Predictors of the Perception of Smoking Health Risks in Smokers With or Without Schizophrenia

Abstract

Objective

This study sought to examine the predictors of health risk perception in smokers with or without schizophrenia.

Methods

The health risk subscale from the Smoking Consequences Questionnaire was dichotomized and used to measure health risk perception in smokers with (n = 67) and without schizophrenia (n = 100). A backward stepwise logistic regression was conducted using variables associated at the bivariate level to determine multivariate predictors.

Results

Overall, 62.5% of smokers without schizophrenia and 40.3% of smokers with schizophrenia completely recognize the health risks of smoking (p ≤ .01). Multivariate predictors for smokers without schizophrenia included: sex (Exp (B) = .3; p < .05), Smoking Consequences Questionnaire state enhancement (Exp (B) = .69; p < .01), and craving relief (Exp (B) = 1.8; p < .01). Among smokers with schizophrenia, predictors were education (Exp (B) = .7; p < .05), nicotine dependence (Exp (B) = .5; p < .01), motivation to quit (Exp (B) = 1.8; p < .01), and Smoking Consequences Questionnaire craving relief (Exp (B) = 1.8; p < .01).

Conclusions

There was overlap and differences between predictors in smokers with and without schizophrenia. Commonly used techniques for education on the health consequences of cigarettes may work in smokers with schizophrenia, but intervention efforts specifically tailored to smokers with schizophrenia might be more efficacious.

Introduction

Smoking is linked to significant morbidity and mortality; tobacco use has been causally linked to cardiac disease, cancer, lung disorders, and diabetes (Substance Abuse and Mental Health Services Administration, 2016; U.S. Department of Health and Human Services, 2014). People with schizophrenia are more likely to smoke; studies report 60% to 70% prevalence (Agaku, King, & Dube, 2014; de Leon et al., 1995; Dickerson et al., 2013). Tobacco-related conditions may be responsible for half of the deaths in persons with schizophrenia (Callaghan et al., 2014). Smokers with schizophrenia have a 2.5 times higher mortality risk compared to nonsmokers with schizophrenia and a 12-fold higher risk for cardiac-related mortality (Kelly et al., 2011).

Health risk knowledge is associated with motivation to quit and cessation in non–mentally ill smokers (Butler, Rayens, Zhang, & Hahn, 2011; Klein, Zajac, & Monin, 2009; White, Redner, Skelly, & Higgins, 2014). Risk perception distinguished persons who intended to stop smoking from those who did not (Williams, Herzog, & Simmons, 2011) and is a main reason for quitting in smokers with schizophrenia (Filia et al., 2014). Therefore, educating smokers about health risks may be valuable to motivate them to consider quitting.

The tobacco-related conditions that contribute to morbidity in smokers with schizophrenia have led to efforts toward better methods of education and motivation toward cessation. Persons with severe mental illness may be motivated to reduce or quit (Peckham et al., 2015); however, the reasons for smoking and underlying reinforcement of tobacco use may differ in this subset of smokers. This study is a secondary data analysis of research conducted to identify clinical and demographic variables associated with motivation to quit smoking among smokers with and without schizophrenia. In this paper, we examine the differences in health risk perception between smokers with and without schizophrenia, expecting that smokers with schizophrenia will have less awareness of the health risks. Then we conduct an exploratory analysis of the patterns of demographic, health, and smoking consequences that are predictors for smoking health risk perception as a step toward understanding how to intervene on health risk perception in smokers with schizophrenia.

Materials and methods

Participants

The study included smokers older than 18 years old, with or without schizophrenia or schizoaffective disorder (referred to throughout as “schizophrenia”) as defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) and verified by the Structured Clinical Interview for Diagnoses (First, Gibbon, Spitzer, & Williams, 2002). This interview was also used to rule out other Axis 1 disorders for both groups. Smokers with schizophrenia were recruited at the Maryland Psychiatric Research Center, University of Maryland-Baltimore School of Medicine, and smokers without schizophrenia were recruited at the National Institute on Drug Abuse (NIDA), Intramural Research Program, through popular media. All participants smoked ≥5 cigarettes daily, had a breath carbon monoxide level of ≥8 parts per million, and were not currently attempting to quit or reduce smoking. This study was approved by institutional review boards at NIDA, University of Maryland-Baltimore, and the State of Maryland Department of Health and Mental Hygiene. Both inpatients and outpatients were recruited for larger study that was previously reported elsewhere (Kelly et al., 2010; Lo et al., 2011); however, only outpatients are included here. Inpatient participants were excluded because they often have a greater symptom severity and restrictions for tobacco use.

Procedure

The study consisted of a single visit. Participants signed consent, completed a semi-structured interview, and answered clinical and demographic information. Following screening procedures, including breath carbon monoxide, participants smoked a cigarette of their choice to standardize the time of last tobacco exposure before study assessments.

Measures

Participants completed the Smoking Consequences Questionnaire-Adult (Copeland, Brandon, & Quinn, 1995), Fagerstrom Test for Nicotine Dependence (Heatherton, Kozlowski, Frecker, & Fagerstrom, 1991), and the Stages of Change (DiClemente et al., 1991) within a battery of other questionnaires. The Smoking Consequences Questionnaire is a 55-item scale that presents short statements, rated on a scale of 0 to 9, indicating how likely participants believe a consequence is for them. The primary outcome of this paper is the perception of health risks domain of the Smoking Consequences Questionnaire. This variable was positively skewed and was transformed, categorizing participants as recognizing the health risks of smoking if the average score was ≥8.25. The Smoking Consequences Questionnaire was included as predictors to examine how perception of other consequences relates to perception of health risk. The Fagerstrom Test for Nicotine Dependence is the standard measure for nicotine dependence. The Stages of Change is a means of assessing motivation to quit on a 7-point scale. These variables were included in analyses in order to examine the relationship between dependence severity and motivation to quit with health risk perception. Participants also answered questions regarding physical illness and general subjective view of their health. The health variables were included in analyses to determine whether a participants’ health state or having a smoking-related illness was associated with health risk perception.

Analysis

Bivariate analyses were conducted to determine appropriate variables for the multivariate model. Backward stepwise logistic regression was then performed to identify the best predictors of perception of health risks of smoking that satisfied both parsimony and goodness of fit. Consistent with procedures outlined by Hosmer and Lemeshow (2004), variables with p < .25 in bivariate testing were entered into the multivariate logistic model. The Hosmer–Lemeshow goodness-of-fit test was used to assess model fit. Variables with p < .1 were removed individually to arrive at a parsimonious model.

Results

Population

Five smokers with schizophrenia and four smokers without schizophrenia were removed for missing values (n = 67 and n = 96, respectively).

Differences between smokers with and smokers without schizophrenia are presented in Table 1. Smokers with schizophrenia were older, were more likely to be White, were more likely to have a pulmonary disorder, and rated their health as worse than smokers without schizophrenia. Smokers with schizophrenia were less likely to completely recognize health risks of smoking. Smokers with schizophrenia also scored higher on the Smoking Consequences Questionnaire domains of stimulation/state enhancement and tastes good/feels good.

Table 1.

Descriptive data and differences between control and clinical participants.

Category	Variable	Smokers With Schizophrenia (n = 67)		Smokers Without Schizophrenia (n = 96)		t/χ2
		M	%/SD	M/n	%/SD
		Demographics
	Age (years)	45.63	10.58	36.99	10.75	−5.08**
	Education (years)	12.01	1.67	11.84	1.88	−0.60
	Gender (male)c	47	70.1	62	64.6	0.55
	Race (White)c	39	58.2	31	32.3	10.82**
Health-related factors
	Pulmonary disorder (yes)c	16	23.9	2	2.1	19.09**
	Subjective view of general health	3.15	1.00	2.68	0.99	−2.92**
Smoking-related factors
	Nicotine dependence	5.57	1.99	5.33	1.98	−0.74
	Cigarettes per day	21.42	11.93	17.15	7.90	−2.56*
	Motivation to quit	4.04	1.86	4.52	1.96	−0.68
Smoking Consequences Questionnaire
	Accepts health risksc	27	40.3	60	62.5	7.816**
	Reduces negative affect	5.98	2.10	6.53	2.25	1.56
	Stimulates/state enhancement	4.97	2.13	3.64	2.24	−3.81**
	Taste good/feels good	5.34	2.06	4.85	2.16	−2.41*
	Facilitates social interaction	5.04	2.10	4.19	2.29	0.22
	Controls appetite	4.06	2.62	4.15	2.78	−0.53
	Craving relief/addiction promotion	6.17	1.94	6.71	1.47	1.91
	Causes negative physical feeling	2.93	2.38	2.36	2.18	−1.57
	Reduces boredom	6.34	1.88	6.14	2.30	−0.61
	Causes negative social impression	4.11	2.17	3.69	2.49	−1.12

Note.

^*p ≤ .05;

^**p ≤ .01.

^cCategorical variable. Subjective view of general health was measured by the Quality of Life Index–Brief Version (Lehman, Kernan, & Postrado, 1995). Nicotine dependence is measured by the Fagerstrom Test of Nicotine Dependence. Motivation to change is measured using the Stages of Change.

Smokers with schizophrenia

Bivariate and multivariate analyses are displayed in Table 2. In bivariate analyses, smokers with schizophrenia who completely recognize the health risks of smoking were less likely to have a pulmonary disorder, but view their general health as worse. Recognizing the health risks of smoking was associated with greater dependence on the Fagerstrom Test for Nicotine Dependence, more cigarettes smoked per day, greater motivation to quit, and greater scores in the Smoking Consequences Questionnaire domains of reduced negative affect, controls appetite, and craving relief/addiction promotion.

Table 2.

Predictors of cigarette use health risk perception in smokers with or without schizophrenia.

Category	Variable	Smokers With Schizophrenia								Smokers Without Schizophrenia
		Bivariate Associations								Bivariate Associations
		Recognize Risk (n = 27)		Do Not Recognize Risk (n = 40)			Multivariate Model			Recognize Risk (n = 60)		Do Not Recognize Risk (n = 36)			Multivariate Model
		n/M	%/SD	n/M	%/SD	t/χ2	OR†	95%	CI	n/M	%/SD	n/M	%/SD	t/χ2	OR†	95%	CI
Demographics
Gender						0.001	—							3.51*
	Male	28	73.5	19	66.7					43	71.7	19	52.8		1
	Female	12	26.5	8	33.3					17	28.3	17	47.2		0.35*	[0.14	0.91]
Health-related factors
Pulmonary disorder						4.31*	‡							N/A	—
	No disorder	34	85	17	63					59	98.3	35	97.2	N/A
	Disorder	6	15	10	37					1	1.7	1	2.8	N/A
Subjective view of general health		2.69	3.52	0.98	2.9	2.58*	‡			3.52	2.69	0.95	2.67	0.13	—
Smoking-related factors
	Nicotine dependence	5.28	6.74	1.61	4.78	4.50**	1.99**	[1.30	3.04]	6.74	5.28	2.05	5.42	−0.31	—	[1.30	3.04]
	Cigarettes per day	17.04	26.81	13.69	17.78	3.01**	‡			26.81	17.04	7.54	17.33	−0.17	—
	Motivation to quit	4.45	4.85	1.56	3.5	3.10**	1.92**	[1.21	3.03]	4.85	4.45	2.05	4.64	−0.46	—	[1.21	3.03]
Smoking Consequences Questionnaire
	Reduces negative affect	6.59	6.76	1.66	5.45	2.61*	‡			6.76	6.59	2.46	6.42	0.36	—
	Stimulates/state enhancement	3.38	5.21	2.07	4.82	0.74	—	[0.55	0.90]	5.21	3.38	2.4	4.08	−1.57	0.70**
	Taste good/feels good	4.66	5.89	1.95	4.97	1.81	‡			5.89	4.66	2.28	5.16	−1.1	‡
	Facilitates social interaction	3.98	5.4	1.86	4.81	1.14	—			5.40	3.98	2.4	4.54	−1.15	‡
	Controls appetite	4.04	4.93	2.68	3.47	2.31*	‡			4.93	4.04	2.94	4.35	−0.53	—
	Craving relief/addiction promotion	6.89	7.08	1.39	5.56	3.41**	1.61*	[1.06	2.45]	7.08	6.89	1.47	6.4	−.59	1.79**	[1.06	2.45]
	Causes negative physical feeling	2.42	3.33	2.49	2.65	1.16	‡			3.33	2.42	2.31	2.26	0.35	—
	Reduces boredom	6.32	6.76	1.82	6.06	1.51	‡			6.76	6.32	2.35	5.84	0.98	—
	Causes negative social impression	3.68	4.68	2.28	3.72	1.8	‡			4.68	3.68	2.79	3.69	−0.02	—

Note.

^*p ≤ .05;

^**p ≤ .01.

^†Adjusted for those variables in the final model.

^‡Variables are excluded in the final model in backward stepwise selection procedure, adjusted p ≥ .20.—Variable not entered in the model, bivariate association p ≥ .25. Subjective view of general health was measured by the Quality of Life Index–Brief Version. Nicotine dependence is measured by the Fagerstrom Test of Nicotine Dependence. Motivation to change is measured using the Stages of Change.

The multivariate model demonstrated adequate goodness of fit (Hosmer and Lemeshow χ²₈ = 12.2, p = .14) and accounted for 54.3% of the variance, χ²₃ = 34.4, p ≤ .001. Smokers with schizophrenia who completely recognize the health risks of smoking scored higher on the Fagerstrom Test for Nicotine Dependence, motivation to quit, and the Smoking Consequences Questionnaire domain of craving relief/addiction promotion.

Smokers without schizophrenia

Bivariate and multivariate analyses are displayed in Table 2. In bivariate analyses, smokers without schizophrenia who recognize the health risks of smoking were less likely to be female. The multivariate model demonstrated adequate goodness of fit (Hosmer and Lemeshow χ²₈ = 10.6, p = .23) and accounted for 20.6% of the variance, χ²₃ = 16.0, p ≤ .001. Smokers without schizophrenia who completely recognize the health risks of smoking were less likely to be female but also scored lower in the Smoking Consequences Questionnaire domain of stimulation/state enhancement and higher in the domain of craving relief/addiction promotion.

Discussion

As expected, smokers with schizophrenia were less likely to completely recognize the health risks of smoking than smokers without schizophrenia, despite having higher average daily cigarette use and significantly higher rates of existing pulmonary disease. Despite multifaceted educational efforts to convey the health risks of smoking through traditional and social media, 38% of smokers without schizophrenia and 60% of smokers with schizophrenia still fail to completely recognize these serious risks. The results of this study highlight the need for more educational efforts on health risks associated with smoking, especially since people who understand the risks have higher cessation rates (Thakkar, Heeley, Chalmers, & Chow, 2015). Ongoing clinical trials on education, perception, and cessation may help determine optimal intervention timing and placement to maximize the relation between health risk and smoking cessation (NCT01685723; Li, Chan, Wang, & Lam, 2015). However, a recent paper examining clinician attitudes toward preventive education on health behaviors showed that one-third of clinicians believed that this reduced the time available for delivery of other services (Bartlem et al., 2016). Thus, mental health systems should provide opportunities for the education of smoking risks.

Smokers with schizophrenia who have the most realistic perceptions of smoking risk are those with high dependency scores and a high motivation to quit. The relationship between high dependency scores and understanding smoking risks in smokers with schizophrenia may reflect heavier smokers’ realizations that significant smoking habits are unhealthy, where lighter smokers may be naïve to the risks of even “light” smoking. This may represent an opportunity for educational intervention. Some of the lack of understanding of risks might be due, in part, to less exposure to those risks in educational settings. Persons are most likely to present with thought disruptive symptoms of schizophrenia in the adolescent and/or young adult years, which may lead to disruption of education. Cognitive impairment and hallucinations/delusions may also make conversations regarding health risks of tobacco smoking more difficult. Therefore, not only could smokers with schizophrenia attain a lower level of reading comprehension, they may also miss out on school-based education on health risks of tobacco use, and their clinicians may not be as focused on cessation education compared to smokers without schizophrenia. Higher reading levels and educational attainment predicted quit attempts, possibly reflecting a better understanding of risks (White et al., 2014). Since materials targeting health risk education may be written beyond reading skills of many smokers with schizophrenia (Meade & Byrd, 1989) and educational limitations may have prevented exposure to classroom-based information, interventions for smokers with schizophrenia may need to be targeted differently than those for the general population.

We found that smokers in both groups who had higher craving relief/addiction promotion expectancies recognized the health risks. Being aware of the negative reinforcing effects of smoking (i.e., relief from craving) requires the acknowledgement of a detrimental effect of smoking (craving/addiction). Acknowledging one detrimental effect may help smokers recognize other detrimental aspects of smoking, leading to quit attempts. This idea is supported by behavioral data; greater cue-induced cravings are associated with a greater likelihood of a quit attempt (Conklin, Parzynski, Salkeld, Perkins, & Fonte, 2012). Awareness of one’s personal susceptibility to cigarette cravings might be associated with other factors related to quit attempts. Having patients examine their cravings before a quit attempt might offer some clinical utility.

In smokers without schizophrenia who recognize health risks were more likely to be male, which replicates previous findings that gender is more important for health risk perception in smokers without than for smokers with schizophrenia (Filia et al., 2014). Smokers without schizophrenia who smoke for state enhancement or stimulation were less likely to recognize cigarette health risks. This finding might represent the complement of what was found with craving relief in that craving relief is a form of negative reinforcement requiring a focus on detrimental aspects of smoking, whereas state enhancement is a form of positive reinforcement requiring a focus on beneficial aspects of smoking. This hypothesis could be examined experimentally by assessing perceptions of health risk in the context of smoking following forced abstinence (when negative reinforcement would be strongest) versus ad libitum smoking.

The present study is limited, as it was a secondary data analysis and not designed specifically to examine perceptions of health risks. Multiple predictors one might wish to include were not measured (e.g., family history of smoking-related deaths, optimism/pessimism), and the options for the independent variable were limited. For example, some measures of health risk perception assess both likelihood and desirability (Brandon & Baker, 1991). Another limitation was that our measure of perception of the health risks of smoking was not normally distributed. The point at which the scale was cut split the sample but also was at a value where the participants would have had to answer at least one of the health risk variables at the highest level. Given the pervasiveness of messages about the health risks of smoking, this cutpoint seems a natural place to split.

This study shows that perception of deleterious health effects of smoking is impaired in many smokers with schizophrenia, with only 40% of that group completely recognizing the likelihood of health risks. More work is needed on educational programs and tailored psychosocial treatments based on how well various clinical subgroups understand the health risks of smoking.