Maraş Powder (Smokeless Tobacco) Use and Associated Factors in Adolescents with Attention-Deficit/Hyperactivity Disorder: A Cross-Sectional Comparative Study
Authors
Asiye Arıcı Gürbüz, Hatice Altun, Feyza Hatice Ekici, Hüseyin Sarıkaya, Semiha Cömertoğlu ArslanFiles
Abstract
Objective: Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder associated with an increased susceptibility to nicotine and other substance use. This study aimed to compare Maraş powder (smokeless tobacco) use among adolescents with and without ADHD,identify related factors,examine differences by ADHD treatment status,and assess adolescents’ knowledge and beliefs about its use.
Method: This cross-sectional comparative study,included 50 adolescents aged 11–17 with ADHD and 50 age- and sex-matched healthy controls. Participants completed a sociodemographic form,a study-specific Maraş powder knowledge,belief and use questionnaire,the DSM-IV Disruptive Behavior Disorders Rating Scale (DBDRS),the Kovacs Children’s Depression Inventory and the State-Trait Anxiety Inventory.
Results: Current regular Maraş powder use was reported by 28.0% of the ADHD group and 10.0% of the control group (OR=3.50,95% CI 1.15–10.63;Fisher p=0.040);while ever use was 32.0% versus 10.0% (OR=4.24,95% CI 1.41–12.70;p=0.007).After adjusted for age and sex,ADHD remained associated with regular use (aOR=3.44,95% CI 1.12–11.99,p=0.031).Within the ADHD group,regular use was reported by 4.2% of adolescents with medical treatment versus 50.0% of untreated adolescents (Fisher p<0.001;aOR=0.04,95% CI 0.003–0.31).Regular users had higher DBDRS,depressive,and state-anxiety scores,but not trait-anxiety scores (all Benjamini– Hochberg-corrected p<0.05).Overall,57.0% of participants either agreed with,or were unsure about,the statement that Maraş powder helps smoking cessation,and substantial misconceptions regarding its harms and regulation were observed in both groups.
Conclusion: In this study,ADHD, lower symptom control and the absence of regular ADHD treatment were associated with a higher prevalence of Maraş powder use. Misconceptions about the harms and the regulation of Maraş powder were common among adolescents in both groups.
References
Akbay, C., Bilgiç, A., & Dölekoğlu, C. Ö. (2017). Kahramanmaraş il merkezinde tüketicilerin sigara ve Maraş otu kullanımını etkileyen faktörlerin analizi. KSÜ Doğa Bilimleri Dergisi, 20(3), 276–282. https://doi.org/10.18016/ksudobil.289471.
Asherson, P. (2017). Drug treatments for ADHD reduce risk of substance use disorders. American Journal of Psychiatry, 174(9), 827–828. https://doi.org/10.1176/appi.ajp.2017.17070733
Barbuti, M., Maiello, M., Spera, V., Pallucchini, A., Brancati, G. E., Maremmani, A. G. I., Perugi, G., & Maremmani, I. (2023). Challenges of treating ADHD with comorbid substance use disorder. Journal of Clinical Medicine, 12(9), 3096. https://doi.org/10.3390/jcm12093096
Charach, A., Yeung, E., Climans, T., & Lillie, E. (2011). Childhood attention-deficit/hyperactivity disorder and future substance use disorders: Comparative meta-analyses. Journal of the American Academy of Child & Adolescent Psychiatry, 50(1), 9–21. https://doi.org/10.1016/j.jaac.2010.09.019
Cohen, R. Y., Sattler, J., Felix, M. R., & Brownell, K. D. (1987). Experimentation with smokeless tobacco and cigarettes by children and adolescents: Relationship to beliefs, peer use, and parental use. American Journal of Public Health, 77(11), 1454–1456. https://doi.org/10.2105/AJPH.77.11.1454
Çok, İ., & Öztürk, R. (2000). Urinary cotinine levels of smokeless tobacco (Maraş powder) users. Human & Experimental Toxicology, 19(11), 650–655. https://doi.org/10.1191/096032700670928812
Danielson, M. L., Claussen, A. H., Bitsko, R. H., Katz, S. M., Newsome, K., Blumberg, S. J., Kogan, M. D., & Ghandour, R. M. (2024). ADHD prevalence among US children and adolescents in 2022: Diagnosis, severity, co-occurring disorders, and treatment. Journal of Clinical Child & Adolescent Psychology. Advance online publication. https://doi.org/10.1080/15374416.2024.2335625
Ercan, E. S., Amado, S., Somer, O., & Çıkoğlu, S. (2001). Development of a test battery for the assessment of attention deficit hyperactivity disorder. Turkish Journal of Child and Adolescent Mental Health, 8(3), 132–145.
Ercan, E. S., Unsel-Bolat, G., Tufan, A. E., Karakoc Demirkaya, S., Bilac, O., Celik, G., Kılıç, B. G., Akyol Ardic, U., Yalin Sapmaz, S., Aksu, H., Yolga Tahiroglu, A., Karacetin, G., Tural, U., Aktepe, E., Rodopman Arman, A., Başgül, S., Coşkun, M., Dursun, O. B., Durukan, İ., … Ünal, F. (2022). Effect of impairment on the prevalence and comorbidities of attention deficit hyperactivity disorder in a national survey: Nation-wide prevalence and comorbidities of ADHD. Journal of Attention Disorders, 26(5), 674–684. https://doi.org/10.1177/10870547211017985
Faraone, S. V., Banaschewski, T., Coghill, D., Zheng, Y., Biederman, J., Bellgrove, M. A., Newcorn, J. H., Gignac, M., Al Saud, N. M., Manor, I., Rohde, L. A., Yang, L., Cortese, S., Almagor, D., Stein, M. A., Albatti, T. H., Aljoudi, H. F., Alqahtani, M. M. J., Asherson, P., … Wang, Y. (2021). The World Federation of ADHD International Consensus Statement: 208 evidence-based conclusions about the disorder. Neuroscience & Biobehavioral Reviews, 128, 789–818. https://doi.org/10.1016/j.neubiorev.2021.01.022
Grassi, G., Moradei, C., & Cecchelli, C. (2024). Prevalence and clinical phenotypes of adult patients with attention deficit hyperactivity disorder and comorbid behavioral addictions. Journal of Behavioral Addictions, 13(2), 473–481. https://doi.org/10.1556/2006.2024.00020
Groenman, A. P., Janssen, T. W. P., & Oosterlaan, J. (2017). Childhood psychiatric disorders as risk factor for subsequent substance abuse: A meta-analysis. Journal of the American Academy of Child & Adolescent Psychiatry, 56(7), 556–569. https://doi.org/10.1016/j.jaac.2017.05.004
Güven, A., & Tolun, F. (2012). Effects of smokeless tobacco "Maraş powder" use on nitric oxide and cardiovascular risk parameters. International Journal of Medical Sciences, 9(9), 786–792. https://doi.org/10.7150/ijms.4563
Humphreys, K. L., Eng, T., & Lee, S. S. (2013). Stimulant medication and substance use outcomes: A meta-analysis. JAMA Psychiatry, 70(7), 740–749. https://doi.org/10.1001/jamapsychiatry.2013.1273
International Agency for Research on Cancer. (2007). Smokeless tobacco and some tobacco-specific N-nitrosamines (IARC Monographs on the Evaluation of Carcinogenic Risks to Humans, Vol. 89). IARC.
Katzman, M. A., Bilkey, T. S., Chokka, P. R., Fallu, A., & Klassen, L. J. (2017). Adult ADHD and comorbid disorders: Clinical implications of a dimensional approach. BMC Psychiatry, 17(1), 302. https://doi.org/10.1186/s12888-017-1463-3
Kaufman, J., Birmaher, B., Brent, D., Rao, U., Flynn, C., Moreci, P., Williamson, D., & Ryan, N. (1997). Schedule for Affective Disorders and Schizophrenia for School-Age Children—Present and Lifetime Version (K-SADS-PL): Initial reliability and validity data. Journal of the American Academy of Child & Adolescent Psychiatry, 36(7), 980–988. https://doi.org/10.1097/00004583-199707000-00021
Keten, H. S., Üçer, H., Önay, H., Cerit, M., Gürsoy, H., & Çelik, M. (2014). Kahramanmaraş'ta yurtta kalan erkek lise öğrencilerinin Maraş otu konusunda bilgi, tutum ve davranışları. Turkish Journal of Family Medicine and Primary Care, 8(4), 111–116. https://doi.org/10.5455/tjfmpc.158578
Kılınç, M., Okur, E., Kurutaş, E. B., Güler, F. I., & Yıldırım, İ. (2004). The effects of Maraş powder (smokeless tobacco) on oxidative stress in users. Cell Biochemistry and Function, 22(4), 233–236. https://doi.org/10.1002/cbf.1093
Kollins, S. H., McClernon, F. J., & Fuemmeler, B. F. (2005). Association between smoking and attention-deficit/hyperactivity disorder symptoms in a population-based sample of young adults. Archives of General Psychiatry, 62(10), 1142–1147.https://doi.org/10.1001/archpsyc.62.10.1142
Kovacs, M. (1981). Rating scales to assess depression in school-aged children. Acta Paedopsychiatrica, 46(5–6), 305–315.
Lee, S. S., Humphreys, K. L., Flory, K., Liu, R., & Glass, K. (2011). Prospective association of childhood attention-deficit/hyperactivity disorder (ADHD) and substance use and abuse/dependence: A meta-analytic review. Clinical Psychology Review, 31(3), 328–341. https://doi.org/10.1016/j.cpr.2011.01.006
Mehrotra, R., Yadav, A., Sinha, D. N., Parascandola, M., John, R. M., Ayo-Yusuf, O., Nargis, N., Hatsukami, D. K., Warnakulasuriya, S., Straif, K., Siddiqi, K., & Gupta, P. C. (2019). Smokeless tobacco control in 180 countries across the globe: Call to action for full implementation of WHO FCTC measures. The Lancet Oncology, 20(4), e208–e217. https://doi.org/10.1016/S1470-2045(19)30084-1
Milberger, S., Biederman, J., Faraone, S. V., Chen, L., & Jones, J. (1997). ADHD is associated with early initiation of cigarette smoking in children and adolescents. Journal of the American Academy of Child & Adolescent Psychiatry, 36(1), 37–44. https://doi.org/10.1097/00004583-199701000-00015
Mitchell, J. T., Howard, A. L., Belendiuk, K. A., Kennedy, T. M., Stehli, A., Swanson, J. M., Hechtman, L., Arnold, L. E., Hoza, B., Vitiello, B., Lu, B., Kollins, S. H., & Molina, B. S. G. (2019). Cigarette smoking progression among young adults diagnosed with ADHD in childhood: A 16-year longitudinal study of children with and without ADHD. Nicotine & Tobacco Research, 21(5), 638–647. https://doi.org/10.1093/ntr/nty045
Molina, B. S. G., Kennedy, T. M., Howard, A. L., Swanson, J. M., Arnold, L. E., Mitchell, J. T., Stehli, A., Kennedy, E. H., Epstein, J. N., Hechtman, L. T., Hinshaw, S. P., & Vitiello, B. (2023). Association between stimulant treatment and substance use through adolescence into early adulthood. JAMA Psychiatry, 80(9), 933–941. https://doi.org/10.1001/jamapsychiatry.2023.2157
Molina, B. S. G., & Pelham, W. E., Jr. (2003). Childhood predictors of adolescent substance use in a longitudinal study of children with ADHD. Journal of Abnormal Psychology, 112(3), 497–507. https://doi.org/10.1001/jamapsychiatry.2023.2157
Öner, N., & Le Compte, A. (1985). Durumluk-Sürekli Kaygı Envanteri el kitabı (2nd ed.). Boğaziçi Üniversitesi Yayınları.
Öy, B. (1991). Çocuklar için Depresyon Ölçeği: Geçerlik ve güvenirlik çalışması. Türk Psikiyatri Dergisi, 2(2), 132–136.
Özkul, Y., Dönmez, H., Erenmemişoğlu, A., Demirtaş, H., & İmamoğlu, N. (1997). Induction of micronuclei by smokeless tobacco on buccal mucosa cells of habitual users. Mutagenesis, 12(4), 285–287. https://doi.org/10.1093/mutage/12.4.285
Rohner, H., Gaspar, N., Philipsen, A., & Schulze, M. (2023). Prevalence of attention deficit hyperactivity disorder (ADHD) among substance use disorder (SUD) populations: Meta-analysis. International Journal of Environmental Research and Public Health, 20(2), 1275. https://doi.org/10.3390/ijerph20021275
Schellekens, A. F. A., van den Brink, W., Kiefer, F., & Goudriaan, A. E. (2020). Often overlooked and ignored, but do not underestimate its relevance: ADHD in addiction – addiction in ADHD. European Addiction Research, 26(4–5), 169–172. https://doi.org/10.1159/000509267
Siddiqi, K., Husain, S., Vidyasagaran, A., Readshaw, A., Mishu, M. P., & Sheikh, A. (2020). Global burden of disease due to smokeless tobacco consumption in adults: An updated analysis of data from 127 countries. BMC Medicine, 18, 222. https://doi.org/10.1186/s12916-020-01677-9
Sinha, D. N., Suliankatchi, R. A., Gupta, P. C., Thamarangsi, T., Agarwal, N., Parascandola, M., & Mehrotra, R. (2018). Global burden of all-cause and cause-specific mortality due to smokeless tobacco use: Systematic review and meta-analysis. Tobacco Control, 27(1), 35–42. https://doi.org/10.1136/tobaccocontrol-2016-053302
Spielberger, C. D., Gonzalez-Reigosa, F., Martinez-Urrutia, A., Natalicio, L. F. S., & Natalicio, D. S. (1971). The State-Trait Anxiety Inventory. Revista Interamericana de Psicología, 5(3–4), 145–158.
Tanrıverdi, G. (2022). Dumansız tütün Maraş otunun sağlığa zararları: Geleneksel derleme. Halk Sağlığı Hemşireliği Dergisi, 4(3), 284–292. https://doi.org/10.54061/jphn.1160825
Ünal, F., Öktem, F., Çetin Çuhadaroğlu, F., Çengel Kültür, S. E., Akdemir, D., Foto Özdemir, D., Çak, H. T., Ünal, D., Tıraş, K., Aslan, C., Kalaycı, B. M., Aydos, B. S., Kütük, F., Taşyürek, E., Karaokur, R., Karabucak, B., Karakök, B., Karaer, Y., & Artık, A. (2019). Reliability and validity of the Schedule for Affective Disorders and Schizophrenia for School-Age Children—Present and Lifetime Version, DSM-5 November 2016—Turkish adaptation (K-SADS-PL-DSM-5-T). Türk Psikiyatri Dergisi, 30(1), 42–50. https://doi.org/10.5080/u23408
Wilens, T. E., Faraone, S. V., Biederman, J., & Gunawardene, S. (2003). Does stimulant therapy of attention-deficit/hyperactivity disorder beget later substance abuse? A meta-analytic review of the literature. Pediatrics, 111(1), 179–185. https://doi.org/10.1542/peds.111.1.179
Wilens, T. E., & Morrison, N. R. (2011). The intersection of attention-deficit/hyperactivity disorder and substance abuse. Current Opinion in Psychiatry, 24(4), 280–285. https://doi.org/10.1097/YCO.0b013e328345c956
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