If you are a parent who’s recently discovered that your adolescent has been smoking cigarettes, chances are you’re not thrilled. Will he get lung cancer? Has she been mixing with the wrong crowd? Will smoking be a gateway to something worse? But one thing you may not have thought about amid this mind-swirl is your teen’s mental health. That may be something to not overlook, and here’s why: we and others have shown that young smokers today are more likely to also have other mental health and substance use problems than smokers from their parents’ and grandparents’ generations. In fact, about 40 percent of all cigarettes consumed today are done so by individuals with an identifiable mental disorder. Some key points: While the dropping numbers of American smokers is something to be celebrated, the percentage of smokers who have a mental health issue is on the rise. Why might this be? To understand the increasing mental health problems in today’s young smokers, one needs to look back at the history of smoking itself, which has changed strikingly over the last several decades. In the first half of the 20th century, before risks of the cigarette were widely recognized, smoking was socially acceptable — even glamorized. Things began to change in the mid-1960s, once reports began to firmly link smoking to lung cancer and a host of other diseases. Since then, not only did the number of smokers decrease, but the very reputation of smoking also shifted to that of being an undesirable and risky behavior. Where social cachet had once wooed new smokers, more negative forces such as vulnerability to risky behaviors or adverse peer pressure took over as the drivers of new smokers. If you need a visual illustration of this shift, just look at Hollywood: once a must-have accessory of starlets in every black-and-white film, cigarettes are now largely relegated to a character in distress or one whose life needs turning around. If you have an adolescent who has been smoking, what might this mean for you? First, try and look beyond the smoking itself to consider what else might be going on in their lives. Ask about problems or stresses they may be undergoing in school or with friends that might be contributing to their smoking. Ask how they picked up the habit, and what their first experiences were like. As a society, we’ve become increasingly punitive about smoking, and the knee-jerk response may be to clamp down. But sitting down and ingesting their view of their experience could be a first step to helping them. If your teen is open to the idea, suggest keeping a daily online mood chart or journal. Or keep one as an observer on their behalf. And remember, teenagers spend a large chunk of their day in school. Teacher reports can be extremely illuminating about behavior, because adolescents frequently behave differently at school than they do at home, and some problems that are related to their smoking (learning problems or disruptive behaviors, for example) show up more prominently in classroom settings. If you think that your child might be having emotional or behavioral problems, ask for a fuller evaluation by a mental health specialist. Anti-smoking treatments may not work as well if there’s a mental disorder along for the ride. But never hesitate to be proactive. The advantage of identifying problems early is that any subsequent treatment plan can be tailored in a way that recognizes and addresses both the smoking and any associated mental health problems. For those with mental health issues, solutions that focus only on the smoking-cessation component (nicotine patches, Nicorette or Chantix) are likely to be less effective. Parents may also face a potential conundrum when the smoking appears to be serving a beneficial purpose. For teenagers with chronic anxiety or stress, for instance, the nicotine in cigarettes can actually help calm and reduce symptoms. Similarly, for those with attentional problems, smoking can aid focus. If smoking seems to help my child, one could ask, should I really be encouraging them to quit? But the answer is still a yes. And that’s because there are other treatments available (medications, evidence-based psychotherapies) that can help with related symptoms of anxiety, depression, and inattention that don’t have the addictive or carcinogenic properties of a cigarette. The bottom line: If you have a teenager who is smoking, look beyond the smoke. Adolescent mental health problems aren’t always visible on the surface, and can be easily missed by a parent or by a clinician if not actively probed for. Smoking, on the other hand, is an external behavior, one that is easier to see (and smell too). If teenage smoking can serve as a flag that helps bring attention to other behavioral and mental health problems lying under the surface, the cigarette may be serving a useful purpose after all.