The above model highlights a number of compelling research questions that could help us to elucidate mechanisms underlying the prevalent comorbidity of ADHD and smoking. A critical aspect of any model of maladaptive behavior, however, is the extent to which it can inform clinical and community-based interventions.
The foregoing review and proposed framework suggest several applications for preventing and reducing smoking and nicotine dependence in individuals who are vulnerable as a result of ADHD and related risk factors. As reviewed above, a number of studies have shown that both a diagnosis of ADHD and ADHD symptomatology (independent of clinical diagnosis) are associated with lifetime risk of regular smoking, higher levels of smoking, and earlier initiation of smoking. These findings suggest that young people with ADHD and/or those who manifest a number of ADHD symptoms might be preferentially targeted for prevention efforts. A sizable literature exists on community and school-based smoking prevention programs.129,130
It is not known, however, whether individuals at risk for smoking as a result of ADHD-related problems would benefit from existing prevention programs, or if they would require novel alternative approaches. Several of the more successful current prevention programs focus on peer and family influences.129,130
It is well established, however, that individuals with ADHD have significant deficits in peer relationships.131
Further, coping skills and parent–child communication have been shown to mediate the association between ADHD and smoking outcomes.132
As such, individuals with ADHD or related symptomatology may benefit from prevention programs that specifically target these important mediating processes.
Our review and proposed model also form the basis for several innovative approaches to treating individuals with ADHD and related problems who have initiated regular smoking. It has been shown that individuals with ADHD have a harder time quitting smoking and show more significant signs and symptoms of smoking withdrawal.7,36,39
Based on these findings and much of the other literature reviewed, it could be argued that individuals with ADHD and related problems smoke, in part, to reduce the requisite symptoms of inattention, hyperactivity, and impulsivity. Based on this conceptualization, treatment strategies that improve these deficits prior to and during a quit attempt may be successful in facilitating smoking cessation among individuals with ADHD. This approach is currently being evaluated in a large clinical trial funded by the National Institute on Drug Abuse. This study will evaluate whether a sustained release formulation of methylphenidate (Concerta®), relative to placebo, increases the effectiveness of a standard smoking treatment (i.e., a nicotine patch and individual smoking cessation counseling) in obtaining prolonged abstinence for adult smokers with ADHD (http://www.clinicaltrials.gov/ct/show/NCT00253747?order=1
). Similarly, novel pharmacological interventions that target either cholinergic or dopaminergic systems have shown some promise in treating both smoking and ADHD. For example, bupropion has shown efficacy in treating adults with ADHD and has also been approved by the Food and Drug Administration as an aid to smoking cessation.133–135
Novel cholinergic agents have also shown promise in treating adults with ADHD.114,115
Whether these agents would work for treating comorbid ADHD–smoking is largely unknown, although one open-label pilot study with adolescents reported positive results.136
Based on the conceptualization reported here for how ADHD and smoking behavior might be related, it stands to reason that nonpharmacological approaches to treating ADHD might also be useful in facilitating smoking cessation. Emerging work shows promise for the use of cognitive-behavioral treatment of adults with ADHD. It would be important to evaluate whether these treatment approaches would serve as useful adjuncts to smoking cessation in those with ADHD.137