5.5.1 Temperament
Having poorer self-control
Rebelliousness
Sensation seeking and adopting risky behaviour
Extraversion
Conscientiousness
5.5.2 Mental health problems
Internalising problems:
Depression
Anxiety
Suicidal ideation
Negative emotions, stress and high negative mood variability
Externalising:
Conduct disorder, ADHD and oppositional defiant disorder
5.5.2.1 Australian research on smoking and mental health problems
5.5.3 Self-concept
5.5.1 Temperament
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 The role of personality traits in smoking may also be affected by family and peer factors4, 5 (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 impulsiveness,6 who are easily distracted, or aggressive may be more likely to take up smoking,7 with research suggesting problems with self-control and attention during mid-adolescence having potential associations with substance use (including tobacco) later in adolescence.8 Research has found disinhibition to be associated with tobacco dependence among adolescent daily smokers, as well as lower age of onset for daily smoking.9
Rebelliousness. Rebelliousness against school and adult authority can predict uptake smoking among adolescents.1, 2, 7, 10 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.11
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, 12, 13 Sensation seeking has even been associated with more favourable attitudes towards smoking among children of primary school-age.14 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.15
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.16 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.17-19 Early uptake of smoking among adolescent girls, for example, has been associated with daily use of alcohol and cannabis,20 lower age of alcohol uptake,21 and engaging in unprotected sex20, 21 and other risky sexual behaviours.21
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.22
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.22, 23 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.22
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 7.12.
Internalising problems:
Depression. A major review in 2011 found a strong association between smoking and depression.24 The reviewers found that longitudinal studies showed evidence for both depression preceding smoking, and smoking preceding depression. However, genetic and psychosocial factors often mediated the relationships.24 In 2018 a nationally representative Population Assessment of Tobacco and Health (PATH) study in the US found internalising problems, including depression, predicted the onset of almost all tobacco product use, however genetic and psychosocial factors were not controlled for in this particular study.25 Young people with internalising problems such as depression were likely to use more than one type of tobacco product.25 Earlier research also found that an experience of psychological distress, including hopelessness, worthlessness and depression was associated with earlier age of uptake.26
A school-based study in China has suggested 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.27 While for adolescent girls especially, depression and smoking are both related to higher levels of weight concerns and dieting. In a 2009 cross-sectional study among Dutch adolescents, a positive correlation between depressive symptoms and smoking was found for both boys and girls.28 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.28 The relationship between body weight and smoking uptake is explored further in Section 5.8.1.1.
The ‘self-medication hypothesis’ had proposed that smoking may help alleviate psychiatric symptoms,26, 29 and has traditionally been used as an explanation for the association between depression (and other mental disorders) and smoking. However, a growing body of research now shows that smoking is ineffective at reducing depressive symptoms. A large systematic review and meta-analysis found smoking cessation to be associated with a reduction in depression, anxiety and stress, as well as improvement in quality of life, compared with those who continued to smoke. The effect was found to be equal to, and some times greater than, that of antidepressant treatment for improving mental health.30, 31
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.24 The US PATH study found anxiety, like depression, predicted the onset of any tobacco use in young people aged 12- to 24-years old.25 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.25 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.26 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.32 Factors such as familial and peer context, genetic factors and other unmeasured confounders, also 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.24
Suicidal 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 among adolescents, suggesting that the relationship is largely mediated by depression status.24 Research among adults, however, has found smoking to be associated with suicidal behaviours—for this information see Section 7.12.
Negative emotions, stress and high negative mood variability. Smoking may be perceived as a means of coping with negative emotions.33 Once smoking behaviour is established, the reinforcing effects of nicotine use (by relieving withdrawal symptoms) underpin its perceived role.34 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.35 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.36, 37 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,38 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 eight and 10 found that high levels of negative mood variability predicted an escalation in smoking behaviour over time.39 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.39
Externalising:
Conduct disorder, ADHD and oppositional defiant disorder. Externalising disorders such as conduct disorder, ADHD and oppositional defiant disorder confer risk for: chronic smoking,40 smoking at an early age, smoking continuation into the 30s,41 faster progression to daily smoking, nicotine addiction,42-44 and may be associated with greater tobacco consumption following uptake.40 ADHD has generally been considered an independent risk factor for smoking;24 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.24 A meta-analysis of 13 prospective cohort studies found ADHD to be associated with nicotine use in adolescents.45 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)46 and by whether the ADHD was left untreated or was in combination with conduct disorder.47 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.44 This is similar to a US study (2016) which found earlier initiation, and faster progression to regular smoking for children with ADHD.43 By late adolescence, participants who exhibited more severe ADHD symptoms in the 2018 study had a higher probability of being daily smokers in adulthood (39.6%) compared to those with low ADHD symptoms (20.3%). Furthermore, those with ADHD recorded more quit attempts, were more likely to experience severe withdrawal symptoms such as craving, difficulty concentrating, and restlessness, and therefore had a greater likelihood of relapse.44
In another study, adolescent conduct problems predicted 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. 48 Adults with mental illness have a much higher prevalence of smoking than the general population. See Section 7.12 for further discussion. The association between smoking and use of other substances is discussed in Section 5.10.
5.5.2.1 Australian research on smoking and mental health problems
Results of the 2017 Australian Secondary School Student’ Use of Tobacco, Alcohol, over-the-counter Drugs, and Illicit Substances (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, 37% reported ever having used tobacco, compared with 16% who did not have a mental health diagnosis. Results were higher for female students, with ever use of tobacco at 38% for those with mental health diagnoses, compared with 15% for female students without mental health diagnoses. Similarly, male students recorded 33% and 17% respectively, for ever use of tobacco products by mental health status.49
Earlier data on the relationship between smoking and mental disorders among Australian adolescents was collected in the 1998–99 child and adolescent component of the National Survey of Mental Health and Wellbeing.50 Three main mental disorders were assessed: conduct disorder, depressive disorder and ADHD. All measures of mental disorders and emotional and behavioural problems were strongly associated with current smoking status.50 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.50 Smoking rates were higher for young people with two or more diagnoses of mental disorders. Reports from both parents and young people were strongly associated with smoking status, suggesting that assessment of emotional and behavioural problems by either the parent or the young person would be a good indicator of potential smoking risk.50
State-wide 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.51 A 10-year longitudinal study conducted among adolescent Victorians found that symptoms of depression and anxiety predicted progression to nicotine dependence well beyond the secondary school years for adolescent smokers.52 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.52
Research in Queensland from the late 1990s found 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).53 Childhood aggression was also associated with smoking behaviour in adolescence.53
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).54 Research has demonstrated a relationship between self-efficacy and the initiation and continuation of smoking behaviour:29 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,55 as well as higher levels of negative health behaviours.56
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 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.57
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.55 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, a weekly smoker by ages 17 and 21.58
Evidence suggests adolescent resilience plays a mixed role in health-related risk-taking behaviours (such as smoking, drinking alcohol and using illegal drugs).59, 60 Researchers using nationally representative US data from a longitudinal study identified three aspects of resilience: overall resilience, self/family resilience, and self-resilience.61 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).61 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.60
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