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

Epidemiology and correlates of daily smoking and nicotine dependence among young adults in the United States

OBJECTIVES

We describe the epidemiology of smoking behaviors in a national young adult sample and identify common and unique demographic, social, and psychological correlates of daily smoking and lifetime and current nicotine dependence by race/ethnicity.

METHODS

Data are from the National Longitudinal Survey of Adolescent Health, wave III. Dependence was measured by the Revised Fagerström Test for Nicotine Dependence. Logistic regressions were estimated.

RESULTS

Hispanic ethnicity, low education, parental and peer smoking, novelty seeking, early age of smoking onset, and pleasurable initial smoking experiences are significantly correlated with daily smoking and lifetime nicotine dependence. Depressive symptoms are uniquely associated with lifetime and current dependence. Few factors are highly associated with current dependence. Initial sensitivity to smoking has a significantly greater impact on daily smoking than on dependence. Correlates of smoking behaviors are mostly common across racial/ethnic groups, although parental and peer smoking are significant for Whites and Hispanics but not for African Americans.

CONCLUSIONS

There are more common than unique correlates of each smoking stage and across racial/ethnic groups. Primary prevention and interventions addressing the factors tested could be uniform for most chronic smokers irrespective of dependence status and race/ethnicity.

Smoking and panic attacks, panic disorder, and agoraphobia: a review of the empirical literature

The empirical literature regarding panic-spectrum problems (i.e., panic attacks, panic disorder, and agoraphobia) and cigarette smoking is reviewed. In the first section of the paper, empirical studies that document the prevalence of smoking and panic-related problems are presented and discussed. In the second section of the paper, studies pertaining to the role cigarette smoking may play in the onset and maintenance of panic-related problems are critically reviewed. In the third section of the paper, studies related to the association between panic vulnerability factors and the nature of smoking behavior are presented. In the fourth section of the paper, specific areas not otherwise covered in the review are presented to stimulate further development in these areas (e.g., specialized treatment development).

Association between psychiatric disorders and smoking stages among Latino adolescents

OBJECTIVE

We examined the prevalence of smoking behaviors and their association with psychiatric disorders within a representative sample of youth from Puerto Rico.

METHOD

A complex sampling design was used and analyses were conducted to account for the unequal selection probability, stratification and clustering. All analyses were weighted back to the 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 (DISC-IV).

RESULTS

After controlling for other comorbidity, major depression and oppositional defiant disorder were significantly associated with nicotine dependence, rather than with lower levels of use. In contrast, conduct disorder was generally associated with lower levels of use rather than with nicotine dependence. As expected, the alcohol and drug use disorders demonstrated some of the strongest associations with individual smoking stages.

CONCLUSIONS

By examining psychiatric correlates of smoking stages within an island-wide sample of adolescents, the present study highlights those disorders that may play a role in the development and/or persistence of smoking behavior in Puerto Rico and further clarifies the appropriate targets for smoking intervention conducted in community settings.

Substance use disorder characteristics and externalizing problems among inpatient adolescent smokers

Attention deficit hyperactivity disorder (ADHD) and/or conduct disorder (CD) have been found to be associated with substance use disorders and cigarette smoking among adolescents. However, studies have often failed to explore these relationships among females from a dimensional perspective, taking into account comorbidity between ADHD and CD symptomatology, and examining ADHD symptom subtypes (i.e., inattention and hyperactivity/impulsivity) separately as they relate to substance involvement and smoking characteristics. This study takes each of the above into consideration when examining the relationship between externalizing symptomatology and substance involvement characteristics in a sample of 191 (62.3% female, mean age = 15.4 years) inpatient adolescent smokers. The results of this study suggest that ADHD and CD symptoms may be related to different types of substance use characteristics. CD symptoms were associated with early onset of substance involvement and ADHD symptoms were related to alcohol and marijuana frequency. ADHD inattention symptoms, but not hyperactivity/impulsivity symptoms, were associated with marijuana and nicotine dependence. Lastly, significant interactions suggested that ADHD symptoms among boys and CD symptoms among girls were related to frequency of any type of substance use prior to inpatient hospitalization. The results of this study point to potentially important clinical implications such as tailoring prevention and intervention efforts according to type of externalizing symptomatology and gender.

Longitudinal follow-up of adolescents with late-onset antisocial behavior: a pathological yet overlooked group

OBJECTIVE

Antisocial behavior that begins in mid- to late adolescence does not fit into commonly accepted taxonomies of antisocial behavior, yet it clearly exists. This study examined how this course of antisocial behavior compares with persisting (beginning by early adolescence and continuing through late adolescence) and desisting (stopping by mid-adolescence) antisocial behavior in terms of risk for later substance dependence and background risk factors (gender, IQ, socioeconomic status, parental antisocial behavior, and parental divorce).

METHOD

A population-based sample of twins from the Minnesota Twin Family Study, evaluated at ages 17 and 20, was used.

RESULTS

The results indicated that youths with late onsets were similar to those with persisting antisocial behavior and that both groups were at higher risk of later nicotine, alcohol, and cannabis dependence than controls; both also had similarly high levels of background risk factors. The late-onset group included a significant overrepresentation of females, whereas the persisting and desisting groups included more males.

CONCLUSIONS

Late-onset antisocial behavior has many of the same negative correlates of persisting antisocial behavior but includes significantly more females. Although they are excluded from the diagnosis of antisocial personality disorder, these youths have clinically significant problems similar to those with this diagnosis.

Poor premorbid school performance is associated with later cigarette smoking among schizophrenia patients

Schizophrenia patients who smoke have been postulated to have genetically mediated dysfunctional nicotinic neurotransmission. We hypothesized that this nicotinic dysfunction would manifest as poorer school performance in adolescence, before the onset of illness, in smoking compared with non-smoking schizophrenia patients. Over a 31-year follow-up period, 100 (65 men) cohort members of the Northern Finland 1966 Birth Cohort were hospitalized and diagnosed with DSM-III-R schizophrenia. The information on school performance was obtained at the end of compulsory schooling at age 16 years. The information on smoking habits was gathered from a questionnaire mailed to cohort members at the age of 31 years. Compared with non-smoking schizophrenia patients, schizophrenia patients who smoked in adulthood had lower overall mean grades, lower mean grades in combined mathematical subjects, and lower grades in music. Poor school performance might represent premorbid nicotinergic dysfunction associated with cognitive deficits in future smokers among schizophrenia patients compared with those who remained non-smokers.

Correlates of regular cigarette smoking in a population-based sample of Australian twins

AIMS

To investigate the role of measured risk factors and the influence of genetic and environmental factors on regular cigarette smoking. Design Members of monozygotic and dizygotic, including unlike-sex twin pairs (n = 6257) from a young adult cohort from the Australian Twin Registry.

METHODS

Cox proportional hazards models were used to determine whether putative risk factors were significantly associated with regular cigarette smoking. Risk factors were classified into four tiers: tier 1 (parental history, including parental education, alcoholism and cigarette smoking), tier 2 (early home and family influences), tier 3 (early life events, e.g. trauma) and tier 4 (psychiatric symptoms/disorders with onset prior to 14 years), after controlling for gender, zygosity and their interactions. Genetic models were fitted to examine the heritability of smoking behavior before and after controlling for significant covariates from the four tiers.

FINDINGS

Parental history of cigarette smoking and alcoholism, parental closeness and home environment, as well as incidence of childhood sexual abuse or other trauma, a history of early onset panic attacks and conduct problems were associated with regular cigarette smoking. Important age interactions were found, particularly for family background risk factors. Regular cigarette smoking was moderately heritable, even after accounting for significant covariates.

CONCLUSIONS

Several measured risk factors are associated with regular smoking. While some of the genetic influences on regular smoking may be shared with these risk factors, a significant proportion of the genetic vulnerability to regular smoking is phenotype-specific.

An exploration of self-reported negative affect by adolescents as a reason for smoking: implications for tobacco prevention and intervention programs

BACKGROUND

Negative affect is related to initiation and maintenance of smoking among youth and understanding its role is important when developing effective prevention and cessation programs. This study investigates the relationship between adolescent negative affect and smoking dependence, behaviors, attitudes, and self-efficacy in order to shed light on differences in adolescent smoking maintenance and cessation.

METHODS

721 smoking youth participated in a cognitive-behavioral smoking cessation program. Reasons for smoking were categorized (alpha = 0.87) and youth were placed into one of two groups based on presence or absence of negative affect. One-way repeated measures ANOVA determined if differences existed between the groups on smoking behaviors, attitudes, and self-efficacy. One-way ANOVA determined if differences existed on Fagerström Nicotine Tolerance Dependence (FTND) scores.

RESULTS

Adolescents indicating negative affect for smoking were significantly more likely to have future smoking intentions and had significantly less self-efficacy to quit smoking than adolescent reporting other reasons.

CONCLUSIONS

This study supports the need to address negative affect among adolescents participating in prevention and cessation programs. An examination of negative affect will provide program developers and facilitators with information to improve their interventions, assist with cessation, and provide an avenue to access other needed health services.

The return to smoking: 1‐year relapse trajectories among female smokers

Research has demonstrated that a lapse in cigarette abstinence often leads smokers to fully relapse (i.e., return to daily smoking). However, patterns of smoking resumption beyond the point at which relapse occurs have not been examined in systematic follow-up studies. Daily cigarette intake data for 108 female adult smokers who participated in a smoking cessation trial were recorded at several points during the 365 days following the participants' quit date. SAS Proc Traj, a group-based mixture modeling procedure, was used to determine cigarette-use trajectories over time (i.e., patterns of smoking resumption). Over the 365 days, 27% of the sample maintained abstinence. Among the 73% who relapsed, four distinct trajectories emerged: low-level users (8% of the overall sample), moderate users (17%), slow-returners (15%), and quick-returners (33%). A few individual characteristics differentiated these groups. Overall, the findings illustrate that, after relapsing, smokers do not follow a unitary course of smoking resumption; rather, they exhibit more variable resumption patterns than previously assumed.

A longitudinal study of the relationship between depressive symptoms and cigarette use among African American adolescents

The relationship between depressive symptoms and cigarette use was examined in a sample of 623 African Americans during adolescence and transition to adulthood by using hierarchical linear modeling. Participants in the study were interviewed across 6 occasions over 8 years. Results indicate that depressive symptoms tend to decrease over time, whereas cigarette use tends to increase for both female and male adolescents. The results also suggest that depressive symptoms predict later cigarette use. Male adolescents who reported more depressive symptoms were more likely than female adolescents to use cigarettes as a way to cope with their mood. These results suggest that depressive symptoms may be important to consider when developing smoking cessation interventions for African American youth.

Anxiety, depression and smoking in schoolchildren--implications for smoking prevention

The prevalence of smoking among 14 to 18-year-old adolescents (one out of three) is as high as in the general population in Hungary. Depression and anxiety disorders are also major public health problems. Our objective was to investigate the correlations between smoking status and anxiety and depressive symptoms, as well as to identify potential implications for the prevention of nicotine dependence. We used a self-developed questionnaire to survey smoking behaviour, and standard self-evaluation tests (the Hungarian version of the Spielberger's State-Trait Anxiety Inventory for Children and the Children's Depression Inventory) to capture anxiety and depressive symptoms in 215 students from randomly selected technical and high schools. Smoking students showed significantly more anxiety and depressive symptoms compared to their non-smoking peers. Importantly, occasional smokers appeared to be more anxious than non-smokers, whereas daily smokers scored higher on the depression inventory than either non-smokers or occasional smokers. The majority of students with high scores suggestive of anxiety or depressive disorders were smokers. Interestingly, Levels of anxiety and depression were associated with smoking status in boys but not in girls. The strong association found between anxiety and depressive symptoms and youth smoking, particularly in boys, suggests that reducing these symptoms (especially high, school-related anxiety) may be preventive against the onset of addictive smoking. This, together with the high level of anxiety and depression found in girls, makes it essential for all professionals dealing with adolescents and education to recognise these symptoms and their significance, and to be aware of the ways of reducing them by changes in the educational system, or medically, if necessary.

Safety and efficacy of the nicotine patch and gum for the treatment of adolescent tobacco addiction

OBJECTIVES

To determine the safety and efficacy of the nicotine patch and gum for adolescents who want to quit smoking.

DESIGN

Double-blind, double-dummy, randomized, 3-arm trial with a nicotine patch (21 mg), nicotine gum (2 and 4 mg), or a placebo patch and gum; all participants received cognitive-behavioral group therapy.

SETTING

Inner-city, outpatient clinic on the East Coast. Subjects. Thirteen- to 17-year-old adolescents who smoked > or =10 cigarettes per day (CPD), scored > or =5 on the Fagerstrom Test of Nicotine Dependence, and were motivated to quit smoking. Intervention. Twelve weeks of nicotine patch or gum therapy with cognitive-behavioral therapy, with a follow-up visit at 6 months (3 months after the end of treatment).

MAIN OUTCOME MEASURES

Safety assessed on the basis of adverse event reports for all 3 groups, prolonged abstinence, assessed through self-report and verified with exhaled carbon monoxide (CO) levels of < or =6 ppm, in intent-to-treat analyses, and smoking reduction (CPD and thiocyanate concentrations) among trial completers.

RESULTS

A total of 120 participants were randomized (72% white, 70% female; age: 15.2 +/- 1.33 years; smoking: 18.8 +/- 8.56 CPD; Fagerstrom Test of Nicotine Dependence score: 7.04 +/- 1.29) from 1999 to 2003. Participants started smoking at 11.2 +/- 1.98 years of age and had been smoking daily for 2.66 +/- 1.56 years; 75% had at least 1 current psychiatric diagnosis. Mean compliance across groups was higher for the patch (mean: 78.4-82.8%) than for the gum (mean: 38.5-50.7%). Both the patch and gum were well tolerated, and adverse events were similar to those reported in adult trials. Changes in mean saliva cotinine concentrations throughout treatment were not statistically significant. Intent-to-treat analyses of all randomized participants showed CO-confirmed prolonged abstinence rates of 18% for the active-patch group, 6.5% for the active-gum group, and 2.5% for the placebo group; the difference between the active-patch and placebo arms was statistically significant. There was no significant effect of patch versus gum or gum versus placebo on cessation outcomes. Abstinence rates at the 3-month follow-up assessment were sustained but were not significantly associated with treatment group. Mean smoking rates, but not CO or thiocyanate concentrations, decreased significantly in all 3 arms but not as a function of treatment group.

CONCLUSIONS

Nicotine patch therapy combined with cognitive-behavioral intervention was effective, compared with placebo, for treatment of tobacco dependence among adolescent smokers. Decreases in the numbers of cigarettes smoked appeared to be offset by compensatory smoking. Additional study of nicotine gum, with enhanced instructional support, is needed to assess its efficacy among adolescent smokers.

Gender differences in the association between substance use and elevated depressive symptoms in a general adolescent population

AIMS

This study explores gender differences in the association between substance use and elevated depressive symptoms in the general adolescent population.

DESIGN

Cross-sectional self-reported anonymous survey, the 2002/2003 Student Drug Use Survey in the Atlantic Provinces. The sample design was a single-stage cluster sample of randomly selected classes stratified by grade and region.

SETTING

The four Atlantic provinces of Canada.

PARTICIPANTS

A total of 12 771 students in junior and senior high schools of the public school systems, representing a response rate of about 97%. The average age of participants was 15.2 years.

MEASUREMENTS

The measure of elevated depressive symptoms was a 12-item version of the CES-D with three categories of depression risk validated in a companion study.

FINDINGS

The prevalence of very elevated depressive symptoms was 8.6% in females and 2.6% in males. Alcohol use and cigarette smoking were found to be independent predictors of elevated depressive symptoms in females, but not males; cannabis use was found to be an independent predictor of elevated depressive symptoms in both males and females. Age was found to have a curvilinear relationship with elevated depressive symptoms in females but not in males. The adolescent's academic performance and province of residence were found to be independent risk factors of elevated depressive symptoms among both males and females. About 10.3% of adolescents considered to be potential candidates for needing help reported having received help because they felt depressed.

CONCLUSIONS

The association between depression risk and age, alcohol use, cigarette smoking and cannabis use in the general adolescent population is not straightforward and may differ according to gender. There is unmet need for help for depression among adolescents.

Developmental heterogeneity in adolescent depressive symptoms: associations with smoking behavior

OBJECTIVE

Previous research has indicated an association between smoking and depression in adolescents, although the nature of the relationship is controversial. We sought to understand this relationship better in a prospective study by investigating whether there are subpopulations of adolescents with different relationships between smoking and depressive symptoms.

METHODS

Our sample was 925 adolescents attending one of five Northern Virginia high schools, grades 9 to 12. We used General Growth Mixture Modeling as our method because it allowed identification and characterization of depressive symptoms trajectories and assessment of the effects of trajectory on 12th grade smoking. We defined the binary variable 12th grade current smoking as smoking on 1 or more of the past 30 days and more than 100 cigarettes smoked in a lifetime, versus not having smoked in the past 30 days.

RESULTS

We identified three trajectories: high, medium, and low depressive symptoms. For adolescents with high symptoms, 9th grade (baseline) smoking was associated with an overall deceleration of depressive symptoms, whereas for adolescents with moderate symptoms, baseline smoking was associated with an overall acceleration in depressive symptoms. Baseline smoking was not associated with rate of change in depressive symptoms for adolescents with low symptoms, nor was it associated with baseline depressive symptoms in any trajectory.

CONCLUSION

These findings demonstrate that there is a relationship between smoking and depressive symptoms in adolescents, and that the relationship can vary by developmental trajectory, suggesting etiological heterogeneity.

Effects of motivational interviewing on smoking cessation in adolescents with psychiatric disorders

OBJECTIVE

To test the hypothesis that among adolescent smokers hospitalised for psychiatric and substance use disorders, motivational interviewing (MI) would lead to more and longer quit attempts, reduced smoking, and more abstinence from smoking over a 12 month follow up.

DESIGN

Randomised control trial of MI versus brief advice (BA) for smoking cessation, with pre- and post-intervention assessment of self efficacy and intentions to change, and smoking outcome variables assessed at one, three, six, nine, and 12 month follow ups.

SETTING

A private, university affiliated psychiatric hospital in Providence, Rhode Island, USA.

PATIENTS OR OTHER PARTICIPANTS

Consecutive sample (n = 191) of 13-17 year olds, admitted for psychiatric hospitalisation, who smoked at least one cigarette per week for the past four weeks, had access to a telephone, and did not meet DSM-IV criteria for current psychotic disorder.

INTERVENTIONS

MI versus BA. MI consisted of two, 45 minute individual sessions, while BA consisted of 5-10 minutes of advice and information on how to quit smoking. Eligible participants in both conditions were offered an eight week regimen of transdermal nicotine patch upon hospital discharge.

MAIN OUTCOME MEASURES

Point prevalence abstinence, quit attempts, changes in smoking rate and longest quit attempt. Proximal outcomes included intent to change smoking behaviour (upon hospital discharge), and self efficacy for smoking cessation.

RESULTS

MI did not lead to better smoking outcomes compared to BA. MI was more effective than BA for increasing self efficacy regarding ability to quit smoking. A significant interaction of treatment with baseline intention to quit smoking was also found. MI was more effective than BA for adolescents with little or no intention to change their smoking, but was actually less effective for adolescents with pre-existing intention to cut down or quit smoking. However, the effects on these variables were relatively modest and only moderately related to outcome. Adolescents with comorbid substance use disorders smoked more during follow up while those with anxiety disorders smoked less and were more likely to be abstinent.

CONCLUSIONS

The positive effect of MI on self efficacy for quitting and the increase in intention to change in those with initially low levels of intentions suggest the benefits of such an intervention. However, the effects on these variables were relatively modest and only moderately related to outcome. The lack of overall effect of MI on smoking cessation outcomes suggests the need to further enhance and intensify this type of treatment approach for adolescent smokers with psychiatric comorbidity.

Identifying and Characterizing Adolescent Smoking Trajectories

Our understanding of longitudinal patterns of adolescent smoking development and the determinants of these patterns is limited. The present study evaluated adolescent smoking trajectories and characterized these trajectories with social, psychological, and behavioral factors in a cohort of adolescents assessed annually from grades 9 to 12. Complete data (smoking practices, novelty seeking, academic performance, substance use, peer smoking, physical activity and sports participation, and tobacco ad receptivity) were available on 968 participants; data were analyzed using latent class growth modeling. Four adolescent smoking trajectories emerged: never smokers, experimenters, earlier/faster smoking adopters, and later/slower smoking adopters. Early adopters were characterized by their high novelty seeking personality, depressive symptoms, poorer academic performance, and receptivity to tobacco advertising, as well as their exposure to other smokers, and use of other substances. Later adopters were characterized quite similarly to the early adopters, although they tended to perform better in school and to be more involved in sports. Experimenters also shared many of these same risk characteristics but to a lesser degree. Overall, never smokers were the most conventional in their profile. These data suggest that there is significant heterogeneity in the timing, rate, and intensity of smoking progression. Adolescent smoking prevention and intervention programs will need to consider this heterogeneity and tailor or enhance attention to risk and protective factors depending on the subpopulation.

Increased mortality in depressive disorders: a review

Several factors have been proposed to explain the relationship between excess mortality and depressive disorders. These include mechanisms such as increased suicide rates, hazardous health behavior (smoking, alcohol use, unhealthy eating), psychologic reactions to developing a medical illness, biological dysregulations (hyperactivity of the hypothalamic pituitary adrenal, neuro-immune dysregulation, sympathoadrenergic dysregulation), and noncompliance with medical treatment. The evidence supporting the role of each of these mechanisms in excess mortality varies considerably. The causal direction in most of the mechanisms is not clear. It is possible that the explanatory factors, such as smoking, compliance, or biological mechanisms, cause depression, or that depression causes these factors, or that both are explained by a third, underlying factor. We will summarize the evidence supporting these mechanisms, and propose options for possible interventions aimed at reducing the increased risk of dying.

The epidemiology of dual diagnosis

The English language literature on the epidemiology of dual diagnosis is reviewed. The literature shows mental disorders to be significantly related to alcohol and drug use disorders. The strongest associations involve externalizing mental disorders and alcohol-drug dependence. Mental disorders are associated with alcohol-drug use, problems among users, dependence among problem users, and persistence among people with lifetime dependence. These dual diagnoses are associated with severity and persistence of both mental and alcohol-drug disorders. A wider range of mental disorders is associated with nicotine dependence. Most people with dual diagnosis report their first mental disorder occurred at an earlier age than their first substance disorder. Prospective studies confirm this temporal order, although significant predictive associations are reciprocal. Analyses comparing active and remitted mental disorders suggest that some primary mental disorders are markers and others are causal risk factors for secondary substance disorders. The article closes with a discussion of ways epidemiologic research can be used to help target and evaluate interventions aimed at preventing secondary substance use disorders by treating early-onset primary mental disorders.

Smoking and sleep disorders

Cigarette smoking is the most important cause of preventable disease, disability, and premature death in the United States. In addition to adverse effects on respiratory, cardiovascular, cerebrovascular, and other systems, accumulating evidence indicates that cigarette smoking may also increase morbidity by adversely affecting sleep. This article focuses on the effects of cigarette smoking, nicotine, and pharmacologic agents used for smoking cessation on neuronal systems regulating sleep and clinically apparent sleep disorders.

Major depression among adolescent smokers undergoing treatment for nicotine dependence

This is the first study to examine the prevalence and effects of major depression (MDD) in a sample of adolescent smokers (N = 211) undergoing treatment for nicotine dependence. We assessed MDD at baseline and end of treatment with the mood disorders portion of the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV). Eleven percent of participants reported a history of MDD (6% of males and 21% of females). Study variables did not distinguish those with and without a history of MDD. End of treatment abstinence rates and relapse rates were similar in both groups. Two participants (1%), both female, experienced onset of MDD during the treatment. The findings provide further evidence that MDD is a comparatively common disorder among children and adolescents and that clinicians should monitor and be prepared to respond to depression that may emerge during the treatment of nicotine-dependent adolescents.

Smoking in adolescence: what a clinician can do to help

Approximately 4400 adolescents try their first cigarette every day in the United States. Trying a few cigarettes or using tobacco more regularly as an adolescent significantly increases the risk of smoking in adulthood. Adolescents can develop nicotine dependency after smoking relatively few cigarettes. This article points out the prevalence and unique aspects of teenage tobacco use. In addition, current recommendations for treating nicotine dependence in adolescents are reviewed.

Defining subgroups of adolescents at risk for experimental and regular smoking

If multiple etiologies of substance use are truly at work in the population, then further strides in the accurate prediction of smoking and the use of other substances will likely be built on diverse pattern-centered approaches that explore the presence of multiple population subgroups across various substance use stages. The present study aimed to identify population subgroups defined by individual risk factors or risk factor constellations that prospectively predict specific smoking stages. Using data from the National Longitudinal Study of Adolescent Health (Add Health), analyses were conducted on the sample that took part in the baseline and 1 year follow-up assessment between 1994 and 1996. Classification and regression tree procedures were used to investigate the structure of individual risk factors, or constellations of risk, that define population subgroups with high rates of both experimental and established smoking. For each level of smoking, a relatively simple model including two subgroups predicted over half of the smoking cases. Findings also indicated that the two group models identified higher rates of regular smokers compared to experimental smokers. Deviant behaviors and alcohol use without permission independently predicted movement to experimentation at follow-up. Progression to regular smoking from both a nonsmoking and experimental smoking status at baseline were each predicted by smoking friends. Additionally, baseline levels of experimental use predicted movement from experimental to regular smoking, while a relatively low grade point average predicted rapid progression from baseline nonuse to regular use at follow-up. By identifying first approximations of patterns, these analyses may lead to clues regarding the major multiple mechanisms at work for the progression of smoking among adolescents.

Smoking and depressive symptoms in Chinese elderly in Hong Kong

OBJECTIVE

To examine the association between smoking and depressive symptoms among Chinese elderly in Hong Kong.

METHOD

Cross-sectional data on smoking and depressive symptoms from 56,167 Chinese elderly aged 65 or over in Hong Kong were analysed using logistic regression.

RESULTS

Current smokers and former smokers were more likely to have depressive symptoms than never smokers. The adjusted odds ratios (OR) and 95% confidence interval (CI) in males and females respectively were 1.62 (1.34-1.96) and 1.43 (1.20-1.70) for current smokers, and were 1.18 (0.99-1.40) and 1.29 (1.12-1.47) for former smokers. Former smokers were less likely to have depressive symptoms than current smokers (OR = 0.80, 95% CI: 0.70-0.92).

CONCLUSION

Smoking is positively associated with depressive symptoms in Chinese elderly. Health care workers should be vigilant about the detection of depressive symptoms in elderly smokers.

Souffrance psychosociale et antécédents biographiques traumatiques des fumeurs

BACKGROUND

The relationship between smoking and various socio-demographic or socio-economic factors, as well as the interactions between depressive mood and smoking are already known. However, the respective contribution of psychological factors and stressful life antecedents during childhood and adolescence warrants further specification.

METHODS

2315 consecutive subjects, aged 16 to 59, consulting for a free work-up in a preventive health centre, supported by the National French Health insurance system, were invited to fill out a series of questionnaires: the GHQ-28 and the LOT, respectively measuring psychosocial distress and dispositional optimism, as well as a questionnaire on socio-demographic, socio-economic and biographical data.

RESULTS

78.1% complete records could be analysed: the "smokers" group (n = 870, 48.1%) declared a current tobacco consumption of at least one cigarette/day. This group was characterized by a predominance of male subjects, older age, modest educational level, low income level and responded to socio-economic criteria of precariousness more frequently (p < 0.001, except for age: p = 0.006). Smoking was also associated with higher levels of psychosocial distress, as assessed by GHQ-28, especially for the depressive mood and anxiety items of the questionnaire (p < 0.001), and with lower levels of dispositional optimism (p < 0.01). As regards biographical data, smokers were characterized by a way of life marked by financial problems, reduced social contacts, and a higher frequency, before the age of 18, of divorce or separation of the parents (p = 0.002), frequent parental quarrels (p < 0.001) or separation from the parents (p < 0.001). The presence of a depressive mood at GHQ-28 as well as frequent parental quarrels remained independent risk factors for smoking in multiple logistic regression (odds ratio respectively equal to 1.61 and 1.34), after adjustment on gender, educational level and the notion of socio-economic precariousness.

CONCLUSION

These results highlight the complementary role of socio-economic, psychological factors and certain stressful life antecedents among the determinants of smoking and should be taken into account for tailoring smoking cessation programs.

Measures and models of nicotine dependence: positive reinforcement

This paper addresses the problem of assessing nicotine dependence. The main objective is to develop theory-led suggestions for measures that will be relevant in the early phases of tobacco use, as well as in established smokers. Theoretical models of addiction falling into the general class of 'positive reinforcement theories' were identified and reviewed. From this review a number of drug effects and patterns of behaviour were distilled and categorized as either vulnerability or dependence indicators. A comparison of those features with the International Classification of Diseases (ICD-10) and Diagnostic and Statistical Manual (DSM-IV) diagnostic systems shows that neither system includes detailed assessment of vulnerability indicators. It is argued that measurement of vulnerability indicators, in addition to dependence indicators, may add to the predictive validity of assessments carried out in early career tobacco users, especially where there is limited evidence of established dependence. In addition, it is suggested that examination of measures that differentiate a subgroup of early career smokers termed 'rapid accelerators' may prove profitable and enable identification of the key parameters of nicotine reinforcement.

Individual and Contextual Influences on Adolescent Smoking

Cigarette smoking among adolescents remains one of the most important public health challenges. Despite much attention to research on the etiology of smoking, notably the examination of factors that differentiate adolescent smokers from never smokers, much less is known about factors that predict the development of dependence once an adolescent tries smoking. This paper reviews individual and contextual influences on the progression of smoking among adolescents. Highlights include a consideration of multiple levels of influence, from intra-individual factors, such as genetics, demographics, temperament and comorbidities, to social influences, such as families and peers, to the more macro, societal/cultural levels of influence, including advertising and tobacco-related policies. More recent work examining microcontextual influences through the use of Ecological Momentary Assessments is also discussed. Finally, the need to consider both developmental and transdisciplinary approaches to understanding the development of nicotine dependence in adolescents is emphasized.

Childhood psychopathology and adolescent cigarette smoking: a prospective survival analysis in children at high risk for substance use disorders

Children of parents with substance use disorders (SUDs) have been shown to demonstrate an increased risk for cigarette smoking in adolescence. In this prospective study, we hypothesized that adolescent cigarette smoking risk would be accounted for by childhood disruptive behavior disorders and parent cigarette smoking. Preadolescent children (ages 10-12 years) of fathers with SUD considered at high average risk (HAR; n=274) and children of fathers without SUD or major psychopathology considered at low average risk (LAR; n=298) participated in structured interviews to determine mental disorder diagnoses and substance use history. Both parents were assessed. The age of onset of daily tobacco use was determined in three follow-up assessments conducted through late adolescence. Conduct disorder (CD) and parental smoking predicted earlier daily cigarette smoking, and mediated the relationship between risk status and offspring daily cigarette smoking. Through the identification of childhood characteristics predicting daily cigarette smoking in adolescence, these results may facilitate targeting of early childhood preventive interventions.

Adolescent tobacco smoking and associated psychosocial health risk factors

OBJECTIVE

To determine the relationship between tobacco smoking and psychosocial health risk factors in adolescents.

DESIGN

An in-class survey of schoolchildren in the final grade of basic school and in all three grades of secondary school.

SETTING

Four of the 11 secondary schools in Tartu, Estonia.

SUBJECTS

977 schoolchildren, ages ranging from 14 to 18.

MAIN OUTCOME MEASURES

A questionnaire was developed to explore various psychosocial aspects of tobacco smoking behaviour. The 21-item Beck Depression Inventory was used to measure depression.

RESULTS

In the total sample, smokers accounted for 24.5% of the girls and 26.5% of the boys, of which 13% of the girls and 19% of the boys were daily smokers. Not enjoying time spent with parents (OR = 0.6), skipping breakfast (OR = 1.3), frequent headache (OR = 1.3) and stomach-ache (OR = 1.4), dislike of school (OR = 0.7), using illicit drugs (OR = 5.0) and having multiple sexual partners (OR = 2.4) were all associated with daily smoking. Higher BDI scores were seen among adolescent smokers, particularly in girls and among pupils whose parents were non-smokers. The girls who smoked daily showed a higher risk of having suicidal thoughts (OR = 2.4) compared with non-smokers.

CONCLUSION

Smoking by adolescents is an indicator of risk for depression, distress and risk-taking health-damaging behaviours.

Comorbidity in young people: perspectives and challenges

Trends in prevalence in substance misuse in young people in the UK are described: increased use over the last decade, the tendency to polydrug use, the narrowing of the gender gap. The complex issues relating to the description, definition and classification, and diagnosis of psychiatric comorbidity and substance misuse are outlined. The fact that there is no uniformly accepted definition of what constitutes 'dual diagnosis' or 'psychiatric comorbidity' in young people is highlighted: this variability impacts upon clinical assessment and study design. Despite these considerable drawbacks, a degree of consistency is beginning to emerge in the co-occurrence of some conditions, e.g. disruptive and suicidal behaviours. It is recognized that psychological distress and substance misuse are also associated with multiple social and physical complications. The rapid advances in treatment options are presented. At present the 'best practice' is implementation of what works for adults with addiction and young people with psychiatric disorder. This includes psychosocial interventions such as motivational enhancement techniques and cognitive behavioural treatment, as well as appropriate safe (usually), short-term use of a range of pharmacological agents. Very few comprehensive designated adolescent addiction services exist, while child and adolescent mental health services are under serious pressure. Thus the need for a longitudinal and multidisciplinary approach, with appropriate assessment instruments in young people, is required to further explore diagnostic classification which will classify the degrees and patterns of relationships between disorders. In this way it may be possible to build up a picture of the nature and extent of numerous complex, and sometimes overlapping, problems and needs in children and adolescents in a variety of settings: primary and secondary care, the criminal justice system and educational establishments. This might strengthen the development of innovative treatment services where novel interventions are tested as a priority.

Motivational Influences on Cigarette Smoking

Cigarette smoking is a leading cause of mortality and morbidity and a particularly common and intractable addictive disorder. Research shows that nicotine is a sine qua non of tobacco addiction and that it produces the hallmark effects of addictive drugs: sensitization, tolerance, physical dependence, and euphoria/elation. Research on the development of smoking reveals that although smoking prevalence has declined from a peak in the mid-1990s, close to 30% of twelfth graders still smoke. Smoking in adolescents is related to development of physical dependence, ethnicity, impulsivity, affective disorder, and peer influences. However, which of these exerts the greatest causal effects is unknown, and their influence no doubt varies across individuals and across development. Once dependence on tobacco smoking is established, evidence suggests that tobacco motivation is strongly influenced by a reduction in withdrawal symptoms, an expectation of stress reduction, and conditioned reinforcement. Nicotine motivation may also be influenced by modulation in stimulus incentive value.

Smoking, stress, and negative affect: correlation, causation, and context across stages of smoking

This transdisciplinary review of the literature addresses the questions, Do stress and negative affect (NA) promote smoking? and Does smoking genuinely relieve stress and NA? Drawing on both human and animal literatures, the authors examine these questions across three developmental stages of smoking--initiation, maintenance, and relapse. Methodological and conceptual distinctions relating to within- and between-subjects levels of analyses are emphasized throughout the review. Potential mechanisms underlying links between stress and NA and smoking are also reviewed. Relative to direct-effect explanations, the authors argue that contextual mediator-moderator approaches hold greater potential for elucidating complex associations between NA and stress and smoking. The authors conclude with recommendations for research initiatives that draw on more sophisticated theories and methodologies.

Depression in adolescence

Major depressive disorder is a common problem for adolescents. It has a wide array of symptoms affecting somatic, cognitive, affective, and social processes. Academic failure, poor peer relationships, behavioral problems, conflict with parents and other authority figures, and substance abuse are some of the consequences of major depressive disorder in this age group. Effective treatments include nontricyclic antidepressants and coping skills training. The nurse is key to depression detection and suicide prevention, especially in primary care settings. Through psychoeducation, nurses can promote recovery from depression by encouraging a healthy lifestyle, enhancing social skills, and assisting the adolescent to identify and use sources of social support. These measures can prevent premature death and promote long-term well-being of the adolescent.

Nicotinic acetylcholine receptors as targets for antidepressants

While the monoamine deficiency hypothesis of depression is still most commonly used to explain the actions of antidepressant drugs, a growing body of evidence has accumulated that is not adequately explained by the hypothesis. This article draws attention to contributions from another apparently common pharmacological property of antidepressant medications--the inhibition of nicotinic acetylcholine receptors (nAChR). Evidence is presented suggesting the hypercholinergic neurotransmission, which is associated with depressed mood states, may be mediated through excessive neuronal nicotinic receptor activation and that the therapeutic actions of many antidepressants may be, in part, mediated through inhibition of these receptors. In support of this hypothesis, preliminary evidence is presented suggesting that the potent, centrally acting nAChR antagonist, mecamylamine, which is devoid of monoamine reuptake inhibition, may reduce symptoms of depression and mood instability in patients with comorbid depression and bipolar disorder. If this hypothesis is supported by further preclinical and clinical research, nicotinic acetylcholine receptor antagonists may represent a novel class of therapeutic agents for treating mood disorders.

Prospective relations of body image, eating, and affective disturbances to smoking onset in adolescent girls: how Virginia slims

This study tested whether body image, eating, and affective disturbances prospectively predicted onset of cigarette smoking in adolescent girls (N = 496). Elevated body dissatisfaction and eating pathology, as well as elevated negative affectivity, showed significant univariate relations to subsequent onset of smoking. In the multivariate model, the effect for body image and eating disturbances remained significant, but the effect for negative affectivity did not. Results support the theory that body image and eating disturbances markedly increase risk for smoking initiation in adolescent girls and further establish the clinical significance of these disturbances. Results also support the theory that negative affect is a risk factor for smoking initiation but suggest that the self-medication model may have less predictive power than previously concluded.

THE ASSOCIATION BETWEEN TOBACCO SMOKING AND REPORTED PSYCHIATRIC SYMPTOMS IN AN ADOLESCENT POPULATION IN THE UNITED ARAB EMIRATES

In this study the relationship between cigarette smoking and certain elements of psychiatric morbidity, especially anxiety and depressive symptoms, was investigated among a sample of adolescents in the United Arab Emirates (UAE). The sample of the study consisted of 473 male secondary school students in the city of Ras Al-Kheima, UAE. Mean age of participants was 16.67 (SD=1.07). They completed the Arabic version of the Self-Reporting Questionnaire (SRQ-20) as well as other demographic information. Data analysis, using oneway ANOVA, revealed significantly higher reported symptoms by smokers compared with those who never smoked and those who started and stopped. The difference between those who smoked and stopped and those who never smoked was also significant.

Cigarette smoking and psychiatric comorbidity in children and adolescents

OBJECTIVE

To review the current state of knowledge of psychiatric comorbidity in adolescent cigarette smokers.

METHOD

assisted literature search was conducted and seminal articles were cross-referenced for comprehensiveness of the search. For each disorder, a synopsis of knowledge in adults is provided and compared with the knowledge in adolescents.

RESULTS

Psychiatric comorbidity is common in adolescent cigarette smokers, especially disruptive behavior disorders (such as oppositional defiant disorder, conduct disorder, and attention-deficit/hyperactivity disorder), major depressive disorders, and drug and alcohol use disorders. Anxiety disorders are modestly associated with cigarette smoking. Both early onset (<13 years) cigarette smoking and conduct problems seem to be robust markers of increased psychopathology, including substance abuse, later in life. In spite of the high comorbidity, very few adolescents have nicotine dependence diagnosed or receive smoking cessation treatment in child and adolescent psychiatric treatment settings.

CONCLUSIONS

There is increasing evidence for high rates of psychiatric comorbidity in adolescent cigarette smokers. Cigarette smoking in adolescence appears to be a strong marker of future psychopathology. Child and adolescent psychiatry treatment programs may be a good setting for prevention efforts and treatment, which should focus on both nicotine dependence and psychiatric disorders.

Differentiating stages of smoking intensity among adolescents: stage-specific psychological and social influences

Researchers' understanding of the impact of sociocultural and psychological factors on the various stages of adolescent smoking uptake is limited. Using national data, the authors examined transitions across smoking stages among adolescents (N = 20,747) as a function of interpersonal, familial, and peer domains. Peer smoking was particularly influential on differentiating regular smoking, whereas alcohol use was most influential on earlier smoking. Although significant, depression and delinquency were attenuated in the context of other variables. Higher school grade was more likely to differentiate regular smoking from earlier smoking stages, whereas African American ethnicity and connectedness to school and family were protective of smoking initiation. Results lend support for an interactional approach to adolescent smoking, with implications for stage-matched prevention and intervention applications.

Smoking in schizophrenia -- all is not biological

High rate of tobacco smoking reported in schizophrenia has been related to the effect of nicotine on the neurobiology of schizophrenia. Nicotine is said to alleviate psychotic symptoms in some patients. The relationship between smoking and psychiatric status may not be simply a biological one as several sociocultural and economic factors could influence smoking behaviour. In this study in India on 286 urban male outpatients with schizophrenia, only 38% were found to be current smokers. This was significantly more than in other psychiatric patients studied (major affective disorders and non-psychotic disorders) but not medically ill controls and not higher than the rates for the general male population in India. Smokeless use of tobacco was infrequent in the study population. More than half of the patients did not experience any positive effects due to smoking. Lack of economic independence and restrictions imposed by the family appeared to be crucial factors that controlled the prevalence of smoking among schizophrenia patients. As smoking is a leading cause of preventable morbidity and mortality, there is a serious need to review the neurobiological issue of smoking in schizophrenia considering the influence culture and social practices could have upon the behaviour.

Prevalence and predictors of premenstrual dysphoric disorder (PMDD) in older premenopausal women. The Harvard Study of Moods and Cycles

BACKGROUND

Consistent data on the prevalence and predictors of premenstrual dysphoric disorder (PMDD) in the general population are lacking.

METHODS

Premenstrual symptoms of 4164 women (aged 36-44 years) were retrospectively assessed by the Moos Premenstrual Inventory. From this original sample, 976 subjects were further interviewed at which time demographic and lifestyle characteristics, gynecologic history, and medical conditions were examined. The Structured Clinical Interview for DSM-IV Axis I disorders (SCID) was used to assess past and current psychiatric morbidity. Additionally, 513 of these women completed a prospective evaluation of premenstrual symptoms by using the Daily Rating of Severity of Problems Form (DRSP).

RESULTS

The diagnosis of PMDD was confirmed in 33 of 513 women (6.4%) who completed the prospective evaluation with daily records. Fourteen subjects (2.7%) met criteria for PMDD without a previous history of depression. PMDD was associated with lower education (odds ratio [OR]=2.3, confidence interval [CI]=1.1-4.9), a history of major depression (OR=3.6, CI=1.7-7.4), and current cigarette smoking (OR=4.1, CI=1.5-11.1). In addition, women not working outside the home were significantly less likely to meet criteria for PMDD (OR=0.2, CI=0.1-0.9).

LIMITATIONS

Only 513 of 976 women agreed to have their symptoms documented prospectively. Symptoms were assessed over the course of one menstrual cycle.

CONCLUSIONS

This study indicates a significant prevalence of PMDD in a large community-based sample. Given the associated impairment in social and occupational functioning seen in PMDD, these prevalence data provide a strong rationale for enhanced recognition and treatment of the disorder.

Anxiety, affect, and activity in teenagers: monitoring daily life with electronic diaries

OBJECTIVE

The everyday experiences of a community sample of adolescents differing in anxiety level were compared by means of electronic diaries.

METHOD

One hundred fifty-five ninth-grade adolescents completed electronic diaries every 30 minutes for two 4-day intervals, reporting their moods, activities, social settings, dietary intake, smoking, and alcohol use. Teenagers were stratified into low-, middle-, or high-anxiety groups on the basis of diary ratings and, separately, questionnaire scores.

RESULTS

High-anxiety teenagers, compared with low-anxiety teenagers, expressed higher levels not only of anxiety and stress but also of anger, sadness, and fatigue, along with lower levels of happiness and well-being. They reported fewer conversations and less recreational activity relative to achievement-oriented pursuits, stronger eating and smoking urges, and more tobacco use. There were few gender differences. Despite a tendency to spend less time with peers, high-anxiety teenagers were more likely to show reduced anxiety when in the company of friends. Sharper differentiations among anxiety subgroups emerged when stratification was based on diary reports rather than on questionnaire scores.

CONCLUSION

Even when anxiety problems fall below diagnostic thresholds, the daily lives of anxious adolescents differ meaningfully from those of their peers in affective, behavioral, and contextual domains.

Child and adolescent psychopathology as risk factors for subsequent tobacco use

A growing body of research suggests that a number of types of psychopathology that occur during childhood and adolescence are also associated with an increased risk for tobacco use. This paper assesses the relationship between several types of child and adolescent psychopathology and subsequent tobacco use. The types of psychopathology that are discussed include 'externalizing' disorders such as conduct problems and attention-deficit/hyperactivity disorder (ADHD), and 'internalizing' disorders such as depression and anxiety disorders. The strongest evidence for connections between child and adolescent psychopathology and subsequent tobacco use is for conduct problems, ADHD, and depression. There is much weaker support for a connection between anxiety disorders and tobacco use. The relationships between conduct problems and ADHD (which frequently co-occur) and subsequent tobacco use are quite robust. Possible explanations of the relationships between conduct problems, ADHD, and tobacco use are presented. There appears to be a bidirectional relationship between depression and tobacco use; i.e., each has a comparable probability of preceding the other. Areas of particular importance are: (a) the effects of various psychopathologies on various aspects of tobacco use; (b) the role of comorbid psychopathologies; (c) identification of protective factors; (d) the effects of moderators (e.g., gender, ethnicity); (e) mechanisms and processes ('active ingredients') associated with various psychopathologies; (f) implications for intervention; and (g) possible cohort effects.

Ethnicity, gender and risk factors for smoking initiation: an overview

Although the prevalence of cigarette smoking has increased dramatically among youth over the past several years, there are significant ethnic and gender differences in prevalence rates. This paper presents highlights of the research literature on ethnic and gender differences in risk factors for smoking. The effects of peer and family influences may vary by both ethnicity and gender. White youth, especially females, may be more susceptible to the negative influence of friends' smoking than are African-American youth. Although the evidence about the relative importance of parent smoking among ethnic groups is contradictory, recent data suggest that African-American parents provide stronger anti-smoking messages than do white parents. The subgroups also vary in their perceptions of the negative consequences of smoking, with Asian-American and African-American females perceiving stronger negative consequences. Cultural expectations may place white females at increased risk for smoking. The link between depressed mood and smoking also varies by subgroup. Finally, popular media figures may influence the appeal of smoking and be differentially relevant to youth subgroups. We need: (1) specific examinations of ethnic and gender effects with attention paid to identifying protective factors among certain ethnic/gender subgroups; (2) to know more about how family influences may vary by the ethnic/gender subgroups and over the developmental course of smoking; (3) to know more about how youth cope with negative moods and the role of smoking in coping; and (4) to investigate whether the factors that protect youth in some subgroups can be diffused to others.