Softening Among U.S. Smokers With Psychological Distress: More Quit Attempts and Lower Consumption as Smoking Drops

Abstract

Introduction It has been argued that as smoking prevalence declines, the remaining smokers represent a “hard core” who are unwilling or unable to quit, a process known as hardening. However, as recently shown, the general smoking population is softening not hardening (i.e., as prevalence falls more quit attempts and lower consumption among continuing smokers). People with psychological distress smoke more, so they may represent hard core smokers. Methods Using cross-sectional time series analysis, in 2016–2017 changes in quit attempts and cigarette consumption were evaluated over 19 years among smokers with serious psychological distress (Kessler-6 score ≥13) based on the National Health Interview Survey (1997–2015), controlling for sociodemographic variables. Results People with psychological distress had higher prevalence and consumed more cigarettes/day than people without distress. The percentage of those with at least one quit attempt was higher among those with psychological distress. The increase in quit attempts over time was similar among smokers in each of the distress levels. For every 10 years the OR of a quit attempt increased by a factor of 1.13 (95% CI=1.02, 1.24, p<0.05). Consumption declined by 3.35 (95% CI= −3.94, −2.75, p<0.01) cigarette/day for those with serious psychological distress. Conclusions Although smoking more heavily than the general population, smokers with psychological distress, like the general population, are softening over time. To improve health outcomes and increase health equity, tobacco control policies should continue moving all subgroups of smokers down these softening curves, while simultaneously incorporating appropriately tailored quitting help into mental health settings.

Health behaviors and psychological distress: changing associations between 1997 and 2016 in the United States

“…Previous studies have shown that the relative risk of smoking associated with psychological distress has become stronger in the last 20 years, because the prevalence of smoking has declined more rapidly among those without psychological distress than among those with psychological distress [10][11][12][13][14] The current results suggest that other health behavior correlates of psychological distress have also changed during the last 10-20 years in the United States: psychological distress has become more strongly associated with physical inactivity and short sleep duration, but less strongly related with heavy alcohol consumption. The previously reported time trends of psychological distress and smoking suggest that the public health improvements have not reached people with mental health problems as effectively as those without mental health problems [10].…”

“…The total sample size was 603,518 participants (21,237-35,469 participants per survey year) aged 18 years and older. These data have previously been used to examine time period trends in psychological distress and smoking [11,13]. NHIS is approved by the Research Ethics Review Board of the National Center for Health Statistics and the U.S. Office of Management and Budget.…”

“…In the general population, mental health is often measured by indicators of non-specific psychological distress, including symptoms of depression, anxiety, stress, and somatic complaints [9]. Studies in the United States [10][11][12][13] and the United Kingdom [14] have reported psychological distress to be associated with diverging trends in smoking. During the last 10-20 years, smoking rates have declined among those without mental disorders but have remained the same, or declined at a slower pace, among those with mental disorders [10,14].…”

Mental health, smoking, harm reduction and quit attempts – a population survey in England

“…Smoking is also associated with poorer treatment outcomes; compared with non-smokers with mental health problems, smokers with mental health problems spend longer time in hospital and less time out of hospital (11). There is some evidence, mainly from the US, that smokers with mental health problems are as likely to make a quit attempt as other smokers (12) but cessation rates are lower. Successful quitting is associated with improved mental health, speci cally reduced anxiety, depression and stress and increased psychological quality of life and positive affect (13); additionally, for speci c medications for severe mental illness, quitting may reduce the required dosage (5) and thus associated side effects.…”

Mental health, smoking, harm reduction and quit attempts – a population survey in England

“…Smoking is also associated with poorer treatment outcomes; compared with nonsmokers with mental health problems, smokers spend longer time in hospital and less time out of hospital (11). There is some evidence, mainly from the US, that they are as likely to make a quit attempt than other smokers (12) but cessation rates are lower. Successful quitting is associated with improved mental health, specifically reduced anxiety, depression and stress and increased psychological quality of life and positive affect (13); additionally, for specific medications for severe mental illness, quitting may reduce the required dosage (5) and thus associated side effects.…”