Nicotine & Tobacco Research, 2017, 3–13

doi:10.1093/ntr/ntw140
Review
Advance Access publication May 19, 2016

Review

The Association of Cigarette Smoking With

Depression and Anxiety: A Systematic Review
Meg Fluharty MRes1,2, Amy E. Taylor PhD1,2, Meryem Grabski MRes1,2,
Marcus R. Munafò PhD1,2

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MRC Integrative Epidemiology Unit (IEU), University of Bristol, Bristol, United Kingdom; 2UK Centre for Tobacco and
1

Alcohol Studies, School of Experimental Psychology, University of Bristol, Bristol, United Kingdom

Corresponding Author: Meg Fluharty, MRes, UK Centre for Tobacco and Alcohol Studies, School of Experimental
Psychology, University of Bristol, 12a Priory Road, Bristol BS8 1TU, United Kingdom. Telephone: 44-117-9546614;
Fax: 44-117-9288588; E-mail: meg.fluharty@bristol.ac.uk

Abstract
Background: Many studies report a positive association between smoking and mental illness.
However, the literature remains mixed regarding the direction of this association. We therefore
conducted a systematic review evaluating the association of smoking and depression and/or anxi-
ety in longitudinal studies.
Methods: Studies were identified by searching PubMed, Scopus, and Web of Science and were
included if they: (1) used human participants, (2) were longitudinal, (3) reported primary data, (4)
had smoking as an exposure and depression and/or anxiety as an outcome, or (5) had depression
and/or anxiety as the exposure and smoking as an outcome.
Results: Outcomes from 148 studies were categorized into: smoking onset, smoking status, smok-
ing heaviness, tobacco dependence, and smoking trajectory. The results for each category varied
substantially, with evidence for positive associations in both directions (smoking to later mental
health and mental health to later smoking) as well as null findings. Overall, nearly half the stud-
ies reported that baseline depression/anxiety was associated with some type of later smoking
behavior, while over a third found evidence that a smoking exposure was associated with later
depression/anxiety. However, there were few studies directly supporting a bidirectional model of
smoking and anxiety, and very few studies reporting null results.
Conclusions: The literature on the prospective association between smoking and depression and
anxiety is inconsistent in terms of the direction of association most strongly supported. This sug-
gests the need for future studies that employ different methodologies, such as Mendelian rand-
omization (MR), which will allow us to draw stronger causal inferences.
Implications: We systematically reviewed longitudinal studies on the association of differ-
ent aspects of smoking behavior with depression and anxiety. The results varied consider-
ably, with evidence for smoking both associated with subsequent depression and anxiety, and
vice versa. Few studies supported a bidirectional relationship, or reported null results, and
no clear patterns by gender, ethnicity, clinical status, length to follow-up, or diagnostic test.
Suggesting that despite advantages of longitudinal studies, they cannot alone provide strong
evidence of causality. Therefore, future studies investigating this association should employ
different methods allowing for stronger causal inferences to be made, such as MR.

© The Author 2016. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco. 3
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0/), which permits
unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited.
4 Nicotine & Tobacco Research, 2017, Vol. 19, No. 1

Introduction Methods
The high co-occurrence of smoking and mental illness is a major Identification of Studies
public health concern, and smoking accounts for much of the We searched PubMed, Scopus, and Web of Science up until August
reduction in life expectancy associated with mental illness.1 Many 1, 2015 using the following search terms: depressi*, anxi*, smok*,
studies report a positive association between smoking and men- tobacco, nicotine, cigarette, caus*, cohort, prospective, longitudinal.
tal illness, with smoking rates increasing with the severity of the The term animal* was specified for exclusion. Two authors (MF and
disease.2,3 Individuals with mental illness also tend to start smok- AT) reviewed the electronic abstracts, selecting the full-text articles
ing at an earlier age, smoke more heavily, and are more addicted to be included.
to cigarettes than the general population. For example, a recent
survey suggests that 42% of all cigarettes consumed in England Selection Criteria
are consumed by those with mental illness, although this includes
Studies were included in the review if they met the following crite-
substance use disorders.4 Additionally, while cigarette consump-
ria: (1) human participants, (2) smoking as the exposure variable
tion in the general population has shown a sustained decrease over
and depression and/or anxiety as the outcome variable, or vice versa
the past 20 years, consumption among smokers with mental illness
(depression and/or anxiety as the exposure variable and smoking
has remained relatively unchanged.1 There is therefore a pressing
as the outcome variable), (3) longitudinal study design, and (4)
need to understand the mechanisms underlying the high rate of

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reported primary data not previously reported elsewhere. Studies
smoking in people with mental illness. Here, we focus specifically
involving cessation, withdrawal, suicide, or trauma, which recruited
on the relationship between cigarette smoking and depression and
participants who were pregnant or diagnosed with a psychiatric
anxiety.
illness other than depression or anxiety, or included participants
Currently, there are several hypotheses that have been proposed
with depression and anxiety comorbid with another psychiatric ill-
to explain the high rates of smoking in people with depression and
ness were excluded. Studies not utilizing a validated diagnostic test
anxiety. The self-medication hypothesis postulates that individu-
for depression or anxiety were excluded. Studies investigating the
als turn to smoking to alleviate their symptoms5–7 and therefore
association of parental smoking on offspring outcomes were also
suggests that symptoms of depression and anxiety may lead to
excluded, as were all experimental studies (eg, randomized con-
smoking. An alternative hypothesis is that smoking may lead to
trolled trials of smoking cessation interventions). RCTs as well as
depression or anxiety, through effects on an individual’s neuro-
secondary analyses of randomized controlled trials were excluded.
circuitry that increases susceptibility to environmental stressors.
Animal models indicate that prolonged nicotine exposure dys-
regulates the hypothalamic–pituitary–adrenal system, resulting Data Extraction
in hypersecretion of cortisol and alterations in the activity of the The following information was extracted from each of the included
associated monoamine neurotransmitter system, whose function is studies, by one author (MF): type of depression/anxiety (major
to regulate reactions to stressors,8 an effect that appears to normal- depression, generalized anxiety disorder, mixed major depression,
ize after nicotine withdrawal.9 The association between smoking and generalized anxiety disorder), method of measuring depression/
and depression/anxiety may also be bidirectional, with occasional anxiety (self-report via diagnostic test, clinical interview, or physi-
smoking initially used to alleviate symptoms, but in fact wors- cian diagnosis) and scale used (continuous or categorical), smoking
ening them over time.10 Finally, there may in fact be no causal behavior (age of smoking onset, smoking status, heaviness of smok-
relationship between smoking and depression/anxiety. Instead, the ing, tobacco dependence, smoking trajectory), sample size, mean
association may be a product of shared risk factors (eg, common age of participants and sex distribution of participants, population
genetic influences)10,11 or confounding. Smokers may also report sampled (eg, general or clinical), and length of follow up. A 100%
that cigarettes alleviate their symptoms due to the misattribu- data check was performed by the same author (MF) and a 10%
tion of withdrawal relief. Given the short half-life of nicotine that data check was independently performed by another author (MG)
results in withdrawal symptoms (including mood symptoms) after to identify data extraction errors. Any errors identified were resolved
a short period of abstinence, smokers may misattribute the relief by mutual consent.
of short-term withdrawal as reflecting a genuine anxiolytic effect
of smoking.7 That is, withdrawal symptoms of increased anxiety Rationale for not Conducting Meta-analysis
and negative affect may be misattributed as reflecting genuine A meta-analysis was not conducted as, even within the general
mood symptoms, which would lead to the impression that smok- population samples available, there was substantial heterogeneity
ing improves mood. (age, location, covariates used, time to follow up, and number of
We are therefore presented with multiple different hypotheses times and frequency of outcomes sampled). Additionally, the stud-
regarding whether there is a causal relationship between smoking ies included were not limited to only those examining an a priori
and depression/anxiety and if so, what the direction of causality hypothesis of mental health and smoking; studies were included if
underlying this relationship is. While experimental studies are gener- they contained the desired outcome and exposure variables within
ally not possible, for both practical and ethical reasons, longitudinal their data set.
studies may help inform our understanding of the causal relationship
between smoking and depression/anxiety by clarifying the temporal
Results
association. Our study aimed to systematically review the literature
comprising longitudinal studies of the associations between smoking Characteristics of Included Studies
and depression/anxiety and conduct meta-analyses where possible. Of the 6232 abstracts reviewed, 5514 were excluded on the basis of
To the best of our knowledge, this is the first systematic review of title and 404 after reviewing the abstract. In total, 314 articles were
this literature. retrieved and assessed for eligibility, and 148 met inclusion criteria
Nicotine & Tobacco Research, 2017, Vol. 19, No. 1 5

(Figure 1). Details of included studies are provided in Supplementary Nicotine Dependence,13 were included in the tobacco dependence
Table S1 and details of excluded full-text studies in Supplementary category. Studies that tracked the different paths of cigarette smok-
Table S2. ing uptake and use in a cohort were included in the smoking trajec-
Studies ranged in sample size from 59 to 90 627 participants tory category, and studies that defined smokers in purely categorical
and in length of follow up from 2 months to 36 years. Of the 148 terms (eg, current, former, and never) were included in the smoking
included studies, 99 (67%) recruited male and female participants, status category. Table  1 summarizes the directions of associations
16 (11%) recruited only females and 7 (5%) recruited only males, investigated within the studies in each smoking category.
while 26 (18%) did not report the sex of the participants. In addi-
tion, 101 studies (70%) sampled participants from the general pop- Smoking Onset
ulation, 15 (10%) from clinical populations, and 16 (10%) from A total of 14 studies investigated the association of baseline depres-
particular ethnic groups, while 16 (10%) had other selection criteria sion with subsequent smoking onset, of which 10 (71%) found evi-
(see Supplementary Table S2). dence to support this association,14–23 while four (29%) found no
Unless otherwise stated, the associations described refer to a posi- evidence of an association.24–27 Five studies investigated the associa-
tive relationship between smoking and depression/anxiety (ie, smok- tion of baseline anxiety on smoking onset, of which four (80%) found
ing is associated with increased depression/anxiety, or increased evidence to support an association with increased risk of smoking
depression/anxiety is associated with increased smoking). onset24,28–30 and one (20%) found no evidence of an association.21 Six

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studies investigated the association of comorbid depression and anx-
Smoking Categories iety with later smoking onset, of which two (33%) found evidence
Studies were categorized based on the basis of the smoking to support this association,31,32 while one (17%) reported comorbid
behavior(s) they assessed: smoking onset, smoking status, smoking depression and anxiety was associated with reduced risk of smoking
heaviness, tobacco dependence, and smoking trajectory. Studies with onset33 and three (50%) found no evidence of an association.34–36
measures of daily or weekly cigarette use were included in the smok- One study investigated the association of smoking onset with later
ing heaviness category. Studies that were able to establish the onset of depression, finding evidence for this association.15 One study investi-
smoking from an initially nonsmoking population were included in gated the association of smoking onset with later anxiety, finding no
the smoking onset category. Studies that measured tobacco depend- evidence for this association.21 Additionally one study investigated
ence, for example, through the DSM-IV12 or the Fagerström Test for the association of smoking onset with later comorbid depression and

Figure 1. Identification of independent studies for inclusion in systematic review.

6 Nicotine & Tobacco Research, 2017, Vol. 19, No. 1

Table 1. Directions of Associations Investigated by Smoking Category

Depression Anxiety Comorbid depression and anxiety

MH into Smoking MH into Smoking MH into Smoking

Category smoking into MH Bidirectional smoking into MH Bidirectional smoking into MH Bidirectional

Smoking onset 13 0 1 4 0 2 5 0 1
Smoking status 29 40 8 0 4 1 1 7 0
Smoking heaviness 9 7 2 1 1 0 0 1 0
Tobacco dependence 12 2 1 6 0 0 5 1 0
Smoking trajectory 7 2 0 1 0 0 1 1 0
Any smoking category 70 51 12 12 5 3 12 10 1

The number of studies investigating each direction(s) of association for each smoking category is shown. Studies investigating multiple directions are repeated
within smoking category. Please note these only include directions investigated and differ from the overall findings within smoking groups detailed in Figure 2.
MH = mental health outcome.

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Figure 2. Main outcomes by smoking category.

anxiety, finding no evidence for this association.31 These findings are A total of 51 studies investigated the association of smoking
summarized in Figure 2. status with later depression, of which 37 (73%) found evidence
to support this association,21,25,47,57,65,70,72–102 while 14 (27%) found
Smoking Status no evidence of this association.28,38,48,64,69,103–111 Four studies investi-
A total of 37 studies investigated the association of baseline depression gated the association of smoking status with later anxiety, of which
with subsequent smoking status, of which 33 (89%) found evidence to two (50%) found evidence to support this association,28,112 while
support this association,21,37–66 while four (11%) found no evidence of two (50%) found no evidence of an association.21,103 Seven studies
an association.67–70 One study investigated the association of anxiety investigated the association of smoking status with later comorbid
with later smoking status, finding evidence of an association.28 One depression and anxiety, of which five (71%) found evidence to sup-
study investigated the association of comorbid depression and anxi- port this association,35,113–116 while two (29%) found no evidence of
ety with later smoking status, finding no evidence of an association.71 an association.117,118 These findings are summarized in Figure 2.
Nicotine & Tobacco Research, 2017, Vol. 19, No. 1 7

Smoking Heaviness both the association between baseline mental health and later smok-
A total of 11 studies investigated the association of baseline depres- ing behavior and baseline smoking behavior and later mental health).
sion with subsequent heaviness of smoking, of which eight (73%) Of these, seven (44%) reported evidence in support of a bidirectional
found evidence that depression was associated with heavier rates of relationship between depression and smoking15,21,47,57,65,125,132 and one
smoking,22,119–125 while two (18%) found that depression was associ- (9%) reported evidence in support of a bidirectional relationship
ated with reduced heaviness of smoking26,126 and one (09%) found no between anxiety and smoking.28
evidence of an association.127 One study investigated the association
of baseline anxiety with subsequent smoking heaviness and found no Sex Differences
evidence of an association.124 Eight studies investigated the associa- A total of eight studies (7% of all studies including both males
tion of heaviness of smoking with later depression, of which seven and females) reported that the relationship between smoking and
(88%) found evidence to support this association,11,82,95,102,125,127,128 depression/anxiety differed between males and females. Two studies
while one (13%) found no evidence of an association.129 One study reported that depression was associated with subsequent smoking
investigated the association of heaviness of smoking with later anxi- behavior only in males,23,64 while one study reported depression was
ety and found evidence to support this association.130 One study associated with subsequent smoking only in females66 and one study
investigated the association of heaviness of smoking with later reported that anxiety was associated with later smoking behavior
comorbid depression and anxiety, finding no evidence of an associa- only in females.140 Additionally, one study reported evidence that

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tion.117 These findings are summarized in Figure 2. smoking status in men was associated with later depression,101 and
two studies reported evidence that smoking status had a stronger
Tobacco Dependence association with later depression in females than males.97,157 Finally,
A total of 13 studies investigated the association of baseline depres- one study reported a bidirectional relationship between smoking and
sion with subsequent tobacco dependence, of which 12 (92%) found depression that was only observed in females.57
evidence to support this association29,120,131–140 while one (8%) found
no evidence of an association.141 Six studies investigated the associa- Clinical Studies
tion of baseline anxiety with later tobacco dependence, of which two Five studies investigated participants with cardiovascular problems.
(33%) found evidence to support this association,140,142 while four One study reported evidence that depression was associated with
(67%) found no evidence of an association.132,137,139,143 Five studies subsequent smoking behavior.44 The other four reported that smok-
investigated baseline comorbid depression and anxiety with subse- ing status was associated with later depression.80,83,87,88 Other studies
quent tobacco dependence, of which three (60%) found evidence to of clinical populations generally reported evidence of an association
support this association, 144–146 while two (40%) found no evidence between smoking and the onset of depression.
of an association.35,147 Three studies investigated the association
of tobacco dependence with later depression, of which two (67%)
found evidence to support this association,6,132 while one (33%) Ethnic Differences
found no evidence of an association.148 Two studies investigated the Five studies recruited participants of East Asian descent (China,
association of tobacco dependence with later comorbid depression Japan, and South Korea), with two studies reporting evidence that
and anxiety, of which one (50%) found evidence to support this depression was associated with later smoking behavior 41,48 and
association,149 while one (50%) found no evidence of an associa- one study reporting no evidence of an association.70 Additionally,
tion.147 These findings are summarized in Figure 2. two studies reported evidence for an association between smok-
ing status and later depression,70,99 while two studies reported
no evidence that smoking status was associated with subsequent
Smoking Trajectory depression.48,108 Three studies recruited African American partici-
A total of seven studies investigated the association of baseline depres- pants, with two studies reporting evidence that depression was
sion with smoking trajectory, of which one (14%) reported that associated with later smoking behavior,54,64 one study report-
depressive symptoms were associated with accelerated cigarette use,150 ing no evidence that depression was associated with subsequent
three (43%) reported that depressive symptoms were associated with smoking onset,153 and one study reporting no evidence that smok-
early smoking onset,17,43,151 one reported that depressive symptoms ing was associated with the onset of depression.64 Four studies
were associated with late onset smoking152 and two (29%) found recruited both African American and Hispanic participants, with
no evidence of an association.153,154. One study reported evidence of three studies reporting that depression and anxiety were associ-
an association of baseline anxiety with early and late onset smok- ated with subsequent smoking trajectories,43,131,156 while one study
ing patterns.155 Another study reported evidence of an association of reported that smoking heaviness was associated with the onset
baseline comorbid depression and anxiety with late onset smoking as of anxiety.130 Other studies of specific ethnic groups generally
opposed to experimental smoking.156 One study reported that indi- reported evidence of an association between smoking and later
viduals in (smoking) starter and maintaining groups were more likely depression and anxiety.
to be depressed at follow up compared with nonsmoking groups.157
Finally, one study reported evidence that early onset smokers devel-
Additional Analyses
oped depression and anxiety approximately five years earlier than late
No clear pattern of results was apparent when studies with different
onset smokers.158 These findings are summarized in Figure 2.
lengths of follow up were considered separately (see Supplementary
Table S3). Additionally, the findings did not vary substantially
Bidirectional Studies between studies using different tests (interview vs. self-diagnostic
Sixteen (11%) of the 148 included studies investigated the associa- test) or scales (continuous vs. categorical) to diagnose depression or
tion between smoking behavior and mental health bidirectionally (ie, anxiety (see Supplementary Table S4).
8 Nicotine & Tobacco Research, 2017, Vol. 19, No. 1

Discussion individual studies was related to the nature of the results reported.
However, this would be challenging, given the diversity of study
In general, the findings across the studies in our systematic review
designs among the included studies. Fifth, while we were able to
were inconsistent. Nearly half of the studies reported that baseline
categorize and investigate a range of different smoking behaviors,
depression or anxiety was associated with some type of later smok-
the same level of detail was not available for depression and anxi-
ing behavior, whether it be the onset of smoking itself, increased
ety. Future reviews should investigate individual symptomology (eg,
smoking heaviness, or the transition from daily smoking into
negative affect, somatic features, etc.) and their relationship with
dependence. These findings support a self-medication model, sug-
smoking behavior, as previous research has indicated that specific
gesting that individuals smoke to alleviate psychiatric symptoms.5,6
symptoms may be differentially associated with smoking motiva-
However, over a third of the studies found evidence for a relation-
tions and tobacco withdrawal.160–162 However, this analysis was
ship in the opposite direction whereby smoking exposure at base-
not possible with the data reviewed here. Sixth, we only focused on
line was associated with later depression or anxiety, supporting the
depression, anxiety, or comorbid depression and anxiety. However,
alternative hypothesis that prolonged smoking increases suscepti-
several studies identified during screening included depression or
bility to depression and anxiety.8,9 Of course, these two putative
anxiety subtypes (eg, post-traumatic stress disorder or social anxi-
causal pathways are not mutually exclusive, but interestingly there
ety). These were excluded in order to maximize comparability among
were relatively few studies reporting evidence for a bidirectional
included studies. Future studies should explore whether there is a
model relationship between smoking and depression and anxiety.

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more consistent pattern of relationship between smoking behavior
One possible reason for this is that many studies only measured
and other diagnostic categories. However, given the disparate results,
or analyzed the variables in the direction of their a priori hypoth-
we observed in our more focused review, it is perhaps unlikely that
esis. For example, studies examining factors for depression in later
clear relationships will emerge.
life measured smoking as a possible factor but typically did not
Despite the advantages of longitudinal studies, they cannot by
analyze the association of baseline depression with later smok-
themselves provide strong evidence of causality. However, applying
ing. Moreover, few studies reported null results; often these were
latent variable mixture modeling to establish group-based trajecto-
only included alongside positive results relating to another out-
ries, as some studies identified did, may help to identify different
come. Additionally, it is possible the associations observed between
patterns within the data that may have otherwise gone unnoticed.
smoking and mental health are a result of shared genetic and envi-
Rather than clustering individuals into simply “smokers” and “non-
ronmental factors.6
smokers,” mixture modeling can identify various groups such as
There are a number of limitations that should be considered when
“experimenters,” “early onset,” “late onset,” “stable,” or “late esca-
interpreting these results. First, the studies included in this review
lating” smokers.163 This approach could provide insight into the type
varied substantially in population sampled, with some recruiting
or critical age of smokers vulnerable to mental illness, or vice versa.
from the general population and others selectively recruiting by sex,
It’s likely that our review did not yield more of these studies, as we
ethnicity, clinical population, or some other characteristic (eg, at-
did not include “trajectory” in our search terms. Future reviews
risk adolescents). This introduced substantial heterogeneity into the
should include an exhaustive search, including a variety of terms
review, thus making meta-analysis inappropriate. The substantial
such as mixture modeling, latent class analysis, and latent trajectory
heterogeneity between study populations could be responsible for
analysis in addition to the term trajectory.
the inconsistent results observed, and future reviews should consider
Additionally, future studies should therefore employ methods
analyzing different populations individually. Second, there was also
that enable stronger causal inference, such as Mendelian randomi-
substantial variation in study designs, including the length of follow
zation (MR).164 This approach uses genetic polymorphisms that
up (between 2 months and 36 years) and confounders adjusted for.
have been previously shown to be robustly associated with one of
Measurement of depression or anxiety was based on a wide range
the exposures of interest; for example, the CHRNA5-A3-B4 gene
of different diagnostic tests, with different cutoffs for determining
cluster is associated with smoking quantity and tobacco depend-
clinical status. Sample size also varied substantially between studies,
ence165,166 and has been used in a number of MR studies.160 It is
ranging from 59 to 90 627, suggesting that some smaller studies may
based on the principle that an individual inherits a random assort-
be inadequately powered. This may lead to an increased likelihood
ment of genes from their parents, and these genes should not be
of false positives since, among statistically significant findings, power
associated with potential confounders.10 Therefore, in theory, a
declines the ratio of true positives to false positives decreases.159 This
robust genetic influence to a particular exposure (eg, smoking)
is because while 5% of null associations will be falsely declared as
would be comparable to a randomized trial in which individuals
significant (assuming a 5% alpha level), the number of true positives
are assigned to a high- or low-exposure group.164 In addition, envi-
correctly identified will decline as power declines (eg, from 80% of
ronmental factors cannot affect the genes that an individual is born
true associations correctly declared as significant in high powered
with, so analyses are not subject to reverse causality or residual
studies to, say, only 20% in low powered studies).159 However, it
confounding. Two studies that have used MR have found no evi-
is also worth noting that very large samples may detect statistically
dence to support a causal association between smoking and depres-
significant associations that are unlikely to be of clinical or popula-
sion and anxiety,117,167 while another found evidence to suggest
tion health importance.
that smoking was associated with lower odds of depression during
Third, we only included published studies, and while the inclu-
pregnancy.168 The results of these studies suggest that observational
sion of unpublished studies may increase the likelihood of including
findings of an association of smoking status with later psychological
lower quality work that has not been peer reviewed, it may also
distress may be a result of shared vulnerability, residual confound-
decrease publication bias, in which studies are only published if
ing, or reverse causality (eg, psychological distress associated with
they have positive results. By expanding our search to include non-
later smoking behavior).167 However, this review yielded the most
published studies, it is possible we may have found more instances
findings in the direction of psychological distress associated with
of null results. Fourth, we did not investigate whether quality of the
Nicotine & Tobacco Research, 2017, Vol. 19, No. 1 9

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Declaration of Interests level correlates of cigarette-smoking trajectories from age 13 to 32 in a
None declared. U.S. population-based sample. Drug Alcohol Depend. 2013;132:301–308.
doi:10.1016/j.drugalcdep.2013.02.021.
18. King SM, Iacono WG, McGue M. Childhood externalizing and internal-
Acknowledgments izing psychopathology in the prediction of early substance use. Addiction.
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The authors are members of the UK Centre for Tobacco and Alcohol Studies, 19. Naicker K, Galambos NL, Zeng Y, Senthilselvan A, Colman I. Social,
a UKCRC Public Health Research: Centre of Excellence. Funding from British demographic, and health outcomes in the 10  years following adoles-
Heart Foundation, Cancer Research UK, Economic and Social Research cent depression. J Adolesc Health. 2013;52:533–538. doi:10.1016/j.
Council, Medical Research Council, and the National Institute for Health jadohealth.2012.12.016.
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gratefully acknowledged. effects of hostility, depression, and bullying on adolescent smok-
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