Cognitive Vulnerability and the Time Course of Performance Anxiety Black, D., Riskind, J. H., Balaban, M. S.,

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Preventing Smoking in Adolescents with ADHD A
High Risk Population
Research supported by a grant from the Virginia
Tobacco Settlement Foundation
Steven W. Evans, Ph.D. Amy L. Williams, B.S.
Sheryle A. Moore, B.S. Zewelanji Serpell,
Ph.D. Lindsay Barnett Jennifer
Capito, B.A.
Methods
Results
Problem Objectives
Baseline assessment data was available for 29
study participants all of whom were in the sixth
grade at one of the participating middle schools.
Participants included 20 males and 9 females
between the ages of 10 and 13. All 29
participants met criteria for ADHD as outlined by
the Diagnostic and Statistical Manual of Mental
Disorders (DSM IV). 20 met criteria for combined
type ADHD and nine met criteria for predominantly
inattentive type. Social Impairment -
Impairment in social functioning was assessed
using parent report on the SSRS. Results
indicate that out of 29 participants, 4 were
rated by their parents as being average or above
in social skills, the rest were rated as below
average, some significantly impaired.
Smoking Behavior - Results from the SUQ
reveal that of the 29 participants, only 2
reported ever having tried a cigarette and
neither of them reported ever having smoked a
cigarette beyond simply trying one.
As part of a long-term treatment study,
researchers developed a comprehensive treatment
program to address specific risk factors
associated with ADHD so as to prevent future
smoking behavior. As a number of individuals are
typically involved in treating adolescents with
this disorder, development of this program was
collaborative in nature, incorporating feedback
and expertise of teachers, physicians,
clinicians, and parents of children of ADHD. The
ultimate goal was to develop a treatment program
that is both effective for treating these
symptoms of ADHD that place adolescents at risk
for smoking and feasible for implementation in
community settings. The Challenging Horizons
Program The resulting program, the Challenging
Horizons Program (CHP), is a community-based
treatment program that is currently being
implemented in 2 middle schools and pediatric
practices in Virginia. The program consists of a
set of psychosocial interventions that are
implemented at school, and a medication
algorithm. CHP treatments are designed to target
the academic and social impairments
characteristic of ADHD that place adolescents
with this disorder at risk for smoking.
Researchers recruited 40 sixth-grade
participants from four middle schools.
Participants attending schools assigned to the
treatment condition receive the treatments
described above. Participants attending schools
assigned to the control condition (n20) receive
typical care for ADHD. For all participants, ADHD
symptoms and impairment, tobacco use, exposure,
and experimentation were measured upon entry into
the program. ADHD symptoms and impairment that
serve as risk factors for smoking were assessed
by the Disruptive Behavior Disorders Rating Scale
(DBD) and the Social Skills Rating System (SSRS).
Smoking behavior was assessed using the Substance
Use Questionnaire (SUQ). Results from baseline
assessments for 29 of the participants who have
completed initial evaluations follow.
Adolescents with Attention Deficit Hyperactivity
Disorder (ADHD) smoke at a significantly greater
rate than their peers without ADHD, suggesting
that ADHD is a risk factor for tobacco use. A
study by Milberger et al (1997) revealed that
ADHD, particularly when comorbid with other
disorders, predicted early initiation of
cigarette smoking. In another study, participants
with inattention problems were found to be more
likely to experiment with cigarette smoking and
to become regular tobacco users (Tercyak, Lerman,
Audrain, 2002). The apparent link between ADHD
and smoking suggests symptoms associated with
this disorder might serve as risk factors for
smoking. It has been argued that the inattention,
impulsivity, and social impairment characteristic
of ADHD contribute to substance experimentation
and use. In one study, impairment in social
functioning (common in youth with ADHD) was the
sole significant predictor of alcohol and
substance abuse, as well as smoking (Greene,
Biederman, Faraone, Wilens, Mick, Blier, 1999).
Because, similar to stimulant medication,
nicotine has been shown to improve attention, the
possibility also exists that smoking may serve as
a form of self-medication for youth with ADHD
(Patton et al., 1996). Such findings suggest that
by specifically targeting the risk factors
associated with ADHD, there is a unique
opportunity to prevent smoking in this youth
population. Our initial objective was to
recruit participants and assess the extent to
which they exhibited the aforementioned risk
factors for smoking and also establish that our
method and design would facilitate intervention
before the onset of smoking in this high risk
population.
Works Cited
Tercyak, K., Lerman, C., Audrain, J. (2002)
Association of attention-deficit /hyperactivity
disorder symptoms with levels of cigarette
smoking in a community sample of adolescents.
Journal of American Academy of Children and
Adolescents, 41(7), 799- 805. Greene, R.,
Biederman, J., Faraone, S., Wilens, T., Mick, E.,
Blier, H. (1999) Further validation of social
impairment as a predictor of substance use
disorders Findings from a sample of siblings of
boys with and without ADHD. Journal of Clinical
Child Psychology, 28(3), 349-354. Lerman, C.
Audrain, J., Tercyak, K., Hawk, L., Bush, A.,
Crystal-Mansour, S., Rose, C., Niaura, R.,
Epstein, L. (2001) Attention deficit
hyperactivity disorder ADHD symptoms and smoking
patterns among participant in a smoking
cessation program. Nicotine and Tobacco
Research, 3(4), 353-359. Biederman, J., Wilens,
T., Mick, e., Spencer, T., Faraone, S. (1999).
Pharmacotherapy of Attention-deficit/hyperactivit
y disorder reduces risk for substance use
disorder. Pediatrics, 104, 1-5. Lambert N.
Hartsough, C. (1998). Prospective study of
tobacco smoking and substance dependencies among
samples of ADHD and Non-ADHD participants.
Journal of Learning Disabilities, 31(6),
533-544. Milberger, S., Biederman, J., Faraone,
S., Chen, L., Jones, J. (1996). Further
Evidence of an association between
Attention-deficit/hyperactivity disorder and
cigarette smoking. The American Journal on
Addictions, 6(3), 205-215.
Recommendations
Conclusions Rationale for Recommendations
Results from baseline assessment establish the
presence of at least two risk factors for smoking
in the sample, inattention and social impairment.
Consistent with studies reporting the average age
of smoking initiation in adolescents with ADHD is
15.5 years (Milberger et al., 1997), results also
show that the majority of participants did not
classify themselves as smokers or report ever
having tried smoking. Because participants are
recruited in the sixth grade, at an age that is
lower than the typical age of smoking onset for
this population, our method and design can
successfully target youth before the critical
period when they are likely to initiate smoking.
The impairment that is associated with ADHD
that places students at risk for smoking will be
evaluated for each participant over the course of
the next five years. Future work will therefore
examine the effectiveness of the Challenging
Horizons Program as a prevention program for
smoking in this high risk population.

• Universal smoking prevention programs may
  prove more effective if supplemented by programs
  that target specific populations.
• Intervention should occur at the level of risk
  in order to prevent future smoking behavior.