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Nicotine Dependence and Comorbid Substance Use and Psychiatric Disorders in an American Indian Male Veteran Sample


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Title: Nicotine Dependence and Comorbid Substance Use and Psychiatric Disorders in an American Indian Male Veteran Sample

Nicotine Dependence and Comorbid Substance Use
and Psychiatric Disorders in an American Indian
Male Veteran Sample
  • Daniel Dickerson, DO, MPH
  • Assistant Research Psychiatrist
  • UCLA, Integrated Substance Abuse Programs (ISAP)
  • May 30, 2008

  • Yale University
  • Stephanie OMalley, PhD
  • Minneapolis V.A. Hospital
  • Joseph Westermeyer, MD, PhD
  • Jose Canaive, MD
  • Paul Thuras, MD
  • Funding Sources
  • T32 AA 015496-02
  • T-TURC P50 AA15632
  • K05-AA014715

Todays agenda
  • Brief history of traditional tobacco use in AI
  • Overview of Nicotine Dependence among American
    Indians/Alaska Natives (AI/AN)
  • Study of nicotine dependence and axis I and II
    comorbidities in AI male veterans
  • Questions/Comments

History of tobacco use among AI
  • Used historically for religious and ceremonial
  • Tobacco used 20x stronger
  • Tobaccos effects included dizziness, vertigo,
    inebriation, intoxication, loss of reason, coma,
    and insanity
  • Europeans expressed their astonishment at the
    tobacco addiction of many AI
  • AI start smoking commercialized form of tobacco
    shortly after European contact

Woodland Bird Effigy Stone Pipe Mississippian
1200 - 1500 AD
Woodland Frog Effigy Stone Pipe Eastern
Tennessee 500 - 800 AD
History of tobacco use among A.I./A.N.
Cultural relevance of tobacco use Iroquois
Creation Story
  • Tobacco grew from the grave of the Earth Mother
    who died after giving birth to the twins
    Good-Minded (the Great Creator) and Evil-Minded
    (the Great World Rim Dweller).
  • Tobacco grew from Earth Mothers head, so that
    it soothes the mind and sobers thought.

Tobaccos reverence as a sacred plant in Native
  • One of four natural sacred herbs
  • Represents the Eastern direction and the mind
  • Used to connect with the spirit world
  • Give back to and thanking the Creator
  • Used to purify, and to work with a clear mind and
  • Used in various ceremonies

Traditional use of tobacco versus commercialized
tobacco use
  • Traditional use of tobacco
  • Prayers to the Creator
  • Purification agent
  • Role of tobacco in creation stories
  • Unify two people or groups
  • Naming Ceremonies
  • Given to elders when one is asking advice
  • Improve physical, spiritual, and mental
  • Evoke the memories of survival, strength, nation,
    and tradition.
  • Commercialized tobacco use
  • Disrespectful to the creator/disconnect from the
  • Addictive
  • Numerous medical consequences
  • Destroys communities/lives
  • Becomes a mundane everyday affair, loses its
    power and important cultural relevance

American Indians/Alaska Natives
  • Comprised of 564 federally-recognized tribes
  • Represent 1.5 or 4.1 million of the total U.S.
    population (U.S. Census Bureau, 2003)
  • Two-thirds live in urban areas
  • Los Angeles has the largest population of AI/AN
    in the U.S. compared to any other city
  • Less than 1 of the total Indian Health Service
    (IHS) budget allocated to urban health care
  • Experience significant health-related disparities
  • 55 rely on IHS for health care services.

Tobacco use rates are highest among AI/AN
  • Commercial tobacco use rates by ethnic group
  • AI/AN 32.4
  • Non-Hispanic whites 21.9
  • Non-Hispanic blacks 23.0
  • Hispanics 15.2
  • Asian/Pacific Islanders 10.4
  • (American Lung Association, 2007)

Why are tobacco use rates higher among AI/AN
  • Lower SES
  • High substance abuse rates
  • Inactive public health policies
  • Poor social conditions
  • Diminishing knowledge of traditional use of
  • Limited treatment prevention programs

Smoking and psychiatric disorders
  • Biochemical and pharmacological findings provide
    a conceptual link
  • Smokers with depressive symptoms have a harder
    time quitting
  • 61 smokers in a N.Y. sample had a past history
    of depression (Glassman, 1988)
  • High smoking prevalence in panic disorder (19.2
    to 56)
  • Prevalence ranges from 53-66 in combat veterans
    with PTSD (Kallman, 2005)
  • Nicotine-dependent and psychiatrically ill
    individuals consume about 70 of all cigarettes
    in the United States (Grant, 2004)

Smoking and substance use disorders
  • Over 75 of alcohol and drug-dependent persons in
    early recovery smoke (Gulliver, 2000)
  • Smoking increases reinforcing value of alcohol
    (Perkins, 2001)
  • Consumption of an alcohol increases smoking
    behavior (Mitchell, 1995)
  • Greater than 80 of opioid-dependent patients
    smoke cigarettes (Grant et al, 2003)
  • 80 of cocaine users smoke (Kalman, 2005)

NESARC findings (Grant, 2004)
  • 43,093 general U.S. respondents
  • 12.8 nicotine dependent (DSM-IV criteria)
  • Associations between nicotine dependence and Axis
    I and II disorders were all statistically
  • Nicotine dependence most prevalent among
    individuals with a current alcohol or drug use
    disorder 34.5 (OR4.4) and 52.4 respectively

Studies of smoking and SUD and PD comorbidities
in AI populations to date
  • Enoch, et al. 2006 found less association
    between alcoholism and smoking than U.S.
  • Henderson, et al. 2005 observed an association
    between alcohol and tobacco use
  • No studies investigating nicotine dependence and
    psychiatric or drug use disorders have been
    performed among AI/AN using DSM criteria

  • In a sample of 480 American Indian male veterans,
    the current study examines
  • rates of psychiatric and substance use disorders
    among those with nicotine dependence
  • rates of nicotine dependence among those with
    psychiatric and substance use disorders
  • odds ratios of nicotine dependence and comorbid
    psychiatric and substance use disorders

  • 1) American Indian male veterans will demonstrate
    significant co-morbidity for nicotine dependence
    and both psychiatric and substance use disorders.
  • 2) The degree of correlation between nicotine
    dependence and psychiatric and substance use
    disorders will be greater than the general U.S.
    population as observed in a recent
    epidemiological study (Grant, 2004).

  • 480 American Indian male veterans from the north
    central region of the U.S.
  • Secondary analysis from an earlier, larger study
  • Community-based survey
  • Utilized targeted sampling
  • Sample structured to include 51 urban and 49
    rural American Indian veterans

  • A demographic questionnaire
  • The Quick-Diagnostic Interview Schedule (Q-DIS),
    utilized to obtain DSM-III-R diagnoses
  • Axis I and axis II diagnosis (antisocial
    personality disorder) were analyzed.

Statistical Analyses
  • Cross-tabulations were used to calculate the
    prevalence of current and lifetime nicotine
    dependence, other Axis I diagnoses and ASPD.
  • Examined diagnostic classes (e.g., any anxiety
    rather than individual diagnoses with the
    exception of PTSD and pathological gambling
  • Odds ratios (OR) with 95 confidence intervals
    (C.I.) from chi-square analysis were used to
    study associations between nicotine dependence
    and both PD and SUD

Subject Characteristics
  • 480 American Indian male veterans
  • 24.2 married
  • 70.7 high school education or higher
  • 84.8 living independently
  • 45.9 working full/part time
  • 39.9 unemployed/disabled

Results Associations between Nicotine Dependence
and Lifetime Psychiatric and Substance Use
Disorders All Significant

Co-Morbid Disorder Prevalence of Comorbid Disorder Odds Ratio of Nicotine Dependence and Comorbid Disorder (95 Confidence Interval)
Co-Morbid Disorder No. Odds Ratio of Nicotine Dependence and Comorbid Disorder (95 Confidence Interval)
Nicotine Dependence 112 23.3 ----
Any Alcohol Use Disorder 148 30.8 1.82 (1.2-2.8)
Any Drug Use Disorder 72 12.6 2.84 (1.7-4.8)
Any Anxiety 107 22.3 3.93 (2.5-6.3)
Any Affective 42 8.8 6.65 (3.4-12.9)
Post Traumatic Stress 57 11.9 4.68 (2.6-8.3)
Antisocial Personality 53 11.0 3.19 (1.8-5.7)
Gambling 45 9.4 2.72 (1.4-5.1)
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Nicotine dependence and PD and SUD in this sample
of AI
  • Lifetime nicotine dependence was associated with
    all lifetime psychiatric and substance use
    disorders studied
  • Unlike the general U.S. population, current
    nicotine dependence was not associated with
    either current alcohol or drug use disorders
  • AI with current alcohol and drug disorders had
    noticeably lower rates of current nicotine
    dependence when compared to the U.S. sample
    (20.7 vs 33.5, and 24.40 vs. 51.6

Nicotine dependence and comorbid depression
  • Several explanations have been proposed
  • -smokers use nicotine to self-medicate
  • their depressed mood
  • -causal influence of smoking on MDD
  • -underlying environmental, genetic, and
  • biological factors may predispose individuals
  • both
  • Sources Glass, 1990 Hughes1988 Kendler et al.,
  • Dierker et al., 2002 Patten et al., 2001
    Williams and Ziedonis, 2004

Nicotine dependence and comorbid depression in
A.I. males
  • Possible anti-depressant qualities of tobacco use
  • A.I. males known to minimize depressive
    symptomatology (ONell, 2000)
  • Possible shared genetic factors?
  • Possible social environmental factors?
  • Consider pre-screening for depressive disorders

Nicotine dependence and comorbid gambling
disorders in A.I. males
  • Similar findings in AI sample as observed in
    general U.S. samples
  • Gambling disorders comorbid with all Axis I
    disorders in prior study (Westermeyer, 2005).
  • Additional psychosocial factors associated with
    problematic gambling among AI (Zitzow, 1996).

Nicotine dependence and gambling disorders in
A.I. males treatment considerations
  • Specific and comprehensive treatments
  • Cognitive Behavior Therapy
  • May consider bupropion (Black, 2004)
  • Stricter clean air laws
  • Address lack of social alternatives
  • Traditional Medicine
  • Further treatment studies for this comorbidity
    are needed.

  • Unestablished cross-cultural validity of Q-DIS
  • Study limited to A.I. males
  • Relatively small sample size
  • Findings not representative of all tribes.
  • Absence of psychotic disorder data

  • Centers for Disease Control. Morbidty and
    Mortality Weekly Report. Cigarette smoking among
    adults-United States, 2006 November 9, 2007 /
  • Dierker LC, Avenevoli S, Stolar M, Merikangas KR.
    2002. Smoking and depression An examination of
    mechanisms of comorbidity. Am J Psychiatry
  • Glass RM. 1990. Blue mood, blackened lungs
    depression and smoking. JAMA 264 1583-1584.
  • Grant, B.(2004). Nicotine Dependence and
    Psychiatric Disorders in the United States. Arch
    Gen Psychiatry, 61, 1107-1115.
  • Grant JE, Potenzy MN. 2005. Tobacco use and
    pathological gambling. Ann Clin Psychiatry
  • Hughes JR. 1988. Clonidine, depression, and
    smoking cessation. JAMA 259 2901-2902.

  • Kalman, D., Morissette, S.B., George, T.P.
    (2005). Co-Morbidity of Smoking in Patients with
    Psychiatric and Substance Use Disorders. AM J
    Addictions, 142, 106-123.
  • Kendler KS, Neale MC, MacLean CJ, Heath AC, Eaves
    LJ, Kessler RC. 1993. Smoking and major
    depression a causal analysis. Arch Gen
    Psychiatry 50 36-43.
  • Kiss E, Piko B, Vetro A. 2006. Frequency of
    smoking, drinking, and substance use and their
    relationship to psychiatric comorbidity in
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    Psychiatr Hung 21 (3) 219-226.
  • Lekka NP, Lee KH, Argyriou AA, Beratis S, Parks
    RW. 2006. Association of cigarette smoking and
    depressive symptoms in a forensic population.
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  • ONell TD. 1996. Coming home among Northern
    Plains Vietnam veterans psychological
    transformations in pragmatic perspective. Ethos
    2000 27441-465.
  • Patten CA, Gillin C, Golshan S, WOlter TD,
    Rapaport M, Kelsoe J. 2001. Relationship of mood
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    patients with a current mood disorder. J Clin
    Psychaitry 62 319-324.

  • Petry NM, Stinson FS, Grant BF. 2005. Comorbidity
    of DSM-IV pathological gambling and other
    psychiatric disorders results from the national
    epidemiologic survey on alcohol and related
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  • Potenza MN, Steinberg MA, McLaughlin SD, Wu R,
    Rounsaville BJ, Krishnan-Sarin S, George TP,
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    tobacco-smoking problem gamblers calling gambling
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  • U.S. Census Bureau, 2003 http//
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    tobacco among individuals with a mental illness
    or an addiction. Addict Behav 291067-1083.
  • Westermeyer J, Canive J, Garrand J, Thuras P,
    Thompson J. 2005. Lifetime prevalence of
    pathological gambling among American Indians and
    Hispanic American Veterans. Am J Public Health
    95(5) 860-865.
  • Zitzow D. 1996. Comparative study of problematic
    gambling behaviors between American Indian and
    non-Indian adults in a Northern Plains
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