May 14, 2001 -- Growing up has never been easy. For girls, pressures and expectations lurk everywhere. Be thin. Fit in. Find a boyfriend.

"There's such insecurity," says psychiatrist Jerilynn Ross, MA, who specializes in treating anxiety disorders. "Teenage girls are so vulnerable. They're anxious about all kinds of things -- the cliques, the boys, their weight. If there's something that gives them a false sense of security, that makes them feel cool, like part of the crowd, they'll do it. They mask their anxiety by hiding behind a protective wall of conformity." Smoking is considered by some girls to be the solution to their anxiety. It turns out, however, that just the opposite may be true. Young smokers may be creating greater anxiety problems for themselves later on. In fact, new research links teen girls' smoking to the onset of anxiety disorders and sudden, unprovoked panic attacks when they reach their 20s and 30s. Why Chicks Flick For many girls, cigarettes seem almost inevitable. Fifteen-year-old Kimberly has been smoking since she was 11, says Marie Justabis, a health teacher at Hazlehurst High School in Jackson, Miss. "She was just doing it to do it. All her friends smoked. Her parents weren't around; she could pretty much do as she pleased." It's the same story for 18-year-old Amy, who lives just down the road from Kimberly. She, too, started smoking because everyone else did, says her counselor, Pamela Luckett. (WebMD is not revealing the girls' last names to protect their privacy.) In fact, more women and girls are taking up smoking than ever before, according to an alarming new report by the U.S. surgeon general. Presently, more than 20% of adult women are regular smokers, and about 30% of high school senior girls have smoked in the past 30 days. Given the widespread knowledge of how harmful cigarette smoking is, we're left with one question. Why? "Many girls believe that smoking helps control weight," says S. Bryn Austin, ScD, an adolescent health researcher at Boston Children's Hospital and a pediatrics instructor at Harvard Medical School. "The tobacco industry certainly markets cigarettes this way in young women's magazines." In fact, girls who are preoccupied with their weight are four times more likely to take up smoking, according to research Austin published recently in the American Journal of Public Health. Both smoking and dieting are ways girls try to cope with their weight concerns, those researchers say. Girls also light up in an attempt to calm their nerves, to help them relieve anxieties they feel in social situations, says Jeffrey G. Johnson, PhD, of Columbia University and the New York State Psychiatric Institute. "If they're anxious in a crowd, cigarette smoking gives them something to do. They feel like they're fitting in with the group, in sync with everyone." But if they're trying to feel better, research shows they may be accomplishing just the opposite. Cigarettes Bad for Body and Mind In a study of nearly 700 young adults between ages 16 and 22, Johnson and colleagues found no evidence that anxiety disorders lead to smoking -- but, instead, that smoking leads to anxiety disorders. Teens who smoked at least one pack of cigarettes a day were 15 times as likely to develop panic disorders during early adulthood when compared with nonsmokers, according to their research. "Those who smoked daily -- but less than a pack a day -- were 2.5 times more likely to develop panic disorder or other severe anxiety disorders," Johnson tells WebMD. Among the other disorders for which smokers are at risk: Those who smoked heavily as teens were five times more likely to develop generalized anxiety disorder, characterized by feelings of apprehension and breathing difficulties. They were seven times more likely to develop agoraphobia, an incapacitating fear of open spaces. "These are serious short-term consequences," says Johnson, who published his findings in the Nov. 8 issue of The Journal of the American Medical Association. Here's what researchers think happens: After only a few years of smoking, lung damage seems to impair breathing, causing the so-called smoker's cough. Smoking also reduces lung capacity, so the smoker takes in less oxygen, and exhales less carbon dioxide. Doctors have known for some time that carbon dioxide can trigger panic in some vulnerable people. In fact, in scientific studies of anxiety disorders, researchers will administer carbon dioxide to set off a panic attack. Thus, smoking to settle one's nerves initiates a vicious cycle. The lung damage gets worse the longer girls smoke, triggering anxiety, which in turn leads to more smoking as girls try to calm their nerves. Panic Attacks 'Very, Very Scary' Nicotine may offer a double-whammy of anxiety. Likely the jitteriness girls experience at times is related to nicotine withdrawal between cigarettes, says Johnson. "If they find that a cigarette is calming, it's because it reduces the withdrawal symptoms -- irritability, anxiety." There's also evidence that smoking can relieve depression, because of nicotine receptors in the brain. But there's no evidence that people who are just beginning to smoke experience any calming effect, says Johnson. "If anything, they get stimulated, get a slight high or buzz from smoking." The addictive effects of nicotine add to the vicious cycle. "People who quit smoking at first experience increased anxiety from withdrawal," he tells WebMD. "That's led a lot of people to believe that smoking keeps anxiety levels down. But studies have shown that after a few weeks -- if they stay away from cigarettes -- their anxiety levels will drop below their presmoking levels," Johnson says. The body's panic response is believed by some experts to be an evolutionary leftover, a device that once ensured survival. In people prone to panic attacks, the response occurs out of the blue, says Patricia Cohen, PhD, professor of epidemiology and psychiatry and co-author of Johnson's paper. Carbon dioxide in the bloodstream stimulates breathing, and excess amounts of it alert the brain that it is in danger of suffocating. Because the evolutionary mechanism sets off a false alarm in some people, they are much more sensitive to levels of carbon dioxide in the bloodstream. Their bodies overreact. The prevailing theory is that panic attacks are often triggered by respiratory problems that are not recognized as such, says Cohen. "Panic attacks often carry fear of death," Cohen tells WebMD. "People who have them don't really know what's caused them. There's trouble breathing, a racing heart, you often break out in a sweat. Panic attacks are very, very scary." Generalized anxiety disorder and agoraphobia have similar symptoms of respiratory distress provoked by nothing specific, she tells WebMD. However, other anxiety disorders like social phobia or a fear of insects might cause the same respiratory distress symptoms, but they generally start exclusively with anxieties over specific stimuli. It's not that everybody who gets panic attacks smokes, says Cohen. "And not everybody who smokes gets anxiety disorders. Genetics likely creates vulnerability, determining who among smokers will develop an anxiety disorder. But social environment also plays a role." Nicoteens Two-thirds of the 16- and 17-year-olds who smoke want to quit but can't, says Mathew Myers, president for Campaign for Tobacco-Free Kids. Up until now, few smoking-cessation programs have been available to kids. But now -- thanks to settlement money pouring in from tobacco industry lawsuits -- they can be found in virtually every state. Generally, these programs include a toll-free "Quitline" manned by counselors, as well as group counseling sessions specifically for teens held in schools and in community centers. "A few of those programs are just over year old, but already have begun showing preliminary positive results," says Myers. In fact, a study in the April issue of the journal Pediatrics focused on smoking-cessation programs in Baltimore schools. Researchers there found that such programs have a big impact on helping teens quit smoking. Ten weeks after the program ended, 41% were no longer smoking; after another 10 weeks, 31% were still smoke-free. To be successful, says Ross, programs have to look deeply at the reasons kids start smoking in the first place. If it's insecurity, low self-esteem, those issues must be dealt with. "Otherwise she may quit smoking, but she'll also find something else to cover up her problems," she says. Working with the state of Mississippi's "Quitline," Amy has begun to cut back on smoking; she's now down to three cigarettes a day, says counselor Pamela Luckett. She's also put her foot down at home; no one smokes in the house anymore -- or in the car. Her driving force: She's worried about the effects of her smoking on her newborn infant. There's also the financial aspect; she wants to buy a house, and smoking is expensive, as Luckett pointed out to her. Group sessions at Hazlehurst High School -- where Kimberly is a sophomore -- have helped her cut back, too, says Justabis, who also serves as volunteer facilitator for the school's NOT (Not On Tobacco) smoking-cessation program. Appeals to the girl's vanity helped there. "She had noticed changes in her skin, but didn't know why. She started cutting back immediately when she realized what it was doing to her skin." Millions of teens keep their smoking secret from parents as long as they can. "What that means is they have already moved from experimental smokers to habitual users before their parents know and can help get them to services that will help them quit," Myers tells WebMD. That's precisely why school programs are so critical, says Myers, "because they go where kids are." Some Helpful Advice His advice to parents: "Talk to your kids, create a safe environment for a youngster who has a smoking habit to talk frankly and honestly about how to get help." And to teenagers: "The most important lesson is the longer you smoke, the harder it's going to be to quit. If a no-smoking program for teenagers is offered in your community, see a school nurse or your own personal doctor for help." Ross' advice: "For parents, one of the hardest challenges is helping a kid feel good about herself and at the same time being firm in teaching right and wrong. A child with a good self-image is going to be less vulnerable to outside influences." Also, she says, remember that teen girls are unbelievably sensitive. "Parents make innocent comments about their bodies -- those little boobies, or look at those hips. We have to be so careful because what we say can be so indelible."

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