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In these stressful pandemic times, health experts have more reason to circle back to the link between anxiety and smoking: Does anxiety cause people to smoke? Or does smoking cause anxiety?

Like many other aspects of mental health and addiction, there are no cut-and-dried conclusions.

"I think we've generated more questions on the subject than we have answers," said Brian Hitsman, associate professor of preventive medicine at Northwestern University Feinberg School of Medicine in Chicago.

Anxiety disorders are the most common mental health issue in the U.S., affecting between 15% and 19% of the adult population and encompassing everything from phobias and panic attacks to intense fear of social situations and chronic worrying.

While U.S. smoking rates have dropped over the past 50 years, about 1 in 5 American adults – 50.6 million – still reported smoking, vaping or using other tobacco products in 2019, according to the released in November from the Centers for Disease Control and Prevention. That data also showed 45% of people with severe anxiety use tobacco. Even for those with mild anxiety, 30% use tobacco. Yet for those who report little to no anxiety, only 18% use tobacco.

Other shows higher rates of anxiety disorders among smokers than the general population. However, a study released last year in said that despite "robust evidence" linking smoking and anxiety, there are "considerable discrepancies for the precise role of anxiety in smoking onset, severity, and cessation outcomes."

Lorra Garey, the study's lead author, said alcohol and substance abuse could be clouding the true connection. Another complicating factor is the two-way relationship between smoking and anxiety.

"It's this perpetual loop feeding into itself. You have anxiety contributing to smoking … and then you have people becoming addicted to nicotine and experiencing acute withdrawal with symptoms that mimic anxiety," said Garey, a research assistant professor at the University of Houston.

"These things are so interrelated it's hard to tease apart," she said. "Ultimately, we need more rigorous research to really track the different factors over time to fully understand them."

Another problem, Hitsman said, is smokers often mistakenly think having a cigarette will tamp down their anxiety.

"It's in their head that smoking is an effective way to manage their emotional distress, but it's probably only making them feel better because it's helping manage their nicotine withdrawal," he said. "Smoking actually increases your heart rate and causes changes in the body that are opposite of relaxation."

In fact, smoking wreaks havoc on the entire cardiovascular system, releasing chemicals that damage and clog arteries, which can lead to a heart attack or stroke.

Whether tobacco use and anxiety rates have been affected by the COVID-19 pandemic is difficult to pinpoint. But Garey suspects they're rising.

"So many factors that contribute to anxiety – financial burden, child care issues – are making it worse. And there's also a concern about a greater severity of smoking, and people who've quit restarting," she said.

Quitting smoking can be incredibly difficult for anyone, largely because of the presence of nicotine, a highly addictive drug the U.S. surgeon general . During the pandemic, people struggling with nicotine addiction might find it harder than usual to set up doctor's appointments or counseling sessions.

Still, there are a wide variety of methods available to help.

Daily exercise, prescription medicine and nicotine replacement products such as gum, patches or lozenges can help battle the cravings that often accompany nicotine withdrawal, Garey said. She also recommended the National Cancer Institute's free telephone counseling line 800-QUIT-NOW (800-784-8669).

Smokers who have anxiety often benefit the most from exercising, practicing mindfulness and doing "belly" breathing exercises that use the diaphragm, she said.

"Smoking is such an automatic, time-consuming thing, so it can be so helpful to take a break, focus on the moment, and replace smoking with something healthy that you really enjoy."

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