5.5 Temperament, mental health problems and self-concept

5.5.1 Temperament and personality traits

There is evidence to suggest that young people with particular personality or temperament traits are more likely to take up smoking.¹ These traits may occur in combination² and can also affect the relationship between adolescent smoking and other risk factors.³ A 2019 US/Australia, twin/cohort study indicated that a personality profile characterised by high neuroticism, low agreeableness, and low conscientiousness on the Big Five personality dimensions was associated with an increased likelihood of developing addictive disorders, including nicotine dependence. These traits also appeared to reflect a more general vulnerability to psychiatric disorders, suggesting they contribute to the risk of addiction.⁴ In a cross-sectional study from 2024, researchers in China found that personality traits of extraversion, agreeableness, and neuroticism were all positively associated with smoking uptake, after adjusting for other factors.⁵ While these two studies show conflicting results about the role of ‘agreeableness’ in relation to smoking, it could be that agreeableness may increase the chance of starting smoking (as agreeable people are more influenced by peers),⁵ but low agreeableness raises the risk of developing nicotine dependence once smoking is established (as low agreeableness is linked to greater impulsivity and rule-breaking).⁴ The role of personality traits in smoking may also be affected by family and peer factors^6,7 (see Sections 5.7 and 5.8) and gender (see Section 5.8.1).

Other characteristics associated with increased likelihood of tobacco use include the following:

Having poorer self-control. Individuals who are less adept at controlling impulsiveness,⁸ who are easily distracted, or aggressive may be more likely to take up smoking, with research suggesting problems with self-control and attention during mid-adolescence having potential associations with substance use (including tobacco) later in adolescence.⁹ Research has found disinhibition to be associated with tobacco dependence among adolescents who smoke daily, as well as lower age of onset for daily smoking.¹⁰

Rebelliousness. Rebelliousness against school and adult authority can predict smoking uptake among adolescents.^1,2,11 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 adolescents.¹²

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.^3,13,14 Sensation seeking has even been associated with more favourable attitudes towards smoking among children of primary school-age.¹⁵ Sensation seeking has also been shown to play a role in young adolescents’ responses to peer offers of cigarettes. When presented with an unwanted opportunity to smoke, sensation seeking adolescents—rather than outwardly refuse or explain to their peers that they don’t want to participate—are more likely to employ tactics such as avoiding the scene altogether, or leaving the scene in order to remove themselves from the excitement of trying a cigarette.¹⁶

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.¹⁷ For example, initiation of smoking is associated with a cluster of risky behaviours such as other drug use, not wearing a seatbelt, having an unhealthy diet, binge drinking, sleep problems, not exercising, and engaging in unsafe sex.^18-20 Early uptake of smoking among adolescent girls, for example, has been associated with daily use of alcohol and cannabis,²¹ lower age of alcohol uptake,²² and engaging in unprotected sex^21,22 and other risky sexual behaviours.²²

Extraversion. Higher extraversion—characterised by sociability and outgoingness— is associated with an increased likelihood of smoking initiation. One potential explanation for this association is that because smoking can be a social activity, people who are extroverted may begin smoking because they are more social.²³

Conscientiousness. Lower conscientiousness may also be associated with an increased probability of smoking. Conscientiousness is the personality trait of being careful or vigilant and is known as the central health related trait. Lower conscientiousness has been associated with obesity, diabetes, cardiovascular disease and stroke, as well as all-cause mortality.^23,24 Individuals with lower conscientiousness are less likely to adhere to healthy lifestyle behaviours, including abstaining from smoking. A meta-analysis of cohort studies found that lower conscientiousness was associated with smoking initiation.²³

5.5.2 Mental health problems

There is a robust relationship between mental health problems and tobacco use among young people. Internalising problems—depression, anxiety and suicidal ideation—as well as externalising problems—conduct disorder, ADHD and oppositional defiant disorder—are risk factors for early smoking onset, transition from experimental to daily smoking, as well as the development of nicotine dependence in young people. For a detailed discussion of mental health and smoking among adults, see Section 9A.3.

Internalising problems:

 Anxiety. Research examining anxiety as an independent risk factor for smoking in adolescents is less developed than in the case of depression and is often cross-sectional, making it difficult to determine causality. Further research is needed to better understand the association between anxiety and smoking in adolescence, although there are likely some commonalities with depression, particularly the psychosocial and genetic factors that may affect the relationship.²⁵ The US PATH study found anxiety, like depression, predicted the onset of any tobacco use in young people aged 12-to-24 years.²⁶ The study found internalising problems, including anxiety, predicted the onset of almost all tobacco product use and young people with internalising problems were also more likely to use more than one type of tobacco product.²⁶ Early uptake of smoking is 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.²⁷ Experiencing or witnessing trauma in childhood (such as childhood sexual or physical abuse or interpersonal violence) is also associated with an increased likelihood of smoking uptake.³⁴  

Suicidal ideation. A 2022 systematic review concluded that smoking is independently associated with the risk of suicidal behaviour (ideations, plans, attempts) in young people.³⁵ Moreover, a US longitudinal study³⁶ of children aged 9-10 (at baseline) found those who had ever used tobacco or e-cigarette products were three to five times more likely to make a suicide attempt. This association was independent of other known suicide risk factors, including socioeconomic status, psychopathy and alcohol, cannabis, and prescription drug use.³⁶ An analysis from 2023³⁷ investigating the association between smoking and suicide attempts among adolescents in 28 countries, focusing on the mediating role of truancy and the moderating effect of gender, found that truancy partially mediated the relationship between smoking and suicide attempts, contributing 21% of the total effect. Additionally, female adolescents who smoked had 36% higher odds of suicide attempts compared to male adolescents. The findings suggest that interventions addressing cigarette smoking and truancy among young people may help prevent suicide attempts.³⁷ Research among adults has also found smoking to be associated with suicidal behaviours—for this information see Section 9A.3.

Negative emotions, stress and high negative mood variability. Smoking may be perceived as a means of coping with negative emotions.³⁸ Once smoking behaviour is established, the reinforcing effects of nicotine use (by relieving withdrawal symptoms) underpin its perceived role.³⁹ Beliefs that smoking will reduce negative affect, and increase positive affect, have been linked to an increase in smoking initiation, experimentation, maintenance, and nicotine dependence in adolescents.⁴⁰ 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.^41,42 For example, there is some evidence that less risk taking in the face of stress may be associated with  more successful quit attempts for adolescents,⁴³ while impulsive individuals may be particularly susceptible to smoking, and smoking relapse during quit attempts, when under stress.³ Therefore, it is not the stress itself, but one’s reaction to stress—in the form of impulsiveness— that affects smoking behaviour. 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 found that high levels of negative mood variability predicted an escalation in smoking behaviour over time.⁴⁴ 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.⁴⁴

Externalising:

Conduct disorder, ADHD and oppositional defiant disorder. Externalising disorders such as conduct disorder, ADHD and oppositional defiant disorder confer risk for: chronic smoking,⁴⁵ smoking at an early age, smoking continuation into the 30s,⁴⁶ faster progression to daily smoking, nicotine addiction,^47-49 and may be associated with greater tobacco consumption following uptake.⁴⁵ ADHD has generally been considered a risk factor for smoking.²⁵ A meta-analysis of 13 prospective cohort studies found ADHD to be associated with nicotine use in adolescents.⁵⁰ 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)⁵¹ and by whether the ADHD was left untreated or was in combination with conduct disorder.⁵² A 16-year longitudinal analysis of children with, and without, ADHD published in 2018 found children diagnosed with ADHD in childhood progressed faster from smoking initiation to daily smoking and recorded shorter time to first cigarette of the day, than children who were not diagnosed with ADHD.⁴⁹ This is similar to a US study (2016) which found earlier initiation, and faster progression to regular smoking for children with ADHD.⁴⁸ By late adolescence, participants who exhibited more severe ADHD symptoms in the 2018 study had a higher probability of smoking daily in adulthood (39.6%) compared to those with low ADHD symptoms (20.3%). Furthermore, those with ADHD recorded more quit attempts but were more likely to experience severe withdrawal symptoms such as craving, difficulty concentrating, and restlessness, and therefore had a greater likelihood of relapse.⁴⁹

In another study, adolescent conduct problems predicted 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.⁵³ Adults with mental illness have a much higher prevalence of smoking than the general population. See Section 9A.3 for further discussion. The association between smoking and use of other substances among adolescents is discussed in Section 5.31.

5.5.2.1 Australian research on smoking and mental health problems

Results of the 2017 Australian Secondary Students’ Alcohol and Drug (ASSAD) survey found tobacco smoking to be higher among students who had reported a mental health diagnosis than those who had not. Of those who identified as having a mental health diagnosis, 36% reported ever having used tobacco, compared with 14% who did not have a mental health diagnosis. Results were higher for female students, with ever use of tobacco at 37% for those with mental health diagnoses, compared with 13% for female students without mental health diagnoses. Male students recorded 33% and 16% respectively, for ever use of tobacco products by mental health status.⁵⁴

Data published in 2022 from the first (1998) and second (2013-14) child and adolescent components of the National Surveys of Mental Health and Wellbeing were analysed to further identify the extent of the relationship between mental disorders/mental health problems, risk behaviours, and tobacco smoking among Australian adolescents. The results showed that while smoking rates had declined in 13- to 17-year-olds with mental disorders since 1998, the strength of the association between mental disorders and smoking had increased, especially among females. Furthermore, a high proportion of 13- to 17-year-olds who had smoked during the last 30 days in 2013-14 had multiple problems and risk behaviours, including comorbid mental health problems, self-harming behaviours and significant problems at school (poor attendance, suspension or having dropped out of school).⁵⁶

At the state level, a 10-year longitudinal study conducted among adolescent Victorians published in 2010 found that symptoms of depression and anxiety predicted progression to nicotine dependence well beyond the secondary school years for adolescent smokers.⁵⁸ 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.⁵⁸

5.5.3 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).⁶⁰ Research has demonstrated a relationship between self-efficacy and the initiation and continuation of smoking behaviour:³¹ 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,⁶¹ as well as higher levels of negative health behaviours.⁶²

Dutch longitudinal research found that while baseline self-efficacy, parental and friends’ smoking did not predict adolescent smoking at the final time point, a decrease in self-efficacy, an increase in proportion of friends who smoke, 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.⁶³

In research among US high school students, self-efficacy partially mediated the positive relationship between baseline depressive symptoms and susceptibility to smoke 18 months later.⁶¹ Investigators suggested more effective interventions aimed at adolescent smoking prevention could target self-efficacy, especially among adolescents experiencing or at risk of depression.

Longitudinal research has also investigated whether a young person’s locus of control (LoC) can influence uptake of smoking.  LoC, or one’s perception of control over one’s life events, can either be more external, whereby one believes events are largely the result of chance or the actions of others, or internal, whereby one believes life events are more so the result of their own actions. A study examining the relationship between LoC and consumption of tobacco in young adults found strong evidence that holding a more external LoC at age 16 was associated with higher odds of nicotine addiction, as well as being, at least, weekly smoking by ages 17 and 21.⁶⁴

Evidence suggests adolescent resilience plays a mixed role in health-related risk-taking behaviours (such as smoking, drinking alcohol and using illegal drugs).^65,66 Researchers using nationally representative data from a longitudinal study in the US identified three aspects of resilience: overall resilience, self/family resilience, and self-resilience.⁶⁷ 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).⁶⁷ 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.⁶⁶

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References

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