Does Smoking During Adolescence Increase the Risk of Developing Anxiety Disorders in Adulthood?
ABSTRACT & COMMENTARY
Source: Johnson JG, et al. Association between cigarette smoking and anxiety disorders during adolescence and early adulthood. JAMA 2000;284:2348-2351.
Studies have shown a positive association between cigarette smoking and some anxiety disorders in adolescents and adults in the general population. One hypothesis is that anxious individuals are at risk for smoking initiation due to factors such as peer pressure, facilitation of social interactions, and the presumed calming effects of smoking. One study reported that adolescents with anxiety or depressive symptoms were at higher risk for smoking than asymptomatic adolescents, and another revealed social fears in adolescents and adults increased risk similarly. Another hypothesis is that cigarette smoking contributes to the development of anxiety disorders. Studies have shown smoking preceded the onset of panic attacks in patients with panic disorder, and daily smoking, as well as pulmonary complaints, were associated with the development of panic disorder in young adults.1 In the current study, a total of 680 youths (51% female) were interviewed in their home using the Diagnostic Interview Schedule for Children in 1983, 1985-86, and 1991-93, with mean ages of 14, 16, and 22, respectively. This was a random sample of a larger group of families interviewed for another study. Data analysis investigated bivariate associations between smoking and anxiety disorders, and controlled for age; sex; difficult child temperament; alcohol and/or drugs, anxiety, and depressive disorders in adolescence; and parental smoking, education, and psychopathology.
At age 16, 6% had anxiety disorders and 6% smoked. At age 22, 10% had anxiety disorders and 15% smoked. Only 2% had anxiety disorders at both ages and 3% smoked heavily (20+ cigarettes/d) at both ages. Anxiety disorders during adolescence were not significantly associated with smoking during early adulthood. After controlling for covariates, adolescents who smoked heavily were at elevated risk for general anxiety disorder (OR 1.36), agoraphobia (OR 1.47), and panic disorder (OR 1.65); overall, 31% of heavy adolescent smokers had anxiety disorders in early adulthood compared to 9% of others. Heavy smoking during both adolescence and early adulthood was associated with increased risk for general anxiety disorder (OR 3.28) and panic disorder (OR 7.55). Age, female sex, difficult childhood temperament, alcohol/drug disorder, and depression were associated with heavy smoking during adolescence.
COMMENT BY DONALD M. HILTY, MD
This study indicates that cigarette smoking increases risk for the development of anxiety disorders (but probably not vice-versa), particularly in those who smoke during both adolescence and early adulthood. This is consistent with the previous Psychiatric Medicine in Primary Care review, which best supported a hypothesis that smoking predisposes a patient to panic attacks. The relationship between depression and smoking is believed to be noncausal and mediated largely or entirely through genetic factors that influence the liability to both smoking and depression.2 Clinicians should educate patients about this finding as another reason to not initiate or to quit smoking, particularly in patients with increased risk of anxiety disorders due to familial anxiety disorders.
References
1. Breslau N, et al. Smoking and panic attacks. Arch Gen Psychiatry 1999;56:1141-1147.
2. Kendler KS, et al. Smoking and major depression: A causal analysis. Arch Gen Psychiatry 1993;50:36-43.
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