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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 20  |  Issue : 1  |  Page : 14-20

Prevalence of nicotine dependence and its impact on quality of life and severity of symptoms in schizophrenic patients


1 Senior Resident, IMH, Hyderabad, Telangana, India
2 Postgraduate, Mamata Medical College, Khammam, Telangana, India
3 Assistant Professor, Kakatiya Medical College, Warangal, Telangana, India
4 Professor, Mamata Medical College, Khammam, Telangana, India

Date of Web Publication20-Jun-2019

Correspondence Address:
Dr. Gautham Tialam
Department of Psychiatry, Kakatiya Medical College, Warangal, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/AMH.AMH_40_18

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  Abstract 


Aims and Objectives: The aim of the study is (1) To assess the prevalence of nicotine dependence and its impact on quality of life and severity of symptoms in patients with schizophrenia. (2) To determine the association between ND and clinical symptomatology of schizophrenia. (3) To explore the impact of ND on the quality of life (QOL) of patients with schizophrenia.
Materials and Methods: The current study is a cross-sectional study done among 100-male schizophrenic patients conducted in the Department of Psychiatry, Mamata General Hospital, Khammam, Telangana, from July 2017 to December 2017. The tools used are the Fagerstrom test for ND (FTND) was administered to assess ND. The Positive and Negative Syndrome Scale (PANSS) for assessing the clinical symptomatology, and the abbreviated World Health Organization QOL (WHOQOL-BREF) for assessing their QOL.
Results: The prevalence of smoking in schizophrenics was 68.75%. Prevalence of ND is higher in illiterates, unemployment, nuclear family, low-socioeconomic status, and hailing from the rural background when compared to that of the nicotine nondependence. Nicotine-dependent were found to be having higher mean scores on the positive subscale and the General Psychopathology Subscale and lower mean scores on negative domain. Within the ND group, correlation testing between the FTND scores and PANSS revealed a negative co-relationship between ND and negative symptoms, whereas the correlation testing between the FTND scores and WHOQOL-BREF scores revealed a negative relationship between ND and psychological, social, and environment domains of QOL. There was a negative correlation between (a) Negative symptoms and all the domain of QOL. (b) General psychopathology and social relationships, environmental among ND.
Summary and Conclusion: Nicotine-dependent patients suffer from the higher levels of symptoms and enjoy a worse QOL compared to that of the nondependent patients with schizophrenia. Bearing in mind the innumerable harms of ND, the evaluation and management of ND must become an integral aspect of the evaluation and management of patients with schizophrenia.

Keywords: Nicotine dependence, quality of life, schizophrenia


How to cite this article:
Latha S P, Kumar M V, Tialam G, Mallepalli PK. Prevalence of nicotine dependence and its impact on quality of life and severity of symptoms in schizophrenic patients. Arch Ment Health 2019;20:14-20

How to cite this URL:
Latha S P, Kumar M V, Tialam G, Mallepalli PK. Prevalence of nicotine dependence and its impact on quality of life and severity of symptoms in schizophrenic patients. Arch Ment Health [serial online] 2019 [cited 2019 Nov 15];20:14-20. Available from: http://www.amhonline.org/text.asp?2019/20/1/14/260773




  Introduction Top


Schizophrenia is a group of heterogeneous disorders characterized by a diverse range of disturbances of perception, thought, emotion, motivation, and motor activity. It is an illness in which the episodes of florid disturbance are usually set against the background of sustained disability.[1] One of the factors that contribute to the disability in patients with schizophrenia is the presence of comorbidities. The common comorbidities encountered in patients with schizophrenia are substance dependence, cognitive impairments, and medical disorders such as obesity, diabetes mellitus, and cardiovascular disease.[2],[3] Nicotine dependence (ND) is one of the most common comorbidities in patients with schizophrenia.

India is the second-largest producer and third-largest consumer of tobacco worldwide.[4] It is estimated that the prevalence of cigarette smoking has been reported to be as high as 65%–88% in cases with schizophrenia.[5],[6] This is higher when compared to that of the individuals with other psychiatric diagnoses (45%–70%) and the general population (25%–40%).[7],[8],[9] The Indian Global Adult Tobacco Survey (GATS) reported that in India, the average prevalence of tobacco use is 48% and 20% among Indian men and women, respectively.[10]

According to Leonard et al., the maintenance of neuro-regulator effects of nicotine is the most important factor of continuing cigarette smoking, once started.[11] However, the most-mentioned theory is “self-medication”. According to this theory, schizophrenia is related to increased dopaminergic activity at the mesolimbic system (positive symptoms) and reduced at prefrontal region (negative symptoms). Thus, cigarette smoking has been proposed to reduce the severity of negative symptoms and improve cognitive functions by temporarily increasing dopaminergic activity in prefrontal subcortical network in schizophrenia. Improvement of selective attention and neuropsychological impairment in patients with schizophrenia after cigarette smoking in some studies supports this theory.[12],[13],[14]

The World Health Organization (WHO) defines the quality of life (QOL) as individuals perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, concern, and standards.[15] In treating and managing schizophrenia, clinicians often focus on treating psychotic symptoms and ignore factors that are directly related to QOL and prognosis of disease.

Hence, the evaluation and management of ND in the evaluation and management of schizophrenia can contribute to improving the outcome of the illness, reducing the associated disability, and improve the quality of illness of these individuals.[16] There is a need to explore the relationship between smoking and clinical characteristics and QOL in schizophrenia patients. In view of this, the present study was undertaken.


  Materials and Methods Top


The current study is a cross-sectional study conducted among 100-male schizophrenic patients. The study was conducted in the Department of Psychiatry, Mamata General Hospital, Khammam, Telangana, from July 2017 to December 2017. The study was approved by the Research Ethics Committee. Patients were briefed in detail about the nature and purpose of the study. Confidentiality was assured, and informed consent was taken.

Criteria for selection of sample patients

Inclusion criteria

  1. All patients who are diagnosed with schizophrenia as per the International Classification of Diseases-10 (ICD-10 diagnostic guidelines were included in the study
  2. Males within the age group of 18–60 years
  3. Patients who are fit to answer the questions
  4. Patients who give consent for the study.


Exclusion criteria

  1. Patient with schizophrenia who are diagnosed to have other psychiatric comorbidities
  2. Patients who are dependent on smokeless tobacco and on any other substance
  3. Patients who require urgent attention for the medical problems
  4. Patients without reliable informants.


Tools

All the patients were systematically interviewed along with the attendant and the socio-demographic characteristics, and the clinical details of all the patients were recorded. The diagnosis of schizophrenia was revised in accordance with the ICD-10 tenth revision. The Fagerstrom test for ND (FTND)[17] was administered to measure the severity of ND. Participants were divided into two groups: (a) based on the FTND scores, participants were classified into low dependence,[1],[2],[3],[4] moderate dependence,[5],[6],[7] and severe dependence (≥8). (b) patients who had not smoked in the previous 12 months were considered as former smokers and those who had smoked <100 cigarettes in their life time were considered as nonsmokers (nicotine nondependent). For the purpose of data analysis, former smokers were included in nonsmokers, i.e., nicotine nondependent.

The study patients from both the groups were administered the Positive and Negative Syndrome Scale (PANSS)for assessing the presence and severity of positive and negative symptoms of schizophrenia. The abbreviated WHOQOL-BREF scale[15] was administered to study the participants from both the groups to assess their QOL.

Statistical analysis

The statistical analysis of data was performed using the data obtained were analyzed using the Statistical Package for the Social Sciences, Version 20 (IBM Corp., SPSS statistics for windows, Armonk, NY, USA) for Windows (version 21) and Microsoft Excel 2010. Means of quantitative data were analyzed using independent Student's t-test. The correlation between the variables was measured using Pearson's correlation coefficient. Qualitative (categorical) data were analyzed using Chi-square test. It is used to find out the association between the two categorical variables. Statistical significance was set at the P < 0.05.


  Results Top


According to [Table 1], nicotine dependence has significant correlation with age, marital status and occupational status. Nicotine dependence is more significant in illiterate than in literate, more in single, followed by the divorced and then married. It is more significant in unemployed than in employed. According to [Table 2] and [Table 3], as the age of onset increases in schizophrenia there is greater nicotine dependenc. According to [Table 3], [Table 4], [Table 5] increase in PANSS score have greater nicotine dependence. Quality of life is poor in nicotine dependent patients in comparison to non nicotine dependent. According to [Table 6], [Table 7], [Table 8], Physical health, psychological health, social relationships and environment are better in nicotine non dependent, in comparison to nicotine dependent individuals.
Table 1: Relationship between socio-demographic variables and smoking

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Table 2: Age of onset of illness versus nicotine and nonnicotine dependence groups

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Table 3: Relationship between clinical variables and nicotine dependence

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Table 4: Severity of illness with nicotine dependence, nicotine nondependence

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Table 5: Co-relation of positive and negative syndrome scale with nicotine dependence

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Table 6: Quality of life among nicotine-dependent and nicotine nondependent

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Table 7: Co-relation between domains of quality of life with nicotine dependence groups

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Table 8: Co-relation between positive and negative syndrome scale and domains of quality of life

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  Discussion Top


In the present study, the prevalence of ND in schizophrenic male patients was 68.75%. Our findings were in accordance with Kelly and McCreadie[18] study reported that the prevalence of ND in schizophrenic male patients was 65%. This difference might have been due to the factors such as small sample size of our study.

The mean age of the schizophrenic patients who were nicotine-dependent are around 37 years greater than nicotine nondependent (31 years), and this difference was found to be statistically significant (P = 0.0001). With the increase in age, patients accumulate experience with their psychotic illness and tend to learn coping mechanisms like smoking to counteract their psychotic symptoms, thus making them more dependent on nicotine. Similar findings have been reported by Xiang et al.[19]

In the present sample, the prevalence of smoking was high in illiterates (45.46%) followed by the primary (33.33%), secondary (13.64%), and graduate (7.57%). This might be because higher education would lead to better access to the illness and have enough information regarding the harmful effects of ND. Similar findings have been reported by Sorensen et al.[20]

Among the whole-study sample, the prevalence of smoking is more in patients who were unmarried (45.45%) followed by the divorce (33.34%) and married (21.21%), and this difference was found to be statistically significant (P = 0.0003). This could be because patients who were single or divorced will not have the necessary care and supervision provided by the spouse, thus making them more dependent on nicotine. Similar findings have been reported by Dollar et al.[21] stated that single and separated patients quite smoking less because they do not have the support of a spouse.

In the present study, regarding occupational status; unemployment (60.6%) was seen higher in nicotine-dependent patients, and this difference was found to be statistically significant (P = 0.005). As schizophrenics have less chances of getting employed and participate in few activities, they use smoking as behavior filler. The present study findings were in concordance with that of studies done by Krishnadas et al.[22] stated that smoking was significantly higher in unemployed people than employed.

Among the nicotine-dependent patients, 66.6% belong to the nuclear families and 33.33% belong to the joint families. The reason of these could be lack of support to take care of things/children in the absence or emergency of one member, limited social interactions/close relationships, considerable erosion of traditional support systems, and increased stress and pressure on nuclearized families, leading to an increased vulnerability to emotional problems and disorders, increased demands on finances.

In the present study, the majority (54.54%) of patients who were nicotine-dependent had a family income <5000 rs/month than that of the patients of nicotine nondependent. This might because socioeconomic status is associated with poverty, unemployment, and poorer awareness regarding the health-related information. The study conducted by Cohen and Williamson[23] resulting in higher ND was accordance with the present study.

The present study findings show that two-third of the schizophrenic patients with nicotine and nicotine nondependence hailed from the rural background. The reason of high prevalence of nicotine abuse in the rural area is might be low income, large number of families below the poverty line, illiteracy, and any other factors poor awareness regarding health leads to depend on nicotine. Similar study by Rani et al.[24] said that the prevalence of smoking tobacco was significantly higher in rural, poorer, and uneducated populations.

The age of onset of smoking (20 years) preceded the onset of schizophrenia (31 years) in patients of nicotine-dependent group and statistically significant between the age of onset of illness and nicotine dependent/nicotine nondependent (P = 0.0002). It has been repeatedly shown that the vast majority of schizophrenia patients start smoking early before the onset of illness was accordance to the present study.[25] Possible reasons for taking up smoking early could be related to self-medication for the symptoms of anxiety or isolated psychosis and might be shared with other risk factors for psychosis.

On comparing the severity of illness with the severity of smoking, we found that the mean scores on positive (22.71 ± 4.86) and general psychopathology (43.5 ± 10.34) domains of PANSS scale were higher in patients with severe dependence than that of patients with mild ND. The mean scores on negative domain of PANSS scale in patients with severe dependence was lower (16.68 ± 4.10) than that of patients with mild dependence (19.88 ± 6.86). The difference between the severity of symptoms and ND were found to be statistically significant. Misiak et al.[26] found that smokers had significantly lower scores of negative symptoms on PANSS compared to that of the scores of positive symptoms, and general psychopathology was accordance to the present study. This finding implies that nicotine may improve schizophrenia symptoms, particularly the negative and cognitive symptoms and worsen the positive symptoms. This could be because in schizophrenia a deficiency of dopamine occurs in the prefrontal cortical region of the brain, thought to contribute to the negative symptoms of the illness (social withdrawal, apathy), while excess dopamine activity occurs in the mesolimbic area of the brain resulting in positive symptoms.[27]

In the present study, there was positive co-relation between the ND positive (r = 0.478), general psychopathology (0.328) and were found to be statistically significant. There was negative co-relation between ND and negative symptoms (r = −0.278) and was statistically significant. With regard to psychopathology, the most impressive association of smoking seemed to be with negative symptoms, and negative symptom score was found to be the strongest contributor to predicting smoking behavior. Ziedonis et al.,[28] Goff et al.[29] have found a positive association of smoking with primarily positive symptoms was accordance with the present study.

In the present study, the mean score of physical, psychological, social relationships, and environmental domains of QOL in nicotine-dependent lower than that of the nicotine nondependent. Higher the score indicates the higher QOL. Nicotine-dependent patients had a poorer overall QOL as compared to that of the nicotine nondependent individuals with schizophrenia and the differences between them are statistically significant. Our findings were accordance with Dixon et al.[30]

In the present study sample, the negative co-relation observed between ND and psychological (r = −0.093), social relationships (r = −0.08), environmental (r = −0.149) domains of QOL. This could be interpreted as heavily nicotine-dependent patients worsens the interpersonal relationships, lack of social support, health and social care, disturbed home environment, and financial crisis. A study by Deng et al.[31] reported that decreased cigarette consumption was associated with an increase in the psychological domain compared to that of the social domain which was accordance to the present study.

The present study sample reports positive co-relation (r = 0.132) between ND and physical domain of QOL. Increased cigarette consumption was associated with an increase of physical domain.

The patients belonging nicotine-dependent group were tested for the correlation between the clinical symptomology and QOL. On analysis, negative co-relation was found between

  1. Negative symptoms and physical domain of QOL (r = −0.098)
  2. Negative symptoms and psychological domain of QOL (r = −0.177)
  3. Negative symptoms and social relationship (r =−0.199), environmental domain of QOL (r = −0.202)
  4. General psychopathology and social relationships (r = −0.244) and environmental (r = 0.06) among the ND. There was significance difference observed between the general psychopathology and social relations. (P = 0.04)


Similar findings seen in Kasckow et al.[32] found that the negative symptoms and general psychopathology had a markedly stronger relationship with the health-related QOL of the elderly outpatients with schizophrenia consistently indicate that negative symptoms and general psychopathology (e.g., anxiety and depression) have a significant negative relationship with QOL.


  Summary and Conclusion Top


  1. The prevalence of smoking in schizophrenics in our study was 68.75%
  2. The prevalence of ND is higher in illiterates, unemployment, nuclear family, low-socioeconomic status, and hailing from the rural background when compared to that of the nicotine nondependence
  3. In our study, we had found that patients who smoke had greater mean age at the onset of illness (31.21 ± 2.94), higher mean scores (82.72 ± 16.86) on PANSS when compared to that of the nonsmokers indicting greater severity of the illness. This relationship was found to be statistically significant
  4. It was found that patients who were severely dependent were found to be having higher mean scores on positive subscale (22.71 ± 4.86) and the General Psychopathology Subscale (43.5 ± 10.34) and lower mean scores on negative domain (16.68 ± 4.10), this difference was found to be statistically significant
  5. Within the ND group, correlation testing between FTND scores and PANSS revealed a negative co-relationship between ND and negative symptoms, whereas correlation testing between FTND scores and WHOQOL-BREF scores revealed a negative relationship between ND and psychological, social, and environment domains of QOL
  6. There was a negative correlation between (a) Negative symptoms and all the domain of QOL. (b) General psychopathology and social relationships, environmental among ND.


Limitations

  1. This is a cross-sectional study design
  2. Our study design cannot show direct causality of smoking, whether beneficial or harmful in patients with schizophrenia
  3. Only male patients were considered in this study sample
  4. Small sample size of the study
  5. Results cannot be generalized
  6. The effect of smoking on antipsychotics was not studied
  7. Patients who use other chewing forms of nicotine-like Ghutkas (chewable tobacco) were excluded from the study.


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]



 

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