Literature Review of Smoking Among Persons with Disabilities Alpa Patel-Larson, ASPH/CDC Fellow Office on Smoking and Health

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Literature Review of Smoking Among Persons with
DisabilitiesAlpa Patel-Larson, ASPH/CDC
FellowOffice on Smoking and Health
National Conference on Tobacco or Health San
Francisco, CA November 20, 2002
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Overview

• Objectives
• Definitions
• Methods
• Results
• Discussion
• Conclusion

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Objectives

• Review common definitions used to describe
  persons with disabilities and smoking
• Review existing research
• Describe current prevalence estimates of tobacco
  use among persons with disabilities
• Describe gaps in knowledge of tobacco-related
  issues among persons with disabilities
• Discuss next steps

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Healthy People 2010 Goals

• Tobacco-related goal
• 27 Reduce illness, disability, and death related
  to tobacco use and exposure to secondhand smoke.
• Persons with disabilities have higher smoking
  prevalence compared to persons without
  disabilities (NHIS 1997).
• Disability-related goal
• 6 Disability and Secondary Conditions - Promote
  the health of people with disabilities, prevent
  secondary conditions, and eliminate disparities
  between people with and without disabilities in
  the U.S. population

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Definitions Tobacco

• Current smoker Smoked gt 100 cigarettes during
  lifetime and smoked every day or some days
• Former smoker Smoked gt 100 cigarettes during
  their lifetime but currently did not smoke

Sources NHIS, 1999.
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Definitions Persons with Disabilities

• People with disabilities People identified as
  having an activity limitation or who use
  assistance or who perceive themselves as having a
  disability.
• Activity limitations Problems in a persons
  performance of everyday functions such as
  communication, self-care, mobility, learning and
  behavior.

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Definitions Disabilities (contd)

• Mental illness Refers collectively to all
  diagnosable mental disorders, which are health
  conditions that are characterized by alterations
  in thinking, mood, or behavior, that are all
  mediated by the brain and associated with
  distress and/or impaired functioning.

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Methods of Literature Review

• PubMed/Medline search years 1982-Present
• Defined broad range of disabilities per HP 2010
• Key terms Disabled persons, mentally disabled
  persons, depression, health status, mental
  disorders, with tobacco, tobacco use disorder,
  nicotine, smoking, cigarette, epidemiology,
  prevalence

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Methods (contd)

• Areas covered national, regional, county-level,
  city or center-focused surveys
• Ages covered children only, youth only, youth
  and adults, adults under 65, adults over 65,
  adults
• N ranged from 119 persons to 77,437

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Overview of Findings

• Disabilities included
• 4 on all disabilities
• 3 on learning disabilities
• 5 on mental retardation or intellectual
  disabilities
• 7 on mental disorders
• 3 on mobility limitations
• 1 each on ADHD, special education, activity
  limitations, depression, anxiety, schizophrenia,
  rheumatoid arthritis, Alzheimers and ageing.
• Tobacco issues covered ever smoked, current
  smoker, former smoker, heavy smoker, quit rates

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Smoking and Learning Disabilities
Children under 18, 1994-1995, cross-sectional
from the National Longitudinal Study
N20780 Without LD Without LD With LD With LD
Smoking N N
Male 22.9 1345 26.8 230
Female 24.0 1555 20.0 89
P lt 0.05 Sources Svetaz, 2000
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Smoking and ADHD
Community cohort of ADHD children in San
Francisco, CA
N492 Age Never Ever Current Former Heavy
1o 15.2 13 31 11 43
2o 15.8 18 24 18 39
Ctrl 16.2 8 33 15 42
All ADHD 12 30 50 13 42
Beh prob 15.4 5 43 43 14 36
Agemate 17.1 21 40 27 12 26
Sources Lambert 1998
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Smoking and Childhood Disabilities
School district in Toledo, OH
N4114 4-5-6th 7-8th 9-10-11-12th
SBH (behavior) 30.0 36.4 31.5
Non-SBH 7.2 16.8 28.3
SLD (learning) 5.3 17.1 30.5
Non-SLD 7.2 16.8 28.3
DH (intellectual) 4.9 14.9 26.9
Non-DH 7.2 16.8 28.3
Sources Gress, 1996
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Smoking and Mental Retardation
Adult state-operated facility in Gainesville,
Florida
N749 MR Severity of MR in facility Smoking Prevalence
Profound or Severe 84 4.3
Mild or Moderate 16 20.5
All MR 100 7.0
Sources Burtner, 1995
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Smoking and Mental Disorder
N4411 youth and adults, 1990-1992,
cross-sectional from the National Comorbidity
Study
Mental Disorder Current smoker Ever smoker Quit rate
All 28.5 47.1
None 22.5 39.1 42.5
Lifetime 34.8 55.3 37.1
Past month 41.0 59.0 30.5
Sources Lasser, 2000.
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Smoking By Mental Disorder
Diagnosis US Population Current Smoker Lifetime Smoker Quit Rate
No mental disorder 50.7 22.5 39.1 42.5
Social phobia 12.5 35.9 54.0 33.4
Agoraphobia 5.4 38.4 58.9 34.5
Panic Disorder 3.4 35.9 61.3 41.4
Major Depression 16.9 36.6 59.0 38.1
Dysthymia 6.8 37.8 60.0 37.0
Panic Attacks 6.5 38.1 60.4 36.9
Simple Phobia 11.0 40. 57.8 30.3
Non-affective Psychosis 0.6 49.4 67.9 27.2
Alcohol abuse/dependence 21.5 43.5 65.9 34.0
Anti-social/conduct 14.6 45.1 62.5 27.8
PTSD 6.4 45.3 63.3 28.4
Generalized anxiety 4.8 46.0 68.4 32.7
Drug abuse/dependence 11.4 49.0 72.2 32.1
Bipolar disorder 1.6 68.8 82.5 16.6
N4411 youth and adults, 1990-1992, National
Comorbidity Study. Source Lasser, 2000
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Smoking and Mental Disorder
Literature Review of 67 studies on psychiatric
illness and cardiovascular disease risk.
Mental disorder median smoking
Schizophrenia 82
Substance abuse 68
Bipolar 66
Personality 57
Depression 51
ADD 48
Bulmia 46
Anxiety 44
Sources Hayward, 1995.
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Smoking and Mental Disorder
Current Heavy
US (N17000) 33 66
MN (N1440) 30 68
Psych (N277) 52 66
Schizophrenia 88
Mania 70
Major Depression 49
Anxiety 47
Personality 46
Adjustment 45
Psychiatric hospital in Minneapolis, Minnesota
Sources Hughes, 1986.
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Smoking and Mobility Limitations
Prospective cohort from NHANES I data in 1986.
N1124 Never Current Former
Young-Old (60-65) 57 20 23
Old-Old (76-80) 79 12 9
Sources Launer, 1994.
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Smoking and Physical Disabilities
BRFSS data in Massachusetts, 1996-1999
N17380 Ever Ever Current Current Former Former
Disability OR OR OR
Non-disabled 45.9 1.0 19.8 1.0 56.9 1.0
All disabled 58.0 1.43 25.6 1.52 55.9 0.75
Orthopedic 57.6 1.38 26.9 1.68 53.3 0.67
Affective 61.5 1.74 39.6 2.08 35.7 0.51
Sensory 48.1 0.98 23.1 1.61 52.0 0.58
Chronic 64.7 1.89 19.1 1.17 70.4 1.16
P lt 0.05 Sources Brawarsky, 2002.
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Summary of Findings

• Current smoking is higher among
• Male children with learning disabilities
• Children with ADHD and behavioral problems
• Children and adults with any mental disorder
• Adults with orthopedic and affective disabilities
• Current smoking is lower among
• Children with intellectual disabilities (MR)
• Adults with profound or severe MR
• Older adults with mobility impairments
• Older adults with chronic conditions (many former
  smokers)
• Adults with sensory disabilities

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Discussion

• Lack of standardization in the definition of
  persons with disabilities
• Gaps in knowledge due to the numerous varied and
  inter-related disabling conditions
• Difficulty in generalizing state and local
  tobacco estimates to national level
• Confounding effects of nicotine dependence and
  depression among persons with disabilities

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Conclusion

• Summary
• Children with disabilities smoke less than
  children without disabilities, except those with
  mental disorders.
• Adults with mental disorders are more likely to
  smoke regardless of condition and residence.
• Adults with physical disabilities have similar
  national prevalence.
• Need national tobacco prevalence, initiation, and
  cessation estimates of all persons with
  disabilities over life span.
• Future studies with NHANES, NHIS-D BRFSS

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Contact for References

• Alpa Patel-Larson
• ASPH/CDC Fellow
• Office on Smoking and Health, Epi Branch
• Centers for Disease Control and Prevention
• 4770 Buford Hwy, NE, MS K-50
• Atlanta, GA 30341
• Email aop2_at_cdc.gov
• Phone [phone]
• Fax [phone]

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References Cited

• Brawarsky, P., Brooks, D. R., Wilber, N., Gertz,
  R. E., Jr., Klein, W. D. (2002). Tobacco use
  among adults with disabilities in Massachusetts.
  Tobacco Control., 11, Suppl-33.
• Burtner, A. P., Wakham, M. D., McNeal, D. R.,
  Garvey, T. P. (1995). Tobacco and the
  institutionalized mentally retarded usage
  choices and ethical considerations. Spec.Care
  Dentist., 15, 56-60.
• Gress, J. R. Boss, M. S. (1996). Substance
  abuse differences among students receiving
  special education school services. Child
  Psychiatry Hum.Dev., 26, 235-246.
• Hayward, C. (1995). Psychiatric illness and
  cardiovascular disease risk. Epidemiol.Rev., 17,
  129-138.
• Hughes, J. R., Hatsukami, D. K., Mitchell, J. E.,
  Dahlgren, L. A. (1986). Prevalence of smoking
  among psychiatric outpatients. Am.J.Psychiatry,
  143, 993-997.
• Lambert, N. M. Hartsough, C. S. (1998).
  Prospective study of tobacco smoking and
  substance dependencies among samples of ADHD and
  non-ADHD participants. J.Learn.Disabil., 31,
  533-544.
• Lasser, K., Boyd, J. W., Woolhandler, S.,
  Himmelstein, D. U., McCormick, D., Bor, D. H.
  (2000). Smoking and mental illness A
  population-based prevalence study. JAMA, 284,
  2606-2610.
• Launer, L. J., Harris, T., Rumpel, C., Madans,
  J. (1994). Body mass index, weight change, and
  risk of mobility disability in middle-aged and
  older women. The epidemiologic follow-up study of
  NHANES I. JAMA, 271, 1093-1098.
• Svetaz, M. V., Ireland, M., Blum, R. (2000).
  Adolescents with learning disabilities risk and
  protective factors associated with emotional
  well-being findings from the National
  Longitudinal Study of Adolescent Health.
  J.Adolesc.Health, 27, 340-348.