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Journal of Rural Community Psychology Volume E7 Number 1 Spring

2004

The relationship between smoking and depression in

the rural Midwestern United States

Jason M. Wise, David Weidner, & Donald. W. Preussler

Center for Rural Psychology, Kaneville, IL

ABSTRACT

The purpose of this study was to determine if there is a relationship between


smoking and depression in a rural population in the Midwestern United States.
Participants included 1,191 adults (age 18-65) assessed and treated by the Farm
Resource Center (FRC) between 1995-2000. For purposes of this study, demographic
and assessment data collected by FRC was analyzed. The participants included
farmers, miners, and other rural individuals and families served by FRC. A
reliable depression scale was formed from the participants’ pre-treatment
assessment symptom checklist responses. In a case control design, smokers were
found to score significantly higher on the depression scale than non-smokers.
Broken down by gender, it was found that the significant difference existed for
females, but not for males. The effect sizes of the differences in both analyses
were small. It was concluded that smoking is mildly related to depression in
women.

INTRODUCTION

The dangers of depression and tobacco use affect the lives of countless
individuals and their families. Major Depressive Disorder has a lifetime risk
rate of 10% to 25% for females and from 5% to 12% for males (American Psychiatric
Association, Diagnostic and Statistical Manual of Mental Disorders, 4th edition,
text revision, 2000). Not only are individuals affected, but family members and
coworkers also suffer the consequences of this problem. The symptoms of
depression can lead to unproductivity and relational difficulties, which can
result in loss of employment, divorce and even suicide.

Although there appears to be a relationship between depression and tobacco use in


the general population, it is not clear whether tobacco use causes depression or
that depression causes use. Little evidence regarding the mechanisms that
influence this association is currently available (Dierker, Avenevoli, Stolar &
Merikangas, 2002), but there appears to be a bi-directional relationship between
the two (D’Mello & Flanagan, 1996).

Hall, Ricardo, Reus and Sees (1993) show that whether conceptualized as a trait,
symptom, or a diagnosable disorder, depression is over-represented among the
tobacco using population. Depressed users are not only less likely to be
successful at quitting, but if they succeed, they also experience more withdrawal
symptoms upon quitting. This study also showed that depressed users are more
likely to relapse to their previous behavior.

Tobacco use may include the use of cigarettes, chewing tobacco, snuff, pipes and
cigars. It is estimated that 72% of the American adult population have used
cigarettes and about 29% report use within a given month (DSM-IV-TR, 2000).
Tobacco use is currently the leading cause of disease burden (loss of healthy life
contributing mainly to non-communicable diseases and injuries) in America (Ezzati,
Lopez, Rodgers, Hoorn and Murray, 2002).

Kinnunen and Nordstrom (2000) postulates that the relationship between tobacco use
and depression may be related to the biological reinforcing effects of nicotine.
The author infers that depressed individuals may view tobacco as self-medication.
Quattrocki, Baird and Yurgelun-Todd (2000) show that nicotine binds to nicotinic
receptors in the brain, which augments various neurotransmitters, including
dopamine, serotonin, norepinephrine, acetylcholine, gammaaminobutyric acid and
glutamate to relieve the symptoms of depression. In addition, nicotine inhibits
monoamine oxidase, the enzyme responsible for breaking down the biogenic amine
neurotransmitters norepinephrine, serotonin, and dopamine in the brain. This may
explain the higher success rates for smoking cessation when an antidepressant is
used as an adjuvant to treatment.

A study of 205 psychiatric patients showed that patients who had never used
tobacco have substantially lower rates of currently diagnosed major depressive
disorder than those who had a history of tobacco use (Acton, Prochaska, Kaplan,
Small & Hall, 2002). Another study, based on a multiple logistic model, showed
that current users had a 40% higher risk of severe depression than non-users
(Tanskane, Viinamaeki, Koivumaa-Honkanen, Hintikka, Jaeaeskelaeinen & Lehtonen,
1999).

While there has been a great deal of research indicating the correlation between
tobacco use and depression among various populations, few studies have considered
geographic factors. No articles were found specifically on the link between
smoking and depression in adult rural populations. The purpose of this study is
to determine if there is a relationship between smoking and depression in the
rural United States.
The Farm Resource Center

The data for this study was collected by the Farm Resource Center (FRC), a non-
profit, non-partisan, non-sectarian corporation established in 1985 to serve farm
families in need of mental health crisis. Farmers, coal miners, and their
families are assessed and treated based on a community intervention model.
Thousands of data points have been collected, including demographic information
such as marital status, employment status, initial presenting problem, occupation,
age, gender, and race. FRC also prides itself in providing treatment that works.
Included in each client’s intervention plan are follow-up treatment, well-being
assessments, and customer satisfaction ratings. FRC is unique in its approach to
assessment and treatment.

Clients come to FRC from a variety of sources. FRC utilizes referral networks in
potential consumers’ communities. Outreach Workers and volunteers from local
environments are utilized in providing services for FRC. Consumers are assessed
on a variety of measures, including symptom checklists, risk for suicide or
domestic violence, medical problems, overall well-being, pre-post GAF, and
progress notes. Each consumer is given a treatment plan with goals based on his
or her needs. As the treatment plan is implemented, each consumer is monitored
closely to ensure that goals are met. Cases are closed in a formal manner.
Referrals are provided throughout treatment, linking consumers to community
resources. Consumers of FRC’s services are linked to the services by a number of
methods including but not limited to local referrals, a toll-free Crisis
Intervention Response line, local outreach workers, volunteers, and community
seminars. The services FRC provides are comprehensive, including assessment,
crisis intervention, referral, consultation, and educational services. FRC’s
unique method of data collection and number of cases collected to date (over
2,000) allow researchers to explore differences in trends in assessment data
between different groups of consumers, thus identifying and meeting the needs of
target populations.

METHOD

Participants

The participants for this study included individuals and families who received
services from FRC between 1995-2000. Only adult participants age 18-65 and were
assessed pre-treatment were included as participants in this study. The total
number of participants who met these criteria was 1,191.

The median age of the participants in this study was 42.0, with the middle 50%
ranging from 33.0-51.0. Of the 1,191 participants, 56.3% (N = 670) were female,
and 43.7% (N = 521) were male. More than half (51.6%) of the participants
reported being married (N = 614). The next largest percentage of participants
(22.2%) were divorced (N = 264), while 13.9% reported never being married (N =
166), 8.9% reported being separated (N = 106), and 3.4% were widowed (N = 41).
A majority (96.3%) of the sample was Caucasian (N = 1,147), with African-Americans
comprising the next largest percentage of participants (2.2%, N = 26). Two-thirds
of the sample reported unemployment (N = 788). The most reported presenting
problems were personal / emotional (62.3%, N = 742) and financial (22.8%, N = 271)
in nature. The remaining presenting problems (employment, family, health, marital)
each comprised less than 5% of the sample.

This sample of participants is representative of individuals and families seeking


and obtaining community services in a rural setting in the Midwestern United
States. The sample includes farmers, coal miners, family members of farmers and
coal miners, and other members of the rural community. All of FRC’s services are
confidential and are provided at no cost to the participants.

Design

This case control study examined the relationship between smoking and depression.
Participants were not assigned to treatment or control conditions. They were
naturally assigned to the demographic characteristics and assessment
characteristics they met. There were no control groups in this study. Every
participant received FRC standard protocol treatment. For purposes of this study,
only demographic and assessment data were used. This study is not aimed at
measuring the effectiveness of treatment nor is it to examine which groups improve
significantly with treatment.

Procedures

The participants received standard treatment in their natural setting. Consumers


are assessed by Outreach Workers on a variety of measures, including symptom
checklists, risk for suicide or domestic violence, medical problems, overall well-
being, pre-post GAF, and progress notes. For purposes of this study, a
“depression” scale was artificially derived from the FRC symptom checklist.
Symptoms of depression included fatigue, insomnia, poor appetite, depressed,
bored, urge to cry, negative thoughts/attitude, lonely, suicidal thoughts,
helplessness/hopelessness, inability to concentrate, decreased energy,
inappropriate crying, over eating, under eating, lowered sex drive, decline in
work effectiveness, and isolation/withdrawal from others. Only status variables
and assessment information were used for this study.

RESULTS

To determine whether there were differences between smokers and non-smokers on the
depression scale, reliability analysis was first conducted on the depression
scale. Using Cronbach’s alpha, a value of 0.83 was computed as an estimate of
internal consistency of the depression scale. (The item “over eating” was dropped
to increase reliability.)

To determine whether smokers and non-smokers differed on depression, an


independent samples t-test was conducted. Because a Kolmogorov-Smirnov test for
normality revealed that depression scores in this sample were not normally
distributed (K-S = .11, p < .001), a nonparametric test of median differences in
depression as a function of smoker/non-smoker status was also conducted using a
Mann-Whitney U test. In addition, the homogeneity of variance assumption required
when conducting t-tests was not found to be violated, Levene's F = 3.28, p = .07.
The samples being compared can be considered independent because participants
belonged to either the "smoker" or "non-smoker" groups. The measure for
depression is the artificially derived depression scale of the FRC symptom
checklist, which is scale-level.

The independent samples t-test revealed that, on average, depression scores for
smokers (`x = 7.05, s = 4.19, n = 472) were significantly higher than depression
scores for non-smokers (`x = 6.20, s = 3.91, n = 719), t(1,189) = -3.55, p < .001.
There is a 95% likelihood that the true difference between these two groups lies
between -1.31 and -0.38. Given that this confidence interval does not include
"0," there appears to be a difference in depression levels between smokers and
non-smokers. The effect size for the result is small, r = .10. The nonparametric
test of median differences produced a similar result, z = -3.37, p = .001.

To determine whether smokers and non-smokers differed by gender on depression, two


independent samples t-tests were conducted. (Because a Kolmogorov-Smirnov test
for normality revealed that depression scores in this sample were not normally
distributed, as described above, two Mann-Whitney U tests were also conducted).
For females, the homogeneity of variance assumption required when conducting t-
tests was found to be violated, Levene's F = 3.93 p < .05.

The independent samples t-test revealed that, on average, depression scores for
female smokers (`x = 7.30, s = 4.19, n = 281) were significantly higher than
depression scores for female non-smokers (`x = 6.23, s = 3.79, n = 389), t(566.07)
= -3.39, p = .001. There is a 95% likelihood that the true difference between
these two groups lies between -1.69 and -0.45. Given that this confidence
interval does not include "0," there appears to be a difference in depression
levels between female smokers and non-smokers. The effect size for the result is
also small, r = .14. The nonparametric test of median differences produced a
similar result, z = -3.23, p = .001.

For males, the homogeneity of variance assumption required when conducting t-tests
was not found to be violated, Levene's F = 0.26 p = .61. The independent samples
t-test revealed that, on average, depression scores for male smokers (`x = 6.69, s
= 4.17, n = 191) was not significantly different than depression scores for male
non-smokers (`x = 6.17, s = 4.05, n = 330), t(519) = -1.38, p = .17. There is a
95% likelihood that the true difference between these two groups lies between
-1.24 and 0.22. Given that this confidence interval includes "0," there appears
to be no difference in depression levels between male smokers and non-smokers.
The effect size for the result is very small, r = .06. The nonparametric test of
median differences produced a similar result, z = -1.38, p = .17.

DISCUSSION

The first finding of this study was the psychometric validation of the depression
scale. Overall reliability of symptoms that comprised the depression scale was
found to be suitable for clinical use. Using the depression scale, smoking was
related to depression in the sample of participants from the rural Midwestern
United States. Depression scores were higher among rural smokers than among non-
smokers. This finding was consistent with the literature review that linked
smoking and depression in the general population.

The magnitude of the difference in depression scores between rural smokers and
non-smokers was small, which suggests that smoking behavior may be one of many
signs to look for when screening for depression. Physicians who provide mental
health screening and treatment for rural populations may especially benefit from
finding out whether patients are smokers. Likewise, the gender of the smoker
appeared to be an important factor in this study. The significance of the
comparison between smoking and depression was accounted for by gender. Female
smokers scored significantly higher on the depression scale compared to female
non-smokers. The differences in depression among male smokers and non-smokers
were not significant.

Possible limits to this study include instrumentation and sample characteristics.


The test instrument is considered fairly reliable to make accurate clinical
decisions, although the comprehensiveness of the instrument could be improved
upon. In addition, although this study included a large number of rural
participants, not all geographic regions and ethnicities are represented. Further
research can aim to replicate this study, with a more comprehensive test
instrument. Other geographic regions may be targeted by other researchers.
Studies of the relationship between smoking and depression in rural minorities
would be of interest.

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