The Association of Cigarette Smoking With Depression and Anxiety: A Systematic Review

<span class=”paragraphSection”><div class=”boxTitle”>Abstract</div><div class=”boxTitle”>Background:</div>Many studies report a positive association between smoking and mental illness. However, the literature remains mixed regarding the direction of this association. We therefore conducted a systematic review evaluating the association of smoking and depression and/or anxiety in longitudinal studies.<div class=”boxTitle”>Methods:</div>Studies were identified by searching PubMed, Scopus, and Web of Science and were included if they: (1) used human participants, (2) were longitudinal, (3) reported primary data, (4) had smoking as an exposure and depression and/or anxiety as an outcome, or (5) had depression and/or anxiety as the exposure and smoking as an outcome.<div class=”boxTitle”>Results:</div>Outcomes from 148 studies were categorized into: smoking onset, smoking status, smoking heaviness, tobacco dependence, and smoking trajectory. The results for each category varied substantially, with evidence for positive associations in both directions (smoking to later mental health and mental health to later smoking) as well as null findings. Overall, nearly half the studies reported that baseline depression/anxiety was associated with some type of later smoking behavior, while over a third found evidence that a smoking exposure was associated with later depression/anxiety. However, there were few studies directly supporting a bidirectional model of smoking and anxiety, and very few studies reporting null results.<div class=”boxTitle”>Conclusions:</div>The literature on the prospective association between smoking and depression and anxiety is inconsistent in terms of the direction of association most strongly supported. This suggests the need for future studies that employ different methodologies, such as Mendelian randomization (MR), which will allow us to draw stronger causal inferences.<div class=”boxTitle”>Implications:</div>We systematically reviewed longitudinal studies on the association of different aspects of smoking behavior with depression and anxiety. The results varied considerably, with evidence for smoking both associated with subsequent depression and anxiety, and vice versa. Few studies supported a bidirectional relationship, or reported null results, and no clear patterns by gender, ethnicity, clinical status, length to follow-up, or diagnostic test. Suggesting that despite advantages of longitudinal studies, they cannot alone provide strong evidence of causality. Therefore, future studies investigating this association should employ different methods allowing for stronger causal inferences to be made, such as MR.</span>

Impact of Telephone-Based Care Coordination on Use of Cessation Medications Posthospital Discharge: A Randomized Controlled Trial

<span class=”paragraphSection”><div class=”boxTitle”>Abstract</div><div class=”boxTitle”>Introduction:</div>Smokers benefit from ongoing cessation support upon leaving the hospital and returning to their home environment. This study examined the impact of telephone-delivered care coordination on utilization of and adherence to cessation pharmacotherapy after hospital discharge.<div class=”boxTitle”>Methods:</div>Inpatient smokers (<span style=”font-style:italic;”>n</span> = 606) were randomized to receive counseling with care coordination (CCC) or counseling alone (C) for smoking cessation. Both groups received written materials and telephone-based cessation counseling during hospitalization and postdischarge. CCC recipients received help in selecting, obtaining, and refilling affordable pharmacotherapy prescriptions during and after hospitalization. Study outcomes included self-reported utilization, duration of use, and type of medication during the 3 months postdischarge.<div class=”boxTitle”>Results:</div>Of the 487 (80%) of participants completing 3-month follow-up, 211 (43.3%) reported using cessation pharmacotherapy postdischarge; this did not differ by study arm (CCC: 44.7%, C: 42.0%, <span style=”font-style:italic;”>p</span> = .55). Use of pharmacotherapy postdischarge was associated with smoking at least 20 cigarettes/day at baseline (odds ratio [OR]: 1.48; 95% confidence interval [CI]: 1.00–2.19) and receipt of pharmacotherapy during hospitalization (OR: 4.00; 95% CI: 2.39–6.89). Smokers with Medicaid (OR: 2.29; 95% CI: 1.32–4.02) or other insurance (OR: 1.69; 95% CI: 1.01–2.86) were more likely to use pharmacotherapy postdischarge than those with no health care coverage. Less than one in four (23.8% of CCC; 22.2% of C) continued pharmacotherapy beyond 4 weeks.<div class=”boxTitle”>Conclusions:</div>Supplemental care coordination did not improve use of postdischarge pharmacotherapy beyond that of inpatient treatment and behavioral counseling. Insurance coverage and use of medications during the hospitalization are associated with higher use of evidence-based treatment postdischarge.<div class=”boxTitle”>Implications:</div>Many hospitalized smokers do not receive the benefits of cessation pharmacotherapy postdischarge and telephone quitline programs often fail to help smokers procure pharmacotherapy. Thus, effective strategies are needed to improve utilization and adherence to evidence-based cessation therapies when smokers leave the hospital. We found that use of postdischarge pharmacotherapy was strongly associated with receipt of pharmacotherapy during the hospitalization and with the availability of insurance to cover the costs of treatment. Additional efforts to coordinate pharmacotherapy services did not improve either utilization or adherence to therapy.</span>

Prenatal Tobacco Exposure Shortens Telomere Length in Children

<span class=”paragraphSection”><div class=”boxTitle”>Abstract</div><div class=”boxTitle”>Introduction:</div>Preliminary evidence suggests a possible association between prenatal tobacco exposure and telomere length in children. This study was conducted to investigate whether maternal smoking during pregnancy was associated with telomere shortening in their children and whether prenatal and childhood exposure to environmental tobacco had any impact on this association.<div class=”boxTitle”>Methods:</div>This is a population-representative study on the association between prenatal tobacco exposure and telomere length in children. Ninety-eight Hong Kong Chinese children aged under 15 years with prenatal tobacco exposure and 98 age- and gender-matched controls were recruited from a population health study with stratified random sampling.<div class=”boxTitle”>Results:</div>Telomere length in children with prenatal tobacco exposure was significantly shorter than in those with no exposure (mean T/S ratio = 24.9 [SD = 8.58] in exposed vs. 28.97 [14.15] in control groups; <span style=”font-style:italic;”>P</span> = 0.02). A negative dose–response relationship was observed between the T/S ratio and tobacco exposure duration: the longer the duration of maternal smoking in pregnancy, the shorter the child’s telomere length. The association between the child’s telomere length and prenatal tobacco exposure remained significant after considering the influence of family socioeconomic status and exposure to environmental tobacco smoke during pregnancy and childhood.<div class=”boxTitle”>Conclusions:</div>Prenatal tobacco exposure was associated with telomere shortening in children. As this may impose significant health impacts through fetal genetic programming, more efforts should be made to reduce fetal tobacco exposure by educating pregnant women to not smoke and motivating smokers to quit in early pregnancy.<div class=”boxTitle”>Implications:</div>As reflected by telomere shortening, prenatal tobacco exposure in children can cause premature aging and increased health risks, which we suggest is entirely preventable. Not smoking during pregnancy or quitting smoking is critical to improving the health outcome of our future generations as prenatal tobacco exposure may affect children’s biological programming.</span>

Prenatal Tobacco Exposure Shortens Telomere Length in Children

<span class=”paragraphSection”><div class=”boxTitle”>Abstract</div><div class=”boxTitle”>Introduction:</div>Preliminary evidence suggests a possible association between prenatal tobacco exposure and telomere length in children. This study was conducted to investigate whether maternal smoking during pregnancy was associated with telomere shortening in their children and whether prenatal and childhood exposure to environmental tobacco had any impact on this association.<div class=”boxTitle”>Methods:</div>This is a population-representative study on the association between prenatal tobacco exposure and telomere length in children. Ninety-eight Hong Kong Chinese children aged under 15 years with prenatal tobacco exposure and 98 age- and gender-matched controls were recruited from a population health study with stratified random sampling.<div class=”boxTitle”>Results:</div>Telomere length in children with prenatal tobacco exposure was significantly shorter than in those with no exposure (mean T/S ratio = 24.9 [SD = 8.58] in exposed vs. 28.97 [14.15] in control groups; <span style=”font-style:italic;”>P</span> = 0.02). A negative dose–response relationship was observed between the T/S ratio and tobacco exposure duration: the longer the duration of maternal smoking in pregnancy, the shorter the child’s telomere length. The association between the child’s telomere length and prenatal tobacco exposure remained significant after considering the influence of family socioeconomic status and exposure to environmental tobacco smoke during pregnancy and childhood.<div class=”boxTitle”>Conclusions:</div>Prenatal tobacco exposure was associated with telomere shortening in children. As this may impose significant health impacts through fetal genetic programming, more efforts should be made to reduce fetal tobacco exposure by educating pregnant women to not smoke and motivating smokers to quit in early pregnancy.<div class=”boxTitle”>Implications:</div>As reflected by telomere shortening, prenatal tobacco exposure in children can cause premature aging and increased health risks, which we suggest is entirely preventable. Not smoking during pregnancy or quitting smoking is critical to improving the health outcome of our future generations as prenatal tobacco exposure may affect children’s biological programming.</span>

Tobacco Use and 12-Month Suicidality Among Adults in the United States

<span class=”paragraphSection”><div class=”boxTitle”>Abstract</div><div class=”boxTitle”>Introduction:</div>To examine how 12-month prevalences of suicidality vary by tobacco use.<div class=”boxTitle”>Methods:</div>Data were from 325 800 adults who participated in the 2008–2014 National Survey on Drug Use and Health. Descriptive analyses and multivariable multinomial logistic regression models were applied.<div class=”boxTitle”>Results:</div>Among adults aged 18 or older in the United States during 2008–2014, 27.4% (annual average, standard error [SE] = 0.14%) were never tobacco users, 38.8% (SE = 0.17%) were former tobacco users, 5.9% (SE = 0.07%) were past-year users of other types of tobacco (non-cigarette), 20.2% (SE = 0.13%) were past-year cigarette-only users, and 7.7% (SE = 0.07%) were past-year users of cigarettes plus other types of tobacco; 2.6% (SE = 0.04%) had suicidal ideation only, 0.7% (SE = 0.02%) had suicidal ideation and suicide plan only, and 0.5% (SE = 0.02%) attempted suicide. After controlling for covariates, compared with never tobacco users, past-year users of cigarettes plus other types of tobacco were at elevated risk of all examined suicidality outcomes (adjusted relative risks [ARRs] = 1.2–1.7), and past-year cigarette-only users were at higher risk of suicide attempt (ARR = 1.4). Early age of first tobacco use was associated with higher risk of suicidal ideation and suicide plan among former tobacco users, past-year tobacco users, and past-year cigarette users (ARRs = 1.2–1.6). Among past-year tobacco users, frequencies of cigarette and cigar use were associated with suicide attempt (ARRs = 1.4–1.7). Nicotine dependence was associated with suicide attempt among past-year cigarette users (ARR = 1.2).<div class=”boxTitle”>Conclusions:</div>Tobacco use is associated with 12-month suicidality among adults. Patients who use tobacco should be assessed further for mental health status and suicide risk.<div class=”boxTitle”>Implications:</div>Our results revealed that tobacco use is independently associated with the 12-month suicidality outcomes among adults and identified how the prevalences of 12-month suicidality outcomes vary by tobacco use status and use characteristics among adults. These results have important clinical implications. Future research should assess the effectiveness of tobacco use questions as simple screeners for more extensive assessment of mental health status and suicide risk.</span>

Tobacco Use and 12-Month Suicidality Among Adults in the United States

<span class=”paragraphSection”><div class=”boxTitle”>Abstract</div><div class=”boxTitle”>Introduction:</div>To examine how 12-month prevalences of suicidality vary by tobacco use.<div class=”boxTitle”>Methods:</div>Data were from 325 800 adults who participated in the 2008–2014 National Survey on Drug Use and Health. Descriptive analyses and multivariable multinomial logistic regression models were applied.<div class=”boxTitle”>Results:</div>Among adults aged 18 or older in the United States during 2008–2014, 27.4% (annual average, standard error [SE] = 0.14%) were never tobacco users, 38.8% (SE = 0.17%) were former tobacco users, 5.9% (SE = 0.07%) were past-year users of other types of tobacco (non-cigarette), 20.2% (SE = 0.13%) were past-year cigarette-only users, and 7.7% (SE = 0.07%) were past-year users of cigarettes plus other types of tobacco; 2.6% (SE = 0.04%) had suicidal ideation only, 0.7% (SE = 0.02%) had suicidal ideation and suicide plan only, and 0.5% (SE = 0.02%) attempted suicide. After controlling for covariates, compared with never tobacco users, past-year users of cigarettes plus other types of tobacco were at elevated risk of all examined suicidality outcomes (adjusted relative risks [ARRs] = 1.2–1.7), and past-year cigarette-only users were at higher risk of suicide attempt (ARR = 1.4). Early age of first tobacco use was associated with higher risk of suicidal ideation and suicide plan among former tobacco users, past-year tobacco users, and past-year cigarette users (ARRs = 1.2–1.6). Among past-year tobacco users, frequencies of cigarette and cigar use were associated with suicide attempt (ARRs = 1.4–1.7). Nicotine dependence was associated with suicide attempt among past-year cigarette users (ARR = 1.2).<div class=”boxTitle”>Conclusions:</div>Tobacco use is associated with 12-month suicidality among adults. Patients who use tobacco should be assessed further for mental health status and suicide risk.<div class=”boxTitle”>Implications:</div>Our results revealed that tobacco use is independently associated with the 12-month suicidality outcomes among adults and identified how the prevalences of 12-month suicidality outcomes vary by tobacco use status and use characteristics among adults. These results have important clinical implications. Future research should assess the effectiveness of tobacco use questions as simple screeners for more extensive assessment of mental health status and suicide risk.</span>

Prevalence and Correlates of the Belief That Electronic Cigarettes are a Lot Less Harmful Than Conventional Cigarettes Under the Different Regulatory Environments of Australia and the United Kingdom

<span class=”paragraphSection”><div class=”boxTitle”>Abstract</div><div class=”boxTitle”>Introduction:</div>The rapid rise in electronic cigarettes (ECs) globally has stimulated much debate about the relative risk and public health impact of this new emerging product category as compared to conventional cigarettes. The sale and marketing of ECs containing nicotine are banned in many countries (eg, Australia) but are allowed in others (eg, United Kingdom). This study examined prevalence and correlates of the belief that ECs are a lot less harmful than conventional cigarettes under the different regulatory environments in Australia (ie, more restrictive) and the United Kingdom (ie, less restrictive).<div class=”boxTitle”>Methods:</div>Australian and UK data from the 2013 survey of the International Tobacco Control Four-Country project were analyzed.<div class=”boxTitle”>Results:</div>More UK than Australian respondents (58.5% vs. 35.2%) believed that ECs are a lot less harmful than conventional cigarettes but more respondents in Australia than in the United Kingdom selected “Don’t Know” (36.5% vs. 17.1%). The proportion that responded “A little less, equally or more harmful” did not differ between countries. Correlates of the belief that ECs are “A lot less harmful” differed between countries, while correlates of “Don’t Know” response did not differ.<div class=”boxTitle”>Conclusions:</div>Consistent with the less restrictive regulatory environment affecting the sale and marketing of ECs, smokers and recent ex-smokers in the United Kingdom were more likely to believe ECs were less harmful relative to conventional cigarettes compared to those in Australia.<div class=”boxTitle”>Implications:</div><span style=”font-style:italic;”>What this study adds:</span> Among smokers and ex-smokers, this study found that the belief that ECs are (a lot) less harmful than conventional cigarettes was considerably higher in the United Kingdom than in Australia in 2013. The finding is consistent with the less restrictive regulatory environment for ECs in the United Kingdom, suggesting that the regulatory framework for ECs adopted by a country can affect smokers’ perceptions about the relative harmfulness of ECs, the group that stands to gain the most from having an accurate belief about the relative harms of ECs.</span>

Reducing the Density and Number of Tobacco Retailers: Policy Solutions and Legal Issues

<span class=”paragraphSection”><div class=”boxTitle”>Abstract</div><div class=”boxTitle”>Introduction:</div>Because higher density of tobacco retailers is associated with greater tobacco use, U.S. communities seek ways to reduce the density and number of tobacco retailers. This approach can reduce the concentration of tobacco retailers in poorer communities, limit youth exposure to tobacco advertising, and prevent misleading associations between tobacco and health messaging.<div class=”boxTitle”>Methods:</div>Communities can reduce the density and number of tobacco retailers by imposing minimum distance requirements between existing retailers, capping the number of retailers in a given geographic area, establishing a maximum number of retailers proportional to population size, and prohibiting sales at certain types of establishments, such as pharmacies, or within a certain distance of locations serving youth. Local governments use direct regulation, licensing, or zoning laws to enact these changes. We analyze each approach under U.S. constitutional law to assist communities in selecting and implementing one or more of these methods. There are few published legal opinions that address these strategies in the context of tobacco control. But potential constitutional challenges include violations of the Takings Clause of the Fifth Amendment, which protects property owners from onerous government regulations, and under the Fourteenth Amendment’s Equal Protection and Due Process Clauses, which protect business owners from arbitrary or unreasonable regulations that do not further a legitimate government interest.<div class=”boxTitle”>Conclusion:</div>Because there is an evidentiary basis linking the density of tobacco retailers to smoking rates in a community, courts are likely to reject constitutional challenges to carefully crafted laws that reduce the number of tobacco retailers.<div class=”boxTitle”>Implications:</div>Our review of the relevant constitutional issues confirms that local governments have the authority to utilize laws and policies to reduce the density and number of tobacco retailers in their communities, given existing public health data. The analysis guides policy makers in crafting laws that comply with constitutional requirements by outlining the most important procedures and evidentiary justifications to use in development, implementation, and enforcement. This perspective also highlights the importance of reviewing state constitutions, statutes, and municipal codes and getting local input from attorneys and community stakeholders to assess the likely success of some methods over others.</span>

How Can Technology Support Smoking Cessation Interventions?

<span class=”paragraphSection”>The last 10 years has seen astonishing growth in the availability and widespread use of various mobile devices—smartphones, tablet computers and, more recently, wearable devices such as smartwatches. These provide unprecedented opportunities for both capturing data and delivering or supporting behavior change interventions. In this issue, a number of articles highlight the potential for technology to augment conventional smoking cessation treatments, and identify future directions that this research should take.</span>