Smoking in People With ADHD

We know that segments of the population with lower education and lower socio-economic resources are at a higher risk for developing smoking dependence. The authors in a new study in the Journal of Attention Disorders wanted to see if there was any relationship between ADHD and nicotine dependence.

First of all, what is nicotine dependence? There is a pretty good clinical definition out there, but basically it boils down to whether you find yourself needing a smoke. If you feel this way then chances are, you have nicotine dependence. Nicotine is a very addictive drug in tobacco which creates a contentment in the brain by releasing a specific neurotransmitter, dopamine. People who have a high nicotine dependence typically crave this feeling.

It should be no surprise then, as we read how the researchers discovered a very strong link between ADHD and nicotine dependence in adulthood. They point out the lack of research in ADHD adults who smoke. The results of their study show a higher rate of smokers in the ADHD study group. This is no real surprise and has been shown before in the literature. But they also found that adult smokers with the ADHD diagnosis had a more severe nicotine dependence and smoked at a significantly more higher frequency when sick. Smoking when sick is an indication of strong nicotine dependence/addiction. ADHD women smoked significantly more frequently and initiated smoking at a younger age.

So what does this tell us? Well, it says that people with ADHD tend to smoke more frequently than other parts of the population. It also states that their nicotine dependence is much higher, especially in women, than in the traditional smoking population.

This is important to note as it may help direct treatment strategies for those who suffer from ADHD.

Nicotine Replacement Therapy as a Quitting Tool

Nicotine replacement therapy (NRT) has been around a long time, with varying degrees of success. Most agree that NRT will double a person's chance of quitting over going cold turkey alone. But the outcomes, defined as smoking cessation, are still pretty small.

A recent study looked at the affect NRT had on smoking reduction and temporary abstinence in England. The researchers wanted to see if NRT use could predict smoking cessation attempts. I'm not really sure why they were asking this question and the end result of the study is not what I find important.

Rather, the scientists state that NRT was associated with an overall smoking reduction of about two cigarettes per day. They also found that people who used NRT were more likely to try to quit smoking that someone who did not use it - which I think is a patently obvious observation that didn't require a study. But that's just my two cents.

Anyway, I wanted to focus on this 2 cigarette per day reduction. Is it just me or does that seem kind of small? Yeah, that's what I thought. But I think I know why it is so small.

Since most NRT is available without a prescription, most people who want to quit can just go online or to a local store and buy nicotine gum or whatever. Lets say a guy wants to quit, but he's not completely sure about how to go through it. More than likely, he's heard about NRT and will probably "try" some nicotine gum or the patch. Hey, you don't need a script and nobody needs to know what you're doing. It's kind of a covert quit attempt. No real planning, no thinking about it, just try and see what happens.

In this scenario, smoking cessation success may be difficult to achieve. The biggest mistake people make is failing to plan a quit attempt. When you approach a serious addiction, which lets face it, nicotine is, you must be serious in your desire to quit. Testing the waters and trying things out are, in the end, not worth the trouble.

I've heard some people using nicotine gum for over a year. Now I don't know if they were addicted to nicotine gum or just felt the need to keep trying, but planning is the answer. So I believe these people in the study were not serious about quitting, rather they were just experimenting with NRT to see if it would magically take their nicotine addiction away. Obviously, it doesn't seem to work that way.

Stopped Smoking

So you finally stopped smoking! Congratulations. The question now becomes, will you stay stopped? Are you ready for the sneaky cravings? Have you prepared yourself for the gentle smoking cues that come with familiar behavior, like having the first cup of coffee in the morning?

I know you've stopped smoking, but you need to treat nicotine addiction as an alcoholic treats his/her alcohol addiction - that is a lifelong battle. Once an addict, always an addict; even if it's "only nicotine". The physiological addictive properties of nicotine rivals opiates and cocaine, so don't underestimate it's power.

It's like Darth Vader telling Luke not to underestimate the power of the dark side. It can hold devastating power over you even after you've stopped smoking. So be a good scout and always be prepared for those cravings. They can derail your plans quicker than you'd imagine.

Nicotine Free Inhalators

Smoking cessation rates are not where people would like them to be. There are a number of reasons for this. Let's face it, smoking is addictive. Many people are predisposed to the addiction which makes it harder for them to quit. Others face pressures in their life and feel like smoking is a crutch for them, a type of coping mechanism. But whatever the cause of a person's failed quit attempt, the person should not stop trying. Each relapse should be followed by a period of evaluation. The smoker should ask the question, "Why did I relapse?". This learning experience can then be logged away for future quit attempts. Studies say that it can take up to 7 quit attempts before someone is successful.

There are few smoking cessation methods which focus on the behavioral component of the nicotine addiction. Support groups try to get to this, but few methods actually help with the day to day ritual of smoking cigarettes. Nicotine free inhalators are one stop smoking aid which tries to address this component of smoking. They are plastic devices that may be used as a substitute coping mechanism for the triggers which cue the smoking ritual.

A recent study looked at how these nicotine free inhalators may improve the quit attempt. It was published in the European Respiratory Journal by Capponnetto and others and is entitled, "Effect of a Nicotine Free Inhalator as Part of a Smoking Cessation Program" [May 2011].

They looked at 120 healthy smokers who were attending a smoking cessation program. They assessed numerous factors like physical dependence, depression, behavioral dependence and motivation. The study participants were put into two groups: 1) received a nicotine free inhalator and 2) reference group. THey were followed up at week 4 and 24.

Overall, they found no significant difference in the quit rates between those who received the inhalator and those who did not. But, for those with a high behavioral dependence, the quit rate was much higher in the inhalator group (67%) compared to the reference group (19%).

The researchers conclude that nicotine free inhalators may be a helpful tool for those trying to quit who have a strong behavioral or ritualistic manipulation/handling of the cigarette. So check them out if you think you have a strong tie to the handling of the cigarette. They just might help you quit.

Does Anxiety or Depression Impact Nicotine Addiciton

Quite awhile ago now, bupropion (Welbutrin) was first used on people who suffered from depression. Researchers were surprised to discover a mis-intended, but beneficial side effect, that being smoking cessation. There is strong long-standing evidence that links depression with smoking behavior and nicotine addiction. I remember there were lots of patients in the 'psych ward' at our hospital that would go outside for their smoke break. I don't mean that to be a mischaracterization, but rather just an anecdotal observation from my hospital days.

Now there are questions as to whether a tendency to anxiety and depressive reactions is some how involved in the clinical presentation of someone with a nicotine addiction. Researchers in Polan sought to answer this question in a study titled, "Anxiety, depression and methods of stress coping in patients with nicotine dependence syndrome". It was published in the Medical Science Monitor: international medical journal of experimental and clinical research - [2011 May 2;12(5):CR272-276] by Pietras, T and others.

Here they compared two groups: smokers with no serious systemic co-morbidities and healthy subjects. Each individual was assessed in the same manner using the same behavioral tools for measuring anxiety, depression and coping abilities. Their results show the average intensity of anxiety as a trait and anxiety as a state were different in these two groups. Depression was also demonstrated to be more intensive in the nicotine addiction group. Finally, those with the nicotine addiction used more emotion-based coping behavior than did the healthy control group subjects.

They concluded that anxiety and depression, along with differences in coping, distinguished those who were addicted to nicotine from their non-smoking, healthy counterparts. So, which came first, the chicken or the egg?

Do people smoke because they're depressed or are they depressed, therefore, they smoke? I don't believe this study answers that rather complex question. Rather, it simply delineates the differences between these two groups. I'm sure bother ends of the argument are true. It is interesting to note, however, that there is a linking between a person's sense of well-being with oneself and his/her environment, with their nicotine addiction.

This fact tells us there is more to smoking cessation than simply quitting cold turkey. Although, for some it is that easy. For many others, it is seemingly complex weave of behavior, genetic predisposition, culture and brain chemistry. This isn't surprising, since most addictions are viewed in those terms already.

"I want to quit, but I enjoy it too much" - Sound Like You?

I've talked about (and blogged about) how addiction works - both the physical and behavioral components. Anyone who is trying to stop smoking must understand the nature of addiction in smoking. They must also have a grasp on any underlying factors that might cause them to pick up that cigarette. Perhaps, they struggle with depression or have some kind of emotional baggage that continues to project smoking as a viable alternative or escape from this unsettling circumstance.

The feeling of satisfaction found with smoking can have a profound influence on a person's psyche. When all else is falling apart, smokers can always count on that old friend to provide a calming oasis in the middle of their troubles. But this begs the question which comes first, the enjoyment or the addiction? It's the old chicken and the egg argument.

Well, scientists in London published their research on this very topic in Drug and Alcohol Dependence. They looked at the enjoyment of smoking versus the urges to smoke as predictors for successful smoking cessation. They surveyed 2,257 smokers. Enjoyment and strength of urges were assessed, as was smoking status, quit attempts and quit success. The results showed that only enjoyment of smoking predicted whether a smoker would actually attempt to quit or not; while the strength of urges predicted whether the quit attempt would be successful.

This provides insight for us to are trying to help people stop smoking. By addressing the "enjoyment" part of the equation, we can help motivate people to journey toward a quit attempt. Then, once they choose to quit, we then need to help them face down the urges to smoke. I would imagine, every former smoker will tell you this is how they went about the process of smoking cessation. They first had to have a reason that was greater than their enjoyment and then, they had to overcome the urges. It seems like a relatively simple formula, I know. But don't some smokers get overwhelmed with the prospect of quitting. Don't they "overthink" it sometimes and then relapse?

The message seems pretty clear and simple. Anyone can quit if they follow this formula. The key though, is to follow it. So, pass this formula on to somebody you know who smokes. They'll be glad you did.