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

Predictors of illicit substance dependence among individuals with alcohol dependence

OBJECTIVE

Individuals with alcohol dependence (AD) are at increased risk for developing dependence on illicit and prescription drugs. The goal of this cross-sectional study was to identify factors associated with drug dependence among individuals with AD.

METHOD

The sample consisted of 855 adults from the Irish Affected Sib Pair Study of Alcohol Dependence who were treated in inpatient or outpatient alcohol treatment programs and met Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria for lifetime AD. We studied predictors of dependence on six classes of drugs: cannabis, sedatives, stimulants, cocaine, opioids, and hallucinogens. Potential predictors examined included gender, age, education, and socioeconomic status; the personality traits of extraversion, neuroticism, and novelty seeking; conduct disorder, major depressive disorder, nicotine dependence, age at onset of alcohol use, early illicit drug use, and parental AD.

RESULTS

Nicotine dependence, depression that began before substance use, and drug use before age 19 each increased the risk for dependence on several substance classes. Male gender, younger age, maternal AD, fewer years of education, higher neuroticism scores, conduct disorder, and early alcohol use each increased the risk of dependence on one or more substance classes.

CONCLUSIONS

Among individuals in treatment for AD, cigarette smoking, early onset of major depression, and early drug use were associated with increased risk for drug dependence. These results suggest individuals with these risk factors may benefit from more intensive screening to prevent the onset of or to identify and treat drug dependence.

Treatment of smokers with co-occurring disorders: emphasis on integration in mental health and addiction treatment settings

This article reviews the research on the treatment of cigarette smoking in individuals who have comorbid mental illnesses or non-nicotinic addictions. The prevalence of smoking in mentally ill and substance-abusing populations is presented, as well as reasons for this high prevalence. The historical role of cigarettes and tobacco in mental illness and addiction is reviewed to help the reader better understand the pervasiveness of smoking in these disorders and the relative absence of intervention efforts in mental heath and addiction treatment settings. The article then discusses the several reasons for integrating smoking treatment into mental health and addiction settings. The outcome research for adult and adolescent comorbid smokers is reviewed, and barriers to treatment are discussed. The review closes with a brief discussion of models of integration and thoughts about prevention.

Therapy for specific problems: youth tobacco cessation

Cigarette smoking is the leading cause of premature morbidity and mortality in the United States. The majority of children smoke their first cigarette in early adolescence, and many older teens have well-established dependence on nicotine. Efforts to promote and support smoking cessation among these youth smokers are critical. The available experimental studies of youth cessation interventions find that behavioral interventions increase the chances of youth smokers achieving successful cessation. Currently there is insufficient evidence for the effectiveness of pharmacological treatments with youth smokers. Many innovative studies have been compromised by challenges in recruiting sufficient numbers of youth, obtaining approval for waivers of parental consent, and high attrition in longitudinal studies. Key areas for future work include bridging the fields of adolescent development and treatment design, matching treatments to developmental trajectories of smoking behavior, better understanding treatment processes and treatment moderators, and building demand for evidence-based cessation treatments.

Implications of participant self-selection for generalizability: who participates in smoking laboratory research?

The generalizability of data from laboratory smoking studies using volunteer samples is debatable. We tracked potential participants from first contact with research staff through screening to study completion. We found that a minority of individuals were ultimately enrolled in the study. Failure to enroll was as often a function of participant lack of attendance at the laboratory as a function of ineligibility. With some exceptions, groups of potential participants were similar regarding demographic characteristics and substance use history. These findings support the generalizability of the sample and highlight the importance of documenting details of study eligibility and participation. The study's limitations are noted.

Collaborative care for adolescent depression: a pilot study

OBJECTIVE

The main objectives of this study were to explore the preliminary outcomes and assess the feasibility and acceptability of a collaborative care intervention designed to improve treatment and outcomes of depression among youth seen in primary care settings.

METHODS

We conducted a pilot intervention study at three clinics in a university affiliated primary care clinic network. The intervention model was designed to support the provision of depression treatment by primary care providers using methods adapted from the IMPACT study developed for the improvement of depression among older adults. Specific components include the provision of regular case management by a nurse depression care manager (DCM), enhanced patient and parent education about depression and its treatment, encouragement of patient self-management with a choice of starting medications or therapy or both, and oversight of the DCM by a mental health specialist. Study participants were assessed regularly by the DCM for 6 months and completed written self-report assessments at baseline, 3, and 6 months after starting the intervention.

RESULTS

40 youth (12-18 years) with major and minor depression enrolled in the intervention. Study participants were predominantly female (90%). The baseline Patient Health Questionnaire (PHQ-9) score was 14.2 (SD=4.5). Patients were similarly divided among initiating medications (n=12), therapy (n=15), or combination therapy (n=8). Five patients withdrew prior to initiating treatment. The mean number of in person and telephone contacts with the DCM was 9 (range=5 to 17). Eighty-seven percent of youth completed the 6-month intervention. At 6 month follow-up, 74% of youth had a 50% or more reduction in depressive symptoms as measured by the PHQ-9. Parents, youth and physicians indicated high levels of satisfaction with the intervention on written surveys and in qualitative exit interviews.

CONCLUSION

The collaborative care model is feasible and highly acceptable to adolescents and parents as demonstrated both by self-report and by engagement in the intervention. It is also associated with improved depressive outcomes at similar levels to adult interventions. Future studies should evaluate these models in a randomized controlled trial.

Long-lasting cognitive deficits resulting from adolescent nicotine exposure in rats

Adolescence is a developmental period, during which the brain and particularly medial prefrontal cortical (mPFC) regions thereof have not fully matured. Because epidemiological data have suggested that adolescent nicotine use may result in disturbances in cognitive function in adulthood, we investigated the long-term effects of adolescent nicotine exposure in rats. Male Wistar rats were exposed to either nicotine (three times daily, 0.4 mg/kg s.c.) or saline for 10 days during (postnatal day (PND) 34-43) or following (PND 60-69) adolescence. After 5 weeks during adulthood, separate groups of animals were tested in operant paradigms taxing attention and distinct measures of impulsivity. Visuospatial attention and impulsive action were tested in the five-choice serial reaction time task, whereas impulsive choice was assessed in the delayed reward task. Our data show that adolescent, but not postadolescent, nicotine exposure affects cognitive performance in adulthood and results in diminished attentional performance and increments in impulsive action, while leaving impulsive choice intact. This altered cognitive performance appeared to be associated with enhanced releasability of dopamine in the mPFC. Together, these data suggest that adolescence is a time window during which the brain is vulnerable to long-lasting cognitive disturbances resulting from nicotine exposure.

Health risk behaviors in relation to making a smoking quit attempt among adolescents

The primary aim of this study was to examine youth risk behaviors in relation to: (a) making a smoking quit attempt, and (b) successful cessation among adolescent smokers. Data were analyzed from the public use dataset of the 2003 national school-based Youth Risk Behavior Survey. The sample consisted of 2,033 students (weighted mean age of 16.3 years, 49.8% female, 73.6% White) who reported a history of daily smoking. While almost two-thirds (63.5%) of adolescent smokers reported making a quit attempt in the last year, only 10% of those were able to successfully quit. Factors associated with making a quit attempt included depression and participating in sports while high-risk sexual activity and engaging in substance use other than alcohol or marijuana were negatively related to making a quit attempt. Externalizing health behaviors (e.g., fighting, drug use, and high risk sexual activity) were associated with decreased likelihood of cessation. Findings from this study may inform efforts to develop more effective smoking prevention and treatment programs for youth.

Comorbidity of psychiatric disorders and nicotine dependence among adolescents: findings from a prospective, longitudinal study

OBJECTIVE

To examine prospectively the comorbidity of DSM-IV psychiatric disorders and nicotine dependence in adolescence.

METHOD

A multiethnic sample (N = 1,039) of adolescents from grades 6 to 10 in the Chicago public schools (mean age 14.1 years) was interviewed at home five times, and mothers were interviewed three times over a 2-year period (2003-2005). Completion rates at each wave were 96% of the initial sample. Selected DSM-IV psychiatric disorders were ascertained from youths and mothers about youths at two annual waves with the NIMH Diagnostic Interview Schedule for Children, Version IV-Y and IV-P; DSM-IV symptoms of nicotine dependence were ascertained from youths at every wave using a measure developed for adolescents.

RESULTS

Psychiatric disorders most often preceded the onset of the first criterion of nicotine dependence. Prospective associations between psychiatric disorders and nicotine dependence were examined through logistic regressions. After controlling for comorbid disorders, it was found that lifetime disruptive disorder significantly predicted the onset of a nicotine dependence criterion (adjusted odds ratio 2.1). Early onset of any psychiatric disorder increased this risk. Other predictors included novelty seeking and extensiveness of smoking. By contrast, nicotine dependence did not predict the onset of a psychiatric disorder; significant predictors included the youths' prior other psychiatric disorders, novelty seeking, and parental depression and antisocial behavior.

CONCLUSIONS

Nicotine dependence does not seem to contribute to the onset of psychiatric disorders, whereas disruptive disorder is an important etiologic factor for nicotine dependence in adolescence.

Temperament, substance use and psychopathology in a prisoner population: implications for treatment

OBJECTIVE

The association between temperament and drug use or temperament and psychopathology has previously been restricted to community clinical or non-clinical samples. The aim of the present study was therefore to examine these associations in a large cohort of Australian offenders using Cloninger's Temperament and Character Inventory (TCI).

METHODS

A total of 1322 prisoners from New South Wales (NSW) who completed all dimensions of the TCI and were screened for mental illness using the Australian National Survey of Mental Health and Wellbeing were included in the study.

RESULTS

A total of 15% of the sample fulfilled the criteria for a diagnosis for depression, 36% for anxiety disorders and 54% for a substance abuse disorder. Using logistic regression analysis, the TCI dimensions of harm-avoidance and low self-direction predicted depression. Being female, a poly-substance user and having high harm-avoidance, persistence, self-direction and self-transcendence predicted anxiety disorders. Significant stepped trends across age, gender, and type of drug use were found for all TCI dimensions.

CONCLUSIONS

The TCI is useful in identifying prisoners with a history of psychopathology and substance misuse. This tool also provides clinically relevant information about at-risk individuals and has the potential to guide the development of intervention programmes for inmates.

Tobacco smoking as a risk factor for major depressive disorder: population-based study

BACKGROUND

Smoking is disproportionately prevalent among people with psychiatric illness.

AIMS

To investigate smoking as a risk factor for major depressive disorder.

METHOD

A population-based sample of women was studied using case-control and retrospective cohort study designs. Exposure to smoking was self-reported, and major depressive disorder diagnosed using the Structured Clinical Interview for DSM-IV-TR (SCID-I/NP).

RESULTS

Among 165 people with major depressive disorder and 806 controls, smoking was associated with increased odds for major depressive disorder (age-adjusted odds ratio (OR)=1.46, 95% CI 1.03-2.07). Compared with non-smokers, odds for major depressive disorder more than doubled for heavy smokers (>20 cigarettes/day). Among 671 women with no history of major depressive disorder at baseline, 13 of 87 smokers and 38 of 584 non-smokers developed de novo major depressive disorder during a decade of follow-up. Smoking increased major depressive disorder risk by 93% (hazard ratio (HR)=1.93, 95% CI 1.02-3.69); this was not explained by physical activity or alcohol consumption.

CONCLUSIONS

Evidence from cross-sectional and longitudinal data suggests that smoking increases the risk of major depressive disorder in women.

Significance of cigarette smoking among youths with bipolar disorder

Cigarette smoking among adults with bipolar disorder (BP) correlates with psychosis, substance use disorders (SUD), and suicidality. Little is known regarding smoking among youths with BP. Youths with BP (n = 441) were divided into three smoking groups: Never, Ever, and Daily. Twenty-five percent reported any smoking (11% daily, 14% ever). Ever and Daily subjects had significantly greater lifetime prevalence of suicide attempts, physical abuse, conduct disorder, and SUD compared to Never subjects. Daily heavy smokers had greater prevalence of SUD and suicide attempts, and worse depression versus daily light smokers. Smoking among youths with BP is independently associated with suicide attempts and SUD.

Examining anger as a predictor of drug use among multiethnic middle school students

BACKGROUND

Anger, a component of negative affect, has previously been associated with increased drug use primarily among white high school-aged students. However, few studies have examined these associations over time, and fewer have examined them among younger adolescents and students of color. Affective factors may play a greater role in drug use for girls relative to boys; yet, little is known regarding differences in associations between affect and drug use by gender.

METHODS

The current study used data from the control condition (N = 2025) of a drug and violence preventive intervention trial to examine the association between self-reported anger levels among multiethnic urban adolescents in the sixth grade and their use of cigarettes, alcohol, and marijuana use 1 year later. Potential gender differences were examined as well.

RESULTS

Multivariate generalized estimating equations models found anger to be significantly associated with increases in smoking, drinking, and marijuana use. There were no significant gender differences found for any of the drug use outcomes.

CONCLUSIONS

Results are consistent with studies conducted on primarily white high school youth, where anger had a small but significant effect on drug use over time. The findings also suggest that drug prevention programs should include emotion regulation skills, such as anger management, in addition to drug resistance skills.

Exercise in the Prevention and Treatment of Adolescent Depression: A Promising but Little Researched Intervention

Despite a dramatic increase in the number of treatment studies for adolescent major depressive disorder in the past 15 years, the majority being clinical trials of medications and cognitive behavioral therapy, response rates have been modest and remission rates low. Moreover, most positive responders posttreatment have many residual symptoms, significant functional impairment, and high rates of relapse. There is a need for the development of new, more effective interventions to treat this severe, chronic condition that usually persists into adulthood with poor long-term outcomes. Findings from preliminary treatment studies suggest that exercise may have the potential to be efficacious as a monotherapy or as part of a combined treatment for adolescent major depressive disorder. This review summarizes the findings and analyzes the design flaws of randomized trials of exercise to treat adolescent depression, offering recommendations on how to design more methodologically sound studies with an emphasis on subject selection criteria; issues related to control conditions, types of diagnostic interviews, and measures needed to establish the diagnosis of depression; types of exercise treatments; and appropriate outcome measures. Future studies of exercise to treat and prevent adolescent major depressive disorder need to be comparable to state-of-the-art treatment studies of pharmacotherapy and cognitive behavioral therapy in this population to more accurately determine its efficacy and potential public health benefits.

The relationship between depressive symptom levels and subsequent increases in substance use among youth with severe emotional disturbance

OBJECTIVE

This study examined the relationship between levels of depressive symptoms and subsequent increases in substance use among 784 youth with severe emotional disturbance enrolled in Medicaid-funded behavioral health care plans.

METHOD

Youth at five sites nationwide were interviewed about their emotional and behavior problems, as well as their use of cigarettes, alcohol, and drugs--at both baseline and follow-up.

RESULTS

(1) Levels of depressive symptoms were significantly associated with concurrent substance use at baseline. (2) Baseline levels of depressive symptoms predicted subsequent changes in substance use, especially use of illicit drugs and multiple drugs. (3) These findings remained significant, even after controlling for sociodemographic, family, and individual characteristics.

CONCLUSIONS

These results indicate that depressive symptoms early in life may signal a risk for increasing involvement in substance use among severe emotional disturbed youth. This finding has important clinical implications for the prevention of substance misuse in this population.

Child abuse and smoking among young women: the importance of severity, accumulation, and timing

PURPOSE

We examined the association between severity, accumulation, and timing of abuse in childhood and adolescence and smoking status among young women.

METHODS

Retrospective self-reported childhood abuse was ascertained with the modified Conflict Tactics Scale from 91,286 Nurses Health Study II participants in 2001 (68,505 returned; 75.0% response rate). Childhood abuse was categorized by severity (mile/moderate/severe), type (physical/sexual), and timing (childhood/adolescence). Smoking status during adolescence was reported at baseline (1989). Logistic regression was used to predict smoking initiation by age 14 and smoking status between the ages of 15 and 19.

RESULTS

A graded association between severity of abuse and early initiation of smoking (by age 14 years) was demonstrated (odds ratio [OR] = 1.9, 95% confidence interval [CI] = 1.7-2.1 for severe physical violence). Young women with both physical and sexual abuse were two times more likely to start smoking by age 14 than were those reporting no abuse (OR = 2.0, 95% CI = 1.8-2.3). Although abuse during childhood increased risk for adolescent smoking (OR = 1.7, 95% CI = 1.8-2.1) for those with childhood physical and sexual abuse, inclusion of adolescent physical and sexual abuse (OR = 2.2, 95% CI 2.1-2.4) diminished the impact of childhood abuse (OR = 1.1, 95% CI 1.1-1.2). The degree of familial emotional support was protective against smoking, and reduced the impact of abuse by 40% among those with high emotional support versus those without (p < .0001).

CONCLUSIONS

A strong and graded association was observed between both severity and accumulation of abuse and the risk of early initiation of smoking among girls. Smoking status during late adolescence was more strongly associated with adolescent abuse than childhood abuse. Early smoking onset is associated with both heightened risk for disease in adolescence but also increased morbidity and mortality in adulthood. Identifying and intervening in potentially modifiable risk factors for smoking onset in young women, such as early-life physical and sexual abuse, and building familial strengths, such as emotional support, may have significant public health implications.

A framework for the economic analysis of child and adolescent mental disorders

Measuring the burden of disease associated with child and adolescent mental disorders is a challenge. The lack of data on cost and intervention effectiveness has impeded the ability to gain support for expenditures for treatment, training and programme development. A better understanding of economic analysis by researchers, clinicians, and advocates can promote initiatives to gain needed economic data to inform policy and programme development. Based on a critical review of the literature and the development of an economic hypothesis, this paper proposes a specific approach to the economic analysis of the burden of child and adolescent mental disorders utilizing accessible outcome data.

The moderating role of health fear on the relation between smoking status and panic symptoms among adolescents

The present study examined the moderating role of health fear on the concurrent relation between smoking status and panic attack symptoms among 249 adolescents (132 females, M(age)=14.86 years). As hypothesized, youth high in health fear reported elevations in panic attack symptoms, whereas this relation was relatively weak among those low in health fear. Importantly, these associations were significant after controlling for age, gender, negative affectivity, and anxiety sensitivity. Also as expected, health fear did not moderate the association between smoking status and depressive symptoms, supporting model specificity. Results are discussed in terms of implications for the panic-smoking association among youth.

Active and passive smoking and depression among Japanese workers

OBJECTIVE

To assess the relation of passive and active smoking to depressive symptoms in 1839 men and 931 women working in a suburb of Tokyo in 2002.

METHOD

Self-reported smoking history and exposure to passive smoking (no, occasional, or regular) at work and at home. Depressive symptoms according to the Center for Epidemiologic Studies Depression Scale, with a cut-off point of 16.

RESULTS

Compared to never smokers unexposed to passive smoking, never smokers reporting regular and occasional exposure to passive smoking at work had increased depressive symptoms. The adjusted odds ratios (aORs) were 1.92 (95% confidence interval (CI) 1.14, 3.23) for regular exposure and 1.63 (95% CI 1.08, 2.47) for occasional exposure. Current smokers had significantly increased depressive symptoms (aOR ranging from 2.25 to 2.38) but former smokers had only marginal increases of depressive symptoms (aOR ranging from 1.43 to 1.55). Gender did not modify the effects of active/passive smoking on depressive symptoms.

CONCLUSION

Passive smoking at work and current smoking appear associated with higher levels of depressive symptoms.

Effect of a pediatric practice-based smoking prevention and cessation intervention for adolescents: a randomized, controlled trial

OBJECTIVE

The purpose of this work was to determine whether a pediatric practice-based smoking prevention and cessation intervention increases abstinence rates among adolescents.

METHODS

Eight pediatric primary care clinics were randomly assigned to either intervention or usual care control condition. The provider- and peer-delivered intervention tested was based on the 5A model recommended by the US Public Health Service clinical practice guidelines and the American Academy of Pediatrics and consisted of brief counseling by the pediatric provider followed by 1 visit and 4 telephone calls by older peer counselors aged 21 to 25 years. A consecutive sample of patients aged 13 to 17 years scheduled for an office visit was eligible regardless of smoking status. Of 2711 patients who agreed to participate, 2709 completed baseline assessments, and 2700 (99.6%) and 2690 (99.2%) completed 6- and 12-month assessments, respectively.

RESULTS

Compared with the usual care condition, nonsmokers who received the provider- and peer-delivered intervention were significantly more likely to self-report having remained abstinent at 6-month and 12-month follow-up; smokers who received the provider- and peer-delivered intervention were more likely to report having quit at the 6-month but not the 12-month follow-up. A number of adolescent characteristics (eg, age, peer smoking, tobacco dependence, and susceptibility) were found to be predictive of abstinence at follow-up.

CONCLUSIONS

A pediatric practice-based intervention delivered by pediatric providers and older peer counselors proved feasible and effective in discouraging the initiation of smoking among nonsmoking adolescents for 1 year and in increasing abstinence rates among smokers for 6 months.

Risk and protective factors associated with trajectories of depressed mood from adolescence to early adulthood

This study used semi-parametric group-based modeling to explore unconditional and conditional trajectories of self-reported depressed mood from ages 12 to 25 years. Drawing on data from the National Longitudinal Study of Adolescent Health (N = 11,559), 4 distinct trajectories were identified: no depressed mood, stable low depressed mood, early high declining depressed mood, and late escalating depressed mood. Baseline risk factors associated with greater likelihood of membership in depressed mood trajectory groups compared with the no depressed mood group included being female, Black or African American, Hispanic or Latino American, or Pacific Islander or Asian American; having lower socioeconomic status; using alcohol, tobacco, or other drugs on a weekly basis; and engaging in delinquent behavior. Baseline protective factors associated with greater likelihood of membership in the no depressed mood group compared with the depressed mood trajectory groups included 2-parent family structure; feeling connected to parents, peers, or school; and self-esteem. With the exception of delinquent behavior, risk and protective factors also distinguished the likelihood of membership among several of the 3 depressed mood groups. The results add to basic etiologic research regarding developmental pathways of depressed mood in adolescence and young adulthood.

Labeling disorder--the relationship between conduct problems and drug use in adolescents

OBJECTIVE

To verify how conduct disorder and conduct problems are associated with gender, age at onset of drug use and categories of drugs used.

METHOD

A test of association was conducted between the presence of comorbidity and gender. Mean age of first use of each drug was compared to mean age of first arrest, of first robbery/theft, and of first drug dealing.

RESULTS

In this sample, approximately 59% of adolescents had already robbed and/or stolen, 38.6% had already been arrested, 32.3% had prior history of drug dealing, 24.1% had depression, and 9.6% had conduct disorder. Prevalence of conduct problems was 65.2%. Tobacco, alcohol, marijuana and cocaine were used before the first robbery and/or theft, first drug dealing, and first arrest.

DISCUSSION

The fact that drug use onset preceded illegal acts suggests that the latter are the consequence of the consumption of the former, or perhaps, the consequence of "social invisibility" (feeling of not belonging to anything or to anybody) by which these youths undergo.

CONCLUSIONS

Labeling these youths as conduct-disordered adolescents may cloud a rather different reality, and it may submit them to more social isolation and stigmatization as well.

Brief screening for adolescent depressive symptoms in the emergency department

BACKGROUND

Depression is the most common psychiatric disorder among adolescents and is more prevalent among those seeking care in the emergency department (ED). However, adolescents are rarely screened for depressive symptoms in the pediatric emergency department (PED).

OBJECTIVES

To evaluate the sensitivity and specificity of one- and two-item screens for depressive symptoms compared to the 20-question Center for Epidemiologic Studies Depression Scale (CESD) among adolescents seeking care in a PED.

METHODS

This was a cross-sectional study of a convenience sample of adolescents 12-17 years old presenting to an urban PED with subcritical illness or injury. Participants completed three screening instruments: the two-question screen, the single-question screen, and the CESD.

RESULTS

A total of 321 patients were approached to enter the study, of whom 212 (66%) agreed to participate. Seventy-eight (37%) of the study participants screened positive for depression on the CESD using a cutoff score of >or=16. The two-question screen had a sensitivity of 78% (95% confidence interval [CI] = 73% to 84%) and specificity of 82% (95% CI = 77% to 87%) for depressive symptoms compared with the CESD. The single-question screen had a sensitivity of 56% (95% CI = 50% to 63%) and specificity of 93% (95% CI = 90% to 96%) compared with the CESD.

CONCLUSIONS

The two-question screen is a sensitive and specific initial screen for depressive symptoms in adolescents being seen in the PED. This quick, simple instrument would be ideal for use in the busy PED setting and would allow clinicians to identify adolescents who require more extensive psychiatric evaluation.

Does smoking intervention influence adolescent substance use disorder treatment outcomes?

Although tobacco use is reported by the majority of substance use disordered (SUD) youth, little work has examined tobacco focused interventions with this population. The present study is an initial investigation of the effect of a tobacco use intervention on adolescent SUD treatment outcomes. Participants were adolescents in SUD treatment taking part in a cigarette smoking intervention efficacy study, assessed at baseline and followed up at 3- and 6-months post-intervention. Analyses compared treatment and control groups on days using alcohol and drugs and proportion abstinent from substance use at follow up assessments. Adolescents in the treatment condition reported significantly fewer days of substance use and were somewhat more likely to be abstinent at 3-month follow up. These findings suggest that tobacco focused intervention may enhance SUD treatment outcome. The present study provides further evidence for the value of addressing tobacco use in the context of treatment for adolescent SUD's.

Temporal association of onset of daily smoking with adolescent substance use and psychiatric morbidity

OBJECTIVE

The association between cigarette smoking and psychiatric disorders is well established for adult populations. However, only limited number of studies has investigated whether the young onset age of daily smoking (DS) among adolescents is associated with psychiatric morbidity and vice versa.

METHODS

Data from 508 adolescents admitted to psychiatric hospitalization were collected. Cox proportional hazard model were used to compare the initiation of DS between adolescents with and without substance use (SUD), and other psychiatric disorders.

RESULTS

Rates of DS were high in each diagnostic category. Boys started smoking at younger age (mean 12.4 years) than girls (13.0 years). Both boys and girls diagnosed with conduct or oppositional defiant disorders (COD) and also girls with SUD started daily smoking earlier as compared to those of same gender without these disorders.COD were found to be primary to the initiation of DS among boys. SUD, psychotic, and depressive disorders (DEP) were found to be secondary to DS among both genders.

CONCLUSIONS

DS in adolescence is related with later SUD. COD are associated with subsequent initiation of DS among boys. The temporal gap between smoking initiation and COD is shorter among girls. Gender difference plays a role in association of DS and DEP. Initiation of DS at very early age should alert health care professionals of development of later psychopathology, especially SUD.

Smoking among adolescents in substance abuse treatment: a study of programs, policy, and prevalence

The study was designed to: (1) identify smoking policies and interventions in adolescent residential treatment settings; (2) examine the prevalence of smoking among adolescents in these settings; and (3) assess relationships between program-level smoking policies and client-level smoking. The Center for Substance Abuse Treatment funded 17 sites to evaluate the effectiveness of Adolescent Residential Treatment (ART) programs for substance abuse. To describe program smoking policies and interventions, we conducted phone interviews with one key informant at each program (N=12). To describe client smoking behaviors, we conducted a secondary data analysis of baseline data for adolescents (N=912) entering ART programs. All sites had no smoking indoors and 75% of the site had tobacco-free grounds for adolescents. Forty-two percent provided their youth with nicotine replacement therapy, and 42% provided counseling for smoking cessation. Also, 33% did not allow staff smoking on and off campus. The prevalence of any smoking in the past month was 66%, and 22% of current smokers were daily smokers at admission. Where smoking was allowed on grounds, adolescents more often reported recent smoking. Smoking behavior is prevalent among adolescents in residential drug treatment, and should be addressed in all such programs through policy implementation and client-level smoking cessation intervention.

Association of post-treatment smoking change with future smoking and cessation efforts among adolescents with psychiatric comorbidity

Little is known about how initial change following a smoking intervention relates to longer-term smoking outcomes among adolescent smokers with psychiatric comorbidity. The present study investigated this relationship among psychiatrically hospitalized adolescents (N = 183) who participated in a controlled trial comparing motivational interviewing to brief advice. Quit attempters (n = 37), reducers (n = 45), and maintainers (n = 101) were assembled based on, respectively, having made a quit attempt, having reduced smoking by at least 50%, and having reduced smoking by less than 50% in the first week after hospital discharge. Hierarchical linear models and generalized estimating equations were conducted to test group differences in average number of cigarettes per smoking day and odds of making a quit attempt during subsequent weeks of a 12-month continuous follow-up, and in cotinine-verified abstinence rates at 1, 6, and 12 months posthospitalization. Baseline smoking levels and presence of a substance use disorder or anxiety disorder were predictive of outcomes. After controlling for covariates, we found that quit attempters smoked less during follow-up than did the other change groups and that reducers smoked less than maintainers. Quit attempters evidenced a higher percentage of quit attempts during follow-up than did the other change groups. Reducers had a greater average percentage of quit attempts during follow-up than did maintainers. However, groups did not differ on cotinine-verified abstinence rates across the follow-up period. Findings have implications for initial post-treatment change as it relates to subsequent smoking and cessation outcomes among adolescent smokers at especially high risk for smoking persistence.

On the development of nicotine dependence in adolescence

Little is known about the natural history of drug dependence. This article describes the development and predictors of DSM-IV nicotine dependence in adolescence when tobacco use is initiated. In a two-stage design, a survey was administered to 6th-10th graders in the Chicago Public Schools to select a cohort of adolescents. Household interviews were conducted with adolescents five times and with one parent (predominantly mothers) three times over 2 years. The analytical sample includes 353 youths, who started using tobacco within 12 months preceding Wave 1 or between Waves 1-5. Survival analysis estimated latency to individual DSM-IV nicotine dependence criteria and the full dependence syndrome. Twenty-five percent of youths experienced the syndrome within 23 months of tobacco use onset. Tolerance, impaired control and withdrawal were experienced most frequently. Youths who developed full dependence experienced their first symptom faster after tobacco use onset than those who experienced only one criterion through the end of the observation period. Cox proportional hazards models estimated the importance of time-constant and time-varying sociodemographic, tobacco and other drug use, parental and peer smoking, social psychological and biological risk factors for experiencing the first criterion and the full syndrome. Pleasant initial sensitivity to tobacco and number of cigarettes smoked the prior month predicted both outcomes. Parental dependence predicted the full syndrome. Significant covariates were generally the same across gender and racial/ethnic subgroups. The predictive significance of the initial smoking experience and parental dependence highlight the potential importance of genetic factors in the etiology of nicotine dependence.

Susceptibility to nicotine dependence: the Development and Assessment of Nicotine Dependence in Youth 2 study

OBJECTIVES

The purpose of this work was to identify characteristics that predict progression from the first inhalation of a cigarette to dependence. We studied a cohort of 1246 public school 6th-graders in 6 Massachusetts communities (mean age at baseline: 12.2 years).

METHODS

We conducted a 4-year prospective study using 11 interviews. We assessed 45 risk factors and measured diminished autonomy over tobacco with the Hooked on Nicotine Checklist and evaluated tobacco dependence according to the International Classification of Diseases, 10th Revision. Cox proportional-hazards models were used.

RESULTS

Among 217 youths who had inhaled from a cigarette, the loss of autonomy over tobacco was predicted by feeling relaxed the first time inhaling from a cigarette and depressed mood. Tobacco dependence was predicted by feeling relaxed, familiarity with Joe Camel, novelty seeking, and depressed mood.

CONCLUSIONS

Once exposure to nicotine had occurred, remarkably few risk factors for smoking consistently contributed to individual differences in susceptibility to the development of dependence or loss of autonomy. An experience of relaxation in response to the first dose of nicotine was the strongest predictor of both dependence and lost autonomy. This association was not explained by trait anxiety or any of the other measured psychosocial factors. These results are discussed in relation to the theory that the process of dependence is initiated by the first dose of nicotine.

Metacognition as a mediator of the relationship between emotion and smoking dependence

This study investigated the role of metacognition as a mediator of the relationship between emotion and smoking dependence. A sample of 104 smokers completed the following questionnaires: Hospital Anxiety and Depression Scale (HADS), Metacognitions Questionnaire 30 (MCQ-30), and Fagerström Test of Nicotine Dependence (FTND). Three dimensions of metacognition (positive beliefs about worry, negative beliefs about worry concerning uncontrollability and danger, and beliefs about cognitive confidence) were found to be positively and significantly correlated with smoking dependence. A positive and significant correlation was also observed between anxiety and depression on the one hand, and smoking dependence on the other. Structural equation modeling was used to test a mediational model in which emotion predicted metacognition which in turn predicted smoking dependence. The results supported the hypothesis that the relationship between emotion and smoking dependence is partially mediated by metacognition, suggesting that metacognitive theory may be relevant to understanding smoking dependence. The implications of these findings are discussed.

Patterns of depressive symptoms in children

PROBLEM

Depressive symptoms in children have been linked to recurrent problems with depression, school problems, and risky health behaviors. Adolescent girls report depressive symptoms three to four times more frequently than adolescent boys. Few studies, however, have examined gender-related depressive symptoms in younger, school-aged children.

METHODS

In the present study, gender differences in depressive symptoms in children ages 10-12 years were explored using the Children's Depression Inventory (CDI) with a convenience sample of 122 suburban middle-class public school fifth and sixth graders.

FINDINGS

A distinct pattern of depressive symptom expression was found with girls reporting more internalizing and more negative self-esteem, and boys reporting more externalizing and more school problems.

CONCLUSION

These findings suggest that despite similarities on a total depressive symptom score, there are distinct gender differences in depressive symptom expression that are identifiable before adolescence and may be associated with normative development.

Relationship between self-reported task persistence and history of quitting smoking, plans for quitting smoking, and current smoking status in adolescents

The task persistence construct has previously been measured primarily behaviorally (e.g., with a mirror-tracing task, or breath holding), and only in adults. It has been shown to differentiate between adult smokers and non-smokers and to predict smoking cessation in adult smokers trying to quit. This theory-based analysis is the first to examine task persistence in adolescent smokers and to examine a two-item, internally consistent, self-report measure of task persistence. Results indicate that task persistence is greater among adolescent non-smokers as compared to adolescent current smokers, and those planning to quit smoking as compared to those with no plans to quit. Contrary to hypotheses, task persistence was not found to be related to prior successful attempts to quit smoking. Our results suggest that a brief, self-report measure of task persistence may be a methodologically sound, practical clinical tool for this population.

Negative mood states and related factors in a sample of adolescent secondary-school students in Barcelona (Spain)

INTRODUCTION

Poor mental health is a common problem in adolescence. Little information is available, however, about the factors influencing negative mood states in otherwise healthy adolescents. We aimed to describe the mood states and related factors in a sample of adolescents in the city of Barcelona (Spain).

METHODS

We administered a health survey to a sample of 2,727 students from public, subsidized, and private schools in Barcelona, aged approximately 14, 16, and 18 years old. To analyze the associations among moods and related factors, we used bivariate logistic regression, and fitted multivariate logistic regressions using the statistically significant variables from the bivariate analysis. To examine the possible group effects of the school on individual students, we employed multilevel analysis.

RESULTS

The frequencies of negative mood states increased with age, with girls consistently reporting more frequent negative mood states than boys. The factors associated with negative mood states were problematic alcohol use, perceived mistreatment or abuse, antisocial behavior, intention to use or current use of illegal drugs (not including cannabis), lower perceived academic performance, and feeling isolated.

CONCLUSIONS

Mood states are influenced by lifestyle and social factors, about which there is little local information. To plan and implement appropriate public health interventions, more complete information about the possible areas of influence is required. To complement the information obtained from studies such as the present study, longitudinal and qualitative studies would be desirable.

Readiness to change smoking behavior in adolescents with psychiatric disorders

There has been recent increased interest in utilizing motivational interviewing (MI) to increase adolescent readiness to quit smoking, but attempts to impact quit rates have thus far been discouraging. A better understanding of factors associated with adolescent readiness to quit smoking prior to receiving any intervention may provide guidance when tailoring future MI interventions in order to increase their effectiveness with this population. Adolescent smokers (N=191) who had been admitted to a psychiatric hospital and enrolled in a clinical trial evaluating MI completed questionnaires that assessed smoking behavior and variables thought to be related to smoking. Confidence to quit smoking and negative beliefs about smoking were significant predictors of adolescents' baseline readiness to quit smoking. The failure to demonstrate relationships between health consequences and readiness suggest that caution may be warranted in the use of feedback, a common component of MI-based interventions. Such feedback tends to focus on health consequences, which was unrelated to adolescent baseline readiness to change smoking behavior in the current study. Parallels between current results and the Theory of Planned Behavior are discussed in consideration of developing more effective MI-based interventions for adolescent smokers.

Association between psychiatric disorders and smoking stages within a representative clinic sample of Puerto Rican adolescents

OBJECTIVE

We examined the prevalence of smoking behaviors and their association with specific psychiatric disorders in a representative sample of youth from behavioral health clinics in Puerto Rico.

METHOD

A complex sampling design was used to select the sample, and analyses were conducted to account for the unequal selection probability, stratification, and clustering. All analyses were weighted back to the clinical population from which they were drawn. Psychiatric and substance use disorders were assessed using the parent and youth versions of the Diagnostic Interview Schedule for Children, Version 4.0.

RESULTS

More than one third of the sample reported experience with cigarette smoking, and approximately one quarter reported smoking at least once per week (23.4%). As expected, the alcohol and drug use disorders demonstrated some of the strongest associations with individual smoking stages. These were the only disorders that remained significantly associated with nicotine dependence after controlling for comorbidity.

CONCLUSIONS

Our findings confirm the need for screening of smoking behavior and nicotine dependence in treatment settings and the integration of psychiatric/substance use treatments with smoking cessation.

Smoking motives in the prediction of affective vulnerability among young adult daily smokers

The primary aim of this study was to examine whether smoking to reduce negative affect was uniquely related to a range of affective vulnerability factors (e.g., anxiety sensitivity, anxious arousal, and negative affectivity) among daily smokers. Participants were 276 young adult daily smokers (124 females; M(age)=25.12, SD=10.37). Partially consistent with prediction, the motivation to smoke to reduce negative affect was significantly related to anxiety sensitivity and negative affectivity, but not anxious arousal; the observed significant effects were above and beyond other theoretically relevant factors (e.g., smoking rate, years smoked, age, gender). In contrast to prediction, habitual smoking motives demonstrated significant incremental associations with anxiety sensitivity and anxious arousal symptoms. These results suggest that there are important associations between certain smoking motives and negative affective states and that such relations are not attributable to other smoking factors (e.g., smoking rate).

Testing the dual pathway hypothesis to substance use in adolescence and young adulthood

BACKGROUND

We tested the dual pathway hypothesis to substance use which posits that substance use can develop via internalizing symptoms or deviant behaviors.

METHOD

Using data from the Add Health study, we used latent class analysis to define subgroups based on patterns of substance use, and logistic regression procedures to evaluate the prospective association between symptoms of depression, deviance, and the individual substance use patterns.

RESULTS

Groups representing similar patterns of substance use were identified in both adolescence and young adulthood. Some support for the dual pathway hypothesis was demonstrated. Deviance was prospectively associated with substance group assignment in both adolescence and young adulthood, while depression uniquely predicted assignment to the smoking group in young adulthood among females.

CONCLUSIONS

Further testing of the dual pathway hypothesis should be built on diverse pattern-centered approaches able to explore the presence of population subgroups.

Cigarette smoking among Greek adolescents: behavior, attitudes, risk, and preventive factors

This study was produced in the context of the first author's thesis at Athens University and was a collaboration between the Department of Clinical Care Medicine, Athens University, and Attiki Child Psychiatric Hospital. It was supported by a project grant from the THORAX Foundation, Greece.

OBJECTIVE

To study the smoking behavior, attitudes, and beliefs of Greek adolescents, as well as the risk and preventive factors for the onset of smoking and to obtain data to serve in the planning of comprehensive antismoking campaigns tailored to the Greek adolescent's specific profile.

SAMPLE AND METHOD

A stratified, nationwide, representative, school-based sample of 3827 Greek adolescents was surveyed during the academic year 2001-2002, using a questionnaire on smoking and Achenbach's Youth Self-Report.

RESULTS

Cigarette smoking is a serious problem among Greek youth. Family and peers play a primary role in shaping smoking attitudes and habits. Adolescents who smoke regularly have increased rates of psychopathology as indicated by higher scores on the Externalising and Attention Problem scales of Achenbach's Youth Self-Report, compared to adolescents who are non-smokers. The data obtained can indeed guide smoking prevention strategies in Greece.

Smoking, traumatic event exposure, and post-traumatic stress: a critical review of the empirical literature

The current review critically examines the extant empirical literature focused on the associations among cigarette smoking, trauma, and post-traumatic stress. Inspection of the extant literature suggests that smoking rates are significantly higher among persons exposed to a traumatic event relative to those without such exposure. Moreover, smoking rates appear particularly high among persons with post-traumatic stress disorder (PTSD). In terms of the direction of this relation, evidence most clearly suggests that post-traumatic stress is involved in the development of smoking. Significantly less is known about the role of trauma and PTSD in terms of cessation outcome. Limitations of extant work, clinical implications, and key directions for future study are delineated.

Child and adolescent psychiatrists' practices in assisting their adolescent patients who smoke to quit smoking

OBJECTIVE

This national study examined the practices and perceptions of smoking cessation activities among child and adolescent psychiatrists.

METHOD

A random sample of child and adolescent psychiatrists was identified from the membership list of the American Academy of Child and Adolescent Psychiatry and was mailed a valid and reliable 34-item questionnaire.

RESULTS

A total of 184 responses (47%) were received. A plurality (48%) of psychiatrists reported being self-taught in smoking cessation techniques. A majority (67%) of psychiatrists were in the maintenance stage for asking about smoking status. However, only 19% consistently made attempts to assess willingness to quit, and 30% consistently gave messages urging the smoker to quit. The perceived number of barriers for addressing smoking was negatively correlated with psychiatrists' levels of confidence (r = -0.35, p <.001) and preparedness (r = -0.39, p <.001) in addressing smoking cessation. Estimations by the psychiatrists of youths who smoked were 61% of those with conduct disorders, 46% of those with schizophrenia, and 40% of those with attention-deficit/hyperactivity disorder.

CONCLUSION

Considering the perceived high rate of patient smoking and the lack of formal training in smoking cessation, more postgraduate education is needed to adequately prepare child and adolescent psychiatrists for addressing tobacco cessation.

Nicotine use and dependence and their association to psychiatric disorders in a large sample of adolescent psychiatric inpatients

The purpose of this research was to evaluate the level of nicotine dependence (ND) and to examine its association to psychiatric disorders in a representative clinical sample of adolescent psychiatric inpatients. The modified Fagerstrom Tolerance Questionnaire (mFTQ) was used to assess the level of ND. Psychiatric DSM-IV diagnoses were obtained by using the Schedule for affective disorder and schizophrenia for school-age children (K-SADS-PL). Of the total of 342 inpatients in the study sample, 259 (75.7%) reported to be current smokers. A sum score 6 or higher in the mFTQ, indicating a high level of ND, was found in 37.9% of all smokers. An increased likelihood for high level of ND was associated with substance related disorders (OR 5.1, 95% CI 2.8-9.3), conduct disorder and oppositional defiant disorders (OR 2.4, 95% CI 1.4-4.4). The usefulness of mFTQ in measuring ND among adolescent inpatients is apparent. Therefore, it can be recommended to be used as a routine screening instrument for ND among adolescents hospitalized due to psychiatric disorders.

Consequences of youth tobacco use: a review of prospective behavioural studies

BACKGROUND

Cigarette smoking represents a significant health problem and tobacco has been identified as causing more preventable diseases and premature deaths than any other drug. Although health consequences from smoking have been documented, there has been a surprising lack of research into behavioural consequences.

AIMS

To review what is known of the long-term relationship between patterns of tobacco use prior to age 18 years and behavioural consequences in adulthood.

METHOD

A literature search of electronic abstraction services from 1980 to September 2005 was conducted. To be included in the review, studies had to have large, representative samples, be longitudinal studies with baseline age under 18 years and follow-up age 18 years or older and clarify effects due to attrition, leaving 16 articles that met the inclusion criteria. Two reviewers evaluated each paper.

FINDINGS

Adolescent tobacco use predicts a range of early adult social and health problems. Surprisingly few studies met the inclusion criteria. The limited evidence available suggests that adolescent tobacco smoking increases the likelihood of early adult tobacco use and the initiation of alcohol use or the development of alcohol-related problems. The link between adolescent tobacco use and subsequent cannabis use was not resolved convincingly from the studies summarized. The effects of tobacco use on later illicit drug use tended to fall away when adjusting for underlying risk factors. Existing studies of the effects of tobacco use on later mental health have many limitations. Nevertheless, a finding that youth tobacco use may predict subsequent mental health problems deserves further investigation. The possible effects of tobacco use on academic/social problems and sleep problems also warrant further investigation.

CONCLUSION

This review highlights links between youth tobacco use and subsequent behavioural and mental health problems. It provides health care professionals with evidence of the possible harmful effects of youth tobacco smoking on later social, emotional, and behavioural well-being.

Antismoking advertisements for youths: an independent evaluation of health, counter-industry, and industry approaches

OBJECTIVES

We used a validated copy test method to examine the effectiveness of 8 types of antismoking advertisements representing health, counterindustry, and industry approaches. We tested the hypothesis that health ads about tobacco victims can lower most adolescents' intent to smoke if the ads elicit disgust and anti-industry feelings rather than fear. We hypothesized null effects for adolescents with conduct disorder because of their abnormally low empathy.

METHODS

Ninth-grade students from 8 California public schools (n=1725) were randomly assigned to view 1 of 9 videotapes containing a TV show with ads that included either a set of antismoking ads or a set of control ads. Participants completed baseline measures assessing personality traits and postexposure measures assessing smoking intent, feelings, beliefs, and ad evaluations.

RESULTS

Ads focusing on young victims suffering from serious tobacco-related diseases elicited disgust, enhanced anti-industry motivation, and reduced intent to smoke among all but conduct-disordered adolescents. Counterindustry and industry ads did not significantly lower smoking intention.

CONCLUSIONS

Sponsors of tobacco use prevention ad campaigns should consider using ads showing tobacco-related disease and suffering, not just counterindustry ads. Ads should be copy tested before airing.

Adolescent depression: challenges and opportunities: a review and current recommendations for clinical practice

Many aspects of the treatment for adolescent depression are still uncertain. However, our body of knowledge continues to accumulate, and our approaches continue to be refined. When we remember that 40 years ago the field was still arguing about the existence of depression in youth, it is clear that significant progress has been made. Recent controversies have provided another opportunity to step back and re-evaluate. Given the chronicity, morbidity, and mortality associated with adolescent depression, the risks of doing nothing are too great. Evidence-based research has provided us with some direction during this unsettling time. After careful reviews, the major professional organizations representing pediatric medicine and psychiatry all support the continued use of SSRI antidepressant medications but emphasize close monitoring. The debates also have heightened interest in effective psychotherapy approaches, particularly CBT and IPT. Given the risk for suicidality in depressed adolescents, assessment and management of safety concerns remain critical, regardless of medication usage. Above all, it is most important that we remain hopeful about our ability to guide adolescents and families through the struggles with depression toward recovery.