Smoking, Depression and Anxiety: A Complex Relationship - Literature review Example

Your full and number Smoking, Depression and Anxiety: A Complex Relationship People often say they smoke to relieve feelings of depression or anxiety. Others are fearful of quitting because they believe these symptoms would overwhelm their lives if they do not smoke to alleviate them. Is there something to the fact that smoking does relieve, at least temporarily, these symptoms, or does it actually exacerbate them? Studies provide some interesting answers or at least varied scientific perspectives on these issues. Depression Any discussion of smoking must, because of the various studies and their results, begin with certain recognitions that include both noncausal and causal relationships. In short, we must look at the whole picture. Some smokers, both adults and adolescents, are simply pre-disposed to smoking due to such factors as those which may prompt the individual toward both smoking and living in a depressed state. The smoker may then smoke because he or she has low self-esteem and because they are conditionally depressed. Causal theories, in contrast, suggest a direct link between depression and smoking. (Vogel et al 57). Within both theories their may also be suggested a biological link as in children who smoke because their parents smoke, or who are patterning their parents. “While genetics may contribute to this link, modeling most likely plays a large part in the connection between parental and adolescent smoking” (Vogel 57). A stronger biological link may be seen in the suggestion that mothers may actually pass on depressive tendencies to their children along with concomitant tendencies to smoke. “...maternal depression and anxiety are associated with greater risk of child behavior problems” (Meadows et al 1162). Is nicotine then, as an addictive drug, passed biologically to the fetus? Many say yes. Then there is the even more interesting notion that nicotine absorbed in the act of smoking may actually be a means of self-medicating to alleviate feelings of sadness and depression. Quoting Balfour and Ridley (2000), Vogel writes: ...depression [may] sensitizes people to stress and that drugs such as nicotine, which stimulates dopamine release in the forebrain, can relieve stress. They also suggest that chronic exposure to tobacco smoke may elicit serotonin-related changes in the brain that cause increased depression when smoking ceases. In short, the relationship between smoking and depression is complex, and most likely involves both causal and noncausal explanations. (Vogel et al 57) This position is a good place to start. Most research studies, while revealing interesting facts about the relationship between smoking and depression and anxiety, come to less than solid conclusions. It is often a “what came first.” Those charged with attempting to discover the answer often find themselves in a position of guessing or assuming certain aspects of the results. This is not to say individuals should disregard any valid connections made, since many links are strongly suggested by more than one study. Looking at a sampling of studies, and discussions of certain findings, an interesting basis for further research is suggested. In a study conducted at University of Mississippi researchers found that chemicals inhaled in cigarette smoke may actually act pharmacologically in the brain just like antidepressants. (Rosher 20) The study, it appears statistically, suggests that smoking itself is more prevalent among a population of smokers than in the general population—an indicator that must inform other studies on smoking and depression. It is not known what specific elements of tobacco smoke cause an alleviation of depression but suggest that nicotine does not act as an MAO inhibitor [an element which acts as an anti-depressant]. Another five-year longitudinal study of 1007 adults suggests strong links between major depression and smoking and examines the role of depression in smoking progression and cessation, and, perhaps more importantly, the role of smoking in first-onset major depression. The History of daily smoking at baseline showed a significantly increased risk for major depression (OR, 1.9; 95% confidence interval, 1.1-3.4). These estimates were reduced somewhat when history of early (i.e., before age 15 years) conduct problems was controlled. Estimates based on lifetime data were consistent with these researchers overall conclusion was the influences “The observed influences from major depression to subsequent daily smoking and smoking to major depression support the plausibility of shared etiologies” (Breslau et al 161-166). Teen Smoking and Depression Teenage depressions and anxiety related to smoking has been widely studied, with smoking trends often related to social acceptance or other factors. One Australian and two American surveys demonstrated an association between symptoms of depression and anxiety. In four teenage groups facts were uncovered which confirm these symptoms in double the amount of teenagers with mental disorders relating to depression and anxiety. As might be expected, attempts to convince these groups that smoking can ruin your health later on had little effect. The soothing action of smoking was obviously seen by the groups with signs of depression and anxiety to be a more attractive. (Patton et al 228-229) In addition, when you are young one rarely thinks of the future and one’s own mortality. Fitting in with the peer group would certainly present as a priority over whether or not one may develop lung cancer or another malady later on in life. In all of this discussion not many researchers would discount what social learning theorists have proposed: that the development of the smoking habit may be strongly influenced by peers. (Patton et al 230). Yet it is still true that a young person with a high level of depressive symptoms and the associated lack of self esteem would likely be more vulnerable to peer group pressure. Anxiety studied as an integral factor in smoking presents some unique discussion points in that the issue itself is not always easily defined. It might be well to define clinical anxiety since the study differentiates between two perceptions of anxiety. The first, anxiety disorder is defined by Mosley Medical Dictionary, Eighth Edition, 2006 as exhibiting symptoms ranging from mild, chronic tenseness, with feelings of timidity, fatigue, apprehension, and indecisiveness, to more intense states of restlessness and irritability that may lead to aggressive acts, persistent helplessness, or withdrawal [from ordinary daily actions and experiences] with physical signs ranging from tremor to hypertension and dangerously increased breathing rates. Morrell and Cohen (284) caution that while a number of studies implicate anxiety as a factor in nicotine withdrawal, most do “not operationally define the construct to distinguish between clinical anxiety and anxious mood” (284). The implications of this failure are obvious, since anxiety as a severe mental disorder often requiring years of therapy and a simply anxious mood that may result from quitting smoking are quite different matters. Morrell and Cohen point out that “... many of the smoking studies that include anxiety as a variable assess what can be more correctly termed ‘anxious mood’” (284). Morrell and Cohen found several comorbidity studies in adolescents showed a weak or non-existent relationship between smokers and anxiety disorders. In 1500 adolescents studied “there was not a high incidence of any specific anxiety disorder” (284). In fact, across the board of subjects it was concluded that smokers in general did not exhibit a higher rate of anxiety disorder than non-smokers. Different more conclusive results, however, were found when a study of adults psychiatric outpatients, 47% of which with severe anxiety order also smoked—a much higher than the control group population.(Morrell and Cohen 284) Smoking and Anxiety The connection between smoking and anxiety relief has also been tested in stressful social interactions. Granted, the difference between a bit of anxiety in social situations differs greatly from severe paralyzing social anxiety. Nevertheless, the finds are significant, especially for those who suffer from a bit of discomfort in social situations—most smokers. Given a controversial topic to discuss in public, studies of smokers found results demonstrated that, “in spite of physiological arousal (e.g. heart rate), participants reported less anxiety when allowed to smoke” (Morrell and Cohen 287). Even on a mild level, this certainly indicates a degree of relationship between smoking and the alleviating of social fears and phobias. As for depression, Morrell and Cohen come to different conclusions they say makes it easier to equate smoking with depression than with anxiety. Evidence regarding the comorbidity between smoking and Major Depressive Disorder (MDD) is generally stronger and more consistent than the evidence regarding the comorbidity between smoking and anxiety throughout the population. In this interesting exception studies found a high thirty percent of young adult smokers with moderate levels of nicotine dependence qualified for a diagnosis of comorbid MDD as compared to 19 percent of mildly dependent smokers and 10 percent of non-dependent smokers. A recent German found a conclusive correlation between daily smoking and depressive mood disorders. (Morrell and Cohen 289). Quitting An Israeli study is quite unequivocal about the relationship between depression, smoking and quitting, but less so about what it first sees as the helpful benefits of nicotine in alleviating depression in alcoholics. Yet the findings are interesting and deserve consideration. “Smokers with comorbid depressive disorders (DD) are more prone to become dependent on nicotine, to progress to a more severe level of dependence, and to experience more severe nicotine withdrawal symptoms than smokers without DD” ( Saatcioglu et al 33). As one would commonly accept the notion of “withdrawal” as unpleasant, we must assume a great degree of physical and psychological discomfort. The researchers in the study go on to state that depression has a negative effect on the outcome of quitting because smoking for people who are depressed may act as a palliative and make them feel better. Related to alcohol treatment, it suggests that smoking might be used, much as methadone is used for drug addicts, to help in the treatment of alcoholism. Since as the study maintains, “90% of people with alcohol dependence are also nicotine dependent” (Saatcioglu et al 33), they are suggesting using nicotine as a means of alleviating depression which in turn helps forward a cure for the alcoholic. The conclusion of the study, however, flies in the face of the above evidence and the researchers are forced to admit their hypothesis that alcoholics with nicotine dependency would be less depressed does not bear out and that the “finding also contradicts the results of most previous studies” (Saatcioglu et al 33). However, given the depression and anxiety “scores” of the sample “...it might be considered that smoking, whether at a level considered nicotine dependence or not, might have an [positive] effect upon depression and anxiety” (Saatcioglu et al 33) which might help the alcoholic to recover. Studies by the National Cancer Institute state quite clearly that most quitters report feelings of increased anxiety within a week of quitting but that the anxiety usually disappears within a month. (NCI Fact Sheet #1). A similar fact sheet from NCI concerning depression states the obvious rather simply: that it is normal to feel sad for a period of time after quitting because many people have a strong urge to smoke when they feel depressed. (NCI Fact Sheet #2) Countering the NCI rather general suggestion, Gregory Ordway, Ph.D., professor of psychiatry and human behavior found, “People who have depression have a very difficult time quitting smoking... And those people who have recovered from major depression and then stop smoking have a greater likelihood of having their depressive symptoms recur when they stop smoking...”(Rosack 20). NCI admits certain studies find that people with major anxiety and depression issues will have major episodes after quitting; they further admit, though in a rather second hand fashion, that even people with no history of anxiety and depression can have episodes after quitting, although “major depression after quitting is rare” (NCI Fact Sheet #2). These somewhat simplistic and contrary statements, however, hardly scratch the surface of the implications of quitting both for people with and without severe anxiety and depression issues. The conclusion of researchers conducting a University of Mississippi study on smoking and depression suggests the complexities involved in simply saying that stopping smoking is a rather easy matter. While cautioning that the findings in the study in no way justify encouraging depressive people to smoke, it does recommend a careful consideration and caution about people with a history of depression quitting smoking. “There is enough evidence that people with depressive symptoms—not just major depression—should strongly be considered for antidepressant therapy to help them stop smoking...” (Rosack quoting Ordway 20). Conclusion Figures from the World Health Organisation (WHO) show that 30 percent of inhabitants in the western world smoke daily. Earlier studies have found that people with mental health problems are twice as likely to smoke as the rest of the population. Anxiety and depression are the most common complaints among these people and both are often present in people who smoke. Arnstein Mykletun, author of the study, puts its relationship to depression and anxiety in the clearest perspective so far. “The strongest correlation with smoking when the subject is both anxious and depressed, next strongest with anxiety without depression and with a marginal correlation between smoking and depression without anxiety. There was no reduction in anxiety and depression over time after smoking was given up” (Medical News 2008). While the study clearly indicated that smoking is linked to anxiety and depression, it also found that people who are depressed but not anxious smoke the same as any other smokers—an interesting caveat that undoubtedly counters or at least questions other studies which securely link the two. Research findings have not revealed conclusively whether common factors influence the development of anxiety, depression, and smoking, whether anxiety and depression lead to smoking, or whether the reverse is true. Nevertheless, a current understanding of the links between smoking, anxiety, and depression supports and aids current prevention and cessation techniques, as well as suggesting new directions for further research and clinical practice. In researching studies and other information published by reliable sources, it is clear that both depression and anxiety may be contributing factors in the smoking addiction, but not always and not necessarily. That they should be factored into and considered in any treatment attempted along with others is obvious. However, care should be taken when dealing with smokers, especially those seeking to quit for whom one or both anxiety and, or depression may be a causal or otherwise related condition. Works Cited Breslau, Naomi et al. “Major Depression and Stages of Smoking: A Longitudinal Investigation.” Arch Gen Psychiatry Vol. 55 (1998):161-166. Retrieved May 25, 2010 from: http://archpsyc.ama-assn.org/cgi/content/abstract/55/2/161 Meadows, Sarah. O., McLanahan, Sara S., Brooks-Gunn, Jeanne. “Parental Depression and Anxiety and Early Childhood Behavior Problems across Family Types.” Journal of Marriage and Family Vol 69 5 (2007) 1162+ Medical News (Web Site). “Smoking Associated with Depression and Anxiety.” (25 February, 2008). Retrieved May 26 from: http://www.medicalnewstoday.com/articles/98344.php Morrell, Holly E.R. and Cohen, E. M. “Cigarette Smoking, Anxiety and Depression.” Journal of Psychopathology and Behavioral Assessment, Vol. 28: 4 (December 2006). Retrieved May 25, 2010 from: http://www.depts.ttu.edu/cohenlab/pubs/2006%20Morrell%20&%20Cohen.pdf National Cancer Institute (NCI). “Fact Sheet.” November 8, 2004. #1: http://www.cancer.gov/cancertopics/factsheet/Tobacco/anxiety #2: http://www.cancer.gov/cancertopics/factsheet/Tobacco/depression Patton, George C. et al. “Is Smoking Associated with Depression and Anxiety in Teenagers.” American Journal of Public Health Vol. 86 2 (1996): 225-230. Rosack, Jim. “Researchers Explore Link Between Smoking and Depression” Psychiatric News Vol. 36 23 (December 7, 2001): 20. Retrieved May 25. 2-10 from: http://pn.psychiatryonline.org/content/36/23/20.full Saatcioglu, Omer, Celikel, Feryal Cam, Cakmak, Duran.“Depression and Anxiety in Alcohol Dependent Inpatients Who Smoke.” The Israel Journal of Psychiatry and Related Sciences. Vo; 45 1 (2008): 33+ Vogel, Julie S., Hurford, David P., Smith, Janet V. and Cole, Amyday. “The Relationship between Depression and Smoking in Adolescents.” Adolescence. Vol 38 149 (2003): 57+ Read More