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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: rcassiar@terra.com.br Submitted: 26 February 2007. Accepted, after review: 28 March 2007.
Psychological characteristics associated with tobacco smoking behavior Introduction
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 disorders
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 Final considerations
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
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