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Impaired Quality of Life of Healthy Young Smokers^*

^* From the Departments of Internal Medicine (Drs. Martinez, Mota, Vianna, Filho, and Silva) and Social Medicine (Dr. Rodrigues), Medical School of Ribeirão Preto, University of São Paulo, Ribeirão Preto, São Paulo, Brazil.

Correspondence to: José A. B. Martinez, MD, Internal Medicine Department, Avenida Bandeirantes 3900, CEP: 14048–900, Ribeirão Preto, SP, Brazil; e-mail: jabmarti{at}fmrp.usp.br

	Abstract

TOP Abstract Introduction Materials and Methods Results Discussion References

 
Study objective: To investigate the health-related quality of life (HRQL) profile of healthy young subjects with a short smoking history.

Design: Observational data at a single point in time.

Setting: Survey in two public universities.

Participants: Seventy-seven smoker students without any comorbidities (39 men; mean ± SD age, 20.5 ± 2.0 years). A control group for HRQL measurements was composed of 97 healthy, never-smoker students from the same universities (55 men; mean ± SD age, 20.6 ± 2.0 years).

Interventions: All subjects were blinded to the study proposal, and answered autoapplicable forms dealing with healthy habits, smoking, and the 36-item short form questionnaire.

Results: Never-smokers showed higher mean quality-of-life scores than smokers in all domains. Statistically significant differences were observed for the domains physical functioning (86.5 ± 12.9 vs 93.4 ± 9.6), general health perceptions (64.3 ± 19.8 vs 79.2 ± 13.4), vitality (58.4 ± 20.0 vs 64.6 ± 16.5), social functioning (59.3 ± 19.7 vs 76.3 ± 19.6), and mental health index (66.4 ± 21.1 vs 71.9 ± 15.5).

Conclusions: Healthy, light-to-moderate smokers with a short smoking history show significant impairment in physical and mental domains of HRQL in comparison to never-smokers. A better elucidation of these aspects may provide useful information for planning smoking-cessation interventions.

Key Words: short form-36 • smoking • quality of life

	Introduction

TOP Abstract Introduction Materials and Methods Results Discussion References

 
Some studies have shown that smoking may lead to impairment of health-related quality of life (HRQL). Significant differences in mean scores, as measured by the 36-item short form (SF-36), have been observed between never-smokers, smokers, and ex-smokers in population surveys.^{1 2 3 4} Similar results were obtained employing the St. George’s Respiratory Questionnaire in a group of subjects older than 55 years.⁵

The results of general population surveys and studies including old people can be potentially influenced by unrecognized smoking-related disorders and other comorbidities. So far, no investigation has been done specifically aimed at investigating HRQL in young subjects with a short smoking history. The objective of the present study was to investigate HRQL in a selected sample of healthy young smokers.

	Materials and Methods

TOP Abstract Introduction Materials and Methods Results Discussion References

 
Students from two public Brazilian universities were invited at random by the same interviewer to participate in a survey about their health status. They were initially asked to answer the HRQL SF-36 questionnaire and, only after that, complete a second form on the presence of health disorders, and use of medications, alcohol, elicit drugs, and tobacco smoking. The subjects were not aware of the final propose of the study when answering the questions. All subjects gave informed consent to participate in the study after returning the forms, and the protocol had been approved by the Institutional Ethics Committee.

HRQL was assessed with a version of the SF-36 questionnaire validated for the Portuguese language spoken in Brazil.⁶ The questionnaire is a generic instrument comprising 36 questions that cover nine health concepts: physical functioning, physical role, pain index, general health perceptions, vitality, social functioning, emotional role, mental health index, and health transition.⁷ The first four domains deal with physical aspects, and the next four reflect psychological features. In the present study, we did not evaluate the ninth component, health transition, which deals with changes in health status during the previous 12 months. Measures of the eight health domains were transformed linearly to scores in scales of 0 (the worst possible condition) to 100 (the best possible condition).⁸

The obtained forms were classified in two groups: smokers and never-smokers. A smoker was defined as a person who had smoked at least one cigarette every day during the last month. Only forms from subjects < 26 years old who denied chronic health conditions, regular use of medications, and illicit drug consumption were enrolled in the analysis. Special care was taken to exclude those with respiratory allergies and asthma.

Results are reported as means (SD). Data were analyzed statistically by analysis of variance for each HRQL domain (response), considering gender, smoking, alcohol consumption, and smoking/alcohol-interaction factors.^{9 10} Comparisons of gender and alcohol consumption frequencies between the two groups were made using the ² test. Statistical calculations were performed using the Stata software (StataCorp; College Station, TX) and a p-value < 0.05 was considered significant.

	Results

TOP Abstract Introduction Materials and Methods Results Discussion References

 
Two hundred seventy-nine students answered the forms. One hundred twelve subjects (40%) were smokers and 167 were never-smokers. One hundred five forms (38%) had to be excluded from analysis due to age > 25 years, presence of health conditions, chronic use of medications, and drug abuse. The final groups were composed by 77 smokers and 97 never-smokers.

Clinical features of both groups are listed in Table 1 . Smokers started smoking at a mean age of 17.5 years (SD, 2.6). The mean smoking duration and intensity were 3.2 years (SD, 2.1) and 1.7 pack-years (SD, 1.8), respectively. Fifty-seven subjects could be classified as light smokers (< 15 cigarettes a day), 18 subjects as moderate smokers (from 15 to 24 cigarettes/d), and 2 subjects as heavy smokers ( 25 cigarettes/d).

The never-smoker group showed higher mean quality-of-life scores than the smoker group in all domains (Table 2 ). Smoking was significantly associated with lower scores in all quality-of-life parameters except physical role, pain index, and emotional role. The comparison of the emotional role domain was marginally significant (p = 0.0576). The statistical analysis showed no influence of a history of alcohol consumption on the results.

	Discussion

TOP Abstract Introduction Materials and Methods Results Discussion References

We have studied healthy young students from two public Brazilian universities, exhibiting similar social and cultural backgrounds. A high proportion of women were observed in our smoker group (49.4%). This fact certainly does not reflect the proportion of smokers among the female population in Brazil, which is approximately 25%. The finding could be explained by a better acceptance to participate in the research among women than in men. It also could be explained by a recent trend observed in the country, where more women are looking for advanced courses than men. The smoker group displayed a higher proportion of subjects reporting regular use of alcohol. This finding agrees with published data demonstrating a relationship between smoking and alcohol abuse.¹¹ It also shows that smokers are more prone to take risks and to adopt less healthy life styles.

The volunteers did not report any chronic illness, and their smoking history was short and of slight intensity. Therefore, most probably, they did not have organic disorders secondary to the chronic use of cigarettes. Nevertheless, a statistically significant reduction was observed in five SF-36 domains, comprising both physical and mental fields. Such findings could not be explained by the observed difference in the alcohol habits between groups. This suggests that young smokers more often have troubles regarding physical performance and social relations. They appear to be aware of such difficulties and do not face their condition with optimism. Similar results have been described in studies involving larger samples and older subjects.^{2 3 4}

Hypothetical explanations for the HRQL decreases may be initially sought in cigarette consumption itself. Smoking produces thousands of chemicals that are absorbed through the lungs. Some substances could have organic actions leading to asthenia, vitality loss, muscle disorders, or psychological derangement. Nicotine, for example, induces tachycardia and peripheral vasoconstriction. Decreases in peripheral blood flow may potentially interfere with tissue metabolism, impairing task performance. In addition, elevations of carbon monoxide and carboxyhemoglobin may also impair tissue oxygenation. The findings that smoking may impair cardiorespiratory variables and decrease maximal oxygen uptake during exercise tests support this hypothesis.^{12 13 14} However, an additional comparison in our data between the SF-36 scores of heavy and moderate smokers with those of the light smokers did not show any significant difference between the groups. This suggests that the HRQL impairments of young smokers do not appear to be influenced by the smoking intensity, and argues against a functional cause for the present results.

Other explanations could be found in the smokers’ psychological profile. In this setting, the previous presence of depression, low self-esteem, and the predisposition to adopt a less healthy lifestyle could be responsible for starting smoking and the detected HRQL changes as well. In fact, it has been shown that the age at the first cigarette experience in adolescents is associated with reduced global life satisfaction.¹⁵

Previous studies have detected better quality-of-life scores for ex-smokers in comparison to current smokers. Although one study has found a relationship between poor scores of quality of life and cough and sputum production, other authors have emphasized that these findings could not be attributed exclusively to the improvement in respiratory symptoms.^{2 3 5} Even though the available data strongly support the concept that smoking cessation is associated with improvements in HRQL, an alternative explanation may be possible. Smokers with best scores on quality of life would probably be those exhibiting more concern about their health status and, consequently, with greatest chances to be successful in smoking-cessation attempts. The study of serial HRQL measurements during smoking-cessation protocols will certainly clarify these questions.

In conclusion, healthy, light-to-moderate smokers with a short smoking history show significant impairment in the physical and mental domains of HRQL in comparison to never-smokers. Hypothetical explanations for these findings include the action of tobacco-generated substances or intrinsic psychological features. A better elucidation of these aspects may provide useful information for planning smoking-cessation interventions.

	Footnotes

 
Abbreviations: HRQL = health-related quality of life; SF-36 = 36-item short form

Received for publication March 25, 2003. Accepted for publication September 10, 2003.

	References

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This Article Abstract Full Text (PDF) Free Submit a response Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in ISI Web of Science Similar articles in PubMed Alert me to new issues of the journal Add to My Personal Article Archive Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via ISI Web of Science (12) Citing Articles via Google Scholar Google Scholar Articles by Martinez, J. A. B. Articles by Rodrigues, A. L. Search for Related Content PubMed PubMed Citation Articles by Martinez, J. A. B. Articles by Rodrigues, A. L., Jr.