Tobacco smoking in individuals with attention-deficit hyperactivity disorder: epidemiology and pharmacological approaches to cessation

Attention-Deficit/Hyperactivity Disorder Symptoms and Later E-Cigarette and Tobacco Use in US Youths

Importance

Information about longitudinal associations of attention-deficit/hyperactivity disorder (ADHD) diagnosis, symptom severity, pharmacotherapy, and incident nicotine and tobacco use, including e-cigarettes, among US youths is limited.

Objective

To evaluate whether ADHD diagnosis, symptom severity, and pharmacotherapy are associated with incident e-cigarette and tobacco use over a 9-year period.

Design, Setting, and Participants

This longitudinal cohort study followed up a nationally representative sample of US youths and their parents in the Population Assessment of Tobacco and Study via questionnaires from wave 1 (September 2013 to December 2014) to waves 2 to 7 (October 2014 to April 2023). Participants were representative of the US civilian noninstitutionalized population. Youths aged 12 to 17 years at wave 1 (N = 13 572) and their parents were interviewed.

Exposures

Time in years and history of ADHD diagnosis, symptom severity, and pharmacotherapy at wave 1 were used to construct 9 mutually exclusive subgroups of US youths, including those with ADHD diagnosis and pharmacotherapy, ADHD diagnosis without pharmacotherapy, and population controls without ADHD diagnosis; within each of these 3 subgroups, ADHD symptom severity was categorized as none, 1 to 2, or 3 to 4 symptoms.

Main Outcomes and Measures

Incident e-cigarette use, cigarette smoking, other tobacco use, and dual use (e-cigarette and cigarette and/or other tobacco use) in weighted percentages with 95% CIs.

Results

Of the 13 572 youths included in the analysis, 6967 (51.3%; 95% CI, 51.2%-51.5%) were male. An estimated 1881 participants (14.1%; 95% CI, 13.2%-15.0%) were diagnosed with ADHD. Multivariable logistic regression analyses indicated that the adjusted odds of incident e-cigarette use, cigarette smoking, other tobacco use, and dual use did not significantly differ between those with asymptomatic ADHD (with or without pharmacotherapy) compared with population controls. In contrast, all subgroups who had 3 or more ADHD symptoms (with or without pharmacotherapy) had significantly higher adjusted odds of e-cigarette use (adjusted odds ratio [AOR], 1.60; 95% CI, 1.34-2.04), cigarette smoking (AOR, 1.52; 95% CI, 1.22-1.89), other tobacco use (AOR, 1.61; 95% CI, 1.27-2.02), and dual use (AOR, 1.72; 95% CI, 1.38-2.14) compared with youths with asymptomatic ADHD or population controls. Among youths with ADHD, those with highly symptomatic ADHD were significantly more likely to initiate e-cigarette (AOR, 1.68; 95% CI, 1.16-2.44) and dual use (AOR, 1.82; 95% CI, 1.17-2.83) than youths without symptoms.

Conclusions and Relevance

In this cohort study of US youths, ADHD symptoms were associated with the onset of nicotine and tobacco use. Findings highlight the importance of early diagnosis and effective treatment of ADHD to alleviate symptoms and reduce the risk of later nicotine and tobacco use.

TOBACCO USE DISORDER AND DUAL DISORDERS Joint statement by the Spanish Psychiatry Society and the Spanish Dual Disorders Society

Tobacco Use Disorder (TUD) is a health problem of the first order in the world population, affecting a vulnerable population, such as people with other mental disorders, whose morbidity and mortality are increased as a result.

Concurrent Disorder Management Guidelines. Systematic Review

Concurrent disorder refers to a diverse set of combinations of substance use disorders and mental disorders simultaneously in need of treatment. Concurrent disorders are underdiagnosed, undertreated, and more complex to manage, practicing the best recommendations can support better outcomes. The purpose of this work is to systematically assess the quality of the current concurrent disorders’ clinical recommendation management guidelines. Literature searches were performed by two independent authors in electronic databases, web, and gray literature. The inclusion criteria were English language clinical management guidelines for adult concurrent disorders between 2000 and 2020. The initial search resulted in 8841 hits. A total of 24 guidelines were identified and assessed with the standardized guidelines assessment tool: AGREE II (Appraisal of Guidelines for Research and Evaluation). Most guidelines had acceptable standards, however, only the NICE guidelines had all detailed information on all AGREE II Domains. Guidelines generally supported combinations of treatments for individual disorders with a very small evidence base for concurrent disorders, and they provided little recommendation for further structuring of the field, such as level of complexity or staging, or evaluating different models of treatment integration.

Attention Deficit Hyperactivity Disorder Increases Nicotine Addiction Severity in Adults Seeking Treatment for Substance Use Disorders: The Role of Personality Disorders

AIMS

To examine the role of attention deficit/hyperactivity disorder (ADHD) and impulsive personality disorders in nicotine addiction severity among treatment-seeking substance use disorder (SUD) patients.

METHODS

In a cross-sectional study, we examined data from the second International ADHD in Substance Use Disorders Prevalence Study (IASP-2) on 402 adults in SUD treatment from Puerto Rico, Hungary, and Australia using diagnostic interviews for ADHD, antisocial (ASP) and borderline (BPD) personality disorders, and the self-report Fagerström Test of Nicotine Dependence (FTND). We compared SUD patients with and without ADHD on nicotine addiction severity. We tested direct and indirect pathways from ADHD to nicotine addiction and mediation through ASP and BPD.

RESULTS

Overall, 81.4% of SUD patients reported current cigarette smoking. SUD patients with ADHD had higher FTND scores and smoked more cigarettes than those without ADHD, with an earlier onset and more years of smoking. ASP mediated the effect of ADHD on all aspects of nicotine addiction severity, whereas BPD did so only on some aspects of nicotine addiction severity.

CONCLUSIONS

SUD patients with comorbid ADHD show more severe nicotine addiction than those without, which is largely explained by comorbid impulsive personality disorders. In SUD patients, it is important to screen for adult ADHD and other psychiatric disorders, especially those with impulse control deficits such as ASP and BPD.

ADHD symptoms impact smoking outcomes and withdrawal in response to Varenicline treatment for smoking cessation

INTRODUCTION

Attention-Deficit/Hyperactivity Disorder (ADHD) is associated with nicotine dependence and difficulty quitting smoking. Few cessation trials specifically consider the impact of ADHD on treatment outcomes, including those testing established pharmacological therapies, such as varenicline.

METHODS

The current study focused on the impact of pretreatment ADHD inattention (IN) and hyperactivity-impulsivity (HI) symptoms on treatment outcome in a randomized controlled trial of varenicline [N=205, average age=34.13(10.07), average baseline cigarettes per day=14.71(7.06)]. Given that varenicline's putative therapeutic mechanism is attenuation of withdrawal severity during abstinence, we also tested changes in withdrawal as a mediator of treatment effects in high and low ADHD groups.

RESULTS

ADHD symptom severity in this sample was in the subclinical range. Cessation was associated with HI, but not IN, such that high HI individuals on varenicline reported the lowest smoking levels at the end of treatment across all groups (3.06cig/day for high HI vs 4.02cig/day for low HI). Individuals with high HI who received placebo had the highest smoking at the end of treatment (7.69cigs/day for high HI vs 5.56cig/day for low HI). Patterns continued at follow-up. Varenicline significantly reduced withdrawal for those with high HI, but not low HI. However, path models did not support an indirect effect of medication on reducing smoking via withdrawal in either group, suggesting that unmeasured variables are involved in varenicline's effect on reducing smoking.

CONCLUSIONS

These data add to a gap in the smoking cessation literature regarding the impact of ADHD symptoms on the efficacy and mechanisms of frontline pharmacological treatments.

Smoking, alcohol and drug use in youth and adults with attention-deficit hyperactivity disorder

BACKGROUND

Previous research suggests a relationship between attention-deficit hyperactivity disorder (ADHD) and smoking, alcohol and illicit drug use, however most studies have focused on adolescents or young adults, or clinically ascertained samples.

AIMS

To analyse population-based data on the relationship between ADHD and at-risk health behaviours in adolescents and adults.

METHOD

Data were derived from a Statistics Canada population-based health survey. The association between the diagnosis of ADHD and smoking, alcohol use, and illicit drug use was examined.

RESULTS

Individuals with ADHD started smoking at a younger age. They consumed more alcoholic drinks on drinking days, and women with ADHD were more likely to engage in binge drinking. Women over the age of 25 and men with ADHD were more likely to meet alcohol-dependence lifetime criteria. People with ADHD were at a greater risk of drug misuse and dependence.

CONCLUSIONS

People with ADHD are more likely to partake in at-risk behaviours.

DECLARATION OF INTEREST

None.

COPYRIGHT AND USAGE

© The Royal College of Psychiatrists 2017. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) license.

ADHD as a risk factor for early onset and heightened adult problem severity of illicit substance use: an accelerated gateway model

The primary aims of the present study were to assess ADHD history as a risk factor for earlier initiation and current use of licit and illicit substances among a sample of drug using adults. It was hypothesized that ADHD history would accelerate the Gateway Theory of drug use. Participants included 941 drug-using African American and Caucasian individuals in Baltimore, Maryland. The sample consisted of 124 (13.2%) participants who reported a history of ADHD and 817 (86.8%) who reported no history of ADHD. The accelerated gateway hypothesis was supported, as a history of self-reported ADHD was significantly associated with younger ages of initiation for alcohol, cigarettes, marijuana, and cocaine use. Participants with a history of ADHD were also more likely to engage in recent HIV-risk behavior, such as injection drug use and needle sharing. This study provides compelling data in support of an accelerated gateway model for substance use related to ADHD history and increased problem severity in adulthood. Targeted substance use prevention and intervention may be beneficial for those with ADHD.

Pharmacological and clinical dilemmas of prescribing in co-morbid adult attention-deficit/hyperactivity disorder and addiction

The present article reviews whether available efficacy and safety data support the pharmacological treatment of adult attention-deficit/hyperactivity disorder (ADHD) in patients with concurrent substance use disorders (SUD). Arguments for and against treating adult ADHD with active SUD are discussed. Findings from 19 large open studies and controlled clinical trials show that the use of atomoxetine or extended-release methylphenidate formulations, together with psychological therapy, yield promising though inconclusive results about short term efficacy of these drugs in the treatment of adult ADHD in patients with SUD and no other severe mental disorders. However, the efficacy of these drugs is scant or lacking for treating concurrent SUD. No serious safety issues have been associated with these drugs in patients with co-morbid SUD-ADHD, given their low risk of abuse and favourable side effect and drug-drug interaction profile. The decision to treat adult ADHD in the context of active SUD depends on various factors, some directly related to SUD-ADHD co-morbidity (e.g. degree of diagnostic uncertainty for ADHD) and other factors related to the clinical expertise of the medical staff and availability of adequate resources (e.g. the means to monitor compliance with pharmacological treatment). Our recommendation is that clinical decisions be individualized and based on a careful analysis of the advantages and disadvantages of pharmacological treatment for ADHD on a case-by-case basis in the context of active SUD.

Attention-deficit/hyperactivity disorder and adverse health outcomes

Attention-deficit/hyperactivity disorder (ADHD) is defined by extreme levels of inattention-disorganization and/or hyperactivity-impulsivity. In DSM-IV, the diagnostic criteria required impairment in social, academic, or occupational functioning. With DSM-5 publication imminent in 2013, further evaluation of impairment in ADHD is timely. This article reviews the current state of knowledge on health-related impairments of ADHD, including smoking, drug abuse, accidental injury, sleep, obesity, hypertension, diabetes, and suicidal behavior. It concludes by suggesting the need for new avenues of research on mechanisms of association and the potential for ADHD to be an early warning sign for secondary prevention of some poor health outcomes.

Attention-deficit/hyperactivity disorder (ADHD) symptoms, craving to smoke, and tobacco withdrawal symptoms in adult smokers with ADHD

BACKGROUND

Tobacco withdrawal symptoms may be confounded with attention-deficit/hyperactivity disorder (ADHD) symptoms among smokers with ADHD.

OBJECTIVE

(1) To assess overlap between ADHD symptoms and tobacco/nicotine withdrawal symptoms and craving; (2) to assess the relationship between craving or withdrawal symptoms and the effect of osmotic-release oral system methylphenidate (OROS-MPH) on ADHD symptoms; (3) to assess the association of ADHD symptoms, craving, and withdrawal symptoms with abstinence.

METHODS

Secondary analysis of a randomized, placebo controlled smoking cessation trial assessing the efficacy of OROS-MPH taken in addition to nicotine patch among individuals with ADHD. ADHD symptoms, withdrawal symptoms, and craving were assessed at baseline and 2, 4 and 6 weeks after a target quit day.

RESULTS

Withdrawal symptoms and craving showed limited and modest overlap with ADHD symptoms prior to abstinence but more extensive and stronger correlation after quit day. Compared to placebo, OROS-MPH reduced ADHD symptoms; this effect was attenuated by controlling for withdrawal symptoms, but not by craving. Craving, but not ADHD symptoms and withdrawal symptoms, was associated with abstinence during the trial.

CONCLUSION

When treating smokers with ADHD (1) craving, rather than tobacco withdrawal symptoms or ADHD symptoms may be the more effective therapeutic smoking cessation targets; (2) careful distinction of craving, withdrawal symptoms, and ADHD symptoms when assessing withdrawal phenomena is needed.

Divergence by ADHD subtype in smoking cessation response to OROS-methylphenidate

INTRODUCTION

Attention deficit hyperactivity disorder (ADHD) is a neuropsychiatric condition subclassified in DSM-IV according to its core symptoms domains as (a) predominantly inattentive (ADHD-IN), (b) predominantly hyperactive/impulsive (ADHD-H), and (c) combined inattentive and hyperactive/impulsive (ADHD-C). Whether these subtypes represent distinct clinical entities or points on a severity continuum is controversial. Divergence in treatment response is a potential indicator of qualitative heterogeneity. This study examined smoking cessation response by ADHD subtype to osmotic-release oral system methylphenidate (OROS-MPH).

METHODS

Male and female adult smokers (ADHD-C = 167 and ADHD-IN = 87) were randomized to receive OROS-MPH or placebo as augmentation treatment to nicotine patch and counseling. Logistic regression was conducted to test the effect of OROS-MPH versus placebo on prolonged smoking abstinence by ADHD subtype.

RESULTS

The subtypes were similar in baseline demographic, smoking, and psychiatric history but differed in smoking cessation response to OROS-MPH or placebo as a function of nicotine dependence level. The 3-way interaction was significant; χ(2)(1) = 8.22, p < .01. Among highly dependent smokers, the prolonged abstinence rates were greater with OROS-MPH than with placebo in the ADHD-C group (60% vs. 31.3%, respectively, p < .05) but higher with placebo than with OROS-MPH in the ADHD-IN group (60% vs. 11.8%, respectively, p < .01). Abstinence rates did not differ by subtype or treatment among smokers who were less nicotine dependent.

CONCLUSION

Contrasting treatment response and divergence in the impact of nicotine dependence level support the hypothesis of ADHD subtypes as distinct clinical entities and may indicate the need and directions for personalized targeted treatments of smokers with ADHD.

Smoking cessation treatment for adolescents

Cigarette smoking in the adolescent population remains a public health concern. A significant portion of the adolescent population currently uses tobacco. Nicotine is particularly addicting in adolescents, and quitting is difficult. The goals for adolescent cigarette smoking efforts must include both primary prevention and smoking cessation. Bupropion and nicotine replacement therapies-including nicotine patches, gum, and nasal spray-have been studied to a limited extent in the adolescent population. Varenicline has not been evaluated as a treatment modality in adolescents. Long-term quit rates in the pharmacotherapy trials have not been optimal; however, decreases in cigarettes smoked per day have been observed. Several evidencebased guidelines include recommendations for smoking cessation in adolescents that include counseling and pharmacotherapy. Pharmacotherapy may be instituted for some adolescents in addition to counseling and behavioral interventions. Therapy should be individualized, based on smoking patterns, patient preferences, and concomitant disease states. Smoking cessation support for parents should be instituted as well. The pharmacist can play a large role in helping the adolescent quit smoking. Further studies evaluating pharmacotherapy options for smoking cessation in adolescents are necessary. If pharmacotherapy is used, it should be individualized and combined with psychosocial and behavioral interventions.

Cognitive effects of nicotine: genetic moderators

Cigarette smoking is the main preventable cause of death in developed countries, and the development of more effective treatments is necessary. Cumulating evidence suggests that cognitive enhancement may contribute to the addictive actions of nicotine. Several studies have demonstrated that nicotine enhances cognitive performance in both smokers and non-smokers. Genetic studies support the role of both dopamine (DA) and nicotinic acetylcholine receptors (nAChRs) associated with nicotine-induced cognitive enhancement. Based on knockout mice studies, beta2 nAChRs are thought to be essential in mediating the cognitive effects of nicotine. alpha7nAChRs are associated with attentional and sensory filtering response, especially in schizophrenic individuals. Genetic variation in D2 type DA receptors and the catechol-O-methyltransferase enzyme appears to moderate cognitive deficits induced by smoking abstinence. Serotonin transporter (5-HTT) gene variation also moderates nicotine-induced improvement in spatial working memory. Less is known about the contribution of genetic variation in DA transporter and D4 type DA receptor genetic variation on the cognitive effects of nicotine. Future research will provide a clearer understanding of the mechanism underlying the cognitive-enhancing actions of nicotine.