Evaluation of the Effect of Severity of Separation Anxiety Disorder on Nicotine Dependence Level
Abstract
Objective: The present study attempts to find the level of association of nicotine dependence with separation anxiety disorder in adults and the interrelationship between these two disorders.
Method: The methodology consisted of 525 individuals aged between 18 and 63 years attending the outpatient clinic of Family Medicine at Hacettepe University. All participants were evaluated in this study with a questionnaire containing all the sociodemographic data, the Fagerström nicotine dependence test (FNBT), and the Separation Anxiety Disorder Severity Scale (SADSS). Data will be processed using the IBM SPSS V23 software package to find the relation between nicotine dependence and separation anxiety.
Results: The analysis also showed that there was no significant statistical relationship between FNBT results and SADSS results, with a correlation of r = 0.037and p = 0.399. In addition, the severity of separation anxiety was found to be higher in females than in males, as identified by the value of p = 0.024. Female participants were more likely to smoke as a way of coping with stress and anxiety compared to male participants. Among males, there was no significant relationship between nicotine dependence and separation anxiety, p = 0.131, suggesting that in males, the nicotine behavior may be influenced more by social and cultural factors.
Conclusion: The results of the present study show that the relationship between nicotine dependence and separation anxiety can be considered from the point of view of gender. Although the relationship between nicotine addiction and anxiety is stronger in females, this relationship is weaker in males. These results indicate that gender differentiation may be performed regarding the treatment of nicotine addiction. Future studies should investigate the interaction of these two diseases in more detail and may help in developing therapeutic measures that are more specific and individualized.
1. Introduction
Tobacco dependence occupies a significant position among worldwide public health issues. The World Health Organization (WHO) reports that tobacco consumption leads to the fatalities of millions annually, and addressing this dependency is a critical aspect of public health strategies [1]. Nonetheless, nicotine addiction extends beyond mere physical dependence; it also encompasses a multifaceted process intertwined with psychological and social influences [2]. In this framework, it has been proposed that the psychological conditions of individuals could significantly influence both the emergence and persistence of nicotine dependence [3].
While separation anxiety disorder is commonly seen in childhood, it can also pose significant challenges for adults [4]. Adult separation anxiety disorder is characterized by the prevalence of intense fear and anxiety in individuals when faced with separation from those with whom they have a strong emotional attachment [5]. The daily lives of individuals may be adversely impacted by this phenomenon, resulting in heightened levels of anxiety [6]. The potential connection between cigarette dependence and separation anxiety is underscored by the notion that psychological issues might initiate smoking behaviors and amplify the degree of addiction [7].
The objective of this research was to investigate the prevalence and intensity of adult separation anxiety disorder among individuals with a cigarette addiction, as well as to assess the correlation between these two phenomena. The limited available literature indicates that few studies have examined the effect of separation anxiety on nicotine dependence [8]. Consequently, this study attempts to provide a thorough review of the relationship between separation anxiety disorder and nicotine dependence, aiming to shed new light on how these two conditions interact. It is thought that the results of the study will provide important clues that psychological factors should be taken into consideration in the treatment of nicotine dependence [9].
The originality of this study was that detailed attention was given to the relationship between separation anxiety disorder and nicotine dependence. It is thought that the results of this study, carried out using quantitative research methods, might contribute to the development of more focused interventions in the fight against nicotine dependence [10].
2. Methods
The study was approved by the Hacettepe University’s Noninterventional Clinical Research Ethics Committee prior to the initiation of the study, in the session dated 23.05.2023, with session no.: 2023/09 and the decision no. 2023/09-48 (Research no. GO 23/352). The research was carried out between May 2023 and May 2024. In this study, face-to-face survey methods will be performed in the Hacettepe University’s Faculty of Medicine, Family Medicine Outpatient Clinics. A questionnaire with a total of 27 questions in 3 sections will be applied to the participants after taking their written and verbal consent for participation upon inclusion criteria: being 18 years of age or older, cooperating with the questionnaire/tests, smoking, and not having a diagnosis of psychiatric disease. The first part of the questionnaire was a sociodemographic information form which consisted of questions about the participants’ gender, age, educational background, and employment status. The Modified Fagerstrom Scale for Nicotine Dependence with 6 questions in the second part, and the Adult Separation Anxiety Disorder Severity Scale (SADSS) that contains 10 questions, is prepared for the third part.
2.1. SADSS
It is a 10-item self-rating scale prepared by the American Psychiatric Association and provides a five-point Likert-type rating (0 = never and 4 = all the time). Participants are requested to rate this scale considering their thoughts, feelings, and behaviors in the last seven days. The severity of separation anxiety is determined by the scores obtained from the items on the scale. The scores obtained from the scale range between 0 and 40, with high scores indicating profound separation anxiety. Subsequently, after obtaining the total score, the “mean total score” is obtained by dividing the scale score by the total number of items which is 10. If the resulting score from the process is a fraction of the number, it is rounded off to the nearest whole number and then rescored as (0) none; the ratings are based on the following scaling: (1) mild, (2) moderate, (3) severe, and (4) extremely severe. In 2020, Coldur et al. conducted validity and reliability in a Turkish context with a sample size of 161 participants. The Kaiser–Meyer–Olkin (KMO) statistic, which is a measure of the adequacy of the data for factor analysis, was 0.919 and Bartlett’s test was 1135.782 (p < 0.001), each considered sufficient to proceed with factor analysis. The result from the confirmatory factor analysis yielded RMSEA of 0.09, CFI of 0.94, and χ2/df of 3.34. In the internal consistency analysis of the DSM-5 SADSS total score and subscores, Cronbach’s alpha coefficient was 0.93. Test–retest: The SADSS was administered at two-week intervals to 80 individuals, comprising 40 patients and 40 HC, for test–retest, and the test–retest correlation coefficient for the SADSS total score was calculated as r = 0.989 and was found to be significant [11].
2.2. Fagerström Nicotine Dependence Test (FNBT)
This nicotine dependence self-test is one of the most used and considered reliable tools in measuring individual nicotine dependence. The test consists of a total of six questions, which cover the details that contribute to the severity of the addiction. The information includes daily cigarette use, the number of years one has been smoking, and the amount of time from waking up before smoking the first cigarette. The overall score of the test runs from 0 to 10, and the higher the score, the higher the level of dependence. The scoring of the FNBT is categorized as follows: 0-2 points “very low dependence,” 3-4 points “low dependence,” 5 points “medium dependence,” 6-7 points “high dependence,” and 8-10 points “very high dependence.” Uysal et al. conducted a validity and reliability study of the Turkish version of the FNBT by evaluating 161 smokers and 160 nonsmokers. In the internal consistency analysis of the total score and subdimensions of the scale, it was determined that Cronbach’s alpha coefficient was 0.82. In the test–retest reliability analysis, it was found that the scores obtained from the FNBT were highly intercorrelated, r = 0.94, when tests were carried out two weeks apart [12]. Therefore, these results suggested that the Turkish adaptation of the FNBT was a reliable and stable instrument for assessing nicotine dependence.
2.3. Statistical Method
The data were analyzed with IBM SPSS V23. The conformity of the data to normal distribution was examined by Kolmogorov–Smirnov and Shapiro–Wilk tests. Kruskal–Wallis’ H test was used for three or more group comparisons of parameters that did not conform to the normal distribution. Multiple comparisons were analyzed with Dunn’s test. The Pearson chi-square test and Fisher–Freeman–Halton test were used to examine the relationship between categorical data. Spearman’s rho correlation coefficient was used to examine the relationship between parameters that did not fit the normal distribution. Binary logistic regression was used to analyze the risk factors affecting nicotine dependence. Finally, the model established to examine the moderating effect of age on the effect of nicotine dependence on separation anxiety was examined with Process Macro’s Model 1. The results are presented as frequency (percentage) for categorical data and mean ± standard deviation, and median (minimum–maximum) for quantitative data. The significance level was taken as p < 0.050.
3. Results
When the percentage and frequency distributions of the participants were analyzed, it was found that the rate of females was 51.8%, while the rate of males was 48.2%. While the rate of those whose marital status is married is 53%, the rate of those who are single is 47%. There were no participants in the “divorced” category within our dataset. In terms of education, the highest rate belongs to the high school and undergraduate categories with 17%. In terms of employment status, the rate of those who work full-time is 26.7%, while the rate of those who work part-time is 24%, and the rate of those who cannot work is 49.3%. While the rate of those who do not have chronic diseases is 68.8%, the rate of those who do is 31.2% (cardiovascular system diseases [24.1%], gastrointestinal system diseases [6.9%], neurological diseases [3.4%], endocrinological diseases [13.8%], rheumatological diseases [13.8%], and other conditions [37.9%]). While the rate of those who do not use medication was 83.8%, the rate of those who do for chronic diseases was 16.2%. The highest rate of smoking duration was obtained in the category of 10 or more years with 31%. While the rate of those who had not tried to quit smoking before was 48.6%, the rate of those who had tried was 51.4%. The highest rate in the reason for starting was found in the category of friend insistence with 52.9%. The mean age of the participants was 40.46 years, and the number of cigarettes smoked per day was 22.09 (Table 1).
| Frequency | Percentage | |
|---|---|---|
| Gender | ||
| Female | 272 | 51.8 |
| Male | 253 | 48.2 |
| Marital status | ||
| Married | 278 | 53.0 |
| Single | 247 | 47.0 |
| Education status | ||
| Illiterate | 54 | 10.3 |
| Primary school | 68 | 13.0 |
| Secondary school | 59 | 11.2 |
| High school | 89 | 17.0 |
| Associate degree | 57 | 10.9 |
| License | 89 | 17.0 |
| Master’s degree | 58 | 11.0 |
| Doctorate and above | 51 | 9.7 |
| Employment status | ||
| Full-time | 140 | 26.7 |
| Part-time | 126 | 24.0 |
| Not working | 259 | 49.3 |
| Presence of chronic disease | ||
| No | 361 | 68.8 |
| Yes | 164 | 31.2 |
| Regular medication use for Chronic Disease | ||
| No | 440 | 83.8 |
| Yes | 85 | 16.2 |
| Duration of smoking | ||
| Less than 1 Year | 121 | 23.0 |
| 1–5 Years | 138 | 26.3 |
| 6–9 Years | 103 | 19.6 |
| 10 and over | 163 | 31.0 |
| Has he tried to quit before? | ||
| No | 255 | 48.6 |
| Yes | 270 | 51.4 |
| Reason for start | ||
| Friend insistence | 274 | 52.9 |
| My own problems | 251 | 48.5 |
| Smoking in the family | 247 | 47.7 |
| Social environment | 255 | 49.2 |
| Looking older | 239 | 46.1 |
| Envying celebrities | 236 | 45.6 |
| Mean ± S.Deviation | Median (min–max) | |
| Age | 40.46 ± 13.3 | 40 (18–63) |
| Cigarette pieces daily | 22.09 ± 10.18 | 21 (2–40) |
- Abbreviations: max, maximum; min, minimum; S. Deviation, standard deviation.
The mean score of the Fagerström Nicotine Dependence Scale was 4.91. The proportions of those who were very low dependence, low dependence, medium dependence, high dependence, and very high dependence were 28.4%, 17.7%, 9%, 18.9%, and 26.1% (Table 2).
| Mean ± S.Deviation | Median(min-max) | |
|---|---|---|
| Fagerström nicotine dependence test score | 4.91 ± 3.2 | 5 (0–10) |
| Frequency | Percentage | |
| Fagerström nicotine dependence level | ||
| 0-2 points: Very low dependence | 149 | 28.4 |
| 3-4 points: Low dependence | 93 | 17.7 |
| 5 points: Medium dependence | 47 | 9.0 |
| 6-7 points: High dependence | 99 | 18.9 |
| 8–10 points: Very high dependence | 137 | 26.1 |
- Abbreviations: max, maximum; min, minimum; S. Deviation, standard deviation.
The mean score on the SADSS was 19.22. The rate of those without anxiety disorder was 12.2%, the rate of those with mild anxiety disorder was 28.4%, the rate of those with moderate anxiety disorder was 23%, the rate of those with severe anxiety disorder was 21.1%, and the rate of those with extremely severe anxiety disorder was 15.2% (Table 3).
| Mean ± S.Deviation | Median (min-max) | |
|---|---|---|
| Separation Anxiety Disorder Severity Scale score | 19.22 ± 12.07 | 18 (0–40) |
| Frequency | Percentage | |
| Severity of separation anxiety disorder | ||
| (0) None | 64 | 12.2 |
| (1) Mild | 149 | 28.4 |
| (2) Moderate | 121 | 23.0 |
| (3) Severe | 111 | 21.1 |
- Abbreviations: max, maximum; min, minimum; S. Deviation, standard deviation.
There was no statistically significant relationship between nicotine dependence level and separation anxiety level (p = 0.232) (Table 4).
| Fagerström nicotine dependence level | Total | Test statistic | p∗ | |||||
|---|---|---|---|---|---|---|---|---|
| Very low dependence | Low dependence | Medium dependence | High dependence | Very high dependence | ||||
| Separation anxiety disorder level | ||||||||
| (0) None | 23 (15.4) | 10 (10.8) | 7 (14.9) | 12 (12.1) | 12 (8.8) | 64 (12.2) | ||
| (1) Mild | 34 (22.8) | 32 (34.4) | 21 (44.7) | 27 (27.3) | 35 (25.5) | 149 (28.4) | ||
| (2) Moderate | 32 (21.5) | 21 (22.6) | 8 (17) | 28 (28.3) | 32 (23.4) | 121 (23) | 19.737 | 0.232 |
| (3) Severe | 33 (22.1) | 17 (18.3) | 7 (14.9) | 22 (22.2) | 32 (23.4) | 111 (21.1) | ||
| (4) Extremely severe | 27 (18.1) | 13 (14) | 4 (8.5) | 10 (10.1) | 26 (19) | 80 (15.2) | ||
- ∗Pearson chi-square test; frequency (percentage).
There was no statistically significant relationship between the FNBT score and the separation anxiety test score (p = 0.399) (Table 5).
| Fagerström nicotine addiction test score | Separation Anxiety Disorder Severity Scale score | ||
|---|---|---|---|
| Fagerström nicotine addiction test score | r | 1 | |
| p | — | ||
| Separation Anxiety Disorder Severity Scale score | r∗ | 0.037 | 1 |
| p | 0.399 | — | |
- ∗Spearman’s rho correlation coefficient.
The relationship between Fagerström nicotine dependence level and categorical variables was analyzed and it was found that there was no statistically significant relationship between them (p ≥ 0.050) (Table 6).
| Fagerström nicotine dependence level | p | |||||||
|---|---|---|---|---|---|---|---|---|
| Very low dependence | Low dependence | Medium dependence | High dependence | Very high dependence | Total | Test statistic | ||
| Gender | ||||||||
| Woman | 89 (32.7) | 50 (18.4) | 24 (8.8) | 44 (16.2) | 65 (23.9) | 272 (51.8) | 7.094 | 0.131 ∗ |
| Male | 60 (23.7) | 43 (17) | 23 (9.1) | 55 (21.7) | 72 (28.5) | 253 (48.2) | ||
| Marital status | ||||||||
| Married | 79 (28.4) | 43 (15.5) | 30 (10.8) | 50 (18) | 76 (27.3) | 278 (53) | 4.504 | 0.342 ∗ |
| Single | 70 (28.3) | 50 (20.2) | 17 (6.9) | 49 (19.8) | 61 (24.7) | 247 (47) | ||
| Education status | ||||||||
| Illiterate | 21 (38.9) | 6 (11.1) | 8 (14.8) | 7 (13) | 12 (22.2) | 54 (10.3) | 36.029 | 0.131 ∗∗ |
| Primary school | 23 (33.8) | 10 (14.7) | 6 (8.8) | 9 (13.2) | 20 (29.4) | 68 (13) | ||
| Secondary school | 7 (11.9) | 13 (22) | 5 (8.5) | 12 (20.3) | 22 (37.3) | 59 (11.2) | ||
| High school | 23 (25.8) | 17 (19.1) | 11 (12.4) | 19 (21.3) | 19 (21.3) | 89 (17) | ||
| Associate degree | 13 (22.8) | 11 (19.3) | 4 (7) | 16 (28.1) | 13 (22.8) | 57 (10.9) | ||
| License | 29 (32.6) | 13 (14.6) | 6 (6.7) | 21 (23.6) | 20 (22.5) | 89 (17) | ||
| Master’s degree | 14 (24.1) | 14 (24.1) | 6 (10.3) | 8 (13.8) | 16 (27.6) | 58 (11) | ||
| Doctorate and above | 19 (37.3) | 9 (17.6) | 1 (2) | 7 (13.7) | 15 (29.4) | 51 (9.7) | ||
| Employment status | ||||||||
| Full time | 39 (27.9) | 27 (19.3) | 16 (11.4) | 21 (15) | 37 (26.4) | 140 (26.7) | 7.851 | 0.448 ∗ |
| Part time | 29 (23) | 19 (15.1) | 11 (8.7) | 28 (22.2) | 39 (31) | 126 (24) | ||
| Not working | 81 (31.3) | 47 (18.1) | 20 (7.7) | 50 (19.3) | 61 (23.6) | 259 (49.3) | ||
| Presence of chronic disease | ||||||||
| No | 103 (28.5) | 66 (18.3) | 29 (8) | 70 (19.4) | 93 (25.8) | 361 (68.8) | 1.534 | 0.821 ∗ |
| Yes | 46 (28) | 27 (16.5) | 18 (11) | 29 (17.7) | 44 (26.8) | 164 (31.2) | ||
| Regular medication use | ||||||||
| No | 119 (27) | 80 (18.2) | 37 (8.4) | 88 (20) | 116 (26.4) | 440 (83.8) | 4.897 | 0.298 ∗ |
| Yes | 30 (35.3) | 13 (15.3) | 10 (11.8) | 11 (12.9) | 21 (24.7) | 85 (16.2) | ||
| Duration of smoking | ||||||||
| Less than 1 year | 35 (28.9) | 26 (21.5) | 9 (7.4) | 18 (14.9) | 33 (27.3) | 121 (23) | 19.441 | 0.078 ∗ |
| 1–5 years | 48 (34.8) | 27 (19.6) | 8 (5.8) | 21 (15.2) | 34 (24.6) | 138 (26.3) | ||
| 6–9 years | 27 (26.2) | 16 (15.5) | 13 (12.6) | 28 (27.2) | 19 (18.4) | 103 (19.6) | ||
| 10 and over | 39 (23.9) | 24 (14.7) | 17 (10.4) | 32 (19.6) | 51 (31.3) | 163 (31) | ||
| Did he/she try to quit | ||||||||
| No | 78 (30.6) | 49 (19.2) | 21 (8.2) | 45 (17.6) | 62 (24.3) | 255 (48.6) | 2.755 | 0.600 ∗ |
| Yes | 71 (26.3) | 44 (16.3) | 26 (9.6) | 54 (20) | 75 (27.8) | 270 (51.4) | ||
| Reason for starting | ||||||||
| Friend insistence | 73 (26.6) | 51 (18.6) | 25 (9.1) | 51 (18.6) | 74 (27) | 274 (100) | 25.605 | 0.374 ∗ |
| My own problems | 66 (26.3) | 45 (17.9) | 27 (10.8) | 44 (17.5) | 69 (27.5) | 251 (100) | ||
| Smoking in the family | 81 (32.8) | 35 (14.2) | 22 (8.9) | 45 (18.2) | 64 (25.9) | 247 (100) | ||
| Social environment | 68 (26.7) | 52 (20.4) | 18 (7.1) | 48 (18.8) | 69 (27.1) | 255 (100) | ||
| Looking older | 72 (30.1) | 49 (20.5) | 15 (6.3) | 43 (18) | 60 (25.1) | 239 (100) | ||
| Envying celebrities | 70 (29.7) | 42 (17.8) | 18 (7.6) | 40 (16.9) | 66 (28) | 236 (100) | ||
- ∗Pearson Chi-Square test.
- ∗∗Fisher–Freeman–Halton test; frequency (percentage).
There was no statistically significant difference between the median values of age and the number of cigarettes consumed per day according to the Fagerström nicotine dependence level (p ≥ 0.050) (Table 7).
| Fagerström nicotine dependence level | Total | Test statistic | p∗ | |||||
|---|---|---|---|---|---|---|---|---|
| Very low dependence | Low dependence | Medium dependence | High dependence | Very high dependence | ||||
| Age | 40.38 ± 13.28 | 41.43 ± 13.13 | 42.45 ± 13.16 | 39.78 ± 14.13 | 39.69 ± 12.95 | 40.46 ± 13.3 | 2.155 | 0.707 |
| 40 (18–63) | 41 (18–63) | 43 (18–63) | 39 (18–63) | 39 (18–63) | 40 (18–63) | |||
| The number of cigarettes smoked per day | 22.34 ± 11.11 | 20.63 ± 10.46 | 20.66 ± 7.87 | 21.93 ± 10.39 | 23.41 ± 9.41 | 22.09 ± 10.18 | 5.253 | 0.262 |
| 23 (4–40) | 21 (2–40) | 20 (6–39) | 21 (5–40) | 24 (6–40) | 21 (2–40) | |||
- ∗Kruskal–Wallis H test; mean ± standard deviation; median (minimum–maximum).
A statistically significant relationship was found between separation anxiety levels and gender (p = 0.024). In females, the rates of those with no anxiety, mild anxiety, moderate anxiety, severe anxiety, and extremely severe anxiety were 11.8%, 23.2%, 26.8%, 20.6%, and 17.6%. In males, the rates of those with no anxiety, mild anxiety, moderate anxiety, severe anxiety, and extremely severe anxiety were 12.6%, 34%, 19%, 21.7%, and 12.6%.
A statistically significant relationship was found between separation anxiety levels and medication for chronic diseases (p = 0.004). In those who did not use medication, the rate of those with no anxiety was 12.3%, mild anxiety was 30.7%, moderate anxiety was 20.2%, severe anxiety was 21.8%, and extremely severe anxiety was 15%. Among medication users for chronic diseases, the rate of those without anxiety was 11.8%, the rate of those with mild anxiety was 16.5%, the rate of those with moderate anxiety was 37.6%, the rate of those with severe anxiety was 17.6%, and the rate of those with extremely severe anxiety was 16.5%.
There was no statistically significant relationship between other sociodemographic characteristics and separation anxiety levels (p ≥ 0.050) (Table 8).
| Severity of separation anxiety disorder | Total | Test Statistic | p∗ | |||||
|---|---|---|---|---|---|---|---|---|
| (0) None | (1) Mild | (2) Moderate | (3) Severe | (4) Extremely severe | ||||
| Gender | ||||||||
| Female | 32 (11.8) | 63 (23.2) | 73 (26.8) | 56 (20.6) | 48 (17.6) | 272 (51.8) | 11.252 | 0.024 |
| Male | 32 (12.6) | 86 (34) | 48 (19) | 55 (21.7) | 32 (12.6) | 253 (48.2) | ||
| Marital status | ||||||||
| Married | 36 (12.9) | 77 (27.7) | 65 (23.4) | 60 (21.6) | 40 (14.4) | 278 (53) | 0.739 | 0.946 |
| Single | 28 (11.3) | 72 (29.1) | 56 (22.7) | 51 (20.6) | 40 (16.2) | 247 (47) | ||
| Education status | ||||||||
| Illiterate | 6 (11.1) | 17 (31.5) | 10 (18.5) | 11 (20.4) | 10 (18.5) | 54 (10.3) | 31.706 | 0.287 |
| Primary school | 10 (14.7) | 14 (20.6) | 10 (14.7) | 16 (23.5) | 18 (26.5) | 68 (13) | ||
| Secondary school | 5 (8.5) | 16 (27.1) | 16 (27.1) | 17 (28.8) | 5 (8.5) | 59 (11.2) | ||
| High school | 12 (13.5) | 31 (34.8) | 18 (20.2) | 18 (20.2) | 10 (11.2) | 89 (17) | ||
| Associate degree | 8 (14) | 17 (29.8) | 14 (24.6) | 8 (14) | 10 (17.5) | 57 (10.9) | ||
| License | 10 (11.2) | 26 (29.2) | 18 (20.2) | 22 (24.7) | 13 (14.6) | 89 (17) | ||
| Master’s degree | 7 (12.1) | 18 (31) | 16 (27.6) | 7 (12.1) | 10 (17.2) | 58 (11) | ||
| Doctorate and above | 6 (11.8) | 10 (19.6) | 19 (37.3) | 12 (23.5) | 4 (7.8) | 51 (9.7) | ||
| Employment status | ||||||||
| Full-time | 22 (15.7) | 44 (31.4) | 26 (18.6) | 30 (21.4) | 18 (12.9) | 140 (26.7) | 8.165 | 0.417 |
| Part-time | 10 (7.9) | 35 (27.8) | 31 (24.6) | 25 (19.8) | 25 (19.8) | 126 (24) | ||
| Not working | 32 (12.4) | 70 (27) | 64 (24.7) | 56 (21.6) | 37 (14.3) | 259 (49.3) | ||
| Presence of chronic disease | ||||||||
| No | 43 (11.9) | 110 (30.5) | 74 (20.5) | 80 (22.2) | 54 (15) | 361 (68.8) | 5.736 | 0.220 |
| Yes | 21 (12.8) | 39 (23.8) | 47 (28.7) | 31 (18.9) | 26 (15.9) | 164 (31.2) | ||
| Regular medication use | ||||||||
| No | 54 (12.3) | 135 (30.7) | 89 (20.2) | 96 (21.8) | 66 (15) | 440 (83.8) | 15.151 | 0.004 |
| Yes | 10 (11.8) | 14 (16.5) | 32 (37.6) | 15 (17.6) | 14 (16.5) | 85 (16.2) | ||
| Duration of smoking | ||||||||
| Less than 1 Year | 8 (6.6) | 37 (30.6) | 30 (24.8) | 24 (19.8) | 22 (18.2) | 121 (23) | 15.189 | 0.231 |
| 1–5 Years | 16 (11.6) | 29 (21) | 38 (27.5) | 34 (24.6) | 21 (15.2) | 138 (26.3) | ||
| 6–9 Years | 15 (14.6) | 28 (27.2) | 24 (23.3) | 20 (19.4) | 16 (15.5) | 103 (19.6) | ||
| 10 and over | 25 (15.3) | 55 (33.7) | 29 (17.8) | 33 (20.2) | 21 (12.9) | 163 (31) | ||
| Did he/she try to quit | ||||||||
| No | 28 (11) | 64 (25.1) | 64 (25.1) | 55 (21.6) | 44 (17.3) | 255 (48.6) | 4.749 | 0.314 |
| Yes | 36 (13.3) | 85 (31.5) | 57 (21.1) | 56 (20.7) | 36 (13.3) | 270 (51.4) | ||
| Reason for starting | ||||||||
| Friend insistence | 27 (9.9) | 79 (28.8) | 66 (24.1) | 57 (20.8) | 45 (16.4) | 274 (100) | 32.058 | 0.126 |
| My own problems | 29 (11.6) | 73 (29.1) | 64 (25.5) | 44 (17.5) | 41 (16.3) | 251 (100) | ||
| Smoking in the family | 26 (10.5) | 73 (29.6) | 57 (23.1) | 56 (22.7) | 35 (14.2) | 247 (100) | ||
| Social environment | 20 (7.8) | 78 (30.6) | 61 (23.9) | 54 (21.2) | 42 (16.5) | 255 (100) | ||
| Looking older | 27 (11.3) | 59 (24.7) | 60 (25.1) | 55 (23) | 38 (15.9) | 239 (100) | ||
| Envying celebrities | 24 (10.2) | 66 (28) | 50 (21.2) | 50 (21.2) | 46 (19.5) | 236 (100) | ||
- Note: Bold values are statistically significant.
- ∗Pearson chi-square test; frequency (percentage).
It was found that there was no statistically significant difference between the median values of age according to separation anxiety levels (p = 0.830).
A statistically significant difference was found between the median values of the number of cigarettes smoked per day according to separation anxiety levels (p = 0.007). While the median value was 15 in those with no anxiety, it was 20 in those with mild anxiety, 25 in those with moderate anxiety, 23 in those with severe anxiety, and 23 in those with extremely severe anxiety. Here, those with no anxiety and those with moderate anxiety were different from each other, while they were like the others (Table 9).
| Severity of separation anxiety disorder level | Total | Test statistic | p∗ | |||||
|---|---|---|---|---|---|---|---|---|
| (0) None | (1) Mild | (2) Moderate | (3) Severe | (4) Extremely severe | ||||
| Age | 40.8 ± 13.73 | 39.77 ± 12.5 | 41.2 ± 13.43 | 39.83 ± 14.52 | 41.21 ± 12.65 | 40.46 ± 13.3 | 1.482 | 0.830 |
| 39 (19–63) | 39 (18–63) | 41 (18–63) | 38 (18–63) | 40.5 (18–63) | 40 (18–63) | |||
| The number of cigarettes smoked per day | 18.44 ± 9.28 | 21.25 ± 10.38 | 23.81 ± 10.42 | 22.86 ± 9.97 | 22.9 ± 9.8 | 22.09 ± 10.18 | 14.133 | 0.007 |
| 15 (5–37)b | 20 (2–40)ab | 25 (5–40)a | 23 (6–40)ab | 23 (5–40)ab | 21 (2–40) | |||
- Note: Bold values are statistically significant.
- ∗Kruskal–Wallis H test; mean ± standard deviation; median (minimum–maximum).
- a-bThere is no difference between severities with the same letter.
Factors affecting nicotine dependence were analyzed by binary logistic regression analysis. When the results of the univariate model were analyzed, it was found that the risk of being addicted to cigarettes was 1.507 times higher for males than for females (p = 0.020). The risk of secondary school graduates being addicted to cigarettes was 2.505 times higher than illiterates (p = 0.018).
When the results of the multiple models were analyzed, it was found that the risk of being a high and very high smoker was 1.626 times higher for males than for females (p = 0.008). Secondary school graduates were 2.865 times more likely to have a high and very high risk of nicotine dependence than illiterates (p = 0.009). It was found that the risk of being high and very high nicotine dependence was 1.660 times higher in part-time workers than in full-time workers (p = 0.049) (Table 10).
| Nicotine dependence | Univariate | Multiple | ||||
|---|---|---|---|---|---|---|
| Very low, low, and medium | High. Very high | OR (95% CI) | p | OR (95% CI) | p | |
| Age | 41.05 ± 13.19 | 39.73 ± 13.43 | 0.993 (0.980–1.005) | 0.257 | 0.985 (0.970–1.001) | 0.065 |
| Gender | ||||||
| Female | 163 (59.9) | 109 (40.1) | Reference | |||
| Male | 126 (49.8) | 127 (50.2) | 1.507 (1.067–2.130) | 0.020 | 1.626 (1.135–2.329) | 0.008 |
| Marital status | ||||||
| Married | 152 (54.7) | 126 (45.3) | Reference | |||
| Single | 137 (55.5) | 110 (44.5) | 0.969 (0.686–1.367) | 0.856 | 0.978 (0.683–1.401) | 0.904 |
| Education status | ||||||
| Illiterate | 35 (64.8) | 19 (35.2) | Reference | |||
| Primary school | 39 (57.4) | 29 (42.6) | 1.370 (0.656–2.862) | 0.403 | 1.484 (0.698–3.153) | 0.305 |
| Secondary school | 25 (42.4) | 34 (57.6) | 2.505 (1.171–5.360) | 0.018 | 2.865 (1.304–6.294) | 0.009 |
| High school | 51 (57.3) | 38 (42.7) | 1.373 (0.682–2.761) | 0.374 | 1.399 (0.675–2.902) | 0.367 |
| Associate degree | 28 (49.1) | 29 (50.9) | 1.908 (0.890–4.090) | 0.097 | 2.190 (1.001–4.792) | 0.050 |
| License | 48 (53.9) | 41 (46.1) | 1.573 (0.784–3.159) | 0.202 | 1.780 (0.863–3.671) | 0.118 |
| Master’s degree | 34 (58.6) | 24 (41.4) | 1.300 (0.605–2.794) | 0.501 | 1.512 (0.688–3.327) | 0.304 |
| Doctorate and above | 29 (56.9) | 22 (43.1) | 1.397 (0.636–3.069) | 0.404 | 1.686 (0.746–3.811) | 0.209 |
| Work status | ||||||
| Full-time | 82 (58.6) | 58 (41.4) | Reference | |||
| Part-time | 59 (46.8) | 67 (53.2) | 1.605 (0.988–2.608) | 0.056 | 1.660 (1.003–2.747) | 0.049 |
| Not working | 148 (57.1) | 111 (42.9) | 1.060 (0.699–1.608) | 0.783 | 1.045 (0.677–1.611) | 0.844 |
| Presence of chronic disease | ||||||
| No | 198 (54.8) | 163 (45.2) | Reference | |||
| Yes | 91 (55.5) | 73 (44.5) | 0.974 (0.672–1.412) | 0.891 | 1.677 (0.968–2.907) | 0.065 |
| Regular medication use | ||||||
| No | 236 (53.6) | 204 (46.4) | Reference | |||
| Yes | 53 (62.4) | 32 (37.6) | 0.698 (0.433–1.126) | 0.140 | 0.584 (0.308–1.107) | 0.099 |
- Note: Cox and Snell R square = 0.046; Nagelkerke R square = 0.062; mean ± standard deviation; frequency (percentage). Bold values are statistically significant.
Finally, the model established to examine the moderating effect of age on the effect of nicotine dependence on separation anxiety in females (F = 2.352; p = 0.073) and males (F = 1.799; p = 0.148) was not statistically significant (Table 11).
| β | S. Error | t | p | 95% confidence interval | F | p | R2 | |||
|---|---|---|---|---|---|---|---|---|---|---|
| Lower limit | Upper limit | |||||||||
| Female | Fixed | 20.180 | 0.723 | 27.925 | < 0.001 | 18.757 | 21.603 | 2.352 | 0.073 | 0.026 |
| Nicotine dependence | −0.257 | 0.227 | −1.131 | 0.259 | −0.704 | 0.190 | ||||
| Age | −0.007 | 0.056 | −0.126 | 0.900 | −0.118 | 0.104 | ||||
| Nicotine dependence × age | −0.044 | 0.018 | −2.477 | 0.014 | −0.079 | −0.009 | ||||
| Male | Fixed | 18.189 | 0.756 | 24.051 | < 0.001 | 16.699 | 19.678 | 1.799 | 0.148 | 0.021 |
| Nicotine dependence | 0.547 | 0.239 | 2.291 | 0.023 | 0.077 | 1.016 | ||||
| Age | 0.024 | 0.056 | 0.430 | 0.668 | −0.086 | 0.134 | ||||
| Nicotine dependence × age | 0.005 | 0.017 | 0.314 | 0.754 | −0.029 | 0.040 | ||||
- Note: Bold values are statistically significant.
4. Discussion
Our results are primarily in agreement with the existing literature on the relationship between nicotine dependence and adult separation anxiety disorder. Even as our results reflect a lack of a direct relationship between nicotine dependence level and separation anxiety level, they suggest that gender may play an important role in the relationship between these two conditions. Our study showed that the severity of separation anxiety disorder was higher for women than for men. This also agrees with studies in the literature on the possible impact of gender not only on separation anxiety but also on nicotine dependence.
One study carried out by Breslau et al. showed that women’s smoking behavior is associated more with anxiety and depression [9]. In this regard, the severity of separation anxiety is higher among women in our investigation; thus, smoking behavior in women is more motivated by psychological factors. Particularly, as women with separation anxiety can be more susceptible to the use of smoking as a form of distraction, this may make them even more vulnerable to nicotine dependence. A systematic review by Fluharty et al. has indicated that women who smoke have higher levels of anxiety and depression than women who do not smoke [7]. It thus appears that in women, nicotine addiction is used more as a tool to manage stress and anxiety. The fact that in our study we did not see the direct effect of nicotine dependence level on the separation anxiety level disturbances indicates that these two disorders may interact by means of different mechanisms in women.
This suggests that nicotine dependence and separation anxiety have no significant relationship, and social and cultural factors may be very influential in men’s nicotine dependence. Indeed, Shear et al. discussed how men’s decisions to smoke were perhaps influenced by the social pressure and habit [4]. This result explains why the association between nicotine dependence and separation anxiety might be weaker in men compared to women.
It appears that nicotine dependence and separation anxiety disorder are closely linked to psychological and social factors. Nicotine addiction in smokers may raise the levels of stress and anxiety because of its effect on the brain’s reward center [13–15]. The high number of cigarettes smoked per day is also associated with a high level of nicotine dependence [16–18]. Parrott’s study shows that nicotine can have stress- and anxiety-reducing effects, but these may reverse in the long term [3]. Thus, it has been suggested that cigarette use in smokers, especially in women, could result in addiction and increased anxiety over time after initially providing relief.
The differences in nicotine dependence between illiterate and secondary school graduates may be partly explained by the difference in health literacy. Studies have shown that lower health literacy is related to higher nicotine dependence and more positive smoking outcome expectations [19]. Illiterate individuals may have less access to health information and smoking cessation resources, which may lead to higher nicotine dependence. In contrast, high school graduates may have sufficient health literacy that enables them to understand the health risks of smoking and learn about quitting resources.
Bandiera et al. showed that mortality related to tobacco use was increased in subjects with problems of mental health and substance use, and within this category, women were more vulnerable, too [10]. The fact that smoking behavior may be related more to psychological stress and anxiety in women can further complicate the relationship between nicotine dependence and separation anxiety in this population. Manicavasagar et al. found that separation anxiety that started in early life continued into adulthood, and the subjects were more likely to resort to addictive substances such as cigarettes [8]. Considering that smoking has stress- and anxiety-reducing effects, such individuals will be more likely to get involved in those behaviors. Furthermore, it is believed that individuals suffering from separation anxiety disorder are more likely to smoke because smoking can temporarily alleviate their conditions [20–22]. This therefore suggests that the relationship is complex and hence deepens the understanding of the etiology of nicotine dependence and separation anxiety. Kessler et al. stated that, “substance dependence and anxiety disorders tend to occur together; this may lead to important treatment strategies” [21]. Based on this information, it is expected that the present study would contribute to the literature.
The present study explains how nicotine dependence and separation anxiety disorder could be interlinked in different ways based on gender differences. Treatments for nicotine dependence and for separation anxiety may require more individualized approaches, with gender playing an important role in treatment strategies [23]. Future research should also take into consideration the role of gender in further interacting with these two conditions and utilize such information to offer better modes of treatment. In addition, it is evident that the biopsychosocial model could also be utilized in understanding the complex interactions between nicotine dependence and separation anxiety, and thus, studies examining the etiological factors of the two conditions more comprehensively are essential [24]. Such results may help in elaborating more specific interventions for people with nicotine dependence and separation anxiety disorder, and this may prove to be of great service to public health [25].
5. Conclusion
The present research focused on the correlation between nicotine dependence and separation anxiety disorder, considering gender as an interaction factor. Thus, in the direct effects, no relationship between nicotine dependence and the severity of separation anxiety was found, but the severity of separation anxiety is higher among women than men. This might imply that the risk of nicotine dependence in women may be more related to psychological stress and the management of anxiety. The lack of significant relation to nicotine dependence and separation anxiety among men again points to the fact that smoking among men is more influenced by social and cultural factors. This indicates that there are some gender differences in the treatment strategies for nicotine dependence and separation anxiety disorder. Treatment strategies should be particular and personalized for the psychological state and gender of an individual. For future research, one must delve more deeply into the interaction between nicotine dependence and separation anxiety and develop more effective methods of treatment for these aspects. It is believed that holistic and individualized treatment approaches developed for people with nicotine dependence and separation anxiety may be helpful in managing the two conditions effectively.
Ethics Statement
This article does not contain any studies with human participants or animals performed by any of the authors. This research involves human participants. Ethical approval was obtained from Hacettepe University’s Noninterventional Clinical Research Ethics Committee (Meeting date: May 23, 2023, Meeting no: 2023/09, Research no: GO 23/352, and Decision no: 2023/09-48) before starting the study.
Consent
Informed consent was obtained from all individual participants included in the study. Informed consent was taken from the patients before the start of the interview and examination. The patients were informed about the intended use of their data in the research article.
Disclosure
The authors have no financial relationships relevant to this article.
Conflicts of Interest
The authors declare no conflicts of interest.
Author Contributions
Concept: E.B.B., İ.F., and C.E.A. Literature review: T.G.S., Ö.K., E.B.B., and İ.F. Design: İ.F. and E.B.B. Data acquisition: İ.F., E.B.B., D.A.B., and H.A. Analysis and interpretation: E.B.B., İ.F., D.A.B., and H.A. Writing manuscript: C.A.Y., İ.F., E.B.B., and T.G.S. Critical revision of the manuscript: C.E.A., H.A., and D.A.B.
Funding
No funding was received for this study.
Acknowledgments
The authors have nothing to report.
Open Research
Data Availability Statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.
