Open Access Open Badges Research article

Cigarette smoking, nicotine dependence and anxiety disorders: a systematic review of population-based, epidemiological studies

Steven Moylan1*, Felice N Jacka12, Julie A Pasco13 and Michael Berk1245

Author affiliations

1 Deakin University School of Medicine, Barwon Health, Geelong, Victoria, Australia

2 Department of Psychiatry, Melbourne University, Parkville, Victoria, Australia

3 NorthWest Academic Centre, Department of Medicine, The University of Melbourne, St Albans, Victoria, Australia

4 Orygen Youth Health Research Centre, Centre for Youth Mental Health, Parkville, Victoria, Australia

5 The Florey Institute for Neuroscience and Mental Health, Parkville, Victoria, Australia

For all author emails, please log on.

Citation and License

BMC Medicine 2012, 10:123  doi:10.1186/1741-7015-10-123

Published: 19 October 2012



Multiple studies have demonstrated that rates of smoking and nicotine dependence are increased in individuals with anxiety disorders. However, significant variability exists in the epidemiological literature exploring this relationship, including study design (cross-sectional versus prospective), the population assessed (random sample versus clinical population) and diagnostic instrument utilized.


We undertook a systematic review of population-based observational studies that utilized recognized structured clinical diagnostic criteria (Diagnostic and Statistical Manual of Mental Disorders (DSM) or International Classification of Diseases (ICD)) for anxiety disorder diagnosis to investigate the relationship between cigarette smoking, nicotine dependence and anxiety disorders.


In total, 47 studies met the predefined inclusion criteria, with 12 studies providing prospective information and 5 studies providing quasiprospective information. The available evidence suggests that some baseline anxiety disorders are a risk factor for initiation of smoking and nicotine dependence, although the evidence is heterogeneous and many studies did not control for the effect of comorbid substance use disorders. The identified evidence however appeared to more consistently support cigarette smoking and nicotine dependence as being a risk factor for development of some anxiety disorders (for example, panic disorder, generalized anxiety disorder), although these findings were not replicated in all studies. A number of inconsistencies in the literature were identified.


Although many studies have demonstrated increased rates of smoking and nicotine dependence in individuals with anxiety disorders, there is a limited and heterogeneous literature that has prospectively examined this relationship in population studies using validated diagnostic criteria. The most consistent evidence supports smoking and nicotine dependence as increasing the risk of panic disorder and generalized anxiety disorder. The literature assessing anxiety disorders increasing smoking and nicotine dependence is inconsistent. Potential issues with the current literature are discussed and directions for future research are suggested.

agoraphobia; anxiety disorder; cigarette smoking; epidemiology; generalized anxiety disorder; nicotine dependence; obsessive-compulsive disorder; panic disorder; post-traumatic stress disorder; specific phobia