Relationship between gender and depressive and anxiety symptoms in smokers

Abstracts

INTRODUÇÃO: O tabagismo apresenta, freqüentemente, comorbidade com ansiedade e depressão, patologias que são mais freqüentes entre as mulheres. OBJETIVO: O objetivo deste estudo foi avaliar a associação entre o grau de dependência de nicotina e os sintomas de ansiedade e depressão em homens e mulheres tabagistas. MÉTODO: Foi realizado um estudo transversal, com uma amostra por conveniência de 475 tabagistas da população geral. Os instrumentos utilizados foram: o Questionário de Tolerância de Fagerström, o Inventário de Depressão de Beck, o Inventário de Ansiedade de Beck e uma Ficha com dados sociodemográficos. RESULTADOS: Nas mulheres, os sintomas de ansiedade (F = 9,691; p < 0,01) e depressão (F = 16,23; p < 0,01) apresentaram associação com a gravidade da dependência da nicotina. Entre os homens, apenas os sintomas de ansiedade (F = 7,219; p = 0,001) estiveram associados com o grau de dependência de nicotina. CONCLUSÃO: As tabagistas mais graves têm mais sintomas de ansiedade e depressão, enquanto os tabagistas mais graves apresentam mais ansiedade. Estes achados apontam para a importância de avaliar esses tipos de sintomas ao serem tratados tabagistas no Brasil.

Tabagismo; ansiedade; depressão

ORIGINAL ARTICLE

Relationship between gender and depressive and anxiety symptoms in smokers

Maria da Graça Tanori de Castro^I; Margareth da Silva Oliveira^II; Renata Brasil Araujo^III; Rosemeri Siqueira Pedroso^IV

^IMSc. in Clinical Psychology, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, RS, Brazil. Psychiatrist. Professor, Lato Sensu Graduate Program in Psychiatry, Instituto Abuchaim, Porto Alegre, RS, Brazil

^IIPhD. Professor, Graduate Program in Psychology, PUCRS

^IIIPhD. Internship supervisor in Chemical Dependence, Centro de Estudos José de Barros Falcão, Fundação Faculdade Federal de Ciências Médicas de Porto Alegre (FFFCMPA), Porto Alegre, RS, Brazil

^IVPsychologist. MSc. in Clinical Psychology

Correspondence

ABSTRACT

INTRODUCTION: Smoking often presents comorbid anxiety and depression, disorders that are more frequent in women.

OBJECTIVE: The aim of this study was to evaluate the association between severity of nicotine dependence and anxiety and depression symptoms in both male and female smokers.

METHOD: A cross-sectional study was performed using a convenience sample of 475 smokers from the general population. The instruments used were Fagerström Test for Nicotine Dependence, Beck Depression Inventory, Beck Anxiety Inventory, and a social and demographic record sheet.

RESULTS: In women, anxiety symptoms (F = 9.691; p < 0.01) and depression (F = 16.23; p < 0.01) were associated with severity of nicotine dependence. In men, only anxiety symptoms (F = 7.219; p = 0.001) were associated with severity of nicotine dependence.

CONCLUSION: Women with severe nicotine dependence have more anxiety and depression symptoms, while severe male smokers only showed more anxiety. The results demonstrated the importance of evaluating these symptoms in the treatment of smokers in Brazil.

Keywords: Smoking, anxiety, depression.

Introduction

Smoking, herein understood as nicotine dependence, is a worldwide public health problem associated with high morbidity and mortality rates. Although its prevalence is being reduced in developed countries, it does not apply to developing countries, even with increase in educational campaigns and knowledge of the risks regarding use of tobacco, which have been well defined since 1964.^1,2 In Brazil, a developing country, smoking has a 10.1% prevalence according to data of the II Home Survey on Use of Psychotropic Drugs, carried out in 2005.³ That second survey, performed only 4 years after the first,⁴ showed a 1.1% increase in tobacco dependence rate in the Brazilian population, which, in terms of impact on public health, is quite concerning. As to female smoking, there was a larger reduction in smoking in men than in women⁵; another Latin American study points to a higher tobacco consumption in women than in men⁶; thus, more public policy attention should be given to the female population of smokers.⁵

According to the American Psychiatric Association,⁷ about 80% of smokers would like to quit smoking, 35% quit every year, but a rate lower than 5% reaches this goal without external support.

Among the various factors that make it difficult to maintain nicotine withdrawal is the high comorbidity rate between dependence to this substance and other psychiatric diseases.^8-10 The tendency of reduced smoking prevalence observed in some populations is not shown in individuals that have any psychiatric disorder. The high rates of premature death presented by this population, which are five times higher than in the general population, are attributed to several diseases associated with nicotine dependence.¹¹

Psychiatric comorbidities, therefore, are important factors to be considered when assessing smokers. Schmitz et al.,¹² assessing a sample of 3,293 smokers, found that more than half of the individuals had another psychiatric diagnosis. Grant et al.⁹ also found a strong association between smoking and other diseases, focusing their study on axis I diagnoses.⁷

As to combined occurrence of more than one psychiatric diagnosis in tobacco dependents, abuse of other substances, major depression and anxiety disorders are the most prevalent comorbid associations.¹¹

Many authors have investigated the association between smoking and anxiety disorders,^12-15 as well as in relation to depression^15-18; however, they did not evaluate association of anxiety or depression symptoms and nicotine dependence severity in different genders.

It can be seen that anxiety and depression disorders, pathologies that are often associated with smoking, are more prevalent in women.¹⁹ Issa et al.²⁰ observed that female smokers have almost twice as more anxiety and depression than male smokers: 67 vs. 38%, respectively.

Considering that anxiety and mood disorders are commonly found in association with tobacco dependence and that there is a relationship of these factors with gender, this study aimed at evaluating the association between degree of nicotine dependence and anxiety and depression symptoms in male and female smokers.

Method

This study had a cross-sectional design. The convenience sample was comprised of 475 smokers in the general population: 36.6% male (n = 174) and 63.4% female (n = 301). Mean age was 37.72 years (standard deviation, SD = 11.71; 18-65).

The individuals were recruited using the snow-ball method: smokers who worked in a hospital belonging to the Brazilian Unified Health System (SUS) indicated other smokers that were successively indicating others until the sample was complete. Indicated individuals were invited by telephone by the main authors of the study. They were explained about the objective of the study and told that their participation was voluntary. Those who agreed to participate scheduled an individual interview with one of the research assistants (trained Psychology students) at the individual's house or at another place.

The team was trained prior to the survey, and observations of other applied surveys were made by one of the project coordinators until all questions were clarified.

Exclusion criteria were individuals who had tobacco-related clinical pathologies or who had psychotic symptoms or cognitive deficits that could change performance in tests. Individuals with clinical pathologies were excluded because this is a factor that could be associated with depression and anxiety symptoms and, therefore, represent a confounding factor.

The instruments used were: 1) record sheet containing sociodemographic data and general information about health and history of tobacco use; 2) Fagerström Test for Nicotine Dependence,^21,22 to assess severity of nicotine dependence; 3) Beck Depression Inventory (BDI), to assess depressive symptoms, validated in Brazil by Cunha,²³ who defined its cut-off points as: minimal (0-11 points), mild (12-19 points), moderate (20-35 points), and severe (36-63 points) depression; 4) Beck Anxiety Inventory (BAI), which measures intensity of anxiety symptoms and has also been validated in Brazil.²³ The cut-off points for the Brazilian population are minimal (0-10 points), mild (11-19 points), moderate (20-30 points), and severe (31-63 points) anxiety.²³

Procedures

The instruments were individually applied by the trained team, starting with the sociodemographic data record sheet and information regarding the profile of tobacco consumption, other psychoactive substances and medical history. The following instruments were applied to all individuals who met the inclusion criteria: Fagerström scale, BDI and BAI.

Data analysis

The database was structured using the Statistical Package for Social Sciences (SPSS), version 12.0. Exploratory data analysis consisted of descriptive and frequency statistical tests. Inferential analysis included chi-square test, Student's t test for independent samples, and analysis of variance (ANOVA) and Tukey's test. Significance level used as a parameter was 5%.

Ethical aspects

The project was approved by the Research Ethics Committee at Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS). The participants were informed about the survey procedures, and the data were collected after signing a consent term.

Results

Sociodemographic data and information regarding tobacco use and its comparison between men and women are shown in Table 1.

Severity of nicotine dependence showed, according to Pearson's linear correlation coefficient, a low intensity correlation with anxiety symptoms assessed by BDI (r = 0.260; p < 0.01) and with depression symptoms assessed by BAI (r = 0.267; p < 0.01).

Student's t test for independent samples showed that women had more depression symptoms than men (t = -3.336; p < 0.01). Mean depressive symptoms in women was 11.41 (SD = 9.81), and 8.45 for men (SD = 7.74). There was also difference between genders as to anxiety symptoms (t = -3.420; p = 0.001), and mean anxiety symptoms was 12.61 in women (SD = 11.37) and 8.96 in men (SD = 10.13).

Mean anxiety and depression symptoms, according to degrees of nicotine dependence in men and women, are shown in Table 2 (ANOVA).

Table 2 - Click to enlarge

Mean BAI and BDI points in different levels of nicotine dependence in men and women shown in Table 1 can be better seen in Figure 1.

Discussion

There was no significant difference between men and women as to sociodemographic data and information regarding tobacco use, which allows for a comparison of both groups in relation to features regarding anxiety and depression symptoms.

Gender was not associated with smoking severity, being similar to other studies in which the authors did not find such difference using the Fagerström Test for Nicotine Dependence.^14,24

There was also no difference as to number of cigarettes between men and women, opposed to the study by Brady & Randall,²⁵ who found that women smoked less than men, although nicotine levels were similar, probably because its metabolism is slower in women.

Our attention was drawn to the fact that anxiety is associated with severity of nicotine dependence both for men and women, but depression is only associated with severity in women, contradicting the results found by Alati et al.²⁶ According to Alati et al.,²⁶ male smokers had higher anxiety levels than non-smokers; however, there was no difference regarding such levels in different degrees of nicotine dependence. The same study did not find association between smoking severity and depression in male individuals, neither between anxiety and depression symptoms and smoking severity in surveyed women. The survey by Alati et al.²⁶ is only similar to our study in their results regarding lack of association between severity of nicotine dependence and depression in men.

These data raise the question of to what extent depressed women are more vulnerable to become more severe smokers and how much the craving experienced by tobacco is triggered by an attempt to relieve a negative affection, which had been previously discussed by Araujo²⁷ and Araujo et al.^28,29 Thus, smoking may be much more related to the reinforcing ability nicotine has of relieving displeasure than of searching for pleasure.

However, when the sample was assessed as a whole (including men and women), more severe tobacco dependents had a higher number of anxiety and depression symptoms. Fergusson et al.³⁰ and Wilhelm et al.¹⁹ found the same association in relation to depression, and Castro et al.³¹ obtained similar results regarding anxiety symptoms. It can be considered that such association, for depression symptoms, was obtained because of the results in women, since there was no difference in the male sample.

In the assessment according to gender, female smokers had more anxiety symptoms than men, a similar result found by Mykeltun et al.¹⁵ and Issa et al.²⁰ As to the other surveyed variable - depressive symptoms - women also had more intense symptoms than men, which is in agreement with the reports by Husky et al.,³² Romans et al.³³ and Perkins et al.³⁴ Issa et al.²⁰ also stressed that, after the withdrawal period, men can "overcome" the smoking habit more easily than women, who tend to compensate the lack of cigarettes with excessive eating. Morano³⁵ also found that women have more recurrences than men, and hypothesizes that one of the causes may be, in addition to weight gain, anxiety, which largely occurs in nicotine withdrawal syndrome. Therefore, the results obtained by those two studies can be one of the consequences of the association between gender and not only anxiety, but also depression symptoms.

A factor to be considered in clinical practice of chemical dependence is the craving, which has a strong association with anxiety, depression and, consequently, recurrences in smokers.^27,28 A finding by Araujo,²⁹ investigating this theme, showed that tobacco craving in women was more related to the ability of negative reinforcement (relief displeasure) than of positive reinforcement. This means that women wanted to use cigarettes to avoid displeasure, as a form of relieving unpleasant feelings related to anxiety and depression symptoms, instead of seeking pleasure.

Based on what has been discussed so far, there is a clear need of using approaches focused on female smokers that consider the fact they form a group that has more anxiety and depression symptoms than men and that demands special attention for the diagnosis of possible comorbidities with axis I⁷ to reduce the chances of using, as previously stressed, tobacco as self-medication²⁹ and increase the chance of maintaining withdrawal.¹¹

Although the instruments used in this study do not allow discussing comorbidity because a diagnosis is not established, they showed that there is an association between anxiety and depression symptoms and smoking severity. We should remember that there are hypotheses attempting to explain psychiatric comorbidities in smokers: causal and noncausal hypotheses. Causal hypotheses consider the existence of psychiatric diseases as a risk increase for smoking and accounting for lower levels of withdrawal maintenance: the patients with another psychiatric diagnosis have two to three times less probability of interrupting tobacco use than the general population. Another causal hypothesis is that smoking is implied in increased risk for occurrence of other psychiatric diagnoses. Noncausal hypotheses attribute such association to the environment and shared genetic factors that predispose to both tobacco dependence and other psychiatric disorders.⁸

It should be stressed that the associations found bring implications about assessment, diagnosis and treatment of smoking for both genders: if professionals do not perform a good assessment of anxiety and depression symptoms and comorbidities that are possibly associated with them, they will not be able to administer a proper treatment for their patients, since the recommended treatment for chemical dependents with comorbidities is a synergic treatment, which should simultaneously contemplate both pathologies.^12,36

At a time when there is a recognized need of a joint approach of smoking and its psychiatric comorbidities,^12,36 bas well as knowledge of the greater difficulty anxious or depressive smokers have of maintaining withdrawal,¹² we should, in the scientific community, support the importance of assessing anxiety and depression symptoms in male and female smokers.

Among the limitations observed is the fact that the instruments used to screen anxiety and depression symptoms are not diagnostic instruments. In addition, few individuals were classified with a higher level of nicotine dependence, possibly because the individuals were taken from the general population, and not among patients seeking treatment for smoking. Another limitation of this study was not having a random sample (convenience), which impairs generalization of results.

Cessation of tobacco use is quite complex and involves several variables; therefore, the more information there is about specificities of tobacco dependents, the more chances there are of helping them in the complex task of maintaining withdrawal.

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Publication Dates

• Publication in this collection
  01 Dec 2008
• Date of issue
  Apr 2008

History

• Accepted
  15 Jan 2008
• Received
  12 Dec 2007