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LAPORAN PENELITIAN doi: 10,1111 /

j.1360-0443.2009.02617.x

remaja merokok dan depresi: bukti untuk


pengobatan sendiri dan rekan mediasi merokok
Janet Audrain-McGovern1, Daniel Rodriguez1 & Jon D. Kassel2
Departemen Psikiatri, University of Pennsylvania, Philadelphia, PA, USA 1 dan Departemen Psikologi, University of Illinois, Chicago, IL, USA 2

ABSTRAK

tujuan Sifat hubungan antara merokok remaja dan depresi tidak jelas dan mekanisme yang menjelaskan komorbiditas
telah menerima sedikit investigasi. Penelitian ini berusaha untuk mengklarifikasi bukti-prece- sementara untuk merokok
dan depresi dan untuk menentukan apakah variabel-variabel ini terkait secara tidak langsung melalui rekan merokok. Peserta
Sampel terdiri dari 1093 remaja yang berpartisipasi dalam studi longitudinal satu prediktor perilaku adopsi merokok. Desain
dan pengukuran Dalam studi kohort prospektif, merokok, depresi, rekan merokok ini dan kovariat lainnya diukur setiap
tahun dari pertengahan masa remaja (kelas 9; umur 14) ke remaja akhir (kelas 12, usia 18). Temuan proses Paralel
pertumbuhan laten model kurva didukung hubungan dua arah antara merokok remaja dan depresi, di mana gejala depresi
lebih tinggi pada masa remaja pertengahan (usia 14) memprediksi pengembangan merokok remaja dari pertengahan sampai
akhir masa remaja (usia 14-18). Sebuah efek tidak langsung tidak bisa signifi- menunjukkan bahwa gejala depresi lebih
tinggi di waktu yang diprediksi peningkatan jumlah rekan-rekan merokok, yang pada gilirannya diprediksi merokok
perkembangan dari pertengahan masa remaja ke masa remaja akhir. Selain itu, perkembangan merokok memperkirakan
perlambatan gejala depresi dari pertengahan sampai akhir masa remaja. Sebuah efek tidak langsung yang signifikan
menunjukkan bahwa merokok lebih besar pada awal diprediksi perlambatan dalam jumlah merokok rekan-rekan di seluruh
waktu, yang memperkirakan perlambatan dalam gejala depresi dari pertengahan masa remaja ke masa remaja akhir.
Kesimpulan penelitian ini memberikan bukti pertama dari proses pengobatan sendiri dua arah dalam hubungan-kapal antara
merokok remaja dan depresi dan menyoroti Peer merokok sebagai salah satu penjelasan untuk komorbiditas tersebut.

Kata kunci Remaja, merokok remaja, depresi, longitudinal, rekan merokok, pengobatan diri sendiri, merokok.

Surat menyurat ke: Janet Audrain-McGovern, Departemen Psikiatri dan Abramson Cancer Center, University of Pennsylvania, 3535 Market Street, Suite 4100, Philadelphia, PA 19104, USA. E-
mail:audrain@mail.med.upenn.edu
Dikirim Agustus 8, 2008; review awal menyelesaikan 6 November 2008 Versi final diterima 13 Maret 2009

PENGANTAR [17-19], dan merokok dan depresi tidak mempengaruhi satu


sama lain dengan cara dua arah [7,10,16 ]. Hal ini plau-
Depresi dan merokok menunjukkan tingginya tingkat co-
morbiditas, dengan kedua dimulai biasanya pada masa
remaja dan melayani sebagai penyebab utama psikososial,
ekonomi dan medis morbiditas dan mortalitas dini [1-5].
Namun, hubungan temporal antara merokok remaja dan
depresi tidak jelas. Penelitian telah menunjukkan bahwa
depresi dan depresi berat gejala (subthreshold depresi)
memprediksi inisiasi merokok, perkembangan merokok
reguler dan kenaikan tingkat merokok rata-rata harian [6-
12]. Sebaliknya, penelitian lain menunjukkan bahwa
merokok memprediksi perkembangan depresi [13-16],
depresi dan pengaruh merokok sama lain secara timbal balik

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sible that the relationship between smoking and depres-
sion may not be causal, but due rather to a common set of
genetic or environmental factors that contribute to both
depression and smoking. The available support for common
genetic influences is growing, but remains limited [20–
22], and research indicates that controlling for potential
confounds is insufficient to explain the asso- ciation
between depression and smoking [7,23–26].
Methodological variability may help to account for
some of the disparate findings (e.g. different definitions of
smoking or stage of smoking, lack of repeated assess-
ments of smoking and depression, lack of control for
potential confounding variables, unidirectional assess-
ments and the removal of respondents who have already
smoked any cigarettes or have a higher level of depression
at baseline) [19,27–29]. In addition, the relationship

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between depression and smoking may not be best repre- We propose to evaluate the temporal precedence for adolescent
sented as a direct effect, but rather an indirect or medi- ated smoking and depression and whether these variables are linked
effect through another variable [29]. indirectly through peer smoking within a prospective cohort design. In
Although the notion that depressed adolescents may contrast to previ- ous research, depression, smoking and peer
acquire a smoking habit more readily in an effort to self- smoking were measured repeatedly across time and modeled lon-
medicate mood (attenuate negative affect and/or increase gitudinally. We anticipated that depression and smoking would be
positive affect) compared to adolescents with no or low characterized by a bidirectional relationship and that peer smoking
depressive symptomatology, the self-medication hypoth- would help to account for this relationship from mid-adolescence to
esis has received little prospective evaluation [30,31]. The late adolescence.
expectation that smoking manages negative affect has
been shown to discriminate smokers from non-smokers, to
predict belonging to a regular smoking trajectory among METHODS
adolescents, and to predict smoking progression [32,33]. A
Participants and procedures
recent laboratory-based study found that smoking a
cigarette reduced negative affect among ado- lescent Participants were high school students (53% female and
smokers who held strong beliefs that smoking alleviates 65% white) taking part in a longitudinal study of the
negative affect [34]. Although these studies did not evaluate social, psychological and genetic determinants of adoles-
depression, this research suggests that depression may cent smoking adoption. Participants were enrolled in one of
promote adolescent smoking acquisition and that smoking five public high schools in northern Virginia. This cohort
uptake may reduce adolescent depres- sion. However, these was drawn from the 2393 students identified through class
conclusions, in part, seem inconsis- tent with rosters at the beginning of 9th grade. Stu- dents were
epidemiological research showing that adolescent ineligible to participate in this study if they had a special
smoking contributes to the development of depression. classroom placement (e.g. severe learning disability). Based
The relationship between depression and smoking on the selection criteria, a total of 2120 (89%) students were
might be explained more clearly through more complex eligible to participate, and of these,
models that consider direct effects as well as indirect or 1533 (72%) parents provided a response regarding
mediated effects [29]. The mechanisms that account for their teenager’s participation. Of the 1533 parents
the comorbidity between depression and smoking have who provided a response, 1151 (75%) consented to
received very little investigation and research has their teen- ager’s participation. Analysis of
yielded no answers [35]. Peer smoking may be an important differences between stu- dents whose parents did
mechanism to consider. Peer smoking has been linked to and did not consent revealed that the likelihood of
adolescent smoking progression [36,37], and has been consent was greater for white parents with more
shown to accentuate the effects of depres- sion on than a high school education than for white parents
adolescent smoking uptake [9]. Cross-sectional data with a high school education or less (89% versus
suggest that depression may make an adolescent more 77%) [47].
vulnerable to peer smoking influences, which in turn The majority of adolescents with parental consent
promote smoking uptake [38]. This may be due to provided their assent (99%, n 1136). The adolescent
affectively vulnerable adolescents’ choice of peers who cohort was formed in the 9th grade and was surveyed each
smoke, or a greater need to gain peer approval, a spring until the end of 12th grade. Thus, four annual
compromised ability to refuse cigarette offers, or the spring data waves were used in these analyses. Data were
perception that cigarette smoking provides benefits to collected on-site during compulsory classes. The surveys
one’s peers [38–41]. Similarly, adolescents who smoke took approximately 30 minutes to complete. Fewer than
may select peers with similar smoking behaviors which are 10% of adolescents were lost to follow-up across the 4
often accompanied by other non-conventional behaviors years. Participants in the present study were adolescents (n
[42–44]. Peer substance use is linked to the 1093) with complete data on the 9th grade covariates.
development of adolescent depression, possibly because University Institutional Review Board approval of the
of the quality of the peer relationship or via engagement study protocol was obtained.
in similar non-conventional behaviors [45,46]. We are not
aware of any research to date that has evaluated Measures
mechanisms that may account for smoking
Depression symptoms
contributing to the development of adolescent depression.
As such, peer smoking is a plausible candi- date to consider.

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Depression symptoms were assessed at each wave with the


Center for Epidemiological Studies Depression (CES-D)
inventory. The CES-D is a valid and reliable 20-item self-

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report measure designed to assess depression symptoms in during the past 12 months (1 0 teams to 4 3 or more teams).
the general population, including adolescents [48–51]. All covariates were measured in the 9th grade. We
Whereas a CES-D score of 16 is indicative of a clinically controlled for these covariates in the model as poten- tial
significant level of depression symptoms in adults, cut- confounding variables given their associations with
offs for adolescents are higher (i.e. 22) [52]. The 20 items smoking, peer smoking and depression symptoms
were summated linearly and then log (base e)- [7,37,54–66].
transformed to correct for univariate non-normality, and to
form a single log depression symptoms score at each wave. Analytical approach

Univariate statistics were generated to describe the study


Smoking population in terms of demographics, smoking practices
Smoking was assessed at each wave with 13 standard and depression symptoms. Univariate estimates were
epidemiological questions, such as ‘Have you tried or generated with SAS 9.2 software, and can be found in
experimented with cigarette smoking, even a few puffs?’ Table 1.
and ‘When was the last time you smoked a cigarette?’ [53].
In the present study, our dependent variable was the Latent growth curve modeling (LGCM)
number of cigarettes smoked in the past 30 days. This LGCM was conducted to assess the direct effects of
item was log (base e)-transformed for each wave for an depression symptoms on adolescent smoking and the
observed continuous measure of past 30-day smoking indirect effects through peer smoking. All LGCM were
at each wave to correct for univariate non- normality. conducted using Mplus version 5.2 software [67]. LGCM is
a multivariate structural equation modeling method that
Peer smoking models repeated measures of an observed variable (e.g.
smoking, depression symptoms) on factors (latent/
Peer smoking was measured at each wave by summating responses
unobserved variables) representing random effects (is). The
to three items asking whether the adolescents’ best friend smokes
random effects are free to vary by individual, thus capturing
and how many of his or her other four best male and four best female
individual variability. LGCMs have an intercept factor
friends smoke (range none to nine friends smoking) [36,37]. Peer
representing baseline level and a slope (trend) factor
smoking was log (base e)-transformed for each wave to correct for
representing growth (e.g. linear, quadratic) or rate of change
univari- ate non-normality.
across time. The shape of the estimated growth curve is
determined by defined factor loadings ( s), which are the
Covariates path coefficients from the trend factor to the observed
Demographic variables included gender (1 male, indicator variable. For instance, if a linear growth curve
2 female) and race (0 white, 1 non-white). House- hold is believed to be the best representation of the average
smoking was assessed with a binary variable (0 no one growth curve, factor loadings from the trend factor to the
living in the household smokes, 1 at least house- hold observed measures would be 0 (trend factor to initial
member smokes). Marijuana use was assessed with one observed measure) 0, 1(trend factor to second observed
item asking: ‘During the past 30 days, how many times measure) 1, 2 (trend factor to third observed measure) 2 and
have you used marijuana?’. Alcohol use was assessed 3 (trend factor to fourth observed measure) 3; there is a 1-
with one item asking: ‘During the past 30 days, on how unit increase in the dependent process (e.g. smoking) for a
many days did you have at least one drink (not just a sip) of 1-unit (e.g. 1 year) increase in time. The factor loadings from
alcohol?’. Response choices ranged from 0 to all 30 days for the intercept factor to the observed measures are fixed at 1.0,
alcohol use and 0 to 40 or more times for marijuana use as intercept does not change with time. Thus, LGCM models
[53]. Individual physical activity was assessed with three individual growth curves over time, with individual (i)
items tapping intensity, duration and frequency of physical specific baseline level and rate of change, and permits
activity per week. Scores on physi- cal activity ranged from estimation of average growth with time.
0 to 7 days of physical activity per week. These three In the present analysis, we conducted associated-
physical activity items were summed and averaged to processes LGCM. Associated-processes LGCM is an exten-
represent the average days of individual physical activity sion of single-process LGCM that allows testing paths
per week. Team sport partici- pation was assessed with a among the random effects (i.e. levels [ 0] and trends [1,2 . . .
single item that requested the number of sports teams for ]) of two or more LGCMs [68]. For instance, we tested paths
which the adolescent played from depression symptoms trend to smoking trend, which
allowed us to assess whether, on average, the rate of
change in depression symptoms over time

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Table 1 Non-standardized regression coefficients (), standard errors, Z-statistics and P-values for the dependent factors in the
primary model (depression symptoms to smoking) and the alternative model (smoking to depression symptoms).

Primary model (depression symptoms to smoking)

Smoking level Smoking trend

 SE Z P-value SE Z P-value

Depression symptoms level 0.07 0.08 0.95 0.34 0.16 0.06 2.44 0.02
Depression symptoms trend – – – – 0.47 0.26 1.76 0.08
Peer smoking level 0.90 0.09 9.79 0.0001 0.22 0.06 3.80 0.0001
Peer smoking trend – – – – 1.45 0.22 6.52 0.0001
Non-white 0.19 0.07 2.75 0.01 0.06 0.05 1.23 0.22
Female 0.09 0.06 1.55 0.12 0.06 0.04 1.36 0.18
Household smoking 0.01 0.02 0.49 0.62 0.00 0.02 0.24 0.81
Alcohol use (past 30 days) 0.00 0.02 0.22 0.82 0.04 0.02 2.01 0.05
Marijuana use (past 30 days) 0.07 0.03 2.69 0.01 0.01 0.02 0.42 0.68
Individual physical activity 0.04 0.02 1.82 0.07 0.03 0.02 1.67 0.10
Team sport participation 0.05 0.02 2.07 0.04 0.00 0.02 0.22 0.83

Depression symptoms level Depression symptoms trend

Smoking level – – – – 0.003 0.03 0.13 0.90


Peer smoking level – – – – 0.09 0.04 2.61 0.01
Non-white 0.05 0.04 1.24 0.22 0.05 0.03 2.02 0.04
Female 0.16 0.04 4.04 0.0001 0.01 0.02 0.57 0.57
Household smoking 0.01 0.02 0.82 0.41 0.00 0.01 0.30 0.76
Alcohol use (past 30 days) 0.02 0.01 1.36 0.17 0.02 0.01 2.50 0.01
Marijuana use (past 30 0.03 0.02 1.32 0.19 0.02 0.01 1.30 0.19
days)
Individual physical activity 0.01 0.01 0.77 0.44 0.02 0.01 1.82 0.07
Team sport participation 0.02 0.02 1.01 0.31 0.00 0.01 0.06 0.95

Peer smoking level Peer smoking trend

Smoking level – – – – 0.05 0.02 2.13 0.03


Depression symptoms level 0.37 0.06 5.99 0.0001 0.06 0.03 1.64 0.10
Depression symptoms trend – – – – 0.52 0.14 3.85 0.0001
Non-white 0.24 0.05 4.86 0.0001 0.08 0.03 2.68 0.01
Female 0.03 0.05 0.70 0.48 0.00 0.03 0.11 0.91
Household smoking 0.01 0.02 0.77 0.44 0.01 0.01 0.89 0.37
Alcohol use (past 30 days) 0.03 0.02 1.92 0.05 0.02 0.01 1.56 0.12
Marijuana use (past 30 0.02 0.02 0.80 0.42 0.01 0.01 0.74 0.46
days)
Individual physical activity 0.06 0.02 3.88 0.0001 0.02 0.01 1.74 0.08
Team sport participation 0.01 0.02 0.71 0.48 0.01 0.01 0.78 0.44

Alternative model (smoking to depression symptoms)

Depression symptoms level Depression symptoms trend

Smoking level 0.07 0.05 1.37 0.17 0.07 0.04 1.71 0.09
Smoking trend – – – – 0.15 0.07 2.14 0.03
Peer smoking level 0.31 0.07 4.30 0.0001 0.07 0.04 1.84 0.07
Peer smoking trend – – – – 0.60 0.19 3.21 0.001
Non-white 0.03 0.05 0.56 0.58 0.07 0.03 2.25 0.02
Female 0.15 0.04 3.65 0.0001 0.02 0.03 0.61 0.55
Household smoking 0.02 0.02 1.04 0.30 0.01 0.01 0.60 0.55

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Alcohol use (past 30 days) 0.01 0.01 0.63 0.53 0.03 0.01 2.68 0.01

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Table 1 Cont.

Alternative model (smoking to depression symptoms)

Depression symptoms level Depression symptoms trend

Marijuana use (past 30 days) 0.02 0.02 1.19 0.24 0.01 0.01 0.79 0.43
Individual physical activity 0.03 0.02 1.94 0.05 0.02 0.01 2.30 0.02
Team sport participation 0.01 0.02 0.44 0.66 0.01 0.01 0.71 0.48

Smoking level Smoking trend

Depression symptoms level – – – – 0.09 0.06 1.63 0.10


Peer smoking level – – – – 0.12 0.06 1.82 0.07
Non-white 0.05 0.06 0.70 0.48 0.14 0.04 3.38 0.001
Female 0.07 0.06 1.29 0.20 0.05 0.04 1.38 0.17
Household smoking 0.002 0.03 0.10 0.92 0.01 0.02 0.45 0.65
Alcohol use (past 30 days) 0.04 0.02 1.73 0.08 0.02 0.02 1.13 0.26
Marijuana use (past 30 days) 0.09 0.03 3.17 0.002 0.03 0.02 1.64 0.10
Individual physical activity 0.01 0.02 0.62 0.54 0.01 0.02 0.89 0.37
Team sport participation 0.04 0.03 1.30 0.20 0.003 0.02 0.20 0.84

Peer smoking level Peer smoking trend

Depression symptoms level – – – – 0.09 0.03 3.02 0.003


Smoking level 0.50 0.05 10.18 0.0001 0.11 0.03 4.18 0.0001
Smoking trend – – – – 0.30 0.03 9.53 0.0001
Non-white 0.24 0.05 5.24 0.0001 0.02 0.03 0.91 0.36
Female 0.07 0.04 1.61 0.11 0.01 0.03 0.47 0.64
Household smoking 0.01 0.02 0.61 0.54 0.01 0.01 0.67 0.50
Alcohol use (past 30 days) 0.02 0.02 1.32 0.19 0.01 0.01 1.29 0.20
Marijuana use (past 30 days) 0.02 0.02 0.94 0.35 0.01 0.01 0.40 0.69
Individual physical activity 0.05 0.02 3.52 0.0001 0.02 0.01 1.84 0.07
Team sport participation 0.04 0.02 2.29 0.02 0.01 0.01 1.04 0.30

Level represents the baseline level for a given growth process; trend represents the rate of change in a given process for a unit change in time; female (1 male,
2 female); non-white (0 white, 1 non-white); 30-day alcohol use (30-day alcohol use, 1 0 days to 7 20 or more days); 30-day marijuana use (30-day
marijuana use, 1 0 times to 6 40 or more times); household smoking (1 at least one household member smokes, 0 nobody living at home smokes). SE:
standard error.

increased (positive effect) or decreased (negative effect) LGCMs we also assessed direct and indirect effects at base-
the rate of change in smoking over time. Three associated line (level to level paths).
processes were modeled in the present study, one each for
the repeated observed measures of depression symptoms
(our exogenous process), adolescent smoking (our endog-
enous process) and peers smoking (mediating mecha-
nism). We were interested in whether depression symptoms
(baseline level or trend) affected smoking pro- gression
(trend) directly and indirectly through changes in peer
smoking across time (trend). We were also inter- ested in
the reverse directional path, which would evalu- ate
whether smoking (baseline level or trend) affected
changes in depression symptoms (trend) directly across
time and indirectly across time through changes in peer
smoking (trend). In both the primary and alternate

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Mengevaluasi model
fit
Model fit dievaluasi dengan model yang 2, Perbandingan fit
index (CFI), root mean square error dari pendekatan
(RMSEA) dan akar standar berarti residual (SRMR).
Kriteria fit disarankan adalah non-signifikan2, CFI 0.95,
RMSEA 0,05-0,08 [69-71]. Nilai RMSEA nol merupakan
model fit tepat [69]. Kami menggunakan kemungkinan kuat
parameter estimasi maksimum untuk mengoreksi
multivariat non-normalitas.

data yang
hilang

Untuk menghitung data yang hilang, pemodelan multivariat digunakan


semua data yang tersedia. Mplus memungkinkan pemodelan dengan
data yang hilang menggunakan estimasi kemungkinan maksimum dari
parameter mean, varians dan kovarians, ketika diminta,
mempekerjakan maksimalisasi harapan (EM) algoritma,

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dengan asumsi data yang hilang secara acak [72]. Kami yang akan diestimasi secara bebas, meningkatkan model fit
menyumbang data yang hilang hanya pada langkah- dengan data lapangan. Diperkirakan beban faktor (4) Untuk
Measures berulang merokok, gejala depresi dan rekan merokok (S), Gejala depresi (DS) Dan rekan merokok (PS)
merokok. Kasus dengan data yang hilang pada kovariat adalah 4 S 2,15, 4 DS 1,70, dan 4 PS 1,76, masing-masing.
tidak dimasukkan dalam analisis. Analisis akhir didasarkan
Efek langsung dari depresi merokok
pada 1093 remaja.
The non-standar koefisien regresi (),-Standar kesalahan dard
(SE), Z-statistik (/ SE) dan terkait P-nilai untuk semua efek
HASIL model yang disajikan pada Tabel 1. koefisien regresi
Standar untuk jalur Model signifikan disajikan pada Gambar
Statistik deskriptif
1 dan 2.
gejala depresi berfluktuasi dengan non-log trans berarti
terbentuk di 13.90 [standar deviasi (SD) 9.16] di kelas 9, Merokok
meningkat menjadi 14,54 (SD 10.30) di kelas 10 dan Tingkat rekan merokok memiliki dampak positif yang signifikan
menjatuhkan ke 13,00 (SD 8,85) di kelas 12. Ini nilai rata- pada tingkat merokok ( 0,90, Z 9.79, P 0,0001), suggest- ing
rata menunjukkan tingkat moderat gejala sion depres- dalam bahwa semakin besar jumlah rekan-rekan merokok di awal,
sampel ini. Jumlah rata-rata rekan-rekan merokok semakin besar tingkat dasar dari merokok. Depresi tingkat
meningkat perlahan-lahan dari 1,79 (SD 2,41) di gejala memiliki dampak positif yang signifikan pada tren
kelas 9 ke 2.16 (SD 2,50) di kelas 12. pada 9
merokok ( 0,16, Z 2,44, P 0,02), yang menunjukkan bahwa
kelas, 10% dari sampel telah merokok setidaknya satu
semakin tinggi gejala depresi pada awal, semakin besar
rokok di 30 hari terakhir (non-log-transformasi berarti 5.59
percepatan penyerapan merokok dari waktu ke waktu.
rokok sebulan, SD 44,73). Ini meningkat menjadi 20% dari
Selain itu, tingkat rekan merokok memiliki efek positif
sampel merokok setidaknya satu rokok di 30 hari terakhir
tidak bisa signifi- pada tren merokok ( 0,22, Z 3.80, P
(non-log-transformasi berarti 20,07 rokok sebulan, SD
0,0001), menunjukkan bahwa sejumlah besar merokok
81,03).
rekan-rekan pada awal diprediksi perkembangan merokok.
tren rekan merokok juga memiliki efek positif yang
Model fit
signifikan pada tren merokok ( 1,45, Z 6.52, P 0,0001),
Tiga-proses LGCM (Gambar. 1) dilengkapi data cukup cating puncak-bahwa percepatan dalam jumlah rekan-rekan
baik, 2 (93, 1093) 204,70, P 0,0001, regresi linier berganda merokok dari waktu ke waktu disejajarkan dengan
(MLR) faktor koreksi skala 1,125, CFI 0,98, RMSEA percepatan dalam merokok dari waktu ke waktu. Tidak ada
0,03 [90% Interval confi- dence (CI) 0,03, 0,04], lain yang signifikan antara faktor efek pada tren merokok.
probabilitas RMSEA 
rekan merokok
0,05 1, SRMR 0.02. Untuk merokok, rekan merokok dan
gejala depresi, kita diperbolehkan faktor terakhir loading Gejala depresi awal memiliki dampak positif yang
dari faktor kecenderungan untuk ukuran kelas 12 diamati signifikan pada awal rekan merokok ( 0,37, Z 5,99,

tingkat Peers Smoking


0,31 0.66
depresi level level

0.25
-0.28
-0.15
0.15

Figure 1 The direct and indirect effects of


Depression Peers Smoking depression on adolescent smoking pro-
0.41 0.69 gression.The model only depicts significant
trend trend trend

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paths among
latent variables
and presents
standardized
values

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Depression 0.36 Peers 0.67 Smoking


level level level

-0.19 -0.36

Depression Peers Smoking


Figure 2 The direct and indirect effects 0.68 0.66
trend trend trend
of adolescent smoking on the
development of depression. The model
only depicts signifi- cant paths among
-0.36
latent variables and pre- sents
standardized values

P 0.0001), indicating that the greater the baseline level merokok. Dengan demikian, kami menguji efek tidak langsung dari
of depression symptoms, the greater the number of peers gejala depresi tingkat ke tingkat merokok
who smoked at baseline. Baseline smoking had a
significant negative effect on peer smoking trend (
0.05, Z 2.13, P 0,03), menunjukkan bahwa semakin
besar merokok pada awal, semakin lambat tion accelera-
dalam jumlah rekan-rekan merokok dari waktu ke waktu.
Namun, gejala depresi tren memiliki efek positif yang
signifikan pada tren rekan merokok ( 0,52, Z 3,85, P
0,0001), menunjukkan bahwa percepatan gejala depresi
dari waktu ke waktu dikaitkan dengan percepatan dalam
jumlah rekan-rekan merokok dari waktu ke waktu. Tidak
ada lain yang signifikan antara faktor efek pada tren rekan
merokok.

gejala depresi

Untuk mengontrol dengan dampak dari merokok baseline dan rekan


merokok, model multivariat juga memperkirakan efek dari tingkat
dasar dari tindakan berulang dari kedua variabel tren gejala depresi.
Rekan merokok tingkat dasar memiliki efek negatif yang signifikan
pada tren gejala depresi ( 0,09, Z 2,61, P 0,01), menunjukkan
bahwa semakin besar peer merokok pada awal, semakin
lambat percepatan dalam tom depresi symp- dari waktu ke
waktu. Tidak ada efek signifikan lain pada tren gejala
depresi.

efek tidak langsung depresi merokok

Kami mengevaluasi apakah ada efek tidak langsung yang signifikan


dari gejala depresi pada merokok perkembangan melalui rekan

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through peer smoking level, depression symptoms


level on smoking trend through peer smoking level or
trend and for depression symptoms trend to
smoking trend through peer smoking trend, for
significance with Delta method standard errors [67].
The total effect, total and specific indirect effects and
direct effects are presented in Table 2, along with
95% CIs for significant indirect effects. To assess
the strength of a mediated effect on a continuum from
absence of mediation to complete mediation, we
estimated the ratio of the specific indirect effect to
total effect, the effect proportion mediated
/B
(Bindirect total ) [73]. Further, the 95% CI, if it does not
include zero, provides a measure of the strength of the
indirect effect, suggesting minimum and maximum
effects [73].

Depression symptoms level to smoking level

Efek total dari gejala depresi tingkat ke tingkat merokok,


termasuk dampak langsung dan tidak langsung melalui
rekan merokok, itu signifikan (Btotal 0,26, Z 3.13, P 0,002,
95% CI 0.10, 0.42). Pengaruh tidak langsung spesifik gejala
depresi awal merokok dasar melalui dasar rekan merokok
signifikan (Btidak langsung 0,33, Z 5.09, P 0,0001, 95% CI
0,21,
0,46). Sebagai efek langsung dari gejala depresi tingkat
tingkat merokok (Blangsung 0,07, Z 0,95, P 0,34,
95% CI 0,22, 0,08) adalah negatif, efek pro
porsi dimediasi melebihi 1,00 (yaitu Btidak langsung 0,33 / Btotal
0,26 1,27). Namun, karena efek langsung (Blangsung) Tidak
signifikan, kami capped efek proporsi dimediasi pada nilai
1,00 [73]. Dengan demikian, kita dapat menyimpulkan
bahwa meningkatkan gejala depresi awal

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model2 utama:
Meja gejala
Partisi jalur depresi
yang memprediksi
dimediasi: Jumlah merokok
efek, efek langsung dan efek tidak langsung.

95% CIb

Efek Memperk SESebu Perkiraan / P-nilai Rendah Ting


ah
irakan SE gi
gejala depresi tingkat untuk mengintip tingkat merokok untuk tingkat
merokok
Jumlah efek 0,26 0,08 3.13 0,002 0.10 0.42
Total pengaruh tidak langsungc 0.33 0,07 5.09 0,0001 0,21 0,46
pengaruh tidak langsung tertentud 0.33 0,07 5.09 0,0001 0,21 0,46
Efek langsung 0,07 0,08 0.95 0.34 0.22 0,08

Jumlah efek 0,13 0,05 2,48 0.01 0,03 0,23


gejala
Totaldepresi
pengaruhtingkat untuk mengintip tingkat merokok untuk tren merokok
tidak langsung 0,03 0,05 0,50 0.62 0,13 0,08
pengaruh tidak langsung tertentu 0,08 0.02 3,35 0,001 0,03 0,13
Efek langsung 0,16 0,06 2,44 0.02 0,03 0,28

Jumlah efek 0,29 0.22 1,29 0,20 0,15 0.72


Depresi gejala tren
Total pengaruh tidakuntuk mengintip merokok tren ke tren merokok
langsung 0,75 0,24 3.11 0,002 0,28 1,23
pengaruh tidak langsung tertentu 0,75 0,24 3.11 0,002 0,28 1,23
Efek langsung 0,47 0,26 1,76 0,08 0,98 0,05

Alternatif Model: merokok memprediksi gejala depresi


tingkat merokok untuk mengintip tingkat merokok untuk tingkat gejala
depresi
Jumlah efek 0,09 0,03 3,08 0,002 0,03 0,14
total tidak langsung 0,15 0,04 4.08 0,0001 0,08 0,23
pengaruh tidak langsung tertentu 0,15 0,04 4.08 0,0001 0,08 0,23
Efek langsung 0,07 0,05 1,37 0,17 0,16 0,03
tingkat merokok rekan merokok tren ke tren gejala depresi
Jumlah efek 0,04 0.02 1,73 0,08 0,08 0.01
Total pengaruh tidak langsung 0.10 0,04 2,97 0,003 0,17 0,04
pengaruh tidak langsung tertentu 0,06 0.02 2,76 0.01 0.11 0.02
Efek langsung 0,07 0,04 1,71 0,09 0.01 0,15
Merokok tren rekan merokok tren ke tren gejala depresi
Jumlah efek 0,04 0,03 1,17 0,24 0.02 0.10
Total pengaruh tidak langsung 0,18 0,06 2,97 0,003 0,06 0,30
pengaruh tidak langsung tertentu 0,18 0,06 2,97 0,003 0,06 0,30
Efek langsung 0,15 0,07 2.14 0,03 0,28 0.01

Hanya efek tidak langsung signifikan dilaporkan. SebuahMetode delta kesalahan standar (SE); b95 interval% confidence (CI) yang mengandung nol tidak
signifikan; cpengaruh tidak langsung Total mewakili total semua efek tidak langsung, termasuk efek tidak langsung tertentu disajikan; defek tidak
langsung tertentu adalah efek tidak langsung yang signifikan. efek tidak langsung yang tidak signifikan tidak disajikan dalam tabel ini untuk kekikiran.

predict an increase in the number of smoking peers at 0.13). The direct effect of depression symptoms level on
baseline which, in turn, predicts baseline smoking level smoking trend (Bdirect 0.16, Z 2.44, P 0.02, 95%
(complete mediation).

Depression symptoms level to smoking trend

The total effect of depression symptoms level to smoking


trend, including the direct and indirect effects through
peer smoking, was significant (Btotal 0.13, Z 2.48, P
0.01, 95% CI 0.03, 0.23). The specific indirect effect
of baseline depression symptoms on smoking trend
through baseline peer smoking was significant (Bindirect
0.08, Z 3.35, P 0.001, 95% CI 0.03,

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CI 0.03, 0.28) was also significant. The effect propor- tion


mediated (i.e. Bindirect 0.08/Btotal 0.13) was 0.61, suggesting
only partial mediation. Thus, higher base- line depression
symptoms predict a greater number of smoking peers
at baseline which, in part, predicts smoking progression.

Depression symptoms trend to smoking trend

The total effect of depression symptoms trend to smok- ing


trend was not significant (Btotal 0.29, Z 1.29, P 0.20,
95% CI 0.15, 0.72). However, depression symptoms
trend had a significant indirect effect on smoking trend
through peer smoking trend (Bindirect 0.75, Z 3.11,
P 0.002, 95% CI 0.28,

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1.23). As the direct effect of depression symptoms trend on increases in the number of smoking peers across time.
smoking trend (Bdirect 0.47, Z 1.76, P 0.08, Finally, depression symptoms
95% CI 0.98, 0.05) was negative, the effect proportion
mediated exceeded 1.00 (i.e. B indirect 0.75/Btotal 
0.29 2.59). However, because the direct effect (B direct)
was not significant, we capped the proportion mediated effect
at a value of 1.00 [73]. Thus, we can conclude that increases
in depression symptoms over time predicts an increase in the
number of smoking peers which, in turn, predicts smoking
progression (complete mediation).

Direct effects of smoking on depression: the


alternative model

We also assessed an alternative directional path whereby smoking


affects the development of depression symptoms directly as well as
indirectly through peer smoking and physical activity. Standardized
regression coefficients for significant model pathways are presented in
Fig. 2.

Depression symptoms

Peer smoking level had a significant positive effect on


depression symptoms level ( 0.31, Z 4.30, P 0.0001),
indicating that the greater the number of peers smoking
at baseline, the higher the depression symptoms at
baseline. Peer smoking trend also had a sig- nificant
positive effect on rate of change in depression symptoms
from 9th to 12th grade ( 0.60, Z 3.21, P 0.001). These
results indicated that acceleration in the number of peers
smoking over time was associated with an acceleration in
depression symptoms over time. Smoking trend, however,
had a significant negative effect on depression symptoms
trend ( 0.15, Z 2.14, P 0.03), indicating that acceleration
in smoking over time was associated with a deceleration
(or slowing of acceleration) in depression symptoms over
time.

Peer smoking

Baseline smoking (level) had a significant positive effect on


peer smoking level ( 0.50, Z 10.18, P 0.0001), indicating
that greater baseline smoking predicted a higher
number of smoking peers at baseline. However, baseline
smoking had a significant negative effect on peer smoking
trend ( 0.11, Z 4.18, P 0.0001). Con- sidered together,
these results indicate that adolescents who have higher
levels of smoking at age 14 also have more peers who smoke
at this age and may reach a ceiling in the number of
smoking peers than those who do not smoke regularly at
mid-adolescence. Smoking trend had a significant positive
effect on peer smoking trend ( 0.30, Z 9.53, P 0.0001),
indicating that accel- eration in smoking predicted

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baseline level ( 0.09, Z 3.02, P 0.003) had a significant


negative effect on peer smoking trend, suggest- ing that the
higher the baseline level of depression symp- toms the
slower the acceleration in the number of peers smoking
over time.

Smoking

To control for the effects of baseline depression and peer smoking, the
multivariate model also estimated the effects of baseline levels of
these two variables on smoking trend. However, there were no
significant effects on smoking trend.

Indirect effects of smoking on depression

To evaluate whether smoking affects the development of depression


symptoms indirectly through peer smoking we tested several indirect
pathways for significance, reversing the pathways tested in the first
model (see Fig. 2). First, we tested the effect of baseline smoking
(level) on baseline depression symptoms (level) through baseline peer
smoking level. This indirect effect was significant (Bindirect 0.15, Z
4.08, P 0.0001, 95% CI 0.08, 0.23). The total effect
was also significant (Btotal 0.09, Z 3.08, P 0.002, 95% CI
0.03, 0.14). The effect proportion mediated exceeded 1
(Bindirect/ Btotal 1.67). However, as the direct effect was
negative and non-significant (see Table 2), the effect
proportion mediated was capped at 1.00, and we can
conclude that the effect of baseline smoking on baseline
depression symptoms was mediated completely through
baseline peer smoking.
In addition to the indirect effect of baseline smoking to
depression symptoms level, the indirect effect of baseline
smoking level to depression symptoms trend through peer
smoking trend was also significant (Bindirect 0.06, Z 2.76, P
0.01, 95% CI 0.11, 0.02), and there was a significant
indirect effect from smoking trend to depression
symptoms trend (Bindirect 0.18, Z 2.97, P 0.003, 95% CI
0.06, 0.30). The total effect of base- line smoking on
depression symptoms trend was not significant (Btotal
0.04, Z 1.73, P 0.08, 95% CI 0.08, 0.01). The effect
proportion mediated for this indirect effect was (B indirect
0.06/Btotal 0.04) 1.50, which exceeds 1.0. This resulted
from a positive direct effect from baseline smoking to
depression symptoms trend (B direct 0.07, Z 1.71, P 0.09,
95% CI 0.01,
0.15). However, because the direct effect (Bdirect) was not
significant, we capped the proportion mediated effect at a
value of 1.00 [73]. Thus, we can conclude that the effect of
baseline smoking on rate of change in depression symptoms
over time is due to the number of peers who smoke,
indicating complete mediation.

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The indirect effect of smoking trend on depression that adolescent smokers reported higher positive affect
symptoms trend was more complicated. The total effect was and lower negative affect after smoking, but these
not significant (Btotal 0.04, Z 1.17, P 0.24,
95% CI 0.02, 0.10). The effect proportion mediated,
however, exceeded 1.00 [i.e. (Bindirect 0.18/Btotal 
0.04) 4.5]. This is because the direct effect of smoking
trend on depression symptoms trend was negative
(Bdirect 0.15, Z 2.14, P 0.03, 95% CI 0.28,
0.01). However, unlike the case of the indirect effect of
baseline smoking level on depression symptoms trend in
which the direct effect was not significant, this direct
effect was significant, indicating effect suppression [73]. In
the presence of effect suppression, the calculated pro-
portion of mediation is not meaningful and the direct
effect cannot be ignored. This suggests that holding the
peer smoking rate of change (trend) constant, the direct
effect of smoking trend on depression symptoms trend is
significant and negative.
For exploratory purposes, we evaluated the moderat- ing
role of gender in the direct and indirect relationship between
depression and smoking. There were no signfi- cant gender
differences in either two-group LGCMs.

DISCUSSION

The present study found evidence for a bidirectional rela-


tionship between adolescent depression and smoking.
Peer smoking helped account for the comorbidity. Depres-
sion symptoms measured at mid-adolescence (age 14)
predicted smoking progression across mid- to late adoles-
cence (age 14–18). Peer smoking mediated these
developmental influences such that higher depression
symptoms predicted an increase in the number of
smoking peers which, in turn, predicted smoking pro-
gression. The assessment of the alternative directional path
indicated that smoking progression predicted a deceleration
of depression symptoms from mid- to late adolescence. A
significant indirect effect indicated that greater smoking
at baseline predicted a deceleration in the number of
smoking peers across time, which pre- dicted a
deceleration in depression symptoms from mid-
adolescence to late adolescence.
The presence of a bidirectional relationship is partially
consistent with previous research [17–19]. In contrast to
those studies that found smoking to be a risk factor for
depression and depression to be a risk factor for smoking,
the bidirectional influences observed in the present study
support a self-medication hypothesis for both directional
paths. That is, depression contributed to smoking uptake and
smoking progression contributed to a dampening or
leveling-off of depression symptoms. A recent cross-
sectional study of smoking-associated mood variation found

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mood modulation effects diminished with high levels of Of note, the alternative indirect path showed that
smoking experience [74]. Variability in negative mood or smoking at mid-adolescence (age 14) predicted a
unstable affect regulation appears to be a risk factor for
smoking escalation among adolescents and smoking
serves to stabilize or decrease the variability in negative
mood states [75]. This study extends this research by
showing prospectively that depression contributes to
smoking uptake and that smoking modulates depression
symptoms. These reciprocal relationships may reinforce
and maintain smoking behavior into adulthood.
These findings also highlight the notion that there may
be overlap in the neural substrates modified by smoking
and antidepressant medication [76]. For example, nicotinic
acetylcholine receptors are thought to be involved in
modulating the release of several neu- rotransmitters
implicated in mood, such as serotonin, norepinephrine,
dopamine, gamma aminobutyric acid (GABA) and
glutamate [76,77]. Nicotine receptor inhibi- tion appears to
mitigate mood instability and may reduce depression [78].
It is possible that long-term (or even shorter-term) smoking
may be followed by adaptations or tolerance to nicotine,
which may promote negative affective states such as
depression [77,79]. The mood- modulating or affective-
regulating functions of nicotine may decline with a greater
smoking history [74,75]. As the epidemiological studies
of the depression–smoking relationship extend into
young adulthood, capturing longer smoking histories and
higher smoking rates, find- ings that smoking predicts
depression are consistent with this explanation [14,24].
Our bidirectional findings may have differed, in part,
from previous research [7,10,17–19] because we used
repeated measures of depression and smoking to account for
baseline levels and changes across time. This may have
allowed us to capture more effectively how these two
variables impact each other from mid-adolescence to late
adolescence [80]. We also controlled for some confound-
ing variables [17–19,81] and considered a more complex
relationship between smoking and depression, which
included an evaluation of indirect effects.
The findings of this study also indicate that depression
contributes to smoking acquisition indirectly by increas-
ing adolescent vulnerability to peers who smoke. The
impact of peer smoking on adolescent smoking acquisi- tion
is well documented [43]. Adolescents with higher levels
of depression may be more sensitive to peer behav- ior more
likely to select non-conventional peers, or both [45,46,82].
A greater number of smoking peers provides better access
to cigarettes, promotes a normative percep- tion of smoking
and may be a source of peer approval [38,83]. These issues
may be especially salient for youth with higher levels of
depression symptoms.

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leveling-off dalam jumlah merokok rekan-rekan di waktu Tingginya tingkat komorbiditas antara depresi dan merokok
yang, pada gilirannya, memberikan kontribusi terhadap menekankan dikan impor- menargetkan upaya pencegahan
perlambatan gejala sion depres-. Temuan ini bertentangan merokok untuk kelompok berisiko tinggi ini. Intervensi yang
dengan apa yang akan kita harapkan, meskipun penelitian memiliki komponen pada pencegahan dan manajemen depresi
cross-sectional telah menunjukkan bahwa jika mereka dapat memiliki dampak penting pada penyerapan merokok serta
menghadiri sekolah dengan prevalensi merokok yang lebih sub- berturut depresi. model berdasarkan pengaruh-sosial
rendah, perokok remaja cenderung memiliki gejala depresi pencegahan merokok atau alamat intervensi teman sebaya untuk
yang lebih tinggi [83]. Hal ini mungkin mencerminkan merokok (misalnya rokok menawarkan keahlian penolakan).
dikan impor- dari peer group milik dan persepsi perilaku Namun, juga mungkin penting untuk mengatasi masalah ini dari
tive norma- pada depresi. Atau, temuan ini mungkin hanya sudut pandang depresi remaja. Sebagai contoh, program yang
mencerminkan hubungan positif antara merokok remaja membahas mengatasi dan negatif keterampilan manajemen
yang lebih besar dan lebih banyak rekan-rekan yang suasana hati, jaringan sosial yang terbatas, perlu untuk persetujuan
merokok pada awal, sehingga rekan-rekan merokok lebih rekan dan mengakses kelompok sebaya non-merokok mungkin
sedikit diperoleh di seluruh waktu. Meratakan-off dalam sangat bermanfaat bagi remaja dengan gejala depresi tinggi.
jumlah perokok rekan kemudian dihubungkan positif Temuan awal menunjukkan bahwa pendekatan sosial
terhadap leveling-off dalam gejala depresi. Tren positif tren pembelajaran berbasis pencegahan merokok cenderung sangat
dari hubungan antara perkembangan merokok, lebih banyak membantu bagi remaja laki-laki tertekan [86].
rekan-rekan merokok dan peningkatan gejala depresi di The strengths of the present study include the collec-
waktu ditekan oleh dampak yang signifikan dan negatif tion of data from a large group of adolescents, repeated
langsung antara perkembangan merokok dan perlambatan measurements of smoking, depression and peer smoking
dalam gejala depresi [73]. Ini mungkin hanya contoh across mid- to late adolescence, an analytical
kompleksitas hubungan antara merokok remaja dan depresi,
mencerminkan bahwa rekan variabel merokok diukur
kuantitas rekan-rekan yang merokok di waktu, tapi tidak
memperhitungkan kualitas dan jenis hubungan sebaya yang
dapat mempengaruhi suasana hati, dan / atau menyoroti
pentingnya mekanisme umum dan unik lainnya. jumlah
yang lebih besar dari rekan-rekan merokok dan peningkatan
gejala depresi di waktu ditekan oleh dampak yang signifikan
dan negatif langsung antara perkembangan merokok dan
perlambatan dalam gejala depresi [73]. Ini mungkin hanya
contoh kompleksitas hubungan antara merokok remaja dan
depresi, mencerminkan bahwa rekan variabel merokok
diukur kuantitas rekan-rekan yang merokok di waktu, tapi
tidak memperhitungkan kualitas dan jenis hubungan sebaya
yang dapat mempengaruhi suasana hati, dan / atau
menyoroti pentingnya mekanisme umum dan unik lainnya.
jumlah yang lebih besar dari rekan-rekan merokok dan
peningkatan gejala depresi di waktu ditekan oleh dampak
yang signifikan dan negatif langsung antara perkembangan
merokok dan perlambatan dalam gejala depresi [73]. Ini
mungkin hanya contoh kompleksitas hubungan antara
merokok remaja dan depresi, mencerminkan bahwa rekan
variabel merokok diukur kuantitas rekan-rekan yang
merokok di waktu, tapi tidak memperhitungkan kualitas dan
jenis hubungan sebaya yang dapat mempengaruhi suasana
hati, dan / atau menyoroti pentingnya mekanisme umum dan
unik lainnya.
Penelitian menunjukkan bahwa hampir 25% dari remaja
perokok tetap [37,53], sekitar 25% dari remaja memiliki
setidaknya satu episode depresi utama oleh usia 18 tahun [2] dan
20-30% dari remaja mengalami gejala depresi [64 , 81,84,85].

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1762 Janet Audrain-McGovern et al. remaja merokok dan depresi 1762

rencana yang konsisten dengan sifat longitudinal data dan memperkuat hubungan antara merokok, ketergantungan
konsep komorbiditas, dimasukkannya variabel pengganggu nikotin dan depresi. Memang, data menunjukkan hubungan
potensial dan tingkat retensi yang baik. Salah satu dua arah antara merokok, ketergantungan nikotin dan
keterbatasan adalah bahwa laporan diri gejala depresi tidak depresi besar pada orang dewasa muda berusia 18-31
dikonfirmasi oleh resmi pandangan antar klinis. Dengan [23,24].
demikian, kita tidak dapat menentukan apakah ini lescents Selain itu, meskipun sampel kami adalah 34% minoritas,
ado- memiliki riwayat depresi besar atau jika mereka kami tidak memiliki cukup remaja dalam satu kelompok ras
memenuhi kriteria untuk diagnosis saat ini. Demikian pula, untuk mengevaluasi perbedaan rasial dalam hubungan
ukuran dasar kami (faktor tingkat depresi) depresi tidak antara depresi dan merokok. Akhirnya, batasan umum dari
mencakup sejarah depresi. Namun, ukuran kami merokok protokol yang membutuhkan persetujuan aktif adalah
pada awal (faktor tingkat merokok) tidak tingkat respon non [88-90]. Meskipun 75% dari orang tua
mempertimbangkan sejarah merokok. calon penelitian masa yang merespon memberikan persetujuan dan perbedaan
depan harus mencakup variabel dasar yang meliputi hidup- antara mereka yang memberikan persetujuan dan mereka
waktu dan depresi hadir. Juga, kita tidak mengukur yang menolak relatif kecil dan beberapa [47], hati-hati
komorbiditas dan pembaur tom symp- kejiwaan, seperti dijamin dalam generalisasi hasil penelitian ini. Namun,
kecemasan [17,85,87]. Meskipun dapat dianggap sebagai sampel kami adalah nasional dan lokal perwakilan
batasan bahwa model kami tidak termasuk ketergantungan karakteristik grafis demografis dasar [91-93], dan tingkat
nikotin, penelitian kami menunjukkan tionships eratnya merokok cukup sebanding dengan yang ditemukan dalam
penting antara gejala depresi dan merokok biasa, yang survei nasional untuk wilayah geografis sampel kami [91,
mungkin atau mungkin tidak mencerminkan nikotin In conclusion, the present study provides the first evi-
merokok tergantung. Banyak dari perokok remaja dapat dence of bidirectional self-medication processes in the
terus merokok sampai dewasa, berpotensi memperkuat relationship between adolescent smoking and depression
hubungan antara merokok, ketergantungan nikotin dan and suggests that peer smoking behavior may help
depresi. Memang, data menunjukkan hubungan dua arah account for the comorbidity. Further research on mecha-
antara merokok, ketergantungan nikotin dan depresi besar nisms may provide novel behavioral and pharmacologi- cal
pada orang dewasa muda berusia 18-31 [23,24]. Meskipun intervention targets for adolescent smoking and/or
dapat dianggap sebagai batasan bahwa model kami tidak depression. Based on these findings, targeting depression
termasuk ketergantungan nikotin, penelitian kami could have an important impact on smoking uptake as well
menunjukkan tionships eratnya penting antara gejala as subsequent depression. The public health implica- tions
depresi dan merokok biasa, yang mungkin atau mungkin of further research could have a significant bearing
tidak mencerminkan nikotin merokok tergantung. Banyak
dari perokok remaja dapat terus merokok sampai dewasa,
berpotensi memperkuat hubungan antara merokok,
ketergantungan nikotin dan depresi. Memang, data
menunjukkan hubungan dua arah antara merokok,
ketergantungan nikotin dan depresi besar pada orang
dewasa muda berusia 18-31 [23,24]. Meskipun dapat
dianggap sebagai batasan bahwa model kami tidak termasuk
ketergantungan nikotin, penelitian kami menunjukkan
tionships eratnya penting antara gejala depresi dan merokok
biasa, yang mungkin atau mungkin tidak mencerminkan
nikotin merokok tergantung. Banyak dari perokok remaja
dapat terus merokok sampai dewasa, berpotensi
memperkuat hubungan antara merokok, ketergantungan
nikotin dan depresi. Memang, data menunjukkan hubungan
dua arah antara merokok, ketergantungan nikotin dan
depresi besar pada orang dewasa muda berusia 18-31
[23,24]. berpotensi memperkuat hubungan antara merokok,
ketergantungan nikotin dan depresi. Memang, data
menunjukkan hubungan dua arah antara merokok,
ketergantungan nikotin dan depresi besar pada orang
dewasa muda berusia 18-31 [23,24]. berpotensi

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kompilasi
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untukuntuk
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104, 1743-1756
104, 1743-1756
1763 Janet Audrain-McGovern et al. remaja merokok dan depresi 1763

on the psychosocial, economic and medical morbidity 11. Rohde P., Lewinsohn PM, Brown RA, Gau JM, Kahler C.
and premature mortality that are associated with these
conditions.

Acknowledgements

This study was supported by a Transdisciplinary


Tobacco Use Research Center grant from the National
Cancer Institute and the National Institute on Drug
Abuse P50 84718 and National Cancer Institute RO1
CA109250. The funding agency had no role in the design and
conduct of the study, collection, manage- ment, analysis and
interpretation of the data or in the preparation, review or approval of
the manuscript. All authors had full access to all the data in the study.
The Principal Investigator (J.A.M.) takes responsibility for the
integrity of the data and the accuracy of the data analysis.

Declarations of interest

None.

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