Revista Adolescência e Saúde

Revista Oficial do Núcleo de Estudos da Saúde do Adolescente / UERJ

NESA Publicação oficial
ISSN: 2177-5281 (Online)

Vol. 14 nº 4 - Oct/Dec - 2017

Original Article Imprimir 

Páginas 97 a 105

Sad-smoke study : Relationship between Smoking with Stress, Anxiety and Depression in Adolescents

Estudio sad-smoke: Relación del TabaquismoconEstrés, Ansiedad y Depresiónen Adolescentes

Estudo sad-smoke: Relação do Tabagismo com Stress, Ansiedade e Depressão em Adolescentes

Autores: Sara Isabel Rodrigues Martins1; Célia Ferreira Folhas Mata2; Pascoal Moleiro3

1. Medical specialty in General and Family Medicine. Master's degree from the Faculty of Medicine of the University of Coimbra (FMUC). Leiria, AC, Portugal
2. Medicine specialty in General and Family Medicine in the Family Health Unit Santiago- in development. Master's degree from the Faculty of Medicine of the University of Lisbon (FMUL). Leiria, AC, Portugal
3. Degree of Consultant of Medical Career and Assistant Graduate of Pediatrics - Doctor of the Pediatric Service of the Hospital Center of Leiria. Leiria, AC, Portugal

Sara Isabel Rodrigues Martins
Unidade de Saúde Familiar (USF) Santiago
Estrada da Mata, nº 56, Marrazes
Leiria, Portugal. CEP: 2415-380

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How to cite this article

Keywords: Smoking, adolescent, depression, anxiety, stress, psychological.
Palabra Clave: Hábito de fumar, adolescente, depresión, ansiedad, estrés psicológico.
Descritores: Hábito de fumar, adolescente, depressão, ansiedade, estresse psicológico.

OBJECTIVE: Characterize the use of tobacco by adolescents between 13-15 years; Identify key fators for smoking behavior; Verify the association between smoking and adolescent depression, anxiety and stress.
METHODS: Cross-sectional and descriptive study with analytical component. Convenience sample of adolescents between 13-15 years attending the 9th grade in schools. It was held from 13 to 30 of April of 2015, using a self-fulfillment confidential and anonymous questionnaire, including part of the GYTS and the EADS-C questionnaires, both validated and translated into Portuguese language.
STATISTICAL ANALYSIS: SPSS 20.0 programm was used for univariate descriptive analysis of numerical variables using the chi-square test (with a 0,05 significance level).
RESULTS: 251 adolescents were analyzed, 51,4% being female, with a mean age of 14,6±0,5 years. It was verified that 32,7% of teens have tried smoking but only 6,8% smoked in the last month. Most of the teens don't think that smokers have more friends, are more at ease in a social event or cigarettes influence body weight. Only 19,1% of adolescents didn't show any depression, anxiety and stress symptoms. The feminine gender had a total score bigger than male with statistically significant difference. There was no statistically significant association between smoking and symptoms of depression, anxiety and stress (p>0,05).
CONCLUSION: This study allowed a better understanding of tobacco use in adolescence as well as attitudes and behaviors towards tobacco. This study was original in this theme and the results may provide a contribution to outline prevention strategies in adolescents.

OBJETIVO: Caracterización del uso de tabaco por adolescentes entre 13-15 años; Identificación de factores clave para el hábito de fumar; Verificaciónde la asociación entre elhumoyestrés, ansiedad y depresiónen adolescentes.
MÉTODOS: Estudio transversal y descriptivo con componente analítico. Muestra de conveniencia con adolescentes entre 13-15 años frecuentando el 9º año escolar. Este fue realizado de 13 a 30 de abril de 2015, utilizando uncuestionario de auto-rellenado, confidencial, anónimo, incluyendo parte delcuestionario GYTS y EADS-C, validados y traducidos a la lengua portuguesa.
ANÁLISIS ESTADÍSTICO: Se utilizóel programa SPSS versión 20.0 para el análisis descriptivo univariabley análisis multivariable utilizando testchi-cuadrado (nivel de significancia de 0,05).
RESULTADOS: Se analizaron 251 adolescentes, 51,4% del sexo femenino con 14,6±0,5 años. Se verificó que 32,7% yahabían experimentado fumar, 6,8% fumaronen el último mes. La mayoría no considera que los fumantes tengan más amistades, estén máscómodosen eventos sociales ni que el cigarro influencie el peso corporal. Apenas 19,1% no presentaroncualquier síntoma de estrés, ansiedad y depresión. El sexo femenino tuve valor de score total superior con diferencia estadísticamente significativa. No se verificó asociación estadísticamente significativa entre experiencia de fumar y síntomas de estrés, ansiedad y depresión (p>0,05).
CONCLUSIÓN: Este estudio permitió mejor conocimiento sobre el consumo de tabaco en la adolescencia, así como de las actitudes y comportamientos. Este estudio fue original enesta temática, pudiendo contribuir para delinear estrategias de prevenciónen adolescentes.

OBJETIVO: Caracterização do uso de tabaco por adolescentes entre 13-15 anos; Identificação de fatores chaves para o hábito de fumar; Verificação da associação entre o fumo e stress, ansiedade e depressão em adolescentes.
MÉTODOS:Estudo transversal e descritivo com componente analítico. Amostra de conveniência com adolescentes entre 13-15 anos frequentando o 9º ano escolar. Este foi realizado de 13 a 30 de abril de 2015, utilizando um questionário de autopreenchimento, confidencial, anônimo incluindo parte do questionário GYTS e EADS-C, validados e traduzidos para língua portuguesa.
ANÁLISE ESTATÍSTICA: Utilizou-se o programa SPSS versão 20.0 para a análise descritiva univariável e análise multivariável utilizando teste qui-quadrado (nível de significância de 0,05).
RESULTADOS: Analisou-se 251 adolescentes, 51,4% do sexo feminino com 14,6±0,5 anos. Verificou-se que 32,7% já tinham experimentado fumar, 6,8% fumaram no último mês. A maioria não considera que os fumantes tenham mais amizades, estejam mais à vontade em eventos sociais nem que o cigarro influencie o peso corporal. Apenas 19,1% não apresentaram qualquer sintoma de stress, ansiedade e depressão. O sexo feminino teve valor de score total superior com diferença estatisticamente significativa. Não se verificou associação estatisticamente significativa entre experiência de fumar e sintomas de stress, ansiedade e depressão (p>0,05).
CONCLUSÃO: Este estudo permitiu melhor conhecimento sobre o consumo de tabaco na adolescência assim como das atitudes e comportamentos. Este estudo foi original nesta temática, podendo contribuir para delinear estratégias de prevenção em adolescentes.


Smoking is the leading preventable cause of premature death and disease. According to the World Health Organization (WHO), the smoking pandemic is responsible for the deaths of 6 million people a year. If left unchecked, could kill millions throughout this century1.

According to estimates made under the Global Burden of Disease 2 initiative (DGB 2010), tobacco consumption was responsible for the deaths of approximately 11,000 smokers or former smokers in Portugal in 2010 (10.3% of the total of deaths this year).

Most smokers begin smoking in their teens. In the European Union, initiation takes place mainly between 12 and 14 years 1 . Adolescence is a period of maturation, where one goes through a contest of habits and customs, in search of oneself.It is in this psychological and social context that tobacco intervenes as a process of socialization. The fact that smoking is considered socially attractive, accompanied by an attitude of rebellion against disapproval by adults as well as the group's pressures, are the main factors that favor adolescents to start smoking and drinking3.

Several studies attempt to identify the predictive factors that lead adolescents to initiate this consumption. The situations with positive relation with the beginning of the consumption are: existence of familiar smokers, academic dissatisfaction, parents or brothers who smoke in the house and to have group of friends smokers4. The identification of the most susceptible adolescents and the previously mentioned factors are the main steps in the primary prevention to be taken to reduce the incidence of smoking.

A study carried out in Portugal in 2006 revealed that at age 13, 20% had tried smoking and about 3% smoked regularly (smokers occasionally and daily)5. When smoking begins, discontinuation is difficult and long-term dependence is likely to occur4.

Another national study on smoking habits conducted with 9th graders applying the Global Youth Tobacco Survey (GYTS ) concluded that half of the adolescents had tried smoking, mostly female children aged 12-15, especially in association with other consumer peers6.

GYTS 7 is a school questionnaire applied to adolescents aged 13-15 years, designed to promote the monitoring of tobacco use in this age group and to guide the implementation and evaluation of smoking prevention and control programs. This questionnaire underwent an expansion and adaptation to the Portuguese reality in its version translated by the National School of Public Health in 20088. According to Farinha et al., There is a relationship between nicotine dependence and severity of anxiety and depression symptoms, especially in the female gender9.

The Anxiety Scale, Depression and Stress (EADS) is the Portuguese version of the Depression Anxiety Stress Scale of Lovibond and Lovibond (1995) adapted by Father Ribeiro, Honored and Leal (2004) 10. This scale was designed with the aim of discriminating the totality of the symptoms of stress , anxiety and depression. Leal et al . (2009) developed a scale to EADS children and adolescents aged 8 to 15 years, the Anxiety Scale, Depression and Stress for Children (EADS-C)11.

Pediatricians and GPs play an important role in preventing smoking by helping parents to stop smoking, which can have a fundamental impact on children's present and future health as well as their behavior in relation to smoking of tobacco12.


The present study aims to: Characterize the use of tobacco by adolescents between 13 and 15 years of age; Identify determining factors for smoking behavior; Check the association between smoking experience and Stress, Anxiety and Depression (SAD).


This cross-sectional, descriptive study with an analytical component was carried out with adolescents aged 13 to 15 years attending the 9th grade of public and private schools in the District of Leiria (Portugal). It was a convenience sample that included adolescents attending schools between April 13 and 30, 2015, who met the inclusion criteria and were invited to participate in the study. We excluded adolescents who refused to participate, those who did not fill out the questionnaire correctly and adolescents under the age of 13 years and above or equal to 16 years.

Data were collected through the application of a confidential, anonymous self-completion questionnaire, after written authorization from the parents. Previously a letter was sent to the Direction of each school establishment to obtain consent for the participation of the study.

A questionnaire constructed by the researchers was used, which includes part of the GYTS questionnaire and the EADS-C questionnaire, both validated and translated into Portuguese used in a free way.

GYTS is a school questionnaire applied to adolescents between 13 and 15 years of age. The questionnaire on smoking habits has a total of 73 questions subdivided into six groups: tobacco use and consumption: questions from 1 to 16;knowledge and attitudes of respondents to tobacco: questions 17 to 34; exposure to tobacco smoke: questions from 35 to 42; attitudes to quit smoking: questions from 43 to 53; knowledge of social media messages about smoking habits: questions from 54 to 68; role of the school as a vehicle for information about tobacco maladies: questions from 69 to 738.

Only 24 questions from the GYTS questionnaire were used because they were the ones that best fit the present study. The EADS-C scale consists of 21 questions that are distributed in three dimensions with seven items each: Stress , Anxiety and Depression. The items included in each dimension propose to evaluate theoretically inclusive aspects of the dimension: Depression- Dysphoria, Discouragement, Devaluation of life, Self-depreciation, Lack of interest or involvement, Anhedonia, Inertia;Anxiety - Autonomic System Excitation, Muscle Skeletal Effects, Situational Anxiety, Subjective Anxiety Experiences; Stress - Difficulty in Relaxing, Snowy Excitement, Easily Agitated / Upset, Irritable / Exaggerated Reaction, Impatience.

The response is given on a Likert scale, where the individual assesses the extent to which they have experienced each symptom during the last week, on a four-point scale of severity or frequency. The scale provides three notes, one for each dimension, determined by the sum of the results of the seven items. The minimum is zero and the maximum is twenty-one, with the highest scores corresponding to the most negative affective states11.

A "sense of coherence" questionnaire was also carried out, consisting of 29 questions organized on the Likert scale of 7 points and a sociodemographic questionnaire of 14 questions.

The data were recorded in electronic database built by the researchers in the program SPSS version 20.0. The univariate descriptive analysis of the numerical variables included minimum, mean, maximum, median and standard deviation;categorical variables were described for absolute and relative frequencies. The association between smoking and depression, anxiety and stress was measured using the t-student test for a significance level of 0.05. In order to minimize bias, two validated questionnaires were used and translated into Portuguese.


Of the questionnaires distributed by the schools were obtained 251 correctly filled and used in this study. Four schools from the region of Leiria participated, two of public education and two of private education, all inserted in an urban environment. Of the 251 adolescent respondents, 51.4% (n = 129) were female with ages ranging from 13 to 15 years, mean age of 14.6 years (± 0.5 years), fashion and median 15 years.

Regarding tobacco experimentation, 32.7% of adolescents (n = 82) did so and 67.3% (n = 169) never smoked as can be seen from Table 1. The experimentation was similar between the sexes. Of the adolescents who had previously tried smoking, the majority were 15 years of age, with a statistically significant difference in relation to the lower ages (p <0.05).

Regarding the age they had when they first tried smoking, 14.7% (n = 37) experienced tobacco between the ages of 14 and 15 years, followed by the age between 12 and 13 years with 13.1% adolescents (n = 33). Of those who have tried smoking, 6.8% (n = 17) maintained their consumption in the last month and 4% smoked on average 2 to 5 cigarettes per day. When asked about the place where smoking is most common, the most important were the parties and social gatherings (47.1%).

With regard to the surrounding social environment, there are several protective factors: most have a best friend who does not smoke (58.2%), do not observe teachers smoking at school (51%), 79.7% were informed by relatives of the negative effects of smoking. Most students (94.8%) believe that tobacco is harmful to their health, even if they smoke for only one to two years (62.5%). However, 98 of the students have at least one parent smoker (39%).

Regarding smoking-related beliefs (Table 2) and how to see the smoker (Figures 1 and 2), most do not believe that smoking increases the number of friends or helps in disinhibition during parties. Most of the adolescents considered a smoker girl less attractive (59.8%) while no differences were found in the attractiveness of a smoking boy (49.8%). Regarding weight loss or gain with tobacco, 45.4% thought there was no change, while 44.2% believed that tobacco made them thin.

Figure 1. Beliefs of adolescents analyzed in relation to smoking if the smoker is female (values expressed as a percentage).

Figure 2. Beliefs of adolescents analyzed in relation to smoking if the smoker is male (values expressed as a percentage).

When questioned about the opinion on adolescents who smoke, most consider them to be stupid because they smoke (45.0% when questioned about girls who smoke and 44.2% if smokers are male) and that 31 , 1% of girls and 21.9% of boys feel lack of confidence / insecurity.

In this study, the EADS-C scale with 21 questions was used to ascertain the presence of stress (S), anxiety (A) and depression (D) symptoms in the sample of adolescents under study and in the attempt to relate these symptoms to the consumption of tobacco. The results are expressed in Table 3. It was verified that only 19.1% of the students did not present any symptom of these three dimensions (SAD), with zero points in the whole scale. The mean of the EADS-C scale was 9.0 adolescent undesirable points presented ≥ 42 points.

Concerning anxiety, the lowest mean of the three dimensions was found, with 1.9 points, with the minimum and maximum score being between 0 and 21 points, showing anxiety levels below the midpoint of the scale (11 points).

Regarding the total scale for the three dimensions (SAD), it was found that the mean was higher in females (11.2 points) than in males (6.5 points). We analyzed the possible association between sex and the presence of SAD symptoms by applying the t-student test , where there was a statistically significant difference between the female sex and higher levels of SAD symptoms (p <0.001). The presence of SAD symptoms, evaluated by the EADS-C scale, did not show a statistically significant association with the tobacco experience (p> 0.05).


The prevalence found in the sample in relation to tobacco experimentation was 32.7%, being similar between both sexes. This percentage is lower than that found in another study carried out in 2013 6 with 9th grade students, where a prevalence of 52% was obtained and the female sex was predominant in the experimentation (55.9%).

According to the WHO (2004), 62% of the adolescents experimented with smoking at age 15, which is in agreement with the data obtained in this study: 69.5% experienced tobacco at age 15, being this value statistically significant in relation to lower ages. This study demonstrates the importance of initiating health education at an early age and is one of the main ways to prevent the acquisition of smoking habits in adolescence.

According to Correia et al.3, 6.6% of the adolescents analyzed recognized smoking currently, and of these, about 58% do it daily. Similar values were found in our study where 6.8% of the students reported consuming the substance, of which 82.4% daily. However, lower percentages were found in other studies8,12.

Several factors were found against tobacco consumption, similar to what was described in other studies4: only 39% of adolescents have one of the parents smokers, most of them have a best friend who does not smoke, most of the students do not observe teachers smoking at school and 79.7% reported being informed by relatives of the harmful effects of tobacco, which means that 94.8% of the sample considers that tobacco is harmful to health.

Regarding the beliefs associated with smoking, the majority think there is no difference in the number of friends, the disinhibition, the perception of the impact on the weight and the attractiveness of the boys between the smokers and the non-smokers. However, many find that girls who do not smoke are more attractive. These beliefs differ from those presented in the study by Ferreira et al.6 in which there was the realization that smokers have fewer friendships than nonsmokers. Although the school has been pointed out in the literature as the most common place to smoke5, in this study it was found that the place where adolescents smoke mostly are parties and social gatherings.

To evaluate SAD symptoms, the EADS-C scale was used. This scale is practical and quick to apply in children and adolescents, presenting a similar structure to the adult version although the values of the loads of the items in the dimension are less discriminating11. In this study, the majority of adolescents, 80.9%, presented at least one point in the entire scale and the mean was higher in females, and a statistically significant difference was found.

Our study concluded that there is no statistically significant association between tobacco experimentation and the presence of SAD symptoms, however there is a trend towards higher values in those who experienced tobacco. In the literature, no other studies were found to evaluate this issue in adolescents, and this study is innovative in this area. In the Faria et al.9 conducted in adults, there was also no relationship between being a smoker, ex-smoker or non-smoker with symptoms of anxiety or depression.

The methodology used in this study presents some limitations, namely with regard to sample selection, which was a convenience sample for the researchers. The sample may be poorly representative of the target population, since although several schools were contacted, few showed a desire to collaborate with the study in the current school year. The place of filling the questionnaire, in the classroom, in the presence of the teacher, may have biased the answers of the participants. All the schools included in the study belong to the urban environment, which can lead to greater accessibility to tobacco, favoring their consumption.

Further longitudinal studies are needed to better characterize the causal link between smoking and SAD symptoms and to reduce the biases and limitations identified in this study. Although this study has not demonstrated an association between SAD symptoms and smoking, the present investigation has its value for being original in this theme and served to better understand the problem of smoking in adolescence.

The results obtained in this study help in the acquisition of primary preventive efforts in smoking in adolescents in order to create fundamental tools to reduce their incidence. Physicians with greater contact with this age group (general practitioners, family physicians and pediatricians) play a major role in the prevention of these risk behaviors, and may have a fundamental impact on the present and future health of the population.


1. World Health Organization. WHO report on the global tobacco epidemic, 2013.[acesso em Março de 2015. Disponível em:

2. Global Burden of Disease. 2010. [acesso em Março de 2015]. Disponível em:

3. Correia P., Carvalho I., Campos R. A. Consumo de Tabaco e Álcool em Adolescentes de Vila Nova de Gaia. ActaPediatrica Portuguesa 2004; 4(35): 329-333.

4. Hock L.K. et al. Correlates of Susceptibility to Smoking among Secondary School Students in Kota Tinggi District, Johor, Malasya. Asian Pacific Journal of Cancer Prevention 2013 14(11): 6971-6978.

5. Fraga S, Ramos E, Barros H. Uso de tabaco por estudantes adolescentes portugueses e fatores associados. Rev. Saúde Pública 2006; 40(4):620-6.

6. Ferreira M, Chitas V, Silva S, Silva R. Hábitos tabágicos dos jovens do 9º ano: estereótipos sobre fumantes, fatores familiares, escolares e de pares e a relação com o consumo de tabaco. Rev Port Saúde Pública 2013; 31(1):108-114.

7. Centers for Disease Control and Prevention. Global Youth Tobacco Survey (GYTS): 2001 handbook. Atlanta: CDC, 2001.

8. GYTS.PT [acesso em Março de 2015]. Disponível em:

9. Farinha H., Raposo de Almeida J., Aleixo A.R., Oliveira H.,Xavier F.,Santos A.I.Relação do tabagismo com ansiedade e depressão nos cuidados de saúde primários. Acta Med Port 2013 Set-Oct; 26(5):523-30.

10. Pais-Ribeiro J.L., Honrado A., Leal I. Contributos para o estudo da adaptação portuguesa das escalas de Ansiedade, Depressão e Stresse (EADS) de 21 itens de Lovibond e Lovibond. Psicologia, Saúde & Doenças 2005, 5: 229-39.

11. Leal I.P., Antunes R., Passos T., Pais-Ribeiro J., Maroco J.Estudo da escala de Depressão, Ansiedade e Stresse para crianças (EADS-C). Psicologia, Saúde & Doenças 2009, 10(2): 277-84.

12. Precioso J., Samorinha C., Macedo M., Antunes H. Prevalência do consumo de tabaco em adolescentes escolarizados portugueses por sexo: podemos ser otimistas? Revista Portuguesa de Pneumologia 2012; 18(4): 182-187.
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