Does smoking cause poor mental health?

Mediating role of health behaviors in income-related health inequalities: evidence from socioeconomically deprived rural areas of China

INTRODUCTION

Existing evidence from high-income countries suggests that higher income is associated with better health outcomes through health-promoting behaviors. However, limited evidence exists regarding income-related health inequalities mediated by health behaviors in low- and middle-income countries. This study focuses on socioeconomically deprived rural areas of China and examines how health behaviors contribute to the association between income and health.

METHODS

In 2023, a cross-sectional study comprising 6,674 participants was conducted in rural Shandong, China, using a stratified cluster random sampling method. Income was measured using annual per capita net household income. Health behaviors included smoking, overdrinking, teeth brushing, fruit and vegetable consumption, and physical activity. Health status was assessed using the self-rated health (SRH) scale, the activities of daily living (ADLs) scale and EuroQol-5 Dimension (EQ5D). The ordinary least squares (OLS) method was adopted to examine the associations among income, health behaviors and health status after controlling for confounding factors. The non-parametric bootstrapping method was employed to further explore the mediating role of health behaviors in income-related health inequalities.

RESULTS

Income was positively associated with SRH, ADLs, EQ5D, and three positive behaviors including teeth brushing, fruit consumption, and physical activity, but was also positively correlated with overdrinking. Mediation analysis revealed that health behaviors mediated 35.05% (SRH), 67.90% (ADLs), and 72.08% (EQ5D) of the association between income and health status.

CONCLUSION

This study has shown income-related inequalities in both health and health behaviors in socioeconomically deprived rural areas of China. The health behaviors mediated the association between income and health status.

Estimating the Prevalence of and Clarifying Factors Associated With Multiple Tobacco Product Use in Japan: A Cross-sectional Study in 2022

BACKGROUND

Multiple tobacco product (MTP) use is a public health concern due to their combined adverse health effects. MTP use may have increased since heated tobacco products (HTPs) became more prevalent in Japan. This study aimed to (1) estimate the recent prevalence of MTP use and clarify the associated factors compared to (2) non-smokers and (3) single-product users.

METHODS

We used data from an internet survey conducted in February 2022. The prevalence of MTP use in Japan was estimated using inverse probability-weighted scores from this survey and a nationwide survey by the Japanese government. Tobacco products include six types: cigarettes, HTPs, e-cigarettes, cigars, pipe/water pipes, and smokeless tobacco products. MTP use was defined using the outcome variable (no use, single-product use, and MTP use) based on these six types of use. Using multivariate logistic regression, we calculated the adjusted odds ratios and 95% confidence intervals (CI) to clarify factors associated with MTP use compared to non-smokers, adjusting demographic variables, psychological distress, self-rated health, and alcohol use. Using multivariate Poisson regression, we calculated the adjusted prevalence ratios (aPRs) and 95% CIs to clarify factors associated with MTP use among smokers, adjusting for these covariates and smoking-related factors like workplace and home smoking rules.

RESULTS

We analyzed 30,141 participants whose mean age was 47.8 years (standard deviation, 17.9), and 14,722 participants were male (48.8%). The estimated prevalence of MTP use was 6.8%. The most common combination of MTP use was cigarettes and HTPs. Compared to non-smokers, being younger, male, alcohol drinkers, and having low education, poor psychological distress, and poor self-rated health were factors associated with MTP use. Among smokers, workplace smoking rules, such as a partial smoking ban and no smoking ban, were not associated with MTP use compared to the indoor smoking ban. However, having no home smoking ban was positively associated with MTP use compared with a ban on both cigarettes and HTPs at home (both cigarettes and HTPs allowed aPR 1.36; 95% CI, 1.15-1.61, HTPs only allowed aPR 1.73; 95% CI, 1.43-2.10).

CONCLUSION

MTP users may account for a high percentage of Japanese smokers.

Age-period-cohort analysis of different mental wellbeing measures in Scotland from 2008 to 2021: The U-shaped curve of mental wellbeing over the life course

BACKGROUND

Common mental disorders are increasingly recognized as a serious public health concern globally. This study reports an age-period-cohort (APC) analysis of mental wellbeing to help identify high-risk groups.

METHOD

Data from Scottish Health Survey from 2008 to 2021 for adults aged 16+ was used with mental wellbeing measured with three different tools: the General Health Questionnaire-12 (GHQ-12), the Warwick-Edinburgh Mental Wellbeing Scale (WEMWBS) and the Revised Clinical Interview Schedule (CIS-R). A graphical analysis was performed using hexamap and Intrinsic Estimator models were employed to estimate the separate effects for age, period and birth cohorts on mental wellbeing.

RESULTS

Age evidenced the most pronounced pattern with a U-shape curve indicative of a deterioration of mental health as individuals enter adulthood, reaching a nadir in their late 50s/ early 60s before gradually improving thereafter. Mental health trends across cohorts were largely stable, although there was a noticeable, albeit non-significant, increase in mental health issues among people born in late 1990s-to mid-2000s. After adjusting for APC effects, better mental health was found for males, people with higher incomes, employed and those currently married. Medium to high level of physical activity were also associated with better mental wellbeing.

CONCLUSION

The study supports arguments for greater attention to mental health among those are working-age adults and for younger generations born after the 1980s. Associations with sex, socio-economic factors may help guide targeting of public health measures while associations with a healthy physical lifestyle support arguments at measures intended to promote a mental health through physical activity.

Receipt of the 5As intervention for smoking cessation among people with and without mental health disorders

Brief interventions for smoking cessation, such as the 5As (ask, assess, advise, assist, arrange) are effective, but limited data are available regarding their delivery to smokers with mental health disorders (MHDs), and whether a disparity in care exists. This study explored the difference in the self-reported receipt of 5As between smokers with and without MHDs in a community setting. Baseline data from 1452 (1206 without and 246 with self-reported MHDs) Australian smokers who participated in a smoking cessation trial were analysed. Participants reported interactions with healthcare providers and receipt of the 5As over the past 12 months. Multivariate logistic regression analysis was employed to investigate the association between receipt of the 5As and MHD status. Smokers with MHDs were significantly more likely to be asked, assessed, advised, and assisted compared to those without MHDs, but arranging follow-up was very low in both groups (7.7% with MHDs and 4.1% without MHDs). This is particularly concerning for vulnerable population like smokers with MHDs, who may struggle more in their quit attempt. The findings highlight the need to enhance the implementation of the 'arrange follow-up' component to improve cessation outcomes and reduce health disparities.

Changes in tobacco use and associated factors among Brazilian adolescents: National Student Health Survey

This cross-sectional study used data from Brazil's National Student Health Survey (PeNSE), from 2015 and 2019, to compare consumption of tobacco products among adolescent students in Brazil and identify associated factors. The study variables were current cigarette smoking, use of other tobacco products and use of any tobacco product. Pearson's Chi-square test was used to ascertain associations between the variables; bivariate and multivariate analyses were performed using logistic regression. Cigarette smoking remained stable between 2015 (6.6%) and 2019 (6.8%), but use of any tobacco product increased (from 10.6% in 2015 to 14.8% in 2019), involving particularly hookahs (7.8%) and e-cigarettes (2.8%). Cigarette smoking was greater among adolescents aged 16 and 17, whose skin colour was black or brown, who missed classes without permission, who reported having no friends, displayed other risk factors, such as drinking alcoholic beverages, or who were passive smokers. The prevalence of smoking has increased over the years and is associated with sociodemographic aspects and other health risk behaviour, highlighting the need for lifelong health promotion actions.

Analysis of patient health questionnaire-9 (PHQ-9) based depression prevalence according to a discordance between quantitative urinary cotinine levels and self-report of second-hand smoke exposure among adults: A cross-sectional study

Background

Second-hand smoke (SHS) exposure appears to be more common among individuals with depression. However, self-report of SHS exposure is an inaccurate classification compared to confirming SHS exposure using urinary cotinine (UC). Additionally, the dose-response relationship between depression and UC is controversial.

Methods

The severe stress rate and depression prevalence was estimated among 14530 Korean participants aged ≥19 years using data patient health questionnaire-9 (PHQ-9) and on UC from the Korean National Health and Nutrition Examination Survey. Measured UCs were divided into four categories: UC- (≤0.3 μg/L), UC± (0.4 μg/L-0.9 μg/L), UC+ (1.0 μg/L-11.9 μg/L), and UC++ (≥12.0 μg/L).

Results

About 55.0 % participants were female and participants' mean age was 51.1 years. Non-smokers were 80.3 %. Among non-smokers, non-SHS exposure participants (SR-) and SHS exposure participants (SR+) were 83.0 % and 17.0 %, respectively. When UC- was used as the reference subgroup, the UC++ subgroup showed a higher depression prevalence, whereas the UC ± subgroup showed a lower prevalence. In the same UC categories, the depression prevalence and severe stress rate were higher among females than among males. Furthermore, the SR + subgroup had a higher severe stress rate than the SR- subgroup.

Conclusions

Our study showed a paradoxical reduction in the depression prevalence and severe stress rate in the UC ± subgroup compared to the UC- subgroup. Additionally, the dose-response relationship between the SHS exposure biomarker and the depression prevalence was not linear. Our study indicates that an emotional stress-based model may be more appropriate for explaining the relationship between depression and SHS exposure.

IntEgrating Smoking Cessation treAtment into usual online Psychological care for people with common mEntal illness: Protocol for an online randomised feasibility and pilot study (ESCAPE digital)

BACKGROUND

In the UK, smoking prevalence in people with depression (34%) and anxiety (29%) is more than double that of the general population (13%). People who stop smoking improve their mental health with comparable effect sizes found for antidepressants. In England, online psychological therapy is a standard treatment for depression and anxiety. Online therapy is an acceptable setting for smoking cessation support; however, integrated smoking and mental health support is not available. This novel study aims to assess the acceptability and feasibility of an online smoking cessation intervention, and trial procedures, offered alongside online mental health treatment as it offers increased reach to people with common mental health difficulties who smoke.

METHODS

A two-armed; Intervention (Integrated SilverCloud smoking cessation support) and control group (SilverCloud usual care), pragmatic, randomised controlled feasibility trial. We aim to recruit 500 adult smokers eligible for online mental health treatment. Follow-up will be conducted at 3-months and 6-months. We will assess the acceptability and feasibility of the trial procedures (i.e., recruitment, data completeness, self-reported acceptability and satisfaction) and the intervention (i.e., self-reported quit attempt, engagement with the smoking cessation and mental health programs, smoking cessation medicine and e-cigarette use, self-reported acceptability and satisfaction) and pilot clinical outcomes (i.e., biologically validated smoking abstinence, anxiety, depression, quality of health).

CONCLUSION

If the Trial is successful, a randomised controlled effectiveness trial will follow to examine whether integrated smoking cessation and mental health treatment increases smoking abstinence and improves depression and anxiety compared to usual care.

TRIAL REGISTRATION

ISRCTN10612149 (https://doi.org/10.1186/ISRCTN10612149), 02/02/2023.

Development of a Personalized Tobacco Cessation Intervention Package (PTCIP) for Persons with Schizophrenia in India

Background

Among persons with schizophrenia (PwS), tobacco use is higher in comparison to the general population, contributing to greater morbidity and mortality. Pharmacological interventions combined with psychosocial interventions are effective in tobacco cessation. While the effectiveness of extant psychosocial interventions-when used in isolation-seems limited, developing better combinations of interventions could help treatment providers deliver tobacco cessation services to PwS at different stages of motivation to quit. We aimed to develop a personalized tobacco cessation intervention package (PTCIP) for PwS.

Methods

The stage-based intervention package was developed through a systematic review of interventions for tobacco cessation, the authors' clinical experience, and expert validation. The components of the intervention package, developed for PwS visiting the outpatient psychiatric department, were retained, removed, or added based on the content validity ratio (CVR).

Results

The final components included brief advice, principles of motivational interviewing, psychoeducation, decisional balance matrix, positive reinforcement, offering various treatment options, personalized feedback using a smoking-risk calculator, and prediction of cardiovascular risk using the WHO package of essential noncommunicable disease (PEN). The delivery of the intervention package was refined based on pilot testing in eight participants.

Conclusion

The tailored package was designed to be delivered by a mental health professional as a single comprehensive 40 min to 45 min face-to-face session, integrated with routine follow-up visits, followed by two telephonic conversations in the second and third week of the initial session. The package needs to be tested in a randomized controlled trial for its effectiveness.

Acceptability of integrating smoking cessation treatment into routine care for people with mental illness: A qualitative study

INTRODUCTION

Improving Access to Psychological Therapies (IAPTs) Services could offer smoking cessation treatment to improve physical and psychological outcomes for service users, but it currently does not. This study aimed to understand participants' views and experiences of receiving a novel smoking cessation intervention as part of the ESCAPE trial (intEgrating Smoking Cessation treatment As part of usual Psychological care for dEpression and anxiety). We used the Capability, Opportunity and Motivation Model of Behaviour (COM-B) to understand the (i) acceptability of the integrated smoking cessation treatment, (ii) views of psychological well-being practitioners' (PWPs) ability to deliver the smoking cessation treatment and (iii) positive and negative impacts of smoking cessation treatment.

METHODS

This was a qualitative study embedded within a feasibility randomized-controlled trial (ESCAPE) in primary care services in the United Kingdom (IAPT). Thirty-six participants (53% female) from both usual care and intervention arms of the ESCAPE trial, including both quitters and nonquitters, were interviewed using semi-structured interviews. Data were analysed using a framework approach to thematic analysis, using the COM-B as a theoretical frame.

RESULTS

Psychological Capability: Integrated smoking cessation treatment was acceptable and encouraged participants to reflect on their mental health. Some participants found it difficult to understand nicotine withdrawal symptoms.

MOTIVATION

Participants were open to change during the event of presenting to IAPT. Some described being motivated to take part in the intervention by curiosity, to see whether quitting smoking would help their mental health. Physical Opportunity: IAPT has a natural infrastructure for supporting integrated treatment, but there were some barriers such as session duration and interventions feeling segmented. Social Opportunity: Participants viewed PWPs as having good interpersonal skills to deliver a smoking cessation intervention.

CONCLUSION

People with common mental illness generally accepted integrated smoking cessation and mental health treatment. Smoking cessation treatment fits well within IAPT's structure; however, there are barriers to implementation.

PATIENT OR PUBLIC CONTRIBUTION

Before data collection, we consulted with people with lived experience of smoking and/or mental illness and lay public members regarding the aims, design and interview schedules. After analysis, two people with lived experience of smoking and mental illness individually gave feedback on the final themes and quotes.

An application of the stress-diathesis model: A review about the association between smoking tobacco, smoking cessation, and mental health

Background

Worldwide, approximately 24% of all adults smoke, but smoking is up to twice as prevalent in people with mental ill-health. There is growing evidence that smoking may be a causal risk factor in the development of mental illness, and that smoking cessation leads to improved mental health.

Methods

In this scholarly review we have: (1) used a modern adaptation of the Bradford-Hill criteria to bolster the argument that smoking could cause mental ill-health and that smoking cessation could reverse these effects, and (2) by considering psychological, biological, and environmental factors, we have structured the evidence to-date into a stress-diathesis model.

Results

Our model suggests that smoking is a psychobiological stressor, but that the magnitude of this effect is mediated and modulated by the individual's diathesis to develop mental ill-health and other vulnerability and protective factors. We explore biological mechanisms that underpin the model, such as tobacco induced damage to neurological systems and oxidative stress pathways. Furthermore, we discuss evidence indicating that it is likely that these systems repair after smoking cessation, leading to better mental health.

Conclusion

Based on a large body of literature including experimental, observational, and novel causal inference studies, there is consistent evidence showing that smoking can negatively affect the brain and mental health, and that smoking cessation could reverse the mental ill-health caused by smoking. Our model suggests that smoking prevention and treatment strategies have a role in preventing and treating mental illness as well as physical illness.

The Detrimental Clinical Associations of Anxiety and Depression with Difficult Asthma Outcomes

Difficult asthma describes asthma in which comorbidities, inadequate treatment, suboptimal inhaler technique and/or poor adherence impede good asthma control. The association of anxiety and depression with difficult asthma outcomes (exacerbations, hospital admissions, asthma control, etc.) is unclear. This study assessed the clinical associations of anxiety and depression with difficult asthma outcomes in patients with a specialist diagnosis of difficult asthma. Using real-world data, we retrospectively phenotyped patients from the Wessex Asthma Cohort of Difficult Asthma (N = 441) using clinical diagnoses of anxiety and depression against those without anxiety or depression (controls). Additionally, we stratified patients by severity of psychological distress using the Hospital Anxiety and Depression Scale (HADS). We found that depression and/or anxiety were reported in 43.1% of subjects and were associated with worse disease-related questionnaire scores. Each psychological comorbidity group showed differential associations with difficult asthma outcomes. Anxiety alone (7.9%) was associated with dysfunctional breathing and more hospitalisations [anxiety, median (IQR): 0 (2) vs. controls: 0 (0)], while depression alone (11.6%) was associated with obesity and obstructive sleep apnoea. The dual anxiety and depression group (23.6%) displayed multimorbidity, worse asthma outcomes, female predominance and earlier asthma onset. Worse HADS-A scores in patients with anxiety were associated with worse subjective outcomes (questionnaire scores), while worse HADS-D scores in patients with depression were associated with worse objective (ICU admissions and maintenance oral corticosteroid requirements) and subjective outcomes. In conclusion, anxiety and depression are common in difficult asthma but exert differential detrimental effects. Difficult asthma patients with dual anxiety and depression experience worse asthma outcomes alongside worse measures of psychological distress. There is a severity-gradient association of HADS scores with worse difficult asthma outcomes. Collectively, our findings highlight the need for holistic, multidisciplinary approaches that promote early identification and management of anxiety and depression in difficult asthma patients.

A polygenic approach to the association between smoking and schizophrenia

Smoking prevalence in schizophrenia is considerably larger than in general population, playing an important role in early mortality. We compared the polygenic contribution to smoking in schizophrenic patients and controls to assess if genetic factors may explain the different prevalence. Polygenic risk scores (PRSs) for smoking initiation and four genetically correlated traits were calculated in 1108 schizophrenic patients (64.4% smokers) and 1584 controls (31.1% smokers). PRSs for smoking initiation, educational attainment, body mass index and age at first birth were associated with smoking in patients and controls, explaining a similar percentage of variance in both groups. Attention-deficit hyperactivity disorder (ADHD) PRS was associated with smoking only in schizophrenia. This association remained significant after adjustment by psychiatric cross-disorder PRS. A PRS combining all the traits was more explanative than smoking initiation PRS alone, indicating that genetic susceptibility to the other traits plays an additional role in smoking behaviour. Smoking initiation PRS was also associated with schizophrenia in the whole sample, but the significance was lost after adjustment for smoking status. This same pattern was observed in the analysis of specific SNPs at the CHRNA5-CHRNA3-CHRNB4 cluster associated with both traits. Overall, the results indicate that the same genetic factors are involved in smoking susceptibility in schizophrenia and in general population and are compatible with smoking acting, directly or indirectly, as a risk factor for schizophrenia that contributes to the high prevalence of smoking in these patients. The contrasting results for ADHD PRS may be related to higher ADHD symptomatology in schizophrenic patients.

The Potential Impact of Widespread Cessation Treatment for Smokers With Depression

INTRODUCTION

Experts recommend integrating smoking-cessation treatments within U.S. mental health settings, but the population health benefits of doing so have not been estimated. This study simulates the impact of widespread cessation treatment for patients with depression under best-case treatment and maximum potential cessation scenarios.

METHODS

Cessation interventions were simulated for U.S. adult smokers seeing a health professional for depression from 2020 to 2100. Interventions included (1) Any Treatment (behavioral counseling, pharmacological, combination) and (2) Pharmacological Treatment (including counseling), combined with increased mental health service utilization each. These were compared with a maximum potential cessation scenario where all patients with major depression quit smoking. Analyses were conducted in 2016-2020.

RESULTS

Widespread uptake of Any Treatment among patients with depression would avert 32,000 deaths and result in 138,000 life-years gained by 2100; Any Treatment combined with 100% mental health service utilization would result in 53,000 and 231,000, respectively. Pharmacological Treatment would avert 125,000 deaths, with 540,000 life-years gained. Pharmacological Treatment combined with 100% mental health service utilization would result in 203,000 deaths averted and 887,000 life-years gained. Health gains under best-case treatment scenarios represent modest fractions of those projected under maximum potential cessation scenarios at current mental health service utilization levels (835,000 deaths averted, 3.73 million life-years gained) and at 100% utilization (1.11 million deaths averted, 5.07 million life years gained).

CONCLUSIONS

Providing smoking-cessation treatment to patients with depression and increasing mental health service utilization would reduce the toll of tobacco on this population. These gains would be considerably larger if cessation treatments were more effective.

Views about integrating smoking cessation treatment within psychological services for patients with common mental illness: A multi-perspective qualitative study

BACKGROUND

Tobacco smoking rates are significantly higher in people with common mental illness compared to those without. Smoking cessation treatment could be offered as part of usual outpatient psychological care, but currently is not.

OBJECTIVE

To understand patient and health care professionals' views about integrating smoking cessation treatment into outpatient psychological services for common mental illness.

DESIGN

Qualitative in-depth interviews, with thematic analysis.

PARTICIPANTS

Eleven Improving Access to Psychological Therapies (IAPT) psychological wellbeing practitioners (PWPs), six IAPT patients, and six stop smoking advisors were recruited from English smoking cessation, and IAPT services.

RESULTS

Patients reported psychological benefits from smoking, and also described smoking as a form of self-harm. Stop smoking advisors displayed therapeutic pessimism and stigmatizing attitudes towards helping people with mental illness to quit smoking. PWPs have positive attitudes towards smoking cessation treatment for people with common mental illness. PWPs and patients accept evidence that smoking tobacco may harm mental health, and quitting might benefit mental health. PWPs report expertise in helping people with common mental illness to make behavioural changes in the face of mood disturbances and low motivation. PWPs felt confident in offering smoking cessation treatments to patients, but suggested a caseload reduction may be required to deliver smoking cessation support in IAPT.

CONCLUSIONS

IAPT appears to be a natural environment for smoking cessation treatment. PWPs may need additional training, and a caseload reduction. Integration of smoking cessation treatment into IAPT services should be tested in a pilot and feasibility study.

PATIENT OR PUBLIC CONTRIBUTION

Service users and members of the public were involved in study design and interpretation of data.

Addressing concerns about smoking cessation and mental health: theoretical review and practical guide for healthcare professionals

Smoking rates in people with depression and anxiety are twice as high as in the general population, even though people with depression and anxiety are motivated to stop smoking. Most healthcare professionals are aware that stopping smoking is one of the greatest changes that people can make to improve their health. However, smoking cessation can be a difficult topic to raise. Evidence suggests that smoking may cause some mental health problems, and that the tobacco withdrawal cycle partly contributes to worse mental health. By stopping smoking, a person's mental health may improve, and the size of this improvement might be equal to taking anti-depressants. In this theoretical review and practical guide we outline ways in which healthcare professionals can raise the topic of smoking compassionately and respectfully to encourage smoking cessation. We draw on evidence-based methods like cognitive behavioural therapy, and outline approaches that healthcare professionals can use to integrate these methods into routine care.

The Christian Orthodox Church Fasting Diet Is Associated with Lower Levels of Depression and Anxiety and a Better Cognitive Performance in Middle Life

Lifestyle choices significantly influence mental health in later life. In this study we investigated the effects of the Christian Orthodox Church (COC) fasting diet, which includes long-term regular abstinence from animal-based products for half the calendar year, on cognitive function and emotional wellbeing of healthy adults. Two groups of fasting and non-fasting individuals were evaluated regarding their cognitive performance and the presence of anxiety and depression using the Mini Mental Examination Scale, the Hamilton Anxiety Scale, and the Geriatric Depression Scale (GDS), respectively. Data on physical activity, smoking, and vitamin levels were collected and correlated with mental health scoring. Negative binomial regression was performed to examine differences in the GDS scores between the two groups. Significantly lower levels of anxiety (7.48 ± 4.98 vs. 9.71 ± 5.25; p < 0.001) and depression (2.24 ± 1.77 vs. 3.5 ± 2.52; p < 0.001), along with better cognitive function (29.15 ± 0.79 vs. 28.64 ± 1.27; p < 0.001), were noticed in fasting compared to non-fasting individuals. GDS score was 31% lower (Incidence Rate Ratio: 0.69, 95% Confidence Interval: 0.56–0.85) in the fasting group compared to the control, while vitamin and ferrum levels did not differ. The COC fasting diet was found to have an independent positive impact on cognition and mood in middle-aged and elderly individuals.

Investigating causality between liability to ADHD and substance use, and liability to substance use and ADHD risk, using Mendelian randomization

Attention-deficit hyperactivity disorder (ADHD) has consistently been associated with substance use, but the nature of this association is not fully understood. To inform intervention development and public health messages, a vital question is whether there are causal pathways from ADHD to substance use and/or vice versa. We applied bidirectional Mendelian randomization, using summary-level data from the largest available genome-wide association studies (GWAS) on ADHD, smoking (initiation, cigarettes per day, cessation, and a compound measure of lifetime smoking), alcohol use (drinks per week, alcohol problems, and alcohol dependence), cannabis use (initiation), and coffee consumption (cups per day). Genetic variants robustly associated with the "exposure" were selected as instruments and identified in the "outcome" GWAS. Effect estimates from individual genetic variants were combined with inverse-variance weighted regression and five sensitivity analyses (weighted median, weighted mode, MR-Egger, generalized summary data-based MR, and Steiger filtering). We found evidence that liability to ADHD increases likelihood of smoking initiation and heaviness of smoking among smokers, decreases likelihood of smoking cessation, and increases likelihood of cannabis initiation. There was weak evidence that liability to ADHD increases alcohol dependence risk but not drinks per week or alcohol problems. In the other direction, there was weak evidence that smoking initiation increases ADHD risk, but follow-up analyses suggested a high probability of horizontal pleiotropy. There was no clear evidence of causal pathways between ADHD and coffee consumption. Our findings corroborate epidemiological evidence, suggesting causal pathways from liability to ADHD to smoking, cannabis use, and, tentatively, alcohol dependence. Further work is needed to explore the exact mechanisms mediating these causal effects.

Modeling smoking-attributable mortality among adults with major depression in the United States

Tobacco-related health disparities disproportionately affect smokers with major depression (MD). Although tobacco simulation models have been applied to general populations, to date they have not considered populations with a comorbid mental health condition. We developed and calibrated a simulation model of smoking and MD comorbidity for the US adult population using the 2005-2018 National Surveys on Drug Use and Health. We use this model to evaluate trends in smoking prevalence, smoking-attributable mortality and life-years lost among adults with MD, and changes in smoking prevalence by mental health status from 2018 to 2060. The model integrates known interaction effects between smoking initiation and cessation, and MD onset and recurrence. We show that from 2018 to 2060, smoking prevalence will continue declining among those with current MD. In the absence of intervention, people with MD will be increasingly disproportionately affected by smoking compared to the general population; our model shows that the smoking prevalence ratio between those with current MD and those without a history of MD increases from 1.54 to 2.42 for men and from 1.81 to 2.73 for women during this time period. From 2018 to 2060, approximately 484,000 smoking-attributable deaths will occur among adults with current MD, leading to 11.3 million life-years lost. Ambitious tobacco control efforts could alter this trajectory. With aggressive public health efforts, up to 264,000 of those premature deaths could be avoided, translating into 7.5 million life years gained. This model can compare the relative health gains across different intervention strategies for smokers with MD.

IntEgrating Smoking Cessation treatment As part of usual Psychological care for dEpression and anxiety (ESCAPE): protocol for a randomised and controlled, multicentre, acceptability, feasibility and implementation trial

BACKGROUND

People with depression/anxiety are twice as likely to smoke and are less responsive to standard tobacco treatments, leading to a reduced life expectancy of up to  13.6 years compared to people without depression/anxiety. However, this group of smokers is motivated to quit, and as a result of quitting smoking, their depression/anxiety is likely to improve. In England, people with depression/anxiety are referred to a primary care-based psychological therapies service known as 'Improving Access to Psychological Therapies' (IAPT), which could offer smoking cessation treatment as part of usual care but currently does not. In this study, we aim (1) to establish the feasibility and acceptability of delivering a smoking cessation treatment alongside IAPT usual care and (2) to establish the feasibility of a multi-centre randomised trial to compare the combined smoking cessation and IAPT treatment to usual IAPT treatment alone.

METHODS

A randomised and controlled, multi-centre trial to test the acceptability, feasibility and implementation of smoking cessation treatment as offered alongside usual IAPT care, compared to usual care alone, with nested qualitative methods. We will include adult daily smokers with depression/anxiety, who would like help to quit smoking and are about to start IAPT treatment. Follow-up will be conducted at 3-months after baseline. The main outcome will be retention in the smoking cessation treatment. Secondary outcomes are smoking-related (biochemically-verified 7-day point prevalence smoking cessation, number of cigarettes smoked per day, Heaviness of Smoking Index), mental health-related (PHQ-9), service-related (number of 'Did Not Attends', number of planned and completed IAPT sessions), acceptability and feasibility (participant and clinician acceptability and satisfaction of intervention as assessed by questionnaires and qualitative interviews, interviews will also explore acceptability and feasibility of data collection procedures and impact of smoking cessation treatment on usual care and mental health recovery) and implementation-related (intervention delivery checklist, qualitative analysis of intervention delivery).

DISCUSSION

If the intervention is shown to be acceptable, feasible and suitably implemented, we can conduct a randomised controlled trial. In a future trial, we would examine whether adding smoking cessation treatment increases smoking abstinence and improves depression and anxiety more than usual care, which would lead to long-term health improvement.

TRIAL REGISTRATION

ISRCTN99531779.