Review Article Psychological characteristics associated with tobacco smoking behavior* Regina de Cássia Rondina1, Ricardo Gorayeb2, Clóvis Botelho3 Abstract This article is a literature review of the psychological aspects of smoking behavior, highlighting personality characteristics of the smoker as an obstacle to smoking cessation. It describes the relationship between smoking behavior and personality, and between smoking and the principal psychiatric disorders. Studies reveal that smokers tend to be more extroverted, anxious, tense, and impulsive, and show more traits of neuroticism and psychoticism than do ex-smokers or nonsmokers. The literature also reveals a strong association between smoking and mental disorders, such as schizophrenia and depression. Understanding the psychological factors associated with tobacco smoking and dependence can further the development and improvement of therapeutic strategies to be used in smoking-cessation programs, as well as of programs aimed at prevention and education. Keywords: Personality; Mental disorders; Smoking.
* Study carried out at the Universidade de São Paulo – USP, University of São Paulo – Ribeirão Preto (SP) Brazil. 1. PhD. Faculdade de Ciências da Saúde/Associação Cultural e Educacional de Garça – FASU/ACEG, School of Health Sciences/Cultural and Educational Association of Garça – Garça (SP) Brazil. 2. Associate Professor in the Neurology, Psychiatry, and Medical Psychology Department. Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo – USP, University of São Paulo School of Medicine – Ribeirão Preto (SP) Brazil. 3. Full Professor. Universidade Federal de Mato Grosso – UFMT, Federal University of Mato Grosso – Cuiabá (MT) Brazil. Correspondence to: Regina de Cássia Rondina. Rua Palmares, 346, CEP 17501-509, Marília, SP, Brasil. Tel 55 14 2105-5600. E-mail: firstname.lastname@example.org Submitted: 26 February 2007. Accepted, after review: 28 March 2007.
Psychological characteristics associated with tobacco smoking behavior
return to levels similar to those observed in controls. Excessive weight gain generally follows alterations in
Approximately 70% of smokers want to stop behavior and personality patterns, frequently mani-
smoking. However, few succeed, and, of those fested as depression, abstention, self-punishment,
that do, most require five to seven attempts before irritability, and aggression. Weight gain, together
definitively dropping the habit.(1) Nicotine depend- with increased stress, intensifies the impulse to eat,
ence is a complex disorder and is difficult to perpetuating the vicious cycle. At the moment, the
overcome. Motivation to kick the habit is one of the three most widely accepted theories to explain the
most important factors in smoking cessation and is relationship between smoking and body weight are
interrelated to a variety of hereditary, physiological, as follows: a) increased metabolic rate, with greater
environmental, and psychological variables.
energy expenditure by smokers; b) differences in
In addition to motivation, the smoker will have quality and quantity of food intake by smokers; c)
to confront a few factors that make this process appetite loss, via nicotine.(4,5)
difficult. Among such factors, the intensity of the
In this review article, emphasizing the person-
withdrawal syndrome is one of the principal contrib- ality profile of the smoker as an important obstacle
uting causes for maintaining the habit. The symptoms to cessation, we describe the relationship between
vary in intensity among people, and generally start smoking and personality and, subsequently, the
within hours after the interruption, increasing in the relationship between smoking and the principal
first 12 h and peaking on the third day. Discomfort psychiatric disorders.
increases at early night, and the most significant complaints refer to increased compulsivity, irrita- Smoking and personality
bility, anxiety, difficulty in concentrating, agitation, and a sensation of sleepiness or dullness, as well
Most studies on the relationship between smoking
as hostility reactions.(1) These alterations can be and personality characteristics, in recent decades, observed for 30 days or more; however, compulsive were carried out according to the theoretical model symptoms can persist for many months or years.
proposed in 1967.(6) According to this approach,
Another great obstacle is the degree of nicotine there are three predominant dimensions of char-
dependence. When the smoker reaches six or more acter or personality supposedly related to smoking: points in the Fagerström test(2) (high or very high extroversion, neuroticism, and psychoticism. degree of dependence), the individual is considered
The extroversion dimension comprises factors
a heavy smoker. Heavy smokers generally smoke such as sociability, assertiveness, positive emotions, the first cigarette up to 30 min after waking up. In vivacity, and activity level.(7) It has been hypothesized addition, they perceive the difficulty of quitting and that there is a relationship between extroversion and have little self-confidence. Among the various forms smoking.(6) In line with this interpretation, extroverts of approaching these patients, we can highlight the and introverts differ as to the level of necessary need to strengthen motivation, without which these stimulation for their well-being. At equivalent patients will not be able to quit smoking. Many stimulation levels, extroverts will be characterized of them report that they want to stop smoking; by low cortical excitation, and introverts by high however, in fact, this verbally expressed desire does cortical excitation. At a medium level of stimula-not faithfully translate their real feelings regarding tion, at which most daily activities occur, extroverts smoking, since they are not duly motivated to do will more likely feel little stimulated, whereas intro-so.(3)
verts will feel highly stimulated. Since they operate
Weight gain is also a factor that makes it difficult below their ideal level of cortical excitation, extro-
to kick the habit. Clinical and epidemiological studies verts might try to change their external environment report that smokers weigh less than do nonsmokers through increased activity, or might try to change and gain weight when they stop smoking. Most their internal environment by ingesting substances, studies show that the use of nicotine results in a such as nicotine and other drugs. However, intro-period of weight loss (or reduction of weight gain). verts will try to reduce the stimulation input. One In addition, cessation of the use of the drug results of the hypotheses is that this difference in cortical in an acute period of weight gain, followed by a excitation levels results from genetic inheritance.(7)
Similarly, traces of neuroticism can make the
The controversy among the results on the rela-
smoker sensitive to the properties of nicotine. tionship between smoking and factors such as People who get high scores on personality tests extroversion and neuroticism remains, probably due that evaluate this dimension possibly receive greater to the fact that smokers are not a homogeneous reinforcement in stressful situations, due to the group.(12,14,17) People smoke for different reasons stress-reducing effects provided by the cigarette.(7) and, therefore, can be influenced, simultaneously, The neuroticism dimension comprises subdimen- by individual variables and situational factors. Two sions of personality, such as anxiety, depression, classes of situations seem to trigger the desire to psychological vulnerability, hostility, and anger, and smoke. One of them consists of boring situations is related to depression and anxiety disorders. The that result in the need to increase cortical stimula-
tion. The second seems to result from stress. For
neurotic individual presents high frequency and some individuals (such as those with high extrover-
intensity of negative affection, resulting from an sion level), smoking would be more attractive in
inefficient self-regulating mechanism for affection dull situations, in order to create cortical stimula-
and modulation of excitation and, therefore, uses tion. However, highly neurotic people would receive
the cigarette to facilitate internal homeostasis. The greater reinforcement through smoking in stressful
hypothesis is that smoking enables the reduction of situations, due to stress-reducing effects provided
negative affection in these individuals.(7)
The psychoticism dimension comprises facets
Therefore, the nature of the association between
of character such as impulsivity, cynicism, cold- smoking and the two dimensions (extroversion and
ness, antisocial tendencies, reduced agreeableness/ neuroticism) remains controversial. Nevertheless,
conformity, reduced constraint/inhibition, search for the association between tobacco consumption
stimulating or exciting sensations, and low consci- and psychoticism is more consistent and has been
confirmed through numerous studies.(12,18,19)
There are also numerous studies in the literature
strated that smokers tend to get higher scores that have focused on other approaches. There is
in extroversion, compared with nonsmokers.(9,10) strong evidence of an association between tobacco
However, in some studies, this association was not consumption and a personality factor characterized
as the need to experience stimulating sensations
The association between smoking and extro- (sensation seeking). The sensation seeking dimen-
version has decreased in recent decades, possibly sion can be defined as the ‘search for new, varied,
because smoking has become a socially undesirable complex and intense sensations and experiences,
habit in many countries. Smokers might have been together with the predisposition to take physical,
punished in situations of interaction, reverting the social, legal, and financial risks in order to have such
tendency toward association with this personality experiences’.(20)
The sensation seeking factor theory was formu-
Data in the literature are also inconsistent lated in 1969.(21) This dimension comprises facets
regarding the neuroticism factor. Numerous studies such as a lack of inhibition, the search for emotions
published in previous decades showed a relationship (enthusiasm), the need for adventure, the need for
between smoking and neuroticism.(9,15) However, this new experiences, and susceptibility to boredom.(22)
association was not detected in some studies.(10,16) The existence of the sensation seeking dimension is
Nevertheless, in contrast with the extroversion factor, also substantiated by biological findings. Individuals
the relationship between neuroticism and smoking with high scores in this factor present low levels of
is more consistent and seems to have grown consid- cortical stimulation. It is supposed that individuals
erably during recent decades. Individuals who are with pronounced traits of this characteristic are
more ‘neurotic’ seem less inclined to quit smoking, chronically understimulated and therefore tend to
even when confronted with the recent social pres- be sensitive to nicotine.(23)
sure; and can feel greater reinforcing effects of
It is supposed that the sensation seeking factor
nicotine, when compared with individuals who are predisposes the individual to engaging in dangerous more emotionally stable.(7)
activities.(20,22) This personality trait has been associ-
Psychological characteristics associated with tobacco smoking behavior
ated with participating in risky experiences, radical original, imaginative, creative, curious, courageous, sports, criminal activities, professional choices, risky independent, liberal, and nontraditional, as well as sexual behavior, smoking, alcoholism, use and abuse having broad interests and preferring variety.(25) of illicit drugs, and gambling. Therefore, the hypoth-
The individual with high scores in the consci-
esis is that individuals with high scores in sensation entiousness factor can be characterized as seeking tend to underevaluate/underappreciate conscientious, careful, reliable, willing, well-organ-risks, compared with individuals with low scores. ized, meticulous, scrupulous, self-disciplined, tidy/For these individuals, the degree of a nticipatory neat, punctual, practical, energetic, connected to anxiety when facing these activities is lower, when work/business, informed, perseverant, etc. However, compared with that of those with low scores.(22)
there are two lines of interpretation for the meaning
There seems to be a strong association between of this personality factor. The conscientiousness
the sensation seeking factor and traits of impulsivity. dimension refers, on one hand, to the strength The definition of impulsivity incorporates elements of the superego, or to self-control/inhibition of such as the tendency to get into situations or rapidly impulsive behaviors. However, the conscientious-respond to stimuli for potential reinforcement, ness dimension is related to the determination to without much planning and without considering succeed as well, or need for achievement. Finally, the potential risks of punishment or loss of grati- the individual with pronounced traits of agreeable-fication. The impulsivity factor can be considered ness/cooperation can be described as cooperative, a deficit in the capacity of inhibiting dangerous reliable, generous, flexible, lively, direct, nice, cour-behaviors, seeking gratification. Specialists in this teous, not irritable, etc.(25) matter propose an even wider personality dimen-
There is evidence of an inverse association
sion, resulting from the conjugation of these between high scores for the conscientiousness two aspects, denominated impulsivity-sensation factor and smoking.(13,26-29) The literature presents seeking, and state that this characteristic is relevant various hypotheses on the nature of this associa-in the predisposition of the individual to run risks tion. Pronounced traits of this personality factor in general and, among them, the consumption of during childhood are associated with a lower risk tobacco or other drugs.(22)
of smoking and other unhealthy behaviors during
Another theoretical model of approaching the adult life. Certain people might engage in unhealthy
issue of the relationship between smoking and behaviors due to their high impulsivity and lack personality was formulated in a study conducted in of consideration regarding short- and long-term 1985.(24) The authors propose five major personality consequences of their behavior. The conscientious-factors: neuroticism, extroversion, conscientious- ness dimension comprises characteristics such as ness, openness to experiences, and agreeableness/ perseverance and discipline, which can contribute to cooperation. The individual with high scores in the adopting healthy behaviors.(27) The conscientious-neuroticism factor can be characterized as nervous, ness factor is associated with behaviors of protection temperamental, insecure, impatient, not relaxed, of health. This set of personality characteristics can emotional, vulnerable, and unstable, among other act as a mediating factor for individual perception aspects.(25) The neuroticism factor is principally of risk. An individual can, for example, believe that related to negative affection. Therefore, it has been smoking is a health hazard and yet be unable follow hypothesized that the inclination or tendency to through on plans to quit smoking due to a lack of eat, smoke or drink in excess is a reflex of this char- self-discipline, which impedes the modification of acteristic. It is supposed that quitting smoking is the smoking behavior.(27) more difficult for individuals with high neuroticism
Although the results remain controversial on
scores, since the negative affection caused by absti- certain points, smokers tend to be more extroverted, nence is stronger for them.(25)
tense, anxious, depressive, and impulsive, as well as
The extroversion factor comprises characteristics presenting greater neuroticism, psychoticism, sensa-
such as sociability, fondness, and spontaneity, as tion seeking, search for novelties, tendencies toward well as being talkative, active, warm, and not a loner. antisocial/unconventional/risky behaviors, together The individual with high scores in the factor of being with traces of mood disorders, when compared with open to new experiences can be described as being nonsmokers and former smokers. Comorbidity between smoking
depressive episode, which can increase their predis-position to relapse.(34) Finally, a fourth hypothesis
and psychiatric disorders
has been presented by some specialists(33,35): a series
An increasing interest in the study of the comor- of common variables, such as genetic and psycho-
bidity between smoking and mental disorders is social factors, contribute to the expression of both observed, since smoking has various implications in (smoking and depression).(33,35) daily clinical practice. Nicotine interferes with the
In view of this, it is fundamental to be aware
functioning of neurotransmission systems and exerts of the characteristics of the patient during the various neuroendocrine effects, which, together treatment for dependence. Before the initiation of with the other effects of nicotine, can influence the treatment, it is necessary to evaluate whether there psychopathological profile and patient responsive- is predisposition to major depression, in order to ness to treatment.(30)
provide systematic follow-up evaluations of the
Some authors consider that studies on the comor- patient.(31,34) In these cases, it is recommended that
bidity between nicotine dependence and psychiatric major depression be treated prior to the cessation disorders can be grouped into two distinct areas(31): of smoking. 1) smoking and psychiatric disorders, with emphasis
There is a consensus regarding the efficacy of
on depression and schizophrenia; and 2) interaction antidepressive medications in the treatment of
dependence. The principal medication currently used
among drugs, especially alcohol and nicotine. This is bupropion.(36) In addition, the smoker can benefit
is an issue of great clinical interest with profound from psychotherapeutic techniques. One strategy
implications and can even create a basis for thera- that has presented positive results when used in
conjunction with medication is cognitive behavioral
Smoking and depression/depressive
therapy. The basis of this treatment consists, among
other aspects, of leading the smoker to identify the risk situations for relapse and develop strategies to
There is strong evidence of comorbidity between face those situations.(36)
smoking and depressive disorders. The probability of smoking cessation is reduced in patients with Smoking and Anxiety depression disorders. Smokers with a history of
There is also evidence of association between
depression are more prone to relapses during the smoking and anxiety, although this relation is even
period of abstinence, when compared with smokers less consistent, when compared with the relation-
without the same history. In smokers with a history ship between smoking and depression.(2,37) It has
of depressive disorders, smoking cessation is a risk been hypothesized that the nature of the relation-
factor for maintaining the clinical profile or the ship between smoking and anxiety varies according
development of a new depressive outbreak.(7,32,33)
to the diagnosis of the anxiety disorder.(38,39)
There are different hypotheses on the nature of
this association. Smoking can help as a sort of self- Smoking and Obsessive-Compulsive
medication to relieve feelings of sadness or negative Disorder
mood. There is evidence that the use of nicotine interferes with neurochemical systems, which, in
There is evidence that the prevalence of smoking
turn, affect neural circuits, such as reinforcing is lower in individuals with obsessive-compulsive
mechanisms associated with mood regulation.(33) disorder (OCD) than in the population in general or in
It has also been hypothesized that, the relation- other psychiatric populations.(38,39) Due to symptoms
ship between smoking and depression is more than such as exaggerated attention, detailed planning,
unidirectional, i.e., that one can influence the other. uneasiness, exaggerated preoccupation, sense of
Depressed smokers can smoke to relieve negative responsibility, lack of spontaneity, and controlled
feelings, and smoking therefore becomes reinforcing emotions, as well as rituals of care and neatness, for these individuals. However, upon cessation of OCD can be considered a hyperfrontality disorder. consumption, smokers with a history of depression Patients who suffer from OCD present pronounced can be at an increased risk of developing a new metabolic activity in the frontal cerebral cortex. It
Psychological characteristics associated with tobacco smoking behavior
is interesting to notice that, in contrast with OCD, Smoking and Panic Disorder
frontal lobe activity is reduced in individuals with
In recent decades, the relationship between panic
schizophrenia. The prevalence of smoking in indi- disorder (PD) and smoking (or nicotine dependence)
viduals with schizophrenia and in individuals with OCD seems to represent two extremes of the same has been investigated by various specialists.(40-42) continuum.(38)
There is evidence that smoking constitutes a risk
It is argued that the low consumption of factor for the appearance of PD. Various studies
tobacco in individuals with OCD can reflect a subja- show that smoking precedes the appearance of the cent genetic factor, possibly related to serotonergic disease, rather than the opposite.(39,43,44) However, and cholinergic systems. Personality traits, such as the mechanisms responsible for this association impulsive and risky behavior, extroversion, uncon- have not yet been elucidated. A study conducted ventional behaviors, and antisocial tendencies, are in 2001 states that the consumption of tobacco related to tobacco consumption and precede the should not be considered an exclusive etiologic initiation of the habit. Coincidently, many of these factor in any case of PD, and that further studies personality traits are rare in individuals with OCD, are needed in order to clarify the possible etiopath-which could explain the low prevalence of smoking ogenic mechanisms that smoking and this disease in individuals with this disturbance.(38)
have in common, as well as to answer specific thera-
One of the hypotheses is that the low prevalence peutic questions.(41)
of smoking in individuals with this disturbance
The literature as a whole suggests that the nature
is related to the neurochemical effects of nico- of the connection between smoking and anxiety
tine in the orbital frontal cortex. A study based differs according to the profile or specific diagnosis
on neuroimaging revealed that patients with OCD of the anxiety disorder. However, specialists in the
present pronounced metabolic activity in the orbital subject have called attention to the importance of
frontal cortex. However, individuals with schizo- taking into account the association that smoking
phrenia exhibit reduced metabolic activity in the presents with anxiety symptoms, anxiety disorders,
frontal lobe, similar to that resulting from lesions and mood disorders when establishing preventive
in this region. Since nicotine increases frontal lobe programs or treatments. It is essential, for example,
activity and reduces the abnormality in sensory that health professionals who deal with adolescents
physiology, it is possible that smoking is a type of know how to recognize symptoms of anxiety and
self-medication in individuals with schizophrenia. depression. By preventing problems of an affective
Nevertheless, theoretically, nicotine would cause a nature, it might be possible to decrease the risk of
contrary effect in individuals with OCD, reinforcing initiation of smoking in adolescents.(45) In treatment
obsessive symptoms, which could contribute to the programs for dependence, techniques and strate-
low prevalence of smoking in individuals with this gies for the control of anxiety and management of
stress, such as muscle relaxation and meditation,
Psychosocial determinants can also affect this have been increasingly adopted. The conjugation
association. Individuals with OCD are frequently of drug therapies, used in combination with tech-
more isolated in school. However, less socially niques of this nature, can increase the efficacy of
competent young adults might start smoking due the treatment of tobacco dependence.(36)
to peer pressure in early adolescence. In addition, characteristic symptoms of OCD, such as fear of Smoking and Schizophrenia
diseases and fear of starting a fire, can help these individuals avoid developing the habit of cigarette
The prevalence of smoking in individuals with
smoking.(38) Therefore, the subject is complex, and schizophrenia tends to be higher in relation to the further studies are still needed in order to confirm population in general as well as in relation to other these results. The issue also underscores the need to psychiatric populations.(30) Although the consump-investigate the nature of this association. The iden- tion of tobacco is decreasing in the population in tification of the factors responsible for this inverse general, patients with schizophrenia continue to association can contribute to understanding the smoke in alarming numbers and to suffer the ill dynamics subjacent to smoking.
A variety of mechanisms could mediate this an attempt at self-medication to relieve the symp-
association. Tobacco consumption might reflect the toms of this disturbance. Smoking is possibly used institutionalization process, as well as the tedium as a resource to improve attention and cognition and low impulse control presented by individuals processes.(48,51) As an example, the administration of with this disease.(30) The hypothesis of the use of nicotine patches in nonsmokers with ADD improves tobacco as self-medication stands out. Individuals cognitive functioning.(52) with schizophrenia report that smoking is relaxing,
reducing anxiety and minimizing the side effects dependence on psychoactive substances in general of medication.(7) In addition, tobacco consump- is also high. It is postulated that the association tion can improve concentration, reduce unpleasant between ADD and drug abuse/dependence reflects hyperstimulation experienced by individuals with an attempt at self-medicating the symptoms of schizophrenia, and promote one of the few avail- the disturbance. However, the literature suggests able pleasures for many individuals with the that multiple factors, including personality char-disease. In addition, it is also possible that nicotine acteristics, as well as genetic and neurobiological reduces negative schizophrenia symptoms, such as determinants, can mediate the interface between apathy, tedium, and emotions related to withdrawal smoking and ADD.(48,49)
Tobacco consumption during pregnancy can
syndrome, while improving the processes of atten- constitute a risk factor for the subsequent appear-
ance of this problem in the affected child.(50,53,54) In
This suggests the existence of a set of complex view of this, we can infer that it is fundamental to
psychopathological, biochemical, and neurophar- provide educational programs for pregnant women
machological interactions mediating the interface in order to make them aware of the multiple risks of
between smoking and schizophrenia.(46) However, smoking during pregnancy.
the subject is controversial, and there are other lines of interpretation. Individuals with schizophrenia are Smoking and alcoholism
less worried about social conventions and the long-term consequences of smoking to health, and are
The literature reveals a strong association
less likely to quit smoking. In addition, the social between smoking and disorders related to alcohol
alienation typically experienced by individuals with abuse or dependence.(31,37) The prevalence of alco-
schizophrenia frequently results from its concomit- holism is approximately 10 to 14 greater in smokers
tance with certain factors, such as low socioeconomic than in nonsmokers, and most studies suggest that
level and belonging to a socially marginalized group, alcoholism precedes smoking.(31,55) Studies that
that tend to increase the prevalence of smoking. confirm the connection between genetic factors
Therefore, it is necessary to adopt differentiated and personality traits can create a basis for inves-
practices in patients with schizophrenia who wish tigations designed to identify which genes are
to stop smoking, such as altering the doses of medi- associated with a complex network of unhealthy
cation in smokers who abstain from tobacco, using behaviors, such as aggression, excessive alcohol
nicotine replacement therapy in higher doses, using consumption, and smoking, as well as with mental
a combination of nicotine patches and gum, as well disorders such as schizophrenia, in order to improve
as providing cognitive behavioral therapy. Smoking and attention deficit disorder Smoking and other Mental Diseases
The prevalence of smoking in adolescents and
Prospective studies carried out with ethnically
adults with attention deficit disorder (ADD) or distinct populations reveal that the consump-
hyperactivity tends to be greater than that seen tion of tobacco during pregnancy is associated
among individuals without ADD.(47) An increasing with a greater incidence of criminal or violent
number of studies have been developed in an behavior in adult life among males.(57) In the studies attempt to elucidate the causes of this relation- mentioned, the association found remains, even ship.(48-50) One of the hypotheses is that tobacco when the analyses are adjusted for the influence consumption in individuals with ADD results from of other risk factors for criminal behavior. Studies
Psychological characteristics associated with tobacco smoking behavior
indicate that smoking during pregnancy precedes behavior is also mediated by the psychosocial and the appearance of behavior disorders in children sociocultural context. It is supposed that genetic and adolescents. In addition, in these studies, the and neurobiological factors, interacting with association found remains, even when the analyses psychosocial/sociocultural dynamics, simultane-are adjusted for the influence of other risk factors ously influence the principal personality dimensions for such problems.(58) The incidence of subsequent of the individual and the predisposition to smoking/criminal behavior might be mediated by damage to psychopathological profiles. the nervous system of the fetus, caused by the toxic
It is possible to state that knowledge of the
substances contained in tobacco smoke.(57)
psychological/psychiatric factors associated with smoking is important for practical purposes and can
be incorporated into the treatment of the nicotine-dependent individual. We can suggest that, prior
There is strong evidence that personality traits to initiating the process of smoking cessation, all
are influenced by determinants of genetic and patients should be evaluated as to the personality
neurobiological nature, among other factors.(56,59) profile and the presence or absence of certain asso-
The most widely accepted concept is that variations ciated psychiatric disturbance, since the lack of
observed in personality characteristics are due, at nicotine can exacerbate the withdrawal syndrome
least in part, to the activity of neurotransmitters. symptoms and even favor the appearance or wors-
The role of mechanisms of transmission and capture ening of psychiatric diseases.
of neuroregulators, such as dopamine and serot-
The close interconnection between smoking
onin, noradrenalin, and norepinephrine, stands out. and psychopathological profiles underscores the
In addition, genetic and neurobiological factors can importance of interdisciplinary co-operation among
also act in the predisposition to personality disor- professionals working in treatment programs
ders and psychopathological profiles.(60)
for nicotine dependence. The crucial role of the
However, in contrast to the effort to understand psychological/psychiatric evaluation and follow-up
the genetic determinants of the risk of alcoholism assessment of the patient throughout the thera-
and chemical dependence in general, there are still peutic process is especially emphasized.
a relatively small number of studies in the literature focusing on the genetic mediation of the asso- References
ciations among personality, psychopathology, and 1. DuPont RL, Gold MS. Withdrawal and reward: implications
for detoxification and relapse prevention. Psychiatric Annals.
nonsmokers, smokers tend to be more extroverted, 2. Fagerström KO. Measuring degree of physical dependence
tense, impulsive, depressive, and anxious, as well as
to tobacco smoking with reference to individualization of treatment. Addict Behav. 1978;3(3-4):235-41.
presenting more traits of neuroticism, psychoticism, 3. Botelho C. Você também pode parar de fumar. Cuiabá:
and sensation seeking, together with tendencies
toward antisocial/unconventional behaviors. In 4. Perkins KA, Epstein LH, Pastor S. Changes in energy balance
addition, it is well established that the prevalence
following smoking cessation and resumption of smoking in women. J Consult Clin Psychol. 1990;58(1):121-5.
of smoking is higher in patients with psychiatric 5. Gonçalves-Silva RMV, Lemos-Santos MG, Botelho C.
disorders than in the population in general. There
Influência do tabagismo no ganho ponderal, crescimento
is evidence that these associations are mediated by
corporal, consumo alimentar e hídrico de ratos. J Pneumol.
genetic and neurobiological factors.
6. Eysenck HJ. The biological basis of personality. Springfield:
However, this line of interpretation does not
rule out the interference of other factors in tobacco 7. Gilbert DG, McClernon FJ, Gilbert BO. The psychology of the
smoking behavior. For example, a study carried out
smoker. In: Bollinger CT, Fagerström KO, editors. The tobacco
in Japan in 1997 revealed a pronounced gender-
epidemic. Prog Respir Res [Basel] 1997;28:132-150.
8. Eysenck HJ. Genetic and environmental contributions
related difference in the prevalence of smoking
to individual differences: the three major dimensions of
(60% for males and only 8.6% for females),(12) in
personality. J Pers. 1990;58(1):245-61.
contrast with studies carried out in other coun- 9. Spielberg CD, Jacobs GA. Personality and smoking behavior.
tries. This leads us to believe that tobacco smoking
10. Seltzer CC, Oechsli FW. Psychosocial characteristics of
across 31 days of cigarette abstinence in women. J Consult
adolescent smokers before they started smoking: evidence
of self-selection. A prospective study. J Chronic Dis. 29. Terracciano A, Costa PT Jr. Smoking and the Five-Factor 1985;38(1):17-26.
Model of personality. Addiction. 2004;99(4):472-81.
11. Wijatkowski S, Forgays DG, Wrzesniewski K, Gorski T. 30. Herrán A, de Santiago A, Sandoya M, Fernández MJ, Diez-
Smoking behavior and personality characteristics in Polish
Manrique JF, Vázquez-Barquero JL. Determinants of smoking
adolescents. Int J Addict. 1990;25(4):363-73.
behaviour in outpatients with schizophrenia. Schizophr Res.
12. Arai Y, Hosokawa T, Fukao A, Izumi Y, Hisamichi S. Smoking
behaviour and personality: a population-based study in 31. Gigliotti AP, Lemos T. Comorbidade Psiquiátrica em Japan. Addiction. 1997;92(8):1023-33.
Tabagismo x Dependência de Álcool e Outras substâncias.
13. Kubicka L, Matejcek Z, Dytrych Z, Roth Z. IQ and personality
In: Associação Brasileira de Estudos do Álcool e Outras
traits assessed in childhood as predictors of drinking and
Drogas. Comorbidades - transtornos mentais x transtornos
smoking behaviour in middle-aged adults: a 24-year
por uso de substâncias de abuso. São Paulo: ABEAD, s.d.
follow-up study. Addiction. 2001;96(11):1615-28.
32. Glassman AH, Covey LS, Stetner F, Rivelli S. Smoking
14. Rondina RC, Gorayeb R, Botelho C, Silva AMC. Um estudo
cessation and the course of major depression: a follow-up
comparativo entre características de personalidade de
universitários fumantes, ex-fumantes e não-fumantes. Rev 33. Windle M, Windle RC. Depressive symptoms and cigarette Psiquiatr RS. 2005;27(2):140-150.
smoking among middle adolescents: prospective associations
15. Haines AP, Imeson JD, Meade TW. Psychoneurotic profiles of
and intrapersonal and interpersonal influences. J Consult
smokers and non-smokers. Br Med J. 1980;280(6229):1422.
16. Eysenck HJ. Smoking, personality and psychosomatic 34. Covey LS, Glassman AH, Stetner F. Cigarette smoking and
disorders. J Psychosom Res. 1963;13:107-30.
major depression. J Addict Dis. 1998;17(1):35-46.
17. Kendler KS, Neale MC, Sullivan P, Corey LA, Gardner CO, 35. Laje RP, Berman JA Glassman AH. Depression and nicotine:
Prescott CA. A population-based twin study in women of
preclinical and clinical evidence for common mechanisms.
smoking initiation and nicotine dependence. Psychol Med.
36. Presman S, Carneiro E, Gigliotti A. Tratamentos
18. Hopper JL, White VM, Macaskill GT, Hill DJ, Clifford CA.
não-farmacológicos para o tabagismo. Rev Psiq Clínic
Alcohol use, smoking habits and the Adult Eysenck Personality
Questionnaire in adolescent Australian twins [corrected] Acta 37. Hughes JR, Hatsukami DK, Mitchell JE, Dahlgren LA. Genet Med Gemellol (Roma). 1992;41(4):311-24. Erratum in:
Prevalence of smoking among psychiatric outpatients. Am J
Acta Genet Med Gemellol (Roma) 1993;42(2):185.
19. Jorm AF, Rodgers B, Jacomb PA, Christensen H, Henderson 38. Bejerot S, von Knorring L, Ekselius L. Personality traits and
S, Korten AE. Smoking and mental health: results from a
smoking in patients with obsessive-compulsive disorder. Eur
community survey. Med J Aust. 1999;170(2):74-7.
20. Zuckerman M, Kuhlman DM. Personality and risk-taking: 39. Johnson JG, Cohen P, Pine DS, Klein DF, Kasen S, Brook
common biosocial factors. J Pers. 2000;68(6):999-1029.
JS. Association between cigarette smoking and anxiety
21. Zuckerman M. Theoretical formulations. In: Zubek JP,
disorders during adolescence and early adulthood. JAMA.
editor. Sensory deprivation: fifteen years of research. New
York: Appleton-Century-Crofts; 1969. p. 407-32.
40. Amering M, Bankier B, Berger P, Griengl H, Windhaber J,
22. Carton S, Jouvent R, Widlöcher D. Sensation seeking,
Katschnig H. Panic disorder and cigarette smoking behavior.
nicotine dependence, and smoking motivation in female and
male smokers. Addict Behav. 1994;19(3):219-27.
41. Valença AM, Nardi AE, Nascimento I, Mezzasalma MA, Lopes
23. Carton S, Le Houezec J, Lagrue G, Jouvent R. Relationships
FL, Zin W. Transtorno de pânico e tabagismo. Rev Bras
between sensation seeking and emotional symptomatology
during smoking cessation with nicotine patch therapy. Addict 42. Goodwin R, Hamilton SP. Cigarette smoking and panic: the Behav. 2000;25(5):653-62.
role of neuroticism. Am J Psychiatry. 2002;159(7):1208-13.
24. Costa PT, McCrae RR. The NEO Personality Inventory Manual. 43. Breslau N, Klein DF. Smoking and panic attacks: an
Odessa: Psychol Assess Resources; 1985.
epidemiologic investigation. Arch Gen Psychiatry.
25. McCrae RR, Costa PT Jr. Validation of the five-factor model
of personality across instruments and observers. J Pers Soc 44. Isensee B, Wittchen HU, Stein MB, Hofler M, Lieb R. Psychol. 1987;52(1):81-90.
Smoking increases the risk of panic: findings from a
26. Gilbert DG, Crauthers DM, Mooney DK, McClernon FJ,
prospective community study. Arch Gen Psychiatry.
Jensen RA. Effects of monetary contingencies on smoking
relapse: influences of trait depression, personality, and 45. Dudas RB, Hans K, Barabas K. Anxiety, depression and habitual nicotine intake. Exp Clin Psychopharmacol.
smoking in schoolchildren--implications for smoking
prevention. J R Soc Health. 2005;125(2):87-92.
27. Hampson SE, Andrews JA, Barckley M, Lichtenstein E, 46. McCloughen A. The association between schizophrenia and
Lee ME. Conscientiousness, perceived risk, and risk-
cigarette smoking: a review of the literature and implications
reduction behaviors: a preliminary study. Health Psychol.
for mental health nursing practice. Int J Ment Health Nurs.
28. Gilbert DG, McClernon FJ, Rabinovich NE, Plath LC, Masson 47. Pomerleau CS, Downey KK, Snedecor SM, Mehringer AM,
CL, Anderson AE, et al. Mood disturbance fails to resolve
Marks JL, Pomerleau OF. Smoking patterns and abstinence
Psychological characteristics associated with tobacco smoking behavior
effects in smokers with no ADHD, childhood ADHD, and adult
and attention deficit hyperactivity disorder symptoms in
ADHD symptomatology. Addict Behav. 2003;28(6):1149-57.
offspring. Am J Psychiatry. 2003;160(11):1985-9.
48. Krause KH, Dresel SH, Krause J, Kung HF, Tatsch K, 54. Kahn RS, Khoury J, Nichols WC, Lanphear BP. Role of
Ackenheil M. Stimulant-like action of nicotine on striatal
dopamine transporter genotype and maternal prenatal
dopamine transporter in the brain of adults with attention
smoking in childhood hyperactive-impulsive, inattentive, and oppositional behaviors. J Pediatr. 2003;143(1):104-10.
deficit hyperactivity disorder. Int J Neuropsychopharmacol. 55. Ritchey PN, Reid GS, Hasse LA. The relative influence of
smoking on drinking and drinking on smoking among high
49. Dinn WM, Aycicegi A, Harris CL. Cigarette smoking in a
school students in a rural tobacco-growing county. J Adolesc
student sample: neurocognitive and clinical correlates.
56. Richards T. Research finds genetic link to personality trait.
50. Kotimaa AJ, Moilanen I, Taanila A, Ebeling H, Smalley SL,
McGough JJ, et al. Maternal smoking and hyperactivity in 57. Brennan PA, Grekin ER, Mednick SA. Maternal smoking
8-year-old children. J Am Acad Child Adolesc Psychiatry.
during pregnancy and adult male criminal outcomes. Arch
51. Lerman C, Audrain J, Tercyak K, Hawk LW Jr, Bush A, 58. Wakschlag LS, Lahey BB, Loeber R, Green SM, Gordon RA,
Crystal-Mansour S, et al. Attention-Deficit Hyperactivity
Leventhal BL. Maternal smoking during pregnancy and
Disorder (ADHD) symptoms and smoking patterns among
the risk of conduct disorder in boys. Arch Gen Psychiatry.
participants in a smoking-cessation program. Nicotine Tob
59. Kirk KM, Whitfield JB, Pang D, Heath AC, Martin NG. Genetic
52. Levin ED, Conners CK, Sparrow E, Hinton SC, Erhardt D,
covariation of neuroticism with monoamine oxidase activity
Meck WH, et al. Nicotine effects on adults with attention-
and smoking. Am J Med Genet. 2001;105(8):700-6.
deficit/hyperactivity disorder. Psychopharmacology (Berl). 60. Laakso A, Vilkman H, Kajander J, Bergman J, paranta M,
Solin O, et al. Prediction of detached personality in healthy
53. Thapar A, Fowler T, Rice F, Scourfield J, van den Bree
subjects by low dopamine transporter binding. Am J
M, Thomas H, et al. Maternal smoking during pregnancy
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