Amin A. Muhammad Gadit  ( Discipline of Psychiatry, Memorial University of Newfoundland, Canada. )

Smoking has been a health hazard that can lead to a large number of complications. There are global efforts to address this problem. Even the tobacco companies are under instructions to write on the cigarette packs to mention the health hazard as a warning. According to WHO, 5.4 million people died in 2008 as a result of tobacco and by 2030 more than 8 million people will be dying every year from tobacco.¹ In Pakistan, about 100,000 people die every year because of smoking. A local research mentions that 24% male and 16% female college students were regular smokers in Karachi.¹ In a local study,² a sample of 9442 individuals aged 15 years or older was analyzed. Overall prevalence of smoking was 15.2%. It was 28.6% among men and 3.4% among women. The highest prevalence was reported in men aged 40-49 (40.9%). According to reports,³ there is a strong association between smoking and mental health disorders. The highest levels of smoking in any population group occur among inpatients in mental health units where up to 50% are heavy smokers. Researchers believe that smoking could act as a trigger for mental ill-health. In UK, smoking rates among adults with depression are about twice as high as among adults without depression. The smoking rates among people with schizophrenia are significantly higher than the general population, with estimates ranging from 58% to 88%. Reports quoting research studies mentioned lower IQ among smokers.Also prenatal smoking exposure was associated with significantly smaller frontal lobe and cerebellar volumes in the brains of preterm infants and young adults and had a significantly increased risk for use of psychiatric drugs than unexposed young adults.⁴ A study conducted in Australia and US revealed that 20% of adult population had a 12-month mental disorder, among adult smokers, with approximately 31.7% in the US and 32.4% in Australia. Female smokers had a higher rate of mental disorders than male smokers and younger ones had higher rates than older smokers.⁵
A new research examined the association between mental health and second hand smoke exposure by measuring the circulating biochemical marker \\\'cotinine\\\', which is found in the saliva. It was concluded that second hand smoke exposure is associated with psychological distress and risk of future psychiatric illness in healthy adults.⁶ A national survey of psychiatric morbidity among over 8,000 people in the general population found that people with neurotic disorders such as depressive episodes, phobias or obsessive compulsive disorders were twice as likely as those with no neurotic disorder to be associated with heavy smoking.⁷ Nearly two thirds (64%) of those identified with a probable psychosis were smokers compared to 29% without psychosis; 35% were heavy smokers compared to 9% without psychosis.⁷ In a population-based study,⁸ current smoking rates for respondents with no mental illness, life time mental illness, and past-month mental illness were 22.5%, 34.8% and 41.0%, respectively. A Danish study⁹ was able to demonstrate association of smoking with increased risk of developing depression. Pratt and Brody¹⁰ noted that about 7% of adults aged 20 and over had depression in 2005-2008, based on National Health and Nutrition Examination Survey (NHANES) data. Persons with depression were more likely to be current smokers than persons without depression. In a study¹¹ conducted on 486 adolescent patients, 129 (28.6%) reported ever-using tobacco products and 168 (14%) were current smokers who had an average of 2 cigarettes per day. Current smoking was associated with significantly increased odds of having mental health problems and substance use disorders. There is a paucity of such studies in developing countries like India and Pakistan. One study conducted by Chandra et al¹² among psychiatric patients revealed that 351 out of 988 (36%) patients reported current tobacco use with 227 (65% of all users) reporting moderate to severe nicotine dependence. It was concluded that current tobacco use as well as nicotine dependence were associated with male gender, a diagnosis of bipolar disorder and the risk of other substance use problems. A local study¹³ in Pakistan was conducted in Manora island of Karachi on pattern of tobacco consumption among adult women of low socioeconomic community. It was found that women consuming tobacco reported more anxiety related symptoms as compared to women who did not consume tobacco.
Extensive literature review confirms that there is a strong association of smoking with mental illness. This makes the issue more serious in terms of addressing the matter of banning cigarette smoking and health education. It appears that the general population is not adequately sensitized about the effects of smoking on mental health. Even the doctors focus more on medical issues rather than mental health problems. Mental health professionals have little training in physical care¹⁴ and higher smoking rates among these practitioners may mitigate against their advising patients who are smokers to stop.¹⁵
At local level in Pakistan, there is a greater need to sensitize the health policy makers, media, general public, general doctors and of course, the mental health practitioners. At this point and time, our insight into this aspect of smoking is either lacking or very much limited. What would be the general opinion?

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