Depression, Smoking, and Quitting

Unfortunately, most of today's smokers struggling with depression are still not benefiting from over a century of advances.
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According to the US Centers for Disease Control and Prevention (CDC) almost half (43%) of the people over the age of 20 who suffer with depression are also smokers. This confirms what clinicians who work to help smokers quit have long seen firsthand. The smoking rate for people with depression in all age groups, for both men and women, is twice that of people without depression. In fact, these are smoking rates similar to those found in the population as a whole back in 1964, when the U.S. Surgeon General first reported on the dangers of smoking. To compound matters, the CDC report also says that in their findings: "Adults with depression were less likely to quit smoking than those without depression."

What's going on here?

Could it be that depressed people smoke because cigarettes deliver an antidepressant effect which provides mood support? Let's keep in mind, however, that these smokers are all still being categorized as depressed, even while they are smoking, so obviously smoking is not a cure-all for them. Is there more smoking in the depressed population because quitting smoking represents a higher hurdle for them than for the general population? Do depressed people become even more depressed from the challenges of quitting and so avoid even trying?

I have long observed that all smokers are not alike; some quit relatively easily on their own while others say it is the hardest thing they have ever done in their lives. The job of clinicians who want to help smokers quit is to understand these differences and to make quitting as easy and pain-free as possible for the different kinds of smokers.

Sigmund Freud gave us an early description of the pain of tobacco withdrawal and depression when he wrote of his own experience in 1894:

The misery of abstinence has been far greater than I ever imagined...suddenly there came a severe cardiac misery, greater than I ever had while smoking. The most violent arrhythmia, constant tension, pressure, burning in the heart region, shooting pains down my left arm...and with it a feeling of depression which took the forms of visions of death.

Freud tried to quit after he developed heart arrhythmia when he was 38, but was soon back to smoking 20 cigars a day. He found not smoking a "torture," and believed smoking tobacco was the "stuff of work" and necessary for the "combat with life". By the time he was 67, he had developed growths on his jaw and palate associated with heavy smoking. During this period he underwent 30 or more minor, and some major, operations to remove precancerous growths. Despite this, he continued to smoke and had a huge prosthesis inserted in his oral and nasal cavities which required repeated painful adjustments. Freud didn't quit his famous cigars until the age 74.

In my new book, "Smoke Free in 30 Days," I describe that many men and women believe, much like Freud, that they will not be as effective in their work without smoking; they believe they will lose their edge. I have treated many individuals who believe that smoking helps them concentrate and that they will lose their cognitive ability if they were to stop.

In all these cases, however, each person who used nicotine replacement therapy appropriately was able to resume a productive work life after he or she stopped smoking. Nicotine replacement can help make this transition much less difficult by relieving withdrawal symptoms. Another medicine, the antidepressant Wellbutrin, (marketed to smokers as Zyban), represents a great advance in providing smokers with mood support as well as relief from withdrawal symptoms. However, medicine alone is unlikely to solve the dilemma posed by addiction to smoking. There is a difference between stopping smoking under duress, and making a positive emotional adjustment to going smoke-free. Ultimately, to make peace with the addiction, and make a happier long-term adjustment, the smoker must challenge the belief that they need to smoke to cope with their lives.

How can we help the smoker who is depressed?

We have learned a great deal about smoking, quitting and depression in the more than 100 years since Freud first discussed it. But unfortunately, most of today's smokers struggling with depression are not benefiting from these advances.

Based on my clinical experience, and my reading of the research literature, I am not convinced that smoking actually serves as a good antidepressant drug. I believe the antidepressant effects of smoking are often exaggerated and overstated. More likely smoking feeds on smoker's mood problems, some of which are created or magnified by withdrawal symptoms. It will surprise you to learn that half of the symptoms of nicotine withdrawal are also symptoms of clinical depression. These include (1) dysphoric or depressed mood; (2) insomnia; (3) difficulty concentrating; (4) increased appetite or weight gain. In order to meet diagnostic criteria for depression these symptoms must cause clinically significant distress or impairment in social, domestic, occupational, or other important areas of functioning. Even the symptoms of nicotine withdrawal that do not overlap with depression involve emotional upset. They include: irritability, frustration, anger, anxiety and restlessness. Just to get an idea of how difficult these kinds of symptoms make it to quit smoking, in research studies two out of three times smokers relapse (slip back to smoking), they report being "triggered" by a negative or stressful emotional experience.

In my book I outline six different patterns of smoking addiction. One of these is "the Emotion-Triggered Smoker". For these smokers, mood problems can not only magnify nicotine withdrawal, but also complicate the emotional adjustment after quitting. If smoking were truly such a great antidepressant, why do so many smokers say they feel better, not just physically but emotionally, after a period of time away from it? They expect to feel worse, but actually feel better without smoking, once they overcome the withdrawal. For many, especially depressed smokers, this requires some small but important shifts in their perceptions about smoking which can help them to completely lose interest in smoking. This shift involves learning to disconnect the automatic smoking response from the trigger of emotional discomfort.

One smoker, whom I will call Christine, quit smoking because, like Freud, she had developed a heart condition which caused her great anxiety. Her identity was wrapped up in smoking. She literally told me "I was born to smoke"! While she suffered from lifelong depression, she told me from the beginning that "anger is my issue," and every time she got angry she automatically reached for a cigarette. When she quit smoking, the anger would begin to build up and over time the tension grew to the point where it eventually triggered her back to smoking. She repeated this pattern several times before she was able to disconnect her smoking addiction from her anger. How did she do this? By making a conscious effort to recognize that "Smoking never helped me solve a real life problem". Once she discovered more productive and healthy ways to react to anger, she lost complete interest in smoking.

Cognitive-behavioral therapy (CBT) for smoking cessation focuses on this kind of shift in perspective and behavior. It turns out that quitting smoking is not only good for your physical health but also helps interrupt emotional patterns of unproductive coping which can keep people stuck in their depression.

The recent CDC report states that: "...studies that have examined ability to quit smoking in persons with depression have shown that with intensive treatment, persons with depression can quit smoking and remain abstinent. These intensive cessation services often use treatments that are also used for depression, including cognitive-behavioral therapy or antidepressant medications. Adults with depression and other mental illnesses are an important subgroup to target for tobacco cessation programs."

Isn't it time -- more than a hundred years after Freud struggled unsuccessfully with this problem -- that we offer these life saving, effective services at every accredited medical and health center and mental health clinic where smokers get their healt hcare?

Dr. Seidman is author of the new book Smoke-Free in 30 Days: The Pain-Free, Permanent Way to Quit with a foreward by Dr. Mehmet Oz (Fireside Trade Paperback Original, January 2010). Dr. Seidman first introduced his own program to stop smoking as a featured expert on The Oprah Winfrey Show with Dr. Oz early in 2008. For more details about the book go to