RESEARCH REPORT doi:10.1111/j.1360-0443.2009.02740.

Cognitive test scores in male adolescent cigarette

smokers compared to non-smokers: a
population-based study add_2740 358..363

Mark Weiser1,2,3, Salman Zarka4,5, Nomi Werbeloff2,6, Efrat Kravitz1 & Gad Lubin2
Department of Psychiatry, Sheba Medical Center,Tel Hashomer, Israel,1 Division of Mental Health, Medical Corps, IDF, Israel,2 Sackler School of Medicine,Tel Aviv
University, Ramat Aviv, Israel,3 Public Health Branch, IDF, Israel,4 School of Public Health, University of Haifa, Haifa5 and Ashkelon Academic College, Ashkelon, Israel6

ABSTRACT

Background Although previous studies indicate that people with lower intelligence quotient (IQ) scores are more
likely to become cigarette smokers, IQ scores of siblings discordant for smoking and of adolescents who began smoking
between ages 18–21 years have not been studied systematically. Methods Each year a random sample of Israeli
military recruits complete a smoking questionnaire. Cognitive functioning is assessed by the military using standard-
ized tests equivalent to IQ. Results Of 20 221 18-year-old males, 28.5% reported smoking at least one cigarette a day
(smokers). An unadjusted comparison found that smokers scored 0.41 effect sizes (ES, P < 0.001) lower than non-
smokers; adjusted analyses remained significant (adjusted ES = 0.27, P < 0.001). Adolescents smoking one to five, six
to 10, 11–20 and 21+ cigarettes/day had cognitive test scores 0.14, 0.22, 0.33 and 0.5 adjusted ES poorer than those
of non-smokers (P < 0.001). Adolescents who did not smoke by age 18, and then began to smoke between ages 18–21
had lower cognitive test scores compared to never-smokers (adjusted ES = 0.14, P < 0.001). An analysis of brothers
discordant for smoking found that smoking brothers had lower cognitive scores than non-smoking brothers (adjusted
ES = 0.27; P = 0.014). Conclusion Controlled analyses from this large population-based cohort of male adolescents
indicate that IQ scores are lower in male adolescents who smoke compared to non-smokers and in brothers who smoke
compared to their non-smoking brothers. The IQs of adolescents who began smoking between ages 18–21 are lower
than those of non-smokers. Adolescents with poorer IQ scores might be targeted for programmes designed to prevent
smoking.

Keywords Cigarettes, cognitive functioning, IQ, military assessment, sib-pairs, smoking.

Correspondence to: Mark Weiser, Department of Psychiatry, Sheba Medical Center, Tel Hashomer 52621, Israel. E-mail: mweiser@netvision.net.il
Submitted 3 February 2009; initial review completed 15 March 2009; final version accepted 15 July 2009

INTRODUCTION Most previous studies were based on childhood IQ

As smoking prevention is a major public health issue, it is
important to identify the risk factors for smoking. Studies
testing the association between childhood intelligence
and later cigarette smoking have reported that those with
lower intelligence quotient (IQ) scores are more likely to
become smokers [1–4] and once they start to smoke are
less likely to give up smoking [1,5,6]. In some cases this
association was attenuated when controlling for socio-
economic status (SES) [1,2] or mediated by lower educa-
tional attainment [7]. Similarly, studies reported that
smoking is associated with lower educational attainment
[1,2,8,9], higher truancy [10] and increased likelihood of
leaving school at an early age [11].
[1,3–7] and included individuals with psychiatric diag-
noses and behavioural disorders, who are more prone to
smoking [12] and more likely to have lower IQ scores
[13,14]. Hemmingsson et al. [2], who assessed smoking
and cognition in a cross-sectional study of Swedish con-
scripts, did not have data on the initiation of smoking
during military service.
To date, no study has systematically examined differ-
ences in IQ among siblings discordant for smoking. Such
a design should reduce the confounding effects of shared
environmental and genetic factors.
The present study therefore set out to examine cogni-
tive functioning in a very large (n = 20 000) population-
based cohort of 18-year-old male adolescent recruits to

© 2009 The Authors. Journal compilation © 2009 Society for the Study of Addiction Addiction, 105, 358–363

the Israeli Defence Forces, including 70 male sib-pairs
discordant for smoking, for whom data about cigarette
smoking at age 18 years and between the ages of 18–21
years were available.
METHODS
Assessment of smoking
The Israel Defence Forces Medical Corps conducts an
ongoing survey designed to provide prevalence estimates
of health indices. As part of the survey, recruits are asked:
‘do you smoke? (yes/no)’; ‘did you smoke in the past?
(yes/no)’; and if yes for at least one of them: ‘how many
cigarettes do/did you smoke in a day?’. The survey is
administered to a random sample of 18-year-old adoles-
cent men when recruited to military service. The sample
is drawn by taking every 20th soldier based on a prede-
termined combination of digits of the subjects’ military
serial number (described in detail by Kark [15]). The
survey and the respective questionnaire are administered
by trained nurses from the Israel Defence Force Health
Surveillance Section. Of those who were asked to partici-
pate in the study, 91% agreed and provided signed
informed consent, which was approved by the Israel
Defence Force Medical Corps Internal Review Board. Of
these, approximately 60% complete the survey a second
time upon release from military service.
The health survey also includes data on father’s edu-
cation, which was used in this study as a measure of SES.
This study was approved by the local Institutional
Review Board.
Israeli draft board registry
All adolescents in the country undergo a mandatory pre-
draft screening at ages 16–17 designed to ascertain their
eligibility to serve in the military. The screening includes
medical and psychiatric history conducted by a physi-
cian, intelligence testing and, for male adolescents only,
also a semi-structured screening interview assessing per-
sonality and behavioural traits. Based on the screening
interview and on findings from the physician’s examina-
tion, adolescents who are suspected of having behav-
ioural disturbances or mental illness are referred for an
in-depth assessment by a mental health professional, and
if the adolescent warrants a psychiatric diagnosis he is
then referred to a board certified psychiatrist. Based on
this screening procedure, those adolescents who are
found to have ICD 9–10, Axis I or Axis II pathology, with
significant functional impairment, are released from mili-
tary service; thus, the sample of adolescents who com-
pleted the smoking questionnaires does not include very
poorly functioning individuals. Adolescents with less
severe functional impairments are drafted to service.
© 2009 The Authors. Journal compilation © 2009 Society for the Study of Addiction
Cognitive test scores among adolescent smokers 359
The intellectual assessment includes four tests (a
modified Otis-type verbal intelligence test, which mea-
sures the ability to understand and carry out verbal
instructions; verbal analogies, a modified version of the
‘similarities’ subtest of the Wechsler Intelligence Scales
that assesses verbal abstraction and categorization;
mathematical knowledge, which measures mathematical
reasoning, concentration and concept manipulation; and
non-verbal analogies, a modified version of Raven’s Pro-
gressive Matrices that measures non-verbal abstract rea-
soning and visual–spatial problem-solving abilities. Tests
are progressive, beginning with relatively simple ques-
tions and becoming more difficult. Tests are group-
administered and are time-limited. All scores are based on
number of correct answers. The sum of the scores for the
four tests forms a validated measure of general intelli-
gence (IQ) [16,17], scored on a nine-point scale (scaled
between 10 and 90, with a 10-point increment at each
score).
Study population
Of 28 918 randomly selected male adolescents who
completed the health questionnaire, we removed 4314
(14.9%) subjects because of missing data from the
smoking questionnaire. Twenty (0.07%) were removed
due to inconsistency of smoking reports (e.g. reported to
be non-smokers, but cigarette number was greater than
zero; reported to be quitters, but answered ‘yes’ for the
question ‘do you smoke?’, etc.). Another 664 (2.3%) ado-
lescents diagnosed with any psychiatric disorder were
also removed. Finally, 3831 (13.2%) adolescents were
removed because of missing data on the medical assess-
ment, SES or cognitive functioning.
Of the 20 221 subjects remaining, 5762 (28.5%)
reported themselves to be ‘smokers’, smoking at least one
cigarette a day dating prior to the draft board assessment.
This prevalence of smoking is in line with data on the
rates of smoking in Israel [18] and among adolescents
and young adults in the western world [19]. Six hundred
and ninety-five (695, 3.4%) reported themselves to be
‘former smokers’ (i.e. used to smoke regularly in the past,
but do not currently smoke) and 13 764 (68.1%)
reported themselves as ‘non-smokers’ (i.e. never smoked
before and are not currently smoking). Smokers were
then divided into four groups, according to the number of
cigarettes smoked per day: one to five cigarettes/day; six
to 10 cigarettes/day; 11–20 cigarettes/day; and 21 or
more cigarettes/day.
As smoking is not permitted during the intelligence
tests administered by the draft board, it is conceivable that
adolescents who smoke would suffer from some degree of
withdrawal symptoms during the tests, leading to poorer
cognitive test scores [20–22]. In order to explore this
Addiction, 105, 358–363
360 Mark Weiser et al.

possibility, we also analysed data on smoking habits col-
lected upon discharge from military service. This enabled
us to study adolescents who did not smoke during the
draft board psychometric assessment, hence did not suffer
from symptoms of withdrawal during the cognitive test,
but started smoking later during their military service.
A third set of analyses identified 70 sib-pairs born to
the same mother and father, in which one brother was a
smoker and the other was not, and compared the cogni-
tive functioning scores of the two brothers discordant for
smoking.
Data analysis
In order to control for the (slight) differences in cognitive
test scores in the draft board over the years, the cognitive
test scores were standardized according to the mean and
standard deviation for each year. Analysis of covariance
(ANCOVA) was used to test the differences in cognitive
functioning between the groups, controlling for the
potential confounding effects of SES as reflected by
father’s years of formal education.
In an attempt to further elucidate the effects of SES,
the study population was divided into three groups
according to SES levels (father’s years of education <12,
=12 or >12). We then examined the differences in cogni-
tive functioning between smokers and non-smokers
within each SES group using t-tests. Paired t-tests were
used to test differences in cognitive functioning within the
sib-pairs. SPSS version 14.0 software was used in all
analyses.
RESULTS
An unadjusted comparison of cognitive test scores of
smokers to non-smokers found that smokers scored 0.41
effect sizes (ES) lower than non-smokers. Analyses con-
trolling for SES found that smokers still had significantly
lower cognitive test scores compared to the non-smokers
(ES = 0.27, P < 0.001, Table 1). The cognitive test scores
of former smokers were intermediate; higher than
present smokers, but lower than adolescents who never
smoked.
When dividing the cohort into three SES levels, based
on father’s education, the findings suggest that the effect
of smoking is similar in all three groups (Table 2), with
smokers scoring lower than non-smokers in all SES
groups.

Table 1 Cognitive functioning of adolescents who smoke or used to smoke compared to cognitive functioning of non-smokers.

Adjusted* difference Adjusted** difference

from non-smokers from non-smokers

Group n Mean IQ (SD) Effect size P Effect size P

Non-smokers 13 764 100.7 (14.5) – –

Former smokers 695 99.2 (15) 0.14 0.029 0.08 0.023
Smokers 5 762 95.0 (15) 0.41 0.000 0.27 0.000

*Adjusted for year of draft board assessment; **adjusted for year of draft board assessment and socio-economic status. IQ: intelligence quotient; SD:
standard deviation.

Table 2 Cognitive functioning of adolescents who smoke or used to smoke compared to cognitive functioning of non-smokers divided
by socio-economic status (SES) groups (low to high).

Adjusted* difference
from non-smokers
SES levels (1 = lowest,
3 = highest) Group n Mean IQ (SD) Effect size P

1 (n = 6726) Non-smokers 4174 94.5 (14) –

Former smokers 220 92.4 (14) 0.14 0.108
Smokers 2332 90.2 (14) 0.36 0.000
2 (n = 7332) Non-smokers 5056 99.5 (14) –
Former smokers 249 98.5 (14) 0.07 0.616
Smokers 2027 94.6 (14) 0.29 0.000
3 (n = 6163) Non-smokers 4534 107.8 (13) –
Former smokers 226 106.4 (14) 0.15 0.291
Smokers 1403 103.6 (13) 0.31 0.000

*Adjusted for year of draft board assessment; IQ: intelligence quotient; SD: standard deviation.

© 2009 The Authors. Journal compilation © 2009 Society for the Study of Addiction Addiction, 105, 358–363
 Cognitive test scores among adolescent smokers 361

Table 3 Cognitive functioning according to number of cigarettes smoked per day compared to cognitive functioning of non-smokers.

Adjusted* difference Adjusted** difference

from non-smokers from non-smokers

Cigarettes/day na Mean IQ (SD) Effect size P Effect size P

0 13 764 100.7 (14.5) – –

1–5 1 571 98.2 (15) 0.21 0.000 0.14 0.000
6–10 2 064 96.3 (14.5) 0.34 0.000 0.22 0.000
11–20 2 063 93.6 (14) 0.48 0.000 0.33 0.000
21+ 513 89.6 (14) 0.76 0.000 0.5 0.000

a
Number of cigarettes was missing for 246 of the smokers; *adjusted for year of draft board assessment; **adjusted for year of draft board assessment and
socio-economic status. IQ: intelligence quotient; SD: standard deviation.

Table 4 Cognitive functioning of adolescents who smoke compared to cognitive functioning of non-smokers—discharge data.

Adjusted* difference Adjusted** difference

from non-smokers from non-smokers

Group n Mean IQ (SD) Effect size P Effect size P

Non-smokers 6516 100.8 (15) – –

Smokers (started smoking before recruitment) 2908 94.3 (14.5) 0.47 0.000 0.29 0.000
Smokers (started smoking after recruitment) 1863 97.4 (14.5) 0.27 0.000 0.14 0.000

*Adjusted for year of draft board assessment; **adjusted for year of draft board assessment and socio-economic status. IQ: intelligence quotient;
SD: standard deviation.

Cognitive test scores were lower as a function of the
number of cigarettes smoked per day (Table 3).
Data on smoking habits at discharge from mandatory
military service at age 21 was available for 55% of the
sample (n = 11 287). Adolescents who started smoking
after the cognitive tests were administered, hence were
not suffering from withdrawal during cognitive testing,
scored 0.14 ES below their non-smoking counterparts
(Table 4), indicating that nicotine withdrawal was prob-
ably not the cause of the difference in cognitive test scores
between smokers and non-smokers.
An additional analysis identified 70 sib-pairs in which
one adolescent smoked and the other did not. The
smoking brother had poorer cognitive test scores than
the non-smoking brother (ES = 0.27; t69 = -2.53, P =
0.014).
DISCUSSION
As a group, male adolescent smokers have lower cogni-
tive test scores compared to non-smokers. Male adoles-
cents who smoke more than a pack of cigarettes a day
scored 0.5 ES (equivalent to 7.5 IQ points) below non-
smokers after adjustments for SES. These findings are
present in smokers from both high as well as low SES
levels. These findings are not due to nicotine withdrawal,
as male adolescents who did not smoke during the draft
board assessment, but did start smoking during their
military service also had cognitive test scores significantly
poorer than non-smoking adolescents. Even analyses
within families of sib-pairs discordant for smoking
showed that the smoking brothers had significantly lower
cognitive test scores compared to their non-smoking
brothers. The cognitive test scores of former smokers
were intermediate; better than that of current smokers,
but poorer than the cognitive test scores of non-smokers.
These data, based on a large population-based
cohort, expand upon and strengthen the results of pre-
viously published longitudinal studies which reported
that childhood IQ is associated with increased risk of
later smoking [1–4,7]. A similar finding was reported
in relation to adolescent IQ, which has been shown to
be strongly associated with educational level, socio-
economic position and income later in life [23]. These
longitudinal data support the possible causal effect of
low IQ and the onset of cigarette smoking, and mitigate
against claims that cigarette smoking damages cognitive
abilities [21].
Of particular interest is the analysis showing that the
1863 adolescents who did not smoke during the draft
board cognitive assessment but did begin to smoke
between ages 18 and 21 had lower cognitive test scores
compared to never-smokers. These data are in contrast
with a very small (n = 18) group taken from a similar

© 2009 The Authors. Journal compilation © 2009 Society for the Study of Addiction Addiction, 105, 358–363
362 Mark Weiser et al.
study using IQ data from the Swedish army [2], which
found that individuals who reported being non-smokers
at age 18 but who did smoke at follow-up (mean
age = 36) had, on average, higher IQ scores. The source of
the apparent discrepancy between their findings and ours
might be that their data were based on a very small
number of adolescents.
Given that variables such as truancy and school dis-
engagement are generally associated with lower IQ [24],
it has been hypothesized that the association between
lower IQ and smoking is mediated by smokers socializing
with other disaffected young people, who encourage each
other to smoke. The current study does not support this
hypothesis as the Israeli military has mandatory induc-
tion, including people with higher as well as lower levels
of functioning.
This the first study to systematically assess differences
in IQ among siblings discordant for smoking, finding that
the smoking siblings had lower IQ scores than their non-
smoking siblings. This is in line with a previous study of
52 same-sex sibling pairs discordant for smoking [25],
reporting that the smoking siblings had significantly
fewer years of education and significantly higher scores
on measures of depression, childhood attention deficit
hyperactive disorder (ADHD) and alcohol dependence
than their non-smoking siblings. This might be inter-
preted as strengthening the association between smoking
and IQ, beyond the genetic and environmental factors
shared by siblings.
The results of the current study are not affected by the
higher prevalence of mental illness among smokers [12],
who also have lower scores on cognitive tests [13,14], as
they were excluded form the analysis. It is therefore most
reasonable to conclude that less intelligent adolescents
are more prone to smoke cigarettes. This is compatible
with other research indicating that low IQ increases risk
for other behaviours related to poor health outcomes,
including heavy alcohol abuse, obesity and hypertension
[1,3,4,26].
Limitations
Cigarette smoking status is based on self-report only;
however, other studies comparing the self-reported
number of cigarettes smoked daily and the levels of nico-
tine present in bodily fluids reported relatively low rates of
smoker misclassification bias [27]. Also, this study is
focused on data collected on adolescents inducted into
the military who were screened and found not to suffer
from any psychiatric disorder, hence adolescents with
psychiatric disorders are not included in these analyses.
However, these excluded adolescents have lower scores on
the cognitive tests administered by the draft board (data
not shown) and smoke more [12], hence their exclusion
© 2009 The Authors. Journal compilation © 2009 Society for the Study of Addiction
probably leads to an under-estimation of the association
between cigarette smoking and cognitive abilities.
Although females serve in the Israeli military, the rules
regarding deferment from service for females are much
more lax compared to males, and in practice lower-
functioning females are under-represented in those
people actually inducted into military service compared
to males. Hence this report relates only to male
adolescents.
In conclusion, poor cognitive functioning is a signifi-
cant risk factor for cigarette smoking in male adolescents
apparent both in a population-based design and within-
family design. Adolescents with poorer scores on cogni-
tive tests might benefit from programmes designed to
prevent smoking.
Declarations of interest
None.
Acknowledgements
We acknowledge funding by the Stanley Medical
Research Institute. The funding source had no involve-
ment in study design, in the collection, analysis, and
interpretation of data, in the writing of the report and in
the decision to submit the article for publication.
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