154 Tobacco Dependence
nicotine transdermal patches ameliorate inattention. This ef-
fect also was observed in nonsmoking adults without ADHD
(Levin et al., 1998). The positive effects of nicotine on the
symptoms of ADHD could be due to the modulatory role of
the nACHR system on dopaminergic neurons (Wonnacott,
Irons, Rapier, Thorne, & Lunt, 1989).
As with ADHD patients, the incidence of smoking in
patients with schizophrenia is 40% to 100% higher than in
patients with other psychiatric disorders and about three times
more prevalent than levels seen in the general population (Goff,
Henderson, & Amico, 1992; Hughes, Hatsukami, Mitchell, &
Dahlgren, 1986). Some authors have suggested that patients
with schizophrenia smoke to alleviate possible medication-
induced side effects (Goff et al., 1992; Jarvik, 1991; O•Farrell,
Connors, & Upper, 1983). However, it also is possible that
these patients use nicotine as a form of self-medication and
to ameliorate certain symptoms associated with the disease
(Goff et al., 1992; Mihailescu & Drucker-Colín, 2000). For
example, patients with schizophrenia have abnormalities in
sensory-gating, which can be improved following nicotine ad-
ministration (Adler, Hoffer, Wiser, & Freedman, 1993). It has
been hypothesized that nicotine can improve some of the nega-
tive symptoms of schizophrenia by increasing dopaminergic
activity in the mesocorticolimbic pathway (Glassman, 1993).
Thus, the ability of nicotine to enhance dopamine release could
provide a possible explanation for the high frequency of smok-
ing seen in patients with schizophrenia.
In a similar vein, there is a higher incidence of smoking in
people who suffer from depression (Balfour & Ridley, 2000;
Breslau, Kilbey, & Andreski, 1993; Choi et al., 1997; Covey,
Glassman, & Stetner, 1998; Kelder et al., 2001). High levels
of depression are associated with higher dependency on
smoking (Breslau et al., 1993). Similar to ADHD and schizo-
phrenia, it is possible that depressed individuals are self-
medicating to alleviate the symptoms of depression and this
behavior could be an important factor for tobacco depen-
dence. However, another explanation could be that there
might be a common genetic basis for the association of the
two disease states (Breslau et al., 1993; Kendler et al., 1993).
ENVIRONMENTAL RISK FACTORS
FOR INITIATION
Tobacco Advertising and Promotions
A signi“cant amount of research over the past few decades
has been devoted to examining the relationship between
mass media advertising and tobacco sales. Tobacco companies
spend nearly half of their marketing dollars on point-of-
purchase promotions in retail stores; this proportion has in-
creased substantially over the past 15 years (Federal Trade
Commission, 2001). In a study based in California, retail out-
lets display an average of 17 tobacco advertising materials,
and 94% of retail outlets display at least some advertising
(Feighery, Ribisl, Schleicher, Lee, & Halvorson, 2001). In ad-
dition, tobacco is marketed through other venues such as mag-
azines, newspapers, clothing and gear, and outdoor advertising
(e.g., billboards).
Despite signi“cant public and scienti“c concern over
whether tobacco advertising promotes youth smoking, the
available evidence was deemed inconclusive in a recent re-
view article on the topic (Lantz et al., 2000). Furthermore, the
extent to which tobacco advertising bans impact youth smok-
ing is not clear (Lantz et al., 2000). Saffer and Chaloupka
(2000), in an analysis of the effects of tobacco advertising in
22 countries across the time period 1970 to 1992, concluded
that tobacco advertising increased tobacco consumption, and
a comprehensive set of advertising bans, in fact, reduced to-
bacco consumption. It is projected that the 1999 ban on
outdoor advertising, as part of the U.S. tobacco industry
settlement, will have little effect on tobacco consumption be-
cause other forms of advertising (print, point-of-purchase,
and sponsorship) have not been banned; thus, these forms
will be the focus of heightened tobacco promotion (Saffer &
Chaloupka, 2000).Effects of Pricing and Tobacco Control PoliciesAlthough cigarettes have been subjected to federal taxes since
the Civil War and state taxes since the 1920s, it wasn•t until
1964 when the Surgeon General•s report was released that
states began to increase taxes to deter smoking (Warner, 1981).
In four states (California, Massachusetts, Michigan, and Ari-
zona), voters have approved tobacco tax increases, with por-
tions of the revenues being earmarked for tobacco control
activities. Based on econometric studies, researchers cite evi-
dence suggesting that higher cigarette prices are associated
with reductions in cigarette smoking in general (National
Cancer Institute, 1993) and in youths, in particular, who may
be especially sensitive to tobacco pricing (Chaloupka &
Wechsler, 1997; Lewit, Coate, & Grossman, 1981; National
Cancer Institute, 1993). However, the fact that several studies
have failed to identify an association between cigarette
prices and smoking among adolescents (Chaloupka, 1991;
Wasserman, Manning, Newhouse, & Winkler, 1991) has led
some investigators to examine whether the price-versus-
consumption relationship differs as a function of key factors