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Letter to the Editor

Report Ignores Risk Factor of Tobacco in Assessing Suicidality

Jill M. Williams, MD and Marc L. Steinberg, PhD

Published: November 25, 2015

See reply by Han and Compton and article by Han et al

This work may not be copied, distributed, displayed, published, reproduced, transmitted, modified, posted, sold, licensed, or used for commercial purposes. By downloading this file, you are agreeing to the publisher’s Terms & Conditions.

Report Ignores Risk Factor of Tobacco in Assessing Suicidality

To the Editor: We read with great interest the recent (March) report by Dr Han and coauthors.1 We agree with the authors that factors that predict the transition from suicidal ideation to attempts are not well understood and warrant further study. Analyses were on more than 200,000 persons using the rich National Survey on Drug Use and Health (NSDUH) dataset that includes numerous measures on mental illness and other substance use in addition to sociodemographics. However, we were perplexed to find that tobacco smoking was not mentioned in the methods or analyses even though the NSDUH contains tobacco use measures.

This is surprising given that there is ample evidence that smoking is associated with increased risk for suicide. Numerous studies have found an association with smoking and increased suicidal thoughts or attempts.2-4 A meta-analysis of 15 prospective studies maintained that cigarette smoking increased the risk of completed suicide (with a relative risk of 1.81 in current vs never smokers), with a significant dose-response relationship in those who smoked more cigarettes per day.5

The report includes 10 other subcategories of specific substance types, many of which were not significantly associated with suicide attempts in the multivariate analysis. The implicit message to the reader is that tobacco use is not an addiction on par with other addictions. The continued lack of recognition of tobacco use as an addiction is problematic for the field of psychiatry.

Most of the excess mortality in mental illness is directly attributable to cigarette smoking.6 There are also financial, social, and behavioral health consequences of being a tobacco user that negatively impact recovery.7,8 Mental health professionals rarely assess and treat tobacco use despite the existence of safe and effective treatments.9 Inclusion of tobacco measures into ongoing research efforts in psychiatry is an important and often cost-neutral way to increase recognition and importance of addressing tobacco use in mental health care. That these authors represent influential federal agencies (SAMHSA [Substance Abuse and Mental Health Services Administration] and NIH [National Institutes of Health]) makes it only more critical to acknowledge tobacco use in all areas of psychiatry research and treatment. Inclusion of tobacco measures is essential if we are to make progress in this area.


1. Han B, Compton WM, Gfroerer J, et al. Prevalence and correlates of past 12-month suicide attempt among adults with past-year suicidal ideation in the United States. J Clin Psychiatry. 2015;76(3):295-302. doi:10.4088/JCP.14m09287 PubMed

2. Breslau N, Schultz LR, Johnson EO, et al. Smoking and the risk of suicidal behavior: a prospective study of a community sample. Arch Gen Psychiatry. 2005;62(3):328-334. doi:10.1001/archpsyc.62.3.328 PubMed

3. Oquendo MA, Bongiovi-Garcia ME, Galfalvy H, et al. Sex differences in clinical predictors of suicidal acts after major depression: a prospective study. Am J Psychiatry. 2007;164(1):134-141. doi:10.1176/ajp.2007.164.1.134 PubMed

4. Hughes JR. Smoking and suicide: a brief overview. Drug Alcohol Depend. 2008;98(3):169-178. doi:10.1016/j.drugalcdep.2008.06.003 PubMed

5. 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. doi:10.1016/j.jpsychires.2012.03.013 PubMed

6. Callaghan RC, Veldhuizen S, Jeysingh T, et al. Patterns of tobacco-related mortality among individuals diagnosed with schizophrenia, bipolar disorder, or depression. J Psychiatr Res. 2014;48(1):102-110. doi:10.1016/j.jpsychires.2013.09.014 PubMed

7. Steinberg ML, Williams JM, Ziedonis DM. Financial implications of cigarette smoking among individuals with schizophrenia. Tob Control. 2004;13(2):206. PubMed

8. Taylor G, McNeill A, Girling A, et al. Change in mental health after smoking cessation: systematic review and meta-analysis. BMJ. 2014;348:g1151. doi:10.1136/bmj.g1151 PubMed

9. National Mental Health Services Survey (N-MHSS) Data Spotlight Report, November 25, 2014. Substance Abuse and Mental Health Services Administration (SAMHSA), 2010. Accessed July 30, 2015.

Jill M. Williams, MDa

Marc L. Steinberg, PhDa

aDivision of Addiction Psychiatry, and Department of Psychiatry, Rutgers University-Robert Wood Johnson Medical School, New Brunswick, New Jersey

Potential conflicts of interest: Drs Williams and Steinberg have received grant research support from Pfizer. Dr Williams has received consultation fees from the American Lung Association.

Funding/support: None reported.

J Clin Psychiatry 2015;76(11):1570-1571

© Copyright 2015 Physicians Postgraduate Press, Inc.

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