See letter by Aubin et al and article by Kuo et al

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Drs Hung and Kuo Reply

To the Editor: Aubin and colleagues recently commented on our findings1 on the risk and protective factors for suicide mortality in patients with alcohol dependence, drawing attention to omission of tobacco smoking as a potential risk factor.

Indeed, the association of smoking and suicide mortality has received increased attention.2 In another study, we showed evidence of excess suicide mortality among young adults exposed to cigarette smoking.3 In the present study,1 we would certainly have included smoking as a candidate predictor if it had been well documented in the medical records. In the limitations section, we stated that data on certain predictors of suicide mortality were unavailable. Smoking status is included among those factors.

Nonetheless, the primary objective in identifying risk factors for suicide is to effectively screen for high-risk individuals and intervene. Therefore, risk factors with good specificity are more desirable. In our present study,1 we argued that depression is too prevalent in patients with alcohol dependence to serve as a useful risk factor.4 Similarly, the prevalence of tobacco smoking in alcohol use disorder is as high as 75%.5 This factor would be too sensitive and not sufficiently specific to predict suicide. Further research is needed to clarify the role of smoking as a predisposing factor in suicide mortality in patients with alcohol dependence. In addition, attempts to identify novel risk factors with better predictive power, such as a combination of childhood adversities and aggressive behaviors,6 are also warranted.


1. Hung GC-L, Cheng CT, Jhong JR, et al. Risk and protective factors for suicide mortality among patients with alcohol dependence. J Clin Psychiatry. 2015;76(12):1687–1693. doi:10.4088/JCP.15m09825 PubMed

2. Li D, Yang X, Ge Z, et al. Cigarette smoking and risk of completed suicide: a meta-analysis of prospective cohort studies. J Psychiatr Res. 2012;46(10):1257–1266. PubMed doi:10.1016/j.jpsychires.2012.03.013

3. Chen VC, Kuo CJ, Wang TN, et al. Suicide and other-cause mortality after early exposure to smoking and second hand smoking: a 12-year population-based follow-up study. PLoS ONE. 2015;10(7):e0130044. doi:10.1371/journal.pone.0130044 PubMed

4. Mann K, Hintz T, Jung M. Does psychiatric comorbidity in alcohol-dependent patients affect treatment outcome? Eur Arch Psychiatry Clin Neurosci. 2004;254(3):172–181. PubMed doi:10.1007/s00406-004-0465-6

5. Guydish J, Passalacqua E, Pagano A, et al. An international systematic review of smoking prevalence in addiction treatment. Addiction. 2016;111(2):220–230. PubMed doi:10.1111/add.13099

6. Hung GC, Caine ED, Fan HF, et al. Predicting suicide attempts among treatment-seeking male alcoholics: an exploratory study. Suicide Life Threat Behav. 2013;43(4):429–438. PubMed doi:10.1111/sltb.12028

Galen Chin-Lun Hung, MD, ScMa,b

Chian-Jue Kuo, MD, PhDa,c,d

aTaipei City Psychiatric Center, Taipei City Hospital, Taipei, Taiwan

bDepartment of Public Health, School of Medicine, National Yang Ming University, Taipei, Taiwan

cDepartment of Psychiatry, School of Medicine, Taipei Medical University, Taipei, Taiwan

dPsychiatric Research Center, Taipei Medical University Hospital, Taipei, Taiwan

Potential conflicts of interest: None.

Funding/support: None.

J Clin Psychiatry 2016;77(7):e907

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