Researchers have long known that people with attention deficit hyperactivity disorder are more likely to use nicotine and tobacco — putting them at higher risk for a host of diseases and increasing the likelihood that they may become addicted to drugs and alcohol. But early diagnosis and treatment of ADHD could help prevent young people from picking up the habit in the first place, according to a new study.
The study, published today in JAMA Network Open, found that young people with more symptoms of ADHD, like forgetfulness, inattention, and impulsivity, had “significantly higher” odds of using e-cigarettes, cigarettes, or other tobacco products during the nine years they were tracked. However, young people who had an ADHD diagnosis with low or no symptoms — both with and without medication — were no more likely than the general population to take up tobacco and nicotine.
The longitudinal cohort study looked at more than 13,572 people between ages 12-17, of whom 1,881 had an ADHD diagnosis.
“This study highlights the importance of monitoring and management of ADHD symptoms and the potential protective impact of effective treatment,” Sean McCabe, who co-authored the study and serves as the director of the Center for the Study of Drugs, Alcohol, Smoking and Health at the University of Michigan School of Nursing, said in an email. “Tobacco remains the leading cause of preventable death so preventing tobacco uptake at any age is a powerful game changer for anyone, including those with ADHD.”
Cigarette smoking, a risk factor for cardiovascular disease, lung cancer, and other diseases, causes one in five deaths annually in the U.S., according to data from the Centers for Disease Control and Prevention. People diagnosed with ADHD in childhood start smoking earlier and become daily smokers faster compared to their peers.
There are several reasons people with ADHD may be more likely to use tobacco and nicotine overall. One is an attempt to self-medicate, McCabe noted. In the short term, nicotine can make people feel more focused and relaxed, although research shows that quitting smoking actually makes people with ADHD feel less anxious. Nicotine can also increase the brain’s release of dopamine, as do ADHD stimulant medications like Adderall.
Another potential reason for the association is that people with ADHD are often drawn to riskier behaviors — like the decision to smoke in the first place.
Because the symptoms of ADHD make people more likely to start using tobacco and nicotine, it makes sense that adolescents with the condition but few or no symptoms — presumably because ADHD is being managed effectively — seem to be less tempted to take up cigarettes and vaping. For example, the study found that more than half of people with highly symptomatic ADHD reported trying e-cigarettes over the nine years, compared to one-third of people with ADHD but no symptoms.
Crucially, medication on its own wasn’t a cure-all. About 20% of people who were taking ADHD medication but still had three or more symptoms tried smoking, compared to 8% of people on ADHD with medication and no symptoms. The key, the authors write, is for health care professionals to work with patients to reduce symptoms as much as possible.
“I think the authors are to be commended on a well conducted study in a large broadly representative cohort,” Joshua Stott, a professor of aging and clinical psychology at University College London who was not involved with the study and who has conducted research on ADHD, said via email. “While the paper does not directly evaluate this, it potentially suggests that it is inattention and hyperactive/impulsive symptoms that drive the early take up of tobacco based products in young people with ADHD and that appropriate support to people with those ADHD symptoms (either through pharmacotherapy or other means) could ameliorate this.”
The paper is also noteworthy in the context of a recent British study, co-authored by Stott, which found people with ADHD have a much shorter life expectancy compared to the general population — seven years shorter for men, and nine years shorter for women. The paper identified smoking as a likely contributing factor, along with accidents, suicides, substance use and other modifiable risk factors.
Among the study’s limitations is that about 14% of its subjects had ADHD, compared to the 11% of children between 3-17 who’ve received the diagnosis according to CDC data. “This does not invalidate the finding but was interesting in terms of whether the sample over-represents children with ADHD diagnoses,” Stott said.
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