5.5 Temperament, mental health problems and self-concept

Last updated October 2014 

Initiation of smoking is associated with a cluster of poor lifestyle habits such as other drug use, not wearing a seatbelt, having an unhealthy diet, sleep problems including not getting enough sleep, not exercising, and engaging in unsafe sex.1,2 Early uptake of smoking among adolescent girls, for example, has been associated with daily use of alcohol and cannabis,3 lower age of alcohol uptake,4 and engaging in unprotected sex3,4 and other risky sexual behaviours.4

Along with the mix of societal, social and family factors that can influence smoking uptake among children and adolescents, the relationships between smoking, personality traits and mental health have also been investigated in research, as summarised in the sections below.

5.5.1 Temperament

There is some evidence to suggest that young people with particular personality or temperament traits are more likely to take up smoking.5 These traits may occur in combination6 and may mediate the relationship between adolescent smoking and other risk factors.7 In more extreme cases, these characteristics may present as mental health problems (see Section 5.5.2). Personality traits may also be moderated or exacerbated by family and peer factors8,9 (see Sections 5.7 and 5.8) and gender (see Section 5.8.1).

Characteristics associated with increased likelihood of tobacco use include the following.

Having poorer self-control. Individuals who are less adept at controlling certain other behaviours, including being impulsive,10 easily distracted or aggressive may be more inclined to take up smoking,11 with recent research suggesting increases in self-control problems and attention problems during mid-adolescence may be associated with substance use (including tobacco) later in adolescence.12 There is some evidence of gender differences in the relationships between different aspects of impulsivity (such as inattention and disinhibition) and adolescent smoking.13 There is also evidence that aspects of impulsive personality (i.e. reward-seeking and disinhibition) may differ in the degree to which they are associated with smoking status compared with nicotine dependence.14, 15 For example, 2009 data from a US study, in which adults aged 30–54 years completed multiple self-report measures of impulsive personality and were interviewed regarding lifetime tobacco use, suggest that reward seeking is associated with smoking continuation, but not tobacco dependence, while disinhibition is associated with tobacco dependence among daily smokers, and a lower age for daily smoking among adolescent onset smokers. Investigators therefore suggested that disinhibition may underlie 'a more pernicious form of tobacco use, in which people become addicted to cigarettes more readily and at a younger age'(p435.14)

Rebelliousness. Rebelliousness against school and adult authority are markers for adoption of smoking.5,6,11,16 As young people are generally told not to use tobacco, smoking may for some represent the flouting of an obvious symbol of adult authority. Similarly, there is some evidence linking the concept of smoking behaviour as 'forbidden fruit' with current smoking and intention to smoke among US adolescents.17

Sensation seeking and adopting risky behaviour. Sensation seeking is the desire to experience novel sensations and the willingness to take risks in their pursuit. Sensation seeking and risk taking are closely associated with tobacco use and other risky behaviours during adolescence and adulthood.7, 18, 19 Evidence suggests that risk-taking behaviours among adolescents tend to cluster rather than occur in isolation; adolescents who engage in one risk-taking behaviour are more likely to engage in others,20 such as inappropriate use of alcohol and other substances, risk taking in sexual activity, and getting into trouble with the police.1,11 US research published in 2009 found that young adult smokers reported less risk, more benefit and more involvement than non-smokers in risky behaviours such as binge drinking and unprotected sex.21 Sensation seeking in primary school-aged children has been associated with more favourable implicit attitudes towards smoking, similar to attitudes of children with family members who smoked.22 Sensation seeking has also been shown to play a role in adolescents' responses to peer offers of cigarettes, being positively related to the use of certain strategies (such as 'leave' and 'avoid') for initial and follow-up smoking offers among US students in grades 6 to 8.23

Emotional distress and anxiety. Adolescents who experience stress, anxiety, anger, irritability and depression may be more likely to take up smoking.1,11,24,25

Smoking may be seen as a means of coping with negative emotions: it has been described as 'one aspect of adaptation to critical development tasks' within the study of resilience and the broad lifespan view of development.26 Once smoking behaviour is established, the reinforcing effects of nicotine use (by modifying affect and provoking withdrawal symptoms) underpin its role.27 Expectancies or beliefs that smoking will reduce negative affect and increase positive affect have been shown to influence smoking behaviour and nicotine dependence in adolescents over time.28 For example, recent US research among adolescents surveyed regularly between 14 and 17 years of age found that higher depression symptoms across mid- to late-adolescence predicted a 17% increase in expectations of smoking reward, which in turn predicted a 23% increase in the odds of smoking progression.29 These kinds of expectancies may vary due to a range of factors such as changes in smoking behaviour; for example, positive expectancies may increase following smoking uptake.7

While little is known about behavioural mechanisms through which stress influences adolescent smoking, aspects of impulsive behaviour may mediate the relationship between perceived stress and adolescent smoking.13, 30 For example, there is some evidence that adolescent smoking cessation success may be associated with less risk taking in the face of stress,31 while under-controlled, impulsive individuals may be particularly susceptible to smoking in order to lessen aversive states.7

High negative mood variability has also been shown to be a risk factor for future smoking escalation; for example, a longitudinal study among Chicago adolescents in grades 8 and 10 over 12 months found that high levels of negative mood variability at baseline significantly differentiated participants who escalated in their smoking behaviour over time from participants who did not progress beyond low levels of experimentation during the course of the study.32 Adolescents who reported an escalation in smoking experienced a reduction in mood variability as smoking increased, whereas participants with consistently high or low levels of cigarette use had more stable mood variability levels.32

5.5.2 Mental health problems

5.5.2.1 Hockenberry review

The evidence for adolescent mental health issues as a risk factor for adolescent smoking onset was reviewed by Hockenberry and colleagues in 2011.33 Four commonly studied mental health symptoms were identified from 746 studies: depression, suicidal ideation, anxiety disorders, and attention deficit hyperactivity disorder (ADHD). A subset of these studies was then used to examine the link between mental illness and associated symptoms and the onset or progression (i.e. transition from experimental to regular tobacco use or increased frequency or intensity) of adolescent smoking.33 Key findings from this review are summarised below.

Depression

The literature was most extensive on smoking and depression,33 with most studies concluding a strong association. The reviewers found that while longitudinal studies typically found temporal precedence for depression and resultant smoking and vice versa, the relationship was often diminished following adjustment for potential mediating or potentiating influences or after controlling for unobservable factors.33

Anxiety

Many studies also addressed anxiety due to the high comorbidity between depression and anxiety. Research results on anxiety were mixed, with findings that heavy smoking in adolescence predicted anxiety onset in later adolescence or early adulthood; social phobia and post-traumatic stress were found to lead to daily smoking; while other studies focused on anxiety found it to be associated with cessation.

Suicide ideation

Most studies on suicidal ideation (thinking about suicide) and smoking examined smoking as a predictor of suicidal ideation. In general, analyses indicate that adjusting for factors such as stress and parental attachment levels, and mental illness diagnoses, removed any significant association between smoking and suicidal ideation, suggesting that the relationship is largely mediated by depression status.33 There is some evidence from US research that adolescent smoking and suicidal ideation is likely linked due to common psychosocial causes rather than a causal pathway from smoking to suicidal ideation; adolescent smokers who did not have a parent who smoked were at higher risk for suicidal ideation than non-smokers.33

ADHD

ADHD was generally considered to be an independent risk factor for smoking33; while studies typically found an association between ADHD and smoking uptake or progression, many were limited by small sample sizes and none dealt with other unobserved factors that potentially drive both ADHD symptom development and smoking.33 ADHD was also found to be associated with nicotine use in adolescents in a meta-analysis of 13 prospective cohort studies.34 Interestingly, there was evidence that this relationship may be mediated by school adjustment (a construct including academic achievement, relationships with other students, academic and behaviour problems, and other general aspects of the child's school experience)35 and by whether the ADHD is left untreated or is in combination with conduct disorder.36

5.5.2.2 Other research on smoking and mental health problems

Negative self-esteem has been found to be associated with cigarette and cannabis use among male adolescents.37 However, although adolescence is thought to be a time wrought with insecurity and self-criticism, a recent meta-analysis of studies of US teenagers suggests that self-esteem among recent generations of young people is at an all-time high, due to an increased cultural emphasis on self-worth and competence.38 When this untested self-esteem confronts reality, young people can experience personal crises and high levels of anxiety. Smoking and other risky behaviours may serve as a coping mechanism in response to these feelings of vulnerability and self-consciousness.5

Other research has also shown a strong association between smoking behaviour and a range of psychiatric conditions in adolescence. Connections between tobacco use (including early uptake, the transition from experimental to daily smoking in adolescence, and the development of nicotine dependence) and disruptive behaviour disorders (such as oppositional defiant disorder, conduct disorder and attention deficit hyperactivity disorder), anxiety, major depressive disorders39 and other substance use disorders40  have been consistently and increasingly reported in the medical literature.33, 41-50  Studies have associated child and adolescent psychopathology with nicotine dependence 47, 51  and heavy smoking.51  For example, Hu et al 48  found adolescent conduct problems to be predictive of adolescent nicotine dependence after two years, with greater effects for males than for females, although other baseline factors such as parental nicotine dependence and adolescent smoking levels were of greater influence. Psychiatric factors such as externalising disorders confer risk for chronic smoking,52  smoking at an early age and smoking continuation into the 30s53  and have been found to be associated with greater tobacco consumption following uptake.52

An analysis of national smoking prevalence in the US found that young teenagers who took up smoking were more likely than non-smokers to suffer from symptoms of mental illness such as hopelessness, worthlessness and depression.54 Earlier experience of symptoms of psychological distress was associated with earlier age of uptake of smoking. Overall, smokers aged 12–17 years were twice as likely as non-smokers of the same age to have experienced a major depressive episode in the previous year.54 Longitudinal US research (2009) examined childhood depressive symptoms as a predictor of adolescent cigarette use in a six-year study among children aged 9–12 years at baseline. Higher levels of childhood depressive symptoms were associated with cigarette use, higher levels of friends’ cigarette use and higher levels of depressive symptoms in adolescence.55  

There is some evidence of bidirectional self-medication processes in the relationship between adolescent smoking and depression, with peer smoking as one explanation for the comorbidity. A longitudinal study followed 1093 US adolescents annually from mid-adolescence (9th grade, age 14) to late adolescence (12th grade, age 18). Higher depression symptoms in mid-adolescence predicted adolescent smoking progression from mid- to late adolescence, while higher depression symptoms across time predicted an increase in the number of smoking peers, which in turn predicted smoking progression from mid- to late adolescence. In addition, smoking progression predicted a deceleration of depression symptoms from mid- to late adolescence. Higher baseline smoking levels predicted a deceleration in the number of smoking peers across time, which predicted a deceleration in depression symptoms from mid- to late adolescence.56  Evidence from the same cohort followed for a further period to 22–23 years of age suggested that higher depression symptoms in emerging adulthood (18–19 years of age) influenced smoking uptake and smoking rate through reductions in substitute reinforcers (alternative, pleasant activities such as arts and crafts). There is evidence that smoking may be ineffective at reducing depressive symptoms: results from a Canadian study following adolescents aged 12–13 years for five years suggested that participants with higher self-medication scores had decelerated rates of change in depression over time compared with participants with lower self-medication scores.57

Depression and smoking are both related to higher levels of weight concerns and dieting among adolescents, especially girls. In a 2009 cross-sectional study among Dutch adolescents (mean age 13.8 years) using a survey that included smoking, depression and weight constructs as well as measured weight and height, a positive correlation of a similar magnitude between depressive symptoms and smoking was found for both boys and girls.58  However, the relationship between weight concern and both depressive symptoms and smoking was stronger among girls. Similarly, dieting was more strongly associated with depressive symptoms for girls and showed a significant correlation with smoking for girls only. After controlling for weight concerns and dieting, the depression–smoking association disappeared for girls but not for boys.58 The relationship between body weight and smoking uptake is explored further in Section 5.8.1.1.

Early uptake of smoking is also associated with an increased likelihood of developing a range of anxiety disorders, including generalised anxiety disorder (experiencing chronic anxiety and worrying often for no reason), panic attacks and panic disorder, and post-traumatic stress disorder.54 Experiencing or witnessing trauma in childhood (such as childhood sexual or physical abuse or interpersonal violence) is also associated with an increased likelihood of uptake of smoking.59  Research examining anxiety as an independent risk factor for smoking in adolescents is less developed than that in the case of depression and is often cross-sectional, making it difficult to determine temporal precedence or causality. Despite this, emerging issues are very similar to studies of depression and smoking: other factors, including familial and peer context, genetic factors and other unmeasured confounders, need to be taken into account in future studies, as does the high comorbidity between depression and anxiety and the difficulty of reliably distinguishing between the two sets of disorders.33 Some evidence from a school-based study in China suggests that male adolescents with high levels of depressive symptoms who have experimented with smoking may be more sensitive to smoking-related social influences such as perceived peer smoking prevalence.60  

Comorbidity of psychiatric illness and smoking may be due to common underlying factors (e.g. intergenerational transmission of parental nicotine dependence61, 62  and psychopathology),61  a predisposition due to neurobiological alterations to the adolescent brain caused by nicotine, or self-medication.54 Use of nicotine to ameliorate symptoms of depression and anxiety is particularly apparent, especially in girls.63  The connection between smoking and psychiatric symptoms may be bidirectional, each reinforcing and promoting the other.47  For example, while the association between smoking and depression in adolescents is well established, the temporal ordering of the association is subject to debate, as described in the evidence review by Hockenberry et al.33 Meta-analyses of 15 longitudinal studies published between January 1990 and July 2008 suggest that the association is bidirectional.64  Studies using clinical measures of depression were more likely to report a bidirectional effect, with a stronger effect of depression predicting smoking. 

There is some evidence from autopsy studies that cigarette smokers have higher levels of brain nicotine receptors than non-smokers, which may mean a higher risk of developing neuropsychiatric disorders.65   Adults with mental illness have a much higher prevalence of smoking than the background population. See Chapter 1, Section 10.2 for further discussion. The association between smoking and use of other substances is discussed in Section 5.31.

5.5.3 Australian research on smoking and mental health problems

The relationship between smoking and several mental disorders among Australian adolescents was investigated from data collected on 1280 adolescents aged 13–17 years in the 1998–99 child and adolescent component of the National Survey of Mental Health and Wellbeing.66  Three main mental disorders were assessed: conduct disorder, depressive disorder and ADHD. Anxiety disorders were not included. Current emotional and behavioural problems were assessed through parent/caregiver appraisal and youth self-reports. After adjusting for demographic and socio-economic factors (age, sex, family structure, household income and age mother left school), all measures of mental disorders and emotional and behavioural problems were strongly associated with current smoking status.66 Young people with conduct disorder or with externalising problems had the highest rates of smoking. Externalising behaviours were more strongly associated with smoking than internalising behaviours. On average, young people with emotional and behavioural problems started smoking at an earlier age, consumed a larger number of cigarettes per day and smoked on more days during the past month than those without such problems, and were more likely to progress to current smoking.66 Smoking rates were higher for young people with two or more diagnoses of mental disorders. Both parent and youth reports were strongly associated with smoking status, suggesting that assessment of emotional and behavioural problems by either the parent or the youth would be a good indicator of potential smoking risk.66

Statewide surveys of adolescent smoking behaviour in Victoria undertaken between 1992 and 1995 showed that teenagers experiencing symptoms of anxiety or depression were much more likely to take up smoking, particularly in settings in which peer group smoking was present. Young girls were especially susceptible to this psychosocial combination of factors.67  Recently published data from a 10-year longitudinal study conducted among adolescent Victorians indicate that symptoms of depression and anxiety in adolescence significantly altered the course of smoking and predicted progression to nicotine dependence well beyond the secondary school years for adolescent smokers.68  Five assessments with 1943 participants were conducted at six-monthly intervals from years 9 and 10, followed by two follow-up assessments during young adulthood (aged 20–21 and 24–25 years). After adjustment for confounding factors (gender, adolescent alcohol and cannabis use), adolescents who smoked and who had high levels of depression and anxiety symptoms were at increased risk for nicotine dependence in young adulthood compared with those who reported low levels of depression and anxiety. In contrast, adolescent depression and anxiety at any level did not predict nicotine dependence in young adulthood for adolescent never smokers. No significant association between adolescent mental health symptoms and daily smoking as a young adult was found for any level of adolescent tobacco use.68

Research into adolescent smoking behaviour in Queensland from the late 1990s has shown that adolescents aged 14 years presenting with delinquency, depression, anxiety or somatisation (conversion of an emotional, mental, or psychosocial problem to a physical complaint) were significantly more likely to be smokers. Male smoking was more strongly linked to ‘external’ behavioural factors (delinquency and depression) and female smoking was more strongly associated with ‘internal’ factors (anxiety/depression or somatisation).69  Childhood aggression is also associated with smoking behaviour in adolescence.69

5.5.4 Self-concept

Self-efficacy is concerned with perceived self-competence and refers to ‘beliefs in one’s capabilities to organize and execute the courses of action required to produce given levels of attainments’ (p624).70  The principle of self-efficacy proposes that high levels of self-efficacy may reduce smoking behaviour.71  Research has demonstrated the contribution of self-efficacy to the initiation and continuation of smoking behaviour.63 low self-efficacy has been associated with smoking initiation and smoking rates as well as greater difficulty quitting and/or higher rates of relapse among adolescents,72  as well as higher levels of negative health behaviours.71 

Recent Dutch longitudinal research examined how baseline self-efficacy and changes in self-efficacy predict adolescent smoking over time, following never smokers at baseline (mean age 13.3 years) over four years.73  Refusal self-efficacy (adolescents’ reported confidence in their ability to stay a non-smoker and to refuse a cigarette) was assessed at each wave. While baseline self-efficacy, parental and friends’ smoking did not predict adolescent smoking at the final time point, baseline sibling smoking did. In addition, growth curve parameters showed that a decrease in self-efficacy, an increase in proportion of smoking friends, and an increase in sibling smoking over time were related to an increase in adolescent smoking. Investigators concluded that a reduction in self-efficacy over time, rather than baseline self-efficacy, is associated with smoking initiation in adolescence.73

In recent research among US high school students, self-efficacy partially mediated the positive relationship between baseline depressive symptoms and susceptibility to smoke 18 months later (accounting for approximately 27% of the variance).72 Investigators suggested more effective interventions aimed at adolescent smoking prevention could target self-efficacy, especially among adolescents experiencing or at risk of depression.

Recent evidence suggests adolescent resilience plays a mixed role in health-related risk-taking behaviours (such as smoking, drinking alcohol and using illegal drugs), with some aspects being protective and others increasing the likelihood of substance use.74, 37 Researchers using nationally representative US data from a longitudinal study of adolescent health identified three aspects of resilience: overall resilience, self/family resilience, and self-resilience.75  Overall-resilient adolescents were less likely to engage in risky behaviours; self/family-resilient adolescents were more likely to engage in risky behaviours, but consumed less; and self-resilient adolescents had a lower risk of smoking but an increased risk for being in an addictive stage of smoking if tobacco users.75 Similarly, research among Slovakian adolescents found that aspects of resilience (‘structured style’ and ‘family cohesion’) were associated with a lower probability of smoking and cannabis use among boys and girls, while ‘social competence’ increased the probability of smoking and cannabis use among both groups.37 

There is some evidence that ‘perceived’ addiction to tobacco among adolescents is associated with smoking behaviours and susceptibility for both smokers and non-smokers. While adolescent smokers report levels of ‘perceived’ tobacco addiction that are related to several measures of nicotine dependence, non-smoking adolescents may also report feeling addicted to tobacco. This can occur even with minimal or no prior tobacco use, suggesting some vulnerability to tobacco use. Multivariate logistic regression analyses of cross-sectional data from 5155 Canadian student non-smokers indicated that, among other demographic, social and substance use factors, perceived mental addiction but not perceived physical addiction to tobacco was significantly associated with smoking susceptibility.76


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