Cigarette smoking, major depression, and other psychiatric disorders among adolescents

Nicotine exposure during adolescence alters the rules for prefrontal cortical synaptic plasticity during adulthood

The majority of adolescents report to have smoked a cigarette at least once. Adolescence is a critical period of brain development during which maturation of areas involved in cognitive functioning, such as the medial prefrontal cortex (mPFC), is still ongoing. Tobacco smoking during this age may compromise the normal course of prefrontal development and lead to cognitive impairments in later life. In addition, adolescent smokers suffer from attention deficits, which progress with the years of smoking. Recent studies in rodents reveal the molecular changes induced by adolescent nicotine exposure that alter the functioning of synapses in the PFC and underlie the lasting effects on cognitive function. In particular, the expression and function of metabotropic glutamate receptors (mGluRs) are changed and this has an impact on short- and long-term plasticity of glutamatergic synapses in the PFC and ultimately on the attention performance. Here, we review and discuss these recent findings.

Predicting young adulthood smoking among adolescent smokers and nonsmokers

OBJECTIVE

To examine predictors of smoking in young adulthood among (1) adolescent nonsmokers and (2) adolescent smokers.

METHODS

Data were analyzed from a longitudinal study of adolescents to young adulthood in 1988-1998.

RESULTS

Predictors of smoking in young adulthood among adolescent nonsmokers included less education, being unmarried in adulthood, lower family social support, non-smoking parents, and increased alcohol use over time. Predictors of smoking in young adulthood among adolescent smokers included lower family social support, more adolescent friends who used drugs, and slower decreases in depressive symptoms over time.

CONCLUSIONS

Distinct factors predict smoking initiation versus maintenance among young adults.

Early mental health morbidity and later smoking at age 17 years

BACKGROUND

We examined the relationship between the onset and pattern of childhood mental health disorders and subsequent current smoking status at age 17 years.

METHOD

Data were from a prospective cohort study of 2868 births of which 1064 supplied information about their current smoking at 17 years of age. The association between the onset and pattern of clinically significant mental health disorders in the child and subsequent smoking at age 17 years was estimated via multivariable logistic regression.

RESULTS

Relative to 17 year olds who never had an externalizing disorder, 17-year-olds who had an externalizing disorder at age 5, 8 or 14 years were, respectively, 2.0 times [95% confidence interval (CI) 1.24-3.25], 1.9 (95% CI 1.00-3.65) or 3.9 times (95% CI 1.73-8.72) more likely to be a current smoker. Children with an ongoing pattern of externalizing disorder were 3.0 times (95% CI 1.89-4.84) more likely to be smokers at the age of 17 years and those whose mothers reported daily consumption of 6-10 cigarettes at 18 weeks' gestation were 2.5 times (OR 2.46, 95% CI 1.26-4.83) more likely to report smoking at 17 years of age. Associations with early anxiety and depression in the child were not found.

CONCLUSIONS

Current smoking in 17-year-olds may be underpinned by early emergent, and then, ongoing, externalizing disorder that commenced as young as age 5 years as well as exposure to early prenatal maternal smoking. The associations documented in adults and adolescents that link tobacco smoking and mental health are likely to be in play at these early points in development.

Persistent heavy smoking as risk factor for major depression (MD) incidence--evidence from a longitudinal Canadian cohort of the National Population Health Survey

BACKGROUND

Reports of bidirectional associations between smoking and major depression (MD) have been interpreted as providing evidence for confounding by shared-vulnerability factors (SV) that predispose individuals to both conditions. If this is true, then smoking cessation may not reduce the risk of MD. From clinical practice and public health perspectives, the long-term outcomes associated with smoking persistence and cessation are potentially important and deserve exploration. To this end, the 12-year risk of MD in persistent heavy smokers and abstainers who were former-heavy smokers with and without adjustment for potential confounders were compared.

METHODS

Follow-up data from the National Population Health Survey (NPHS) was used. Multinomial logistic (ML) models were fit to identify potential confounders. Using proportional hazard (PH) models, unadjusted and adjusted hazard ratios (HRs) for MD outcome were estimated for different smoking patterns.

RESULTS

The unadjusted HR relating the risk of MD among current-heavy versus former-heavy smokers was 4.3 (95% CI: 2.6-6.9, p < 0.001). Current-heavy smoking predicted onset of MD (HR = 3.1, 95% CI: 1.9-5.2, p < 0.001) even after adjustment for age, sex and stress - the main confounders. However, this was not the case for the never, former-light, and current-light categories. Evidence of decreased risk of MD among former-heavy relative to current-heavy smokers as function of smoking cessation maintenance time was also found.

CONCLUSIONS

Contrary to common beliefs about the benefits of smoking for mental health, our results suggest that current-heavy rather than ever-heavy smoking is a major determinant of MD risk and point towards the benefits of smoking cessation maintenance.

Cigarette smoking and mood disorders in U.S. adolescents: sex-specific associations with symptoms, diagnoses, impairment and health services use

OBJECTIVE

To report sex-specific associations between cigarette smoking and DSM-IV disorders, symptoms, and mental health services use related to depression and anxiety in a nationally representative sample of U.S. adolescents.

METHODS

Data on two samples were drawn from the 1999-2004 National Health and Nutrition Examination Surveys to examine the association of ever smoking (versus never smoking) with depression (n=1884 12-15 year-olds) and anxiety (n=6336 12-19 year-olds). Sex-specific associations between smoking and DSM-IV diagnoses, subthreshold and severe disorder, symptoms, impairment and mental health services use were assessed using logistic regression modeling.

RESULTS

Rates of DSM-IV depression and anxiety were increased in adolescent female ever smokers as compared to never smokers (OR=3.9, 95% CI: 1.3-11.3 and OR=10.6, 95% CI: 3.1-37.0, respectively). Females also showed statistically significant increases in severe disorder, subthreshold disorder, all symptoms of major depressive disorder, most symptoms of panic disorder, and increases in severe impairment, especially those related to schoolwork and teachers. Male adolescents showed smaller variations in depression and anxiety by smoking status, but were more likely to seek mental health services.

CONCLUSIONS

Smoking prevention efforts may benefit from specifically targeting female youth who show signs of depression or anxiety diagnoses through a school-based program, while greater benefits with males may be evident through programs integrated into mental health services.

Psychological, peer, and family influences on smoking among an adolescent psychiatric sample

Although much is known about adolescent cigarette use and initiation in community samples, less is known about these factors among adolescents in clinic-referred populations or those with severe psychopathology. Data were collected from 106 adolescents aged 12 to 15 years (M = 13.6, SD = 0.74) recruited from a psychiatric inpatient facility. Hierarchical logistic regressions assessed the relationship among psychological, peer, and family environment factors and smoking at baseline and 18 months posthospitalization. Conduct problem symptoms, friends' cigarette use, and friends' marijuana use were associated with greater odds of lifetime and current smoking at baseline but not at follow-up. After accounting for the significant effect of baseline use, greater family conflict predicted decreased odds of having initiated smoking at the 18-month follow-up. The period following inpatient psychiatric hospitalization may represent an important window for smoking cessation and prevention efforts targeting peer and family factors, especially for youth with externalizing problems.

Reward expectations lead to smoking uptake among depressed adolescents

AIMS

While the comorbidity between adolescent depression and smoking has been well documented, less is known about why smoking is disproportionately higher among depressed adolescents. Emerging research suggests that reward-related mechanisms may be important to consider. This study sought to determine whether adolescents with higher depression symptoms have greater smoking reward expectations, which in turn, influence smoking progression.

PARTICIPANTS

The sample was composed of 1393 adolescents participating in a longitudinal survey study of adolescent health behaviors.

DESIGN AND MEASUREMENTS

In this prospective cohort study, variables were measured via self-report every six months from age 14 to age 17 resulting in six waves of data. Findings Parallel processes latent growth curve modeling indicated that higher depression symptoms across mid to late adolescence predicted a 17% increase in smoking reward expectations (β=3.50, z=2.85, p=0.004), which in turn predicted a 23% increase in the odds of smoking progression (β=0.206, z=3.29, p=0.001). The indirect effect was significant with delta method (β(indirect)=0.72, z=3.09, p=0.002; 95% CI=0.26, 1.18) and bootstrap (β(indirect)=0.72, z=2.10, p=0.03; 95% CI=0.05, 1.39) standard errors.

CONCLUSIONS

The study provides novel evidence that expectations of smoking reward facilitate smoking uptake among depressed adolescents. Smoking reward expectations may identify depressed adolescents at risk of smoking. Addressing alternative ways to meet the reward expectations rather than smoking may be an important component to consider in the preventing smoking and promoting smoking cessation among adolescents with elevated depression symptoms.

Tobacco use and psychiatric comorbidity among adolescents in substance abuse treatment

Adolescents in substance abuse treatment have approximately four times higher rates of tobacco use compared with adolescents in the general population, yet many substance abuse treatment programs do not provide tobacco cessation interventions. This study examined change in tobacco use among 151 adolescents in state-funded substance abuse treatment from intake to 12-month follow-up in relation to psychiatric comorbidity and substance use. Most adolescents (67.5%) used tobacco at intake and follow-up. Having a diagnosis of a mood, anxiety, or behavioral disorder was significantly associated with change in tobacco use. Individuals with a psychiatric disorder were less likely to be nonusers of tobacco than to be individuals who continued tobacco use (adjusted odds ratio [OR] = 0.153, 95% confidence interval [CI] = 0.040-0.587, p < .01), and they were less likely to have initiated tobacco use at follow-up than individuals who continued tobacco use (adjusted OR = 0.320, 95% CI = 0.105-0.970, p < .05). Contrary to the hypothesis, alcohol use and drug use during the 12-month follow-up was not significantly related to change in tobacco use. Adolescents in substance abuse treatment with comorbid psychiatric disorders may be particularly vulnerable to continuing tobacco use.

Mindfulness training for smoking cessation: results from a randomized controlled trial

BACKGROUND

Cigarette smoking is the leading cause of preventable death in the world, and long-term abstinence rates remain modest. Mindfulness training (MT) has begun to show benefits in a number of psychiatric disorders, including depression, anxiety and more recently, in addictions. However, MT has not been evaluated for smoking cessation through randomized clinical trials.

METHODS

88 treatment-seeking, nicotine-dependent adults who were smoking an average of 20cigarettes/day were randomly assigned to receive MT or the American Lung Association's freedom from smoking (FFS) treatment. Both treatments were delivered twice weekly over 4 weeks (eight sessions total) in a group format. The primary outcomes were expired-air carbon monoxide-confirmed 7-day point prevalence abstinence and number of cigarettes/day at the end of the 4-week treatment and at a follow-up interview at week 17.

RESULTS

88% of individuals received MT and 84% of individuals received FFS completed treatment. Compared to those randomized to the FFS intervention, individuals who received MT showed a greater rate of reduction in cigarette use during treatment and maintained these gains during follow-up (F=11.11, p=.001). They also exhibited a trend toward greater point prevalence abstinence rate at the end of treatment (36% vs. 15%, p=.063), which was significant at the 17-week follow-up (31% vs. 6%, p=.012).

CONCLUSIONS

This initial trial of mindfulness training may confer benefits greater than those associated with current standard treatments for smoking cessation.

Effects of nicotine on electroencephalography and affect in adolescent females with major depressive disorder: a pilot study

BACKGROUND

Given that smoking is typically initiated during adolescence, and that this period in brain development seems to be uniquely sensitive to nicotine, depressed youth may be most susceptible to the neuromodulatory and mood-altering effects of nicotine. Electroencephalographic (EEG) studies suggest that individuals with major depressive disorder (MDD) exhibit left frontal lobe hypoactivation (indexed by increased EEG alpha), a region implicated in positive affect regulation, as well as right parietal hypoactivation. Smoking/nicotine abstinence has been associated with increased left frontal and right parietal alpha activity (reduced activation), which has been correlated with increased depression ratings; nicotine administration seems to normalize this depression-associated asymmetry.

OBJECTIVES

This pilot study investigated whether acute nicotine administration in adolescent female smokers with MDD would alter resting EEG activity and affect.

METHODS

Subjective mood ratings and EEG recordings were acquired before and 2 hours after administering a transdermal placebo or nicotine (21 mg) patch to 8 adolescent female smokers with MDD.

RESULTS

Nicotine induced a modest increase in alpha1 amplitude in the right hemisphere and simultaneously decreased left-favoring alpha1 amplitude asymmetry. It also attenuated left alpha1 and alpha2 amplitude in the central region. Consistent with nicotine's stimulatory action, nicotine decreased theta amplitude in the right parietal region. No accompanying mood alterations were found, although smoking withdrawal and craving as well as physical symptom scores were reduced with nicotine.

CONCLUSIONS

The results of this pilot study, the first to examine the electrocortical effects of nicotine in depressed adolescents, indicate that nicotine modulates EEG asymmetry measures, laying the stage for further research regarding the role of nicotine on affective neurocircuitry in this population.

Multiple perspectives on tobacco use among youth with mental health disorders and addictions

PURPOSE

Youth and young adults with mental health disorders and addictions are at a high risk of becoming nicotine dependent, and at least half will die of tobacco-related diseases. In comparison to the general population, this population also faces neurobiological and psychosocial vulnerabilities. There is a critical need for community services and research targeting tobacco interventions for these individuals.

METHODS

A concurrent mixed methods study was conducted by collecting data from in-depth key informant interviews, focus groups, and a survey. Qualitative key informant interviews with healthcare professionals (n = 11) and youth focus groups (n = 32) were conducted by using semi-structured questioning regarding barriers and facilitators to tobacco interventions. Content analysis was used to code transcripts and categorize themes. Survey data were also collected from 230 smokers ages 13 to 17 years (n = 62) and young adults ages 18 to 25 years (n = 40) at three community mental health centers. The survey inquired about tobacco use, motivation to quit, history of quit attempts, and treatment preferences.

RESULTS

Five thematic categories were identified in both the adult key informant interviews and the focus groups with youth: (1) motivation to quit, (2) cessation treatment needs, (3) social influence, (4) barriers to treatment, and (5) tobacco-free policy. Among those surveyed, 44% currently smoked. Youth and young adult survey respondents who smoked were often motivated to quit, few had used proven tobacco cessation aids, but there was interest in access to nicotine replacement therapy.

CONCLUSION

Merged qualitative and quantitative findings support past literature regarding youth in the general population but also expand upon our knowledge of issues specific to youth and young adults with mental health disorders and addictions. Findings suggest interventions warranting further attention in community treatment settings.

Development of the motivational system during adolescence, and its sensitivity to disruption by nicotine

The brain continues to develop during adolescence, and exposure to exogenous substances such as nicotine can exert long-lasting adaptations during this vulnerable period. In order to fully understand how nicotine affects the adolescent brain it is important to understand normal adolescent brain development. This review summarizes human and animal data on brain development, with emphasis on the prefrontal cortex, for its important function in executive control over behavior. Moreover, we discuss how nicotine exposure during adolescence can disrupt brain development bearing long-term consequences on executive cognitive function in adulthood.

Self-efficacy mediates the effect of depression on smoking susceptibility in adolescents

INTRODUCTION

Research indicates that negative affect and/or depression is associated with increased prevalence for smoking and higher levels of nicotine dependence in adults and adolescents. A previous study with adult smokers attempting to quit indicated that low levels of self-efficacy partially mediated depression's adverse effect on posttreatment cessation.

METHOD

The current study attempted to test self-efficacy as a potential mediator between depressive symptoms and smoking susceptibility in adolescents. One thousand and ninety-three nonsmoking high-school students who were part of a large clinical trial evaluating an interactive CD-ROM-based smoking prevention/cessation curriculum (project ASPIRE) were included in this analysis. These students completed an extensive battery before treatment and 18 months after treatment, which included measures of depression, self-efficacy, smoking status, and smoking susceptibility.

RESULTS

Results indicated that self-efficacy partially mediated the positive relationship between baseline depressive symptoms and susceptibility to smoke at 18 months, accounting for approximately 27% of the variance.

CONCLUSIONS

Perhaps future interventions to prevent smoking in adolescents can target self-efficacy potentially resulting in more effective outcomes, particularly in adolescents with current depressive symptoms or who may be at risk for future depression.

Tobacco use in youth with mental illnesses

Despite an abundance of literature documenting the prevalence and dangers of youth tobacco use, there is a relative dearth of literature in the area of effective cessation treatments for youth (Fiore et al. in Clinical tobacco guideline: treating tobacco use and dependence, 2008). Additionally, although it has been widely accepted that mental illness is highly correlated with tobacco use and dependence, little research has been done to support prevention and cessation efforts for youth with mental illnesses. This paper summarizes the literature on tobacco use and cessation in youth, with a focus on describing the existing knowledge base for youth with mental illnesses.

A pilot examination of stress-related changes in impulsivity and risk taking as related to smoking status and cessation outcome in adolescents

INTRODUCTION

Psychosocial stress and impulsivity are each associated with smoking in adolescents. There is also evidence that stress can increase impulsive responding, and impulsive adolescent smokers attempting cessation are at greater risk of relapse. We performed a pilot investigation to examine stress-induced changes in response inhibition, inattention, and risk taking as related to smoking status and posttreatment smoking abstinence.

METHODS

Twelve adolescent smokers participating in a smoking cessation intervention and 15 adolescent nonsmokers completed a 2-session protocol assessing stress-related change in response inhibition and inattention (on the Conners' Continuous Performance Test-II), risk taking (on the Balloon Analogue Risk Task), nicotine withdrawal symptoms, and self-reported stress.

RESULTS

At baseline, smokers had greater inattentive responding and risk taking when compared with nonsmokers. Stress exposure led to significant increases in stress, anger, and depression in all participants and also increased nicotine craving (on the Minnesota Nicotine Withdrawal Scale item) and impulsive responding in smokers. After covarying for baseline differences in impulsivity/risk taking, smokers who were not abstinent at the end of treatment experienced greater stress-induced risk taking when compared with those who were abstinent.

CONCLUSIONS

In all, it appears that response inhibition and risk taking may be differentially altered by stress exposure in adolescent smokers and nonsmokers and that adolescent smoking cessation success may be associated with less risk taking in the face of stress.

Adolescent mental health as a risk factor for adolescent smoking onset

Smoking continues to be a leading cause of preventable deaths and rates of trying cigarettes and progression to daily smoking among adolescents continues to remain high. A plethora of risk factors for smoking among adolescents has been addressed in the research literature. One that is gaining particular interest is the relationship between adolescent mental health and smoking (both initiation and progression). This paper reviews the evidence for adolescent mental health as a risk factor for cigarette smoking. We focus on the specific mental health conditions that have been more thoroughly addressed as possible risk factors in community-dwelling adolescents. We discuss the multiple hypotheses that have been posited as to the nature of the relationship between adolescent mental health and smoking, as well as detailing so called third factors that may account for the observed relationship. We highlight the contribution of the existing studies to the body of knowledge on this topic, as well as the limitations and open questions that remain as a result. We conclude with discussion of a broad research agenda going forward.

Obesity and depressed mood associations differ by race/ethnicity in adolescent girls

Abstract Objectives. To evaluate bidirectional associations between obesity and depressed mood in adolescent girls, and determine if associations differed by racial/ethnic group. Methods. We analyzed data collected from 918 adolescent girls studied in 6(th) and 8(th) grades in the Trial of Activity for Adolescent Girls (TAAG). Racial/ethnic group was defined as non-Hispanic white, non-Hispanic black, and Hispanic. Height and weight were measured and obesity was defined as a body mass index-for-age ≥95(th) percentile. The Center for Epidemiologic Studies Depression Scale (CES-D) was used to measure depressive symptoms and depressed mood, defined as CES-D ≥24. Generalized estimating equations were used to examine associations between 6(th) grade obesity and 8(th) grade depressed mood, as well as 6(th) grade depressed mood and 8(th) grade obesity. Results. Racial/ethnic group was a statistically significant effect modifier in both directions of association (p<0.02). Among white girls, 6(th) grade obesity was associated with greater likelihood of depressed mood in 8(th) grade (odds ratio [OR]=2.47, 95% confidence interval [CI]: 1.85, 3.30), whereas for black and Hispanic girls this association was not observed (OR= 1.16 and 0.82, respectively). Also for white girls, 6(th) grade depressed mood was associated with greater likelihood of obesity in 8(th) grade (OR = 4.47, CI: 1.96, 10.24), whereas for black and Hispanic girls, OR=0.83 and 1.89, respectively. Conclusions. Associations between obesity and depressed mood may be most problematic among adolescent girls in the white racial/ethnic group. Our results are consistent both with depressed mood contributing to obesity and obesity contributing to depressed mood.

Changes in genetic and environmental influences on the development of nicotine dependence and major depressive disorder from middle adolescence to early adulthood

This longitudinal study used a representative community sample of same-sex twins (485 monozygotic pairs, 271 dizygotic pairs) to study longitudinal changes in genetic and environmental influences on nicotine dependence (NicD) symptoms and major depressive disorder (MDD) symptoms and the longitudinal relationships between NicD and MDD symptoms at three relatively discrete ages spanning middle adolescence to early adulthood (ages 15, 18, and 21). Clinical interviews were used to assess NicD and MDD symptoms lifetime at age 15 and during the previous 3 years at the two subsequent assessments. Biometric models revealed similar patterns of findings for NicD and MDD. Heritability increased with age, particularly between ages 15 and 18. Shared environmental influences were small, and the proportion of variance attributed to shared environmental influences decreased with age. Nonshared environmental influences were moderate to large in magnitude and were entirely age specific. Both NicD and MDD symptoms showed considerable stability from age 15 to 21, and at each age those with one disorder showed elevated rates of the other. However, a cross-lagged model revealed no longitudinal predictive relationships between MDD symptoms and NicD symptoms after accounting for stability of symptoms within disorders. In summary, the transition between middle and late adolescence is a critical period for developmental shifts in the magnitudes of genetic and environmental influences on both MDD and NicD symptoms. Despite similarities in the development of genetic and environmental influences for the two phenotypes, the association between NicD and MDD reflects concurrent covariation rather than one phenotype being an antecedent influence on the subsequent development of the other.

Genetics of addictions

Addictions include a group of common, heritable psychiatric illnesses that have multiple psychiatric and medical comorbidities. Robust genetic associations have been found for alcohol dependence, nicotine dependence, and cocaine dependence. Common genetic associations have been found between alcohol dependence and aerodigestive cancers and between nicotine dependence and lung disease. These associations highlight the importance of understanding the genetics of substance dependence in the context of its multiple medical and psychiatric comorbidities.

Association of adolescent symptoms of depression and anxiety with daily smoking and nicotine dependence in young adulthood: findings from a 10-year longitudinal study

AIMS

To examine the association of adolescent depression and anxiety symptoms with daily smoking and nicotine dependence in young adulthood.

DESIGN

A prospective cohort study of adolescent and young adult health (n = 1943). Teen assessments occurred at 6-monthly intervals, with two follow-up assessments in young adulthood (wave 7, 1998; wave 8, 2001-03).

SETTING

Victoria, Australia. Participants Students who participated at least once during the first six (adolescent) waves of the cohort study.

MEASUREMENTS

Adolescent depression and anxiety symptoms were assessed using the Revised Clinical Interview Schedule (CIS-R). Young adult tobacco use was defined as: daily use (6 or 7 days per week) and dependent use (> or =4 on the Fagerstrom Test for Nicotine Dependence).

FINDINGS

Among adolescent 'less than daily' smokers, those with high levels of depression and anxiety symptoms had an increased risk of reporting nicotine dependence in young adulthood [odds ratio (OR) 3.3, 95% confidence interval (CI) 1.2-9.1] compared to young adults who had low levels of adolescent depression and anxiety symptoms, after adjusting for potential confounding factors. Similarly, in the adjusted model (OR 1.9, 95% CI 1.0-3.4), among adolescent 'daily' smokers, those with high levels of depression and anxiety symptoms had an almost two-fold increase in the odds of reporting nicotine dependence in young adulthood compared to young adults with low levels of adolescent depression and anxiety symptoms.

CONCLUSIONS

Adolescent smokers with depression and anxiety symptoms are at increased risk for nicotine dependence into young adulthood. They warrant vigilance from primary care providers in relation to tobacco use well into adulthood.

Smoking status, mental disorders and emotional and behavioural problems in young people: child and adolescent component of the National Survey of Mental Health and Wellbeing

OBJECTIVE

To examine the relationship between smoking behaviour, mental disorders and emotional and behavioural problems in a nationally representative sample of young people.

METHOD

Data were taken from the child and adolescent component of the National Survey of Mental Health and Wellbeing which assessed mental health problems in two main ways: using a fully structured interview (the Diagnostic Interview Schedule for Children) and using the Child Behaviour Checklist and the Youth Self Report, which assess emotional and behavioural problems on a dimensional scale. The relationship between smoking and mental health problems was assessed using logistic regression.

RESULTS

Among young people with conduct disorder 72% had smoked in the last 30 days, 46% of young people with depressive disorder, and 38% among young people with attention deficit hyperactivity disorder. This compared with 21% of young people with none of these disorders. Odds ratios (OR) for current smoking were consistently elevated for young people with mental health problems after adjusting for demographic and socio-economic factors across all measures of mental health used. The OR for current smoking in young people with parent-reported externalizing behaviours in the clinical range was 4.5 (95%CI: 3.1-6.8), and for young people with parent-reported internalizing problems in the clinical range the OR was 2.7 (95%CI: 1.8-4.0). Young people with mental health problems started smoking on average at a younger age, were more likely to progress to current smoking, and smoked on average a higher number of cigarettes per day.

CONCLUSIONS

After adjusting for demographic and socio-economic factors, young people with mental health problems were more likely to start smoking, progress to daily smoking, and smoke more heavily. Mental illness is an important issue to consider in tobacco control in young people.

Substance use and common child mental health problems: examining longitudinal associations in a British sample

AIMS

To examine the longitudinal associations in both directions between mental health and substance use in adolescence.

DESIGN

Three-year longitudinal cohort.

SETTING

Britain (nationally representative sample).

PARTICIPANTS

3607 youths aged 11-16 years at baseline.

MEASUREMENTS

Externalizing and internalizing mental health problems were measured using brief questionnaires (parent-reported Strengths and Difficulties Questionnaire) and diagnostic interviews, including clinician-rated diagnoses of mental disorder. Substance use was measured by youth self-report, and included regular smoking, frequent alcohol consumption, regular cannabis use and ever taking other illicit drugs.

FINDINGS

Externalizing (specifically behavioural) problems at baseline independently predicted all forms of substance use, with a particularly strong effect on smoking. In all cases this association showed a dose-response relationship. In contrast, although internalizing problems had a strong univariable association with smoking, this disappeared after adjusting for comorbid externalizing problems. There was little or no evidence that baseline substance use predicted mental health at follow-up.

CONCLUSIONS

Externalizing problems predict adolescent substance use, and adjusting for comorbid externalizing problems is vital when investigating the effects of internalizing problems. A dose-response effect of externalizing problems is seen across the full range. Programmes seeking to prevent adolescent substance use by reducing externalizing problems may therefore wish to consider population-wide interventions rather than targeting individuals only at the negative extreme.

Single versus recurrent depression history: differentiating risk factors among current US smokers

INTRODUCTION

The strong relationship between persistent tobacco use and Major Depressive Disorder (MDD) has motivated clinical trials of specialized treatments targeting smokers with a history of MDD. Meta-analyses suggest positive responses to specialized treatments have been observed consistently among smokers with history of recurrent rather than a single episode of MDD. Approximately 15% of current US smokers have a history of recurrent MDD. Little is known about the risk factors that contribute to persistent smoking and differentiate these at-risk smokers, US.

METHODS

The National Comorbidity Survey - Replication (NCS-R) included a survey of 1560 smokers participants aged 18 and older in the United States. Lifetime history of MDD was categorized according to chronicity: no history (No MDD), single episode (MDD-S) and recurrent depression (MDD-R). The relationship between the chronicity of MDD, smoking characteristics, cessation history, nicotine dependence, comorbidity with psychiatric disorders, and current functional impairments were examined.

RESULTS

MDD-R smokers reported fewer lifetime cessation efforts, smoked more cigarettes, had higher levels of nicotine dependence, had higher rates of comorbid psychiatric disorders and greater functional impairment than smokers with No MDD. MDD-S smokers were not consistently distinguished from No MDD smokers on cessation attempts, level of daily smoking, nicotine dependence or functional impairment indices.

CONCLUSIONS

The study highlights the importance of chronicity when characterizing depression-related risk of persistent smoking behavior. Although, clinical trials suggest MDD-R smokers specifically benefit from specialized behavioral treatments, these services are not widely available and more efforts are needed to engage MDD-R smokers in efficacious treatments.

Evaluation of the PHQ-2 as a brief screen for detecting major depression among adolescents

OBJECTIVE

To examine the validity of the Patient Health Questionnaire 2 (PHQ-2), a 2-item depression-screening scale, among adolescents.

METHODS

After completing a brief depression screen, 499 youth (aged 13-17 years) who were enrolled in an integrated health care system were invited to participate in a full assessment, including a longer depression-screening scale (Patient Health Questionnaire 9-item depression screen) and a structured mental health interview (Diagnostic Interview Schedule for Children). Eighty-nine percent (n = 444) completed the assessment. Criterion validity and construct validity were tested by examining associations between the PHQ-2 and other measures of depression and functional impairment.

RESULTS

A PHQ-2 score of > or =3 had a sensitivity of 74% and specificity of 75% for detecting youth who met Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria for major depression on the Diagnostic Interview Schedule for Children and a sensitivity of 96% and specificity of 82% for detecting youth who met criteria for probable major depression on the Patient Health Questionnaire 9-item depression screen. On receiver operating characteristic analysis, the PHQ-2 had an area under the curve of 0.84 (95% confidence interval: 0.75-0.92), and a cut point of 3 was optimal for maximizing sensitivity without loss of specificity for detecting major depression. Youth with a PHQ-2 score of > or =3 had significantly higher functional-impairment scores and significantly higher scores for parent-reported internalizing problems than youth with scores of <3.

CONCLUSIONS

The PHQ-2 has good sensitivity and specificity for detecting major depression. These properties, coupled with the brief nature of the instrument, make this tool promising as a first step for screening for adolescent depression in primary care.

Quitting smoking does not increase the risk of major depressive episodes among users of Internet smoking cessation interventions

BACKGROUND

Limited evidence has suggested that quitting smoking increases the incidence of major depressive episodes (MDEs), particularly for smokers with a history of depression. Further evidence for this increase would have important implications for guiding smoking cessation.

METHOD

Spanish- and English-speaking smokers without a current MDE (n=3056) from an international, online smoking cessation trial were assessed for abstinence 1 month after their initial quit date and followed for a total of 12 months. Incidence of screened MDE was examined as a function of abstinence and depression history.

RESULTS

Continued smoking, not abstinence, predicted MDE screened at 1 month [smoking 11.5% v. abstinence 7.8%, odds ratio (OR) 1.36, 95% confidence interval (CI) 1.04-1.78, p=0.02] but not afterwards (smoking 11.1% v. abstinence 9.8%, OR 1.05, 95% CI 0.77-1.45, p=0.74). Depression history predicted MDE screened at 1 month (history 17.1% v. no history 8.6%, OR 1.71, 95% CI 1.29-2.27, p<0.001) and afterwards (history 21.7% v. no history 8.3%, OR 3.87, 95% CI 2.25-6.65, p<0.001), although the interaction between history and abstinence did not.

CONCLUSIONS

Quitting smoking was not associated with increased MDE, even for smokers with a history of depression, although a history of depression was. Instead, not quitting was associated with increased MDE shortly following a quit attempt. Results from this online, large, international sample of smokers converge with similar findings from smaller, clinic-based samples, suggesting that in general, quitting smoking does not increase the incidence of MDEs.

Genetics of addictions

Addictions include a group of common, heritable psychiatric illnesses that have multiple psychiatric and medical comorbidities. Robust genetic associations have been found for alcohol dependence, nicotine dependence, and cocaine dependence. Common genetic associations have been found between alcohol dependence and aerodigestive cancers and between nicotine dependence and lung disease. These associations highlight the importance of understanding the genetics of substance dependence in the context of its multiple medical and psychiatric comorbidities.

Smoking and sleep disorders in Chinese adolescents

OBJECTIVE

To investigate the association between adolescent smoking and sleep disorders.

METHODS

In the Hong Kong student obesity surveillance project, 29,397 Chinese students, aged 12-18 years, completed a health survey. Insomnia was defined as having any of the following three symptoms: difficulty initiating sleep (DIS), difficulty maintaining sleep (DMS) and early morning awakening (EMA). The presence of snoring and difficulty breathing during sleep (DBS) was also reported. Logistic regression yielded adjusted odds ratios (ORs) for each sleep disorder by smoking status.

RESULTS

Compared with never smokers, the ORs (95% CI) of insomnia were 1.39 (1.25-1.54) for experimenters (smoked once or a few times) and 0.91 (0.83-1.00) for current smokers. The corresponding ORs were 1.42 (1.16-1.74) and 3.58 (3.15-4.06) for snoring (P for trend<0.001) and 1.40 (1.10-1.79) and 3.39 (2.97-4.03) for DBS (P for trend<0.001). Current smokers compared with never smokers were less likely to report DIS (OR=0.43, 95% CI=0.38-0.50, P<0.001) and EMA (OR=0.83, 95% CI=0.73-0.94, P=0.003), but more likely to report DMS (OR=1.45, 95% CI=1.28-1.63, P<0.001).

CONCLUSIONS

In terms of dosage, adolescent smoking was associated with snoring and DBS, with increasing ORs from never smokers to experimental and current smokers. Current smoking was associated positively with DMS, but negatively with DIS and EMA.

Relationships of personality and psychiatric disorders to multiple domains of smoking motives and dependence in middle-aged adults

INTRODUCTION

Individual differences in psychopathology and personality may associate with dependence on smoking for specific motivational reasons. However, the associations among psychopathology, personality, and smoking dependence and motives have not been examined simultaneously in studies to date, leaving it unclear whether specific patterns of affective and behavioral functioning are associated with specific aspects of smoking dependence.

METHODS

The present study examined these associations in 296 current smokers aged 35-43 years. Smoking dependence and motives were assessed with structured interview, the Fagerström Test for Nicotine Dependence, and the Wisconsin Inventory of Smoking Dependence Motives.

RESULTS

Regardless of the measure of smoking dependence tested, a lifetime history of major depression and high levels of trait stress reaction were consistently related to greater current smoking dependence severity. Substance dependence showed significant associations with some measures of smoking dependence but had relatively few effects when entered in models along with depression history and trait stress reaction. In multivariate models, alcohol dependence and conduct disorder history did not show unique significant associations with smoking dependence nor did trait aggression, alienation, control, or harm avoidance.

DISCUSSION

Results indicate little specificity in the associations of particular psychiatric diagnoses or personality traits with specific self-reported facets of smoking dependence. It appears that a general vulnerability to depression and negative emotions is the most robust indicator of vulnerability to high levels of self-reported smoking dependence, regardless of which dimensions of smoking dependence are analyzed.

Smoking, parent smoking, depressed mood, and suicidal ideation in teens

OBJECTIVES

We address whether smoking is related to suicidal ideation in teens and whether there is evidence of a causal pathway.

METHODS

We use data from the 2002 National Annenberg Survey of Youth and employ multivariate logistic regression to model each teen's risk of suicidal ideation as a function of self-report of depressive symptoms, own smoking, parent smoking, and demographic and household income variables.

RESULTS

Individuals reporting depressive symptoms have an increased risk of suicidal ideation (odds ratio [OR] = 13.13; 95% CI = 5.98-28.81). Relative to teens who do not smoke and whose parents do not smoke, teens who smoke and do not have a parent who smokes have increased risk of suicidal ideation (OR = 8.10; 95% CI = 2.88-22.80), whereas those with a parent who smokes do not have a statistically significant increased risk of suicidal ideation regardless of teen smoking behavior.

CONCLUSION

Relative to teens who do not smoke and do not have parents who smoke, suicidal ideation risk is increased in teens who smoke only if they do not have a parent who smokes. We find evidence that the smoking and suicidal ideation of the teens is likely due to common psychosocial causes rather than a causal pathway from smoking to suicidal ideation.

Intentions to quit smoking among youth in substance abuse treatment

INTRODUCTION

Smoking cessation interventions for adolescents in substance abuse treatment have shown promise. However, a better understanding of the correlates of substance use disordered (SUD) youths' intentions toward smoking cessation will help tailor cessation interventions to this population. The current study examined tobacco use, smoking-related self-efficacy, substance use and intentions to quit using alcohol and illicit drugs as correlates of intentions to quit smoking among youth in SUD treatment.

METHODS

Participants were 178 adolescents who were in inpatient (n=90) or outpatient (n=88) SUD treatment and had smoked at least once in the past 30 days. The sample was 44% female, 72% non-Hispanic Caucasian, with a mean age of 16.2 years (SD=1.2). Participants rated the likelihood that they would be nonsmokers in the next year (9-point scale).

RESULTS

SUD youth intention to quit smoking averaged 4.9 out of 10 (SD=3.2), comparable to intention to quit drinking (M=5.3, SD=3.6), but lower than their intention to quit using drugs (M=6.0, SD=3.4). Teens' intentions to quit smoking were associated with nicotine dependence (r=-.30, p<.01) and smoking cessation related self-efficacy (r=.36, p<.01), but not with pretreatment substance use severity (r=-.15). Controlling for nicotine dependence, teens' intentions to quit smoking were positively related to smoking cessation self-efficacy (pr=.26, p<.01) and intention to quit using illicit drugs (pr=.15, p<.05), but unrelated to intention to quit drinking.

DISCUSSION

Findings highlight the appropriateness of addressing adolescent tobacco use during SUD treatment, but emphasize the importance of assessing intention and other cognitions for each substance, as they may differ markedly.

Is the relationship between smoking and mental health influenced by other unhealthy lifestyle factors? Results from a 3-year follow-up study among adolescents in Oslo, Norway

PURPOSE

Several studies have confirmed that smoking is a risk factor for depression in adolescence. These studies have not controlled for other lifestyle factors. The aim of this longitudinal study was to assess the relationship between smoking and depressive symptoms, controlling for other lifestyle factors.

METHODS

This school-based longitudinal self-report survey was conducted among 15- and 18-year-old students in Oslo, Norway. From a baseline cohort of 3811 students, 2489 (65%) participants were followed up after 3 years and completed questionnaires at baseline and follow-up. Mental distress was assessed with Hopkins Symptom Checklist, version 10.

RESULTS

There was a statistically significant association between daily smoking at age 15 and mental distress at age 18 for girls, but not for boys (odds ratio [OR]=2.0 [1.5-2.8] and 1.3 [0.7-2.4], respectively). In girls, the association remained statistically significant even after adjustment for sociodemographic variables and several lifestyle factors. In an analysis of 15-years-old "never smokers," a statistically significant association was found between smoking and mental distress for both genders at age 18. Mentally distressed adolescents at age 15 did not show a higher proportion of smoking at age 18 compared with those not distressed.

CONCLUSIONS

In addition to supporting earlier findings that smoking seems to be causally related to depressive symptoms among adolescent girls, the contribution of this study is that this association only to some extent is confounded by other unhealthy lifestyle habits.

Contribution of hypothalamic-pituitary-adrenal activity and environmental stress to vulnerability for smoking in adolescents

Although tobacco smoking, which has been linked to depression, is a major public health problem, little is known about the neurobiological factors that confer vulnerability to smoking in youngsters and the effects of adolescent smoking on the course of depression. This study examined whether hypothalamic-pituitary-adrenal (HPA) activity and stressful life experiences are related to smoking behavior in depressed and non-depressed adolescents, and whether smoking predicts a worsening course of depression. Smoking history and stressful experiences were assessed in 151 adolescents (48 with no personal or family history of psychiatric disorder, 48 with no psychiatric history, but at high risk for depression by virtue of parental depression, and 55 with current major depressive disorder). Evening salivary cortisol and nocturnal urinary-free cortisol were measured for three consecutive evenings. The participants were then followed at regular intervals for up to 5 years to assess smoking history, clinical course of depression and stressful experiences during the follow-up period. Increased evening/night-time cortisol levels were associated with both initiation and persistence of smoking during follow-up. Stressful life experiences further increased the risk for smoking in depressed as well as non-depressed youth. Smoking was also associated with a higher frequency of depressive episodes during follow-up. A model that included stressful experiences and cortisol levels reduced the contribution of smoking per se to depression. High evening/night-time cortisol level appears to be a vulnerability marker for smoking in adolescents, with stressful experiences further increasing the risk for smoking in vulnerable youth. High evening/night-time cortisol levels and stressful experiences accounted, at least partially, for the association between depressive illness and smoking behavior.

Smoking abstinence and reinstatement effects in adolescent cigarette smokers

INTRODUCTION

The study objectives were to examine smoking abstinence and reinstatement effects on subjective experience and cognitive performance among adolescent smokers.

METHODS

Adolescents (aged 14-17 years, 60 daily smokers and 32 nonsmokers) participated. Participants completed baseline assessments (Session 1) and returned to the laboratory 1-3 days later to repeat assessments (Session 2); half of the smokers were randomly assigned to 15-17 hr tobacco abstinence preceding Session 2.

RESULTS

During Session 2, abstaining smokers reported significantly greater increases in withdrawal symptoms, smoking urges, and negative affect compared with smokers who did not abstain and compared with nonsmokers. Smoking reinstatement reversed abstinence effects, returning to baseline levels for smoking urges and negative affect. Abstaining smokers showed significantly enhanced cognitive performance on two of six tasks (two-letter search compared with nonabstaining smokers; serial reaction time compared with nonsmokers); smoking reinstatement resulted in significant decrements on these two tasks relative to nonabstaining smokers.

DISCUSSION

Effects of smoking abstinence and reinstatement on self-report measures are consistent with earlier research with adolescent as well as adult smokers and may help to elucidate the motivational underpinnings of smoking maintenance among adolescent smokers. Effects found on cognitive performance were contrary to hypotheses; further research is needed to understand better the role of cognitive performance effects in smoking maintenance among adolescents.

Adolescent smoking and depression: evidence for self-medication and peer smoking mediation

AIMS

The nature of the relationship between adolescent smoking and depression is unclear and the mechanisms that account for the comorbidity have received little investigation. The present study sought to clarify the temporal precedence for smoking and depression and to determine whether these variables are linked indirectly through peer smoking.

PARTICIPANTS

The sample was composed of 1093 adolescents participating in a longitudinal study of the behavioral predictors of smoking adoption.

DESIGN AND MEASUREMENTS

In this prospective cohort study, smoking, depression, peer smoking and other covariates were measured annually from mid-adolescence (9th grade; age 14) to late adolescence (12th grade, age 18).

FINDINGS

Parallel processes latent growth curve models supported a bidirectional relationship between adolescent smoking and depression, where higher depression symptoms in mid-adolescence (age 14) predicted adolescent smoking progression from mid- to late adolescence (ages 14-18). A significant indirect effect indicated that higher depression symptoms across time predicted an increase in the number of smoking peers, which in turn predicted smoking progression from mid-adolescence to late adolescence. In addition, smoking progression predicted a deceleration of depression symptoms from mid- to late adolescence. A significant indirect effect indicated that greater smoking at baseline predicted a deceleration in the number of smoking peers across time, which predicted a deceleration in depression symptoms from mid-adolescence to late adolescence.

CONCLUSIONS

The current study provides the first evidence of bidirectional self-medication processes in the relationship between adolescent smoking and depression and highlights peer smoking as one explanation for the comorbidity.

Educational attainment and smoking among women: risk factors and consequences for offspring

We examine the association between education and smoking by women in the population, including smoking during pregnancy, and identify risk factors for smoking and the consequences of smoking in pregnancy for children's smoking and behavioral problems. Secondary analyses of four national data sets were implemented: The National Survey of Drug Use and Health (2006), the National Longitudinal Survey of Youth (1979-2004); the National Longitudinal Survey of Adolescent Health (Wave III); National Health and Nutrition Examination Survey (2005-2006). The lower the level of education, the greater the risk of being a current smoker, smoking daily, smoking heavily, being nicotine dependent, starting to smoke at an early age, having higher levels of circulating cotinine per cigarettes smoked, and continuing to smoke in pregnancy. The educational gradient is especially strong in pregnancy. Educational level and smoking in pregnancy independently increase the risk of offspring smoking and antisocial and anxious/depressed behavior problems. These effects persist with control for other covariates, except maternal age at child's birth, which accounts for the impact of education on offspring smoking and anxious/depressed behavior problems. Women with low education should be the target of public health efforts toward reducing tobacco use. These efforts need to focus as much on social conditions that affect women's lives as on individual level interventions. These interventions would have beneficial effects not only for the women themselves but also for their offspring.

A systematic review of longitudinal studies on the association between depression and smoking in adolescents

Background

It is well-established that smoking and depression are associated in adolescents, but the temporal ordering of the association is subject to debate.

Methods

Longitudinal studies in English language which reported the onset of smoking on depression in non clinical populations (age 13-19) published between January 1990 and July 2008 were selected from PubMed, OVID, and PsychInfo databases. Study characteristics were extracted. Meta-analytic pooling procedures with random effects were used.

Results

Fifteen studies were retained for analysis. The pooled estimate for smoking predicting depression in 6 studies was 1.73 (95% CI: 1.32, 2.40; p < 0.001). The pooled estimate for depression predicting smoking in 12 studies was 1.41 (95% CI: 1.21, 1.63; p < 0.001). Studies that used clinical measures of depression were more likely to report a bidirectional effect, with a stronger effect of depression predicting smoking.

Conclusion

Evidence from longitudinal studies suggests that the association between smoking and depression is bidirectional. To better estimate these effects, future research should consider the potential utility of: (a) shorter intervals between surveys with longer follow-up time, (b) more accurate measurement of depression, and (c) adequate control of confounding.

Smoking cessation for adolescents: a review of pharmacological and psychosocial treatments

Unlike the vast literature on smoking cessation in adults, research in adolescents has gained significant attention only within the last decade. Even with this increase in focus, research into pharmacological aids for smoking cessation in adolescents (e.g., nicotine replacement therapy, bupropion) is a more recent phenomenon and has produced only modest results. While more extensive, much of the research on behaviorally- or psychosocially-based adolescent smoking cessation interventions has been limited by a lack of control for contact time, biochemical verification of self-reported abstinence, and/or a theoretical focus for the interventions. The MEDLINE, PubMed, PSYCInfo, EMBASE, ERIC, CINHAL, Cochrane CENTRAL and Systematic Review databases were searched for articles relevant to adolescent smoking cessation treatment. After briefly examining the adolescent smoking cessation research prior to 2000, more recent developments in pharmacological aids and psychological treatment will be reviewed. Investigations have made progress in elucidating efficacious treatments for adolescent smokers, but much work remains to be done in both pharmacological and non-pharmacological areas of treatment. With the current state of the literature as a guide, future directions for research into smoking cessation for adolescents will be proposed.

Smoking and mental illness: results from population surveys in Australia and the United States

BACKGROUND

Smoking has been associated with a range of mental disorders including schizophrenia, anxiety disorders and depression. People with mental illness have high rates of morbidity and mortality from smoking related illnesses such as cardiovascular disease, respiratory diseases and cancer. As many people who meet diagnostic criteria for mental disorders do not seek treatment for these conditions, we sought to investigate the relationship between mental illness and smoking in recent population-wide surveys.

METHODS

Survey data from the US National Comorbidity Survey-Replication conducted in 2001-2003, the 2007 Australian Survey of Mental Health and Wellbeing, and the 2007 US National Health Interview Survey were used to investigate the relationship between current smoking, ICD-10 mental disorders and non-specific psychological distress. Population weighted estimates of smoking rates by disorder, and mental disorder rates by smoking status were calculated.

RESULTS

In both the US and Australia, adults who met ICD-10 criteria for mental disorders in the 12 months prior to the survey smoked at almost twice the rate of adults without mental disorders. While approximately 20% of the adult population had 12-month mental disorders, among adult smokers approximately one-third had a 12-month mental disorder--31.7% in the US (95% CI: 29.5%-33.8%) and 32.4% in Australia (95% CI: 29.5%-35.3%). Female smokers had higher rates of mental disorders than male smokers, and younger smokers had considerably higher rates than older smokers. The majority of mentally ill smokers were not in contact with mental health services, but their rate of smoking was not different from that of mentally ill smokers who had accessed services for their mental health problem. Smokers with high levels of psychological distress smoked a higher average number of cigarettes per day.

CONCLUSION

Mental illness is associated with both higher rates of smoking and higher levels of smoking among smokers. Further, a significant proportion of smokers have mental illness. Strategies that address smoking in mental illness, and mental illness among smokers would seem to be important directions for tobacco control. As the majority of smokers with mental illness are not in contact with mental health services for their condition, strategies to address mental illness should be included as part of population health-based mental health and tobacco control efforts.

Smoking and mental illness: results from population surveys in Australia and the United States

BACKGROUND

Smoking has been associated with a range of mental disorders including schizophrenia, anxiety disorders and depression. People with mental illness have high rates of morbidity and mortality from smoking related illnesses such as cardiovascular disease, respiratory diseases and cancer. As many people who meet diagnostic criteria for mental disorders do not seek treatment for these conditions, we sought to investigate the relationship between mental illness and smoking in recent population-wide surveys.

METHODS

Survey data from the US National Comorbidity Survey-Replication conducted in 2001-2003, the 2007 Australian Survey of Mental Health and Wellbeing, and the 2007 US National Health Interview Survey were used to investigate the relationship between current smoking, ICD-10 mental disorders and non-specific psychological distress. Population weighted estimates of smoking rates by disorder, and mental disorder rates by smoking status were calculated.

RESULTS

In both the US and Australia, adults who met ICD-10 criteria for mental disorders in the 12 months prior to the survey smoked at almost twice the rate of adults without mental disorders. While approximately 20% of the adult population had 12-month mental disorders, among adult smokers approximately one-third had a 12-month mental disorder--31.7% in the US (95% CI: 29.5%-33.8%) and 32.4% in Australia (95% CI: 29.5%-35.3%). Female smokers had higher rates of mental disorders than male smokers, and younger smokers had considerably higher rates than older smokers. The majority of mentally ill smokers were not in contact with mental health services, but their rate of smoking was not different from that of mentally ill smokers who had accessed services for their mental health problem. Smokers with high levels of psychological distress smoked a higher average number of cigarettes per day.

CONCLUSION

Mental illness is associated with both higher rates of smoking and higher levels of smoking among smokers. Further, a significant proportion of smokers have mental illness. Strategies that address smoking in mental illness, and mental illness among smokers would seem to be important directions for tobacco control. As the majority of smokers with mental illness are not in contact with mental health services for their condition, strategies to address mental illness should be included as part of population health-based mental health and tobacco control efforts.

Adult versus adolescent onset of smoking: how are mood disorders and other risk factors involved?

AIMS

To examine the strength of association between smoking and mood disorders and the association between smoking and its traditional risk factors, comparing those who started smoking in adolescence with those who started smoking in early adulthood.

DESIGN AND PARTICIPANTS

The analyses relied on prospective data from the Zurich Study. This longitudinal community study started in 1979 with a stratified sample of 591 participants aged 20/21 years, weighted towards those with mental disorders. Follow-up interviews were conducted at ages 23, 28, 30, 35 and 41.

MEASUREMENTS

In this analysis the adult versus adolescent onset of smoking was regressed on the cumulative prevalence of mood disorders, personality characteristics measured by the Freiburg Personality Inventory, common risk factors such as parental smoking, conduct and school problems, troubles with the family and basic socio-demographic variables (sex, education).

FINDINGS

In the Zurich Study cohort we found that 61.6% were former or current smokers, of whom 87% started smoking before the age of 20 and 13% after the age of 20. Adolescent onset of smoking was associated strongly with later major depression, dysthymia or bipolar disorders and, furthermore, with parental smoking, extroverted personality and discipline problems and rebelliousness in youth. However, only depression and dysthymia were associated with adult onset smoking and other risk factors associated with smoking were not so associated in this group.

CONCLUSIONS

Correlates of smoking onset in adolescence are mainly not applicable to the onset of smoking in young adulthood. Smoking onset beyond adolescence is an open research issue.

Mechanisms underlying the comorbidity of tobacco use in mental health and addictive disorders

We discuss potential explanations for the high prevalence of tobacco use and tobacco dependence (TD) in people with mental health and addictive (MHA) disorders. The biopsychosocial basis for this comorbidity is presented, integrating evidence from epidemiologic and clinical studies. We also review evidence that suggests a shared vulnerability related to biological, genetic, and environmental factors may be the most parsimonious mechanism to explain the association between TD and MHA disorders. Finally, we review the examples of various MHA disorders that are associated with TD, and suggest avenues for new investigation that could aid in the development of rationale and more effective treatments for tobacco and MHA disorder comorbidities.

Are adolescents being screened for emotional distress in primary care?

PURPOSE

To assess primary care providers' rates of screening for emotional distress among adolescent patients.

METHODS

Secondary data analysis utilizing data from: (1) well visits in pediatric clinics within a managed care plan in California, and (2) the 2003 California Health Interview Survey (CHIS), a state population sample. The Pediatric clinic sample included 1089 adolescent patients, ages 13 to 17, who completed a survey about provider screening immediately upon exiting a well visit. The CHIS sample included 899 adolescents, ages 13 to 17, who had a routine physical exam within the past 3 months. As part of the survey, adolescents answered a question about whether they had talked with their provider about their emotions at the time of the exam. Logistic regressions, controlling for age, gender, race/ethnicity, and adolescent depressive symptoms were performed.

RESULTS

About one-third of adolescents reported a discussion of emotional health. Females were significantly more likely to be screened than males (36% vs. 30% in clinic; 37% vs. 26% in CHIS); as were older and Latino adolescents in the clinic sample. Although 27% of teens endorsed emotional distress, distress was not a significant predictor of talking to a provider about emotions.

CONCLUSIONS

Primary care clinicians/systems need to better utilize the primary care visit to screen adolescents for emotional health.

Personality, psychiatric disorders, and smoking in middle-aged adults

INTRODUCTION

A number of personality traits have been associated with cigarette smoking. Current smokers generally show higher levels of negative emotionality and lower levels of behavioral constraint than former smokers and those who never smoked. However, prior investigations have not examined thoroughly whether these smoking-personality associations are unique to smoking status or simply reflect the fact that these personality traits tend to be elevated across numerous forms of psychopathology. Likewise, prior studies have not addressed whether personality shows differential associations with smoking based on the presence or absence of lifetime psychiatric disorders.

METHODS

The present study examined these questions using data from 472 current, 311 former, and 324 never-smokers aged 34-44 years.

RESULTS

Current smokers reported being more reactive to stress, more aggressive, more alienated, and less harm avoidant than both former smokers and never-smokers, whereas former smokers and never-smokers showed similar personality profiles overall. Psychiatric disorder history did not interact with smoking status in predicting personality. Controlling for differences in four major lifetime psychiatric disorders (major depression, alcohol dependence, drug dependence, and conduct disorder) reduced the differences in personality traits associated with smoking status. However, smoking status continued to relate uniquely and significantly to higher levels of negative emotionality and behavioral under control with the most robust effect observed for trait alienation.

DISCUSSION

These results provide the most comprehensive depiction to date of interrelations among personality, psychopathology, and smoking and suggest an important role of personality in smoking that is not redundant with or conditional upon lifetime psychopathology.

Unsuspected or unacknowledged depressive symptoms in young adult emergency department patients

OBJECTIVES

The objective was to determine the frequency of unsuspected or unacknowledged depressive symptoms among young adult emergency department (ED) patients.

METHODS

The Beck Depression Inventory-II (BDI-II) and a demographic/lifestyle questionnaire were administered to a cross-section of medically stable, English-speaking young adult ED patients (aged 18-23 years) with nonpsychiatric chief complaints. The frequency of moderate to severe depressive symptoms was determined. Group results were analyzed with descriptive statistics; multivariate analysis assessed for patient characteristics associated with depressive symptoms.

RESULTS

A total of 2,898 patients were screened; 2,255 were eligible for enrollment, and 1,264 enrolled (56%; 64% female, 42% African American; mean age = 21 [+/-1.7] years). Twenty-nine percent had BDI-II scores consistent with moderate to severe depressive symptoms. Patient characteristics associated with depressive symptoms included knowledge of someone who had intentionally hurt him- or herself (odds ratio [OR] = 2) or died a violent nonaccidental death (OR = 1.4), low personal income (OR = 1.8), chronic health issues (OR = 1.7), cigarette smoking (OR = 1.6), and African American race (OR = 1.5). Those who attended school (OR = 0.5), engaged in frequent social activities (OR = 0.5), or drove a car (OR = 0.7) were less likely to have depressive symptoms. Patients lacked insight into their depressive symptoms.

CONCLUSIONS

There is a high prevalence of depressive symptoms in young adult ED patients. Young adults often do not recognize, or are reluctant to acknowledge, depressive symptoms. Specific patient characteristics may be useful in deciding which young adults should undergo ED screening for depression.

Cigarette smoking, stages of change, and major depression in the Canadian population

OBJECTIVE

To describe the 12-month prevalence of major depression in relation to smoking status, nicotine dependence levels, commitment to quit, attempts to quit, and maintenance of smoking cessation in the Canadian general population.

METHOD

Data from Public Use Microdata File of the Canadian Community Health Survey: Health and Well-Being were used. The Composite International Diagnostic Interview--Short Form (CIDI-SF) for major depression was used to assess depressive disorder status. The survey also included a smoking module. There were 49,249 respondents assessed by the CIDI-SF, of whom 10,236 were administered the smoking module. Analyses used appropriate measures to deal with survey design effects.

RESULT

The prevalence of major depression was highest in current smokers, followed by ever smokers, former smokers, and was lowest in the never smokers. This pattern persisted after stratification for age and sex. For quitting, the prevalence of major depression was highest among people who tried to quit, followed by those who considered quitting, those who quit in the past year, and lowest among those who maintained their smoking cessation status for longer than 1 year. The prevalence of depression among those with a high nicotine dependence level, as assessed by the Fagerstrom Tolerance Questionnaire, was about twice that of people with a low nicotine dependence level.

CONCLUSION

The strikingly high prevalence of major depression among current smokers who are young, trying to quit, and with high nicotine dependence levels in the general population indicates that further longitudinal exploration of this topic is urgently needed.