Tobacco Use and Comorbidity

There is clear evidence of high rates of psychiatric comorbidity, including other substance abuse, among adolescents and adults who smoke. For example, it has been estimated that individuals with psychiatric disorders purchase approximately 44 percent of all cigarettes sold in the United States, which undoubtedly contributes to the disproportionate rates of morbidity and mortality in these populations. In addition, studies have shown that as many as 80 percent of alcoholics smoke regularly, and that a majority of them will die of smoking-related, rather than alcohol-related, disease.

In young smokers, the behavior appears to be strongly associated with increased risk for a variety of mental disorders. In some cases—such as with conduct disorders and attention-deficit hyperactivity disorder—these disorders may precede the onset of smoking, while in others—such as with substance abuse—the disorders may emerge later in life. Whether daily smoking among boys and girls is the result or the cause of a manifest psychiatric condition, it is troubling that so very few adolescents have their nicotine dependence diagnosed or properly treated. Preventing the early onset of smoking and treating its young victims are critical primary-care priorities, the fulfillment of which could have a dramatic impact on our ability to prevent or better address a wide range of mental disorders throughout life.

Among adults, the rate of major depressive episodes is highest in nicotine–dependent individuals, lower in nondependent current smokers, and lowest in those who quit or never started smoking. Furthermore, there is evidence showing that, for those who have had more than one episode, smoking cessation may increase the likelihood of a new major depressive episode. Adult tobacco use also increases risk for the later development of anxiety disorders, which may be associated with an increased severity of withdrawal symptoms during smoking cessation therapy. But the most extensive comorbidity overlap is likely the one that exists between smoking and schizophrenia, since, in clinical samples, the rate of smoking in patients with schizophrenia has ranged as high as 90 percent.