Feeling Sad: A Trigger to Reach for a Cigarette?

Non-smokers may not understand the intensity of craving for nicotine experienced by cigarette smokers, nor the intensity of negative emotions when the smoker attempts abstinence. In an attempt to study this addiction, the effect of nicotine on altering the smoker’s emotional state, and the effect of the emotional state on triggering the need to smoke, have been studied extensively.

Does smoking relieve feelings of depression and anxiety? A recent review of current studies looking at the relationship between cigarette smoking and dysphoric mood mentions that in England, 42% of cigarette smokers have a mental illness. And although smoking has declined in the general population, there has been no decrease among those with mental illness. More than half of the 148 studies reviewed found an association between depression, anxiety, and smoking; in about a third of the studies mentioned, people with these two mental disorders were more likely to smoke in the future, than those without these disorders. Might those who are beginning to experience mood changes, which have not yet reached clinical significance, be using nicotine to help “medicate” their moods?

This relationship between acute changes in mood and smoking is still actively being studied. In one such study, non-smoking medical students were given a series of tests that were designed to induce feelings of stress. They then were told to smoke under controlled conditions (number of puffs were monitored) and their moods compared with their pre-smoking mood. The results were unexpected: The female students experienced a reduction in their stress after smoking, but the moods of the male subjects worsened. The males became hostile, angry, less calm, and more discontented after exposure to the nicotine. Whether the same results would have been found among habitual smokers was not studied.

Other studies have shown that smokers reach for their cigarettes during stressful situations if, of course, they are in an environment that allows smoking.

One interesting study that tracked the moods of male smokers for several days, found that a bad mood (negative affect) was associated with increased smoking, but instead of relieving the depressed, anxious or stressed mood, the smoking worsened it. These findings are somewhat similar to those found among the male non-smokers mentioned earlier.

Interesting confirmation of the compelling desire to smoke in association with a negative mood comes from two studies that looked at specific emotional states and desire to smoke. About 120 men and women who were smokers, some of whom suffered from depression, were shown two film clips. One was about the death of a father, and the other was a scene from a national park. Those with a diagnosis of depression smoked significantly more in response to the sad film than the non-depressed group. The other neutrally emotional film had no impact on desire to smoke among either group.

These findings were confirmed and expanded in studies that included a survey of more than 10,000 smokers and laboratory experiments. The survey data found that sadness was the only emotion smokers reported associated with their need to smoke, and also the cause for their relapse twenty or so years after they had stopped.

Videos designed to elicit specific emotional states and presented to smokers triggered smoking only when the content was sad (death of a life partner) but not when the content was emotionally neutral (woodworking) or disgusting (cleaning a filthy toilet).

Identifying sadness per se, rather than other negative emotional states as provoking the addictive behavior of the smoker, may be useful in helping them quit. Behavioral techniques to aid the smoker in the transition to stop have been developed over the past several decades, along with drugs to reduce cravings and perhaps help with the mood changes that sometimes accompany smoking withdrawal. But these findings showing that sadness may increase the need of a smoker for nicotine may be very important in determining the optimal time to initiate a smoking withdrawal program (and also in preventing possible relapse.) Clearly the sadness caused by a life situation (sickness, grave disappointment, death) and/or by depression itself must be recognized as a risk factor for relapse for the ex-smoker. And attempting to induce the smoker to give up nicotine, under those circumstances, may be futile as well. Interventions that help the individual lessen or overcome the intensity of this emotion may be a better approach than conventional smoking withdrawal programs.

However, as with any of the explanations that attempt to understand addictive behavior, it is necessary to go beyond evidence of a defined trigger. One thing lacking from both of the studies on sadness and smoking is whether, or how, the smoker’s emotional state changed after consuming nicotine. Did the smoker-subject become less sad? If so, how long did the effect last? What was the “dose” of nicotine needed, i.e., how many puffs were required, before the emotional state changed? And what, if other, emotional states had been induced by the film clips or videos such as fear, stress, anger, confusion, frustration, and anxiety to name just a few, were these possible emotional triggers to smoking? Would the subjects have used cigarettes to alter their mood state?

We still have much to learn about how to end this addiction.