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Nicotine dependence and quality of life in hospitalized patients with psychiatric illness: Findings from a cross-sectional study
*Corresponding author: Manish Singh, Department of Psychiatry, Hind Institute of Medical Sciences, Sitapur, Uttar Pradesh, India. dr.manish94singh@gmail.com
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Received: ,
Accepted: ,
How to cite this article: Singh M, Pathak A, Rana Y, Yadav V, Singh R. Nicotine dependence and quality of life in hospitalized patients with psychiatric illness: Findings from a cross-sectional study. Arch Biol Psychiatry. 2025;3:23-9. doi: 10.25259/ABP_17_2024
Abstract
Objectives:
Nicotine dependence (ND) is common among patients with psychiatric illnesses and significantly impacts their quality of life (QoL). This study aims to assess ND and its effect on the QoL among hospitalized patients with psychiatric illnesses in rural North India and to assess ND and its impact on QoL among hospitalized patients with psychiatric illnesses in rural North India.
Material and Methods:
A cross-sectional study was conducted at a tertiary care center in Sitapur over 18 months, including 360 hospitalized psychiatric patients (aged 18–60 years) diagnosed as per the International Classification of Diseases-10 criteria. ND was assessed using the Fagerström test (FTND/FTND-ST), and QoL was evaluated using the World Health Organization QoL scale - (Brief Indian Version) (WHOQOL-BREF) scale. Statistical analyses included independent t-tests, Pearson correlation, Cohen’s d, and two-way analysis of variance.
Results:
ND was prevalent in 43.33% of patients. ND patients had significantly lower QoL scores across all WHOQOL-BREF domains. Correlation analysis showed a significant negative association between ND and QoL. Large effect sizes indicated a pronounced impact of ND on QoL.
Conclusion:
ND is common among hospitalized patients with psychiatric illnesses and ND significantly worsens QoL across physical, psychological, social, and environmental domains. These findings highlight the need for integrated interventions addressing both ND and psychiatric illness.
Keywords
Hospitalization
Nicotine dependence
Prevalence
Psychiatric illness
Quality of life
INTRODUCTION
Nicotine dependence (ND) poses a significant public health concern, particularly among patients with psychiatric illness. The interaction between mental health issues and nicotine addiction intensifies the difficulties faced by this group, resulting in worse health outcomes and a lower quality of life (QoL).[1] Research indicates that patients with psychiatric illness are notably more likely than the general population to smoke and be dependent on nicotine.[1] This heightened prevalence can be attributed to several factors, including the use of nicotine to self-medicate and alleviate psychiatric symptoms, as well as nicotine’s mood and cognitive-enhancing effects.[2]
Up to half of tobacco users die from its use, according to the World Health Organization (WHO). Over 8 million individuals die from tobacco use every year. Of those deaths, almost 7 million are directly related to tobacco use, and over 1.2 million are related to second-hand smoke exposure for nonsmokers. More than 80% of the 1.3 billion tobacco smokers worldwide reside in low and middle-income nations. 22.3% of people worldwide, including 36.7% of males and 7.8% of women, were smokers in 2020.[3] In India, 42.4% of males, 14.2% of women, and 28.6% (266.8 million) of all adults presently smoke tobacco, according to the Global Adult Tobacco Survey India Report 2016–2017. In both rural and urban areas, the prevalence of tobacco usage is 32.5% and 21.2%, respectively.[4]
It is noteworthy how common ND is among patients with psychiatric illness in the US and other Western nations. Research conducted in Europe has revealed incidence rates as high as 51% in Germany,[5] 45% in the UK,[6] 67% in Australia,[7] and 57% in the US,[8] among those suffering from psychiatric disorders. With prevalence estimates ranging from 60% to 90%, those with schizophrenia have some of the highest rates of smoking among those with psychiatric diseases. Estimates of the prevalence of smoking among people with bipolar disorder range from 50% to 70%, which is much higher than in the overall population.[9] An Indian study examined tobacco use among 510 male patients diagnosed with different psychiatric illnesses. According to their findings, smoking was more common in individuals with mood disorders (24%) than in those with schizophrenia (38%) and non-psychotic disorders (n = 23%). Despite its value, this study only included men in its sample, evaluated smoking alone but not any other tobacco use and did not estimate the level of dependence.[10]
Numerous studies examining the frequency of ND among Indian inpatients with psychiatric illness have produced differing results because of variations in the study populations, diagnostic standards, and assessment instruments. Thakur et al. (2013) discovered a prevalence rate of 64.7%,[11] Sharma et al. (2020) found a prevalence rate of 70% among hospitalized.[12] In spite of these findings, a great deal more thorough, large-scale study is still required to fully comprehend the prevalence and consequences of ND in this community.
Patients with psychiatric illness experience a notable decline in their QoL due to nicotine addiction. This interaction is complex and mutually influential, impacting multiple facets of health and well-being. A thorough understanding of this relationship is crucial for developing effective strategies to improve smoking cessation rates and enhance the QoL in this vulnerable population.[13]
Patients with psychiatric illness who are dependent on nicotine frequently encounter elevated levels of anxiety and sadness. Nicotine offers momentary alleviation, resulting in a cycle of dependence where the cessation of nicotine intake worsens psychiatric disorders. This process impedes the establishment of long-term mental health stability.[14]
Murthy and Manjunatha found that ND significantly reduces QoL among patients with psychiatric illness in India.[15] Batra and Prasad also reported poorer QoL scores among ND psychiatric patients in North India.[16]
Need for study
This study fills a significant knowledge vacuum on the prevalence, clinical correlates, and effects of ND in hospitalized patients with psychiatric illness in rural North India. While substantial research exists in urban areas and developed countries, rural settings with their unique sociocultural and economic dynamics remain under-researched.[17] This lack of region-specific data hinders the development of tailored interventions and policies to address this significant issue.
Understanding ND patterns and their impact on QoL in patients with psychiatric illnesses is crucial for designing effective smoking cessation programs that improve mental health outcomes. This study aims to provide detailed data on the prevalence of ND and QoL among patients with psychiatric illness in a rural Indian context.
Statement of problem
ND is disproportionately high among individuals with psychiatric illness and contributes to greater disability and reduced QoL.[18] While several studies have explored this association in urban and international contexts, region-specific data from rural North India are lacking.[19,20]
Rural populations face distinct barriers such as limited access to mental health care and cessation resources, which may influence both dependence patterns and treatment outcomes.[20] Despite the high burden, ND in this subgroup remains under-researched.
This study aims to address this gap by evaluating the prevalence of ND and its impact on QoL among psychiatric inpatients in rural North India. The results are intended to support the development of integrated intervention models tailored to this setting.
MATERIAL AND METHODS
Study area
This study was conducted at a tertiary care center in Sitapur, which serves a diverse population from both rural and urban regions. The facility provides specialized psychiatric care, making it an appropriate setting for assessing ND among hospitalized patients with psychiatric illness.
Study design
A descriptive cross-sectional study was conducted to assess the prevalence of ND and its impact on QoL among patients with psychiatric illness.
Study period
Eighteen months (12 months for data collection and 6 months for data analysis).
Sample size: 360
The sample size was determined using Cochran’s formula for absolute error-based sampling, ensuring adequate statistical power to detect differences in QoL between ND and non-dependent groups.
The formula used was: n ≥z2pq/e2 where:
n = required sample size
z = z-score for 95% confidence interval (1.96)
p = estimated prevalence (36%, based on Chandra et al.[21])
q = 1 − p (0.64)
e = margin of error
Applying these values, the calculated sample size was 354, and a final sample of 360 was taken to improve statistical reliability and account for potential non-responses or missing data.
Sampling method
A total of 360 hospitalized patients with psychiatric illness aged 18–60 years were recruited using consecutive sampling. All eligible patients admitted to the psychiatry ward during the study period who met the inclusion criteria were approached for participation. Consecutive sampling was chosen to minimize selection bias and ensure the sample reflected the inpatient population.
Inclusion criteria
All the inpatients who have a psychiatric diagnosis as per the International Classification of Diseases-10 (ICD-10) diagnostic guidelines were included in the study
Males and females within the age group of 18–60 years
Patients who give consent for the study.[22]
Exclusion criteria
Patients who require urgent attention for serious medical problems
Patients without reliable informants
Primary Substance use disorder diagnosis other than ND syndrome
Patients lacking capacity or having cognitive deficits due to delirium, dementia, etc.[22]
Study method
Around 360 patients with psychiatric illness in the age group 18–60 of either sex who were admitted to the psychiatry ward of the tertiary care center, Sitapur, who had given informed consent (including their attenders/guardians) for the study were included. The following psychiatric conditions were assessed among hospitalized patients: Schizophrenia, bipolar affective disorder, major depressive disorder, generalized anxiety disorder, obsessive-compulsive disorder, acute and transient psychotic disorder, persistent delusional disorder, and unspecified nonorganic psychosis. Assessments were conducted during hospitalization while patients were receiving treatment for their primary psychiatric illness. Given the cross-sectional design, QoL scores reflect the patient’s condition at the time of assessment rather than before or after treatment completion [Flowchart 1].
- Study protocol.
Instruments
Sociodemographic variables, along with medical and psychiatric histories, were systematically documented using a semi-structured pro forma.
ICD 10 - International Classification of Mental and Behavioral Disorders, 10th edition, Diagnostic Criteria for Research.[23]
FTND - Fagerstrom test for Nicotine Dependence (for smokers).[24]
FTND-ST - Fagerstrom test for Nicotine Dependence (for smokeless tobacco)[25]
WHOQOL BREF - World Health Organization Quality of Life scale Brief Indian Version.[26]
RESULTS
Prevalence of ND syndrome in hospitalized patients with psychiatric illness
The prevalence of nicotine dependence syndrome among hospitalized patients with psychiatric illness is presented in Table 1. There are 156 individuals who are classified as ND (any form of tobacco, i.e., smoker/smokeless/both). This group represents 43.33% of the total sample. There are 204 individuals who are classified as non-nicotine dependent (NND). This group represents 56.67% of the total sample. The proportion of NND individuals is higher than that of ND individuals. Specifically, 13.34% more individuals are non-dependent compared to those who are dependent.
| Nicotine dependence status | Number of cases | Percentage (%) |
|---|---|---|
| Nicotine dependent | 156 | 43.33 |
| Nicotine nondependent | 204 | 56.67 |
| Total | 360 | 100 |
Psychiatric illnesses and ND
The distribution of psychiatric diagnoses among ND and NND patients is presented in Table 2. Bipolar affective disorder (41.18%), depressive episode (40.98%), and schizophrenia (42.55%) were among the most common diagnoses in the ND group, with significant individual P-values (P = 0.03, 0.02, and 0.01, respectively). However, an overall Chi-square test of independence revealed no statistically significant association between psychiatric diagnosis and ND status (χ2 = 1.80, df = 7, P = 0.97).
| Psychiatric diagnosis | Total (N=360) | Nicotine dependent* (N=156) | Non nicotine dependent** (N=204) | Prevalence of ND (%) | P-value |
|---|---|---|---|---|---|
| Acute and transient psychotic disorder | 24 | 12 | 12 | 50.00 | 0.45 |
| Bipolar affective disorder | 85 | 35 | 50 | 41.18 | 0.03* |
| Persistent delusional disorder | 12 | 6 | 6 | 50.00 | 0.52 |
| Depressive episode | 61 | 25 | 36 | 40.98 | 0.02* |
| Generalized anxiety disorder | 40 | 18 | 22 | 45.00 | 0.49 |
| Obsessive-compulsive disorder | 19 | 10 | 9 | 52.63 | 0.51 |
| Schizophrenia | 94 | 40 | 54 | 42.55 | 0.01* |
| Unspecified nonorganic psychosis | 25 | 10 | 15 | 40.00 | 0.46 |
ND and QoL
To explore the impact of ND on QoL, we conducted a statistical analysis comparing the distribution of QoL ratings between ND and NND groups using the WHOQOL-BREF scale.
Data description
We examined data from two groups:
ND group (n = 156): Individuals diagnosed with ND
NND group (n = 204): Individuals without ND.
Comparison of QoL between ND and non-dependent groups
The comparison of quality of life between nicotine-dependent and non-dependent groups is presented in Table 3. The comparison of WHOQOL-BREF scores between ND and non-dependent individuals revealed significantly poorer QoL across all four domains for the ND group. Specifically, ND individuals had lower mean scores in: Physical Health: 45.2 versus 60.8 (P = 0.03), psychological well-being: 48.3 versus 65.1 (P = 0.04), social relationships: 50.1 versus 68.5 (P = 0.009), and environmental factors: 52.6 versus 70.3 (P = 0.001).
| WHOQOL-BREF domain | Nicotine dependent | Nicotine non-dependent | P-value | Pearson correlation coefficient (r) | Effect size (Cohen’s d) |
|---|---|---|---|---|---|
| Physical health | 45.2±10.5 | 60.8±9.6 | 0.03* | 0.35 | 1.57 |
| Psychological | 48.3±11.2 | 65.1±10.3 | 0.04* | 0.38 | 1.61 |
| Social relationships | 50.1±9.8 | 68.5±8.7 | 0.009* | 0.42 | 1.80 |
| Environment | 52.6±10.0 | 70.3±9.2 | 0.001* | 0.45 | 1.85 |
Statistical analysis and effect sizes
Independent samples t -tests confirmed significant differences in QoL scores between the groups (P < 0.05 for all domains). Pearson correlation coefficients between FTND/FTNDST scores and WHOQOL-BREF domain scores showed a significant negative correlation, with r values ranging from −0.35 to −0.45. Effect size analysis (Cohen’s d) indicated large effects across all domains, ranging from 1.57 to 1.85, demonstrating the substantial impact of ND on QoL.
Controlling for psychiatric illness in QoL analysis
Table 4 presents the Two-Way ANOVA results controlling for psychiatric illness in the analysis of quality of life. To ensure that the impact of ND on QoL was not influenced by psychiatric illness, a two-way analysis of variance was performed with ND (dependent vs. non-dependent) and psychiatric diagnosis as fixed factors, and QoL domains (physical, psychological, social, and environmental) as dependent variables. The analysis showed that ND remained a significant predictor of lower QoL across all domains (P < 0.05), while psychiatric illness also significantly influenced QoL (P < 0.05). However, no significant interaction was found (P > 0.05), indicating that the negative impact of ND on QoL was consistent across different psychiatric disorders, confirming that ND independently contributes to poorer QoL outcomes.
| Effect | F-value | P-value | Effect Size (η2) |
|---|---|---|---|
| Nicotine dependence | 10.23 | 0.002* | 0.08 |
| Psychiatric illness type | 8.45 | 0.010* | 0.07 |
| Interaction (Nicotine×Psychiatric illness) | 1.21 | 0.12 | 0.02 |
DISCUSSION
Prevalence of ND among psychiatric inpatients
In the present study, 43.33% of hospitalized psychiatric patients were found to be ND. This finding aligns with prior studies that report higher rates of tobacco use among individuals with psychiatric disorders compared to the general population.
The slightly lower prevalence observed in our study may be attributed to the use of standardized tools (FTND/FTND-ST) that assess physiological dependence rather than occasional use, as well as the controlled hospital environment, where access to tobacco is restricted and patients are under medical supervision. In addition, sociocultural norms in rural North India and the inclusion of diagnostic categories such as anxiety and depression, which are associated with lower tobacco use compared to schizophrenia or bipolar disorder, may have contributed to the differences.
ND and QoL
The study found a significant negative association between ND and QoL across all four WHOQOL-BREF domains. ND individuals had substantially lower mean QoL scores, with large effect sizes and statistically significant t-values. These findings support the independent contribution of ND to diminished QoL, even after accounting for psychiatric diagnosis.
Comparable results have been reported by Murthy and Manjunatha,[15] Batra and Prasad,[16] and Ziedonis and Williams,[5] all of whom observed lower QoL among ND psychiatric populations. However, Sarma and George did not find a significant difference in QoL, indicating that results may vary depending on population and methodology.[5,12]
The adverse impact of ND on QoL is likely multifactorial – physiologically, it may worsen pre-existing health conditions and psychiatric symptoms; socially, it can contribute to isolation and strained interpersonal relationships; environmentally, it may increase financial burden and stigma. Moreover, limited access to cessation support in psychiatric settings further perpetuates the cycle of dependence and poor QoL.
These findings emphasize the need for integrated treatment strategies that address both psychiatric illness and ND to improve overall well-being in this vulnerable population.
Limitations of the study
Study conducted in a single rural tertiary care center, limiting generalizability to other regions of rural North India. Sample size may not represent the broader population. The study did not account for all potential environmental and social factors influencing ND, psychiatric morbidity, and QoL. The study did not separately evaluate QoL affected solely by psychiatric illness or the combined effect of psychiatric illness and ND. The study did not thoroughly assess other potential comorbidities that could affect the QoL. Data on medical complications associated with ND were not collected. The exclusion of outpatients may limit the generalizability of findings to the broader community. The sociocultural context of rural North India may limit the applicability of results to other cultural settings.
CONCLUSION
This study highlights the high prevalence of ND (43.33%) among hospitalized psychiatric patients and its significant negative impact on QoL. ND was associated with lower scores across all WHOQOL-BREF domains, emphasizing the need for integrated smoking cessation and mental health interventions.
Further research is needed to explore underlying mechanisms and assess the effectiveness of targeted treatment programs. Addressing ND in this population is essential for improving overall health outcomes and enhancing QoL.
Acknowledgment:
A special thanks to Dr. Jaymin Pandav and Dr. Divya Kushwaha, who played an important role in preparing this research article.
Ethical approval:
The research/study approved by the Institutional Review Board at Hind Institute of Medical Sciences, Sitapur, number IHEC-HIMSA/MD-MS-21/RD-21/03-23, dated 23rd March 2023.
Declaration of patient consent:
The authors certify that they have obtained all appropriate patient consent.
Conflicts of interest:
There are no conflicts of interest.
Use of artificial intelligence (AI)-assisted technology for manuscript preparation:
The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.
Financial support and sponsorship: Nil.
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