, Gill, &
Hall, 2004), or specific diagnoses, such as bipolar disorder,
major depression, and panic disorder (N. Breslau & Klein, 1999;
Glassman et al., 1990; Gonzalez-Pinto et al., 1998). These studies
found that individuals diagnosed with various forms of mental
illness smoked at very high rates. For example, a recent meta-
analysis of 42 studies across 20 countries found an average current
smoking prevalence of 62% among individuals diagnosed with
schizophrenia (de Leon & Diaz, 2005). Neurobiological, psy-
chosocial, and systemic factors are thought to contribute to the
high rates of tobacco use among psychiatric populations. These
include the reinforcing mood-altering effects of nicotine, shared
environment or genetic factors, reduced ability to cope during
cessation efforts, and limited access to targeted evidence-based
tobacco cessation treatment (Dursun & Kutcher, 1999; Kendler
et al., 1993; Ziedonis et al., 2008; Schroeder & Morris, 2010).
Abstract
Introduction: This study examines differences in smoking
behaviors between adults with and without serious psychological
distress (SPD) in California, which has the longest running
comprehensive tobacco control program in the world.
Methods: Cross-sectional data from the 2007 California Health
Interview Survey on 50,880 noninstitutionalized adults were
used to analyze smoking prevalence, cigarette consumption,
and quit ratio. Persons with SPD were identified using the K6
scale, a clinically validated psychological screening instrument.
Results: About 3.8% of California adults screened positive for
SPD in the past 30 days (acute SPD) and an additional 4.8%
screened positive for SPD in the past 2–12 months (recent SPD).
Persons with SPD were more likely to be current smokers than
those without SPD (adjusted odds ratios [AOR] = 2.54, 95%
CI = 2.02−3.19 for acute SPD and AOR = 2.20, 95% CI =
1.79−2.71 for recent SPD). Current smokers with acute SPD
were more likely to smoke 20 cigarettes daily than those with-
out SPD (AOR = 1.59, 95% CI = 1.06−2.39). The quit rate was
lower among ever-smokers with acute (AOR = 0.46, 95% CI =
0.35−0.62) or recent SPD (AOR = 0.55, 95% CI = 0.42−0.71)
than those without SPD. While persons with acute or recent
SPD comprised 8.6% of adults, they consumed 19.2% of all
cigarettes in California.
Conclusions: In California, adults with SPD were more likely
to be current smokers and to smoke heavily and less likely to
quit than those without SPD. The findings underscore the need
for effective smoking cessation strategies targeting this group.
Introduction
Cigarette smoking remains the leading cause of preventable
mortality and morbidity in the United States, causing 443,000
Original Investigation
Cigarette Smoking and Serious
Psychological Distress: A Population-
Based Study of California Adults
Hai-Yen Sung, Ph.D.,
1
Judith J. Prochaska, Ph.D., M.P.H.,
2
Michael K. Ong, M.D., Ph.D.,
3
Yanling Shi, M.S.,
1
&
Wendy Max, Ph.D.
1
1
Institute for Health & Aging, School of Nursing, University of California, San Francisco, CA
2
Department of Psychiatry, University of California, San Francisco, CA
3
Department of Medicine, University of California, Los Angeles, CA
Corresponding Author: Hai-Yen Sung, Ph.D., Institute for Health & Aging, School of Nursing, University of California at San
Francisco, 3333 California Street, Suite 340, San Francisco, CA 94118, USA. Telephone: 415-502-4697; Fax: 415-476-3915;
E-mail: hai-yen.sung@ucsf.edu
Received February 11, 2011; accepted June 13, 2011
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Cigarette smoking and serious psychological distress
There have been relatively few population-based research
investigations that have compared the smoking behaviors of
persons with and without mental illness across the spectrum of
psychiatric disorders. The first of such population-based studies
was conducted by Lasser et al. (2000) analyzing data from the
1991–1992 National Comorbidity Survey. Their results showed
that persons with alcohol, drug, or mental problems (ADM) in
the past month comprised 28.3% of the U.S. population, were
twice as likely to be current smokers as those without ADM dis-
orders (41.0% vs. 22.5%), and accounted for 40.6% of all cur-
rent smokers and 44.4% of total cigarettes sold in the United
States. Using the same data, another study found that persons
with nonsubstance-related mental illness in the past twelve
months constituted 24% of the U.S. population but consumed
about 40% of all cigarettes in the United States (Saffer &
Dave, 2005). Using data from the 2001–2002 National Epide-
miologic Survey on Alcohol and Related Conditions, Grant,
Hasin, Chou, Stinson, and Dawson (2004) found that individu-
als with ADM disorders in the past twelve months made up
30.3% of the population but consumed 46.3% of all cigarettes in
the United States. These three studies defined mental illness
based on the Diagnostic and Statistical Manual of Mental
Disorders, Revised third edition DSM-III-R or fourth edition
DSM-IV (American Psychiatric Association, 1987, 1994), and
they reached a strikingly similar conclusion that more than 40%
of all cigarettes sold in the United States are consumed by indi-
viduals with mental illness. However, a recent study, which also
defined mental illness according to the DSM-IV but focused on
a nationally representative sample of Black Americans in 2001–
2003, derived much lower estimates, reporting that those with
mental illness in the past twelve months represented 18.1% of
the sample but consumed 23.9% of all cigarettes by Blacks
(Hickman, Delucchim & Prochaskam, 2010), perhaps due to
the fact that Blacks have a lower prevalence of mental disorders
than Whites (J. Breslau et al., 2006; Kessler et al., 1994).
Instead of using the diagnostic criteria such as those in the
DSM-IV, Hagman, Delnevo, Hrywna, and Williams (2008)
defined mental illness with a clinically validated brief psycho-
logical screening instrument, the K6 scale (Kessler et al., 2002,
2003), designed to screen populations for serious psychological
distress (SPD). Using the 2002 National Survey of Drug Use and
Health data, they found that 8.3% of U.S. adults had SPD in the
past twelve months, and those with SPD had higher rates of cur-
rent cigarette smoking than those without SPD (44.9% vs.
26.0%). Based on the K6 scale data from the 2007 National
Health Interview Survey, McClave, McKnight-Eily, Davis, and
Dube (2010) estimated that current smoking prevalence was
38.1% for adults with SPD compared with 18.3% for adults
who had no lifetime diagnosis of five specific mental illnesses.
Neither of these two studies examined the proportions of all
current smokers and total cigarettes accounted for by persons
with mental illness.
Although the above-mentioned population-based studies
indicate that persons with mental illness smoke at higher rates
than those without, all but one of these studies were based on
national data collected from 1991 to 2003 when the overall
smoking prevalence in the United States was relatively high,
ranging from 26% to 22% (Centers for Disease Control and
Prevention, 1994, 2005). It is unknown whether this association
still exists at a lower level of national smoking prevalence.
California has the longest running and largest comprehen-
sive tobacco control program in the world and is recognized
internationally for its success in tobacco control (Roeseler &
Burns, 2010). In 2009, California’s current smoking prevalence
was one third lower than the national average (12.9% vs. 20.6%;
Centers for Disease Control and Prevention, 2009, 2010). Yet
there are still approximately 3.6 million current adult smokers
in the state. Given California’s leading role in national and
international tobacco control efforts, its low smoking preva-
lence, and its large and diverse population, California provides
an exemplary case study for informing future trends in the asso-
ciation between smoking and mental illness.
The objective of this study is to examine differences in the
smoking prevalence, cigarette consumption, and quit ratios
between persons with and without SPD in California. We
hypothesized that California adults with SPD have a lower
smoking prevalence than U.S. adults with SPD and that within
California, adults with SPD have a higher smoking prevalence
than those without SPD, constitute a disproportionately high
proportion of all current smokers, and consume a dispropor-
tionately high proportion of total cigarettes in California. The
identification of population subgroups that remain at elevated
risk for tobacco use in California will provide useful informa-
tion on the future direction of tobacco control strategies for
other states, the United States, and other countries.
Methods
Data Source
This study used data from the 2007 California Health Interview
Survey (CHIS). The CHIS, conducted biennially since 2001, is
the largest state-level health survey and one of the largest health
surveys in the United States (Brown, Holtby, Zahnd, & Abbott,
2005). CHIS is a random-digit dialing telephone survey of
California’s civilian noninstitutionalized population living in
households and uses a multistage stratified sampling design.
Beginning in 2007, CHIS also includes a sample of cell phone–
only households. Within each sampled household, one adult
aged 18 years is randomly selected for an extended adult inter-
view (Adult File) to obtain detailed information on demographic
and socioeconomic characteristics, smoking behavior, other
risk behaviors, access to and use of health care services, health
conditions, and mental health. Proxy interviews are allowed for
frail and ill persons aged 65 years. After excluding proxy inter-
views (N = 168), the final unweighted sample from the 2007
CHIS Adult File contained 50,880 adults.
Serious Psychological Distress (SPD)
We defined SPD using the K6 scale, a short but broad-
gauged screening measure of nonspecific psychological distress
rather than a disorder-specific diagnostic measure. The K6 scale
was originally developed by Kessler et al. (2002) based on item
response theory models to be used in population-based surveys
to screen for individuals who are likely to meet diagnostic criteria
for “serious mental illness” in a given year, which was estimated
by previous studies to constitute about 6% of the U.S. adult pop-
ulation (Kessler et al., 1996). The K6 scale has been clinically
validated to be an accurate screening scale for serious mental
illness. In a methodological study comparing the performance
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Nicotine & Tobacco Research, Volume 13, Number 12 (December 2011)
of four different screening scales in predicting “serious mental
illness,” defined as having at least one DSM-IV disorder other
than substance use disorders in the past twelve months and
having serious impairment with a Global Assessment of Func-
tioning score of less than 60, the K6 scale was the most efficient
screening scale with a sensitivity of 0.36, specificity of 0.96, and
a total classification accuracy of 0.92 (Kessler et al., 2003). Its
brevity, accuracy, and ability to discriminate DSM-IV cases
from noncases make the K6 scale a popular screening instru-
ment for serious mental illness in population-based health
surveys (Kessler et al., 2003; Furukawa, Kessler, Slade, & An-
drews, 2003; Veldhuizen, Cairney, Kurdyak, & Streiner, 2007).
The K6 consists of six questions asking respondents to rate
on a Likert scale how frequently they experienced the following
symptoms: felt nervous, hopeless, restless or fidgety, worthless,
sad or depressed, and that everything was an effort within a
particular reference period, for example, the past thirty days.
For each question, a value of 0, 1, 2, 3, or 4 was assigned to the
answer: none of the time, a little of the time, some of the time,
most of the time, or all of the time, respectively. Responses to the
six items were summed to yield a K6 score between 0 and 24,
with higher scores indicating a greater tendency toward mental
illness. Following the literature (Hagman et al., 2008; Kessler
et al., 2003), we defined a person as having SPD if the K6 score
was 13.
The 2007 CHIS included two sets of K6 questions in the
Adult File that referenced the 30-day and 12-month periods
prior to the date of interview. For this study, we classified
respondents based on their past thirty-day and past twelve-month
K6 scores into three mutually exclusive groups: acute SPD,
recent SPD, and no SPD. Acute SPD referred to those respon-
dents who were screened for SPD in the past thirty days. Recent
SPD referred to those respondents who were screened for SPD
in the past twelve months but not in the past thirty days. No
SPD referred to those respondents without SPD in the past
twelve months.
Smoking Outcome Measures
Ever-smokers were defined as having smoked at least 100 ciga-
rettes in their lifetime. Current smokers were defined as having
smoked 100 cigarettes in their lifetime and now smoking ciga-
rettes daily (daily smokers) or some days (someday smokers).
Daily smokers were asked how many cigarettes they smoked per
day on average. Someday smokers were asked how many ciga-
rettes they smoked per day in the past thirty days when they
smoked; however, the CHIS did not ask how many days they
smoked in the past thirty days. We categorized current smokers
as heavy smokers (current daily smokers who smoked 20
cigarettes/day) or moderate/light smokers (current someday
smokers or daily smokers who smoked <20 cigarettes/day). For-
mer smokers were defined as those who smoked 100 cigarettes
in their lifetime but reported not smoking now. The quit ratio,
considered a measure of total cessation in a population, was cal-
culated as the ratio of former smokers to ever-smokers.
We estimated the proportion of all cigarettes smoked by
persons with SPD in California by calculating the following
ratio: (N
1
× C
1
× 365)/(N
1
× C
1
× 365 + N
2
× C
2
× 365), where N
1
and N
2
represent the total number of current daily smokers with
and without SPD in the past twelve months, respectively; C
1
and
C
2
denote the mean number of cigarettes per day by current
daily smokers with and without SPD, respectively (Lasser et al.,
2000).
Covariates
Based on literature review, we included the following covariates.
Sociodemographic characteristics included age, gender, race/
ethnicity, education level, poverty level, employment status, and
marital status. Based on federal poverty level (FPL) guidelines
and self-reported household annual income, the CHIS classified
poverty level into four categories: <100%, 100%–199%, 200%–
399%, and 400% of the FPL. Other risk behaviors included
body weight status defined by body mass index (underweight
<18.5 kg/m
2
; normal = 18.5–24.9 kg/m
2
; overweight = 25.0–29.9
kg/m
2
; obesity 30.0 kg/m
2
) and binge drinking status defined
as those who drank 5 alcoholic drinks for males or 4 alcoholic
drinks for females in a single episode in the past year.
Statistical Analysis
Cross-tabulations were used to calculate the prevalence of acute
SPD and recent SPD by all the covariates, including sociodemo-
graphic characteristics and other risk behaviors. A multivariate
multinomial logistic regression model including all the covari-
ates evaluated the odds of acute SPD and recent SPD, with
“no SPD” as the reference group. This allowed us to simulta-
neously evaluate the odds of acute SPD and recent SPD in a
single model.
Then, we analyzed the impact of SPD status on smoking
behaviors with multivariate regression models by controlling
for all the covariates described above. For the impact of SPD
status on the prevalence of ever smoking and current smoking
among all adults, the proportion of daily smokers or heavy
smokers among current smokers, and the quit ratio among
ever-smokers, we used multivariate logistic regression models
to estimate adjusted odds ratios (AOR) and their 95% CIs for
each explanatory variable. For the impact of SPD status on the
average number of cigarettes smoked per day for current daily
smokers and current someday smokers, we used multivariate
linear regression models to estimate the coefficient and p value
for each explanatory variable.
All the analyses were based on weighted analyses conducted
by applying the sample weights from the CHIS data to adjust for
nonresponse and unequal probabilities of sample selection and
thus to derive unbiased estimates for the California population.
We conducted all the analyses using the SAS procedures that
take into consideration the design effects of complex sample
surveys to produce accurate SEs and CIs (SAS Institute Inc.,
2009). We considered estimates to be statistically significant if
the p value from a two-tailed test was <.05.
Results
Prevalence of SPD
Applying the sample weights, the unweighted sample of 50,880
adult respondents is equivalent to the weighted total of 26.8 million
adults. In 2007, nearly 2.3 million adults or 8.6% of the 26.8
million adults in California were screened positive for SPD in
the past twelve months, including 3.8% with acute SPD and
4.8% with recent SPD. Compared with never-smokers, current
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Cigarette smoking and serious psychological distress
smokers were more likely to have acute SPD (7.8% vs. 2.9%, p <
.01) and recent SPD (9.0% vs. 4.2%, p < .01), whereas former
smokers did not show statistical differences in SPD prevalence.
Table 1 shows that all the covariates considered in this study
were significantly correlated with SPD status. The multivariate
multinomial logistic regression results show that Hispanics,
non-Hispanic Asians, and non-Hispanic Blacks were less
likely to have recent SPD compared with non-Hispanic Whites.
Table 1. Prevalence of SPD by Sociodemographic Characteristics and Risk Behaviors
and the Estimated Multivariate Multinomial Logistic Model for Having Acute SPD or
Recent SPD, California, 2007
Characteristics
Unweighted
sample size
Prevalence of SPD (%) Multinomial logistic model AOR (95% CI)
Acute SPD
a
Recent SPD
b
Acute SPD
a
Recent SPD
b
All adults 50,880 3.8 4.8
Age (years)
18–25 (reference) 3,181 3.1 10.5
26–34 4,632 4.0 5.7 1.80 (1.12–2.89)* 0.66 (0.50–0.87)*
35–49 12,801 4.0 4.4 2.09 (1.37–3.18)* 0.57 (0.41–0.78)*
50+ 30,266 3.7 2.3 1.35 (0.94–1.95) 0.25 (0.18–0.35)*
Gender
Male (reference) 20,410 3.1 3.4
Female 30,470 4.4 6.1 1.19 (0.98–1.45) 2.07 (1.74–2.47)*
Race/ethnicity
Non-Hispanic White (reference) 33,193 3.1 5.1
Hispanic 9,067 4.7 4.6 0.88 (0.68–1.14) 0.62 (0.48–0.80)*
Non-Hispanic Asian 4,332 2.7 3.3 0.90 (0.59–1.36) 0.61 (0.43–0.88)*
Non-Hispanic Black 2,391 5.6 4.8 1.10 (0.78–1.54) 0.65 (0.43–0.97)*
Non-Hispanic American Indians/Alaska 419 12.3 5.0 2.85 (1.45–5.59)* 0.88 (0.54–1.46)
Non-Hispanic other 1,478 5.1 7.6 1.35 (1.02–1.77)* 1.18 (0.77–1.80)
Education status
<High-school degree 4,924 7.1 3.9 1.43 (1.11–1.85)* 0.91 (0.64–1.31)
High-school graduate (reference) 11,333 4.0 5.5
Some college 14,415 4.0 6.2 1.13 (0.87–1.46) 1.09 (0.90–1.32)
College or more 20,208 1.7 3.6 0.62 (0.46–0.84)* 0.85 (0.68–1.08)
Poverty level
<100% FPL (reference) 7,094 7.0 6.7
100%−199% FPL 8,307 5.8 4.7 0.88 (0.71–1.09) 0.76 (0.57–1.03)
200%−399% FPL 12,640 3.1 5.6 0.56 (0.43–0.72)* 0.97 (0.72–1.30)
400% FPL 22,839 2.0 3.6 0.46 (0.34–0.64)* 0.72 (0.54–0.95)*
Employment level
Full-time (reference) 25,446 2.3 4.7
Part-time 3,950 2.5 6.4 1.02 (0.68–1.53) 1.05 (0.77–1.42)
Employed but not work 169 12.4 3.3 4.12 (0.98,17.30) 0.76 (0.28–2.06)
Unemployed and look for work 1,232 7.8 9.6 2.78 (1.89–4.07)* 1.58 (1.09–2.28)*
Unemployed but not look for work 20,083 6.4 3.9 2.62 (2.05–3.35)* 1.05 (0.81–1.36)
Marital status
Married (reference) 26,088 2.8 2.7
Never married 7,771 4.3 8.2 1.75 (1.33–2.31)* 1.80 (1.41–2.28)*
Other 17,021 5.6 6.3 1.61 (1.32–1.95)* 2.21 (1.79–2.73)*
Body weight status
Underweight 1,229 4.8 5.1 1.28 (0.66–2.48) 0.89 (0.56–1.42)
Normal (reference) 20,331 3.0 4.9
Overweight 18,040 3.2 4.5 1.02 (0.81–1.28) 1.26 (1.02–1.55)*
Obesity 11,280 5.9 4.9 1.65 (1.36–2.01)* 1.37 (1.11–1.68)*
Binge drinking status
No (reference) 39,010 3.9 3.9
Yes 11,870 3.5 6.8 1.24 (0.97–1.59) 1.46 (1.20–1.79)*
Note. All the estimates are based on weighted analyses accounting for complex survey design. AOR = adjusted odds ratios; FPL = federal poverty
level; SPD = serious psychological distress.
a
Screened for SPD in the past thirty days.
b
Screened for SPD in the past twelve months but not past thirty days.
*Statistically significant at p < .05, two-tailed test.
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Nicotine & Tobacco Research, Volume 13, Number 12 (December 2011)
Non-Hispanic American Indians/Alaska Natives and non-His-
panic other racial group were more likely to have acute SPD
compared with non-Hispanic Whites. Moreover, compared
with the relative reference groups, acute SPD was significantly
more likely among middle-aged adults (26–49 years old); those
without a high-school degree; and those who were the poorest
(<100% FPL), unemployed, unmarried, and obese. Recent SPD
was significantly more likely among women; young adults
(18–25 years old); and those who were the poorest (<100%
FPL), unemployed, unmarried, overweight or obese, and binge
drinkers.
Smoking Prevalence by SPD Status
According to the 2007 CHIS data, 38.0% of adults in California
were ever-smokers and 14.4% were current smokers (Table 2).
Smoking prevalence increased with the acuity of SPD status. For
adults without SPD, ever smoking prevalence was 37.0% com-
pared with 45.4% for adults with recent SPD and 52.4% for
adults with acute SPD. Current smoking prevalence was 13.1%
for adults without SPD compared with 27.2% and 30.1% for
adults with recent SPD and acute SPD, respectively. After con-
trolling for other covariates, the positive relationship between
smoking rates and the acuity of SPD status was still statistically
significant. Adults with recent SPD were approximately two
times as likely to be ever-smokers (AOR = 1.81, 95% CI =
1.51−2.17) and current smokers (AOR = 2.20, 95% CI =
1.79−2.71) as those without SPD. This relationship was slightly
stronger among those with acute SPD (AOR = 1.84, 95% CI =
1.53−2.20 for ever-smokers; AOR = 2.54, 95% CI = 2.02−3.19
for current smokers). As for the impact of other covariates, it is
worth noting that binge drinkers were more likely to be ever-
smokers and current smokers, and underweight was positively
associated with the odds of being a current smoker, while
obesity had the opposite effect.
Among current smokers without SPD, 66.0% were daily
smokers compared with 68.8% for those with recent SPD and
75.4% for those with acute SPD (Table 3). After controlling for
other covariates, the differences observed in the proportion of
current smokers who were daily smokers by SPD status were not
statistically significant. The proportion of heavy smokers among
current smokers was 17.6%, 15.5%, and 27.7% for those with-
out SPD, with recent SPD, and with acute SPD, respectively.
After controlling for other covariates, the multivariate logistic
regression results indicated that those current smokers who had
acute SPD were more likely to be heavy smokers than those
without SPD (AOR = 1.59, 95% CI = 1.06−2.39), while those
with recent SPD did not significantly differ from those without
SPD in the proportion of heavy smokers.
Cigarette Consumption by SPD Status
Daily smokers without SPD smoked on average 12.7 cigarettes a
day (standard error of the mean [SEM] = 0.3) in contrast to 12.4
cigarettes/day (SEM = 0.5) for those with recent SPD and 15.2
cigarettes/day (SEM = 0.6) for those with acute SPD (Table 4).
Someday smokers smoked on average 4.0 cigarettes/day (SEM =
0.2) on those days when they smoked for those without SPD, 4.5
cigarettes/day (SEM = 0.7) for those with recent SPD, and 5.8
cigarettes/day (SEM = 1.4) for those with acute SPD. After con-
trolling for other covariates, daily smokers who had acute
SPD smoked 2.0 cigarettes/day more than those without SPD
(p < .01); those with recent SPD did not significantly differ from
those without SPD. For someday smokers, the difference in the
number of cigarettes smoked per day between those with and
without SPD was not statistically significant. Based on current
smoking rates, the proportions of daily smokers among current
smokers, and average numbers of cigarettes smoked per day as
presented above, we estimated that 19.2% of all cigarettes
smoked by daily smokers in California were consumed by those
who had SPD in the past twelve months (i.e., acute and recent
SPD groups combined).
Quit Ratio by SPD Status
The overall quit ratio for adults in the generation population in
California was 0.62, meaning that 62.0% of ever-smokers no
longer smoked at the time of the survey. The quit ratio differed
by SPD status: 0.65 for those without SPD, 0.40 for those with
recent SPD, and 0.43 for those with acute SPD (data not shown).
The multivariate logistic regression results indicated that per-
sons with either type of SPD were significantly less likely to be a
former smoker compared with those without SPD (AOR = 0.46,
95% CI = 0.35−0.62 for acute SPD and AOR = 0.55, 95% CI =
0.42−0.71 for recent SPD).
Discussion
Our findings indicate that the adult current smoking prevalence
rate was lower among California’s general population com-
pared with the U.S. general population (14.4% vs. around 20%)
and also lower among those with SPD in California (27.2%–
30.1%) compared with those with SPD in the United States
(44.9%; Hagman et al., 2008). Given that the estimated preva-
lence of 12-month SPD by Hagman et al. (2008) was very simi-
lar to our estimate (8.3% vs. 8.6%), the finding suggests that
California’s tobacco control program may have contributed to
the relatively lower smoking prevalence even among persons
with SPD. Nevertheless, California’s adults with SPD were more
than twice as likely to be current smokers and about 50% less
likely to have quit smoking compared with those without SPD,
consistent with findings from previous U.S. population–based
studies (Lasser et al., 2000; Hagman et al., 2008). In summary,
persons with SPD in California smoked at a lower prevalence
than those with SPD nationally; nonetheless, they smoked at a
higher prevalence than the California general population.
While persons with SPD in the past twelve months com-
prised 8.6% of adults in California, they accounted for 16.8% of
all current smokers (7.8% with acute SPD and 9.0% with recent
SPD) and consumed 19.2% of all cigarettes smoked by daily
smokers. Our estimated proportion of cigarette consumption by
persons with SPD (19.2%) is lower than the widely cited figure
in the literature that nearly half of all cigarettes in the United
States are consumed by persons with mental illness (Grant et al.,
2004; Lasser et al., 2000; Saffer & Dave, 2005; Ziedonis &
Williams, 2003). This discrepancy is due to differences in mental
illness measurement. The previous studies estimated that per-
sons with mental illness comprised over 24% of U.S. adults
based on a wide range of mental disorder diagnoses, including
alcohol/drug abuse or dependence and phobias (Grant et al.,
2004; Saffer & Dave, 2005). In this study, 8.6% of adults were
screened positive for SPD based on the K6 scale, which is a non-
specific psychological distress measure not based on diagnoses
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Cigarette smoking and serious psychological distress
Table 2. Smoking Prevalence by SPD Status and the Estimated Multivariate Logistic
Regression Models for Smoking Status, California, 2007
Characteristics Unweighted sample size
Ever smoking
prevalence % (95% CI)
Current smoking
prevalence % (95% CI)
All adults 50,880 38.0 (37.3–38.6) 14.4 (13.8–15.1)
Acute SPD
a
1,876 52.4 (48.3–56.4) 30.1 (25.9–34.3)
Recent SPD
b
2,134 45.4 (41.4–49.5) 27.2 (23.3–31.1)
No SPD
c
46,870 37.0 (36.2–37.7) 13.1 (12.6–13.7)
Multivariate logistic regression model: AOR (95% CI) AOR (95% CI)
SPD status
Acute SPD
a
1.84 (1.53–2.20)* 2.54 (2.02–3.19)*
Recent SPD
b
1.81 (1.51–2.17)* 2.20 (1.79–2.71)*
No SPD
c
(reference)
Age (years)
18–25 (reference)
26–34 2.60 (2.16–3.13)* 2.01 (1.60–2.53)*
35–49 2.93 (2.47–3.46)* 1.88 (1.49–2.38)*
50+ 5.05 (4.26–5.99)* 1.60 (1.27–2.01)*
Gender
Male (reference)
Female 0.45 (0.42–0.48)* 0.54 (0.49–0.59)*
Race/ethnicity
Non-Hispanic White (reference)
Hispanic 0.47 (0.42–0.52)* 0.50 (0.42–0.58)*
Non-Hispanic Asian 0.57 (0.51–0.64)* 0.89 (0.74–1.07)
Non-Hispanic Black 0.89 (0.76–1.03) 1.28 (1.06–1.54)*
Non-Hispanic American Indians/Alaska 1.43 (0.92–2.21) 1.44 (1.02–2.03)*
Non-Hispanic other 0.99 (0.82–1.20) 1.34 (1.05–1.71)*
Education level
<High-school degree 1.02 (0.90–1.16) 1.11 (0.94–1.30)
High-school graduate (reference)
Some college 0.89 (0.83–0.96)* 0.78 (0.69–0.88)*
College or more 0.48 (0.45–0.52)* 0.32 (0.28–0.36)*
Poverty level
<100% FPL (reference)
100%−199% FPL 0.98 (0.86–1.11) 0.85 (0.71–1.02)
200%−399% FPL 1.00 (0.89–1.14) 0.89 (0.74–1.07)
400% FPL 0.91 (0.80–1.04) 0.68 (0.56–0.82)*
Employment status
Full-time (reference)
Part-time 0.92 (0.81–1.04) 0.68 (0.56–0.82)*
Employed but not work 1.18 (0.65–2.14) 0.95 (0.43–2.10)
Unemployed and look for work 1.19 (0.99–1.44) 1.29 (1.03–1.61)*
Unemployed but not look for work 1.05 (0.97–1.14) 0.79 (0.70–0.89)*
Marital status
Married (reference)
Never married 1.09 (0.96–1.24) 1.65 (1.38–1.98)*
Other 1.61 (1.49–1.75)* 2.07 (1.84–2.34)*
Body weight status
Underweight 1.00 (0.81–1.24) 1.47 (1.03–2.09)*
Normal (reference)
Overweight 0.96 (0.89–1.03) 0.93 (0.83–1.04)
Obesity 1.02 (0.95–1.11) 0.83 (0.72–0.94)*
Binge drinking status
No (reference)
Yes 2.26 (2.09–2.44)* 2.38 (2.16–2.62)*
Note. All the estimates are based on weighted analyses accounting for complex survey design. AOR = adjusted odds ratios; FPL = federal poverty
level; SPD = serious psychological distress.
a
Screened for SPD in the past thirty days.
b
Screened for SPD in the past twelve months but not past thirty days.
c
No SPD in the past twelve months.
*Statistically significant at p < .05, two-tailed test.
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Nicotine & Tobacco Research, Volume 13, Number 12 (December 2011)
or impairment but has great precision in identifying “serious
mental illness” in the past twelve months, estimated to afflict
about 6% of U.S. adults (Kessler et al., 1996, 2001). Given that
the K6 scale has low sensitivity but high specificity for serious
mental illness (Kessler et al., 2003), persons identified with SPD
would appear to be a subset of those with serious mental illness.
On the other hand, our results indicate a greater degree of smoking
disparity among persons with SPD in terms of two measures.
The first, the ratio of the proportion of all cigarettes smoked by
persons with SPD and the prevalence of SPD, was 2.2 (=19.2/8.6)
in our study compared with 1.6 (=44.4/28.3) in the study by
Lasser et al. (2000). The second, the ratio of the proportion of
current smokers with SPD and the prevalence of SPD, was 2.0
(=16.8/8.6) in our study compared with 1.4 (=40.6/28.3) in the
Table 3. Proportion of Current Smokers Who Are Daily or Heavy Smokers by SPD Status
and the Estimated Odds Ratios from Multivariate Logistic Regression Models for Daily or
Heavy Smoking Status, California, 2007
Characteristics Unweighted sample size
Proportion of daily
smokers (%)
Proportion of heavy
smokers (%)
All current smokers 6,611 67.0 (64.8–69.2) 18.2 (16.7–19.7)
Acute SPD
a
602 75.4 (67.0–83.9) 27.7 (20.4–35.0)
Recent SPD
b
551 68.8 (61.4–76.2) 15.5 (11.5–19.5)
No SPD
c
5,458 66.0 (63.7–68.4) 17.6 (16.1–19.1)
Multivariate logistic regression model
d
AOR (95% CI) AOR (95% CI)
SPD status
Acute SPD
a
1.33 (0.80–2.21) 1.59 (1.06–2.39)*
Recent SPD
b
1.21 (0.85–1.73) 0.96 (0.66–1.40)
No SPD
c
(reference)
Note. All the estimates are based on weighted analyses accounting for complex survey design. AOR = adjusted odds ratio; SPD = serious
psychological distress.
a
Screened for SPD in the past thirty days.
b
Screened for SPD in the past twelve months but not past thirty days.
c
No SPD in the past twelve months.
d
Other covariates, which are included in the logistic regression model but are not shown in this table, include age, gender, race/ethnicity,
education level, poverty level, employment status, marital status, body weight status, and binge drinking status.
*Statistically significant at p < .05, two-tailed test.
Table 4. Average Number of Cigarettes Smoked Per Day by SPD Status and the Estimated
Coefficients From Multivariate Linear Regression Models Among Current Smokers,
California, 2007
Daily smokers Someday smokers
Characteristics
Unweighted
sample size
Average number of
cigarettes per day (95% CI)
Unweighted
sample size
Average number of
cigarettes per day (95% CI)
All current smokers 4,756 12.9 (12.4–13.4) 1,855 4.2 (3.8–4.6)
Acute SPD
a
483 15.2 (14.0–16.4) 119 5.8 (2.9–8.7)
Recent SPD
b
413 12.4 (11.4–13.5) 138 4.5 (3.0–6.0)
No SPD 3,860 12.7 (12.2–13.3) 1,598 4.0 (3.7–4.4)
Linear regression model
c
Coefficient p value Coefficient p value
SPD status
Acute SPD
a
2.01 <0.01* 0.96 0.44
Recent SPD
b
−0.08 0.88 0.58 0.44
No SPD (reference)
Note. All the estimates are based on weighted analyses accounting for complex survey design. SPD = serious psychological distress.
a
Screened for SPD in the past thirty days.
b
Screened for SPD in the past twelve months but not the past thirty days.
c
Other covariates, which are included in the linear regression model but are not shown in this table, include age, gender, race/ethnicity, education
level, poverty level, employment status, marital status, body weight status, and binge drinking status.
*Statistically significant at p < .05, two-tailed test.
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Cigarette smoking and serious psychological distress
study by Lasser et al. (2000). The difference is likely due to a
greater degree of mental illness severity captured by the K6 scale.
This study contributes to the literature by including two mu-
tually exclusive levels of SPD acuity—“acute SPD” in the past
thirty days and “recent SPD” in the past two to twelve months.
We observed that current smoking prevalence increased from
13.1% for persons without SPD to 27.2% for those with recent
SPD and to 30.1% for those with acute SPD. This study also ex-
tends existing research by examining the proportion of heavy
smokers conditional on current smoking. We found that persons
with acute SPD not only were more likely to be current smokers
but also tended to be heavy smokers once they smoked. Heavier
smoking suggests higher nicotine dependence (Diaz et al., 2005).
Therefore, this result suggests that persons with SPD in the most
recent 30 days should be particularly aided by their clinicians and
other professional providers with smoking prevention and cessa-
tion efforts (Schroeder, 2009). Individuals with SPD also were
less likely to quit smoking after starting. The findings highlight
the need for health policy interventions to limit the exposure to
tobacco use among those with SPD.
A critical policy intervention to reduce smoking among per-
sons with SPD or other serious mental disorders would be
broadening the restriction on tobacco use in hospital settings
mandated by the Joint Commission on Accreditation of Hospital
Organization to include psychiatric and addictive treatment set-
tings (Prochaska, 2009). Since 1992, U.S. hospitals have banned
tobacco use following this mandate, the exceptions being psy-
chiatric and addiction treatment settings. Psychiatric inpatient
settings that have voluntarily adopted smoke-free policies have
done so with little to no disruption in clinical care (Lawn & Pols,
2005). Incorporating evidence-based tobacco treatment curric-
ulum in psychiatry and psychology residency training programs
would provide increased delivery of cessation interventions for
smokers with mental illness because it has been shown to im-
prove residents’ knowledge, attitudes, confidence, and behav-
iors for treating tobacco dependence among patients with
mental illness (Prochaska, Fromont, et al., 2008). Also, enhanc-
ing quitline counseling protocols to best meet the needs of
smokers with mental illness would provide an opportunity to
improve successful quitting among this group as a recent study
indicated that about 25% of smokers who called a large state
quitline had major depression in the past two weeks, and they
had lower successful quit rates than nondepressed smokers
(Hebert, Cummins, Hernández, Tedeschi, & Zhu, 2011). In-
creasing cigarette taxes could be effective in reducing smoking
prevalence among this group based on previous research that
smoking participation for individuals with mental illness was
significantly sensitive to cigarette prices (Ong, Zhou, & Sung,
2010; Saffer & Dave, 2005).
Our study has several limitations. First, we used cross-
sectional data and hence could not examine the trends in the
association between SPD and smoking over time or directly test
whether the implementation of a comprehensive tobacco
control program results in increasing or decreasing smoking
disparities between those with and without SPD. Second, as
with previous population-based studies (Grant et al., 2004;
Hagman et al., 2008; Hickman et al., 2010; Lasser et al., 2000;
McClave et al., 2010; Saffer & Dave, 2005), our data only focused
on civilian noninstitutionalized populations, and hence, our
results may not generalize to institutionalized or homeless adults.
Third, because the CHIS did not ask someday smokers how
many days they smoked in the past thirty days, we could not
include someday smokers in the calculation of the proportion of
all cigarettes consumed by Californians with SPD. Fourth, the
2007 CHIS did not collect other mental health measures, such as
the DSM-IV diagnoses of mental disorders; therefore, we could
not directly assess how the greater degree of smoking disparity
found in this study might result from the difference in mental
illness measurement.
In conclusion, this case study confirms that disproportionately
high smoking prevalence and cigarette consumption among
persons with mental illness also exist in California, a state where
the smoking prevalence among both the general population and
those with SPD is relatively lower than national estimates due to
the long-running comprehensive tobacco control program.
This finding underscores the need to implement more effective
smoking cessation interventions targeting this group, such as
integrating tobacco treatment into mental health settings and
comprehensive tobacco control programs (Prochaska, 2010). Given
the low quit rate among persons with mental illness and the fact
that the tobacco industry has designed products and marketing
strategies to target consumer segments with mental illness
(Cook, Wayne, Keithly, & Connolly, 2003; Prochaska, Hall, &
Bero, 2008), it is important to conduct research to examine the
effectiveness of potential tobacco control policies, in addition to
individual treatment approaches (Schroeder, 2009), in reducing
smoking among this subgroup. Also, many mental health pro-
viders and administrators believe that tobacco cessation treat-
ment is unrealistic for their clients and will negatively effect
on psychiatric symptoms or management (Schroeder & Morris,
2010). Future research evaluating the health and economic bur-
den of smoking for those with mental illness is needed to moti-
vate mental health providers and policy makers to promote and
fund smoking cessation treatment for this subgroup.
Funding
This study was supported by funding from the Tobacco-Related
Disease Research Program of the University of California
(#18XT-0092 and #13KT-0152), the National Institute on Drug
Abuse (#K23 DA018691 and #P50 DA09253), and the National
Institute of Mental Health (#P30 MH082760).
Declaration of Interests
None declared.
Acknowledgments
The authors are grateful to Dr. Teh-wei Hu and two anonymous
reviewers for their helpful comments. However, the authors
alone are responsible for the findings.
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    • "In general, there is a directly proportional relationship between intensity of clinical psychiatrics and severity of depending on smoking [13]. Among the co-morbid conditions associated with smoking, the authors encounter state of mind disorders (depression and bipolar disorder), psychotic disorders (schizophrenia), alcoholism and other drug addictions, anxiety disorders, eating disorders, and a background of attention deficit disorders [14]. As previously mentioned, the treatment any smoker must receive includes a combination of pharmacological treatment and psychological counseling. "
    [Show abstract] [Hide abstract] ABSTRACT: Objective: Analysis of abstinence rates of smokers per gender at 3, 6, 9 and 12 months in a Smoking Cessation Unit from January 2008 to December 2009. Methods: Descriptive retrospective study. Analysis of socio-demographic variables, smoking patterns, associated comorbidities, continuous abstinence rates, success, relapses, failure and dropping out. Results: 278 smokers started treatment (33%); 55.4% males and 44.6% females (mean age of 48.3 and 44.06 years, respectively). The main associated comorbidities were: psychiatric (38.7%), cardiovascular (dyslipemia 25%) and respiratory (COPD (chronic obstructive pulmonary disease) 9.7%) in females; cardiovascular (dyslipemia 34.4%), psychiatric (34.4%) and respiratory (COPD 19.5%) in males. VRN (Varenicline) was prescribed in 40.2% males and 32.2% females; NRT (nicotine replacement therapy) was used in 46.6% and 38.7%, respectively; bupropion was employed in 6.5% and 21.8%, respectively. Psychological counseling was offered only to 7.8% males and 8.1% females. The continuous abstinence rates in males at 3, 6, 9 and 12 months were 51.3%, 37.7%, 32.5% and 30.5%, respectively, and were 45.2%, 29.8%, 25.0% and 24.2% for females. Failure was 9.7% for females and 18.8% for males. Success was more frequent for those on VRN (n = 41 males; n = 12 females). No relapses were indicated for 42 females and 71 males. The percentage of relapses was higher at 3 months (29.0% females, 19.5% males). Conclusions: The study observed differences in treating abstinence between genders (in the abstinence rates and failure index). This implies having to consider incorporating the gender variable into the diagnosis, treatment and prevention of smoking.
    Full-text · Article · Sep 2015
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    • "Furthermore, the study assessed participants for psychiatric and substance abuse disorders, which are common comorbidities among smokers [15-17], showing the acceptability of the game and the study process among participants with comorbid psychiatric or substance use disorders. "
    [Show abstract] [Hide abstract] ABSTRACT: The main objective of our study was to assess the impact of a board game on smoking status and smoking-related variables in current smokers. To accomplish this objective, we conducted a randomized controlled trial comparing the game group with a psychoeducation group and a waiting-list control group. The following measures were performed at participant inclusion, as well as after a 2-week and a 3-month follow-up period: “Attitudes Towards Smoking Scale” (ATS-18), “Smoking Self-Efficacy Questionnaire” (SEQ-12), “Attitudes Towards Nicotine Replacement Therapy” scale (ANRT-12), number of cigarettes smoked per day, stages of change, quit attempts, and smoking status. Furthermore, participants were assessed for concurrent psychiatric disorders and for the severity of nicotine dependence with the Fagerström Test for Nicotine Dependence (FTND). A time × group effect was observed for subscales of the ANRT-12, ATS-18 and SEQ-12, as well as for the number of cigarettes smoked per day. At three months follow-up, compared to the participants allocated to the waiting list group, those on Pick-Klop group were less likely to remain smoker. Outcomes at 3 months were not predicted by gender, age, FTND, stage of change, or psychiatric disorders at inclusion. The board game seems to be a good option for smokers. The game led to improvements in variables known to predict quitting in smokers. Furthermore, it increased smoking-cessation rates at 3-months follow-up. The game is also an interesting alternative for smokers in the precontemplation stage.
    Full-text · Article · Jan 2013 · Substance Abuse Treatment Prevention and Policy
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    • "The results demonstrate that while a majority of smokers were classified at the time of the survey as " precontemplative " with respect to the readiness to quit, a desire to quit smoking was evident in that the great majority had made quit attempts in the past (82%) and 47% had done so within the last year. Consistent with previous studies, the quit ratio for the current sample was lower than general population rates (Généreux, Roya, Montpetit, Azzoud, & Grattond, 2012; Zhu, Wong, Tang, Shi, & Chen, 2007), and similar to previously reported quit ratios for persons with a mental illness (Lasser et al., 2000; Sung, Prochaska, Ong, Shi, & Max, 2011). Despite a low quit ratio, reflecting a low likelihood of quit attempts translating into successfully maintained smoking cessation, a large proportion of those making a quit attempt in the last 12 months indicated a period of abstinence of more than a month. "
    [Show abstract] [Hide abstract] ABSTRACT: Introduction: Mental health inpatients smoke at higher rates than general population smokers. However, provision of nicotine-dependence treatment in inpatient settings is low, with barriers to the provision of such care including staff views that patients do not want to quit. This paper reports the findings of a survey of mental health inpatients at a psychiatric hospital in New South Wales, Australia, assessing smoking and quitting motivations and behaviors. Methods: Smokers (n = 97) were surveyed within the inpatient setting using a structured survey tool, incorporating the Fagerström Test for Nicotine Dependence, Reasons for Quitting Scale, Readiness and Motivation to Quit Smoking Questionnaire, and other measures of smoking and quitting behavior. Results: Approximately 47% of smokers reported having made at least one quit attempt within the past 12 months, despite nearly three quarters (71.2%) being classified as in a “precontemplative” stage of change. Multinomial logistic regressions revealed that self-reporting “not enjoying being a smoker” and having made a quit attempt in the last 12 months predicted having advanced beyond a precontemplative stage of change. A high self-reported desire to quit predicted a quit attempt having been made in the last 12 months. Conclusions: The majority of smokers had made several quit attempts, with a large percentage occurring recently, suggesting that the actual quitting behavior should be considered as an important indication of the “desire to quit.” This paper provides further data supporting the assertion that multimodal smoking cessation interventions combining psychosocial and pharmacological support should be provided to psychiatric inpatients who smoke.
    Full-text · Article · Apr 2012 · Nicotine & Tobacco Research
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