NCHS Data Brief ■ No. 34 ■ April 2010

u.s. department of health and human services

centers for disease control and prevention

national center for health statistics

Depression and Smoking in the U.S. Household Population 

Aged 20 and Over, 2005–2008

laura a. pratt, ph.d., and debra J. Brody, m.p.h.

Key findings

Data from the National 

Health and Nutrition 

Examination Surveys, 

2005–2008

•	 Adults aged 20 and over 

with depression were more 

likely to be cigarette smokers 

than those without depression. 

•	 Women with depression had 

smoking rates similar to men 

with depression, while women 

without depression smoked 

less than men.

•	 The percentage of adults 

who were smokers increased 

as depression severity 

increased. 

•	 Among adult smokers, 

those with depression smoked 

more heavily than those 

without depression. They were 

more	likely	to	smoke	their	first	

cigarette within 5 minutes of 

awakening and to smoke more 

than one pack of cigarettes per 

day.

•	 Adults with depression 

were less likely to quit 

smoking than those without 

depression.

Depression is a chronic disease that often results in limitations in work, 

family, and social (1). Persons with depression have higher rates of 

cardiovascular disease and diabetes and more risk behaviors for these 

diseases, such as smoking, poor diet, or lack of exercise, than persons without 

depression (2).

Since	1964,	when	the	Surgeon	General’s	first	Report on Smoking and Health

was released (3), cigarette smoking among adults in the United States has 

been reduced by one-half. However, 21% of the adult population still smokes 

(4). Better understanding the characteristics of adults who continue to smoke 

and the relationship between smoking and depression may lead to improved 

tobacco cessation interventions (5).

Keywords: mental illness • tobacco • National Health and Nutrition 

Examination Survey

Adults with depression were more likely to be current 

cigarette smokers than those without depression.

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NCHS Data Brief ■ No. 34 ■ April 2010

■  2  ■

In every sex-age group, adults with depression were more likely to smoke than those without 

depression (Figure 1).

Over one-half of men with depression aged 40–54 were current smokers compared with 26% of 

men without depression of the same age.

Among women aged 40–54, of those with depression, 43% were smokers compared with 22% of 

those without depression.

Among adults with depression, men and women had similar rates of smoking, whereas among 

adults without depression, men were more likely to be smokers than women.

The percentage of adults who were current smokers increased as 

depression severity increased.

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Adults with even mild depressive symptoms were more likely to smoke than adults with no 

depressive symptoms (Figure 2).

Among adults with moderate or severe depressive symptoms, women and men had similar high 

rates of smoking ranging from 39% to 48%. 

More than one-quarter of men with mild or no depressive symptoms smoked, while less than 

one-fifth of women with mild or no depressive symptoms did so. 
NCHS Data Brief ■ No. 34 ■ April 2010

■  3  ■

Adult smokers with depression were more likely to be heavy smokers than 

adult smokers without depression.

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Slightly	more	than	one-half	of	adult	smokers	with	depression	smoked	their	first	cigarette	of	the	

day	within	5	minutes	of	waking	up,	while	30%	of	smokers	without	depression	smoked	their	first	

cigarette within 5 minutes of awakening (Figure 3).

Twenty-eight percent of adult smokers with depression smoked more than a pack of cigarettes per 

day, which was almost twice the rate for adult smokers without depression.
NCHS Data Brief ■ No. 34 ■ April 2010

■  4  ■

Adults with depression were more likely to have ever smoked than those 

without depression. Among ever smokers, adults with depression were less 

likely to have quit smoking than those without depression.

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Over 60% of adults with depression had smoked at some point in their lives (ever smokers), and 

the rate was similar across age groups. Among adults without depression, the proportion who 

were ever smokers ranged from 43% among those aged 20–39 to 53% among persons aged 55 

and over (Figure 4).

In every age group, ever smokers with depression were less likely to have quit smoking than ever 

smokers without depression. 

The percentage of ever smokers who no longer smoke increased with age both among persons 

with depression and persons without depression. 

Among ever smokers aged 20–39 with depression, 17% had quit smoking, whereas 36% of 

persons in this age group without depression had quit smoking. Among ever smokers aged 55 

and over with depression, 57% had quit smoking while almost 75% of persons in this age group 

without depression had quit. 

Summary

About 7% of adults aged 20 and over had depression in 2005–2008, based on National Health 

and Nutrition Examination Survey (NHANES) data. Persons with depression were more likely to 

be current smokers than persons without depression. Almost one-half of adults under age 55 with 

current depression were current smokers, while less than one-quarter of people in this age group 

without depression were smokers. 
NCHS Data Brief ■ No. 34 ■ April 2010

■  5  ■

The proportion of adults who were current smokers tended to increase with an increase in 

depression severity. Even persons with mild depressive symptoms below the threshold for 

the diagnosis of depression were more likely to be smokers than people with no depressive 

symptoms. 

Adults	with	depression	were	more	likely	to	smoke	over	a	pack	a	day	and	smoke	their	first	

cigarette within 5 minutes of waking up than were adults without depression. Both of these are 

indicators of heavy smoking. Heavy smoking is highly correlated with inability to quit (6,7). 

Those with depression had a higher rate of smoking initiation (ever smoking) as well as a lower 

quit rate. They were also heavier smokers than persons without depression. Individuals with 

other mental illnesses have similar smoking patterns (8,9). Studies have shown that persons 

with depression and other mental illnesses smoke a disproportionate share of all the cigarettes 

consumed in the United States (8).

The few 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 (5). Adults with 

depression and other mental illnesses are an important subgroup to target for tobacco cessation 

programs. 

Definitions

Depression: Measured in NHANES using the Patient Health Questionnaire (PHQ–9), a 9-item 

screener that asks questions about the frequency of symptoms of depression over the past 2 weeks 

(10). In the PHQ–9, response categories “not at all,” “several days,” “more than half the days,” 

and “nearly every day” are given a score ranging from 0 (not at all) to 3 (more than half the days). 

A	total	score	is	calculated	ranging	from	0	to	27.	Depression	was	defined	as	a	PHQ–9	score	of	10	

or higher, a cut point that has been well validated and is commonly used in clinical studies that 

measure	depression	(10).	No	depression	was	defined	as	a	PHQ–9	score	of	0–9.

The PHQ–9 is based on the diagnostic criteria for major depressive disorder in the Diagnostic 

and Statistical Manual of Mental Disorders, Fourth Edition. Major depression includes mood 

symptoms such as feelings of sadness or irritability, loss of interest in usual activities, inability 

to experience pleasure, feelings of guilt or worthlessness, and thoughts of death or suicide, 

cognitive	symptoms	such	as	inability	to	concentrate	and	difficulty	making	decisions,	and	physical	

symptoms such as fatigue, lack of energy, feeling restless or slowed down, and changes in sleep, 

appetite, and activity levels (11).

In NHANES, it is possible that severely depressed persons disproportionately chose not to 

participate in the survey or health examination, which included administration of the PHQ–9. 

Because smoking rates increase with depression severity, it is possible that the prevalence 

estimates in this report may underestimate the actual prevalence rate of smoking among persons 

with depression. In addition, people who are being successfully treated for depression will not be 

identified	by	the	PHQ–9	as	depressed.	

Because the PHQ–9 instrument assesses depression in the past 2 weeks only, the depression status 

of persons at the time of cigarette smoking initiation or time of quitting is not known. 
NCHS Data Brief ■ No. 34 ■ April 2010

■  6  ■

Depression severity: Refers to the severity of depressive symptoms. The following four severity 

categories	were	defined	based	on	the	total	score	from	the	PHQ–9	screening	instrument	(10):

None or minimal 0–4 

Mild 5–9 

Moderate 10–14 

Severe 15 or more

These depression severity categories are used in Figure 2. In Figures 1, 3, and 4, none or minimal 

and mild depressive symptoms (PHQ–9 scores of 0–9) correspond to “no depression,” while 

moderate and severe depressive symptoms (scores of 10 or more) correspond to “depression.”

Current smoker:	Defined	by	the	question,	“Do	you	now	smoke	cigarettes?”	Persons	who	

responded “every day” or “some days” were included in the current smoker category. Persons 

who	reported	using	only	other	forms	of	tobacco	were	not	included	in	this	definition.

Heavy smokers:	Identified	by	two	questions:	“How	soon	after	you	wake	up	do	you	smoke?	

Would	you	say.	.	.five	minutes,	from	six	to	thirty	minutes,	from	more	than	30	minutes	to	one	

hour,	or	more	than	one	hour?”	and	“During	the	past	30	days,	on	the	days	that	you	smoked,	how	

many	cigarettes	did	you	smoke	per	day?”	The	average	number	of	cigarettes	per	day	was	then	

categorized as less than one pack per day (less than 20 cigarettes), a pack a day (20 cigarettes), 

and more than a pack a day. In population studies, these two questions are a common way to 

measure heavy smoking, which is highly related to nicotine dependence and ability to quit (6,7).

Ever smokers:	Defined	as	answering	“yes”	to	the	question,	“Have	you	smoked	at	least	100	

cigarettes	in	your	entire	life?”	Ever	smokers	include	current	and	former	smokers.

Former smokers or persons who have quit smoking:	Defined	as	answering	“yes”	to	the	question,	

“Have	you	smoked	at	least	100	cigarettes	in	your	entire	life?”	and	“no”	to	the	question,	“Do	you	

now	smoke	cigarettes?”	The	percentage	of	persons	who	have	quit	smoking	is	calculated	using	a	

“quit	ratio”	defined	as	the	number	of	former	smokers	divided	by	the	number	of	ever	smokers	(12).

Data source and methods

NHANES is a continuous survey of the civilian noninstitutionalized U.S. population conducted 

to assess the health and nutrition of Americans. Persons living in institutions, where rates of 

depression and smoking are higher than in the community, are not included in NHANES. Survey 

participants complete a household interview and visit a mobile examination center (MEC) for 

a physical examination and private interview. The annual interview and examination sample 

includes approximately 5,000 persons of all ages. In 2005–2006, non-Hispanic black persons, 

Mexican-American persons, adults aged 60 and over, and low income persons were oversampled 

to improve the statistical reliability of the estimates for these groups. In 2007–2008, the same 

groups were oversampled except that rather than oversampling only Mexican-American persons, 

all Hispanic persons were oversampled.

This report is based on the analysis of data from interviews in the household and in the MEC. 

The questions on cigarette smoking were asked in the household interview and the depression 

questions were asked in the MEC. Questions were administered in English and Spanish. Persons 

who reported using only forms of tobacco other than cigarettes were not considered smokers for 

this analysis. 
NCHS Data Brief ■ No. 34 ■ April 2010

■  7  ■

The NHANES sample examination weights, which account for the differential probabilities 

of selection, nonresponse, and noncoverage, were used for all analyses. Standard errors of the 

percentages were estimated using Taylor series linearization, a method that incorporates the 

sample design and weights.

Differences between subgroups were evaluated using the univariate t statistic. A test for trends 

was done to evaluate changes in the estimates by depression severity and to test for trends by age 

in	Figure	4.	All	significance	tests	were	two-sided	using	p	<	0.05	as	the	level	of	significance.	All	

comparisons	reported	are	statistically	significant	unless	otherwise	indicated.	Data	analyses	were	

performed using SAS version 9.2 (SAS Institute, Cary, N.C.) and SUDAAN version 9.0 (RTI, 

Research Triangle Park, N.C.).

About the authors

Laura A. Pratt is with the Centers for Disease Control and Prevention’s National Center for Health 

Statistics,	Office	of	Analysis	and	Epidemiology.	Debra	J.	Brody	is	with	the	Centers	for	Disease	

Control and Prevention’s National Center for Health Statistics, Division of Health and Nutrition 

Examination Surveys. 

References

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and	well-being	of	depressed	patients.	Results	from	the	Medical	Outcomes	Study.	JAMA	

262(7):914–9. 1989.

2. Katon	WJ.	Clinical	and	health	services	relationships	between	major	depression,	depressive	

symptoms, and general medical illness. Biol Psychiatry 54(3):216–26. 2003.

3. Office	of	the	Surgeon	General.	Smoking	and	Health.	Washington,	DC:	Public	Health	Service.	

1964. 

4. National Center for Health Statistics. Health, United States, 2008, with chartbook. Hyattsville, 

MD: 2009.

5. Ziedonis	D,	Hitsman	B,	Beckham	JC,	Zvolensky	M,	Adler	LE,	Audrain-McGovern	J,	et	al.	

Tobacco use and cessation in psychiatric disorders: National Institute of Mental Health report. 

Nicotine Tob Res 10(12):1691–715. 2008.

6. Heatherton	TF,	Kozlowski	LT,	Frecker	RC,	Rickert	W,	Robinson	J.	Measuring	the	heaviness	

of	smoking:	Using	self-reported	time	to	the	first	cigarette	of	the	day	and	number	of	cigarettes	

smoked	per	day.	Br	J	Addict	84(7):791–9.	1989.

7. Hymowitz N, Cummings KM, Hyland A, Lynn WR, Pechacek TF, Hartwell TD. Predictors 

of	smoking	cessation	in	a	cohort	of	adult	smokers	followed	for	five	years.	Tob	Control	6	Suppl	

2:S57–62. 1997.

8. Lasser	K,	Boyd	JW,	Woolhandler	S,	Himmelstein	DU,	McCormick	D,	Bor	DH.	Smoking	and	

mental	illness:	A	population-based	prevalence	study.	JAMA	284(20):2606–10.	2000.

9. Grant BF, Hasin DS, Chou SP, Stinson FS, Dawson DA. Nicotine dependence and psychiatric 

disorders in the United States: Results from the National Epidemiological Survey on Alcohol and 

Related Conditions. Arch Gen Psychiatry 61(11):1107–15. 2004.
NCHS Data Brief ■ No. 34 ■ April 2010

ISSN 1941–4927 (Print ed.) 

ISSN 1941–4935 (Online ed.) 

CS210343 

T36284 (04/2010) 

DHHS Publication No. (PHS) 2010–1209