title: Joint Association of Active and Passive Smoking with Psychiatric Distress and Violence Behaviors in a Representative Sample of Iranian Children and Adolescents: the CASPIAN-IV Study.
abstract: BACKGROUND
  Mental health and smoking have been receiving increasing attention in adolescents all over the world. Although some studies have assessed the independent association of active/passive smoking with mental health, joint association of active and passive smoking with mental health remains unclear.
  
  
  OBJECTIVE
  This study was designed to evaluate the joint association of smoking status (active and passive smoking) with psychiatric distress and violent behaviors in Iranian children and adolescents.
  
  
  METHODS
  In this national survey, 13,486 students, aged 6-18 years, living in rural and urban areas of 30 provinces of Iran were selected via multistage, cluster sampling method. Psychiatric distress (including worthless, angriness, worrying, insomnia, confusion, depression, and anxiety), violence behaviors (including bullying, victim, and physical fight), and smoking status (nonsmoker, only passive smoker, only active smoker, and active and passive smoker) were assessed. The questionnaire was prepared based on the World Health Organization Global School-based Student Health Survey (WHO-GSHS). Data were analyzed by the Stata package.
  
  
  RESULTS
  Psychiatric distress and violent behaviors had linearly positive association with smoking status (p trend < 0.001). Compared to "nonsmoker" group, participants who were exposed to passive smoking besides active tobacco use were at increased risk of having angriness (odds ratio (OR) 2.55, 95 % confidence interval (CI) 1.86-3.48), worrying (OR 1.66, 95 % CI 1.24-2.20), and anxiety (OR 1.99, 95 % CI 1.52-2.61) and victim (OR 1.77, 95 % CI 1.34-2.33) and bully behaviors (OR 3.08, 95 % CI 2.33-4.07).
  
  
  CONCLUSIONS
  The current findings suggest that active and passive tobacco smoking has synergistic effect on psychiatric distress. Since majority of smokers with psychiatric distress do not receive mental health services or counseling on smoking, strategies to address mental health problems and smoking prevention should be included as a part of school health services.
authors.affiliation: Pediatrics Department, Child Growth and Development Research Center, Research Institute for Primordial Prevention of Non-communicable Disease, Isfahan University of Medical Sciences, Isfahan, Iran.
authors.forename: Roya
authors.initials: R
authors.lastname: Kelishadi
authors.affiliation: Research Department, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran.
authors.forename: Amir Eslami Shahr
authors.initials: AE
authors.lastname: Babaki
authors.affiliation: Department of Community Medicine, Alborz University of Medical Sciences, Karaj, Iran. mqorbani1379@yahoo.com.|Chronic Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran. mqorbani1379@yahoo.com.
authors.forename: Mostafa
authors.initials: M
authors.lastname: Qorbani
authors.affiliation: Chronic Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran.
authors.forename: Zeinab
authors.initials: Z
authors.lastname: Ahadi
authors.affiliation: Chronic Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran. rheshmat@tums.ac.ir.
authors.forename: Ramin
authors.initials: R
authors.lastname: Heshmat
authors.affiliation: Pediatrics Department, Ahvaz University of Medical Sciences, Ahvaz, Iran.
authors.forename: Mohammad Esmaeil
authors.initials: ME
authors.lastname: Motlagh
authors.affiliation: Pediatrics Department, Child Growth and Development Research Center, Research Institute for Primordial Prevention of Non-communicable Disease, Isfahan University of Medical Sciences, Isfahan, Iran.
authors.forename: Gelayol
authors.initials: G
authors.lastname: Ardalan
authors.affiliation: Chronic Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran.
authors.forename: Asal
authors.initials: A
authors.lastname: Ataie-Jafari
authors.affiliation: Department of Medical Emergencies, Qom University of Medical Sciences, Qom, Iran.
authors.forename: Hamid
authors.initials: H
authors.lastname: Asayesh
authors.affiliation: Department of Epidemiology, School of Public Health, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
authors.forename: Rasool
authors.initials: R
authors.lastname: Mohammadi
mesh_terms: D000293:Adolescent; D000374:Aggression / Q000523:psychology; D001007:Anxiety / Q000453:epidemiology; D058445:Bullying / Q000706:statistics & numerical data; D002648:Child; D003863:Depression / Q000453:epidemiology; D005260:Female; D006801:Humans; D007492:Iran / Q000453:epidemiology; D008297:Male; D008603:Mental Health; D012907:Smoking / Q000523:psychology*; D013334:Students / Q000523:psychology*; D011795:Surveys and Questionnaires; D014028:Tobacco Smoke Pollution / Q000706:statistics & numerical data*; D014029:Tobacco Use Disorder / Q000453:epidemiology; D014754:Violence / Q000706:statistics & numerical data*
chemical_list: D014028:Tobacco Smoke Pollution
keywords: Pediatric; Psychiatric distress; Tobacco smoking; Violent behaviors