Intellectual Impairment in Childhood

to฀have฀more฀behavioural฀abnormalities฀ [43,฀46–50] ,฀namely,฀heightened฀aggressiveness฀ [21,฀ 46–49,฀51] ,฀and฀an฀increased฀tendency฀to฀drug฀and฀nicotine฀dependence฀ [47,฀50] .฀Secondly,฀ depressive฀and฀anxious฀reactions฀have฀been฀described,฀and฀this฀inding฀applies฀more฀to฀boys฀ than฀to฀girls฀ [41,฀48,฀51] .฀Naturally,฀the฀value฀of฀any฀conclusion฀regarding฀childhood฀behav- iour฀depends฀on฀the฀test฀selected฀Child฀Behaviour฀Check-List,฀Child฀Problem฀Behaviour฀ Index,฀Home฀Observation฀for฀Measurement฀of฀the฀Environment฀etc.฀ [50,฀51,฀54] .฀Two฀studies฀ have฀shown฀an฀increased฀frequency฀of฀ADHD฀in฀children฀whose฀mothers฀smoked฀during฀ pregnancy฀ [45,฀55] .฀Similarly,฀an฀increased฀prevalence฀of฀idiopathic฀mental฀retardation฀was฀ detected฀in฀children฀passively฀exposed฀to฀cigarette฀smoke฀during฀pregnancy฀and฀postnatally฀ OR฀=฀1.9;฀CI:฀1.0–3.4,฀compared฀with฀a฀non-exposed฀control฀group฀ [56] . According฀to฀a฀study฀published฀in฀1999,฀long-term฀nicotine฀consumption฀has฀been฀linked฀ with฀self-medicating฀efforts฀to฀cope฀with฀the฀effects฀of฀adverse฀childhood฀experiences;฀peo- ple฀exposed฀to฀highly฀adverse฀experiences฀in฀childhood฀will฀also฀be฀under฀increased฀stress฀in฀ adulthood฀ [57] .฀In฀a฀retrospective฀cohort฀study,฀a฀total฀of฀9,215฀adults฀with฀mean฀ages฀of฀55.3฀ years฀women฀and.฀58.1฀years฀men฀responded฀to฀a฀survey฀questionnaire฀to฀identify฀the฀ adverse฀experiences฀to฀which฀they฀had฀been฀exposed฀in฀childhood:฀emotional,฀physical฀and฀ sexual฀abuse;฀a฀battered฀mother;฀parental฀separation฀or฀divorce;฀and฀growing฀up฀with฀a฀sub- stance-abusing,฀mentally฀ill฀or฀incarcerated฀household฀member.฀In฀persons฀reporting฀ive฀or฀ more฀categories฀of฀adverse฀childhood฀experiences,฀the฀association฀with฀cigarette฀consump- tion฀was฀unequivocal:฀they฀had฀a฀5.4-fold฀higher฀risk฀of฀smoking฀initiation฀by฀the฀age฀of฀14฀ years;฀a฀3.1-fold฀higher฀risk฀of฀ever฀smoking฀at฀a฀later฀time;฀and฀a฀2.8-fold฀higher฀risk฀of฀still฀ being฀a฀smoker฀at฀the฀time฀of฀the฀survey฀ [57] .฀Primary฀prevention฀of฀these฀adverse฀childhood฀ experiences฀and฀speciic฀treatment฀for฀those฀affected฀could฀help฀to฀reduce฀smoking. Trinidad฀et฀al.฀examined฀interactions฀between฀emotional฀intelligence฀EI฀and฀smoking฀ risk฀factors฀on฀smoking฀intentions฀in฀adolescents฀ [58] .฀They฀deined฀EI฀as฀the฀ability฀to:฀ accurately฀perceive,฀appraise฀and฀express฀emotion;฀access฀andor฀generate฀feelings฀in฀facil- itating฀thought;฀understand฀emotion฀and฀emotional฀knowledge;฀and฀regulate฀emotions.฀EI฀ of฀416฀sixth฀graders฀53฀girls฀from฀middle฀schools฀in฀the฀Los฀Angeles฀area฀mean฀age฀=฀ 11.3฀years;฀32฀Latino,฀29฀AsianPaciic฀Islander,฀13฀white,฀19฀Multiethnic,฀6฀ Others฀was฀assessed฀with฀an฀abbreviated฀version฀of฀the฀Multifactor฀Emotional฀Intelligence฀ Scale,฀Adolescent฀Version฀MEIS.฀This฀was฀a฀competence-based฀measure฀assessing฀an฀ individual’s฀ability฀to฀perceive,฀understand฀and฀manage฀emotion.฀Logistic฀regression฀mod- els฀were฀it฀to฀test฀interactions฀between฀EI฀and฀ever฀trying฀cigarettes,฀hostility฀and฀per- ceived฀ability฀to฀refuse฀a฀cigarette฀from฀someone฀just฀met,฀on฀intentions฀to฀smoke฀in฀the฀ next฀ year.฀ The฀ scientists฀ found฀ that฀ high฀ EI฀ adolescents฀ were฀ more฀ likely฀ to฀ intend฀ to฀ smoke฀in฀the฀next฀year฀if฀they฀had฀previously฀experimented฀with฀smoking.฀Those฀with฀low฀ EI฀were฀more฀likely฀to฀intend฀to฀smoke฀if฀their฀perceived฀ability฀to฀refuse฀a฀cigarette฀offer฀ from฀a฀person฀they฀just฀met฀was฀low฀or฀hostility฀level฀was฀high.฀In฀conclusion,฀the฀study฀ indicated฀that฀EI฀interacts฀with฀risk฀factors฀to฀reduce฀smoking฀intentions,฀and฀contributes฀ evidence฀to฀a฀link฀between฀EI฀and฀smoking฀in฀adolescents฀ [58] . In฀examining฀the฀criminal฀behaviour฀of฀children฀whose฀mothers฀smoked฀during฀preg- nancy฀ [59,฀60] ,฀two฀large-scale฀studies฀have฀revealed฀a฀higher฀rate฀of฀criminal฀offences฀in฀ adulthood฀among฀such฀offsprings฀ [55] .฀In฀a฀cohort฀of฀5,636฀men,฀compared฀with฀the฀sons฀of฀ mothers฀who฀did฀not฀smoke,฀the฀sons฀of฀mothers฀who฀smoked฀during฀pregnancy฀had฀a฀more฀ than฀twofold฀risk฀of฀having฀committed฀a฀violent฀crime฀or฀having฀repeatedly฀offended฀ [55] .฀ When฀maternal฀smoking฀during฀pregnancy฀was฀combined฀with฀predisposing฀factors฀such฀as฀ maternal฀age฀20฀years,฀a฀single-parent฀family,฀an฀unwanted฀pregnancy,฀and฀a฀developmental฀ lag฀in฀walking฀and฀talking,฀the฀odds฀ratios฀increased฀ninefold฀for฀violent฀crimes฀and฀14-fold฀ for฀persistent฀offences.฀Non-violent฀crimes฀were฀not฀associated฀with฀maternal฀smoking.฀A฀ second฀study฀in฀4,169฀men฀ [58] ฀revealed฀associations฀between฀violent฀crimes฀and฀maternal฀ smoking,฀particularly฀in฀the฀third฀trimester฀of฀pregnancy.฀This฀study฀took฀account฀of฀addi- tional฀data฀such฀as฀maternal฀rejection,฀socio-economic฀status,฀maternal฀age,฀pregnancy฀and฀ delivery฀complications,฀paternal฀criminal฀record฀and฀parental฀psychiatric฀hospitalisation. Although฀plausible฀explanations฀have฀not฀yet฀been฀found฀for฀an฀association฀between฀ violent฀crime฀and฀maternal฀smoking,฀the฀social฀and฀educational฀level฀of฀the฀parents฀is฀par- ticularly฀important฀because฀in฀some฀countries฀Great฀Britain,฀Norway฀smoking฀is฀primar- ily฀an฀activity฀of฀people฀who฀leave฀school฀at฀an฀early฀age฀see฀Sect.฀2.7฀in฀Chap.฀2.฀In฀these฀ terms,฀it฀is฀essential฀that฀assessments฀of฀such฀indings฀in฀future฀should฀also฀take฀account฀of฀ all฀the฀socio-demographic฀factors฀pertinent฀to฀the฀child.฀Failure฀to฀do฀so฀could฀lead฀to฀rash฀ and฀unwarranted฀conclusions฀with฀considerable฀social฀and฀political฀impact.

7.1.4 Smoker Personality Profiles and Genetic Inheritance of Smoking

In฀a฀study฀carried฀out฀from฀1991฀to฀1995฀and฀involving฀12,057฀subjects,฀it฀was฀demon- strated฀that฀increases฀in฀the฀number฀of฀cigarettes฀smoked฀are฀seen฀to฀occur฀in฀very฀young฀ and฀old฀patients฀and฀particularly฀those฀who฀have฀suffered฀psychiatric฀disturbances฀16–21-฀ and฀51–75-year-olds,฀OR฀=฀1.5฀and฀1.57;฀c 2 ฀=฀6.8;฀p฀=฀0.078฀ [58] .฀This฀is฀especially฀ problematic฀for฀smokers฀who฀are฀virtually฀still฀adolescents,฀since฀they฀go฀on฀to฀become฀ heavily฀dependent.฀One฀year฀after฀a฀psychiatric฀disturbance,฀these฀persons฀smoked฀increas- ing฀numbers฀of฀cigarettes฀ [61] .฀The฀genetic฀inheritance฀of฀smoking฀was฀seen฀by฀analysing฀ smoking฀ behaviour฀ in฀ three฀ successive฀ generations.฀ The฀ results฀ revealed฀ evidence฀ of฀ Mendelian฀inheritance฀ratios฀modiied฀by฀familial฀factors฀ [62] . A฀common฀interpretation฀of฀why฀mentally฀ill฀people฀smoke฀larger฀numbers฀of฀cigarettes฀ than฀people฀without฀any฀mental฀illness฀is฀that฀smoking฀provides฀a฀kind฀of฀“self-treatment”฀ of฀their฀symptoms฀ [63,฀64] .฀Such฀diseases฀might฀encourage฀smoking,฀revealing฀a฀causality฀ between฀the฀two฀factors.฀A฀causal฀relationship฀is฀assumed฀ [8,฀11,฀65] ฀in฀depressive฀adoles- cents฀and฀adults฀in฀whom฀a฀signiicantly฀raised฀level฀of฀cigarette฀consumption฀correlated฀ with฀a฀high฀risk฀of฀developing฀a฀depressed฀mood฀syndrome฀ [65] .฀Smokers฀also฀show฀a฀ higher฀level฀of฀risk฀for฀irst฀occurrence฀of฀panic฀attacks,฀and฀severe฀anxiety฀disorders฀in฀late฀ adolescence฀and฀early฀adulthood฀than฀non-smokers฀or฀ex-smokers฀ [8,฀66] .฀Cigarette฀smok- ing฀by฀schizophrenic฀patients฀also฀encourages฀the฀induction฀of฀new฀episodes฀ [11] . More฀pronounced฀extraversion฀has฀been฀observed฀in฀smokers฀than฀in฀non-smokers฀ [67] .฀ Tobacco฀ dependence฀ and฀ withdrawal฀ symptoms฀ were฀ more฀ frequently฀ associated฀ with฀ neurotic฀disturbances฀and฀these฀phenomena฀have฀also฀been฀described฀in฀a฀review฀article:฀ neurotic฀personality฀traits฀depression,฀anxiety,฀irritability฀and฀disturbed฀social฀reactions฀ impulsive฀reactions,฀search฀for฀asocial฀stimuli,฀low฀level฀of฀conscientiousness,฀a฀limited฀ ability฀to฀compromise฀and฀lower฀socio-economic฀status฀ [68] ฀were฀found฀in฀connection฀ with฀smoking. Psychosocial฀characteristics฀that฀predispose฀adolescents฀to฀take฀up฀smoking฀were฀inves- tigated฀in฀a฀sixth฀grade฀class฀and฀again฀2฀years฀later฀in฀the฀eighth฀grade฀in฀Canada฀ [69] .฀The฀ signiicant฀ factors฀ were฀ found฀ to฀ include฀ attitudes฀ and฀ behaviour฀ relative฀ to฀ smoking,฀ smoking฀by฀others฀in฀the฀children’s฀environment,฀gender฀and฀stress.฀The฀gender฀difference฀ in฀the฀sixth฀grade฀lay฀in฀the฀fact฀that฀boys฀were฀more฀inluenced฀than฀girls฀by฀people฀smok- ing฀ in฀ their฀ environment.฀ In฀ the฀ eighth฀ grade,฀ on฀ the฀ other฀ hand,฀ boys฀ tended฀ to฀ start฀ ฀smoking฀for฀reasons฀related฀to฀personal฀abilities฀coping฀with฀life,฀self-respect,฀social฀inte- gration,฀acquisition฀of฀skills,฀conformist฀tendencies฀and฀rebellion.฀The฀main฀reasons฀why฀ girls฀took฀up฀smoking฀at฀this฀age฀were฀related฀to฀people฀in฀their฀environment฀who฀smoked฀ and฀rebellion.฀Regular฀smoking฀often฀begins฀as฀experimental฀smoking฀within฀one’s฀peer฀ group,฀especially฀in฀children฀of฀a฀depressive฀or฀anxious฀nature฀ [70] .฀In฀female฀teenagers,฀ regular฀smoking฀correlates฀with฀a฀tendency฀to฀depression฀and฀anxiety฀reactions฀ [71] .฀Other฀ depressive฀symptoms฀that฀predispose฀to฀adolescent฀smoking฀include฀unhappiness,฀despon- dency,฀hopelessness฀about฀the฀future฀and฀dificulty฀in฀falling฀asleep฀ [71] . According฀to฀the฀indings฀from฀twins฀research,฀the฀comorbidity฀of฀organic฀depression฀ and฀nicotine฀dependence฀results฀from฀general฀familial฀factors฀that฀may฀be฀of฀a฀genetic฀ nature฀ [72] .฀A฀genetic฀study฀revealed฀relationships฀between฀neuroses฀and฀smoking฀behav- iour฀ nicotine฀ volume฀ uptake,฀ dependence,฀ motivation฀ to฀ smoke฀ and฀ the฀ polymorphic฀ region฀5-HTT-LPR:฀s฀or฀l฀allele,฀short฀or฀long฀allele,฀ss฀or฀sl฀linked฀to฀the฀5-HT฀trans- porter฀gene.฀A฀predominance฀of฀functional฀polymorphism฀of฀the฀serotonin฀transporter฀gene฀ was฀posited,฀as฀was฀domination฀of฀the฀genotype฀5-HTTLPR-s฀over฀5-HTTLPR-l.฀Apparently,฀ the฀ neurosis฀ and฀ the฀ 5-HTTLPR-s฀ constellation฀ interact฀ in฀ their฀ inluence฀ on฀ nicotine฀ dependence฀ [73,฀74] .฀Another฀study฀involving฀72฀autistic฀subjects฀revealed฀variances฀in฀the฀ distribution฀of฀the฀two฀phenotypes฀ss฀and฀sl฀ [75] .

7.1.5 Depression

7.1.5.1 Smoking Prevalence

The฀prevalence฀of฀smoking฀among฀those฀who฀suffer฀from฀depression฀is฀higher฀than฀in฀the฀ normal฀population฀ [5] ฀but฀lower฀than฀among฀people฀with฀schizophrenia.฀In฀recent฀years,฀there฀ has฀been฀growing฀interest฀in฀the฀thesis฀of฀comorbidity฀of฀depressive฀conditions฀and฀raised฀ciga- rette฀consumption,฀already฀pronounced฀in฀adolescence฀Table฀ 7.2 ฀ [4,฀6,฀72,฀76,฀77] .฀Depressive฀ symptoms฀and฀clinical฀pictures฀with฀depressive฀content฀are฀more฀common฀among฀people฀who฀ Variable฀ Depressive฀illness฀ No฀depressive฀illness฀ OR฀95฀CI Whole฀group 90฀20.0 857฀5.1 4.6฀2.5–8.4 Men 26฀23.1 447฀5.2 5.5฀2.0–15.1 Women 64฀18.9 410฀5.1 4.3฀2.0–9.2 Table 7.2 ฀฀฀Nicotine฀dependence฀among฀1,265฀adolescents฀with฀or฀without฀concurrent฀depression.฀ Frequency฀igures,฀absolute฀and฀percentage฀,฀as฀well฀as฀odds฀ratios฀with฀a฀95฀conidence฀ interval฀ [52]