Despite decades of public health efforts, tobacco use remains a persistent public health issue, especially for individuals experiencing depression and anxiety. These two common mental health conditions are closely linked to tobacco use, both in terms of higher smoking prevalence and the emotional mechanisms that sustain nicotine dependence. Understanding this relationship is essential for effective prevention, treatment, and recovery strategies.
While smoking rates have declined across the general population, they remain disproportionately high among individuals with depression and anxiety. Research shows that people with these conditions account for nearly 40% of all cigarettes consumed in the U.S., despite representing a much smaller share of the population.¹ Population-based studies, including a major Norwegian survey, have found that individuals with symptoms of anxiety and depression are significantly more likely to be current smokers compared to those without these symptoms.²
This association is particularly concerning because individuals with depression or anxiety often smoke more heavily and are more likely to become nicotine dependent.³ Additionally, the co-occurrence of both conditions has been found to strengthen the association with tobacco use, suggesting a compounding effect.² The relationship between tobacco use and emotional distress is commonly explained by the self-medication hypothesis. According to this model, individuals with anxiety or depression may start or continue smoking to alleviate symptoms like sadness, tension, or irritability.⁴ Nicotine can provide short-term relief by temporarily boosting neurotransmitters such as dopamine and serotonin, which influence mood and reward.⁵
However, this relief is typically fleeting and may represent the alleviation of nicotine withdrawal rather than an improvement in underlying mental health. As nicotine levels drop, symptoms such as restlessness, low mood, and anxiety re-emerge, reinforcing the cycle of dependence.⁶ Beyond psychological explanations, nicotine’s interaction with the hypothalamic–pituitary–adrenal (HPA) axis, which regulates the stress response, provides a biological basis for its effects on mood. Chronic nicotine use dysregulates this system, increasing stress sensitivity and emotional instability over time.⁷
Additionally, Mendelian randomization studies have found causal evidence that smoking increases the risk of developing depression and even schizophrenia, rather than simply being a consequence of them.⁸ This supports the view that smoking may not only sustain but also exacerbate or even initiate mood disorders in vulnerable individuals.
Contrary to the belief that quitting smoking could worsen mental health, evidence shows the opposite. A major meta-analysis of 26 studies found that individuals who quit smoking experienced significant reductions in depression, anxiety, and stress, along with improved overall mood and quality of life.⁹ These benefits applied to people with and without diagnosed mental illness. More recent longitudinal research, including a 2023 population-based study, reinforced these findings, showing sustained mental health improvements after quitting—especially among people with a history of psychiatric symptoms.¹⁰
While many people with anxiety or depression want to quit smoking—and do so for the same reasons as the general population—they may face unique challenges. These include more severe nicotine withdrawal symptoms, increased emotional sensitivity, and heightened stress reactivity.¹¹ ¹² These barriers can increase the likelihood of relapse and require targeted support during cessation efforts. Integrated treatment approaches that combine pharmacological aids (such as nicotine replacement therapy, varenicline, or bupropion) with cognitive-behavioral therapy (CBT) have been shown to be particularly effective for individuals with co-occurring mood symptoms.¹³
Furthermore, systematic screening for anxiety and depression in tobacco cessation settings can identify individuals who may benefit from additional psychological support. Studies show that many smokers seeking help with quitting have undiagnosed or untreated mood disorders.¹⁴ Public education must challenge the enduring myth that smoking helps reduce stress or improve mood. These beliefs, often reinforced by tobacco industry messaging, undermine cessation efforts. Instead, communication should emphasize that quitting smoking improves—not worsens—mental health.
Clinically, cessation support should be framed not just as a step toward physical wellness, but also as a powerful tool for improving emotional well-being. In fact, quitting smoking may be one of the most effective lifestyle changes for enhancing mental health among individuals with depression and anxiety.
The connection between tobacco use and depression/anxiety is not only real—it is profound. While individuals may smoke to cope with emotional distress, long-term tobacco use often worsens symptoms and undermines recovery. Fortunately, quitting smoking consistently leads to improvements in mood, anxiety levels, and quality of life. Supporting cessation in people with depression and anxiety is both a public health priority and a compassionate response to emotional suffering.
Systemic, evidence-based screening and treatment of tobacco dependence is integral to improving patient health outcomes. These standards are in alignment with the US Public Health Service’s Clinical Practice Guideline – Treating Tobacco Use and Dependence: 2008 update, which includes best practice systems strategies for organizations to use with their clientele. Systems Strategy One ensures that a tobacco-user identification system is present in every clinic. That system should include the evidence-based tobacco dependence treatment prompts of the 5A’s: Ask, Advise, Assess, Assist and Arrange. Systems Strategy Two ensures that education, resources, and feedback are present to promote provider intervention. The final Systems Strategy is to identify dedicated staff at a given provider’s location to dispense tobacco dependence treatment and assess the delivery of this treatment with other staff members in the office.
For more information on how to best address tobacco use, visit the Center for Disease Control website to identify your state’s tobacco control program contacts.
Kristen Richardson, RN, CTTS, is Director and Danielle O’Brien, MS, CTTS, is Program Coordinator of the Central New York Regional Center for Tobacco Health Systems at St. Joseph’s Health in Syracuse, NY. The program is funded through a grant from the New York State Department of Health Tobacco Control Program. More information can be found at www.nyhealthsystems.org. Kristen Richardson or Danielle O’Brien can be reached directly at Kristen.Richardson@sjhsyr.org and Danielle.L.Obrien@sjhsyr.org.
Footnotes
- Benowitz, N. L. (2010). Nicotine addiction. New England Journal of Medicine, 362(24), 2295–2303.
- Benson, T. A., Thomas, E., & Gillespie, N. A. (2023). Smoking cessation and changes in mental health: A longitudinal population-based study. JAMA Network Open, 6(2), e2251467.
- Cook, B. L., Wayne, G. F., Kafali, E. N., et al. (2006). Trends in smoking among adults with mental illness and association with federal parity law. JAMA, 311(2), 172–182.
- Fiore, M. C., Jaén, C. R., Baker, T. B., et al. (2008). Treating tobacco use and dependence: 2008 update. U.S. DHHS.
- Hughes, J. R. (2007). Effects of abstinence from tobacco: Valid symptoms and time course. Nicotine & Tobacco Research, 9(3), 315–327.
- Lasser, K., Boyd, J. W., Woolhandler, S., et al. (2000). Smoking and mental illness: A population-based prevalence study. JAMA, 284(20), 2606–2610.
- Matta, S. G., et al. (2007). Guidelines on nicotine dose selection for in vivo research. Psychopharmacology, 190(3), 269–319.
- Mykletun, A., Overland, S., Aarø, L. E., et al. (2008). Smoking in relation to anxiety and depression: Evidence from a large population survey. European Psychiatry, 23(2), 77–84.
- Parrott, A. C. (1999). Does cigarette smoking cause stress? American Psychologist, 54(10), 817–820.
- Prochaska, J. J., et al. (2006). Return to smoking after psychiatric hospitalization. American Journal on Addictions, 15(1), 15–22.
- Schroeder, S. A., & Morris, C. D. (2010). Confronting a neglected epidemic. Annual Review of Public Health, 31, 297–314.
- Taylor, G., McNeill, A., Girling, A., et al. (2014). Change in mental health after smoking cessation: Systematic review and meta-analysis. BMJ, 348, g1151.
- Wootton, R. E., Richmond, R. C., Stuijfzand, B. G., et al. (2019). Evidence for causal effects of lifetime smoking on risk for depression and schizophrenia. Psychological Medicine, 50(14), 2435–2443.
- Zvolensky, M. J., Schmidt, N. B., & McCreary, B. T. (2003). Smoking and panic disorder. Journal of Anxiety Disorders, 17(4), 447–460.69
