Joint Association of Active and Passive Smoking with Psychiatric Distress and Violence Behaviors in a Representative Sample of Iranian Children and Adolescents: the CASPIAN-IV Study

Abstract

Background Mental health and smoking have been receiving increasing attention in adolescents all over the world. Although some studies have assessed the independent association of active/passive smoking with mental health, joint association of active and passive smoking with mental health remains unclear. Purpose This study was designed to evaluate the joint association of smoking status (active and passive smoking) with psychiatric distress and violent behaviors in Iranian children and adolescents. In this national survey, 13,486 students, aged 6-18 years, living in rural and urban areas of 30 provinces of Iran were selected via multistage, cluster sampling method. Psychiatric distress (including worthless, angriness, worrying, insomnia, confusion, depression, and anxiety), violence behaviors (including bullying, victim, and physical fight), and smoking status (nonsmoker, only passive smoker, only active smoker, and active and passive smoker) were assessed. The questionnaire was prepared based on the World Health Organization Global School-based Student Health Survey (WHO-GSHS). Data were analyzed by the Stata package. Psychiatric distress and violent behaviors had linearly positive association with smoking status (p trend < 0.001). Compared to "nonsmoker" group, participants who were exposed to passive smoking besides active tobacco use were at increased risk of having angriness (odds ratio (OR) 2.55, 95 confidence interval (CI) 1.86-3.48), worrying (OR 1.66, 95 CI 1.24-2.20), and anxiety (OR 1.99, 95 CI 1.52-2.61) and victim (OR 1.77, 95 CI 1.34-2.33) and bully behaviors (OR 3.08, 95 CI 2.33-4.07). The current findings suggest that active and passive tobacco smoking has synergistic effect on psychiatric distress. Since majority of smokers with psychiatric distress do not receive mental health services or counseling on smoking, strategies to address mental health problems and smoking prevention should be included as a part of school health services.