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

1. 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

2. Acknowledgements Yale University Stephanie O’Malley, 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

3. Today’s agenda • Brief history of traditional tobacco use in AI populations • 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

4. Used historically for religious and ceremonial purposes Tobacco used 20x stronger Tobacco’s 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 History of tobacco use among AI Woodland Bird Effigy Stone Pipe Mississippian 1200 - 1500 AD Woodland Frog Effigy Stone Pipe Eastern Tennessee 500 - 800 AD

5. History of tobacco use among A.I./A.N.

6. 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 Mother’s head, so that “it soothes the mind and sobers thought.” Cultural relevance of tobacco use: Iroquois Creation Story

7. 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 heart Used in various ceremonies Tobacco’s reverence as a sacred plant in Native communities

8. 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 well-being Evoke the memories of survival, strength, nation, and tradition. Commercialized tobacco use: Disrespectful to the creator/disconnect from the culture Addictive Numerous medical consequences Destroys communities/lives Becomes a mundane everyday affair, loses its power and important cultural relevance Traditional use of tobacco versus commercialized tobacco use

9. 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.

10. 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)

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

12. 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)

13. 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)

14. 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 significant • Nicotine dependence most prevalent among individuals with a current alcohol or drug use disorder [34.5% (OR=4.4) and 52.4% respectively (OR=8.1)]

15. 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. population • 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

16. Background • 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

17. Hypothesis 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).

18. Methods • 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

19. Assessments • 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.

20. 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

21. 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

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

27. 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% respectively).

28. Nicotine dependence and comorbid depression • Several explanations have been proposed including: -smokers use nicotine to self-medicate their depressed mood -causal influence of smoking on MDD -underlying environmental, genetic, and biological factors may predispose individuals to both Sources: Glass, 1990; Hughes1988; Kendler et al., 1993). Dierker et al., 2002; Patten et al., 2001; Williams and Ziedonis, 2004

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

30. 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).

31. 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.

32. Limitations • 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

33. References • Centers for Disease Control. Morbidty and Mortality Weekly Report. Cigarette smoking among adults-United States, 2006 November 9, 2007 / 56(44);1157-1161 • Dierker LC, Avenevoli S, Stolar M, Merikangas KR. 2002. Smoking and depression: An examination of mechanisms of comorbidity. Am J Psychiatry 159:947-953. • 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 17(4):237-241 Hughes JR. 1988. Clonidine, depression, and smoking cessation. JAMA 259: 2901-2902.

34. References • Kalman, D., Morissette, S.B., George, T.P. (2005). Co-Morbidity of Smoking in Patients with Psychiatric and Substance Use Disorders. AM J Addictions, 14:2, 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 depressed child and adolescent population. 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. Depress Anxiety 0:1-6. • O’Nell TD. 1996. Coming home among Northern Plains Vietnam veterans: psychological transformations in pragmatic perspective. Ethos 2000; 27:441-465. • Patten CA, Gillin C, Golshan S, WOlter TD, Rapaport M, Kelsoe J. 2001. Relationship of mood disturbance to cigarette smoking status among 252 patients with a current mood disorder. J Clin Psychaitry 62: 319-324.

35. References • 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 conditions. J Clin Psychiatry 66(5). 564-574. • Potenza MN, Steinberg MA, McLaughlin SD, Wu R, Rounsaville BJ, Krishnan-Sarin S, George TP, O’Malley SS. 2004. Characteristics of tobacco-smoking problem gamblers calling gambling helpline. Am J Addict 2004; 13:471-493. • U.S. Census Bureau, 2003 http://www.census.gov/statab/www/sa04aian.pdf • Williams, JM, Ziedonis D. 2004. Addressing tobacco among individuals with a mental illness or an addiction. Addict Behav 29:1067-1083. • 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 reservation. Am Indian Alsk Native Ment Health Res. 2: 27-41.