Tobacco smoking and health-related quality of life among university students: Mediating effect of depression

Autoři: Marija Milic aff001;  Tatjana Gazibara aff003;  Tatjana Pekmezovic aff003;  Darija Kisic Tepavcevic aff003;  Gorica Maric aff003;  Aleksandra Popovic aff004;  Jasmina Stevanovic aff002;  Karamchand Hukumchand Patil aff001;  Hagai Levine aff001
Působiště autorů: Braun School of Public Health and Community Medicine, Hebrew University-Hadassah, Jerusalem, Israel aff001;  Department of Epidemiology, School of Medicine, University of Pristina temporarily seated in Kosovska Mitrovica, Kosovska Mitrovica, Serbia aff002;  Institute of Epidemiology, School of Medicine, University of Belgrade, Belgrade, Serbia aff003;  School for Sports and Physical Education, University of Belgrade, Belgrade, Serbia aff004
Vyšlo v časopise: PLoS ONE 15(1)
Kategorie: Research Article


The aim of this study was to assess the association between cigarette smoking and health-related quality of life (HRQoL) among students in two different universities, and the potential mediating effect of depression. Participants were students who came for mandatory check-ups at Student Health Care Centers in two Universities in Serbia, differing by socio-politically and economically environments. Students completed socio-demographic questionnaire, Beck Depression Inventory (BDI) and the SF-36 questionnaire for assessment of HRQoL. In both populations, after adjustment for socio-demographic, behavioral and health factors, smoking was associated with poorer Mental Composite Score (MCS) and Physical Composite Score (PCS) (Belgrade 1,624 students: MCS β = 3.38, 95% confidence interval [CI] 1.31, 5.44, PCS β = 1.01, 95% CI -0.50, 2.52; Kosovska Mitrovica 514 students: MCS β = 5.06, 95% CI 1.74, 8.37, PCS β = 3.29, 95% CI 0.75, 5.83). After additional adjustment for BDI score, the observed associations were lost (Belgrade: MCS β = 1.12, 95% CI -0.57, 2.80, PCS β = -0.40, 95% CI -1.71, 0.92; Kosovska Mitrovica: MCS β = 0.77, 95% CI -2.06, 3.60, PCS β = 0.56, 95% CI -1.75, 2.87). Higher BDI score was associated with poorer PCS and MCS across all quintiles. The association of smoking with impairment of HRQoL among university students in two different settings was mediated by higher levels of depressive symptoms. These findings highlight the need for further research on the interaction between smoking, mental health and quality of life, with implications for prevention, diagnosis and treatment.

Klíčová slova:

Alcohols – Depression – Mental health and psychiatry – Quality of life – Regression analysis – Serbia – Schools – Smoking habits


1. GBD 2015 Tobacco Collaborators. Smoking prevalence and attributable disease burden in 195 countries and territories, 1990–2015: a systematic analysis from the Global Burden of Disease Study 2015. Lancet. 2017;389(10082):1885–1906. doi: 10.1016/S0140-6736(17)30819-X 28390697

2. U.S. Department of Health and Human Services. The Health Consequences of Smoking-50 Years of Progress: A Report of the Surgeon General. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014.

3. Morrell HE, Cohen LM, McChargue DE. Depression vulnerability predicts cigarette smoking among college students: Gender and negative reinforcement expectancies as contributing factors. Addict Behav. 2010;35(6):607–11. doi: 10.1016/j.addbeh.2010.02.011 20181432

4. Ibrahim AK, Kelly SJ, Adams CE, Glazebrook C. A systematic review of studies of depression prevalence in university students. J Psychiatr Res. 2013;47(3):391–400. doi: 10.1016/j.jpsychires.2012.11.015 23260171

5. Goodman E, Capitman J. Depressive symptoms and cigarette smoking among teens. Pediatrics. 2000;106:748–55. doi: 10.1542/peds.106.4.748 11015518

6. Boden JM, Fergusson DM, Horwood LJ. Cigarette smoking and depression: tests of causal linkages using a longitudinal birth cohort. Br J Psychiatry. 2010;196(6):440–6 doi: 10.1192/bjp.bp.109.065912 20513853

7. Klungsoyr O, Nygard JF, Sorensen T, Sandanger I. Cigarette smoking and incidence of first depressive episode: an 11-year, population-based follow-up study. Am J Epidemiol. 2006;163:421–32. doi: 10.1093/aje/kwj058 16394201

8. Fluharty M, Taylor AE, Grabski M, Munafò MR. The Association of Cigarette Smoking With Depression and Anxiety: A Systematic Review. Nicotine Tob Res. 2017;19(1):313.

9. Royal College of Physicians RCoP. Smoking and Mental Health. London: RCP; 2013.

10. Wootton RE, Richmond RC, Stuijfzand BG, Lawn RB, Sallis HM, Taylor GMJ, Hemani G, Jones HJ, Zammit S, Davey Smith G, Munafò MR. Evidence for causal effects of lifetime smoking on risk for depression and schizophrenia: a Mendelian randomisation study. Psychol Med. 2019:1–9. doi: 10.1017/S0033291719002678

11. King JL, Reboussin BA, Spangler J, Cornacchione Ross J, Sutfin EL. Tobacco product use and mental health status among young adults. Addict Behav. 2018;77:67–72. doi: 10.1016/j.addbeh.2017.09.012 28965069

12. Nur N, Kıbık A, Kılıç E, Sümer H. Health-related Quality of Life and Associated Factors Among Undergraduate University Students. Oman Med J. 2017;32(4):329–34. doi: 10.5001/omj.2017.62 28804586

13. Becoña E, Vázquez MI, MíguezMdel C, Fernández del Río E, López-Durán A, Martínez Ú, at al. Smoking habit profile and health-related quality of life. Psicothema. 2013;25(4):421–6. doi: 10.7334/psicothema2013.73 24124772

14. Vogl M, Wenig CM, Leidl R, Pokhrel S. Smoking and health-related quality of life in English general population: implications for economic evaluations. BMC Public Health. 2012;12:203. doi: 10.1186/1471-2458-12-203 22429454

15. Pekmezovic T, Popovic A, Tepavcevic DK, Gazibara T, Paunic M. Factors associated with health-related quality of life among Belgrade University students. Qual Life Res. 2010;20(3):391–7. doi: 10.1007/s11136-010-9754-x 20878242

16. Paro HB, Morales NM, Silva CH, Rezende CH, Pinto RM, Morales RR, et al. Health-related quality of life of medical students. Med Educ. 2015;44(3):227–35.

17. Deshpande PR, Rajan S, Sudeepthi BL, Abdul Nazir CP. Patient-reported outcomes: A new era in clinical research. Perspectives in Clinical Research. 2011;2(4):137–44. doi: 10.4103/2229-3485.86879 22145124

18. Ware JE Jr, Gandek B. Overview of the SF-36 Health Survey and the International Quality of Life Assessment (IQOLA) Project. J Clin Epidemiol. 1998;51(11):903–12. doi: 10.1016/s0895-4356(98)00081-x 9817107

19. The World Bank. World Bank Data for Serbia. Available from: = RS-XT. [last accessed December 12, 2018].

20. Milošević Georgiev A, Kotur-Stevuljević J, Krajnović D. Socio-demographic Factors Associated with Smoking Habits Among University Students in Belgrade, Serbia. Zdr Varst. 2019;58(1):11–20. doi: 10.2478/sjph-2019-0002 30745946

21. Ilic I, Grujicic Sipetic S, Radovanovic D, Ilic M. Cigarette Smoking and E-Cigarette Use by Pharmacy Students in Serbia. Behav Med. 2019:1–9. doi: 10.1080/08964289.2018.1541863

22. Lo J, Patel P, Roberts B. A systematic review on tobacco use among civilian populations affected by armed conflict. Tobacco Control. 2016;25(2):129–40. doi: 10.1136/tobaccocontrol-2014-052054 25770116

23. Kisic-Tepavcevic D, Gazibara T, Popovic A, Trajkovic G, Pekmezovic T. The impact of alcohol on health-related quality of life in Belgrade University students. Am J Drug Alcohol Abuse. 2013;39(2):130–5. doi: 10.3109/00952990.2012.746348 23421572

24. Gazibara T, Pekmezovic T, Popovic A, Paunic M, Kisic-Tepavcevic D. Chronic diseases among university students: prevalence, patterns and impact on health-related quality of life. Vojnosanit Pregl 2018; 75(12): 1178–84.

25. Gazibara T, Milic M, Parlic M, Stevanovic J, Lazic D, Maric G, et al. Illict drug use and academia in North Kosovo: Prevalence, patterns, predictors and health-related quality of life. PLoS One. 2018;13(7):e0199921. doi: 10.1371/journal.pone.0199921 30011284

26. Centers for Disease Control and Prevention. National Health Interview Survey-Adult Tobacco Use- Glossary. Available from: [last accessed September 25, 2018].

27. SF-36 Health survey (original version) language recalls. Available from: [last accessed March 24, 2018].

28. ProQolid Patient-Reported Outcome and Quality of Life Instruments Database SF-36 Health Survey Serbian version. Available from: [last accessed March 24, 2018].

29. Beck AT, Beck RW: Screening depressed patients in family practice: A rapid technique. Postgraduate Medicine. 1972;52:81–5. doi: 10.1080/00325481.1972.11713319 4635613

30. Wang YP, Gorenstein C. Psychometric properties of the Beck Depression Inventory-II: a comprehensive review. Rev Bras Psiquiatr. 2013;35(4):416–31. doi: 10.1590/1516-4446-2012-1048 24402217

31. Novovic Z, Mihic Lj, Tovilovic S, Jovanovic V, Biro M. Psychometric characteristics of the Beck depression inventory on a Serbian student sample. Psihologija. 2011;44:225–43.

32. VanderWeele T. Mediation Analysis: A Practitioner's Guide. Annual Review of Public Health. 2016;37:17–32. doi: 10.1146/annurev-publhealth-032315-021402 26653405

33. Ware JE, Kosinski M. SF-36 Physical and Mental Health Summary Scales: A Manual for Users of Version 1. 2nd ed. Lincoln, RI: QualityMetric Inc; 2001

34. Ware JE, Kosinski M. Interpreting SF-36 summary health measures: a response. Qual Life Res. 2001;10(5):405–13;discussion 415–20. doi: 10.1023/a:1012588218728 11763203

35. Arslan G, Ayranci U, Unsal A, Arslantas D. Prevalence of depression, its correlates among students, and its effect on health-related quality of life in a Turkish university. Ups J Med Sci. 2009;114(3):170–77. doi: 10.1080/03009730903174339 19736608

36. Otto C, Haller AC, Klasen F, Hölling H, Bullinger M, Ravens-Sieberer U; BELLA study group. Risk and protective factors of health-related quality of life in children and adolescents: Results of the longitudinal BELLA study. PLoS One. 2017;12(12):e0190363. doi: 10.1371/journal.pone.0190363 29284054

37. Evren C, Evren B, Bozkurt M, Ciftci-Demirci A. Effects of lifetime tobacco, alcohol and drug use on psychological and behavioral problems among 10th grade students in Istanbul. Int J Adolesc Med Health. 2015;27(4):405–13. doi: 10.1515/ijamh-2014-0040 25460280

38. Flensborg-Madsen T, von Scholten MB, Flachs EM, Mortensen EL, Prescott E, Tolstrup JS. Tobacco smoking as a risk factor for depression. A 26-year population-based follow-up study. J Psychiatr Res. 2011;45(2):143–9. doi: 10.1016/j.jpsychires.2010.06.006 20630542

39. Coste J, Quinquis L, D'Almeida S, Audureau E. Smoking and health-related quality of life in the general population. Independent relationships and large differences according to patterns and quantity of smoking and to gender. PLoS One. 2014;9(3):e91562. doi: 10.1371/journal.pone.0091562 24637739

40. Haustein KO, Haffner S, Woodcock BG. A review of the pharmacological and psychopharmacological aspects of smoking and smoking cessation in psychiatric patients. Int J Clin Pharmacol Ther 2002; 40: 404–18. doi: 10.5414/cpp40404 12358157

41. Minichino A, Bersani FS, Calò WK, Spagnoli F, Francesconi M, Vicinanza R, et al. Smoking Behaviour and Mental Health Disorders—Mutual Influences and Implications for Therapy. Int J Environ Res Public Health. 2013;10(10):4790–811. doi: 10.3390/ijerph10104790 24157506

42. Carceller-Maicas N, Ariste S, Martínez-Hernáez A, Martorell-Poveda MA, Correa-Urquiza M, DiGiacomo SM. [Smoking as a form of self-medication for depression or anxiety in young adults: results of a mixed-methods study]. Adicciones. 2014;26(1):34–45. [Article in Spanish] 24652397

43. Kumar B, Shah MAA, Kumari R, Kumar A, Kumar J, Tahir A. Depression, Anxiety, and Stress Among Final-year Medical Students. Cureus. 2019;11(3):e4257. doi: 10.7759/cureus.4257 31139516

44. Mikolajczyk RT, Maxwell AE, Naydenova V, Meier S, El Ansari W. Depressive symptoms and perceived burdens related to being a student: Survey in three European countries. Clin Pract Epidemiol Ment Health. 2008;4:19. doi: 10.1186/1745-0179-4-19 18598340

45. Stallman HM. Psychological distress in university students: A comparison with general population data. 2010;45(4):249–57

46. Bewick B, Koutsopoulou G, Miles J, Slaa E, Barkham M. Changes in undergraduate student‘s psychological well-being as they progress through university. Stud High Educ. 2010;35:633–45.

47. Grøtan K, Sund ER, Bjerkeset O. Mental Health, Academic Self-Efficacy and Study Progress Among College Students—The SHoT Study, Norway. Front Psychol. 2019;10:45. doi: 10.3389/fpsyg.2019.00045 30733694

48. Taylor G, McNeill A, Girling A, Farley A, Lindson-Hawley N, Aveyard P. Change in mental health after smoking cessation: systematic review and meta-analysis. BMJ. 2014;348:g1151. doi: 10.1136/bmj.g1151 24524926

49. Karp JF, Levine AS. Mental Health Services for Medical Students—Time to Act. N Engl J Med. 2018 Sep 27;379(13):1196–8. doi: 10.1056/NEJMp1803970 30257155

50. Hamaideh SH. Stressors and reactions to stressors among university students. International Journal of Social Psychiatry. 2011;57(1):69–80. doi: 10.1177/0020764010348442 21252357

51. Hays JT, Croghan IT, Baker CL, Cappelleri JC, Bushmakin AG. Changes in health-related quality of life with smoking cessation treatment. Eur J Public Health. 2012;22(2):224–9. doi: 10.1093/eurpub/ckq137 20884658

52. Hughes JR, Stead LF, Hartmann-Boyce J, Cahill K, Lancaster T. Antidepressants for smoking cessation. Cochrane Database Syst Rev. 2014;(1):CD000031. doi: 10.1002/14651858.CD000031.pub4 24402784

53. Feldman I, Donchin M, Levine H. A smoke-free medical campus in Jerusalem: data for action Isr J Health Policy Res. 2016; 5:20. doi: 10.1186/s13584-016-0080-9 27274394

54. Schroeder SA. Smoking cessation should be an integral part of serious mental illness treatment. World Psychiatry. 2016;15(2):175–6. doi: 10.1002/wps.20332 27265708

55. World Bank Group. Serbia Overview of Tobacco Use, Tobacco Control Legislation, and Taxation. Available from: [last accessed October 28, 2019].

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