ADHD symptoms are associated with risk for smoking


Teenagers and adults with attention deficit/hyperactivity disorder (ADHD) are more likely to smoke cigarettes and become nicotine dependent than their peers who do not have ADHD. They are also more likely to start smoking at an earlier age and have a more difficult time successfully quitting as compared to the general population. This is obviously a public health concern because the regular use of cigarettes is associated with a host of negative health consequences.

In addition, for many people, cigarette use can be a gateway to drug use.

Relationship Between ADHD and Smoking
There are a number of factors that seem to contribute to this risk for smoking/tobacco use by those with ADHD. Genetics may play a large role. Both ADHD and smoking are highly heritable. Studies have identified a number of similar genetic markers associated with both ADHD and smoking. These findings suggest that there are common neurobiological factors that may contribute to the development of ADHD and a person’s risk for tobacco use.

Studies that have examined the relationship between genes, smoking and ADHD have shown that ADHD symptoms interact with genes to increase smoking risk. In addition, in utero smoking exposure may interact with genes to increase the odds of ADHD. Though we don’t understand fully all the mechanisms responsible, both neurobiological and behavioral factors seem to contribute to these higher rates of smoking in teens and adults with ADHD.

Social influences such as being exposed to smoking by family members and peers also raise this risk for cigarette use.

Problems with impulse control might also explain why more teens and adults with ADHD are more likely to engage in risky habits such as smoking. ADHD can make it more difficult to look clearly to the future and take into account the negative health consequences of current actions.

Nicotine and Self-Medication
Nicotine is a known central nervous system stimulant and appears to act on the brain in a similar way as the psychostimulants, methylphenidate, and dextroamphetamine that are most commonly used to treat ADHD. For some people, nicotine (the primary addictive substance in tobacco) in cigarettes may serve as a form of self-medication for ADHD symptoms. Read more about how stimulants work to treat ADHD.

A number of studies have found that nicotine can improve attention. “Nicotine exerts beneficial effects on a range of processes know to be disrupted in individuals with ADHD, including attention, inhibitory control, and working memory,” writes Dr. Scott Collins, associate professor of psychiatry and medical psychology at the Duke University School of Medicine and director of the Duke ADHD Program. “As such, it has often been proposed that those with ADHD are at heightened risk for smoking because of the beneficial effects of nicotine across a range of cognitive processes.”

It is possible that nicotine may help some smokers with ADHD compensate for their low levels of attention, arousal, and concentration. Additional research is needed in this area to more fully understand the effect of nicotine on symptoms of ADHD and how this might increase the risk for smoking in teens and adults with ADHD.

Reducing Risk for Smoking
We know that people with ADHD smoke at rates that are significantly higher than their non-ADHD peer group. It is also suspected that smoking for those with ADHD may be linked to self-medication for ADHD symptoms. Therefore, it is possible that identifying and treating ADHD earlier may prevent the onset of smoking altogether.

A study published in the Journal of Pediatrics (online: August 2012) shows promise that treatment for ADHD may indeed contribute to a reduced risk of smoking in teens with ADHD. Researchers at Massachusetts General Hospital and Harvard Medical School conducted a two-year, prospective clinical trial of extended-release methylphenidate for smoking prevention in adolescents.

They compared clinical trial subjects with ADHD receiving extended-release methylphenidate (Ritalin) with a sample of “naturalistic” adolescent ADHD subjects – some of whom were receiving stimulants – as well as with adolescents who did not have ADHD. The smoking rate at the end of the study was significantly lower in ADHD subjects who were receiving stimulant treatment than it was in ADHD subjects who were not, and there was no significant difference between ADHD subjects receiving stimulant treatment and non-ADHD subjects.

“Although considered preliminary until replicated in future randomized clinical trials, the findings from this single-site, open-label study suggest that stimulant treatment may contribute to a decreased risk for smoking in adolescents with ADHD,” said the researchers. “If confirmed, this finding would have significant clinical and public-health impacts.”

Future research is needed to help us better understand the link between ADHD and smoking so that more effective prevention and treatment strategies can be developed, particularly targeted prevention programs for youth with ADHD.


Francis Joseph McClernon and Scott Haden
; ‘ADHD and Smoking: From Genes to Behavior,’ Annals of the New York Academy of Sciences, 2008 October; 1141: 131-147.

Hammerness P, Joshi G, Doyle R, Georgiopoulos A, Geller D, Spencer T, Petty CR, Faraone SV, Biederman J; ‘Do Stimulants Reduce the Risk
Cigarette Smoking in Youth with Attention-Deficit/Hyperactivity Disorder? A Prospective, Long-Term, Open-Label Study of Extended-Release Methylphenidate,’ Journal of Pediatrics, 2012 August 7.

Kenneth P. Tercyak; Caryn Lerman; Janet Audrain; ‘Association of Attention-Deficit/Hyperactivity Disorder Symptoms With Levels of Cigarette Smoking in a Community Sample of Adolescents,’ J. Am. Acad. Child Adolescent Psychiatry, 41:7, July 2002.

, ‘Where There’s Smoke, There’s….ADHD: What the Science Says,’ Attention Magazine; Children and Adults With Attention-Deficit/Hyperactivity Disorder, 2012 October.

By Keath Low, Reviewed by Steven Gans, MD