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Physical and Psychological Nicotine in Greeks: An Epidemiological
pyrig ORIGINALoARTICLE N ot C for Pu bli cat ion Dependence te ss e n c e Study
Vasileios Margaritisa/Eleni Mamai-Homataa
Purpose: Smoking is the most widespread addictive behaviour in the world, as it causes physical and psychological dependence on nicotine. The objective of the present study was to discern the prevalence and the relative risks of nicotine dependence of adult people in Athens, Greece, as this country holds first place in cigarette consumption in the European Union. Materials and Methods: A random sample of 202 current smokers (82 men and 120 women) was drawn from residents aged v 18 years in Athens, the capital of Greece. A questionnaire on the physical (Fagerstrom Test of Nicotine Dependence) and psychological (American Psychiatric Association’s diagnostic criteria of nicotine abuse) nicotine dependence was used. Results: According to the results of the present study, 12.4% of the sample reported null physical nicotine dependence, and 31.7% had low, 25.7% had moderate and 30.2% had high nicotine dependence. Multiple logistic regression analysis revealed that younger people (aged 18 to 24 and 25 to 34, odds ratio [OR] = 0.047, P u 0.033 and OR = 0.096, P u 0.038, respectively) were less prone to developing physical dependence. Women tended to be systematically less dependent than men (25% and 37.8% high dependence, respectively). Furthermore, 75.7% of the sample had psychological nicotine dependence. Binary logistic regression analysis and chi-square test revealed that younger people (18- to 24-year-olds, OR = 0.081, P u 0.008) and individuals of inferior education (v2 = 7.826, P u 0.05) were less prone to develop psychological dependence. In addition, women showed a higher percentage of withdrawal symptoms compared with men (80% and 68%, respectively). Conclusions: The results of the present study provided compelling evidence that physical and, in particular, psychological nicotine dependence of adult people in Athens, Greece, was significant, and this calls for a course of action that should be taken by public health policy-makers to reduce smoke consumption. Key words: clinician, nicotine physical/psychological dependence, smoking, smoking cessation Oral Health Prev Dent 2010; 8: 33–39.
moking is considered to be the single greatest preventable cause of death and illnesses in developed countries (Watt and Robinson, 1999; Graul and Prous, 2005; Le Foll and Melihan-Cheinin, 2005). According to the World Health Organization (WHO,
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a
Department of Preventive and Community Dentistry, Dental School of Athens, Greece.
Correspondence: Vasileios Margaritis, 177 Vouliagmenis Av, 17237 Athens, Greece. Tel: +0030 2109704047. Email: vmargar@dent. uoa.gr
Vol 8, No 1, 2010
Submitted for publication: 25.06.08; accepted for publication: 19.11.08.
2003), five million individuals in the world die annually because of smoking (Graul and Prous, 2005), and most of them die due to cancer and cardiovascular diseases (Watt and Robinson, 1999). While current smokers are 1.3 billion worldwide (Graul and Prous, 2005), it becomes obvious that the habit of smoking constitutes a global problem of public health. The persistence of cigarette smoking can be explained by an underlying physical and psychological dependence on nicotine. The pharmacological and behavioural basis for nicotine dependence acts in a way similar to that of cocaine and heroin (Niu et al, 2000). It is known that nicotine, similar to other 33
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MATERIALS AND METHODS
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addictive substances, is associated with the neurons of the reward areas of the brain, and this influences the dopamine levels in the brain (Mansvelter and McGehee, 2000; Mansvelter et al, 2002). Furthermore, recent studies (Kendler et al, 1999; Lerman et al, 1999; True et al, 1999) have indicated that several genes play an important role in starting or quitting smoking. Finally, the World Health Organization classifies smoking as a mental and behavioural disorder (Code ICD F 10-19), and the American Psychiatric Association (1994) describes smoking as an addictive behaviour. The clinician and the dental team must participate in the smoker’s effort to give up smoking by suggesting specific ways of smoking cessation. In Greece this is very important as it is first in cigarette consumption in the EU (European Community Household Panel [ECHP], 2006). The purpose of the present study was to assess the prevalence and the relative risks of physical and psychological nicotine dependence on the basis of the data collected from a recent epidemiological study of currently smoking adult people in Athens, Greece.
pyrig No Co t fo rP Diagnostic definition of nicotine addiction ub lica A questionnaire on physical and psychological nico-tion te group of tine dependence was used: the first ss e n c e
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questions (physical dependence) was a Greek translation of the modified Fagerstrom test of nicotine dependence (FNTD) (Heatherton et al, 1991) and the second group (psychological dependence) consisted of questions that were based on the American Psychiatric Association’s diagnostic criteria of nicotine abuse (Table 1) (American Psychiatric Association, 1994). A letter explaining the purpose of the study was sent to each participant. The smokers of the sample were divided into four categories based on physical nicotine dependence according to their FNTD score; 1: null dependence (0); 2: low (1 to 3); 3: moderate (4 to 5); 4: high (6 to 10). Similarly, smokers were divided into two categories of psychological nicotine dependence (I: nonpsychological nicotine dependence and II: psychological nicotine dependence) by fulfilling or not fulfilling at least three of the diagnostic criteria of Table 1 (American Psychiatric Association, 1994). Furthermore, besides the questions on physical and psychological nicotine dependence, information was collected on general sociodemographic characteristics and on smoking behaviour and smoking status (e.g. number of cigarettes smoked per day).
Study sample A random sample of 202 current smokers (82 men and 120 women) was drawn from residents aged v 18 years in Athens, Greece. This sample was defined through a representative multistage sampling of adults from all Athens’ municipalities (the smallest Greek administrative divisions) that reflect the social and economic status of the population in Greece. In the municipalities that were considered, individuals were randomly selected from the electoral lists provided by the regional municipal offices, within the strata of sex and age group, to be representative of the demographic structure of the population. A random replacement was made for subjects who could not be traced. Current smokers are defined as those who were used to smoking at least one cigarette per day for the past year (American Psychiatric Association, 1994; Niu et al, 2000). All 202 smokers were interviewed at their homes during the last trimester of 2007. A questionnaire on physical and psychological nicotine dependence was distributed to them, 30 min before the interview.
34
Data analysis The outcome variables were FNTD and psychological test scores. The analyses consisted of three main stages. First, the prevalence of each dependent symptom for both tests in the sample was calculated. Second, possible associations between several demographic data (sex, age and education level) and the presence of nicotine physical/psychological dependence were observed. Chi-square test was carried out to test the strength of associations between independent and categorical sample proportions. Finally, the estimates of the relative risks of nicotine dependence are reported by calculating the odds ratios (ORs) and the corresponding 95% confidence intervals (CIs), using multiple and binary logistic regression analyses. The dependent outcome was the presence of the physical/psychological dependence and the independent predictors were age, sex and education level. Significant confounders, as well as interactions, are retained in the models. Deviance residuals are calculated for evaluating goodness-offit of the model. All reported probability values
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No C t fo rP Table 1 The American Psychiatric Association’s diagnostic criteria of nicotine abuse (American Psychiatric Association, ub lica 1994) tio n te 1. Nicotine tolerance: either need for markedly increased amounts of nicotine to achieve intoxication or ss e n c e markedly diminished effect with continued use of the same amount of nicotine.
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Nicotine withdrawal symptoms: either (a) or (b). (a) Two (or more) of the following symptoms developed within several hours to a few days of reduction in high or prolonged use of nicotine: • • • • • • • •
sweating or rapid pulse increased hand tremor insomnia nausea or vomiting physical agitation anxiety transient visual, tactile or auditory hallucinations/illusions grand mal seizures.
(b) Nicotine is consumed to relieve or avoid withdrawal symptoms.
3.
Greater use of nicotine than intended: nicotine was often consumed in larger amounts or over a longer period than was intended.
4.
Unsuccessful efforts to cut down or control nicotine use: persistent desire or unsuccessful efforts to cut down or control nicotine use.
5.
Great deal of time spent in consuming nicotine.
6.
Nicotine caused reduction in social, occupational or recreational activities: important social, occupational or recreational activities given up or reduced due to nicotine use.
7.
Continued use of nicotine, despite it causing significant problems: the use of nicotine is continued, despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been worsened by prolonged use.
(P values) are based on two-sided tests and compared to a significance level of 5%. The analysis of coded data was carried out using SPSS version 13.0.
RESULTS Physical nicotine dependence According to the results of the present study, 12.4% of the sample had null physical nicotine dependence, 31.7% low, 25.7% moderate and 30.2% high (Table 2). Women tended to be systematically less dependent than men (25% and 37.8% high dependence, respectively). In addition, an interesting element was that 40% of the smokers of the present study smoked 6 to 30 min after they awoke. Multiple logistic regression analysis was performed to assess the OR of nicotine physical dependent individuals adjusted for sex, age and education level. Thus, younger people (18 to 24 and 25- to 34-year-olds, ORs = 0.047, P u 0.033 and OR = 0.096, P u 0.038, respectively) were less prone to develop physical dependence. Vol 8, No 1, 2010
Psychological nicotine dependence In the present study, 75.7% of the smokers had this specific kind of nicotine dependence (Table 2). Women and men had similar percentages. Smokers with a higher education level had a considerably higher psychological nicotine dependence (v2 = 7.826, P u 0.05) compared with those of a lower level of education. In addition, younger smokers showed less psychological nicotine dependence (v2 = 13.322, P u 0.010) than the older ones. Binary logistic regression analysis adjusted for age, sex and education level also revealed that younger people (18- to 24-year-olds, OR = 0.081, P u 0.008) were less prone to develop psychological dependence.
Other findings As it was observed in the present study, women evidenced a higher percentage of withdrawal symptoms compared with men (80% and 68%, respectively). The most important withdrawal symptoms reported 35
82
Total
15
9 60 6 40
3 20 7 46.7 3 20.0 2 13.3
18–24
65
15 23.1 50 76.9
11 16.9 23 35.4 18 27.7 15 20
25–34
57
13 22.8 44 77.2
7 12.3 19 33.3 15 26.3 16 28.1
35–44
Age (years)
43
10 23.3 33 76.7
3 7 11 25.6 12 27.9 17 39.5
45–54
22
2 9.1 20 90.9
1 4.5 4 18.2 4 18.2 13 59.1
v 55
13 17 40 30
15 13 27 45
100
Total
100
24 42 24 10
20 20 34 26
Women
Cigarettes per day u 10 11–20 21–30 v 31 Time of exposure (years) u5 6–10 11–20 v 21
Men
Sex
100
55 45 0 0
17 30 30 23
18–24
100
21 33 46 0
29 37 31 3
25–34
Table 3 Smoke consumption and time of nicotine exposure of the sample (values in per cent)
Physical dependence categories: 1, null dependence score 0; 2, low score 1–3; 3, moderate score 4–5; and 4, high score 6–10. Psychological dependence categories: I, non-psychological nicotine dependence and II, psychological nicotine dependence.
120
28 23.3 92 76.7
21 25.6 61 74.4
202
15 12.5 44 36.7 31 25.8 30 25.0
Women
10 12.2 20 24.4 21 25.6 31 37.8
Men
Sex
Physical dependence 1 N 25 % 12.4 2 N 64 % 31.7 3 N 52 % 25.7 4 N 61 % 30.2 Psychological dependence I N 49 % 24.3 II N 153 % 75.7
Total
100
5 9 58 28
20 37 27 16
35–44
Age (years)
18
9 50 9 50
4 22.2 5 27.8 3 16.7 6 33.3
Basic education
63
16 25.4 47 74.6
7 11.1 21 33.3 14 22.2 21 33.3
High school
100
3 3 26 68
24 21 31 24
45–54
35
7 20 28 80
3 8.6 8 22.9 13 37.1 11 31.4
College (2–3 years)
Education level
19 26 22 33
v 55
86
17 19.8 69 80.2
11 12.8 30 34.9 22 25.6 23 26.7
University (4–6 years)
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Table 2 Prevalence of physical and psychological nicotine dependence in a Greek population
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A significant number of the Athenian smokers (30.2%) reported a high physical nicotine dependence. This percentage was higher than that observed in Italy (Gallus et al, 2005) (17.6%), although in that study smokers from the age of 15 years were included. In addition, the prevalence of high physical dependence observed in Greece was similar to that reported in the USA (36%) (Hughes and Gust, 1987), Austria (Schoberberger and Kunze, 1997) (37%) and China (30.1%) (Niu et al, 2000). These comparisons indicate that smokers in Greece had one of the highest physical dependence scores in Europe, and an explanation might be that Greece is first in cigarette consumption in the EU (ECHP, 2006). The physical nicotine dependence of the smokers in Greece is also reinforced by the percentage of those who had unsuccessfully quit smoking (27%), which was greater than that observed in Italy (23%) (Gallus et al, 2005). Furthermore, men smokers in the present study were more prone to high dependence than women smokers because men begin smoking at a younger age (ECHP, 2006) and smoke more cigarettes (General Household Survey, 2000; National Statistics of Great Britain, 2003) on a daily basis. These findings are also confirmed in the present study (Table 3). In agreement with Henningfled (1990), Niu et al (2000) and Gallus et al (2005), the present study suggested that smoking more cigarettes, starting smoking at a younger age and smoking for a longer duration are all positively and significantly associated with a higher FNTD score for nicotine dependence. The last two of the above findings could explain why younger smokers reported less physical dependence than older smokers and this emphasises that the time of exposure to nicotine is very important for the dependence. The extremely low proportion of smokers aged 18 to 24 years reporting high dependence on tobacco is worth mentioning, whereas > 20% of this age group reported null and another 46.7% reported low dependence scores. This indicates that, in most regular smokers, tobacco dependence is not yet established in the young, who are also a key target for the promotion of the tobacco industry (Ling and Glantz, 2002; Biener and Albers,
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were irritability, restlessness, anxiety and difficulty in concentration. Furthermore, 22% of the sample did not quit smoking due to the fear of gaining weight. This percentage was significantly higher at the younger age group (18 to 24, v2 = 14.543, P u 0.007).
No C t fo r Pyoung 2004). Moreover, compared with adults, ub smokers absorb more nicotine per cigarette, even lica with their first few cigarettes (McNeill et al, 1987, tion te focus of 1989; O’Loughlin et al, 2002). Thus, the ss e n c e anti-smoking intervention in adolescents and the young is a clear priority. Furthermore, the observation that 44.1% of smokers in Greece reported null or low physical dependence scores indicates the large scope for counselling and intervention in stopping smoking on a population basis. The prevalence of psychological nicotine dependence varies worldwide. In the present study it was observed to be 75.7%, whereas in the USA and Japan it was 57% according to Berrettini and Lerman (2005) and 24% to 54% according to Saito et al (1998) and Hashimoto and Sakagushi (2001). The high percentage that was observed among smokers in Greece is probably due to their temperament and also to possible differences in the methodology for the collection of results. Smokers with a higher education level showed a higher dependence score, and this could partly be explained by the fact that smoking constitutes a socially acceptable need and is regarded as an alternative form of entertainment (Steka, 2004). On the contrary, the use of other addictive substances (e.g. alcohol and cannabis) is less socially acceptable and more common in individuals of a lower educational level (Siciliani et al, 1985; Fuentealba, 2000; Carasco et al, 2001; Culina, 2005; Gasquet et al, 2005). Moreover, smokers and particularly those with a higher education level, describe nicotine as a tranquillising substance (Steka, 2004). Finally, the results of the present study on nicotine withdrawal symptoms were also observed in an experimental study (Hatsukami, 1995) in which increased appetite was reported as an additional withdrawal symptom. In summary, the results of the present study provide compelling evidence that physical and especially psychological nicotine dependence of smoking adults in Athens was significant, and this calls for a course of action that should be taken by the public health policy-makers to reduce cigarette consumption. The present study has several limitations. To begin with, while the sample consisted of adult men and women from Greece, the results should not be generalised to other ethnic groups with different population characteristics. However, as Greece is one of the older members of the EU, the results of the present study can provide good estimates of the prevalence of nicotine dependence in the population of developed western countries. 37
1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, ed 4. Washington, DC: American Psychiatric Association, 1994. 2. Berrettini WH, Lerman CE. Pharmacotherapy and pharmacogenetics of nicotine dependence. Am J Psychiatry 2005;162:1441–1445. 3. Biener L, Albers AB. Young adults: vulnerable new targets of tobacco marketing. Am J Public Health 2004;94: 326–330. 4. Carasco P, Astasio P, Ortega P, Jimenez R, Gil A. Factors related to psychotropic drugs consumption among the Spanish adult population. Med Clin 2001;116:324–329. 5. Culina H. Prevalence, health outcomes and patterns of psychotropic substance in the Chinese population in Hong Kong; a population-based study. Subst Use Misuse 2005;40:187–209. 6. ECHP (European Community Household Panel). Reports 2006. Available at: http://epp.eurostat.ec.europa.eu/portal/ page/portal/product_details/publication?p_product_code= 3-08032004-AP. Accessed 27 November 2009. 7. Fuentealba R. Consumption of licit and illicit drugs in Chile. Results of 1998 study. Rev Panam Salud Publica 2000;7:79–87. 8. Gallus S, Pacifici R, Colombo P, La Vecchia C, Garattini S, Apolone G et al. Tobacco dependence in the general population in Italy. Ann Oncol 2005;16:703–706. 9. Gasquet I, Negre-Pages L, Fourrier A, Nachbaur G, El-Hasnaoui A, Kovess V et al. Psychotropic drug use and mental psychiatric disorders in France: results of the general population ESEMeD/MHEDEA 2000 epidemiological study. Encephale 2005;31:195–206.
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The first author would like to present and thank Prof. Mrs Eleni Homata (Department of Preventive and Community Dentistry, Dental School of Athens, Greece) for her unconditional support and constant help. In addition, the author would like to thank the team of the community dentistry department for their assistance and cooperation.
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In addition, a standard psychometric instrument for assessing psychological nicotine addiction does not exist (Shaffer, 1997). However, the questionnaire that was used in the present study consisted of questions that were based on the American Psychiatric Association’s diagnostic criteria of nicotine abuse. These criteria are accepted by the global scientific community. The high frequency of individuals with a high education level who were recruited in the present study is most likely the result of participation bias; therefore, the importance of risk factors detected is limited to this population group. Finally, certain information was retrieved from smokers’ reports and is therefore subject to recall bias.
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