Research Article

Smoking and Depressive Symptoms in a

College Population
S. Lee Ridner, ARNP, PhD; Ruth R. Staten, ARNP, PhD;
and Fred W. Danner, PhD

ABSTRACT: A number of studies have documented the relationship between smoking and de-
pression in adolescent and adult populations. The purpose of this study was to examine the level
of depressive symptoms among college-age smokers and to determine whether or not increases in
cigarette use were associated with increases in the number of depressive symptoms. A nonexper-
imental cross-sectional design was used. Of the random sample (N 5 895), 28% were current
smokers, and more than 26% of the total sample reported high levels of depressive symptoms.
Current smokers were more likely to report an increased level of depressive symptoms than non-
smokers were. Correlates of depressive symptoms included grade point average, marijuana use,
and increased work hours. When controlling for these variables, the number of days smoked was
predictive of depressive symptoms. School nurses have an important role in preventing smoking
and treating smokers, as well as in preparing adolescents for the transition to college where many
begin smoking.
KEY WORDS: college students, depression, smoking

INTRODUCTION cigarette smoking is associated with an increased inci-

School nurses play an integral role in the health care
of students. Under their watchful eyes, an untold num-
ber of adolescents (and their parents) make a successful
transition from high school to college. It is a time of
new beginnings, and the possibilities seem endless. It
is also a time when the developmental tasks of identity
formation and an increase in autonomy collide and put
students at risk for a number of behaviors that can have
long-term health consequences. Unfortunately, smok-
ing is one of the behaviors often encountered at this
age. Cigarette smoking is a known contributor to car-
diovascular disease, stroke, cancer, and obstructive lung
disease (Centers for Disease Control and Prevention,
[CDC], 2004a). Now, there is mounting evidence that
S. Lee Ridner, ARNP, PhD, is an assistant professor at the School
of Nursing, University of Louisville, Louisville, KY.
Ruth R. Staten, ARNP, PhD, is an associate professor at the College
of Nursing University Health Service, University of Kentucky, Lex-
ington, KY.
Fred W. Danner, PhD, is a professor at the College of Education,
University of Kentucky, Lexington, KY.
dence of depressive symptoms and major depression.
The purpose of this study was to examine the level of
depressive symptoms among college-age smokers and
to determine whether or not increases in cigarette use
were associated with increases in the number of de-
pressive symptoms, after controlling for other factors
associated with depressive symptoms.
REVIEW OF LITERATURE
Tobacco is the leading cause of death in the United
States, accounting for more than 440,000 American
lives lost every year (CDC, 2002). A nationwide study
of 140 college campuses in 1999 found that nearly one
third of college students 18–24 years of age were cur-
rent smokers (smoked during the past 30 days; Rigotti,
Lee, & Wechsler, 2000). Of the college students who
smoke regularly (on a daily basis), more than one
fourth transitioned to daily smoking while in college
(Wechsler, Rigotti, Gledhill-Hoyt, & Lee, 1998). These
findings suggest that during college, cigarette smoking
becomes engrained, putting young people at risk for
numerous tobacco-related diseases.

Volume 21, Number 4 August 2005 The Journal of School Nursing 229
 Of the college students who smoke
regularly (on a daily basis), more than
one fourth transitioned to daily smoking
while in college.
Several large epidemiological studies of adults have
found an association between smoking and major de-
pression (Breslau, Kilbey, & Andreski, 1991; Glassman,
Helzer, Convey, Cottler, Stetner, Tipp, & Johnson,
1990). A major depressive episode is a period longer
than 2 weeks during which there is either a depressed
mood or loss of interest in nearly all activities (Amer-
ican Psychiatric Association, 2000). The mood distur-
bance must be accompanied by at least four other
symptoms (e.g., significant weight loss/gain, insom-
nia/hypersomnia, psychomotor agitation/retardation,
fatigue, feelings of worthlessness/guilt, decreased con-
centration, and morbid thoughts). The symptoms
must persist nearly every day for most of the day. The
depressive symptoms must be accompanied by signif-
icant clinical distress, social or occupational distress,
or a functional change in other important areas. Al-
though a number of instruments exist to screen for
the depressive symptoms, the diagnosis of depression
must be made in the clinical setting to differentiate
between major depressive episodes and other organic
causes of mood disturbances.
Nicotine, the active drug in cigarettes, has a wide
variety of psychopharmacologic effects. It is thought to
increase serotonin levels and endogenous opioids and
to stimulate dopamine receptors in the brain, thereby
elevating mood (Pomerleau & Pomerleau, 1987; U.S.
Department of Health and Human Services, 1988).
Among current smokers, scores on measures of depres-
sive symptoms have been correlated with the amount
that both men and women smoked (Haukkala, Uutela,
Vartiainen, McAlister, & Knekt, 2000). Prospective co-
hort studies with young adults (ages 21–30) showed
that a history of major depression at baseline increased
the risk of daily smoking, and daily smoking at baseline
increased the risk of subsequent episodes of major de-
pression (Breslau, Kilbey, & Andreski, 1993; Breslau, Pe-
terson, Schultz, Chilcoat, & Andreski, 1998). Because
most first-time smoking occurs in adolescence (U.S. De-
partment of Health and Human Services, 1994), studies
also have been conducted with this population to bet-
ter understand the phenomena.
Among current smokers, scores on
measures of depressive symptoms have
been correlated with the amount that both
men and women smoked.
In adolescents, studies also have shown links be-
230 The Journal of School Nursing August 2005
tween smoking and depression (Escobedo, Reddy, &
Giovino, 1998; Goodman & Capitman, 2000; Patton,
Carlin, Coffey, Wolfe, Hibbert, & Bowes, 1998; Vogel,
Hurford, Smith, & Cole, 2003; Wu & Anthony, 1999).
Some researchers have found that higher levels of de-
pressive symptoms at baseline increased the risk of
smoking initiation in this age group (Escobedo, Reddy,
& Giovino, 1998; Patton, Carlin, Coffey, Wolfe, Hib-
bert, & Bowes), whereas others found evidence for the
opposite: Goodman and Capitman, as well as Wu and
Anthony, noted that current smoking increased the risk
of depressive symptoms at follow-up. The complexity
of the causal relations has led some investigators to
posit that smoking and depression have a shared eti-
ology (Breslau, Peterson, Schultz, Chilcoat, & Andreski,
1998).
An increased level of depressive symptoms has been
associated with many other factors besides smoking.
Increased levels of depressive symptoms are found dur-
ing late adolescence among college students, when
compared with levels in the general population (Blum-
berrry, Oliver, & McClure, 1978; Nolan & Willson,
1994; Sherer, 1985; Wells, Klerman, & Deykin, 1987).
In general, women are more likely than men to report
depressive symptoms (Kessler, McGonagle, Swartz,
Blazer, & Nelson, 1993; Weissman, Bland, Joyce, New-
man, Wells, & Wittchen, 1993; Weissman & Klerman,
1977). Adolescents who use alcohol and other drugs or
who have poor academic performance (Diego, Field, &
Sanders, 2003), and college students who are heavy ep-
isodic drinkers are more likely to report an increased
level of depressive symptoms (Weitzman, 2004). Lenz
(2004) documented a sevenfold increase in smoking
among young college students who reported a lifetime
diagnosis of depression or treatment for depression.
There are no known reports of the correlation between
the frequency of cigarette smoking and the level of de-
pressive symptoms in the college population. This
study will examine smoking and level of depressive
symptoms in a college population.
METHODS
Measures
The survey instrument was an 89-item questionnaire
adapted from the CDC National College Health Risk
Behavior Survey (NCHRBS) and included questions
about safety, sleep, nutrition, exercise, alcohol, tobacco
and other drugs, sexual health, and mental health
(CDC, 1997). Current cigarette use was assessed using
an ordinal measure of the frequency of smoking. Stu-
dents reported how many days during the last 30 that
they smoked. Responses ranged from 1 (none) to 7 (all
30 days). Binge drinking (five or more drinks at one
sitting) was measured using the same 7-item ordinal
scale. Marijuana use was also assessed using a 7-item
ordinal scale. However, responses for the marijuana
item ranged from 1 (none) to 7 (more than 100 times).
Volume 21, Number 4
 The Centers for Epidemiologic Studies Depression
Scale (CES-D) was used to measure depressive symp-
toms (Radloff, 1977). The CES-D contains 20 questions
that measure the presence of symptoms and com-
plaints associated with depression. The items are
scored from 0 (rarely or none of the time) to 3 (most
or all of the time), which results in a total score rang-
ing from 0–60. The standard cutoff score for an in-
creased level of depressive symptoms is greater than
or equal to 16. The Cronbach’s alpha is reported be-
tween .85 and .91 (McDowell & Newell, 1996). De-
mographic data also were collected.
Sample
This cross-sectional survey collected data from a
random sample of 1,700 18- to 24-year-old undergrad-
uate students who were registered full-time for classes
during the Spring 2004 semester at a southeastern
public university. The university registrar randomly
selected a sample from the list of enrolled undergrad-
uates (n 5 18,000). Mailing labels were provided to the
investigators.
Procedure
Participants received a mailed questionnaire with a
cover letter explaining the purpose of the study and
the importance of participating. The participants were
encouraged to respond and to return the question-
naire in the enclosed, addressed, stamped envelope.
Two dollars were included in the mailing as an incen-
tive for completing the questionnaire. The study used
a passive consent procedure. Completing and return-
ing the questionnaire served as informed consent to
participate. All research protocols and procedures were
reviewed by the institutional review board of the uni-
versity to ensure participant protection.
Stamped postcards with the subjects’ names also
were included with the questionnaire. Respondents
were asked to complete both the questionnaire and
the postcard and to return the postcard separately to
indicate completion of the questionnaire. This proce-
dure preserved the anonymity for the participants
while allowing the researchers to track who should re-
ceive a follow-up questionnaire. One week after the
questionnaires were mailed, a postcard was sent re-
minding the participants of the importance of the
study and requesting completion and return of the
questionnaire. Approximately 3 weeks following the
initial mailing, second follow-up letters and replace-
ment questionnaires were mailed to all who had not
returned a postcard. An attempt was made to find cor-
rect addresses for those whose questionnaires had
been returned as undeliverable. After the second ques-
tionnaire mailing, those who did not return question-
naires were considered nonrespondents, and no fur-
ther follow-up was made (Dillman, 2000).
Volume 21, Number 4 August 2005
RESULTS
A total of 895 completed questionnaires were re-
ceived and 125 were undeliverable, yielding a re-
sponse rate of 57%. More females (61%) responded
than their proportion in the larger undergraduate
sample from which they were selected. The partici-
pants were similar to the population in race (91% were
White-non-Hispanic), and 27% held membership in a
social fraternity or sorority. The participants were
more likely to live in residence halls (34%) than was
the student body as a whole (25%). The mean age was
21 years, and 98% were single. The majority (77%)
described their health as good; 43% did not work for
pay, and 19% worked 20 hours or more. The respon-
dents were similar to the population in class standing:
freshman, 26%, sophomores, 23%, juniors, 23%, and
seniors 28%.
Analysis of Variables
Overall, 28% of the students reported smoking at
least one time during the past 30 days. Of the current
smokers, 50% smoked fewer than 10 days, 27%
smoked between 10 and 29 days, and 23% smoked
daily during the past month. Nearly 90% were light
smokers, smoking 10 or fewer cigarettes per day. Only
1% of smokers reported smoking greater than one
pack per day (more than 20 cigarettes). More than
50% of the students who ever smoked regularly (every
day for 30 days) did so after age 17. Of the current
Nearly 90% were light smokers, smoking
10 or fewer cigarettes per day. Only 1%
of smokers reported smoking greater than
one pack per day.
smokers, 33% who ever smoked regularly reported do-
ing so after age 17. See Table 1 for the demographic
characteristics of the smoking and nonsmoking
groups. The mean score on the CES-D was 11.9 (SD 5
8.9), with scores ranging from 0–52. More than 26%
of the sample reported an increased level of depressive
symptoms with a CES-D score $16. More than 39% of
the students reported that they did not binge-drink
during the past 30 days. Of those who reported drink-
ing five or more alcoholic beverages in one sitting,
61% reported between one and five episodes. The re-
mainder (39%) reported binge drinking anywhere
from 6 days to every day. Current marijuana use was
reported by 21% of the students. Of those who used
marijuana during the past 30 days, more than one
third (35%) reported using the drug once or twice. The
students were performing well academically. The ma-
jority (61%) reported a grade point average (GPA) of
3.0 or greater.
Analysis of Smoking Groups. The smoking and non-
The Journal of School Nursing 231
smoking groups did not differ on age, race, place of
residence, or GPA. The current smokers were more
likely to be men (32%) than women (26%), x2(1, N 5
895) 5 4.1, p , .05. Current smokers reported binge
drinking a greater number of times (t892 5 12.8, p ,
.001) and smoking marijuana more frequently (t762 5
4.7, p , .001) during the past month than the non-
smoking group.
Analysis of Depressive Symptoms. A significantly
higher mean score on the CES-D was reported by the
current smokers (t836 5 2.7, p 5 .01). When using the
dichotomous form of the variable (score $16 on the
CES-D), the current smokers continued to report high-
er levels of depressive symptoms than the nonsmok-
ers, x2(1, N 5 738) 5 7.6, p , .01. Even when the more
conservative cutoff point of $20 was used for the CES-
D score, smokers continued to report more symptoms,
x2(1, N 5 738) 5 4.7, p , .05. The CES-D mean scores
did not differ by sex or place of residence. Also, there
were no differences when dichotomizing the variable
by sex or place of residence. Minority participants did
report a greater number of depressive symptoms (t838
Table 1. Demographic Characteristics of Smoking Groups (N
5 895)
Groups
Current
Nonsmoker Smoker
Characteristic n (%) n (%) Total N (%)
5 2.3, p 5 .02), and there were significant intercorre-
lations between the CES-D score and several study var-
iables. Higher CES-D scores were associated with a
lower GPA, a greater number of hours worked, in-
creased marijuana use, and an increased number of
days smoked (Table 2).
A significantly higher mean score on the
CES-D was reported by the current
smokers.
Multivariate Analysis. Hierarchical linear regression
was conducted to explore the association between
number of days smoked and level of depressive symp-
toms, while controlling for GPA, hours worked, mar-
ijuana use, and binge drinking. The covariates entered
the model simultaneously in step one; next, the num-
ber of days smoked entered the model. When the CES-
D score was regressed onto the predictor variables, the
overall model was significant for predicting depressive
symptoms (p , .01), and the number of days partici-
pants smoked was a significant predictor of depressive
symptoms even after controlling for several known
correlates of depression (Table 3).
DISCUSSION

Gender
National data show that the current smoking rates
Male 235 (36) 110 (44) 345 (39) of college men and women are very similar, 22% and
Female 409 (64) 141 (56) 550 (61) 23%, respectively (Johnston, O’Malley, & Bachman,
Age 2004). However, the current study revealed that cur-
18–20 392 (61) 145 (58) 537 (60) rent smokers were more likely to be men than women.
21–24 249 (39) 105 (42) 354 (40) A greater number of women returned the survey com-
Ethnicity pared with the reference population, and this may
Caucasian 570 (91) 229 (92) 799 (91) have skewed the results. Another possible explanation
Minority 60 (9) 20 (8) 80 (9) is that in a southeastern state known for tobacco pro-
Housing duction, a higher number of men in the 18- to 24-
On campus 324 (50) 109 (43) 433 (48) year-old age group actually smoke. Statewide data for
Off campus 299 (46) 136 (54) 435 (49) the general population in the 18- to 24-year-old age
Parents 19 (3) 6 (2) 25 (3) group showed that 35% of men and 31% of women
Others 1 — — — 1 — were smokers (CDC, 2004b). Therefore, the college
Hours worked students may be exhibiting the behaviors found in the
None 278 (43) 107 (43) 385 (43) larger population. For the daily smokers, there was no
20 or less 253 (39) 85 (34) 338 (38)
difference between men and women. This trend is
More than 20 112 (17) 58 (23) 170 (19)
similar to that found in the larger population of U.S.

Table 2. Intercorrelation between CES-D and Study Variables

Hours Marijuana Days Smoked
GPA Worked Past 30 Days of Past 30

CES-D 2.125* .071* .066* .110**

GPA .019 .021 2.020
Hours worked .002 .081**
Marijuana use in past
30 days .315**
Note. CES-D 5 Centers for Epidemiologic Studies Depression Scale.
* p , .05, ** p , .01.

232 The Journal of School Nursing August 2005 Volume 21, Number 4
college students (Johnston, O’Malley, & Bachman,
2004).
Even though women were overrepresented in the
sample, there was not a difference in the level of de-
pressive symptoms that they reported, compared with
men. This finding is consistent with earlier studies of
depressive symptoms in college students (Nolan &
Willson, 1994; Wells, Klerman, & Deykin, 1987). More
recent studies of college students that measured psy-
chological distress (including depressive symptoms)
did find gender differences between the symptoms
(Adlaf, Gliksman, Demers, & Newton-Taylor, 2001;
Rosenthal & Schreiner, 2000). It is unclear why some
samples of college women and men do not differ on
the reporting of depressive symptoms and others do
differ. In the overall sample, 26% of women and men
reported an increased level of depressive symptoms.
This rate is well above the adult rate (9.5%) for affec-
tive disorders in the United States (Regier, Narrow,
Rae, Manderscheid, Locke, & Goodwin, 1993), but
consistent with higher levels of depressive symptoms
in other college samples (Wells, Klerman, & Deykin).
A key finding of this study was that college smokers
report higher levels of depressive symptoms than non-
smokers. Although the relationship is well document-
ed in both adolescent and adult populations, this is
one of the first reports in a college sample. Also, this
study offers some support for the assumption that an
increase in number of days smoked is associated with
an increased level of depressive symptoms among col-
lege students.
A key finding of this study was that
college smokers report higher levels of
depressive symptoms than nonsmokers.
There are a number of limitations to the current
study, the most important being the cross-sectional
design. A prospective cohort study of college students
that measures the change in behaviors over time could
add greatly to the current literature. In addition to fol-
lowing a cohort of students, a study that uses multiple
methods of data collection may produce more accu-
rate results. This would help reduce the limitation of
self-report data. The sample itself had some limita-
tions. The study sample was mostly Caucasian, well
Table 3. Predictors of Depression in College-Age Students
Standardized
Variables Beta
GPA 2.084
Hours worked .047
Marijuana use in past 30 days .039
Binge drinking in past 30 days 2.073
Days smoked in past 30 days .098
Note. R2 5 .024.
Volume 21, Number 4
educated, middle class, and from a state known for its
tobacco production. Thus, the generalizability of the
findings to other groups of college students may be
limited. A follow-up study using a stratified sampling
strategy would help reduce potential error.
IMPLICATIONS FOR SCHOOL NURSING PRACTICE
There are a number of recommendations that are
important for school nurses. Prevention is paramount.
Although for many, initiation and establishment of
smoking begins in middle or high school, smoking
continues to be a concern as students enter college.
Continued dialogue between parents and their stu-
dent about smoking is important for reducing the
short- and long-term consequences of smoking. In
preparation for the transition from high school to col-
lege, school nurses and others involved in the process
of anticipatory guidance for college-bound students
must promote health behaviors that may decrease or
may prevent the adoption of smoking and other un-
healthy behaviors. Of the current smokers in this
study, 33% who ever smoked regularly reported doing
so after age 17. School nurses have an important role
in the prevention and treatment of the 67% of current
smokers who started at earlier ages.
Although for many, initiation and
establishment of smoking begins in
middle or high school, smoking continues
to be a concern as students enter
college. Continued dialogue between
parents and their student about smoking
is important for reducing the short- and
long-term consequences of smoking.
Other preventive strategies include policy changes
to make all residence halls smoke-free. Weschler and
colleagues (2001) found that smoke-free residence
halls provided protection against smoking initiation
after 19 years of age. Making all residence halls smoke-
free may prevent the initiation of nonsmokers and the
transition of current smokers to daily smokers, and
may have an impact on mental health in the college-
age population. Also, attention to the experience of
t p
22.186 .029
1.207 .228
0.959 .338
21.768 .077
2.266 .024
August 2005 The Journal of School Nursing 233
depressive symptoms in college students, and partic-
ularly in those who are smoking as well as engaging
in other risky behaviors, is important in reducing the
immediate concerns related to depression. This is also
an opportunity to prevent unhealthy behaviors and
what could be lasting consequences of depression as
it affects short- and long-term goals. Finally, current
clinical guidelines recommend treating tobacco de-
pendence in children and adolescents, as well as in
adults (Fiore, Bailey, Cohen, Dorfman, Goldstein,
Gritz, Heyman, Jaen, Kottke, Lando, Mecklenberg,
Mullen, Nett, Robinson, Stitzer, Tommasello, Villejo,
& Wewers, 2000). Appropriate interventions for chil-
dren include counseling and behavioral therapy,
whereas prescription bupropion or nicotine replace-
ment therapy (NRT) may be considered when treating
adolescents. There is no evidence that bupropion or
NRT is harmful to adolescents (Fiore and colleagues);
therefore, it is important to explore the use of phar-
macotherapy in this population.
The 18- to 24-year-old age group is relatively
healthy and free of chronic conditions, but their phys-
ical and mental well-being is compromised by smok-
ing. School nurses are in a unique position to inter-
vene and to affect the health of a large number of
adolescents. Efforts to assess, to counsel, and to treat
smoking among students will improve lives and will
prevent disease sequelae for an entire generation.
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