Increased risk of suicidal ideation in smokers and former smokers compared to never smokers: evidence from the Baltimore ECA follow-up study

Disparities in the prevalence of suicidal ideation according to oral contraceptive pill use among US women: A cross-sectional study

Background and Aims

The relationship between oral contraceptive pill (OCP) and suicidal ideation remains unclear. This study aims to estimate the prevalence of suicidal ideation among US women and evaluate their associates overall and according to OCP use status.

Methods

Data from the National Health and Nutrition Examination Survey (NHANES) 2005-2012 were used to calculate the prevalence and associates of suicidal ideation in women using OCP. Suicidal ideation was assessed using the Patient Health Questionnaire-9. Overall and OCP-specific weighted prevalence of suicidal ideation were estimated. Multivariable logistic regressions were used to investigate overall and OCP-specific associates.

Results

The prevalence of suicidal ideation was 3.6% with no evident disparity between OCP groups, suggesting that OCP use is not associated with increased prevalence of suicidal ideation. Smoking was inversely associated with suicidal ideation in the former users of OCP. In the overall population, the prevalence of suicidal ideation was greater in those who were: Black or Hispanic, smoking, taking antidepressants, those with lower educational attainment, and women with low and middle income.

Conclusion

Our findings suggest that OCP use was not associated with increased prevalence of suicidal ideation. Unique associates were identified among different OCP groups.

Predicting suicide attempts among Norwegian adolescents without using suicide-related items: a machine learning approach

Introduction

Research on the classification models of suicide attempts has predominantly depended on the collection of sensitive data related to suicide. Gathering this type of information at the population level can be challenging, especially when it pertains to adolescents. We addressed two main objectives: (1) the feasibility of classifying adolescents at high risk of attempting suicide without relying on specific suicide-related survey items such as history of suicide attempts, suicide plan, or suicide ideation, and (2) identifying the most important predictors of suicide attempts among adolescents.

Methods

Nationwide survey data from 173,664 Norwegian adolescents (ages 13-18) were utilized to train a binary classification model, using 169 questionnaire items. The Extreme Gradient Boosting (XGBoost) algorithm was fine-tuned to classify adolescent suicide attempts, and the most important predictors were identified.

Results

XGBoost achieved a sensitivity of 77% with a specificity of 90%, and an AUC of 92.1% and an AUPRC of 47.1%. A coherent set of predictors in the domains of internalizing problems, substance use, interpersonal relationships, and victimization were pinpointed as the most important items related to recent suicide attempts.

Conclusion

This study underscores the potential of machine learning for screening adolescent suicide attempts on a population scale without requiring sensitive suicide-related survey items. Future research investigating the etiology of suicidal behavior may direct particular attention to internalizing problems, interpersonal relationships, victimization, and substance use.

Vaping and Sleep as Predictors of Adolescent Suicidality

PURPOSE

To investigate sleep quantity as a moderator of vaping and self-reported suicidality among adolescents.

DESIGN

Cross-sectional. Setting: United States high schools.

SAMPLE

10,520 high-school students with complete data on the primary outcome of suicide attempt in the past year (76.9% response rate).

MEASURES

2019 Youth Risk Behaviors Survey.

ANALYSIS

Logistic regression to examine main effects and potential moderation.

RESULTS

Students with under seven sleep hours on school nights (OR = 2.6; 95% CI = 2.1-3.3) and who vaped in the past month (OR = 3.0; 95% CI = 2.1-3.9) had higher odds of attempting suicide in the last year. Sleep quantity moderated the relationship between vaping and suicidal thoughts in the past year (P = .01) but did not moderate the relationship between vaping and a suicide plan (P = .15) or suicide attempts (P = .06). Specifically, vaping had a smaller effect on suicidal thoughts among students who slept under seven hours on school nights (OR = 1.8) compared to the descriptively larger effect among participants with more sleep (OR = 2.5).

CONCLUSIONS

Students who vape or report low sleep quantity would be ideal participants in suicide prevention interventions as they may be at higher risk for suicidality. Organizations implementing sleep or vaping interventions should incorporate information regarding the higher odds of suicide among students with low sleep quantity or vaping habits.

Vaping and Mental Health Conditions in Children: An Umbrella Review

The e-cigarette (EC) epidemic began in the United States (US) in 2007; since 2014 EC is the most commonly used form of tobacco. However, the mental health implications of vaping are grossly unknown. The aim of this umbrella review is to provide astate-of-the-art summary of existing research concerning vaping and mental health conditions in children. Following the PRISMA Statement 2020 guidelines, a systematic search was conducted across PubMed, Cochrane Library, and Google Scholar up to April 15th, 2022 to locate relevant studies. The Joana Briggs Institute (JBI) methodology for umbrella reviews and quality appraisal tool was utilized. Six studies, pooling a total of 846,510 adolescents aged 21 years or below, were included by collating 85 primary clinical studies. Of these, 58.8% of the primary clinical studies originated in the US, with 4.7% from Canada, South Korea, and the United Kingdom each; 3.5% each from England and Taiwan; 2.4% each from Australia, France, Hawaii, Mexico, and Russia; and 1.2% each from Denmark, Greece, Hong Kong, Iceland, New Zealand, Poland, and Switzerland. Overall, significant associations were found between mental health outcomes, including depression and suicidality, among current EC users and those who had ever used EC. Compared to adolescents who had never used EC, both depression and anxiety were reportedly higher among EC users. Impulsive behaviors, reported as impulsivity, were also found to be correlated with the adoption of EC use. However, there is a lack of evidence regarding the impact of EC use on mental health outcomes in children. This umbrella review highlights the urgent need to further explore the effects of current EC use from a psychiatric and public health perspective.

The relationship between causes of suicidal attempts in Iran and individual and social variables: a retrospective study

OBJECTIVE

Determine the prevalence of suicide attempts and the relationships between the different causes of attempts with sociodemographic and clinical characteristics among individuals in Iran.

METHODS

A retrospective review of data about suicide attempts from poisoning care centers in Babol city between 2017 and 2021. Multinomial regression analysis (with mental illness being the reference variable) was used to determine the factors associated with the different causes of suicide attempts (addiction, romantic relationship problems, and economic problems).

RESULTS

The overall prevalence of completed suicide in the population sampled was 10.8% (95% confidence interval 9.5-12.1) (244/2,263). Relative to mental disorder, given that other variables in the model are held constant the following were associated with suicide attempts. A previous history of suicide attempts was associated with increasing the relative risk ratio of attempting suicide while having no positive history of smoking was associated with reducing the relative risk ratio of a suicidal attempt. However, the use of multiple drugs to attempt suicide was associated with an increased relative risk ratio of attempting suicide with romantic relationship problems and addiction as causes of suicide attempts. The first year of data collection (2017) and the female gender were both associated with an increased relative risk ratio of having a suicide attempt due to romantic relationships and economic problems. A family history of suicide was associated with an increased relative risk ratio of suicide attempts due to romantic relationship problems. However, using Pesticides-aluminum phosphide and detergent and javel water to attempt reduced the relative risk ratio of attempting due to romantic relationship problems. Age, self-employment, middle income, and married were associated with an increased relative risk ratio of suicide attempts among individuals due to addiction. However, staying longer at the emergency department was associated with a reduced relative risk ratio of having had a suicide attempt due to addiction.

CONCLUSIONS

This study highlights the interplay between romantic hardships, addiction, economic hardships as reasons for suicide attempts and various sociable variables in a population in Northern Iran. The most associated reason for suicide attempts was romantic relationship hardships. Therefore, interventions such as sessions on conflict resolution, boundary setting, and management of grieving would greatly benefit this society and reduce the rate of suicide, especially among individuals with a history of suicide attempts.

Emotion dysregulation and hazardous drinking in relation to suicidal ideation among Spanish-speaking Latinx daily-smokers

OBJECTIVE

Suicidal ideation has increased among Latinx individuals in the last decade. Smoking increases the likelihood of suicidal ideation but work on Latinx smokers is minimal. Hazardous drinking and emotion dysregulation could be factors related to suicidal ideation among Latinx smokers, as has been evident in non-Latinx White samples. The current study sought to examine the main and interactive effects of emotion dysregulation and hazardous drinking in relation to suicidal ideation among Latinx daily-smokers.

METHODS

Participants were 371 Spanish-speaking daily-smokers (58.8% female; M_age = 33.3; SD_age = 9.8) recruited from the United States through Qualtrics. We used structural equation modeling (SEM) to test an interactive model of emotion dysregulation and hazardous alcohol consumption in relation to suicidal ideation; we also tested the effect of emotion dysregulation on suicidal ideation as a function of hazardous drinking status.

RESULTS

Results indicated that latent emotional dysregulation was associated with greater suicidal ideation (p < 0.001); however, hazardous drinking was not related to suicidal ideation (p = 0.186). The interactive term of emotional dysregulation and hazardous drinking was significantly related to suicidal ideation (p = 0.017). Specifically, greater emotion dysregulation was significantly related to suicidal ideation among Latinx smokers who engaged in hazardous drinking (p < 0.001) but not those who did not engage in hazardous drinking (p = 0.123).

CONCLUSIONS

The current findings suggest that smoking combined with hazardous drinking may be related to increased suicidal ideation among Latinx smokers. Findings are discussed in relation to the potential role of intervention strategies that focus on emotion dysregulation and hazardous drinking among Latinx current daily smokers to mitigate suicidal risk among this established health disparities population.

Smoking and suicidal ideation among college students: Smoking expectancies as potential moderators

Objective: In the present study, we sought to establish a link between suicidal ideation (SI) and smoking in college students, determine whether psychopathology accounted for the association, and determine whether smoking expectancies were moderators. Participants: Participants (N = 607) were identified as nonsmokers, exsmokers, infrequent smokers, or daily smokers. Methods: Participants were assessed for smoking patterns, smoking expectancies, psychopathology, SI, and past suicide attempts. Results: Daily smokers had the highest level of SI. There was a dose-response relationship between smoking and SI, such that the higher the daily smoking rate, the greater the SI, even when controlling for depression, alcohol use, and drug use. Trend-level results indicated that at lower smoking rates, elevated smoking-related negative affect reduction (NAR) expectancies were associated with lower SI, while elevated NAR expectancies in combination with higher smoking rates were associated with greater SI. Conclusion: Smoking cessation programs for college students should screen for SI.

Electronic cigarette use and suicidal behaviors among adolescents

BACKGROUND

The aim of this study was to investigate the association of the use of e-cigarettes, which are regarded as alternatives to traditional cigarettes and are easy to purchase, with suicidal behaviors in adolescents.

METHODS

Data for 5405 middle and high school students aged 13-18 years who had used e-cigarettes were extracted from the 2016 Korean Youth Risk Behavior Web-Based Survey and analyzed using multiple logistic regression.

RESULTS

Among those who used e-cigarettes for 1-30 days in the past 30 days, suicidal ideation (odds ratio [OR] = 1.58, 95% CI, 1.31-1.89), suicidal plans (OR = 2.44, 95% CI, 1.94-3.08), suicidal attempts (OR = 2.44, 95% CI, 1.85-3.22) and serious attempts (OR = 3.09, 95% CI, 1.51-6.32) were higher compared to those who did not use an e-cigarette in the past 30 days.

CONCLUSIONS

Suicidal behaviors are significantly higher among current adolescent e-cigarette smokers than adolescents who have not used an e-cigarette in the past 30 days. Therefore, comprehensive intervention is needed to protect adolescents' mental health.

Proposal for the Inclusion of Tobacco Use in Suicide Risk Scales: Results of a Meta-Analysis

There is an association between smoking and suicide, even though the direction and nature of this relationship remains controversial. This meta-analysis aimed to evaluate the association between smoking and suicidal behaviours (ideation, planning, suicide attempts, and death by suicide). On 24 August 2020, we searched the PubMed, Cochrane library, Scopus, Web of Science, TRIP, and SCIENCE DIRECT databases for relevant articles on this topic. Twenty prospective cohort studies involving 2,457,864 participants were included in this meta-analysis. Compared with never smokers, former and current smokers had an increased risk of death by suicide (relative risk [RR] = 1.31; 95% CI [1.13, 1.52] and RR = 2.41; 95% CI [2.08, 2.80], respectively), ideation (RR = 1.35; 95% CI [1.31, 1.39] and RR = 1.84; 95% CI [1.21, 2.78]), and attempted suicide (RR = 1.27; 95% CI [0.56, 2.87] and RR = 1.71; 95% CI [0.73, 3.97]). Moreover, compared to never smokers, current smoker women (RR = 2.51; 95% CI [2.06-3.04] had an increased risk of taking their own life (Q = 13,591.53; p < 0.001) than current smoker men (RR = 2.06; 95% CI [1.62-2.62]. Furthermore, smoking exposure (former and current smokers) was associated with a 1.74-fold increased risk (95% CI [1.54, 1.96]) of suicidal behaviour (death by suicide, ideation, planning, or attempts). Thus, because of the prospective relationship between smoking and suicidal behaviours, smoking should be included in suicide risk scales as a useful and easy item to evaluate suicide risk.

Assessing the Determinants of the Wish to Die among the Elderly Population in Ghana

Background: A wish to die is common in elderly people. Concerns about death wishes among the elderly have risen in Ghana, where the ageing transition is comparable to other low-and middle-income countries. However, nationally representative research on death wishes in the elderly in the country is not readily available. Our study aimed to assess the determinants of the wish to die among the elderly in Ghana. Methods: We analysed data from the World Health Organisation Global Ageing and Adult Health Survey, Wave 1 (2007–2008) for Ghana. Data on the wish to die, socio-demographic profiles, health factors and substance abuse were retrieved from 2147 respondents aged 65 and above. Ages of respondents were categorised as 65–74 years; 75–84 years; 85+ to reflect the main stages of ageing. Logistic regression models were fitted to assess the association between these factors and the wish to die. Results: Age, sex, place of residence, education, body mass index, hypertension, stroke, alcohol consumption, tobacco use, income, diabetes, visual impairment, hopelessness and depression had statistically significant associations with a wish to die. Older age cohorts (75–84 and 85+) were more likely to have the wish to die (AOR = 1.05, CI = 1.02–1.16; AOR = 1.48, CI = 1.22–1.94), compared to younger age cohorts (65–74 years). Persons who felt hopeless had higher odds (AOR = 2.15, CI = 2.11–2.20) of experiencing the wish to die as compared to those who were hopeful. Conclusions: In view of the relationship between socio-demographic (i.e., age, sex, education and employment), hopelessness, anthropometric (body mass index), other health factors and the wish to die among the elderly in Ghana, specific biopsychosocial health promotion programmes, including timely identification of persons at risk, for appropriate intervention (e.g., psychotherapy, interpersonal support, alcohol-tobacco cessation therapy, clinical help) to promote their wish for a longer life is needed.

Multiple imputation validation study: addressing unmeasured survey data in a longitudinal design

Background

Questionnaires used in longitudinal studies may have questions added or removed over time for numerous reasons. Data missing completely at a follow-up survey is a unique issue for longitudinal studies. While such excluded questions lack information at one follow-up survey, they are collected at other follow-up surveys, and covariances observed at other follow-up surveys may allow for the recovery of the missing data. This study utilized data from a large longitudinal cohort study to assess the efficiency and feasibility of using multiple imputation (MI) to recover this type of information.

Methods

Millennium Cohort Study participants completed the 9-item Patient Health Questionnaire (PHQ) depression module at 2 time points (2004, 2007). The suicidal ideation item in the module was set to missing for the 2007 assessment. Several single-level MI models using different sets of predictors and forms of suicidal ideation were used to compare self-reported values and imputed values for this item in 2007. Additionally, associations with sleep duration and smoking status, which are related constructs, were compared between self-reported and imputed values of suicidal ideation.

Results

Among 63,028 participants eligible for imputation analysis, 4.05% reported suicidal ideation on the 2007 survey. The imputation models successfully identified suicidal ideation, with a sensitivity ranging between 34 and 66% and a positive predictive value between 36 and 42%. Specificity remained above 96% and negative predictive value above 97% for all imputed models. Similar associations were found for all imputation models on related constructs, though the dichotomous suicidal ideation imputed from the model using only PHQ depression items yielded estimates that were closest with the self-reported associations for all adjusted analyses.

Conclusions

Although sensitivity and positive predictive value were relatively low, applying MI techniques allowed for inclusion of an otherwise missing variable. Additionally, correlations with related constructs were estimated near self-reported values. Therefore, the other 8 depression items can be used to estimate suicidal ideation that was completely missing from a survey using MI. However, these imputed values should not be used to estimate population prevalence.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12874-020-01158-w.

Insomnia Is Associated With Frequency of Suicidal Ideation Independent of Depression: A Replication and Extension of Findings From the National Health and Nutrition Examination Survey

OBJECTIVE

Insomnia is associated with suicidality, although the mechanisms of this association are unclear. This study sought to replicate previous findings showing that insomnia symptoms but not sleep duration are associated with frequency of suicidal ideation in adults. We further investigated whether depression or sleep duration moderates the association between insomnia symptoms and frequency of suicidal ideation.

MATERIALS AND METHODS

We used the 2005-2006 cycle of the National Health and Nutrition Examination Survey to replicate previously reported findings from the 2007-2008 cycle. We used ordered logistic regression to determine whether insomnia symptoms were associated with frequency of suicidal ideation independently of depression and other potential confounds. To extend these findings, we tested whether depression or sleep duration moderated the association between insomnia symptoms and frequency of suicidal ideation. We further replicated these findings in parallel analyses using the combined data from the 2005-2006 and 2007-2008 cycles.

RESULTS

This study replicated previous results showing that insomnia symptoms are associated with frequency of suicidal ideation in the NHANES 2005-2006 cycle (OR = 1.09, p < 0.05), even after adjusting for potentially confounding variables, including depression. Neither depression nor sleep duration moderated this association. Difficulty with sleep maintenance insomnia symptoms were most robustly associated with frequency of suicidal ideation (OR ≥ 1.97, p < 0.05). Sleep duration was not robustly associated with suicidal ideation.

CONCLUSIONS

In this study, we found that insomnia symptoms were uniquely associated with frequency of suicidal ideation. This association cannot be explained by the shared association with depression or sleep duration.

An examination of factors associated with tobacco smoking amongst patients presenting with deliberate self-poisoning

BACKGROUND

Understand factors related to related to tobacco smoking amongst individuals who present with deliberate self-harm is important. This article explores the relationship between tobacco use with mental health diagnoses and substance use in a cohort of overdose admissions.

METHODS

Secondary analysis of an existing health service database with 7133 patients admitted for deliberate self-poisonings from 1997 to 2013 was conducted. A data collection form was used on admission to capture information on patient demographics, drugs ingested, use of drugs of misuse, regular medications and management and complications of poisoning. The data was analysed using a multiple logistic regression model.

RESULTS

Within a deliberate self-poisoning population, those diagnosed with: an amphetamine substance use disorder (OR = 1.84, p < .001), alcohol use disorder (OR = 1.68, p < .001), other substance use disorder (OR = 1.77, p < .001), psychotic diagnoses (OR = 1.17, p = .032), or had a history of self-harm (OR = 1.15, p = .011) were more likely to be a current tobacco smoker. Those who were older (OR = 0.99, p < .001) or diagnosed with a mood disorder (OR = 0.87, p = .018) were less likely to smoke tobacco.

LIMITATIONS

The study was unable to differentiate between suicide attempts and self-harm self-poisonings.

CONCLUSIONS

Among a deliberate self-poisoning population those who were younger, diagnosed with a variety of substance use disorders, or had a history of previous self-poisoning were more likely to use tobacco. Those with a mood disorder were less likely to smoke tobacco.

Current advances in research in treatment and recovery: Nicotine addiction

The health harms of combusted tobacco use are undeniable. With market and regulatory pressures to reduce the harms of nicotine delivery by combustion, the tobacco product landscape has diversified to include smokeless, heated, and electronic nicotine vaping products. Products of tobacco combustion are the main cause of smoking-induced disease, and nicotine addiction sustains tobacco use. An understanding of the biology and clinical features of nicotine addiction and the conditioning of behavior that occurs via stimuli paired with frequent nicotine dosing, as with a smoked cigarette, is important for informing pharmacologic and behavioral treatment targets. We review current advances in research on nicotine addiction treatment and recovery, with a focus on conventional combustible cigarette use. Our review covers evidence-based methods to treat smoking in adults and policy approaches to prevent nicotine product initiation in youth. In closing, we discuss emerging areas of evidence and consider new directions for advancing the field.

The Relationship Between Smoking and Suicidal Behavior in Psychiatric Patients with Major Depressive Disorder

Smoking is frequently associated with suicidal behavior, but also with confounding other risk factors. We investigated whether smoking independently predicts suicidal ideation, attempts (SAs), or modifies risk of SAs during major depressive episodes (MDEs). In the Vantaa Depression Study (VDS), a 5-year prospective study of psychiatric patients (N = 269) with major depressive disorder (MDD), we investigated the association of suicidal ideation and smoking, and smoking as an independent risk factor for SAs in 2-level analyses of risk during MDEs. Smoking was not significantly associated with suicidal ideation, nor SAs after controlling for confounding factors, and no evidence of a significant effect during MDEs was found. Smoking was neither significantly associated with suicidal ideation, nor predicted suicide attempts.

Nicotine Dependence and Pre-Enlistment Suicidal Behavior Among U.S. Army Soldiers

INTRODUCTION

Identification of modifiable risk factors for suicidal behaviors is a priority for the U.S. Army. This study investigated associations of nicotine dependence with suicidal behaviors among incoming soldiers.

METHODS

Lifetime DSM-IV nicotine dependence, mental disorders, suicidal behaviors, and their ages of onset were retrospectively assessed in the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) New Soldier Study. Discrete-time survival analysis of person-year data from 30,436 soldiers was performed to evaluate associations of nicotine dependence with subsequent suicidal ideation, plans, and attempts. Among respondents with lifetime ideation (n=4,060), models tested associations of nicotine dependence with progression from ideation to first onset of plan, from plan to first attempt, and, among ideators without plans, from ideation to first unplanned attempt. A hierarchy of models incorporated increasing controls for other risk factors. Data were collected in 2011-2012 and analyzed in 2017-2018.

RESULTS

In models controlling for sociodemographic characteristics, nicotine dependence was associated with onset of all suicidal behaviors (AORs, 2.07-4.08, p<0.001) and with each type of progression of suicidal behavior (AORs, 1.48-2.44, p<0.005). After adjusting for childhood adversities and mental disorders, nicotine dependence remained associated with onset of ideation (AOR=1.27, 95% CI=1.10, 1.46, p=0.001) and attempt (AOR=1.83, 95% CI=1.41, 2.37, p<0.001); and with progression from ideation to unplanned attempt (AOR=2.03, 95% CI=1.17, 1.74, p<0.001).

CONCLUSIONS

Nicotine dependence exhibited associations with onset of suicidal ideation and suicide attempt-and with progression from ideation to unplanned attempt-that were independent of other measured risk factors. Awareness of associations of nicotine dependence with suicidal behaviors may inform risk assessment, facilitate targeting of prevention efforts, and provide further impetus for reducing nicotine dependence.

Innovative approaches to support smoking cessation for individuals with mental illness and co-occurring substance use disorders

INTRODUCTION

Tobacco remains the leading preventable cause of death in the US, accounting for over 520,000 deaths annually. While the smoking prevalence has declined over the past 50 years, those with mental illness and addictive disorders continue to smoke at high levels and with significant tobacco-related health problems. Areas covered: This review highlights the epidemiology, contributing factors, and evidence-base for intervening upon tobacco use in those with mental illness and addictive disorders. Historically underprioritized, a growing body of literature supports treating tobacco within mental health and addiction treatment settings. Critically, treating tobacco use appears to support, and not harm, mental health recovery and sobriety. This review also summarizes novel, emerging approaches to mitigate the harms of cigarette smoking. Expert commentary: People with mental illness and addictive disorders have a high prevalence of tobacco use with serious health harms. Treating tobacco use is essential. Evidence-based strategies include individual treatments that are stage-matched to readiness to quit and combine cessation medications with behavioral therapies, supported by smoke-free policies in treatment settings and residential environments. Emerging approaches, with a focus on harm reduction, are electronic nicotine delivery systems and tobacco regulatory efforts to reduce the nicotine content in cigarettes, thereby reducing their addiction potential.

Smoking, Mental Illness, and Public Health

Tobacco use remains the leading preventable cause of death worldwide. In particular, people with mental illness are disproportionately affected with high smoking prevalence; they account for more than 200,000 of the 520,000 tobacco-attributable deaths in the United States annually and die on average 25 years prematurely. Our review aims to provide an update on smoking in the mentally ill. We review the determinants of tobacco use among smokers with mental illness, presented with regard to the public health HAVE framework of “the host” (e.g., tobacco user characteristics), the “agent” (e.g., nicotine product characteristics), the “vector” (e.g., tobacco industry), and the “environment” (e.g., smoking policies). Furthermore, we identify the significant health harms incurred and opportunities for prevention and intervention within a health care systems and larger health policy perspective. A comprehensive effort is warranted to achieve equity toward the 2025 Healthy People goal of reducing US adult tobacco use to 12%, with attention to all subgroups, including smokers with mental illness.

Smoking and Suicide: A Meta-Analysis

BACKGROUND

Many studies have reported a positive association between smoking and suicide, but the results are inconsistent. This meta-analysis was carried out to estimate the association between smoking and suicidal ideation, suicide plan, suicide attempt, and suicide death.

METHODS

Major electronic databases including PubMed, Web of Science, Scopus, and ScienceDirect were searched until May 2015. The reference lists of included studies were screened too. Epidemiological studies addressing the association between smoking and suicidal behaviors were enrolled. The heterogeneity across studies was explored by Q-test and I2 statistic. The possibility of publication bias was assessed using Begg's and Egger's tests and Trim & Fill analysis. The results were reported based on risk ratio (RR) and odds ratio (OR) with 95% confidence intervals (CI) using a random-effects model.

RESULTS

We identified a total of 8062 references and included 63 studies with 8,063,634 participants. Compared to nonsmokers, the current smokers were at higher risk of suicidal ideation (OR = 2.05; 95% CI: 1.53, 2.58; 8 studies; I2 = 80.8%; P<0.001), suicide plan (OR = 2.36; 95% CI: 1.69, 3.02; 6 studies; I2 = 85.2%; P<0.001), suicide attempt (OR = 2.84; 95% CI: 1.49, 4.19; 5 studies; I2 = 89.6%; (P<0.001), and suicide death (RR = 1.83; 95% CI: 1.64, 2.02; 14 studies; I2 = 49.7%; P = 0.018).

CONCLUSIONS

There is sufficient evidence that smoking is associated with an increased risk of suicidal behaviors. Therefore, smoking is a contributing factor for suicide. Although this association does not imply causation, however, smoking prevention and cessation should be the target of suicide prevention programs.

Gender Differences in Relations of Smoking Status, Depression, and Suicidality in Korea: Findings from the Korea National Health and Nutrition Examination Survey 2008-2012

OBJECTIVE

As mental health problems may play an important role in initiating and maintaining cigarette smoking in females and there are an increasing number of female smokers, we evaluated the relationship between smoking status and mental health problems including depression and suicide ideation in women in Korea.

METHODS

We analyzed the 5-year cumulative data (19 years of age or older, n=32,184) from the Korean National Health and Nutrition Examination Survey (KNHANES) conducted from 2008 to 2012. Logistic regression analyses were used to evaluate associations between cigarette smoking status and mental health parameters while controlling for potentially confounding variables.

RESULTS

Among current smokers, females showed higher lifetime prevalence in having a depressive episode, a doctor-diagnosed major depression, a current diagnosis of depression, or receiving treatment for depression in comparison with males. In addition, females were more likely to report on having a depressive episode, suicidal ideation and attempts, and psychiatric counselling within the previous year, as compared to males. Female former smokers showed intermediate characteristics in parameters of mental health status within the previous year, ranking between lifetime non-smokers and the current smokers.

CONCLUSION

Identifying the factors related to mental health status among current smokers can increase opportunities for an early intervention and help reduce the prevalence of smoking and increase smoking cessation rates particularly in females. Developing adaptive coping strategies other than smoking in female youth is potentially important in reducing the initiation of smoking.

Why young people's substance use matters for global health

During puberty, when young people are completing their education, transitioning into employment, and forming longer-term intimate relationships, a shift in emotional regulation and an increase in risky behaviour, including substance use, is seen. This Series paper considers the potential effects of alcohol, tobacco, and illicit drug use during this period on: social, psychological, and health outcomes in adolescence and young adulthood; role transitions, and later health and social outcomes of regular substance use initiated in adolescence; and the offspring of young people who use substances. We sourced consistent support for causal relations between substance use and outcomes and evidence of biological plausibility from different but complementary research designs. Many adverse health and social outcomes have been associated with different types of substance use. The major challenge lies in deciding which are causal. Furthermore, qualitatively different harms are associated with different substances, differences in life stage when these harms occur, and the quality of evidence for different substances and health outcomes varies substantially. The preponderance of evidence comes from a few high-income countries, thus whether the same social and health outcomes would occur in other countries and cultures is unclear. Nonetheless, the number of harms that are causally related to substance use in young people warrant high-quality research design interventions to prevent or ameliorate these harms.

Anxiety and its disorders as risk factors for suicidal thoughts and behaviors: A meta-analytic review

Suicidal thoughts and behaviors are highly prevalent public health problems with devastating consequences. There is an urgent need to improve our understanding of risk factors for suicide to identify effective intervention targets. The aim of this meta-analysis was to examine the magnitude and clinical utility of anxiety and its disorders as risk factors for suicide ideation, attempts, and deaths. We conducted a literature search through December 2014; of the 65 articles meeting our inclusion criteria, we extracted 180 cases in which an anxiety-specific variable was used to longitudinally predict a suicide-related outcome. Results indicated that anxiety is a statistically significant, yet weak, predictor of suicide ideation (OR=1.49, 95% CI: 1.18, 1.88) and attempts (OR=1.64, 95% CI: 1.47, 1.83), but not deaths (OR=1.01, 95% CI: 0.87, 1.18). The strongest associations were observed for PTSD. Estimates were reduced after accounting for publication bias, and diagnostic accuracy analyses indicated acceptable specificity but poor sensitivity. Overall, the extant literature suggests that anxiety and its disorders, at least when these constructs are measured in isolation and as trait-like constructs, are relatively weak predictors of suicidal thoughts and behaviors over long follow-up periods. Implications for future research priorities are discussed.

Tobacco use and suicide attempt: longitudinal analysis with retrospective reports

Background

Suicide has been associated with smoking/tobacco use but its association of and change in smoking/tobacco use status with suicide attempt (SA) is not well established.

Methods

We investigated whether persistent, former tobacco use, initiation, quitting tobacco use, relapse to tobacco use, and DSM-IV nicotine dependence predict independently SA using Wave 1 and 2 data of the National Epidemiologic Survey of Alcohol and Related Conditions. Data from 34,653 US adults interviewed at Wave 1 (2001-02) and Wave 2 (2004-05) were analyzed. The main outcome measure was SA between Wave 1 and Wave 2 as reported at Wave 2.

Results

Among the 1,673 respondents reporting lifetime SA at Wave 2, 328 individuals reported SA between Wave 1 and Wave 2. Current and former tobacco use at Wave 1 predicted Wave 2 SA independently of socio-demographic characteristics, psychiatric history, and prior SA (Adjusted Odds Ratio (AOR): 1.49; 95% CI: 1.13-1.95, AOR: 1.31; 95% CI:1.01-1.69, respectively versus never tobacco users). The strongest association with SA was observed among former tobacco users who relapsed after Wave 1 (AOR: 4.66; 95% CI: 3.49-6.24) and among tobacco use initiators after Wave 1 (AOR: 3.16; 95% CI: 2.23-4.49). Persistent tobacco use (current tobacco use at both Wave 1 and Wave 2) also had an increased risk of SA (AOR: 1.89; 95% CI: 1.47-2.42). However, former tobacco users in both Waves 1 and 2 did not show a significantly elevated risk for SA in Wave 2 (AOR:1.09, 95% CI: 0.78-1.52) suggesting that the risk resided mainly in Wave 1 former tobacco users who relapsed to tobacco use by Wave 2. DSM-IV nicotine dependence did not predict SA at Wave 2.

Conclusion

In a representative sample of US adults, relapse, tobacco use initiation, and persistent tobacco use, which are amenable to intervention, were associated with risk of SA.

The meaning of smoking for patients with mental disorder

When patients smoke cigarettes in psychiatric services, it brings to the forefront current ethical and political dilemmas. This study aims to explore the meaning attributed to smoking by mental health patients who smoke and who are hospitalized in a psychiatric ward of a general hospital. This qualitative descriptive study was conducted with 96 smokers who were hospitalized in a psychiatric ward in Brazil. Semi-structured interviews, test of nicotine dependence, and content thematic analysis were carried out. The results show that tobacco has an important role in the lives of psychiatric patients. The meanings they attribute to tobacco use are related to overcoming difficulties that are consequential of mental disorders and of side effects caused by their treatments.

Prevalence and correlates of smoking status among veterans affairs primary care patients with probable major depressive disorder

In an attempt to guide planning and optimize outcomes for population-specific smoking cessation efforts, the present study examined smoking prevalence and the demographic, clinical and psychosocial characteristics associated with smoking among a sample of Veterans Affairs primary care patients with probable major depression. Survey data were collected between 2003 and 2004 from 761 patients with probable major depression who attended one of 10 geographically dispersed VA primary care clinics. Current smoking prevalence was 39.8%. Relative to nonsmokers with probable major depression, bivariate comparisons revealed that current smokers had higher depression severity, drank more heavily, and were more likely to have comorbid PTSD. Smokers with probable major depression were also more likely than nonsmokers with probable major depression to have missed a health care appointment and to have missed medication doses in the previous 5months. Smokers were more amenable than non-smokers to depression treatment and diagnosis, and they reported more frequent visits to a mental health specialist and less social support. Alcohol abuse and low levels of social support were significant concurrent predictors of smoking status in controlled multivariable logistic regression. In conclusion, smoking prevalence was high among primary care patients with probable major depression, and these smokers reported a range of psychiatric and psychosocial characteristics with potential to complicate systems-level smoking cessation interventions.

Pathological Internet use among European adolescents: psychopathology and self-destructive behaviours

Rising global rates of pathological Internet use (PIU) and related psychological impairments have gained considerable attention in recent years. In an effort to acquire evidence-based knowledge of this relationship, the main objective of this study was to investigate the association between PIU, psychopathology and self-destructive behaviours among school-based adolescents in eleven European countries. This cross-sectional study was implemented within the framework of the European Union project: Saving and Empowering Young Lives in Europe. A representative sample of 11,356 school-based adolescents (M/F: 4,856/6,500; mean age: 14.9) was included in the analyses. PIU was assessed using the Young's Diagnostic Questionnaire. Psychopathology was measured using the Beck Depression Inventory-II, Zung Self-Rating Anxiety Scale and Strengths and Difficulties Questionnaire. Self-destructive behaviours were evaluated by the Deliberate Self-Harm Inventory and Paykel Suicide Scale. Results showed that suicidal behaviours (suicidal ideation and suicide attempts), depression, anxiety, conduct problems and hyperactivity/inattention were significant and independent predictors of PIU. The correlation between PIU, conduct problems and hyperactivity/inattention was stronger among females, while the link between PIU and symptoms of depression, anxiety and peer relationship problems was stronger among males. The association between PIU, psychopathology and self-destructive behaviours was stronger in countries with a higher prevalence of PIU and suicide rates. These findings ascertain that psychopathology and suicidal behaviours are strongly related to PIU. This association is significantly influenced by gender and country suggesting socio-cultural influences. At the clinical and public health levels, targeting PIU among adolescents in the early stages could potentially lead to improvements of psychological well-being and a reduction of suicidal behaviours.

Tobacco use disorder and the risk of suicide mortality

BACKGROUND AND AIMS

Tobacco use may be a risk factor for suicide mortality; however, prior research has produced equivocal findings and has been limited by relatively small sample sizes to study the rare event of suicide, as well as a lack of adjustment for other important factors, including psychiatric illness. We estimate the predictive association between tobacco use disorder and the risk of suicide mortality, adjusting for other important variables.

DESIGN

A prospective cohort study.

SETTING

The United States Veterans Health Administration (VHA).

PARTICIPANTS

All individuals who received VHA services in fiscal year (FY) 2005 and were alive at the start of FY 2006 (n = 4 863 086).

MEASUREMENTS

Tobacco use disorder was assessed via FYs 2004-05 VHA National Patient Care Database records. The outcome of suicide mortality was assessed during the follow-up interval from the beginning of FY 2006 to the end of FY 2008 using National Death Index records.

FINDINGS

Of the 4 863 086 individuals in the study, 4823 died by suicide during the follow-up interval. In the unadjusted model, tobacco use disorder was associated with an increased risk of suicide [hazard ratio (HR) = 1.88; 95% confidence interval (CI) = 1.76, 2.02]. After adjustment for model covariates, the association remained statistically significant, although attenuated (HR = 1.36, 95% CI = 1.27, 1.46).

CONCLUSIONS

Tobacco use disorder may confer a modest excess risk of death by suicide. Psychiatric disorders may partially explain the relationship between tobacco use disorder and suicide.

Smoking and suicidality in subjects with bipolar disorder: results from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC)

BACKGROUND

Smoking in patients with bipolar disorder is known to be related to suicidality. This link has not been investigated, however, in community-based samples. The aim of this study is to delineate the sociodemographic and clinical characteristics of bipolar smokers and examine the relationship between these characteristics and suicidal ideation or attempts in an epidemiologic database, the National Epidemiological Survey on Alcohol and Related Conditions (NESARC).

METHODS

Subjects (n = 1,643) with bipolar disorder I and II, defined by the DSM-IV criteria, who had a history of low moods lasting more than 2 weeks were included in our analysis. Current smokers, former smokers, and lifetime nonsmokers were compared in terms of demographic, clinical characteristics, and functional level. Suicidality, evaluated by a history of suicide ideation and attempts while in low mood were compared.

RESULTS

Current smokers with bipolar disorder showed a greater number of DSM-IV symptoms while in acute episodes, higher rate of alcohol, and drug use disorders, as well as poorer functional levels than nonsmokers. Previous smokers displayed intermediate characteristics between current smokers and nonsmokers. The logistic regression analysis revealed that current smoking status predicted the risk of having a history of attempted suicide (Odds ratio 1.35, 95% CI: 1.05-1.76) after adjusting for age, sex, race, bipolar subtype, lifetime axis II/anxiety/alcohol use/substance use disorder; however, lifetime smoking status did not.

CONCLUSIONS

The present study confirms that current cigarette smoking can predict attempted suicide in a community representative sample of people with bipolar disorder.

Smoking and suicidality in subjects with major depressive disorder: results from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC)

BACKGROUND

Detailed characteristics of depressive smokers and its association with suicidality were still less investigated. The aim of this study was to delineate characteristics of smokers with major depressive disorder (MDD) and examine the relationship between these characteristics and suicidality using an epidemiologic database, the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC).

METHODS

A total of 5695 subjects with MDD, defined by the DSM-IV criteria, were included in our analysis. Current smokers, former smokers, and lifetime nonsmokers were compared in terms of demographic, clinical characteristics, and functional level. Suicidality, evaluated by history of suicide ideation and attempts while in a low mood was evaluated and compared among the groups.

RESULTS

Current smokers with MDD showed a greater number of DSM-IV symptoms while in acute episodes, a higher rate of alcohol and drug-use disorders, and poorer functional levels than nonsmokers. Previous smokers displayed intermediate characteristics between current smokers and nonsmokers. The logistic regression analysis revealed that both current and former smoking status predicted the risk of having a history of attempted suicide (current smokers: odds ratio 1.62, 95% C.I. 1.42-1.86; former smokers: odds ratio 1.37, 95% C.I. 1.13-1.66) after adjusting for demographic data, a history of subthreshold hypomania, and a lifetime axis II/anxiety/alcohol use/substance-use disorder.

LIMITATIONS

Retrospective, cross-sectional evaluation; suicidality assessed only in the most severe depressive episode.

CONCLUSIONS

The present study corroborates that smokers with MDD showed distinct clinical characteristics, and cigarette smoking can predict attempted suicide in a community representative sample of people with MDD.

Factors associated with current smoking and heavy alcohol consumption among women of reproductive age: the Fourth Korean National Health and Nutrition Examination Survey 2007-2009

OBJECTIVE

To identify factors associated with smoking and heavy alcohol consumption among women of reproductive age.

STUDY DESIGN

Cross-sectional study.

METHODS

Data from 5031 women aged 20-49 years who participated in the Fourth Korean National Health and Nutrition Examination Survey 2007-2009 were analysed. Variables were classified as sociodemographic factors, psychological factors, gynaecological factors and chronic conditions. Factors that influence high-risk behaviours associated with adverse pregnancy outcomes were identified using multiple logistic regression analysis.

RESULTS

Among women of reproductive age, prevalence rates of smoking, heavy alcohol consumption and both were 7.3%, 21.4% and 4.3%, respectively. Among the sociodemographic factors, young age, a lower level of education and unmarried status were more likely to be associated with high-risk behaviours such as smoking, heavy alcohol consumption and both. Psychological factors such as stress intensity and suicidal ideation were also significantly associated with all the above-mentioned high-risk behaviours. In addition, an association was found between high-risk behaviours and oral contraceptive use.

CONCLUSIONS

Identifying the factors associated with high-risk behaviours may help in the design of interventions to decrease the prevalence of smoking and heavy alcohol consumption. Population-level reduction of these high-risk behaviours among women of reproductive age may improve pregnancy outcomes and also decrease the prevalence of chronic diseases, including cancer, in the long term.

Suicidal ideation among Métis adult men and women--associated risk and protective factors: findings from a nationally representative survey

Objective

To determine the prevalence of suicidal ideation among Métis men and women (20–59 years) and identify its associated risk and protective factors using data from the nationally representative Aboriginal Peoples Survey (2006).

Study design

Secondary analysis of previously collected data from a nationally representative cross-sectional survey.

Results

Across Canada, lifetime suicidal ideation was reported by an estimated 13.3% (or an estimated 34,517 individuals) of the total population of 20-to-59-year-old Métis. Of those who ideated, 46.2% reported a lifetime suicide attempt and 6.0% indicated that they had attempted suicide in the previous 12 months. Prevalence of suicidal ideation was higher among Métis men than in men who did not report Aboriginal identity in examined jurisdictions. Métis women were more likely to report suicidal ideation compared with Métis men (14.9% vs. 11.5%, respectively). Métis women and men had some common associated risk and protective factors such as major depressive episode, history of self-injury, perceived Aboriginal-specific community issues, divorced status, high mobility, self-rated thriving health, high self-esteem and positive coping ability. However, in Métis women alone, heavy frequent drinking, history of foster care experience and lower levels of social support were significant associated risk factors of suicidal ideation. Furthermore, a significant interaction was observed between social support and major depressive episode. Among Métis men, history of ever smoking was the sole unique associated risk factor.

Conclusion

The higher prevalence of suicidal ideation among Métis women compared with Métis men and the observed gender differences in associations with some associated risk and protective factors suggest the need for gender-responsive programming to address suicidal ideation.

Genetics of smoking and depression

Smoking and depression are significant public health problems with multiple etiological dimensions and outcomes. Although each condition is important by itself, they are important because they often potentiate each other. Consequently, it is also essential to understand the nature their relationship. This representative review focuses on the genetic etiology of the relationship in the context of reviewing first the epidemiology of depression and smoking, and then by exploring behavioral and molecular genetic studies, and other psychiatric and medical comorbidities. At this point, epidemiological evidence for a relationship between depression and smoking/nicotine dependence is compelling. Although behavioral genetic results differ somewhat by gender and in accordance with specific definitions of depression and smoking variables, recent studies show converging evidence for common genetic factors underlying the relationship, often in addition to non-shared environmental factors. The search for underlying genes and genetic mechanisms is at an early stage, but shows promising candidate genes and genetic approaches for future studies.

Daily marijuana use and suicidality: the unique impact of social anxiety

Despite a clear relationship between marijuana use and suicidality, little is known about psychological vulnerability factors that may interact with marijuana use to increase suicidality among this high-risk group. The present study examined the moderational impact of social anxiety on the relationship between marijuana use status (current users vs abstainers) and suicidality among 343 community adults. We also examined whether social anxiety moderated the relation between more frequent use (daily vs less frequent) among the 134 current marijuana users. Although social anxiety did not moderate the relation between use status and suicidality, it did moderate the relation between daily use status and suicidality after controlling for a wide range of relevant variables (e.g., demographics, depression, negative affect, and other types of anxiety). The overall model accounted for 59% of the variance in suicidality such that daily marijuana users with elevated social anxiety reported the highest suicidality. Findings highlight the importance of considering social anxiety in efforts to understand and prevent suicidality among this high-risk population.

Smoking and suicidal behaviours in a sample of US adults with low mood: a retrospective analysis of longitudinal data

OBJECTIVE

To investigate whether: (1) smoking predicts suicide-related outcomes (SROs), (2) prior SRO predicts smoking, (3) smoking abstinence affects the risk of SRO and (4) psychiatric comorbidity modifies the relationship between smoking and SRO.

DESIGN

Retrospective analysis of longitudinal data obtained in wave 1 (2001-2002) and wave 2 (2004-2005) of the National Epidemiologic Survey on Alcohol and Related Conditions.

SETTING

Face-to-face interviews conducted with persons in the community.

PARTICIPANTS

US adults (N=43 093) aged 18 years or older were interviewed in wave 1 and reinterviewed (N=34 653) 3 years later. For the present study, the sample was the subset of persons (N=7352) who at the wave 2 interview reported low mood lasting 2 weeks or more during the past 3 years and were further queried regarding SRO occurring between waves 1 and 2.

OUTCOME MEASURES

SRO composed of any of the following: (1) want to die, (2) suicidal ideation, (3) suicide attempt, reported at wave 2. Current smoking reported at wave 2.

RESULTS

Current and former smoking in wave 1 predicted increased risk for wave 2 SRO independently of prior SRO, psychiatric history and socio-demographic characteristics measured in wave 1 (adjusted OR (AOR)=1.41, 95% CI 1.28 to 1.55 for current smoking; AOR=1.32, 95% CI 1.21 to 1.43 for former smoking). Prior SRO did not predict current smoking in wave 2. Compared with persistent never-smokers, risk for future SRO was highest among relapsers (AOR=3.42, 95% CI 2.85 to 4.11), next highest among smoking beginners at wave 2 (AOR=1.82, 95% CI 1.51 to 2.19) and lowest among long-term (4+ years) former smokers (AOR=1.22, 95% CI 1.12 to 1.34). Compared with persistent current smokers, risk for SRO was lower among long-term abstainers (p<0.0001) but not among shorter-term abstainers (p=0.26).

CONCLUSIONS

Smoking increased the risk of future SRO independently of psychiatric comorbidity. Abstinence of several years duration reduced that risk.

Suicidal behavior, smoking, and familial vulnerability

INTRODUCTION

Smoking is a well-established correlate of suicidal behavior. It is not known if familial risk factors contribute to this association.

METHODS

Data were obtained via semistructured interviews with 1,107 twin fathers, 1,919 offspring between ages 12-32 years, and 1,023 mothers. Familial vulnerability to nicotine dependence and suicidal behavior was modeled via father and maternal self-report of these behaviors. Multinomial logistic regression models were computed with and without familial risk factors to estimate the association between offspring ever smoking, regular smoking, nicotine dependence, and a 4-level offspring suicide variable: (a) none, (b) ideation, (c) ideation + plan, and (d) ideation + plan + attempt or ideation + attempt. All models were stratified by gender and adjusted for sociodemographics, familial risk factors including parental suicidal behavior, nicotine dependence, and conduct disorder, and offspring conduct disorder, depression, alcohol abuse/dependence, and illicit drug abuse/dependence.

RESULTS

After adjusting for covariates and familial risk factors, ever smoking was not significantly associated with suicidal behavior in males and females. In males, regular smoking was associated with ideation + plan (odds ratio [OR] = 5.47; 95% CI: 1.05-28.60), and in females, regular smoking was associated with ideation + plan + attempt or ideation + attempt. In both genders, nicotine-dependent smoking was associated with ideation + plan + attempt or ideation + attempt (males: OR = 6.59; 95% CI: 1.91-22.70, females: OR = 3.37; 95% CI: 1.25-9.04). Comparison of models with and without familial risk factors indicated that there is no mediation of smoking status and suicidal behavior by familial risk.

CONCLUSIONS

Smoking and nicotine dependence are correlated with suicidal behaviour. Contributions from familial risk factors did not significantly alter this association.

Over-the-counter nicotine replacement therapy for everyone: is it the best solution?

The persistent use of different forms of nicotine replacement therapy (NRT) is an under-investigated issue in medical research. While the data concerning the proportion of long-term users in the population of total NRT users seems reassuring at first glance, we must recognize that the small relative numbers (proportions) conceal a population of persistent NRT users with a considerable absolute number of members. Furthermore, only a small amount of data is available concerning the safety of persistent NRT use. At the present time we therefore have no basis for declaring that the population of long-term users are under cover (we are only able to state that persistent use of NRT is undoubtedly safer than the continuation of smoking). Consequently, there is a need to conduct large-scale studies with the primary aim of monitoring for misuse of OTC NRT and assessing the possible physical and mental health risks of persistent NRT use.

Varenicline for tobacco dependence: panacea or plight?

INTRODUCTION

This review examines the postmarketing experience with varenicline, including case reports, newer clinical trials and secondary analyses of large clinical datasets.

AREAS COVERED

Varenicline has been shown to be an effective treatment in a broad range of tobacco users with medical, behavioral and diverse demographic characteristics. Recent studies finding excellent safety and efficacy in groups of smokers with diseases including chronic obstructive pulmonary disease are particularly encouraging and call for increased use of this medication for smoking cessation. Despite case reports of serious neuropsychiatric symptoms in patients taking varenicline, including changes in behavior and mood, causality has not been established. Recent analyses of large datasets from clinical trials have not demonstrated that varenicline is associated with more depression or suicidality than other treatments for smoking cessation.

EXPERT OPINION

Now that additional clinical trials in specific populations and observational studies on treatment-seeking smokers outside of clinical trials have been published, we can be confident that varenicline remains the most efficacious monotherapy for smoking cessation and that its side-effect profile remains good. The risk-to-benefit ratio of receiving varenicline to quit smoking must include the increased chances of quitting smoking and avoiding the sizeable risks of smoked-caused disease and death that remain if tobacco addiction is not properly treated.

Substance use and suicide

PURPOSE OF REVIEW

To address gaps identified in earlier reviews, namely, the comparative influence of substance use on attempted suicide and completed suicide; the proximal role of substance use as a trigger of suicidal behaviour; the association between substances and suicidal behaviour; suicide and substance use disorders in youth; and the influence of combinations of risk factors, including psychiatric morbidity, on suicide.

RECENT FINDINGS

The presence of an alcohol use disorder is confirmed as a distal risk factor for completed suicide, as well as attempted suicide. Alcohol use at the time of the suicide attempt is associated with low-risk methods. The use of other substances as a trigger of suicidal behaviour is highlighted in recent studies, but the circumstances leading to the suicidal act and the direct influence of substances in suicidal behaviour need to be explored further. Inhalant use and cocaine use are particularly associated with suicidal behaviour. Young people with multiple risk behaviours, such as substance use and risky sexual behaviours, are at high risk for suicidal behaviour. Psychiatric comorbidity with substance use escalates the risk for suicidal behaviour. Environmental interventions, such as reduction in the number of bars, may be helpful in reducing alcohol-related morbidity, including suicides.

SUMMARY

Prevention strategies for reducing suicidal behaviour among substance users need to be prioritized at the individual and the national level through effective design, policy and implementation.