Saturday October 22nd 2016

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ADHD and teen smoking: What parents should know

By Dr. Lisa R. Fortuna, MD, MPH

Research has shown that young people with Attention Deficit Hyperactivity Disorder (ADHD) may be more prone to nicotine addiction than their peers. Here, expert Dr. Lisa R. Fortuna, MD, MPH explores this issue and WHAT YOU AS A PARENT need to know. Then, we invite your questions or comments about teen smoking and ADHD or mental health issues at the end.

ADHD in teens

Attention Deficit Hyperactivity Disorder (ADHD) is a common behavioral and developmental disorder that affects about 10% of school-age children and is characterized by inattention, impulsivity, hyperactivity, and other problems related to attention and organization. Boys are about two times more likely than girls to be diagnosed with ADHD, though it’s not yet quite understood why.

ADHD seems to be connected to higher smoking risk

One major concern is that young people with ADHD are prone to addiction including to nicotine. It appears that youth with ADHD respond differently to smoking and nicotine and have a vulnerability to developing nicotine dependence once they start smoking. The exact reason for this association between ADHD and smoking remain largely unknown. Behaviorally, teens with ADHD report liking the feeling of nicotine right from the beginning and to find smoking particularly relaxing as compared to their peers without ADHD (McClernon & Kollins, 2008). In fact, nicotine may act in a similar way to stimulants (which are medications used to treat ADHD) in certain parts of the brain resulting in improvements in attention, vigilance, and short-term memory in teens with ADHD (Krause et al., 2002)

But it is not all good news. Both adults and children with ADHD are significantly more likely to experience a number of nicotine withdrawal symptoms, including irritability and difficulty concentrating when they try to quit smoking. This may contribute to their becoming chronic smokers and vulnerable to the health problems associated with smoking.

How does nicotine affect ADHD brains?

Nicotine seems to induce negative changes in the developing brain and impedes the formation of white matter (signifying a slowing in brain development), especially in youth who initiate smoking early. This has been associated with problems related to memory and learning. This is actually really bad news for teens with ADHD who are already prone to academic difficulty. The jury is still out regarding which youth are most susceptible to these negative changes as a result of smoking.

Further, the so-called “smokeless” or e-cigarettes may potentially be contributing to this problem in teen populations since they are becoming even more popular than traditional cigarettes and can attract youth who would otherwise be less prone to using traditional tobacco products. Teens may feel e-cigarettes are safer and can actually help them quit smoking. There is no evidence that this is true for teens.

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What can parents do about it?

Identification, early prevention and intervention are important for decreasing rates of smoking and its consequences, especially among youth who are most vulnerable. The clinical and prevention implications for nicotine and ADHD are many, but here are some practical and evidence based practices that your teen’s healthcare provider can offer:


It is recommended that children be screened for whether they have initiated smoking, including e-cigarettes or other tobacco products as early as middle school. There are three recommended steps:

1.1. Screening quickly to assess the severity of tobacco and nicotine use to help identify the appropriate level of       treatment.

1.2. Brief intervention focuses on increasing insight and awareness regarding tobacco and nicotine use and motivation toward behavioral change.

1.3. Referral to treatment provides those identified as needing more extensive treatment with access to specialty care


For youth with ADHD, they should be offered information about the special risks of smoking for them, the implications for developing nicotine dependence and what we know about smoking and ADHD.


Treatment of ADHD symptoms using medical and non-medication interventions as appropriate.


Helping address nicotine addiction takes make forms. An interesting and helpful exercise is to use a Breath Carbon Monoxide (CO) Meter. It’s well established that expired breath CO correlates well with the percentage of CO in the blood and amount of inhaled smoke. High CO levels are an indicator of nicotine dependence and risk to health, impaired athletic performance etc. Teens breathe into a meter, receive their CO reading and can be given information about what their CO levels mean regarding health risks. They can be challenged to reduce their CO level at each visit and maybe even win a prize. Motivating is everything!


For regular and moderate to heavy smokers nicotine replacement therapy (ERT), and setting a quit date can help.  Current research indicates that 75% of teens who currently smoke want to quit.


The National Institutes of Health/ National Cancer Institute offers an on-line smoking cessation program for teens. The site offers information on the effects of nicotine, offers smoking cessation strategies, and if the teen signs up they are sent a daily motivating text-message to support their smoking cessation plan.

Identification, early prevention and intervention are important for decreasing rates of smoking and its consequences, especially among youth who are most vulnerable. More research is needed into the effects of e-cigarettes in adolescence since they deliver a significant amount of nicotine and are growing in popularity. Importantly, we need to invest in prevention and prohibiting the targeting of youth as consumers of tobacco products in general.

Reference Sources: Krause, K. H., Dresel, S. H., Krause, J., Kung, H. F., Tatsch, K., & Ackenheil, M. (2002). Stimulant-like action of nicotine on striatal dopamine transporter in the brain of adults with attention deficit hyperactivity disorder. Int J Neuropsychopharmacol, 5(2), 111-113.
McClernon, F. J., & Kollins, S. H. (2008). ADHD and smoking: from genes to brain to behavior. Ann N Y Acad Sci, 1141, 131-147.
Thatcher, A. E-cigarettes more popular than tobacco among youth. CMAJ, 187(6), E184.

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About Dr. Lisa Fortuna, MD, MPH

Lisa R. Fortuna, MD, is board-certified in child and adolescent psychiatry and in addiction medicine, with over fifteen years of clinical experience with children, adolescents, and families. She is currently faculty at Boston University School of Medicine and medical director of Child and Adolescent Psychiatry at Boston Medical Center. She has published highly cited articles in the areas of post-traumatic stress disorder (PTSD), adolescent substance abuse, and Latino and immigrant mental health. She is the author of (with Zayda Vallejo M. Litt), Treating Co-Occurring PTSD and Addiction: Mindfulness Based Cognitive Therapy for Adolescents with Trauma and Substance Use Disorders (New Harbinger, 2015).

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