Download Smoking Behavior

Preventing Smoking in Adolescents with ADHD: A High
Risk Population
Research supported by a grant from the Virginia Tobacco Settlement Foundation
Steven W. Evans, Ph.D.
Amy L. Williams, B.S.
Sheryle A. Moore, B.S.
Zewelanji Serpell, Ph.D.
Problem & Objectives
Methods
Adolescents with Attention Deficit Hyperactivity
Disorder (ADHD) smoke at a significantly greater rate
than their peers without ADHD, suggesting that ADHD is
a risk factor for tobacco use. A study by Milberger et al
(1997) revealed that ADHD, particularly when comorbid
with other disorders, predicted early initiation of cigarette
smoking. In another study, participants with inattention
problems were found to be more likely to experiment
with cigarette smoking and to become regular tobacco
users (Tercyak, Lerman, Audrain, 2002).
The apparent link between ADHD and smoking
suggests symptoms associated with this disorder might
serve as risk factors for smoking. It has been argued that
the inattention, impulsivity, and social impairment
characteristic of ADHD contribute to substance
experimentation and use. In one study, impairment in
social functioning (common in youth with ADHD) was
the sole significant predictor of alcohol and substance
abuse, as well as smoking (Greene, Biederman, Faraone,
Wilens, Mick, & Blier, 1999). Because, similar to
stimulant medication, nicotine has been shown to improve
attention, the possibility also exists that smoking may
serve as a form of self-medication for youth with ADHD
(Patton et al., 1996). Such findings suggest that by
specifically targeting the risk factors associated with
ADHD, there is a unique opportunity to prevent smoking
in this youth population.
Our initial objective was to recruit participants and
assess the extent to which they exhibited the
aforementioned risk factors for smoking and also
establish that our method and design would facilitate
intervention before the onset of smoking in this high risk
population.
As part of a long-term treatment study, researchers
developed a comprehensive treatment program to address
specific risk factors associated with ADHD so as to prevent
future smoking behavior. As a number of individuals are
typically involved in treating adolescents with this disorder,
development of this program was collaborative in nature,
incorporating feedback and expertise of teachers,
physicians, clinicians, and parents of children of ADHD.
The ultimate goal was to develop a treatment program that
is both effective for treating these symptoms of ADHD that
place adolescents at risk for smoking and feasible for
implementation in community settings.
Tercyak, K., Lerman, C., & Audrain, J. (2002) Association of
attention-deficit
/hyperactivity disorder symptoms with levels
of cigarette smoking in a
community sample of adolescents.
Journal of American Academy of Children and Adolescents, 41(7),
799- 805.
Greene, R., Biederman, J., Faraone, S., Wilens, T., Mick, E., & Blier,
H. (1999) Further
validation of social impairment as a predictor
of substance use disorders: Findings from a sample of siblings of
boys with and without ADHD. Journal of Clinical Child
Psychology, 28(3), 349-354.
Lerman, C. Audrain, J., Tercyak, K., Hawk, L., Bush, A., CrystalMansour, S., Rose, C., Niaura, R., & Epstein, L. (2001) Attention
deficit hyperactivity disorder ADHD symptoms and smoking
patterns among participant in a smoking
cessation program.
Nicotine and Tobacco Research, 3(4), 353-359.
Biederman, J., Wilens, T., Mick, e., Spencer, T., & Faraone, S.
(1999). Pharmacotherapy
of Attention-deficit/hyperactivity
disorder reduces risk for substance use
disorder. Pediatrics,
104, 1-5.
Lambert N. & Hartsough, C. (1998). Prospective study of tobacco
smoking and substance dependencies among samples of ADHD and
Non-ADHD participants.
Journal of Learning Disabilities,
31(6), 533-544.
Milberger, S., Biederman, J., Faraone, S., Chen, L., & Jones, J.
(1996). Further
Evidence of an association between Attentiondeficit/hyperactivity disorder and
cigarette smoking. The
American Journal on Addictions, 6(3), 205-215.
The Challenging Horizons Program
The resulting program, the Challenging Horizons
Program (CHP), is a community-based treatment program
that is currently being implemented in 2 middle schools and
pediatric practices in Virginia. The program consists of a set
of psychosocial interventions that are implemented at
school, and a medication algorithm. CHP treatments are
designed to target the academic and social impairments
characteristic of ADHD that place adolescents with this
disorder at risk for smoking.
Researchers recruited 40 sixth-grade participants
from four middle schools. Participants attending schools
assigned to the treatment condition receive the treatments
described above. Participants attending schools assigned to
the control condition (n=20) receive typical care for ADHD.
For all participants, ADHD symptoms and impairment,
tobacco use, exposure, and experimentation were measured
upon entry into the program. ADHD symptoms and
impairment that serve as risk factors for smoking were
assessed by the Disruptive Behavior Disorders Rating Scale
(DBD) and the Social Skills Rating System (SSRS).
Smoking behavior was assessed using the Substance Use
Questionnaire (SUQ). Results from baseline assessments
for 29 of the participants who have completed initial
evaluations follow.
Recommendations
 Universal smoking prevention
programs may prove more effective
if supplemented by programs that
target specific populations.
 Intervention should occur at the
level of risk in order to prevent
future smoking behavior.
Jennifer Capito, B.A.
Results
Number of Participants
Works Cited
Lindsay Barnett
Baseline assessment data was available for 29 study
participants all of whom were in the sixth grade at one of
the participating middle schools. Participants included 20
males and 9 females between the ages of 10 and 13. All 29
participants met criteria for ADHD as outlined by the
Diagnostic and Statistical Manual of Mental Disorders
(DSM IV). 20 met criteria for combined type ADHD and
nine met criteria for predominantly inattentive type.
ADHD SubType
Inatte ntive Type
Com bine d Type
Social Impairment - Impairment in social functioning was
assessed using parent report on the SSRS. Results indicate
that out of 29 participants, 4 were rated by their parents as
being average or above in social skills, the rest were rated
as below average, some significantly impaired.
Parent Ratings on the SSRS
9
8
7
6
5
4
3
2
50-60
61-70
71-80
81-90
91-100
abov e 100
SSRS Score s (a s cor e of 100 indicates ave r age social s kills )
Smoking Behavior - Results from the SUQ reveal that of the
29 participants, only 2 reported ever having tried a cigarette
and neither of them reported ever having smoked a cigarette
beyond simply trying one.
Conclusions & Rationale for Recommendations
Results from baseline assessment establish the
presence of at least two risk factors for smoking in the
sample, inattention and social impairment. Consistent with
studies reporting the average age of smoking initiation in
adolescents with ADHD is 15.5 years (Milberger et al.,
1997), results also show that the majority of participants did
not classify themselves as smokers or report ever having
tried smoking. Because participants are recruited in the sixth
grade, at an age that is lower than the typical age of smoking
onset for this population, our method and design can
successfully target youth before the critical period when
they are likely to initiate smoking.
The impairment that is associated with ADHD that
places students at risk for smoking will be evaluated for
each participant over the course of the next five years.
Future work will therefore examine the effectiveness of the
Challenging Horizons Program as a prevention program for
smoking in this high risk population.