Affiliations: University of Catania, Catania, Italy,
Medical School of Ribeirão Preto, University of São Paulo, Ribeirão Preto, Brazil
Correspondence to: Marco Raciti, MD, University of Catania, Via S. Citelli 6, Catania 95124, Italy; e-mail: firstname.lastname@example.org
In their recent article, Martinez et al (February 2004)1analyzed data obtained from 174 university students, who were asked to answer to a specific questionnaire investigating their health condition (the Medical Outcomes Study 36-item short form [SF-36]), and found that smoking leads to impaired quality of life. Although in these young smokers with a smoking history of short duration (3.2 years; 1.7 pack-years) there are no obvious clinical conditions linked to cigarette smoking, they appeared to be less active, and experienced a more frequent incidence of symptoms of depression and anxiety. Similar results have been described in population studies2–4 in which old people and people with a long smoking history were included, but those results were clearly expected. On the contrary, it is surprising to note that in the study by Martinez et al1 important changes in SF-36 scores were recorded in young smokers with a short smoking history.
However, it is not clear whether the worsening in their quality of life was caused by cigarette smoking per se or if, on the contrary, altered psychobehavioral conditions were preexisting and favored smoking. Since Martinez et al1 failed to show important differences, in term of SF-36 scores, between heavy/moderate and light smokers, it is likely that the decline in the psychological-behavioral conditions in young smokers is not correlated with the level of smoking intensity and is unlikely to be its cause. Rather, the evidence of an altered psychological-behavioral profile could be the cause of the smoking habit. This has been well-documented by evidence5–6 that the prevalence of smoking is extremely high in psychiatric patients and in people who experience anxiety and depression. Moreover, a history of depression and low self-esteem, and a predisposition to adopt a poor lifestyle are often considered to be risk factors for smoking initiation and the development of nicotine addiction.7This is in agreement with findings8 emphasizing a strict relation between smoking and alcohol abuse in smokers compared to never-smokers.
Regrettably, in the study by Martinez et al1 the analysis of the transitory health condition (the ninth element in the SF-36 questionnaire, which analyzes health changes in the previous 12 months) was not included, thus failing to clarify this important issue.
We are thankful for the interest and comments of Raciti et al about our recent article (February 2004).1 We agree with them that the most plausible explanation for the observed differences in quality of life between smokers and never-smokers should be previous psychologically altered profiles, which could strongly contribute to smoking initiation. In fact, the finding that cigarette consumption severity does not appear to have influenced our results favors this hypothesis, as comparisons between heavy/moderate smokers and light smokers failed to demonstrate significant differences in terms of Medical Outcomes Study 36-item short-form health survey (SF-36) scores. However, as our sample size was small, we may not completely exclude an effect of smoking itself on the study results. The number of individuals in the first group was small (18 moderate smokers and 2 heavy smokers), and we are facing a substantial type II error in this setting.
We do not think that an analysis of the transitory health condition element on the SF-36 questionnaire would necessarily be useful in elucidating these aspects of the study because virtually all smokers included in the study were already consuming cigarettes 12 months before the interview. We think that definitive answers regarding this important matter may only be obtained with the performance of longitudinal studies involving larger samples of representative populations.
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