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00005768-199602000-0001200005768_1996_28_233_brown_relationship_2miscellaneous-article< 114_0_15_5 >Medicine & Science in Sports & Exercise©1996The American College of Sports MedicineVolume 28(2)February 1996pp 233-240Evaluation of smoking on the physical activity and depressive symptoms relationship[Applied Sciences: Epidemiology]BROWN, DAVID R.; CROFT, JANET B.; ANDA, ROBERT F.; BARRETT, DRUE H.; ESCOBEDO, LUIS G.Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Division of Chronic Disease Control and Community Intervention, Atlanta, GA 30341-3724Submitted for publication August 1994.Accepted for publication April 1995.David Brown, Ph.D., Janet Croft, Ph.D., and Rob Anda, M.D, M.S., are with the Division of Chronic Disease Control and Community Intervention, and Luis Escobedo, M.D., M.P.H., is with the Office on Smoking and Health, Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention (CDC), 4770 Buford Highway N.E., Atlanta, GA 30341-3724. Drue Barrett, Ph.D., is with the Division of Environmental Hazards and Health Effects, National Center for Environmental Health, CDC. The original source for the data used in this study is the National Center for Health Statistics (NCHS), CDC. The analyses, interpretations, and conclusions reached in this study, however, are those of the authors and not NCHS.Address for correspondence: David R. Brown, Ph.D., Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Mail Stop K-46, 4770 Buford Highway NE, Atlanta, GA 30341-3724.ABSTRACTPhysical activity is inversely associated with depressive symptoms, and cigarette smoking is positively associated with depressive symptoms. Data from the first National Health and Nutrition Examination Survey (NHANES I) and the NHANES I Epidemiologic Follow-up study were analyzed to determine whether the relationship between physical activity and self-reported distress (depressive symptoms as measured by the Center for Epidemiologic Studies Depression Scale) was different for cigarette smokers and nonsmokers. Logistic regression was used to calculate odds ratios (adjusted for age, race, sex, education, alcohol use, and perceived health status) for depressive symptoms (≥16) associated with physical activity and smoking status among 2,054 respondents. At baseline, the odds ratio for depressive symptoms was about 2 times higher for moderately active smokers and nonsmokers, and 3 times higher for low active smokers and nonsmokers, compared with highly active nonsmokers. For 1,132 persons with a low number of depressive symptoms (<16) at baseline, the incidence of depressive symptoms after 7-9 yr of follow-up was about 2 times higher for low/moderately active smokers and nonsmokers than for highly active nonsmokers. The association between physical activity and the prevalence and incidence of depressive symptoms is not significantly modified by smoking status.Depression is a serious mental health problem affecting the U.S. population. It has been estimated that the lifetime prevalence rates for major depressive disorder (MDD) and dysthymia, as defined by the Diagnostic and Statistical Manual, Third Edition (DSM-III)(1), are 3.5% and 1.8% of the population, respectively(38). Another 1.4% of the population suffers from both conditions (38). Thus, about 6.7% of 249 million Americans (4), or 17 million people, suffer from major depression or dysthymia at some point. This estimate does not include the much greater number of persons who have morbidity due to depressive symptoms, but who do not meet diagnostic criteria for a depressive disorder(16).The effects of emotional distress on the health status of Americans is pervasive. People who report a high number of depressive symptoms report more physical illnesses (13,30) and are more likely to see a physician for a physical illness (13,36) than are persons with few depressive symptoms. Depressive symptoms have also been associated with smoking (2) and low levels of physical activity (5,11,28,33). On the other hand, reductions in depression have resulted from exercise interventions (20).Results from the first National Health and Nutrition Examination Survey(NHANES I) indicate that the prevalence of depressive symptoms is higher among smokers than nonsmokers (2) and that depressive symptoms decrease with increasing physical activity(11,33). Anda et al. (2) found that the prevalence of current cigarette smoking increased, and the quit ratio (i.e., the number of persons who quit smoking divided by the number of persons who “ever smoked” × 100) decreased, as symptoms of depression as measured by the Center for Epidemiologic Studies Depression Scale (CES-D) increased. In addition, prospective findings from the NHANES I Epidemiologic Follow-up Study (NHEFS) (2) showed that persons reporting depressive symptoms (i.e., ≥16) at baseline were less likely than persons reporting a low number of depressive symptoms (i.e.,<16) to quit smoking over the course of a 9-yr follow-up period.Farmer et al. (11) reported that a relationship exists between depressive symptoms and little or no involvement in physical activity based on a cross-sectional analysis of NHANES I data. In addition, a prospective evaluation of data obtained during the 9-yr NHANES I Epidemiologic Follow-up Study indicated that little or no recreational physical activity was a significant predictor of depressive symptoms in white women, but not men, who had fewer than 16 depressive symptoms at baseline. Low levels of recreational activity in men with depressive symptoms at baseline predicted continued depressive symptoms at follow-up.Stephens (33) conducted secondary analyses of four National surveys (two conducted in Canada and two in the United States) and found that physical activity was positively related to mental health, which included infrequent symptoms of depression. This conclusion was based in part on an analysis of the NHANES I recreational physical activity and CES-D data.It is possible that depressive symptoms, physical activity, and smoking interact. Physical activity may influence the smoking and depressive symptoms relationship, and smoking status may affect the physical activity and depressive symptoms relationship. However, Anda et al.(2) did not control for physical activity as a confounding variable that could have altered the association between smoking and depressive symptoms, and Farmer et al. (11) and Stephens (33) did not control for smoking in their studies of physical activity and depressive symptoms. Similarly, investigators in another study who have reported an association between physical activity and depressive symptoms did not control for the possibility that smoking status may alter this relationship (28).The purpose of this study was to determine whether smoking is a confounding factor that would challenge the independence of the physical activity and reduced depressive symptoms relationship reported previously. In our cross-sectional analysis of NHANES I data, we evaluated the combined effect of physical activity and smoking status on prevalence of depressive symptoms at baseline. In a longitudinal analysis of participants free of depressive symptoms in the NHANES I (1975) and reexamined in the 1982-1984 NHANES Epidemiologic Follow-up Study, we assessed the combined effect of these factors on the incidence of depressive symptoms.METHODSSources of DataThe NHANES I obtained information on sociodemographic variables, health history, and health behaviors, such as smoking status, alcohol use, and diet, by sampling the U.S. civilian, noninstitutionalized population from 1971 through 1975 (23). In 1975, 3,059 participants aged 25-74 yr were reinterviewed. In these interviews, respondents were asked about their involvement in physical activity and the extent to which they experienced symptoms of depression (22). Unlike the NHANES I, which oversampled certain population subgroups, such as the elderly, persons living in poverty, and women of childbearing age, no oversampling was done for the reinterviews. This sample was younger, had more former and current smokers, a lower proportion of women, fewer black adults, and a greater proportion of educated persons than did the NHANES I population. Respondents were made aware that their answers were confidential and part of a large scale investigation that could be published as statistical summaries and without identifying information.Complete data on smoking, physical activity, and depressive symptoms were available for 2,963 (97%) persons reinterviewed. We excluded 909 of these respondents because they reported health problems at baseline (1975) such as arthritis, gout, bronchitis or emphysema, heart attack, stroke, or fractures that could have adversely affected their level of physical activity or depresive symptoms. The persons excluded were older, were less active, were less well educated, and had a somewhat greater prevalence of depressive symptoms than did the 2,054 remaining participants (67% of reinterviewees) but did not differ with respect to smoking behavior, sex, or race.In the NHANES Follow-up Study (8,19), 300 (15%) participants were not relocated, 365 (18%) reported having physical health problems (e.g., asthma, angina, heart attack, stroke), and for 72 (3%) follow-up CES-D scores were not available. Thus, data were available for 1,317(64%) follow-up participants.Measurement of Depressive SymptomsDepressive symptoms were assessed by using the Center for Epidemiologic Studies Depression Scale (CES-D) (27), a 20-item, self-reported measure of depressive symptoms. Respondents were asked to rate each item, indicating frequency of depressive symptoms during the previous week (0 = rarely or none of the time, 3 = most or all of the time). The terms“depressive symptoms” were used to categorize respondents reporting ≥ 16 symptoms, a standard cutoff score based on CES-D norms(37). Persons with CES-D scores greater than 16 are distressed (12). However, anxiety, substance use disorders, major depressive disorders, and other depressive disorders diagnosed by using the Structured Interview for the DSM-III-R (SCID)(32) have all been found to be significant predictors of CES-D scores (12). Therefore, our measure of depressive symptoms is a measure of self-reported distress and does not provide for the classification of respondents for whom depression would be diagnosed.Measurement of Physical ActivityRespondents were asked two questions about their level of physical activity: “In your usual day, aside from recreation, how active are you?” and “Do you get much exercise in things you do for recreation?” Respondents indicated that they were either very active, moderately active, or quite inactive during their usual day, and that they obtained much, moderate, or little or no recreational activity.In earlier NHANES I research, Stephens (33) focused on recreational physical activity and depressive symptoms. Farmer et al.(11) evaluated the separate relationships between depressive symptoms and recreational physical activity and depressive symptoms and activity obtained aside from recreation. We combined these two physical activity items to obtain an index somewhat representative of respondents' total physical activity level.We categorized physical activity by three levels: low active, moderately active, and highly active. Respondents were at a high level if they reported that they were moderately or very active during their usual day, and obtained much or a moderate amount of recreational exercise. Respondents were defined as moderately active if they reported that they were moderately or very active during their normal day, or participated in much or a moderate amount of recreational activity. Respondents were defined as low active if they reported that they were quite inactive during the day and had little or no recreational activity.We believe that the categorization of our physical activity groups makes sense from the standpoint of obtaining results that possess good ecological validity. Respondents may typically perceive they obtain a moderate to high level of nonrecreational and recreational physical activity, or conversely, a low level of nonrecreational and recreational activity. It may also be the case that respondents perceive themselves as being active only during nonrecreational or recreational time but not both.Measurement of Smoking StatusRespondents were defined as current smokers if they reported having smoked 100 or more cigarettes during their lifetime and that they currently smoked, as former smokers if they reported having smoked 100 or more cigarettes during their lifetime but did not currently smoke, and as never smokers if they had not smoked at least 100 cigarettes during their lifetime. Our definitions of smoking status are based on questions asked in nearly all nationally representative surveys of the U.S. population and allows for comparisons among studies using smoking data from the different surveys.Statistical MethodsWe calculated the unadjusted prevalence of depressive symptoms at baseline by using selected characteristics and the distribution of physical activity levels by smoking status. Estimates of the frequency of depressive symptoms by physical activity and smoking status were obtained from an analysis of covariance model in which sex, race, and age were covariates. Multivariate logistic regression was used to assess the relationship of smoking status(smoker vs nonsmoker) and level of physical activity to prevalence of depressive symptoms in 1975. Covariates included race (white, black), sex, age, alcohol use (frequent or >1 drink per week, occasional or ≤1 drink per week, nondrinker), educational level (some college, 12 yr of school,<12 yr of school), and perceived health status (excellent, good to very good, poor to fair). For the longitudinal cohort with baseline CES-D scores less than 16, similar models were used to examine the relationship of physical activity and smoking behavior to the risk of developing depressive symptoms.RESULTSCross-Sectional AnalysesA greater percentage of women (55%) than men (46%) and whites (92%) than blacks (8%) were respondents in the study. At baseline, 47% of the sample was less than 40 yr old, 72% had 12 or more years of education, 81% were drinkers(occasional or frequent), and 89% perceived their health status as good to excellent. Over 39% of respondents were current smokers, 39% never smokers, and 22% former smokers. Sixty-nine percent were highly active, 25% moderately active, and 6% low active.At baseline, 303 (15%) respondents had depressive symptoms. The unadjusted prevalence of depressive symptoms differed by physical activity level, smoking status, alcohol use, perceived health status, sex, race, and education(Table 1). There was a lower prevalence of depressive symptoms among the respondents aged 50-69 yr than for younger aged groups. The prevalence of high, moderate, and low physical activity did not differ substantially by smoking status (data not shown).TABLE 1. Prevalence of depressive symptoms by selected characteristics, among persons interviewed in the First National Health and Nutrition Examination Survey Augmentation Sample (1975).After adjusting for differences in age, race, and sex, the prevalence of depressive symptoms among persons defined as highly active differed between former smokers and never smokers (Fig. 1). However, the prevalence of depressive symptoms among the low and moderate physical activity groups did not differ between former smokers and never smokers; therefore, these two categories were combined into a single category of nonsmokers for the cross-sectional and longitudinal analyses.Figure 1-Prevalence (%) of depressive symptoms by smoking status and physical activity level, First National Health and Nutrition Examination Survey Augmentation Sample, 1975. Prevalence adjusted for age, race, and sex.The crude prevalence ratios and the adjusted odds ratios showed that both smokers and nonsmokers who were low active had at least 3 times the odds of having depressive symptoms than did highly active nonsmokers (referent)(Table 2). Both smokers and nonsmokers who were moderately active had about twice the odds of having depressive symptoms than did the referent group. Due to the small sample sizes associated with the low active smoker (N = 52) and low active nonsmoker (N = 67) groups, we combined the low and moderately active smokers, and the low and moderately active nonsmokers for the longitudinal analyses.TABLE 2. Prevalence of depressive symptoms, by physical activity level and smoking status, the First National Health and Nutrition Examination Survey Study (1975).Longitudinal AnalysesThe percentage of respondents in each age group at baseline and follow-up were similar (Table 3). Therefore, our cross-sectional and longitudinal findings should not be influenced by a different percentage of respondents in the age categories at the two different points in time. This is important because the prevalence of physical activity typically declines with age (7,24,34) and the validity of the CES-D as a measure of depressive symptoms in the elderly has been questioned(24,39).TABLE 3. Number and percent of respondents in each age group at baseline and follow-up, the First National Health and Nutrition Examination Survey Study (1975) and Follow-up Study (1982-1984).Eighty-six percent of the follow-up participants had CES-D scores less than 16. The unadjusted, cumulative incidence of depressive symptoms in this group was 7.3% during the 7-9 yr of follow-up. For low/moderately active smokers and nonsmokers, the crude risk of developing depressive symptoms was about twice that of highly active nonsmokers (Table 4). For both smokers and nonsmokers who were highly active, the crude risk of developing depressive symptoms did not differ significantly. Similar results were obtained after adjusting for sociodemographic characteristics, alcohol use, and perceived health status.TABLE 4. Risk of developing depressive symptoms among persons in the longitudinal cohort with baseline CES-D* scores < 16, by physical activity and smoking status, the First National Health and Nutrition Examination Survey Study (1975) and Follow-up Study (1982-1984).DISCUSSIONThe cross-sectional analysis at baseline revealed a lower prevalence of depressive symptoms for respondents aged 50-69 yr than for younger persons(Table 1). This finding probably reflects our exclusion of persons with adverse health conditions from the study. Respondents who were excluded were older and had a somewhat higher prevalence of depressive symptoms than respondents who remained in the study. It is commonly thought that the prevalence of depression is higher in the elderly than in younger age groups. This belief is apparently based on findings related to studies of depressive symptomatology and not major depression. The prevalence of depressive symptoms has been found to be higher in the elderly than in younger groups; however, prevalence of major depression has been reported to be lower in the elderly than in the young (3,24). It may be that the higher prevalence of depressive symptoms reported by the elderly compared with younger aged persons is in part due to the fact that the elderly have more physical health problems than the young (24). For example, Murrell, Himmelfarb, and Wright (21) studied a community sample of men and women 55 yr and older and found that the strongest association with depressive symptoms was with conditions related to self-reported physical health.Anda et al. (2) found that the percentage of current smokers increased as CES-D scores increased. Unlike the present study, Anda et al.'s findings could in part be due to the fact that they did not exclude respondents from their study who reported health problems. It is possible that Anda et al. found an association between smoking and depressive symptoms due to a third variable (i.e., persons with health problems both smoked more and had a greater number of depressive symptoms). This explanation is unlikely, however, as smoking status did not substantially differ between those respondents who were and were not excluded from the present study for health problems (nonsmokers, 37% vs 39%, respectively; former smokers, 25% vs 22% respectively, current smokers, 38% vs 39% respectively).The prevalence of high, moderate, and low physical activity did not differ substantially by smoking status in this investigation. A review by Wankel and Sefton (35), related to physical activity involvement and smoking, indicates that other studies have also failed to find a relationship between these behaviors. Furthermore, a review of the physical activity determinants literature by Dishman and Sallis(9) indicates that there is weak or mixed evidence for a negative association between physical activity and smoking. Overall, however, Wankel and Sefton thought that there was sufficient evidence to the contrary to warrant a conclusion that there is an inverse association between smoking status and involvement in leisure-time physical activity, although this association seems modest (35).Our baseline results regarding physical activity and smoking singularly are consistent with those from earlier research on physical activity and depressive symptoms by Farmer et al. (11) and Stephens(33), and on smoking and depressive symptoms by Anda et al. (2) (Table 1). Prevalence of depressive symptoms increased as activity levels decreased (highly active = 11%, moderately active = 21%, and low active = 34%) and was higher for smokers than nonsmokers (current = 18% vs 13% for never and former).When physical activity and smoking were evaluated in combination, the prevalence of depressive symptoms and the risk of developing depressive symptoms were greater for smokers and nonsmokers who reported low levels of physical activity than for highly active nonsmokers. Both the prevalence and the incidence of depressive symptoms increased with decreasing levels of physical activity, but within each level of physical activity, the likelihood of being depressed was similar for both smokers and nonsmokers compared with the referent group.The lack of increased prevalence of and risk for depressive symptoms for smokers within physical activity categories may be explained in at least two ways. First, the association between physical activity and depressive symptoms may be greater than the association between smoking and depressive symptoms, because physical inactivity, or psychomotor retardation, is part of the syndrome of depression, whereas smoking may be used by some but not all persons as a form of self-medication to attenuate distress or symptoms of depression (6,14,26). Second, the mechanisms that account for the associations between depression and physical activity and depression and susceptibility to smoking may be similar. Thus, it may be difficult to distinguish between both the separate contributions of physical activity and smoking to depressive symptoms.The causal mechanisms linking physical activity, smoking, and depressive symptoms/depression are unknown. Physical inactivity is symptomatic of depression, and it is possible that increasing the physical activity level of depressed persons results in an anti-depressant effect by altering monoaminergic neurotransmitter systems and the hypothalamic-pituitary-adrenal(HPA) axis (10). Dysregulation of monoaminergic systems and the HPA axis have been implicated in the pathogenesis of depression, and physical activity as well as pharmacological interventions may decrease depression through these mechanisms (10). Smoking also alters neurobiological factors. Nicotine stimulates the nicotine receptors and various hypothalamic and pituitary hormones, and releases “biogenic amines, including the catecholamines and possibly 5-hydroxytryptamine”(15, p. 13). Thus, smoking may be prevalent among depressed persons because of nicotine's initial stimulant and subsequent sedative effects on mood (29), or because smoking is negatively reinforced by enabling persons to avoid the negative emotional state associated with smoking withdrawal(18,25,31).Although depression may lead to physical inactivity and susceptibility to smoking, it is also possible that smoking or physical inactivity interact with personality, psychosocial factors, environmental circumstances(17), or genetic factors (15) that predispose some persons to depression. We found some support for this possibility in that persons with no depressive symptoms, who were low to moderately physically active, and were smokers at baseline had almost two times the odds of having depressive symptoms at follow-up than were persons with no depressive symptoms, who were highly active, nonsmokers at baseline.LimitationsOur data are based on self-reported measures and misclassification may have influenced the results. Since the CES-D is a measure of depressive symptoms and not of diagnosed depression, our findings are not generalizable to a clinically depressed population.Our definition of smoking status categorized respondents as smokers and nonsmokers. However, other definitions of current smokers (e.g., stratified by the number of cigarettes smoked per day) could possibly lead to different findings.Furthermore, our definition of physical activity resulted in a high percentage of respondents classified as highly active (69%) and a low percentage as low active (6%). These results differ from a report that 30.5% of the U.S. is inactive (i.e., respondents reported obtaining no physical activity during the past month) and 9.1% is highly active(7). Highly active was defined as obtaining physical activity involving rhythmic contractions of large muscle groups during the past month 3 or more times per week, 20 or more minutes per occasion, at 60% or greater of age- and sex-specific maximum cardiorespiratory capacity(7). In our study, respondents were classified based on their self-perceived level of physical activity and not based on the frequency, duration, and intensity of their activity, or other more precise measures of energy expenditure (e.g., 7-d recall, portable accelerometers). Despite the fact that the NHANES I items yield a crude estimate of physical activity, we felt that we could obtain insight into the effect of smoking on the physical activity and depressive symptoms relationship by building upon previous NHANES I studies that found independent associations between physical activity and depressive symptoms and smoking and depressive symptoms.Farmer et al. (11) evaluated the association between depressive symptoms and recreational and nonrecreational physical activity separately, and we evaluated the relationship between depressive symptoms and recreational and nonrecreational activity combined. Similar to our findings, the data were skewed in the direction of higher levels of self-reported activity in the Farmer et al. study. Farmer et al. (11) noted that 30% of the NHANES population reported little or no exercise in things done for recreation and that 70% reported obtaining much or moderate exercise in things done for recreation. Ten percent of the population reported being quite inactive in a usual day apart from recreation, and 90% reported being moderately or very active in a usual day apart from recreation.Stephens also evaluated the association between mental health and recreational activity based in part on NHANES I data(33). Stephens categorized respondents into three groups(much exercise, moderate exercise, little or no exercise), but did not report the number or percentage of respondents included in each category. In the present study, the respondents' self-perceptions do indeed represent three distinct groups, and findings indicate that the prevalence of depressive symptoms were graded and inversely associated with level of physical activity. These findings are consistent with those of Farmer et al. and Stephens, other previous research that evaluated the physical activity and depressive symptoms relationship (e.g., 5,28), and the physical activity and depression literature (20).Summary and RecommendationsIf exercise is not contraindicated due to cancer, emphysema, bronchitis, or other factors, the smoker-like the nonsmoker-should be encouraged to increase physical activity. Our findings reveal that regardless of whether a person is a smoker or nonsmoker, being physically active may provide mental health dividends. These benefits do not appear to be substantially attenuated in smokers compared with nonsmokers. 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self-reportEPSTEIN, LH; PALUCH, RA; COLEMAN, KJ; VITO, D; ANDERSON, Khttp://journals.lww.com/acsm-msse/Fulltext/1996/09000/Determinants_of_physical_activity_in_obese.12.aspxhttp://pdfs.journals.lww.com/acsm-msse/1996/09000/Determinants_of_physical_activity_in_obese.00012.pdf