Adult ADHD and Nicotine Use
Participant characteristics, diagnosis, and tobacco consumption patterns are described in Table 2.
Of the 12 participants, seven were female and five were male. Their average age was 40, and they ranged from 25–53. At the time of the interview, all participants were currently smoking cigarettes, but their patterns of smoking varied greatly (from a minimum of 3–5 a week to a maximum of 35 a day), as did the severity of their nicotine dependence, according to the FTND (from very low to very high).
Ten participants had the combined type of ADHD, one had the predominantly inattentive type, and one had the predominantly hyperactive-impulsive type. All but two had another comorbid mental disorder. The most common comorbidities were SUD (other than nicotine dependence) and affective disorders. Six participants (50%) were employed, two (16%) were students, and four (33%) were unemployed or had an uncertain employment status.
In our analysis of the interview data, we identified two main themes linking ADHD and tobacco use: smoking as an attempt at self-medication, and smoking as sensationalism, the search for a positive self-image and peer-group-mediated behavior. Examples of these themes follow, but it bears noting that there was significant overlap among themes: some participants identified more than one specific link between ADHD and smoking and had adopted a multifaceted explanatory model to describe the relationship. Following the description of those themes, we also describe participants' beliefs about the influence of prescription drugs and about their experiences with other psychotropic substances.
The majority of participants readily acknowledged that cigarette smoking had psychological and physiological effects on them. Nine study subjects described a link between ADHD and tobacco use, but one participant reported that he had not thought about a connection:
"I don't know, and I don't want to lie to you. Maybe, I really don't know. I cannot really judge it, because I have always been the same, not one time with ADHD and one time without it."
Mrs. G.
Two participants did not address this subject in their narratives. In order to avoid leading questions and to preserve a non-judgmental stance, participants were not pressed on this subject.
Most frequently, subjects acknowledged a link between ADHD and tobacco use by giving reasons for smoking cigarettes. Upon further exploration of the effects of nicotine consumption, participants expressed very different but generally positive views of those effects. Many attributed their cigarette use to general feelings of stress or being overwhelmed in different social contexts:
"…If I am getting out of some sort of stressful situation and I get the feeling my brain 'rotates,' then I get the feeling that I should go have a cigarette and then one can see the world much clearer."
Mr. K.
Other study subjects used cigarettes specifically to reduce inner tension, to treat symptoms of restlessness, and for relaxation purposes:
"It reduces tension, I even believe partially. It really depends on the moment, but I would even say it relaxes the muscles. Especially in those moments when you have not smoked for a while and you absolutely want to smoke, then you can notice this."
Mrs. C.
Participants repeatedly commented on the positive effects they perceived in relation to their ability to concentrate, be attentive, and solve problems. Two subjects also compared nicotine's effects to those of other substances.
"…and you know earlier I was using other [illegal] drugs, and you know every time I had to do something, on which I absolutely had to concentrate on, something minor, then I would take heroin. Then I could behave and concentrate. And it could have been the most boring stuff in the world, for example. And you know a cigarette has a very similar effect, like alcohol, like some sort of sedative, which has the effect on me that I can do something really boring, something where I have to crunch numbers for hours at a time, then [cigarettes] help me with that."
Mrs. J.
One participant with major depressive disorder attributed mood-stabilizing properties to nicotine:
"And you know, I am not accurately diagnosed with ADHD. I am somewhere in between a depression and ADHD, so this is an area where no one can say exactly, and you know, I think that I come more from the depressive side, in that sense it is a form of self-medication. It is a surrogate to comfort yourself and to retreat. Alone with one's cigarette – it is almost like you can solve all the problems of the world, somehow, I think."
Mr. B.
Another study subject associated a difficult upbringing, including emotional neglect by his parents, with cigarette smoking; he felt that it took the form of self-medication for emotional dysfunction.
"I always had the feeling that I got too little emotional warmth. Maybe it is because my mother was overwhelmed, because I was an ADD child…but something was missing all my life, despite the fact that I have an intact marriage, children, family, and social stability. I am compensating for something that is missing. And if I can make that happen with 2–3 cigarettes, then I am very happy with that."
Mr. A.
Subjects also frequently expressed the view that smoking had positive effects on interpersonal relationships, a valuable asset for socializing that could be used as a way of connecting to others:
"…smoking gives me a feeling of belonging and togetherness, something I can really enjoy, so I can lay back and smoke one [cigarette]…I find it very pleasant to be together with a group of people and everybody says, let's go, we will have a smoke, then I like it."
Mrs. G.
Some participants had a completely different view, primarily associating their tobacco use not with a search for specific effects but with a desire to take risks, to try something new with the appeal of the forbidden. We label this subtheme "sensationalism." One study subject believed that patients suffering from ADHD are more likely to use psychotropic substances in general. (Of note, this subtheme has some overlap with views and perceptions regarding the initiation of smoking and its effects on interpersonal relationships.)
"Generally speaking, if I compare myself to others, I am less fearful. My readiness to assume risk is just higher compared to others, which is also a small part of the reason I began to smoke. Although you know that everything is harmful and so on, but the appeal of the forbidden, to begin with, is something symptomatic for individuals with ADHD, this wanting to know how it really is, this experimenting and this behavior…"
Mr. B.
This subtheme is further illustrated by two female participants, who described themselves as "rebellious" and "revolutionary," and expressed a desire to subvert perceived social norms. Furthermore, they associated smoking with a positive self-image.
"…it might be connected to the fact that I always was a bit of a misfit as child, and later more into revolution and rebellion. And as a smoker you were somehow always more on the unhealthy side, but this was very clear to me, and for years I thought 'I don't want to quit smoking, the earlier I die…' and so on…[started giggling], yes, and I think it has to do with the fact that the people who smoke are not the usual ones…and I identified myself with that…and I never had a self-perception as a non-smoker…that did not fit…"
Mrs. C.
Unlike the participants who were looking for a sense of belonging, other study subjects who had initiated their tobacco use in adolescence voiced explanations that emphasized their search for a self-image of "coolness" among a group of peers, even if they found smoking repelling.
"It was a process. Initially I found it disgusting, but I wanted to belong to that group of people… I really did have the feeling then, with smoking, that I am one of the more cool people with a more laid-back style."
Mrs. G.
All participants had some experience with prescribed psychotropic medications, mostly stimulants and antidepressants. We describe these findings separately but do not label them as a theme, because they do not present explanatory models linking ADHD and tobacco use. Subjects generally believed that medications had affected their tobacco use patterns, though the medications' influences were experienced and expressed quite differently. Some participants reported that stimulant therapy (e.g., methylphenidate) initially reduced their tobacco use patterns:
"… in the very beginning, right when I started, I had the feeling that it did [decrease the desire for smoking], but this effect wore off quickly. Yes, the first day I had like no desire. Maybe I should take more Ritalin [methylphenidate]."
Mrs. D.
Other subjects believed methylphenidate increased their craving for smoking cigarettes:
"… I actually had the feeling that I was smoking more cigarettes when I started Ritalin. Although I don't know how closely this is connected, but I did have the feeling that it is, because I felt I received for a time too high of a dosage, and then when I had little highs, I noticed I smoked or drank more."
Mrs. H.
A minority did not notice any difference:
"… No my smoking patterns did not change much when I started Ritalin, I am like that, it is a habit, it is not about the smoking really. It is more, I answer the phone and I have a cigarette, or I sit in front of my computer and then I have one in my hand, I am not even smoking it, because I am typing. Then my keyboard is full of ashes, and smoke is in my nose but not because I am inhaling, but just because the cigarette is around…"
Mrs. J.
One study subject experienced a medication with stimulant-like properties as so calming that her desire for cigarette smoking abated:
"…I have the impression that, since Dexamin [dexamphetamine], calms me down, calms me down very much. I have the feeling that smoking became less important and played only a minor role, because for a time I was not smoking excessively. Yes, because I had the feeling that I was calm, that smoking was not that important anymore. I was still smoking out of habit, but it still had an influence. Since with Ritalin I was partially still very nervous and then smoking was there, this goes hand in hand…"
Mrs. E.
Another participant had this experience with the use of an antidepressant:
"… Really, I did not notice an effect at all and I had been trying with Dr. Eich [DE] for three years now. And the first time that I had the feeling that [medication] was useful was with Fluctine [fluoxetine], that gave me more of a balance…until now I had to say, it is not working for me, Concerta [methylphenidate] did not at all…"
Mrs. G.
Results
Participant characteristics, diagnosis, and tobacco consumption patterns are described in Table 2.
Of the 12 participants, seven were female and five were male. Their average age was 40, and they ranged from 25–53. At the time of the interview, all participants were currently smoking cigarettes, but their patterns of smoking varied greatly (from a minimum of 3–5 a week to a maximum of 35 a day), as did the severity of their nicotine dependence, according to the FTND (from very low to very high).
Ten participants had the combined type of ADHD, one had the predominantly inattentive type, and one had the predominantly hyperactive-impulsive type. All but two had another comorbid mental disorder. The most common comorbidities were SUD (other than nicotine dependence) and affective disorders. Six participants (50%) were employed, two (16%) were students, and four (33%) were unemployed or had an uncertain employment status.
In our analysis of the interview data, we identified two main themes linking ADHD and tobacco use: smoking as an attempt at self-medication, and smoking as sensationalism, the search for a positive self-image and peer-group-mediated behavior. Examples of these themes follow, but it bears noting that there was significant overlap among themes: some participants identified more than one specific link between ADHD and smoking and had adopted a multifaceted explanatory model to describe the relationship. Following the description of those themes, we also describe participants' beliefs about the influence of prescription drugs and about their experiences with other psychotropic substances.
Overall Beliefs About the Link Between ADHD and Tobacco Use
The majority of participants readily acknowledged that cigarette smoking had psychological and physiological effects on them. Nine study subjects described a link between ADHD and tobacco use, but one participant reported that he had not thought about a connection:
"I don't know, and I don't want to lie to you. Maybe, I really don't know. I cannot really judge it, because I have always been the same, not one time with ADHD and one time without it."
Mrs. G.
Two participants did not address this subject in their narratives. In order to avoid leading questions and to preserve a non-judgmental stance, participants were not pressed on this subject.
Theme I: Smoking as an Attempt at Self-medication
Most frequently, subjects acknowledged a link between ADHD and tobacco use by giving reasons for smoking cigarettes. Upon further exploration of the effects of nicotine consumption, participants expressed very different but generally positive views of those effects. Many attributed their cigarette use to general feelings of stress or being overwhelmed in different social contexts:
"…If I am getting out of some sort of stressful situation and I get the feeling my brain 'rotates,' then I get the feeling that I should go have a cigarette and then one can see the world much clearer."
Mr. K.
Other study subjects used cigarettes specifically to reduce inner tension, to treat symptoms of restlessness, and for relaxation purposes:
"It reduces tension, I even believe partially. It really depends on the moment, but I would even say it relaxes the muscles. Especially in those moments when you have not smoked for a while and you absolutely want to smoke, then you can notice this."
Mrs. C.
Participants repeatedly commented on the positive effects they perceived in relation to their ability to concentrate, be attentive, and solve problems. Two subjects also compared nicotine's effects to those of other substances.
"…and you know earlier I was using other [illegal] drugs, and you know every time I had to do something, on which I absolutely had to concentrate on, something minor, then I would take heroin. Then I could behave and concentrate. And it could have been the most boring stuff in the world, for example. And you know a cigarette has a very similar effect, like alcohol, like some sort of sedative, which has the effect on me that I can do something really boring, something where I have to crunch numbers for hours at a time, then [cigarettes] help me with that."
Mrs. J.
One participant with major depressive disorder attributed mood-stabilizing properties to nicotine:
"And you know, I am not accurately diagnosed with ADHD. I am somewhere in between a depression and ADHD, so this is an area where no one can say exactly, and you know, I think that I come more from the depressive side, in that sense it is a form of self-medication. It is a surrogate to comfort yourself and to retreat. Alone with one's cigarette – it is almost like you can solve all the problems of the world, somehow, I think."
Mr. B.
Another study subject associated a difficult upbringing, including emotional neglect by his parents, with cigarette smoking; he felt that it took the form of self-medication for emotional dysfunction.
"I always had the feeling that I got too little emotional warmth. Maybe it is because my mother was overwhelmed, because I was an ADD child…but something was missing all my life, despite the fact that I have an intact marriage, children, family, and social stability. I am compensating for something that is missing. And if I can make that happen with 2–3 cigarettes, then I am very happy with that."
Mr. A.
Theme II: Smoking as a Social Behavior
Subjects also frequently expressed the view that smoking had positive effects on interpersonal relationships, a valuable asset for socializing that could be used as a way of connecting to others:
"…smoking gives me a feeling of belonging and togetherness, something I can really enjoy, so I can lay back and smoke one [cigarette]…I find it very pleasant to be together with a group of people and everybody says, let's go, we will have a smoke, then I like it."
Mrs. G.
Some participants had a completely different view, primarily associating their tobacco use not with a search for specific effects but with a desire to take risks, to try something new with the appeal of the forbidden. We label this subtheme "sensationalism." One study subject believed that patients suffering from ADHD are more likely to use psychotropic substances in general. (Of note, this subtheme has some overlap with views and perceptions regarding the initiation of smoking and its effects on interpersonal relationships.)
"Generally speaking, if I compare myself to others, I am less fearful. My readiness to assume risk is just higher compared to others, which is also a small part of the reason I began to smoke. Although you know that everything is harmful and so on, but the appeal of the forbidden, to begin with, is something symptomatic for individuals with ADHD, this wanting to know how it really is, this experimenting and this behavior…"
Mr. B.
This subtheme is further illustrated by two female participants, who described themselves as "rebellious" and "revolutionary," and expressed a desire to subvert perceived social norms. Furthermore, they associated smoking with a positive self-image.
"…it might be connected to the fact that I always was a bit of a misfit as child, and later more into revolution and rebellion. And as a smoker you were somehow always more on the unhealthy side, but this was very clear to me, and for years I thought 'I don't want to quit smoking, the earlier I die…' and so on…[started giggling], yes, and I think it has to do with the fact that the people who smoke are not the usual ones…and I identified myself with that…and I never had a self-perception as a non-smoker…that did not fit…"
Mrs. C.
Unlike the participants who were looking for a sense of belonging, other study subjects who had initiated their tobacco use in adolescence voiced explanations that emphasized their search for a self-image of "coolness" among a group of peers, even if they found smoking repelling.
"It was a process. Initially I found it disgusting, but I wanted to belong to that group of people… I really did have the feeling then, with smoking, that I am one of the more cool people with a more laid-back style."
Mrs. G.
Influence of Prescription Drugs on Tobacco Use Patterns
All participants had some experience with prescribed psychotropic medications, mostly stimulants and antidepressants. We describe these findings separately but do not label them as a theme, because they do not present explanatory models linking ADHD and tobacco use. Subjects generally believed that medications had affected their tobacco use patterns, though the medications' influences were experienced and expressed quite differently. Some participants reported that stimulant therapy (e.g., methylphenidate) initially reduced their tobacco use patterns:
"… in the very beginning, right when I started, I had the feeling that it did [decrease the desire for smoking], but this effect wore off quickly. Yes, the first day I had like no desire. Maybe I should take more Ritalin [methylphenidate]."
Mrs. D.
Other subjects believed methylphenidate increased their craving for smoking cigarettes:
"… I actually had the feeling that I was smoking more cigarettes when I started Ritalin. Although I don't know how closely this is connected, but I did have the feeling that it is, because I felt I received for a time too high of a dosage, and then when I had little highs, I noticed I smoked or drank more."
Mrs. H.
A minority did not notice any difference:
"… No my smoking patterns did not change much when I started Ritalin, I am like that, it is a habit, it is not about the smoking really. It is more, I answer the phone and I have a cigarette, or I sit in front of my computer and then I have one in my hand, I am not even smoking it, because I am typing. Then my keyboard is full of ashes, and smoke is in my nose but not because I am inhaling, but just because the cigarette is around…"
Mrs. J.
One study subject experienced a medication with stimulant-like properties as so calming that her desire for cigarette smoking abated:
"…I have the impression that, since Dexamin [dexamphetamine], calms me down, calms me down very much. I have the feeling that smoking became less important and played only a minor role, because for a time I was not smoking excessively. Yes, because I had the feeling that I was calm, that smoking was not that important anymore. I was still smoking out of habit, but it still had an influence. Since with Ritalin I was partially still very nervous and then smoking was there, this goes hand in hand…"
Mrs. E.
Another participant had this experience with the use of an antidepressant:
"… Really, I did not notice an effect at all and I had been trying with Dr. Eich [DE] for three years now. And the first time that I had the feeling that [medication] was useful was with Fluctine [fluoxetine], that gave me more of a balance…until now I had to say, it is not working for me, Concerta [methylphenidate] did not at all…"
Mrs. G.
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