Cigarette smoking and 9/11-related posttraumatic stress disorder among World Trade Center Health Registry enrollees, 2003–12
Introduction
Multiple studies have reported a strong association between smoking and mental health conditions including depression, anxiety, non-specific psychological distress, and posttraumatic stress disorder (PTSD) (Cook et al., 2014, Fu et al., 2007, Lawrence et al., 2011, Vanable et al., 2003). Adults with mental health conditions, including PTSD, smoke at rates twice as high as those in good mental health (Lasser et al., 2000, Feldner et al., 2007, Lawrence et al., 2009, Morris et al., 2014). Despite recent declines in smoking prevalence in the general population, smoking rates have not declined similarly among those with poor mental health (Cook et al., 2014). Though smokers with poor mental health attempt to quit at levels comparable to other smokers, they appear to be less successful (Fu et al., 2007, Lawrence et al., 2011, Morris et al., 2014).
The September 11, 2001 (9/11) terrorist attack on the World Trade Center (WTC) in New York City (NYC) resulted in elevated rates of PTSD and depression among exposed persons immediately and for years post-disaster (Brackbill et al., 2009, Galea et al., 2002). Population-based studies following 9/11 have found increased smoking rates among those directly exposed with or without current PTSD symptoms (Vlahov et al., 2002, Vlahov et al., 2004a, Vlahov et al., 2004b, Wu et al., 2006). Becker and Murphy (1988) theorize that psychosocial stress reduces the likelihood that current smokers will quit and makes former smokers more susceptible to relapse and more likely than current smokers to increase cigarette consumption. In a review of studies on smoking, traumatic exposure(s) and PTSD, Feldner et al. (2007) noted elevated rates of smoking (current and lifetime) and nicotine dependence among persons exposed to traumatic events compared to persons without traumatic exposure; however, in multiple studies, PTSD was related to current smoking beyond the effects of the traumatic exposure itself. PTSD can be an impediment to successful quitting (Fu et al., 2007, Morris et al., 2014). Smokers with PTSD are more likely to relapse than smokers without PTSD (Beckham et al., 2013, Zvolensky et al., 2008). Hapke et al., (2005) found that trauma exposed persons with PTSD were significantly less likely to quit than individuals with no history of traumatic exposure; there was no significant difference in the odds of quitting among trauma exposed persons without PTSD compared to individuals with no history of traumatic exposure. Smoking and the reduced probability of quitting among trauma exposed persons with PTSD are characterized by two distinct smoking motivations (Feldner et al., 2007). Trauma exposed persons with PTSD may smoke in response to trauma-related cues (Beckham et al., 1996, Beckham et al., 2005) and may be more likely smoke in order to reduce negative affect (e.g., anger, contempt, guilt, fear) (Calhoun et al., 2011, Dedert et al., 2012, Feldner et al., 2007).
The high burden of PTSD among persons directly exposed to 9/11 and other disasters may increase the probability of continued smoking and relapse, while hindering smoking cessation among this group. Using data from the WTC Health Registry (Registry), we examined smoking prevalence and the association between PTSD and quitting over a 7–9 year period among a cohort with firsthand traumatic exposure. Based on previous studies, we hypothesized that enrollees with 9/11-related PTSD would be more likely to smoke and less likely to quit than persons without PTSD.
Section snippets
Data source
The Registry is a cohort study of 71,431 individuals directly exposed (firsthand, in-person exposure) to the events of 9/11 in NYC and was designed to monitor the physical and mental health effects of 9/11 for at least twenty years. Details on Registry eligibility criteria, recruitment methods, and findings have been published elsewhere (Brackbill et al., 2009, Farfel et al., 2008, Murphy et al., 2007). In summary, Registry enrollees comprise rescue/recovery workers and volunteers; lower
Results
The largest proportion of enrollees was male (62.3%), age 45 to 64 years at W1 (48.5%), non-Hispanic white (72.1%), had a 2002 household income of at least $50,000 (68.0%), and had attended some college or higher (79.0%; Table 1). There was a significant trend in PTSD prevalence, increasing from W1 (14.3%) to W3 (17.1%; Table 2).
We observed a significant downward trend in the adjusted prevalence of smoking from 12.6% at W1 to 9.2% at W3 (Table 1). At both waves, the largest proportion of smokers
Discussion
In this study of 34,458 persons directly exposed to the WTC disaster we observed a significant decrease in the smoking prevalence from 2003–04 to 2011–12. At Waves 1 and 3 the largest proportion of smokers were non-daily smokers, who were the most likely to have quit smoking by W3. As in previous studies (Feldner et al., 2007), the prevalence of smoking was greatest among enrollees with PTSD, and in multivariable analyses the likelihood of quitting by W3 was lower among enrollees with PTSD.
Conclusion
Our findings may be applicable to those affected by other disasters and who suffer from PTSD, whether disaster-related or not. Disaster exposed smokers, especially those with PTSD, are at greater risk for adverse health outcomes including cardiovascular disease, cancer, respiratory disorders, and diabetes. This group merits special attention in order to address their smoking behavior, and might benefit greatly from PTSD-specific smoking cessation interventions, including counseling and
Conflict of interest statement
The authors declare that there are no conflicts of interest.
Acknowledgments
The authors are grateful for the helpful advice and comments from Drs. Mark Farfel, Steven Stellman, James Cone, Susan Kansagra, Venkatarama Koppaka, James Hadler, and Thomas Farley and Christine Johnson; and for the technical assistance from Dr. Lisa Gargano and Josiane Georges.
This publication was supported by Cooperative Agreement Number 5U50/OH009739 from the National Institute for Occupational Safety and Health (NIOSH) of the Centers for Disease Control and Prevention (CDC); U50/ATU272750
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2019, Addictive BehaviorsCitation Excerpt :However, this escalation in cigarette use does not appear to be due to posttraumatic stress symptoms because posttraumatic stress was not associated with daily cigarette use or nicotine dependence after Hurricane Katrina. These results contradicted other studies that showed that smokers with PTSD and posttraumatic stress were more likely to be heavy smokers (≥20 cigarettes daily) than light smokers (Joseph et al., 2012; Welch, Jasek, Caramanica, Chiles, & Johns, 2015), and were more likely to be dependent on nicotine than non-PTSD smokers (Goodwin, Pagura, Spiwak, Lemeshow, & Sareen, 2011; Thorndike, Wernicke, Pearlman, & Haaga, 2006). However, some studies showed no association between posttraumatic stress and cigarette use and nicotine dependence (Parslow & Jorm, 2006; Thorndike et al., 2006).
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2018, Addictive BehaviorsCitation Excerpt :Details of included studies are provided in Supplementary Appendix B. Thirteen studies examined prevalence of prior or current use of tobacco products among individuals with a history of or current PTSD (Baschnagel, Coffey, Schumache, Drobes, & Saladin, 2008; Boscarino, 2008; Bromet et al., 2016; Cook, Jakupcak, Rosenheck, Fontana, & McFall, 2009; Cougle, Zvolensky, Fitch, & Sachs-Ericsson, 2010; Crum-Cianflone et al., 2016; de la Hoz, Jeon, Miller, Wisnivesky, & Celedón, 2016; Fullerton et al., 2013; Gabert-Quillen, Selya, & Delahanty, 2015; Lawrence et al., 2009; Welch, Jasek, Caramanica, Chiles, & Johns, 2015; Witteveen et al., 2010; Zen, Whooley, Zhao, & Cohen, 2012), of which 11 provided rates of cigarette smoking while only two assessed the use of other tobacco products (smokeless, pipe, cigars, chewing tobacco) (Crum-Cianflone et al., 2016; Fullerton et al., 2013). Eleven studies provided rates of current tobacco use among individuals with PTSD (Baschnagel et al., 2008; Bromet et al., 2016; Cook et al., 2009; Crum-Cianflone et al., 2016; de la Hoz et al., 2016; Fullerton et al., 2013; Gabert-Quillen et al., 2015; Lawrence et al., 2009; Welch et al., 2015; Witteveen et al., 2010; Zen et al., 2012), which when combined yield a prevalence of 24% (95% CI, 18.9%–29.9%; Q (11) = 242.631, I2 = 95.466, p < 0.0001).
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2017, American Journal of Preventive MedicineLung Function Trajectories in World Trade Center-Exposed New York City Firefighters over 13 Years the Roles of Smoking and Smoking Cessation
2016, ChestCitation Excerpt :Most important, we found that those who quit smoking during follow-up had better lung function than those who continued to smoke, despite weight gain, demonstrating that, despite the prevailing fatalism of that time,24 that the “damage has already been done,” tobacco cessation efforts postdisaster can be successful even in a highly exposed, traumatized workforce.
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2015, Comprehensive PsychiatryCitation Excerpt :Yet, these results are consistent with past empirical work that has linked greater levels of PTSD symptoms with poor cessation outcome in cross-sectional surveys of the general population [28], self-guided (unaided by intervention) quit attempts [30], treatment studies [33], and longitudinal observational studies [11]. The present findings also are consistent with a recent study showing that PTSD was prospectively associated with reduced odds of quitting among adults exposed to the 9/11 attacks [40]. Future work is needed to explore the mechanisms underlying these associations, including such factors as affect regulation processes (e.g., negative reinforcement smoking expectancies or motives, emotional reactivity, distress intolerance) and physical illness (e.g., respiratory symptoms, disease), explicitly implicated in models of trauma-smoking comorbidity [1,32].