ARTICLES
Cigarette Smoking and Psychiatric Comorbidity in Children and Adolescents

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ABSTRACT

Objective:

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

Method:

Medline 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.

Section snippets

Adult Studies

At least two reports indicate that, in a small sample of smokers and nonsmokers with attention-deficit/ hyperactivity disorder (ADHD), a nicotine transdermal patch improved the Clinical Global Impression scores and caused increased vigor, reduction in reaction time on the Continuous Performance Test, and improved accuracy of time estimation (Conners et al., 1996;Levin et al., 1996). Pomerleau and colleagues (1995) found that adults with ADHD are more likely to smoke and may have a harder time

ODD/CD AND SMOKING

Evidence from studies involving genetic and epidemiological approaches in both community and psychiatric samples indicates a strong link between disruptive behavior disorders and cigarette smoking. Cigarette smoking in subjects with oppositional defiant disorder (ODD)/CD may represent a general pattern of defiant behaviors or individuals with CD may have an increased vulnerability to the development of nicotine dependence (Donovan et al., 1988;Jessor and Jessor, 1977). Pomerleau and colleagues

SMOKING AND MOOD DISORDERS

Major depression is the mood disorder most consistently and robustly associated with cigarette smoking.

Adult Studies

Research on anxiety disorders and nicotine dependence in adults is limited, although most studies exploring mood disorders assess or query about anxiety symptoms or disorders. Despite systematic assessment of anxiety symptoms, there is a dearth of research focused specifically on anxiety disorders and comorbid nicotine dependence. Breslau and colleagues (1991) used the National Institute of Mental Health Diagnostic Interview Schedule (Robins et al., 1981) to investigate the OR of major

Adult Studies

Not surprisingly, early tobacco use increases the risk of developing nicotine dependence (Breslau et al., 1993). Cigarette smoking has also been associated with increased odds of alcohol and drug use in several reports (Black et al., 1999;Burling and Ziff, 1988;Golding et al., 1983;Henningfield et al., 1990;Hughes and Frances, 1995;Joseph et al., 1990;Kao et al., 2000;Revell et al., 1985;Torabi et al., 1993). Several reports indicate that smokers are more likely to drink alcohol than

POSSIBLE MECHANISMS FOR THE LINK BETWEEN SMOKING AND PSYCHIATRIC DISORDERS

The exact mechanism of the comorbidity between smoking and psychiatric disorders is not known. The comorbidity may be explained by the combination of one or more of the following factors: chance, common vulnerability to both psychiatric disorders and smoking (familial/genetic or environmental), self-medication, and common neurobiological alterations. For example, a yet unidentified substance in cigarette smoke inhibits brain monoamine oxidase (MAO) A activity by an average of 28% in the various

SUMMARY AND CLINICAL IMPLICATIONS

Many psychiatric disorders are highly comorbid with cigarette smoking in adolescents. Most studies have examined the relationship between loosely defined “regular” cigarette smoking and psychiatric disorders, whereas the emerging evidence indicates that DSM-IV based diagnosis of nicotine dependence is even more robustly associated with psychiatric comorbidity (Breslau, 1995;Dierker et al., 2001).

In clinical settings, it is important to assess adolescent smokers for psychiatric disorders and to

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    Financial support for this project was provided by the career development K12 award, grant DA00357-01, given jointly from the AACAP and NIDA to Dr. Upadhyaya.

    Reprint requests to Dr. Upadhyaya, 2N IOP, Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, 67 President Street, Charleston, SC 29425.

    DOI: 10.1097/01.CHI.0000024845.60748.8F

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