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1. Glassman AH, Helzer JE, Covey LS et al, Smoking, smoking cessation and
major depression. JAMA, 264: 1546-1549, 1990.

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 Smoking, Smoking Cessation,
and Major Depression
Alexander H. Glassman, MD; John E. Helzer, MD; Lirio S. Covey, PhD; Linda B. Cottler, PhD;
Fay Stetner, MS, MPA; Jayson E. Tipp, MA; Jim Johnson, PhD

A relationship between cigarette smoking and major depressive disorder was years later. More specifically, Hughes
suggested in previous work involving nonrandomly selected samples. We con- et al9 showed that patients with a cur¬
ducted a test of this association, employing population-based data (n 3213) = rent major depression were more likely
collected between 1980 and 1983 in the St Louis Epidemiologic Catchment Area to smoke than the general population.
Several years ago, during a clinical
Survey of the National Institute of Mental Health. A history of regular smoking trial to examine the usefulness of cloni-
was observed more frequently among individuals who had experienced major dine in smoking cessation, we reported
depressive disorder at some time in their lives than among individuals who had observations regarding the relationship
never experienced major depression or among individuals with no psychiatric between major depression and smok¬
diagnosis. Smokers with major depression were also less successful at their ing.10 Although all subjects were euthy-
attempts to quit than were either of the comparison groups. Gender differences in mic at the time of the study, an unusual¬
rates of smoking and of smoking cessation observed in the larger population ly high proportion (61%) had a history of
were not evident among the depressed group. Furthermore, the association major depression. Furthermore, such a
between cigarette smoking and major depression was not ubiquitous across all history was found to have a strong nega¬
tive influence on the ability to stop
psychiatric diagnoses. Other data are cited indicating that when individuals with
a history of depression stop smoking, depressive symptoms and, in some cases, smoking. Because these observations
were post hoc, we searched for another
serious major depression may ensue. data set that would allow us to test this
(JAMA. 1990;264:1546-1549) apparent relationship between major
depression and smoking status.
Between 1980 and 1983, the National
THE DIAGNOSIS of major depres¬ ti ve affect, a very broad term referring Institute of Mental Health conducted a
sion, in contrast to the more common tension, and anger as well as
to anxiety, population-based survey in five differ¬
depressed mood, is characterized by the depressed mood, or with depressive ent regional centers to establish the
persistence of the mood disturbance symptoms. Waal-Manning and de Ha- community prevalence of the more fre¬
(day after day), often lasting months, meF showed that smokers rated higher quent and serious psychiatric illnesses.
along with a series of associated symp¬ on symptomatic measures of both anxi¬ That study, known as the Epidemiolog¬
toms.1 Although there is some evidence ety and depression than did nonsmok- ie Catchment Area (ECA) Program,
for a relationship between major de¬ ers.° Pomerleau et alB demonstrated was originally planned to assess smok¬
pression and drug abuse,2"4 this relation¬ ing behavior as well as psychiatric ill¬
ship has generally not extended to nico¬ See also pp 1541 and 1583.
ness.11 However, all centers except St
tine dependence. A number of authors Louis, Mo, and Durham, NC, opted to
have linked smoking either with nega- delete the smoking questions. We test¬
that smokers who identified negative ed the association between a lifetime
From the New York State Psychiatric Institute and the
Department of Psychiatry, College of Physicians and
affect as a reason for smoking were diagnosis of major depression and both
Surgeons, Columbia University, New York, NY (Drs more likely to fail in their attempts to the frequency of cigarette smoking and
Glassman, Covey, and Johnson and Ms Stetner); the
Department of Psychiatry, University of Vermont, Bur-
quit, and Shiffman' found that negative failure during smoking cessation ef¬
lington (Dr Helzer); and the Department of Psychiatry,
affect is the most common antecedent of forts, using the St Louis data set.
Washington University, St Louis, Mo (Dr Cottler and Mr a smoking relapse. Kandel and Davies8
METHODS
Tipp).
Reprint requests to New York State Psychiatric Insti-
reported that depressive symptoms
tute, 722 W 168th St, New York, NY 10032 (Dr among 15- to 16-year-old children were The ECA Program is a collaborative
Glassman). associated with their smoking status 9 study of the prevalence and incidence of

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 Table 1 —Rates of Smoking Behaviors by Psychiatric Diagnosis In the St Louis ECA* (1980-1983) questions about the various depressive
TotalSample symptoms specified in DSM-III. The di¬
Major Depressive No Psychiatric Excluding Major agnosis of major depression is based on
Disorder Diagnosis Depressive Disorder an assessment of whether a sufficient
Ever smoked, number of depressive symptoms co-oc¬
%(No.)t 74 (144) 53 (1249) 57 (1729)
Cessation rate, curred to meet the DSM-III criteria and
%(No.)t 14 (20) 31 (382) 28 (483) whether they persisted for the required
minimum of 2 weeks.' All diagnoses are
*ECA indicates Epidemiologie Catchment Area. nonhierarchical; that is, any DSM-III
tFor major depressive disorder vs no psychiatric diagnosis, x! 29.52, P<001 ; for major depressive disorder vs
=

total sample excluding major depressive disorder, x2 19.98, P< .001. exclusion rules based on the presence of
tFor major depressive disorder vs no psychiatric diagnosis, x? 16.73, P< .001 ; for major depressive disorder vs
=
other diagnoses were ignored. Those
total sample excluding major depressive disorder, x' 12.65, P< .001.
=

meeting the criteria for a particular di¬

Table2—Comparison of Smoking Behavior Rates by Sex and Psychiatric Diagnosis in the St Louis ECA*
(1980-1983)
Ever smokers, % (No.)
No psychiatric diagnosis
Total sample excluding major
depressive disorder
Major depressive disorder
Cessation rate, % (No.)
No psychiatric diagnosis
Total sample excluding major
depressive disorder
Major depressive disorder
*ECA indicates Epidemiologie Catchment Area.
tNS indicates not significant.
psychiatrie disorders and the associated
use of health services.12 The interview
instrument used for this study was the
Diagnostic Interview Schedule,'3 an in¬
strument designed to enable nonclini-
cian examiners to gather the personal
information necessary to assess the cur¬
rent and lifetime occurrence of major
psychiatric disorders, including major
depression, as defined by the Diagnos¬
tic and Statistical Manual of Mental
Disorders, Third Edition.1
Sample Selection
The sampling frames for the ECA
Program were federally defined mental
health catchment areas, of which there
are 1400 in the United States as a whole.
In St Louis, three catchment areas were
selected that together had a demo¬
graphic composition that approximated
both the demographic structure of the
entire St Louis metropolitan area and
the demographic structure of the Unit¬
ed States as a whole. The catchment
areas were selected to provide repre¬
sentation from inner-city areas, subur¬
ban areas, and semirural areas on the
distant outskirts. Sampling was accom¬
plished by randomly selecting
tracts, blocks within census tracts, and
households within blocks. Once a house¬
hold had been selected, an interviewer
personally contacted someone living
within the household and enumerated
all the household members by age. A
single respondent aged 18 years or over
Male Female
64(617) 46(632)
68 (889) 49 (840)
80 (40) 72 (104)
36 (222) 25 (160)
31 (275) 25 (208)
13 (5) 14 (15)
was then selected
according to a Kish
grid.14 Eighty percent of the identified
respondents were successfully inter¬
viewed, and a poststratification adjust¬
ment was made to correct for nonre-
sponse.12 Blacks were purposely over-
sampled but weighted back to their true
proportion in the total population. The
3213 subjects reported on herein repre¬
sent all those from the household and
institutional samples for whom we have
complete smoking and depression his¬
tories.
The Interview
The Diagnostic Interview Schedule
begins with a section on demographic
information. The section on cigarette
use is near the start ofthe interview and
begins with a question on whether the
respondent ever smoked cigarettes dai¬
ly for a month or more. Only those who
had smoked for this minimum amount of
time sometime in their lives were asked
the remaining questions on smoking.
All smokers were asked if they had ever
tried to quit. Persons who had smoked
one-half pack per day (ppd) or more
were asked about recent smoking; those
census who had not smoked 0.5 ppd or more in
the last year were considered successful
quitters.
The section on major depressive dis¬
order (MDD) begins with a question
about lifetime occurrence of sad or dys-
phoric mood persisting for 2 weeks or
more and proceeds to a series of lifetime
agnosis may also meet the criteria for
any others.
Analysis of Data
The smoking behaviors of subjects
P who met the criteria for MDD were
compared with the smoking behaviors
<.001 of (1) subjects who did not meet the
<.001 criteria for any psychiatric diagnosis
NSt and (2) the total sample, excluding sub¬
<.001 jects with MDD. For each of these
groups we calculated the percentage of
<.01 smokers who had smoked cigarettes
NSt
daily for a month or more, based on the
total number of subjects interviewed,
and the percentage of former smokers of
at least 0.5 ppd who had last smoked 0.5
ppd more than 1 year ago, based on the
total number of ever smokers. We used
Yates' corrected x2 analysis to test the
significance of the differences observed.
Odds ratios and 95% confidence limits
for being a smoker were calculated for
major depression and other psychiatric
diagnoses. For all calculations the data
were analyzed with ECA Program
weights that adjust for the selection of
only a single respondent from each
household, regardless of its size, for the
oversampling of blacks, and for nonre-
sponse.12
RESULTS
The average age of the sample was
42.5 (±18) years, the average number
of years of education was 11.7 ( ±2.85)
years, 60.5% were married, and 19.5%
were black. Eighteen percent were be¬
tween 18 and 24 years of age, 40% were
between 25 and 44 years, 27% were be¬
tween 45 and 64 years, and 16% were
over 65 years of age. The lifetime preva¬
lence of major depressive disorder in
the entire sample was 5.1%. Among in¬
dividuals who had never smoked, the
prevalence was 2.9%, while among
those who had ever smoked daily for at
least 1 month it was 6.6%.
In Table 1, we present the propor¬
tions of ever smokers and of those who
no longer smoke 0.5 ppd among persons
with no psychiatric diagnosis, those
with major depression, and the total
sample excluding those with major de¬
pression. The smoking behaviors of sub¬
jects with major depression are clearly

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 different from those of persons with ei¬
ther no depression or no diagnosis
(P<.001). Depressed subjects are more
likely to have ever smoked, and they are
less likely to have been successful in
their efforts to stop smoking (Table 1).
A multiple logistic regression showed
that the relationship between major de¬
pression and smoking was independent
of age, sex, education, marital status,
and race (adjusted odds ratio, 2.9; 95%
confidence limits, 1.7 and 4.9).
Table 2 displays the association be¬
tween gender and smoking behaviors
by diagnostic status. In the sample ex¬
cluding MDD and among subjects with
no psychiatric diagnosis, males are
more likely than females to have ever
smoked and to have been successful in
their attempts to quit smoking. These
gender differences disappear, however,
among the depressed group. The rate of
ever smoking among depressed females
becomes similar to the rate in depressed
males, and male depressed smokers ap¬
pear to have as little success in quitting
as do female depressed smokers.
Table 3 presents evidence regarding
the association between cigarette smok¬
ing and psychiatric diagnoses that are
common among the general population.
The unadjusted odds ratio for smoking
among individuals with MDD is signifi¬
cant (2.38, 95% confidence limits, 1.65
and 3.44). Because MDD can coexist
with other psychiatric diagnoses and
this comorbidity is particularly common
with dysthymia, the relationship be¬
tween smoking and psychiatric diagno¬
sis was examined in cases free of MDD.
When subjects comorbid for major de¬
pression are removed from the sample,
the associations with dysthymia and ag¬
oraphobia that were observable when
MDD was included are no longer signifi¬
cant (Table 3). Once this is done, only
the association between smoking and
alcoholism (abuse and dependence) con¬
tinues to be significant.
COMMENT
The results found in this general pop¬
ulation sample confirm our hypothesis
that major depression influences rates
of cigarette smoking and smoking cessa¬
tion. Hughes et al9 showed that smoking
is more common among depressed pa¬
tients presenting to a psychiatric clinic
than in general population-based sam¬
ples. However, not until the present
study has this relationship been verified
directly from entirely community-based
data. St Louis ECA data indicate that
this association between smoking and
depression exists not just among pa¬
tients presenting to a psychiatrist for
treatment but also among everyone
with a lifetime diagnosis of major de-
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Table 3—Odds Ratios for Ever Smoking by Selected Psychiatric Diagnoses
1983)
Diagnosis
Major depression
Dysthymia_1.63 (1.11-2.40)_1.22 (0.73-2.03)
Simple phobia_1.19 (0.90-1.58)_1.03 (0.76-1.40)
Agoraphobia_1.76 (1.20-2.56)_1.23 (0.80-1.89)
Obsessive-compulsive disorder_1.33 (0.80-2.24)_1.74 (0.87-3.51)
Panic_1.57 (0.86-2.84)_2.13 (0.81-5.65)
Alcoholism
*ECA indicates Epidemiologie Catchment Area.
pression, whether or not they ever
sought treatment. Of additional signifi¬
cance, this association between major
depression and smoking was not ubiqui¬
tous across the other psychiatric diag¬
noses examined. In fact, although
smoking has frequently been linked to
anxiety and tension reduction, the anxi¬
ety-related diagnoses of phobia, pan¬
ic, and obsessive-compulsive disorder
showed no significant association with
smoking when subjects comorbid for de¬
pression were excluded in the analysis.
As might be expected, the rate of smok¬
ing was very high among individuals
with a diagnosis ofalcoholism. Although
this was not tested because of the limit¬
ed number of cases, we suspect that the
highest rates of smoking would be found
among the most severely ill schizo¬
phrenic patients.
Beyond demonstrating the associa¬
tion of smoking with major depression,
the St Louis ECA interview also ob¬
tained information about smoking ces¬
sation. This allowed a test of our prior
post hoc observation that a history of
major depression adversely affects the
outcome o smoking cessation efforts.
In fact, srj >kers without a psychiatric
diagnosis \v ire more successful in such
efforts than smokers with a lifetime di¬
agnosis of major depression (31% vs
14%, P<.001, Table 1). As also seen in
national survey data,15 males are gener¬
ally more successful in cessation efforts
than females (31% vs 25%, P<.001, Ta¬
ble 2). However, among smokers with a
lifetime diagnosis of major depression,
being male conveyed no such advantage
(13% vs 14%, not significant).
One of the limitations of this data set
is that there is no absolute measure of
quitting. The cessation rate is based on
the number of subjects who had ever
smoked but had not smoked 0.5 ppd for
more than 1 year. Thus, we are only able
to say with precision that the ability to
stop or to smoke less than 10 cigarettes
per day for more than 1 year is markedly
diminished among smokers with a life-
in the St Louis ECA* (1980-
Odds Ratio (95% Confidence Interval)
Subjects With Subjects With
Major Depressive Major Depressive
Disorder Included Disorder Excluded
2.38(1.65-3.44)
4.68 (3.65-6.01) 5.23 (4.05-6.76)
time diagnosis of major depression. For
this reason, we did not compare the ces¬
sation rate among psychiatric diag¬
noses. The original observation that a
diagnosis of major depression had an
adverse effect on total smoking cessa¬
tion was based on complete cessation
confirmed by blood cotinine analysis.10
These data support that earlier obser¬
vation. In fact, among heavy smokers,
the ability to cut down to a few ciga¬
rettes per day and to maintain that lim¬
ited smoking behavior for any extended
period of time is rare.
Once the adverse impact of a history
of depression on smoking cessation be¬
came apparent, it seemed reasonable to
ask whether these smokers failed to quit
because they developed depressive
symptoms during nicotine withdrawal.
The DSM-III-R lists seven withdrawal
symptoms associated with smoking ces¬
sation, but depressed mood is not one of
them.16 In a recent examination of with¬
drawal symptoms during the first week
following smoking cessation, we ob¬
served that, among smokers without a
history of major depression, symptoms
of depression were, in fact, rather
uncommon and, when they did occur,
were generally mild.17 However, among
smokers with a history of major depres¬
sion, depressed mood during withdraw¬
al was very common and was associated
with failure in smoking cessation ef¬
forts. These observations in turn raised
the question of whether antidepressant
drugs might prevent the development
of these depressive symptoms and mod¬
erate the adverse impact of a history of
depression on smoking cessation. Clini¬
cal data suggest this to be the case,1S and
we are presently undertaking a placebo-
controlled study to test these uncon¬
trolled observations.
Unfortunately, the adverse conse¬
quences associated with a history of ma¬
jor depression in smoking cessation may
not be limited to the high proportion of
smokers who fail to quit. Clinical experi¬
ence suggests that those few depressed
 smokers who do succeed in stopping are
at increased risk to develop another epi¬
sode of major depression.19,20 We have
seen a number of cases in which smokers
with a history of major depression who
are not depressed at the time they try to
quit get seriously depressed shortly af¬
ter giving up cigarettes. It could be ar¬
gued that the occurrence of serious de¬
pression in these cases is merely the
onset of a random depression in smokers
who already have a history of depres¬
sion. We have no appropriate control
group that allows us to rigorously test
that clinical impression. However, on a
number of occasions we have seen seri¬
ous depressions that gradually devel¬
oped following smoking cessation disap¬
pear within hours of resuming cigarette
smoking. In addition, a number of these
patients had experienced depressive
episodes associated with prior smoking
cessation attempts. These observa¬
tions, together with our earlier evi¬
dence that these smokers frequently de¬
velop depressive symptoms when they
try to stop,11 suggest that these are
causally connected events and that nico¬
tine withdrawal can provoke episodes of
major depression.
Certainly, the most common outcome
of cigarette smoking cessation efforts
among smokers with a lifetime history
of depression is failure. Among the lim¬
ited number of such smokers who do
succeed, many develop symptoms of de¬
pression. As with other transient with-
References
1. American Psychiatric Association, Committee
on Nomenclature and Statistics. Diagnostic and
Statistical Manual of Mental Disorders, Third
Edition. Washington, DC: American Psychiatric
Association; 1980.
2. Dilsaver SC. The pathologies of substance abuse
and affective disorders: an integrative model? J
Clin Psychopharmacol. 1987;7:1-10.
3. Bukstein OG, Brent DA, Kaminet Y. Comorbid-
ity of substance abuse and other psychiatric disor-
ders in adolescents. Am J Psychiatry. 1989;146:
1131-1141.
4. Kosten T. The symptomatic and prognostic im-
plications of psychiatric diagnoses in treated sub-
stance abusers. NIDA Res Monogr. 1988;81:416\x=req-\
421.
5. Waal-Manning HJ, de Hamel FA. Smoking hab-
it and psychometric scores: a community study. N
Z Med J. 1978;88:188-191.
6. Pomerleau OF, Adkins D, Pertschuk M. Predic-
tors of outcome and recidivism in smoking cessation
treatment. Addict Behav. 1978;3:65-70.
7. Shiffman S. Relapse following smoking cessa-
tion: a situational analysis. J Clin Psychol.
1982;50:71-86.
8. Kandel DB, Davies M. Adult sequelae of adoles-
DownloadedViewFrom:
publicationhttp://jama.jamanetwork.com/
stats by a Columbia University User on 03/30/2014
drawal manifestations, in most patients
these depressive symptoms will pass in
a few weeks; however, some cases will
evolve into full-blown major depres¬
sion. The relative frequency of these
outcomes is not clear. For some smok¬
ers, it seems that smoking can diminish
the chances of recurring depression,
and, with cessation of smoking, treat¬
ment to mitigate this risk may be
necessary.
The recognition of the relationship
between cigarette smoking and major
depression has a number of implica¬
tions. As social attitudes and public poli¬
cy act to diminish the rate of smoking in
general, both the number of people who
start and those who are unable to stop
will increasingly consist of individuals
who are vulnerable to depression. Giv¬
en that major depression is more com¬
mon in women, the ratio of women to
men who smoke will increase. This is
exactly what has been occurring; among
young smokers, women outnumber
men.15 This could also help to ex¬
plain why men have tended to be more
successful in smoking cessation trials.
The increased frequency of smoking
among individuals with major depres¬
sion might also explain the excess medi¬
cal mortality often attributed to major
depression.21 We have already alluded
to the use of antidepressants to facili¬
tate smoking cessation in smokers with
a history of major depression. Finally,
these data raise the question of how
cent depressive symptoms. Arch Gen Psychiatry.
1986;43:255-262.
9. Hughes JR, Hatsukami DK, Mitchell JE, Dahl-
gren LA. Prevalence of smoking among psychiatric
outpatients. Am J Psychiatry. 1986;143:993-997.
10. Glassman AH, Stetner F, Walsh BT, et al.
Heavy smokers, smoking cessation, and clonidine:
results of a double-blind, randomized trial. JAMA.
1988;259:2863-2866.
11. Regier DA, Myers JK, Kramer M. The NIMH
Epidemiologic Catchment Area Program: histori-
cal context, major objectives, and study population
characteristics. Arch Gen Psychiatry. 1984;41:934\x=req-\
941.
12. Eaton WW, Kessler LG. Epidemiologic Field
Methods in Psychiatry: The NIMH Epidemiologic
Catchment Area Program. Orlando, Fla: Academic
Press Inc; 1985.
13. Robins LN, Helzer JE, Croughan J, Ratcliff
KS. National Institute of Mental Health Diagnostic
Interview Schedule: its history, characteristics and
validity. Arch Gen Psychiatry. 1981;38:381-390.
14. Kish L. Survey Sampling. New York, NY:
John Wiley & Sons Inc; 1965.
15. The Health Consequences of Smoking: Nico-
tine Addiction: A Report of the Surgeon General.
nicotinic cholinergic receptors mediate
this relationship between smoking and
major depression.
What is unique about this St Louis
ECA data set is that it contains simulta¬
neously collected information about
smoking behavior and symptoms neces¬
sary to make a number of psychiatric
diagnoses. It strongly confirms the as¬
sociation between major depression and
both cigarette smoking rates and smok¬
ing cessation rates. It also demon¬
strates that this relationship exists in
the community as well as in treatment
samples and that an association with
smoking is not common to all psychiatric
conditions. Together with the evidence
that depression increases the risk of be¬
coming a smoker5 and our clinical data
that, for smokers with a history of de¬
pression, successful smoking cessation
carries a risk for depression," the St
Louis ECA data suggest a chronic and
pernicious interrelationship between
cigarette smoking and depression.
This study was supported in part by grants
DA04732, DA05585, DA05619, and DA06163 from
the National Institute for Drug Abuse, by an
Established Investigator Award from the National
Alliance for Research on Schizophrenia and De¬
pression, and by Suzanne C. Murphy. Addi¬
tional support was provided by grant
NIMH5R01MH43525 from the National Institute
for Mental Health, by the Epidemiological Catch¬
ment Area Program, by grants MH-31302 and DA-
04001 from the US Public Health Service, and by
the MacArthur Foundation Risk Factor Network.
We thank Douglas Mayer for computer assis¬
tance.
Rockville, Md: US Public Health Service; 1988. US
Dept of Health and Human Services publication
CDC 88-8046.
16. American Psychiatric Association, Committee
on Nomenclature and Statistics. Diagnostic and
Statistical Manual of Mental Disorders, Third
Edition, Revised. Washington, DC: American Psy-
chiatric Association; 1987.
17. Covey LS, Glassman AH, Stetner F. Depres-
sion and depressive symptoms in smoking cessa-
tion. Comp Psychiatry. 1990;31:350-354.
18. Glassman AH, Covey LS, Stetner F. Smoking
cessation, depression, and antidepressants. Read
before the 142nd Annual Meeting of the American
Psychiatric Association; May 6-11,1989; San Fran-
cisco, Calif. Abstract.
19. Flanagan J, Maany I. Smoking and depression.
Am J Psychiatry. 1982;139;4:541.
20. Glassman AH, Covey LS, Stetner F. Smoking
cessation and major depression. Read before the
28th Annual Meeting of the American College of
Neuropsychpharmacology; December 10-15, 1989;
Maui, Hawaii. Abstract.
21. Bruce ML, Leaf PJ. Psychiatric disorders and
15-month mortality in a community sample of older
adults. Am J Public Health. 1989;79:727-730.