Adult ADHD and Nicotine Use
Adult ADHD and Nicotine Use
In this qualitative study, nine out of twelve subjects clearly identified perceived links between tobacco use and their ADHD. One had not thought about a connection and two participants did not address this topic in their narrative. In addition, subjects described an influence of prescription medications, as well as an effect of other psychotropic substances on their thoughts and behaviors related to tobacco use.
We identified two core beliefs linking ADHD and cigarette smoking. The first theme, smoking as an attempt at self-medication, was adopted by the majority of the participants as their preferred description of the link between smoking and ADHD. Subjects generally had a positive view of the effects of tobacco, describing a range of beneficial uses: reducing tension, alleviating restlessness, relaxing in general, improving attention, regulating emotional distress, and relieving depressive symptoms. Thus participants might use tobacco to try to treat the symptoms and cognitive deficits arising from adult ADHD. These qualitative reports are in accord with previous findings that nicotine may improve clinical symptoms and cognitive function in adults with ADHD. Overall, our results provide further support for the hypothesis that smoking is a form of self-medication among adults with ADHD.
The second theme, smoking as a social behavior demonstrated that smoking was considered by many to enhance social functioning and to have a positive impact on interpersonal relationships.
Furthermore, some participants primarily initiated tobacco use not to attenuate symptoms of inattention or hyperactivity but to live a more exciting lifestyle, to undermine perceived social norms, to enhance their self-image, and to gain access to a desired non-conformist peer group. It is possible that the ADHD participants in this study who favored this motive are more impulsive and behaviorally disinhibited than others; however, none fulfilled ICD-10 criteria for a conduct disorder in the past, or a current personality disorder. It must be noted that subjects who identified this motive began smoking against the backdrop of their overall subjective experiences, cultural norms and institutions, gender roles, and aesthetics, all of which are strong influences on smoking behavior in general.
At first glance, the views of our study participants do not differ greatly from explanations given by cigarette-smokers without ADHD. For example, a recent qualitative study of cigarette-smoking college students found that smoking "served as an aid in alleviating anticipated stress"; "helped clear the mind when shifting from one subject to another"; "helped to refocus thoughts during a study session, facilitating greater concentration"; "served as a reward to celebrate the completion of a study session or an examination"; and helped to change the mindset when "transitioning from studying to being social". However, it must be noted that nicotine effects in adults with ADHD might exceed those in healthy volunteers, because they improve the attention of the former, as well as their clinical symptomatology. Comparisons with healthy volunteers or the general population might therefore be misleading.
Finally, findings on the influence of prescription drugs on tobacco use patterns were heterogeneous. Given that existing literature on the effects of stimulant medication on smokers with ADHD presents conflicting conclusions, we were intrigued to learn how subjects would describe the influence of stimulant medication on their tobacco-use patterns. However, only a few subjects made a clear assertion. The majority believed that the effects of stimulant therapy on nicotine craving wore off quickly, resulting in only a transient decrease in smoking, or that stimulants had no effect on cigarette use or even reinforced it. This supports Hurt et al., Winhusen et al., and Rush et al.
Furthermore, Vansickel et al. recently reported that immediate-release methylphenidate used by smokers with ADHD actually increased both the total number of cigarettes smoked and their carbon monoxide levels. Other investigators did not find significantly increased daily smoking rates in adults with ADHD. It has been suggested that differences in formulation might explain this discrepancy. In our sample, we did not find evidence for a link between smoking patterns and stimulant formulations.
We acknowledge the limitations of this study. First, we wished to obtain a comprehensive understanding of participants' views, so we conducted extensive interviews with a small sample. Second, all study subjects were recruited from the same outpatient treatment facility, so it is unclear to what extent the present findings can be generalized. Third, since a majority of potential participants could not be interviewed for this study, there may have been an additional self-selection or non-response bias, further limiting generalizability. Fourth, interviews were conducted by a clinical psychologist and analyzed by a team of psychiatrists and psychologists actively involved in multimodal treatment for patients with ADHD, which may have influenced categorization.
The results we have presented should therefore be verified by further studies with more diverse patient groups. An initial step could be to recruit participants from more diverse treatment modalities, younger age group (e.g. adolescents 15 – 18 years) and with a wider variety of comorbidities. Since the majority of our participants belonged to the adult ADHD combined subtype, further research could also focus on the inattentive and hyperactive subtypes or presentations according to DSM-V. Finally, we did not include a non-ADHD comparison group, which could significantly enhance our understanding of the perceived differences in nicotine effects between adults with ADHD and the general population.
Discussion
In this qualitative study, nine out of twelve subjects clearly identified perceived links between tobacco use and their ADHD. One had not thought about a connection and two participants did not address this topic in their narrative. In addition, subjects described an influence of prescription medications, as well as an effect of other psychotropic substances on their thoughts and behaviors related to tobacco use.
We identified two core beliefs linking ADHD and cigarette smoking. The first theme, smoking as an attempt at self-medication, was adopted by the majority of the participants as their preferred description of the link between smoking and ADHD. Subjects generally had a positive view of the effects of tobacco, describing a range of beneficial uses: reducing tension, alleviating restlessness, relaxing in general, improving attention, regulating emotional distress, and relieving depressive symptoms. Thus participants might use tobacco to try to treat the symptoms and cognitive deficits arising from adult ADHD. These qualitative reports are in accord with previous findings that nicotine may improve clinical symptoms and cognitive function in adults with ADHD. Overall, our results provide further support for the hypothesis that smoking is a form of self-medication among adults with ADHD.
The second theme, smoking as a social behavior demonstrated that smoking was considered by many to enhance social functioning and to have a positive impact on interpersonal relationships.
Furthermore, some participants primarily initiated tobacco use not to attenuate symptoms of inattention or hyperactivity but to live a more exciting lifestyle, to undermine perceived social norms, to enhance their self-image, and to gain access to a desired non-conformist peer group. It is possible that the ADHD participants in this study who favored this motive are more impulsive and behaviorally disinhibited than others; however, none fulfilled ICD-10 criteria for a conduct disorder in the past, or a current personality disorder. It must be noted that subjects who identified this motive began smoking against the backdrop of their overall subjective experiences, cultural norms and institutions, gender roles, and aesthetics, all of which are strong influences on smoking behavior in general.
At first glance, the views of our study participants do not differ greatly from explanations given by cigarette-smokers without ADHD. For example, a recent qualitative study of cigarette-smoking college students found that smoking "served as an aid in alleviating anticipated stress"; "helped clear the mind when shifting from one subject to another"; "helped to refocus thoughts during a study session, facilitating greater concentration"; "served as a reward to celebrate the completion of a study session or an examination"; and helped to change the mindset when "transitioning from studying to being social". However, it must be noted that nicotine effects in adults with ADHD might exceed those in healthy volunteers, because they improve the attention of the former, as well as their clinical symptomatology. Comparisons with healthy volunteers or the general population might therefore be misleading.
Finally, findings on the influence of prescription drugs on tobacco use patterns were heterogeneous. Given that existing literature on the effects of stimulant medication on smokers with ADHD presents conflicting conclusions, we were intrigued to learn how subjects would describe the influence of stimulant medication on their tobacco-use patterns. However, only a few subjects made a clear assertion. The majority believed that the effects of stimulant therapy on nicotine craving wore off quickly, resulting in only a transient decrease in smoking, or that stimulants had no effect on cigarette use or even reinforced it. This supports Hurt et al., Winhusen et al., and Rush et al.
Furthermore, Vansickel et al. recently reported that immediate-release methylphenidate used by smokers with ADHD actually increased both the total number of cigarettes smoked and their carbon monoxide levels. Other investigators did not find significantly increased daily smoking rates in adults with ADHD. It has been suggested that differences in formulation might explain this discrepancy. In our sample, we did not find evidence for a link between smoking patterns and stimulant formulations.
We acknowledge the limitations of this study. First, we wished to obtain a comprehensive understanding of participants' views, so we conducted extensive interviews with a small sample. Second, all study subjects were recruited from the same outpatient treatment facility, so it is unclear to what extent the present findings can be generalized. Third, since a majority of potential participants could not be interviewed for this study, there may have been an additional self-selection or non-response bias, further limiting generalizability. Fourth, interviews were conducted by a clinical psychologist and analyzed by a team of psychiatrists and psychologists actively involved in multimodal treatment for patients with ADHD, which may have influenced categorization.
The results we have presented should therefore be verified by further studies with more diverse patient groups. An initial step could be to recruit participants from more diverse treatment modalities, younger age group (e.g. adolescents 15 – 18 years) and with a wider variety of comorbidities. Since the majority of our participants belonged to the adult ADHD combined subtype, further research could also focus on the inattentive and hyperactive subtypes or presentations according to DSM-V. Finally, we did not include a non-ADHD comparison group, which could significantly enhance our understanding of the perceived differences in nicotine effects between adults with ADHD and the general population.
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