The Relationship Between Stress, Smoking, Anxiety and

Depression
Cody Judge, Kaylee Loomis, Erin Silversmith
Dept. of Kinesiology, California State University, San Marcos, CA 92096

Abstract
Background: Smoking and stress are major
contributors to chronic disease and premature
death in America. Individuals with elevated stress
levels are more likely to smoke, and smokers have
higher perceived stress levels during periods of
smoking
cessation,
revealing
a
complex
relationship between these two factors. Purpose:
The purpose of this review is to examine the
association between stress, smoking, anxiety and
depression. Methodology: Literature searches
were conducted using three databases and
keywords: stress, nicotine, addiction, tobacco,
smoking, and anxiety. Results: Regular smokers
report that they smoke to relieve stress, however,
research reveals that it is more likely that they
smoke to relieve the symptoms of nicotine
withdrawal. Individuals with preexisting anxiety,
depression, or PTSD are more likely to smoke and
to relapse after a period of smoking cessation.
Conclusion: Stress relief may serve as motivation
to initiate smoking, but relieving withdrawal
symptoms is arguably the reason individuals
continue to smoke.
Introduction
Word Count: 150
Tobacco use is the single most preventable
cause of death in the United States (Center for
Disease Control and Prevention, 2013).
According to a national survey, people with a
diagnosed psychiatric disorder are twice as likely
to smoke as those without a psychiatric disorder
(National Institutes of Health, 2009).
The psychiatric disorders that this review of
literature discusses are anxiety, depression, and
post traumatic stress (PTSD).
Anxiety Disorder- an excessive amount of fear
or worry about a situation, event, or
circumstance (NIH 2009).
Depression- a mood disorder that is
characterized by feelings of sadness or
hopelessness. Depression can range from mild
to extreme cases (NIH 2009).
Post-Traumatic Stress Disorder- a mental
health disorder that is triggered by a stressful or
traumatic event. People are diagnosed with
PTSD if symptoms of elevated anxiety,
insomnia, or heightened perceived stress levels
last for months or years after the event (NIH,
2009).

A bidirectional relationship exists between

smoking and stress. This relationship is easily
observed in psychiatric disorders. A greater
exposure to stress increases the risk of smoking,
and chronic smoking increases a person's
perceived level of stress.
The purpose of this review of literature is to
examine the association between smoking, stress,
and psychiatric disorders, including anxiety,
depression and post-traumatic stress disorder
(PTSD).

Methods
Literature searches were conducted using
psychINFO, PubMed and Google Scholar.
Keywords: stress, nicotine, addiction, smoking,
tobacco, anxiety, and withdrawal.
Inclusion Criteria consisted of studies with human
subjects and peer-reviewed research.
Studies were excluded if they had animal subjects,
or if they were published before the year 1982.
14 total studies including both empirical research
and reviews of literature were selected and
included in our review.
Statistical and background information was
retrieved from research articles published on the
Centers for the Disease Control (CDC) and the
National Institutes of Health (NIH) websites.

Results

Factors associated with smoking that cause stress

An opposing viewpoint in the literature argues that rather than
stress being a causative factor for smoking, it is the elevated
perceived stress and anxiety that coincides with smoking
cessation and nicotine withdrawal that compels a smoker to
continue to smoke.
The negative symptoms associated with nicotine withdrawal
include depressed mood, anxiety, irritability and attention
deficits.
The acute withdrawal symptoms that occur during abstinence
from smoking make it difficult for smokers to quite and can
cause a higher risk of relapse than if these symptoms were
managed.

Empirical research by Silverstein (1982) determined

that smokers were no more relaxed than nonsmokers
during a stressful situation. Also, smokers with low-dose
ciagarettes were no calmer than smokers who werent
allowed to smoke, revealing that the act of smoking
without nicotine provides no relief of anxiety.
Association between stress, smoking, anxiety and
depression
21% of the U.S. population smoke (Morisette et al,
2007)
Habitual smoking increases the likelihood of
developing severe withdrawal symptoms (Morisette et
al, 2007)
An increase in smoking leads to an increase in state
anxiety (Morisette et al, 2007)
Combat exposure has a greater prevalence of smoking
(56%) compared to a low amount of combat exposure
(39%) (Morisette et al, 2007)

Stress as a cause for Smoking

Many smokers report beginning to smoke to relieve
stress. The positive reinforcement that comes from
smoking causes them to continue to smoke in order to
cope with everyday stress (Bruijnzeel, 2012).
Smokers experience improved attention span and
memory, mild euphoria, and temporary relaxation when
they smoke (Bruijnzeel, 2012).
A wide variety of stressors have been shown to
increase the number of smokers out of the total number
of subjects exposed to the stressor, as well as increase
their consumption of cigarettes. For instance, exposure
to loud noises can cause people to smoke. An increase
of individuals that smoke has been consistently seen
following traumatic and catastrophic events in history
including natural disasters such as Hurricane Katrina
and the Terrorist Attacks on 9/11.

Discussion and Conclusions

Exposure to stress contributes to smoking onset.
Smokers report beginning to smoke in order to cope
with stress.
Smoking, and the symptoms associated with
nicotine withdrawal, contribute to the maintenance
phase of smoking and increase the likelihood of
relapse after a period of smoking cessation.
Further research could include observing perceived
stress levels in individuals who are attempting to quit
in order to further test the hypothesis that nicotine
withdrawal symptoms induce elevated perceived
stress levels.

These findings imply that teaching individuals

better coping mechanisms for stress can
prevent onset of smoking. Future research can
be done to test effectiveness of various
teaching strategies to equip smokers and
nonsmokers alike with healthy coping
mechanisms that can assist with quitting and
prevent onset of smoking in nonsmokers.
Using alternative nicotine products can aid in
smoking cessation and reduce the risk of
relapse. This is because the act of smoking
doesnt provide relaxation beyond what a
nonsmoker would experience, but rather it
relieves the symptoms of nicotine withdrawal.
If the withdrawal symptoms are removed
through the use of a nicotine patch or gum,
then the habit of smoking can more easily be
broken.

References
1. Bruijnzeel, A. W. (2012). Tobacco addiction and the
dysregulation of brain stress systems. Neuroscience And
Biobehavioral Reviews, 36(5), 1418-1441. doi: 10.1016/j.
neu biorev.2012.02.015
2. Center for Disease Control and Prevention(CDC). Current
Cigarette Smoking Among Adults in the United States.
(2015, January 23). Retrieved April 27, 2015, from http:
//www.cdc.gov/tobacco/data_statistics/fact_sheets/
adult_data/cig_smoking
3. Morissette, S., Gulliver, S., Kamholz, B., Tull, M., Zimering, R.
Anxiety, Anxiety Disorders, Tobacco Use, and Nicotine:
A Critical Review of Interrelationships. Psychological
Bulletin. 2007. 133(2), 245-272.
4. National Institutes of Health (NIH). Expert Panel Addresses
High Rates of Smoking in People with Psychiatric
Disorders. (2009, February 18). Retrieved April 27, 2015,
from http://www.nihm.nih.gov/news/science-news/2009/
expert-panel-addresses-high-rates-of-smoking-in-peoplewith-psychiatric-disorders.shtml
5. Silverstein, B., 1982. Cigarette Smoking, Nicotine Addiction,
and Relaxation. Journal of Personality and Social
Psychology. Volume 42:5, 946-950.

For Further Information

Please contact Devan R. Romero, Dr.PH.
Assistant Professor, Department of Kinesiology
California State University, San Marcos
(760) 750-8259 (phone)
(760) 750-3190 (fax)
dromero@csusm.edu