Cigarette smoking among psychiatric patients in Brazil Tabagismo entre pacientes psiquiátricos no Brasil Tabaquismo entre los pacientes psiquiátricos en Brasil

The aim of this study was to estimate tobacco smoking prevalence among psychiatric patients attended in care facilities in Brazil and assess associated factors. A cross-sectional multicenter study was conducted of psychiatric patients (N = 2,475) selected from 26 care facilities. Current and ex-smokers were compared to those who had never smoked. Odds ratios were estimated using logistic regression. The current and past smoking prevalence rates were 52.7% and 18.9%, respectively. Being male, aged 40 years or over, drug and alcohol use, unprotected sex and a history of physical violence were factors associated with both current and past smoking, while a low education level (≤ 8 years of schooling), history of homelessness, not practicing a religion, current or previous psychiatric hospitalization, and main psychiatric diagnosis substance use disorders, were factors only associated with current smoking. Tobacco smoking prevalence among this population was high and was higher than the rate in the general population. Appropriate interventions and smoking prevention policies should be incorporated into mental health services. Smoking; Mental Health; Risk Factors Resumo O objetivo do estudo foi estimar a prevalência e os fatores associados com o tabagismo entre pacientes psiquiátricos no Brasil. Estudo multicêntrico de corte transversal foi conduzido com 2.475 pacientes com transtorno mental, selecionados de 26 serviços. Fumantes e ex-fumantes foram comparados com aqueles que nunca fumaram. Odds ratios foram estimados por meio de regressão logística. As prevalências de fumantes e ex-fumantes foram 52,7% e 18,9%, respectivamente. Sexo masculino, idade 40+ anos, uso de drogas e álcool, prática de sexo desprotegido e histórico de agressão física estiveram associados tanto com fumantes quanto com ex-fumantes. Já a escolaridade ≤ 8 anos, história de ter morado na rua, não ter prática religiosa, internação psiquiátrica atual ou anterior, e transtorno por uso de substâncias como diagnóstico psiquiátrico principal foram associados somente ao tabagismo atual. A prevalência de tabagismo nessa população foi alta e maior do que para a população geral brasileira. Políticas de intervenção e prevenção do tabagismo devem ser adotadas pelos serviços de saúde mental. Hábito de Fumar; Saúde Mental; Fatores de Risco 1195 ARTIGO ARTICLE http://dx.doi.org/10.1590/0102-311X00027113 Barros FCR et al. 1196 Cad. Saúde Pública, Rio de Janeiro, 30(6):1195-1206, jun, 2014 Introduction Tobacco smoking remains a serious public health problem worldwide and, although its magnitude and relative impact vary among different populations, it is considered the main avoidable cause of death in a number of countries 1. Smoking is a major contributing factor to excess mortality and morbidity from cardiovascular diseases among patients with severe mental illness 2,3. Excess mortality due to smoking has also been shown among patients with other diseases, such as HIV. A study in Denmark indicated that mortality due to smoking is greater than mortality attributable to HIV among people with HIV/AIDS, showing that the number of life years lost due HIV was 5.1, compared to 12.3 because of smoking 4. It has been repeatedly shown that smoking prevalence among psychiatric populations is higher than among the general population. The prevalence of current smoking among people with mental illness is higher than in the general population in the USA (34.8% and 28.5%, respectively) 5, Canada (46.8% and 14%, respectively) 6, and Australia (31.2% and 18.7%, respectively) 7. In Australia, a study showed that prevalence is higher among patients with severe mental illness than in people with general mental illness (51.2% and 26.4%, respectively) 7, while in Canada smoking prevalence was 51.8% in patients with schizophrenia compared to 39.2% among those with mood disorder or anxiety 6. A more recent study of a nationally representative probability sample of 9,282 people in the USA showed that adults affected by a mental disorder in the past 12 months smoked almost twice as much as adults without mental disorders 8. A dose-response relationship has been observed between the number of psychiatric diagnoses and smoking 5, showing that prevalence is highest among individuals with four or more psychiatric diagnoses. Also, smokers in the USA that experienced high levels of psychological distress smoked more cigarettes per day and smoking rates varied according to type of mental disorder. Smoking prevalence was 21.3% among those with no mental disorder compared to 37.8% in people with anxiety disorders, 45.1% in those with mood disorders, and 63.6% among adults with substance use disorders 8. Although there are few publications on smoking among patients with mental illness in Brazil, evidence suggests that smoking prevalence is higher among this group than in the general population: population based studies show that smoking prevalence was 21% in Pelotas (State of Rio Grande do Sul) 9 and 19% in Campinas (State of São Paulo) 10, while among patients with severe psychiatric illness in São Paulo it was 59% 11, almost three times higher. The intricate relationship between explanatory variables, including clinical, behavioral and sociodemographic factors, associated with higher smoking prevalence among patients with mental illness is still the subject of much research. An association has been found between smoking and severe mental illness (schizophrenia, bipolar disorders and other psychoses), markers for clinical severity (e.g. previous hospitalization) and substance use disorders 11,12,13,14,15. However, the nature of these associations is not always clear. Sociodemographic factors such as male gender, older age, lower education, and not being married have also been identified. On the other hand, female and younger smokers had higher rates of mental disorders than male or older smokers, respectively 8. Behavioral correlates of smoking, including alcohol and illicit drug use, are also more common among psychiatric patients 6,12,13,14,15,16. Several studies indicate that psychiatric patients often “self-medicate” smoking as a form of relaxation and also to reduce anxiety and relieve some of the symptoms of the illness and the side effects of antipsychotic drugs 17,18. All these effects are directly associated with nicotine and the dependence on this drug has been shown to be more intense among psychiatric patients than in the general population 19. Despite evidence of the benefits of supporting the smoking cessation efforts of people with serious mental illness during hospital stays and beyond, quit rates are low and recurrence is high. Understanding the potential reasons for this situation is essential to improving the effectiveness of smoking cessation programs in psychiatric settings 20. Most studies about smoking in psychiatric populations have been conducted in high income countries. In Brazil, the few studies that exist on smoking among psychiatric patients use small samples and are limited to one service or to patients with severe mental illness 11,21,22. Thus, the aims of the present study were to estimate the prevalence of current and past tobacco smoking and assess associated factors among each group of a national representative sample of patients with chronic mental illness in public psychiatric facilities in Brazil. This study also assessed the association between severe mental illness and past and current smoking, adjusted for clinical, sociodemographic and behavioral factors. CIGARETTE SMOKING AMONG PSYCHIATRIC PATIENTS 1197 Cad. Saúde Pública, Rio de Janeiro, 30(6):1195-1206, jun, 2014 Methods