Nicotine Dependence and Comorbid Substance Use and Psychiatric Disorders in an American Indian

Male Veteran Sample

Nicotine Dependence and Comorbid Substance Use and Psychiatric Disorders in an American Indian

Male Veteran Sample

Daniel Dickerson, DO, MPHAssistant Research Psychiatrist

UCLA, Integrated Substance Abuse Programs (ISAP)

May 30, 2008

Daniel Dickerson, DO, MPHAssistant Research Psychiatrist

UCLA, Integrated Substance Abuse Programs (ISAP)

May 30, 2008

AcknowledgementsAcknowledgements

Yale University Stephanie O’Malley, PhD

Minneapolis V.A. Hospital Joseph Westermeyer, MD, PhD Jose Canaive, MD Paul Thuras, MD

Funding Sources T32 AA 015496-02 T-TURC P50 AA15632 K05-AA014715

Yale University Stephanie O’Malley, PhD

Minneapolis V.A. Hospital Joseph Westermeyer, MD, PhD Jose Canaive, MD Paul Thuras, MD

Funding Sources T32 AA 015496-02 T-TURC P50 AA15632 K05-AA014715

Today’s agendaToday’s agenda

• Brief history of traditional tobacco use in AI populations

• Overview of Nicotine Dependence among American Indians/Alaska Natives (AI/AN)

• Study of nicotine dependence and axis I and II comorbidities in AI male veterans

• Questions/Comments

• Brief history of traditional tobacco use in AI populations

• Overview of Nicotine Dependence among American Indians/Alaska Natives (AI/AN)

• Study of nicotine dependence and axis I and II comorbidities in AI male veterans

• Questions/Comments

History of tobacco use among AIHistory of tobacco use among AI

• Used historically for religious and ceremonial purposes

• Tobacco used 20x stronger• Tobacco’s effects included

dizziness, vertigo, inebriation, intoxication, loss of reason, coma, and “insanity”

• Europeans expressed their astonishment at the tobacco addiction of many AI

• AI start smoking commercialized form of tobacco shortly after European contact

• Used historically for religious and ceremonial purposes

• Tobacco used 20x stronger• Tobacco’s effects included

dizziness, vertigo, inebriation, intoxication, loss of reason, coma, and “insanity”

• Europeans expressed their astonishment at the tobacco addiction of many AI

• AI start smoking commercialized form of tobacco shortly after European contact

Woodland Bird Effigy Stone PipeMississippian 1200 - 1500 AD

Woodland Frog Effigy Stone Pipe Eastern Tennessee 500 - 800 AD

History of tobacco use among A.I./A.N.

History of tobacco use among A.I./A.N.

Cultural relevance of tobacco use: Iroquois Creation Story

Cultural relevance of tobacco use: Iroquois Creation Story

• Tobacco grew from the grave of the Earth Mother who died after giving birth to the twins Good-Minded (the Great Creator) and Evil-Minded (the Great World Rim Dweller).

• Tobacco grew from Earth Mother’s head, so that “it soothes the mind and sobers thought.”

• Tobacco grew from the grave of the Earth Mother who died after giving birth to the twins Good-Minded (the Great Creator) and Evil-Minded (the Great World Rim Dweller).

• Tobacco grew from Earth Mother’s head, so that “it soothes the mind and sobers thought.”

Tobacco’s reverence as a sacred plant in Native communities

Tobacco’s reverence as a sacred plant in Native communities

• One of four natural sacred herbs

• Represents the Eastern direction and the mind

• Used to connect with the spirit world

• Give back to and thanking the Creator

• Used to purify, and to work with a clear mind and heart

• Used in various ceremonies

• One of four natural sacred herbs

• Represents the Eastern direction and the mind

• Used to connect with the spirit world

• Give back to and thanking the Creator

• Used to purify, and to work with a clear mind and heart

• Used in various ceremonies

Traditional use of tobacco versus commercialized tobacco use

Traditional use of tobacco versus commercialized tobacco use

• Traditional use of tobacco:• Prayers to the Creator• Purification agent• Role of tobacco in creation

stories• Unify two people or groups• Naming Ceremonies• Given to elders when one is

asking advice• Improve physical, spiritual, and

mental well-being• Evoke the memories of

survival, strength, nation, and tradition.

• Traditional use of tobacco:• Prayers to the Creator• Purification agent• Role of tobacco in creation

stories• Unify two people or groups• Naming Ceremonies• Given to elders when one is

asking advice• Improve physical, spiritual, and

mental well-being• Evoke the memories of

survival, strength, nation, and tradition.

• Commercialized tobacco use:

• Disrespectful to the creator/disconnect from the culture

• Addictive• Numerous medical

consequences• Destroys communities/lives• Becomes a mundane everyday

affair, loses its power and important cultural relevance

• Commercialized tobacco use:

• Disrespectful to the creator/disconnect from the culture

• Addictive• Numerous medical

consequences• Destroys communities/lives• Becomes a mundane everyday

affair, loses its power and important cultural relevance

American Indians/Alaska NativesAmerican Indians/Alaska Natives• Comprised of 564 federally-recognized tribes• Represent 1.5% or 4.1 million of the total U.S.

population (U.S. Census Bureau, 2003)

• Two-thirds live in urban areas• Los Angeles has the largest population of AI/AN

in the U.S. compared to any other city• Less than 1% of the total Indian Health Service

(IHS) budget allocated to urban health care • Experience significant health-related disparities• 55% rely on IHS for health care services.

• Comprised of 564 federally-recognized tribes• Represent 1.5% or 4.1 million of the total U.S.

population (U.S. Census Bureau, 2003)

• Two-thirds live in urban areas• Los Angeles has the largest population of AI/AN

in the U.S. compared to any other city• Less than 1% of the total Indian Health Service

(IHS) budget allocated to urban health care • Experience significant health-related disparities• 55% rely on IHS for health care services.

Tobacco use rates are highest among AI/AN

Tobacco use rates are highest among AI/AN

Commercial tobacco use rates by ethnic group:

AI/AN: 32.4%

Non-Hispanic whites: 21.9%

Non-Hispanic blacks 23.0%

Hispanics 15.2%

Asian/Pacific Islanders 10.4%

(American Lung Association, 2007)

Commercial tobacco use rates by ethnic group:

AI/AN: 32.4%

Non-Hispanic whites: 21.9%

Non-Hispanic blacks 23.0%

Hispanics 15.2%

Asian/Pacific Islanders 10.4%

(American Lung Association, 2007)

Why are tobacco use rates higher among AI/AN

Why are tobacco use rates higher among AI/AN

• Lower SES• High substance

abuse rates• Inactive public health

policies• Poor social conditions• Diminishing

knowledge of traditional use of tobacco

• Limited treatment & prevention programs

• Lower SES• High substance

abuse rates• Inactive public health

policies• Poor social conditions• Diminishing

knowledge of traditional use of tobacco

• Limited treatment & prevention programs

Smoking and psychiatric disordersSmoking and psychiatric disorders

• Biochemical and pharmacological findings provide a conceptual link

• Smokers with depressive symptoms have a harder time quitting

• 61% smokers in a N.Y. sample had a past history of depression (Glassman, 1988)

• High smoking prevalence in panic disorder (19.2% to 56%)

• Prevalence ranges from 53-66% in combat veterans with PTSD (Kallman, 2005)

• Nicotine-dependent and psychiatrically ill individuals consume about 70% of all cigarettes in the United States (Grant, 2004)

• Biochemical and pharmacological findings provide a conceptual link

• Smokers with depressive symptoms have a harder time quitting

• 61% smokers in a N.Y. sample had a past history of depression (Glassman, 1988)

• High smoking prevalence in panic disorder (19.2% to 56%)

• Prevalence ranges from 53-66% in combat veterans with PTSD (Kallman, 2005)

• Nicotine-dependent and psychiatrically ill individuals consume about 70% of all cigarettes in the United States (Grant, 2004)

Smoking and substance use disorders

Smoking and substance use disorders

• Over 75% of alcohol and drug-dependent persons in early recovery smoke (Gulliver, 2000)

• Smoking increases reinforcing value of alcohol (Perkins, 2001)

• Consumption of an alcohol increases smoking behavior (Mitchell, 1995)

• Greater than 80% of opioid-dependent patients smoke cigarettes (Grant et al, 2003)

• 80% of cocaine users smoke (Kalman, 2005)

• Over 75% of alcohol and drug-dependent persons in early recovery smoke (Gulliver, 2000)

• Smoking increases reinforcing value of alcohol (Perkins, 2001)

• Consumption of an alcohol increases smoking behavior (Mitchell, 1995)

• Greater than 80% of opioid-dependent patients smoke cigarettes (Grant et al, 2003)

• 80% of cocaine users smoke (Kalman, 2005)

NESARC findings (Grant, 2004)NESARC findings (Grant, 2004)

• 43,093 general U.S. respondents• 12.8% nicotine dependent (DSM-IV criteria)• Associations between nicotine dependence and

Axis I and II disorders were all statistically significant

• Nicotine dependence most prevalent among individuals with a current alcohol or drug use disorder [34.5% (OR=4.4) and 52.4% respectively (OR=8.1)]

• 43,093 general U.S. respondents• 12.8% nicotine dependent (DSM-IV criteria)• Associations between nicotine dependence and

Axis I and II disorders were all statistically significant

• Nicotine dependence most prevalent among individuals with a current alcohol or drug use disorder [34.5% (OR=4.4) and 52.4% respectively (OR=8.1)]

Studies of smoking and SUD and PD comorbidities in AI populations to dateStudies of smoking and SUD and PD comorbidities in AI populations to date

• Enoch, et al. 2006: found less association between alcoholism and smoking than U.S. population

• Henderson, et al. 2005: observed an association between alcohol and tobacco use

• No studies investigating nicotine dependence and psychiatric or drug use disorders have been performed among AI/AN using DSM criteria

• Enoch, et al. 2006: found less association between alcoholism and smoking than U.S. population

• Henderson, et al. 2005: observed an association between alcohol and tobacco use

• No studies investigating nicotine dependence and psychiatric or drug use disorders have been performed among AI/AN using DSM criteria

BackgroundBackground

• In a sample of 480 American Indian male veterans, the current study examines: – rates of psychiatric and substance use

disorders among those with nicotine dependence

– rates of nicotine dependence among those with psychiatric and substance use disorders

– odds ratios of nicotine dependence and comorbid psychiatric and substance use disorders

• In a sample of 480 American Indian male veterans, the current study examines: – rates of psychiatric and substance use

disorders among those with nicotine dependence

– rates of nicotine dependence among those with psychiatric and substance use disorders

– odds ratios of nicotine dependence and comorbid psychiatric and substance use disorders

HypothesisHypothesis

1) American Indian male veterans will demonstrate significant co-morbidity for nicotine dependence and both psychiatric and substance use disorders.

2) The degree of correlation between nicotine dependence and psychiatric and substance use disorders will be greater than the general U.S. population as observed in a recent epidemiological study (Grant, 2004).

1) American Indian male veterans will demonstrate significant co-morbidity for nicotine dependence and both psychiatric and substance use disorders.

2) The degree of correlation between nicotine dependence and psychiatric and substance use disorders will be greater than the general U.S. population as observed in a recent epidemiological study (Grant, 2004).

MethodsMethods

• 480 American Indian male veterans from the north central region of the U.S.

• Secondary analysis from an earlier, larger study

• Community-based survey• Utilized targeted sampling • Sample structured to include 51% urban

and 49% rural American Indian veterans

• 480 American Indian male veterans from the north central region of the U.S.

• Secondary analysis from an earlier, larger study

• Community-based survey• Utilized targeted sampling • Sample structured to include 51% urban

and 49% rural American Indian veterans

AssessmentsAssessments• A demographic questionnaire

• The Quick-Diagnostic Interview Schedule (Q-DIS), utilized to obtain DSM-III-R diagnoses

• Axis I and axis II diagnosis (antisocial personality disorder) were analyzed.

• A demographic questionnaire

• The Quick-Diagnostic Interview Schedule (Q-DIS), utilized to obtain DSM-III-R diagnoses

• Axis I and axis II diagnosis (antisocial personality disorder) were analyzed.

Statistical Analyses Statistical Analyses • Cross-tabulations were used to calculate the

prevalence of current and lifetime nicotine dependence, other Axis I diagnoses and ASPD.

• Examined diagnostic classes (e.g., any anxiety rather than individual diagnoses with the exception of PTSD and pathological gambling

• Odds ratios (OR) with 95% confidence intervals (C.I.) from chi-square analysis were used to study associations between nicotine dependence and both PD and SUD

• Cross-tabulations were used to calculate the prevalence of current and lifetime nicotine dependence, other Axis I diagnoses and ASPD.

• Examined diagnostic classes (e.g., any anxiety rather than individual diagnoses with the exception of PTSD and pathological gambling

• Odds ratios (OR) with 95% confidence intervals (C.I.) from chi-square analysis were used to study associations between nicotine dependence and both PD and SUD

Subject CharacteristicsSubject Characteristics

• 480 American Indian male veterans

• 24.2% married

• 70.7% high school education or higher

• 84.8% living independently

• 45.9% working full/part time

• 39.9% unemployed/disabled

• 480 American Indian male veterans

• 24.2% married

• 70.7% high school education or higher

• 84.8% living independently

• 45.9% working full/part time

• 39.9% unemployed/disabled

Results: Associations between Nicotine Dependence and Lifetime Psychiatric and Substance Use Disorders All Significant

Results: Associations between Nicotine Dependence and Lifetime Psychiatric and Substance Use Disorders All Significant

Co-Morbid Disorder

Prevalence of Comorbid Disorder Odds Ratio of Nicotine

Dependence and Comorbid Disorder (95% Confidence Interval)No.%

Nicotine Dependence 11223.3 ----

Any Alcohol Use Disorder

14830.8 1.82 (1.2-2.8)

Any Drug Use Disorder 7212.6 2.84 (1.7-4.8)

Any Anxiety 10722.3 3.93 (2.5-6.3)

Any Affective 428.8 6.65 (3.4-12.9)

Post Traumatic Stress 5711.9 4.68 (2.6-8.3)

Antisocial Personality 5311.0 3.19 (1.8-5.7)

Gambling 459.4 2.72 (1.4-5.1)

Nicotine Dependence and Alcohol Use Disorders in American Indian Male Veteran Sample

19 19.8 18.1 20.7

0

10

20

30

40

50

NicotineDependence

Alcohol UseDisorders

Among ThoseWith NicotineDependence

Alcohol UseDisorder

NicotineDependenceAmong Those

With Alcohol UseDisorders

Axis I Disorder

Pre

vale

nce

Rat

e (%

)

Odds Ratio 1.14 (0.6-2.0)

Nicotine Dependence And Drug Use Disorders in American Indian Male Veteran Sample

1911 8.5

24.4

01020304050

NicotineDependence

Drug UseDisorders

Among ThoseWith NicotineDependence

Drug UseDisorders

NicotineDependenceAmong ThoseWith Drug Use

Disorders

Axis I Disorder

Pre

vale

nce

Rat

e (%

)

Odds Ratio 1.43 (0.7-3.0)

Nicotine Dependence and Affective Disorders in American Indian Male Veteran Sample

19 16.57.1

44.1

01020304050

NicotineDependence

AffectiveDisorders

Among ThoseWith NicotineDependence

AffectiveDisorders

NicotineDependenceAmong ThoseWith Affective

Disorders

Axis I Disorder

Pre

vale

nce

Rat

e (%

)

Odds Ratio 3.84 (1.9-7.9)

Nicotine Dependence and Gambling Disorder In American Indian Male Veteran Sample

1912.2

6.9

33.3

0

10

20

30

40

50

NicotineDependence

GamblingDisorder Among

Those WithNicotine

Dependence

GamblingDisorder

NicotineDependenceAmong ThoseWith Gambling

Disorder

Axis I Disorder

Pre

vale

nce

Rat

e (%

)

Odds Ratio 2.32 (1.1-5.0)

Nicotine dependence and PD and SUD in this sample of AI

Nicotine dependence and PD and SUD in this sample of AI

• Lifetime nicotine dependence was associated with all lifetime psychiatric and substance use disorders studied

• Unlike the general U.S. population, current nicotine dependence was not associated with either current alcohol or drug use disorders

• AI with current alcohol and drug disorders had noticeably lower rates of current nicotine dependence when compared to the U.S. sample (20.7% vs 33.5%, and 24.40% vs. 51.6% respectively).

• Lifetime nicotine dependence was associated with all lifetime psychiatric and substance use disorders studied

• Unlike the general U.S. population, current nicotine dependence was not associated with either current alcohol or drug use disorders

• AI with current alcohol and drug disorders had noticeably lower rates of current nicotine dependence when compared to the U.S. sample (20.7% vs 33.5%, and 24.40% vs. 51.6% respectively).

Nicotine dependence and comorbid depression

Nicotine dependence and comorbid depression

• Several explanations have been proposed including:

-smokers use nicotine to self-medicate their depressed mood -causal influence of smoking on MDD -underlying environmental, genetic, and biological factors may predispose individuals to both

Sources: Glass, 1990; Hughes1988; Kendler et al., 1993).Dierker et al., 2002; Patten et al., 2001; Williams and Ziedonis, 2004

• Several explanations have been proposed including:

-smokers use nicotine to self-medicate their depressed mood -causal influence of smoking on MDD -underlying environmental, genetic, and biological factors may predispose individuals to both

Sources: Glass, 1990; Hughes1988; Kendler et al., 1993).Dierker et al., 2002; Patten et al., 2001; Williams and Ziedonis, 2004

Nicotine dependence and comorbid depression in A.I. males

Nicotine dependence and comorbid depression in A.I. males

• Possible anti-depressant qualities of tobacco use

• A.I. males known to minimize depressive symptomatology (O’Nell, 2000)

• Possible shared genetic factors?

• Possible social environmental factors?

• Consider pre-screening for depressive disorders

• Possible anti-depressant qualities of tobacco use

• A.I. males known to minimize depressive symptomatology (O’Nell, 2000)

• Possible shared genetic factors?

• Possible social environmental factors?

• Consider pre-screening for depressive disorders

Nicotine dependence and comorbid gambling disorders in A.I. malesNicotine dependence and comorbid gambling disorders in A.I. males

• Similar findings in AI sample as observed in general U.S. samples

• Gambling disorders comorbid with all Axis I disorders in prior study (Westermeyer, 2005).

• Additional psychosocial factors associated with problematic gambling among AI (Zitzow, 1996).

• Similar findings in AI sample as observed in general U.S. samples

• Gambling disorders comorbid with all Axis I disorders in prior study (Westermeyer, 2005).

• Additional psychosocial factors associated with problematic gambling among AI (Zitzow, 1996).

Nicotine dependence and gambling disorders in A.I. males: treatment considerations

Nicotine dependence and gambling disorders in A.I. males: treatment considerations

• Specific and comprehensive treatments• Cognitive Behavior Therapy • May consider bupropion (Black, 2004)

• Stricter clean air laws • Address “lack of social alternatives”• Traditional Medicine• Further treatment studies for this comorbidity are

needed.

• Specific and comprehensive treatments• Cognitive Behavior Therapy • May consider bupropion (Black, 2004)

• Stricter clean air laws • Address “lack of social alternatives”• Traditional Medicine• Further treatment studies for this comorbidity are

needed.

LimitationsLimitations

• Unestablished cross-cultural validity of Q-DIS

• Study limited to A.I. males

• Relatively small sample size

• Findings not representative of all tribes.

• Absence of psychotic disorder data

• Unestablished cross-cultural validity of Q-DIS

• Study limited to A.I. males

• Relatively small sample size

• Findings not representative of all tribes.

• Absence of psychotic disorder data

ReferencesReferences• Centers for Disease Control. Morbidty and Mortality Weekly

Report. Cigarette smoking among adults-United States, 2006 November 9, 2007 / 56(44);1157-1161

• Dierker LC, Avenevoli S, Stolar M, Merikangas KR. 2002. Smoking and depression: An examination of mechanisms of comorbidity. Am J Psychiatry 159:947-953.

• Glass RM. 1990. Blue mood, blackened lungs: depression and smoking. JAMA 264: 1583-1584.

• Grant, B.(2004). Nicotine Dependence and Psychiatric Disorders in the United States. Arch Gen Psychiatry, 61, 1107-1115.

• Grant JE, Potenzy MN. 2005. Tobacco use and pathological gambling. Ann Clin Psychiatry 17(4):237-241

Hughes JR. 1988. Clonidine, depression, and smoking cessation. JAMA 259: 2901-2902.

• Centers for Disease Control. Morbidty and Mortality Weekly Report. Cigarette smoking among adults-United States, 2006 November 9, 2007 / 56(44);1157-1161

• Dierker LC, Avenevoli S, Stolar M, Merikangas KR. 2002. Smoking and depression: An examination of mechanisms of comorbidity. Am J Psychiatry 159:947-953.

• Glass RM. 1990. Blue mood, blackened lungs: depression and smoking. JAMA 264: 1583-1584.

• Grant, B.(2004). Nicotine Dependence and Psychiatric Disorders in the United States. Arch Gen Psychiatry, 61, 1107-1115.

• Grant JE, Potenzy MN. 2005. Tobacco use and pathological gambling. Ann Clin Psychiatry 17(4):237-241

Hughes JR. 1988. Clonidine, depression, and smoking cessation. JAMA 259: 2901-2902.

References References • Kalman, D., Morissette, S.B., George, T.P. (2005). Co-Morbidity of Smoking

in Patients with Psychiatric and Substance Use Disorders. AM J Addictions, 14:2, 106-123.

• Kendler KS, Neale MC, MacLean CJ, Heath AC, Eaves LJ, Kessler RC. 1993. Smoking and major depression: a causal analysis. Arch Gen Psychiatry 50: 36-43.

• Kiss E, Piko B, Vetro A. 2006. Frequency of smoking, drinking, and substance use and their relationship to psychiatric comorbidity in depressed child and adolescent population. Psychiatr Hung 21 (3): 219-226.

• Lekka NP, Lee KH, Argyriou AA, Beratis S, Parks RW. 2006. Association of cigarette smoking and depressive symptoms in a forensic population. Depress Anxiety 0:1-6.

• O’Nell TD. 1996. Coming home among Northern Plains Vietnam veterans: psychological transformations in pragmatic perspective. Ethos 2000; 27:441-465.

• Patten CA, Gillin C, Golshan S, WOlter TD, Rapaport M, Kelsoe J. 2001. Relationship of mood disturbance to cigarette smoking status among 252 patients with a current mood disorder. J Clin Psychaitry 62: 319-324.

• Kalman, D., Morissette, S.B., George, T.P. (2005). Co-Morbidity of Smoking in Patients with Psychiatric and Substance Use Disorders. AM J Addictions, 14:2, 106-123.

• Kendler KS, Neale MC, MacLean CJ, Heath AC, Eaves LJ, Kessler RC. 1993. Smoking and major depression: a causal analysis. Arch Gen Psychiatry 50: 36-43.

• Kiss E, Piko B, Vetro A. 2006. Frequency of smoking, drinking, and substance use and their relationship to psychiatric comorbidity in depressed child and adolescent population. Psychiatr Hung 21 (3): 219-226.

• Lekka NP, Lee KH, Argyriou AA, Beratis S, Parks RW. 2006. Association of cigarette smoking and depressive symptoms in a forensic population. Depress Anxiety 0:1-6.

• O’Nell TD. 1996. Coming home among Northern Plains Vietnam veterans: psychological transformations in pragmatic perspective. Ethos 2000; 27:441-465.

• Patten CA, Gillin C, Golshan S, WOlter TD, Rapaport M, Kelsoe J. 2001. Relationship of mood disturbance to cigarette smoking status among 252 patients with a current mood disorder. J Clin Psychaitry 62: 319-324.

ReferencesReferences• Petry NM, Stinson FS, Grant BF. 2005. Comorbidity of DSM-IV pathological

gambling and other psychiatric disorders: results from the national epidemiologic survey on alcohol and related conditions. J Clin Psychiatry 66(5). 564-574.

• Potenza MN, Steinberg MA, McLaughlin SD, Wu R, Rounsaville BJ, Krishnan-Sarin S, George TP, O’Malley SS. 2004. Characteristics of tobacco-smoking problem gamblers calling gambling helpline. Am J Addict 2004; 13:471-493.

• U.S. Census Bureau, 2003 http://www.census.gov/statab/www/sa04aian.pdf• Williams, JM, Ziedonis D. 2004. Addressing tobacco among individuals with

a mental illness or an addiction. Addict Behav 29:1067-1083.• Westermeyer J, Canive J, Garrand J, Thuras P, Thompson J. 2005. Lifetime

prevalence of pathological gambling among American Indians and Hispanic American Veterans. Am J Public Health 95(5): 860-865.

• Zitzow D. 1996. Comparative study of problematic gambling behaviors between American Indian and non-Indian adults in a Northern Plains reservation. Am Indian Alsk Native Ment Health Res. 2: 27-41.

• Petry NM, Stinson FS, Grant BF. 2005. Comorbidity of DSM-IV pathological gambling and other psychiatric disorders: results from the national epidemiologic survey on alcohol and related conditions. J Clin Psychiatry 66(5). 564-574.

• Potenza MN, Steinberg MA, McLaughlin SD, Wu R, Rounsaville BJ, Krishnan-Sarin S, George TP, O’Malley SS. 2004. Characteristics of tobacco-smoking problem gamblers calling gambling helpline. Am J Addict 2004; 13:471-493.

• U.S. Census Bureau, 2003 http://www.census.gov/statab/www/sa04aian.pdf• Williams, JM, Ziedonis D. 2004. Addressing tobacco among individuals with

a mental illness or an addiction. Addict Behav 29:1067-1083.• Westermeyer J, Canive J, Garrand J, Thuras P, Thompson J. 2005. Lifetime

prevalence of pathological gambling among American Indians and Hispanic American Veterans. Am J Public Health 95(5): 860-865.

• Zitzow D. 1996. Comparative study of problematic gambling behaviors between American Indian and non-Indian adults in a Northern Plains reservation. Am Indian Alsk Native Ment Health Res. 2: 27-41.