What are the psychiatric and non-psychiatric correlates of tobacco smoking status in bipolar disorders? Researchers investigated these associations in a large patient cohort.
“Ms Sheila” is a 50-year-old Caucasian female with bipolar I disorder, most recent episode depressed. Her mood disorder has been stable on lithium, and she has not had any psychiatric hospitalizations in the past 15 years. She has smoked 2+ packs of cigarettes per day for more than 30 years. She also has comorbid hypertension, hyperlipidemia, and chronic obstructive pulmonary disease, for which she is adherent with medication.
At a recent outpatient appointment, Ms Sheila expresses a desire to quit—or at least cut down on—smoking. However, she reports significant anxiety about quitting smoking and notes that she has experienced a mild worsening of her depressive symptoms over the past month. She asks if smoking cessation, beyond its benefits to her physical health, will have any potential long-term effects on her mood disorder. As her psychiatrist, how would you advise her?
Bipolar disorder is associated with a significant increased burden of premature mortality, with 70% of deaths attributable to somatic comorbidities.1 The lifetime prevalence of tobacco smoking in bipolar disorder is up to 70%, which is the main modifiable risk factor for cardiometabolic disorders in this population.2
There is also evidence that tobacco smoking may worsen the clinical course of bipolar disorder, including potentially through risks of suicidal behavior,3,4 decreases in quality of life,5 and interaction with medications.6
Despite the availability of efficacious treatments, remission rates for smoking cessation are 60% lower in individuals with bipolar disorder.7 Furthermore, only 33% of individuals with bipolar disorder have been advised to quit smoking by a health care professional.8
The Current Study
Nobile and colleagues9 analyzed data from the FACE-BD cohort of > 3000 individuals with bipolar disorder to identify independent risk factors for never smoking tobacco, versus formerly smoking tobacco, versus currently smoking tobacco in individuals with bipolar disorder. FACE-BD is a network of 12 centers in France.
Individuals with bipolar disorder are referred to the center by other clinicians, where they are assessed and followed annually for 3 years. Individuals are interviewed for diagnosis using the Structured Clinical Interview for DSM-IV disorders, sociodemographic and clinical characteristics, current treatment regimen, and medical history. Mood symptoms are assessed using the Montgomery and Åsberg Depression Rating Scale (MADRS) and the Young Mania Rating Scale (YMRS). Additional validated tools were used to assess anxiety, affective lability, impulsiveness, childhood trauma, and global functioning.
Study authors also assessed individuals for the following medical conditions: history of cardiovascular disorders, metabolic disorders, anthropomorphic measurements of obesity, and blood for complete blood count, ionogram, glucose, and lipids. Metabolic syndrome was defined according to the criteria of the National Cholesterol Education Program's Adult Treatment Panel III report.
Patients were trichotomized as current smokers (≥ 5 cigarettes/day for ≥ 3 months), former smokers (≥ 100 lifetime cigarettes, but none over the past year), and never smokers (< 100 lifetime cigarettes). Univariate multinomial logistic regression models were used to assess clinical and sociodemographic variables and smoking status (never-smoker = reference group). A multivariate multinomial logistic regression model was performed including all independent variables associated with smoking status with a p-value < 0.1. P-values were corrected for multiple comparisons.
Data on smoking status was available for 3625 participants, including 1529 never-smokers, 1680 current smokers, and 416 former smokers. The mean age was 41, 62% were female, and the mean illness duration was 17 years. Cohort participants were mostly euthymic, but with residual depressive symptoms.
Current smokers were more likely to be younger and male compared with never-smokers. Current smokers had a higher risk of lifetime suicide attempt than never- and former smokers (OR=1.4-1.5). Current smokers also had significantly higher scores on depression, anxiety, and emotional lability than never-smokers.
There was also an increasing gradient for impulsivity from never- to former to current smokers. Former and current smokers had higher childhood trauma scores than never-smokers. Current smokers also had significantly worse functioning than the other groups.
There was also a gradient toward an increased prevalence of comorbid substance use disorders from never- to current smokers. Former smokers had a poorer metabolic profile compared to the other groups, with higher BMI and more frequent dyslipidemia and metabolic syndrome. There were no significant differences between groups regarding C-reactive protein asthma, thyroid dysfunction, epilepsy, and neoplasia. Current smokers were more likely to be prescribed antipsychotics than the other groups.
In the multivariate model, age (younger for current smokers) and lifetime comorbid alcohol and cannabis use disorders (which increased in current smokers) were the strongest factors associated with smoking status. Current smokers were also more likely to be single and diagnosed with bipolar I disorder. There was no association between smoking status and metabolic syndrome after controlling for antipsychotic medications.
The authors concluded current smokers had higher depression, anxiety, and impulsivity levels than former and never-smokers. They also had a higher risk of comorbid substance use disorders with a gradient from never to former to current smokers—suggesting shared liability. In individuals not using antipsychotics, current smokers were at higher risk to have a metabolic syndrome than never-smokers.
Study strengths include the large sample sizes of individuals with each smoking status, and the availability of a broad range of sociodemographic and clinical data. Study limitations included the cross-sectional design, and the absence of data on duration and cumulative exposure to tobacco. The authors also noted that current substance use comorbidity could influence clinical characteristics.
The Bottom Line
Tobacco smoking was associated with increased comorbidity in individuals with bipolar disorder. As in the general population, smoking cessation decreased the risk of comorbidities to the levels of never-smokers. Findings strongly highlight the need for widespread smoking cessation interventions in this patient population.
Dr Miller is a professor in the Department of Psychiatry and Health Behavior at Augusta University in Augusta, Georgia. He is on the Editorial Board and serves as the schizophrenia section chief for Psychiatric Times®. The author reports that he receives research support from Augusta University, the National Institute of Mental Health, and the Stanley Medical Research Institute.
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8. Prochaska JJ, Reyes RS, Schroeder SA, et al. An online survey of tobacco use, intentions to quit, and cessation strategies among people living with bipolar disorder. Bipolar Disord. 2011;13(5-6):466-473.
9. Nobile B, Godin O, Gard S, et al. Physical and mental health status of former smokers and non-smokers patients with bipolar disorder. Acta Psychiatr Scand. 2023;147(4):373-388.