Smoking, traumatic event exposure, and post-traumatic stress: a critical review of the empirical literature

Cognitive-affective characteristics of smokers with and without posttraumatic stress disorder and panic psychopathology

The present study evaluated differences among daily smokers with posttraumatic stress disorder (PTSD), panic disorder (PD), panic attacks (PA), and no axis I psychopathology (past 6 months) in terms of several cognitive-affective variables implicated in both the onset and maintenance of anxiety psychopathology and cigarette smoking. The sample consisted of 123 daily smokers (62% women: M(age)=29.7, SD=11.9). Compared to the PA and no psychopathology groups, the PTSD group reported significantly higher levels of anxiety sensitivity, discomfort intolerance, negative affectivity, anxious arousal, and anhedonic depression; and, the PTSD group reported significantly lower levels of perceived control over anxiety-related events than the PA group. The PD group, compared to those in the PA and no psychopathology groups, reported significantly higher levels of anxiety sensitivity, negative affectivity, and anxious arousal; and significantly lower levels of perceived control over anxiety-related events. No significant differences were evident between the PTSD and PD groups. Theoretical and clinical implications of the present findings are discussed in terms of smoking and emotional vulnerability.

The role of comorbidity in explaining the associations between anxiety disorders and smoking

INTRODUCTION

Research has generally found strong associations between smoking and anxiety disorders. The present study sought to examine the role of comorbidity in explaining these relationships.

METHODS

Participants from the National Comorbidity Survey-Replication (N = 5,692) were included in the present study. Axis I disorders were assessed using the World Mental Health Survey Initiative version of the World Health Organization Composite International Diagnostic Interview. In addition, smoking and mental health treatment history were assessed.

RESULTS

Multivariate analyses covarying for demographic variables and psychiatric and substance use comorbidity found that posttraumatic stress disorder was uniquely associated with every smoking outcome of interest, including 12-month and lifetime daily and heavy smoking, nicotine dependence, and cessation failure. Generalized anxiety disorder and social anxiety disorder were associated with fewer smoking-related outcomes, and contrary to predictions, panic disorder was only independently associated with 12-month daily smoking. Panic attack history, however, was uniquely associated with 12-month daily and heavy smoking, nicotine dependence, and lifetime cessation failure. In addition, analyses indicated that greater number of anxiety disorders was associated with greater prevalence of each smoking outcome, and the presence of even one anxiety disorder was associated with elevated smoking prevalence.

DISCUSSION

Several specific anxiety disorders were found to be uniquely associated with smoking behavior. Findings suggest that comorbidity may only explain the associations with smoking difficulties for some anxiety disorders.

Emotional dysregulation: concurrent relation to sexual problems among trauma-exposed adult cigarette smokers

Despite the documented association between trauma exposure and sexual problems (sexual dissatisfaction and sexual functioning), only a paucity of studies have investigated possible mechanisms underlying this association. The present study tested the role of emotion dysregulation in regard to levels of sexual dissatisfaction and functioning among a sample of 43 trauma-exposed cigarette smokers (17 women; M(age) = 20.20, SD = 10.87). When controlling for negative affectivity, type of trauma (sexual vs. nonsexual), daily smoking rate, posttraumatic stress symptoms, and anxiety sensitivity, emotion dysregulation provided an independent and unique contribution to sexual dissatisfaction but not to sexual function. These preliminary findings suggest that emotion dysregulation may be more important to understanding certain sexual problems (dissatisfaction) among cigarette-smoking trauma survivors than previously recognized, and this topic is, therefore, worthy of further investigation.

Temporal relations between sleep problems and both traumatic event exposure and PTSD: a critical review of the empirical literature

There has been growing interest in the interrelations among traumatic event exposure, posttraumatic stress disorder (PTSD), and sleep problems. A wealth of research has examined the associations among these factors and there is an emerging literature focused on how sleep problems relate to both traumatic event exposure and PTSD across time. The current review provides a detailed analysis of studies pertaining to the temporal patterning of sleep problems and traumatic event-related factors (e.g., traumatic event exposure, PTSD) and draws conclusions regarding the current state of this literature. Research coalesces to suggest (1) exposure to a traumatic event can interfere with sleep, (2) PTSD is related to the development of self-reported sleep problems, but evidence is less clear regarding objective indices of sleep, and (3) limited evidence suggests sleep problems may interfere with recovery from elevated posttraumatic stress levels. Future research now needs to focus on understanding mechanisms involved in these patterns to inform the prevention and treatment of comorbid sleep problems and PTSD.

Anxiety sensitivity and panic reactivity to bodily sensations: relation to quit-day (acute) nicotine withdrawal symptom severity among daily smokers making a self-guided quit attempt

The current investigation explored the main and interactive effects of panic attacks in response to laboratory-induced bodily sensations and anxiety sensitivity in predicting acute nicotine withdrawal symptoms among daily smokers making a self-guided quit attempt. Participants were 99 daily smokers (58% women; M(age) = 28.4 years, SD = 11.7) who completed a battery of questionnaires, a voluntary hyperventilation challenge, and a measure of nicotine withdrawal symptoms 12 hr after making a self-guided quit attempt. Results indicated that the interaction of anxiety sensitivity and panic responsivity to the challenge predicted quit-day nicotine withdrawal symptom severity above and beyond the main effects (p < .05). The form of the interaction indicated that the relationship between postchallenge panic attack status and acute nicotine withdrawal was more robust among individuals who were low in anxiety sensitivity. Individuals who did not experience a panic attack posthyperventilation who were also low in anxiety sensitivity reported the lowest levels of nicotine withdrawal. Results suggest that anxiety sensitivity may be less relevant with regard to acute nicotine withdrawal severity among individuals with panic-related problems.

Evaluating the mediating role of coping-based smoking motives among treatment-seeking adult smokers

INTRODUCTION

Empirical work has demonstrated a linkage between smoking rate and anxious arousal symptoms. However, there is little understanding of the mechanisms underlying this association.

METHOD

The present investigation examined the role of coping-based smoking motives in terms of mediating the relations between smoking rate and anxious arousal symptoms and anxious arousal symptoms and smoking rate among a sample of treatment-seeking adult smokers (N = 123; 84 women; M(age) = 45.93, SD = 10.34).

RESULTS

Results indicated that coping motives mediated the relations between smoking rate and anxious arousal symptoms and anxious arousal symptoms and smoking rate.

DISCUSSION

These results suggest that coping motives play a key role in terms of better understanding the association between smoking rate and anxious arousal symptoms.

Influence of PTSD symptom clusters on smoking status among help-seeking Iraq and Afghanistan veterans

INTRODUCTION

Despite the strong association between smoking and posttraumatic stress disorder (PTSD), mechanisms influencing smoking in this population remain unclear. Previous smoking research has largely examined PTSD as a homogenous syndrome despite the fact that PTSD is composed of four distinct symptom clusters (i.e., reexperiencing, effortful avoidance, emotional numbing, and hyperarousal). Examination of the relationship between smoking and PTSD symptom clusters may increase understanding of mechanisms influencing comorbidity between smoking and PTSD. The goals of the present study were to (a) examine the influence of overall PTSD symptom severity on likelihood of smoking and smoking heaviness and (b) examine the influence of each PTSD symptom cluster on smoking.

METHODS

Participants (N = 439) were Operation Iraqi Freedom/Operation Enduring Freedom combat veterans referred to VA mental health services.

RESULTS

Multinomial logistic regression was chosen to accommodate a three-level outcome, in which the likelihood of being a nonsmoker was compared with (a) light smoking (1-9 cigarettes/day), (b) moderate smoking (10-19 cigarettes/day), and (c) heavy smoking (> or =20 cigarettes/day). Results showed that veterans with higher levels of overall PTSD symptomatology were more likely to endorse heavy smoking (Wald = 4.56, p = .03, odds ratio [OR] = 1.65). Veterans endorsing high levels of emotional numbing were also more likely to endorse heavy smoking (Wald = 6.49, p = .01, OR = 1.81); all other PTSD symptom clusters were unrelated to smoking.

DISCUSSION

The association between emotional numbing and heavy daily smoking suggests that veterans with PTSD may smoke to overcome emotional blunting following trauma exposure.

Anxiolytic effects of nicotine in a rodent test of approach-avoidance conflict

RATIONALE

Nicotine has been reported to produce both anxiolytic and/or anxiogenic effects in humans and animals.

OBJECTIVES

This study examined whether pretreatment with nicotine would alter anxiety in a unique runway model of approach-avoidance conflict.

MATERIALS AND METHODS

Food-restricted rats were trained to run a straight alley once a day to obtain food upon goal-box entry. Beginning on trial 11, food reward was followed by a series of five foot shocks (0.3-0.4 mA, 0.5 s) in the goal box. Non-shocked control rats continued to run for food only. The resulting association of the goal box with both a positive (food) and negative (foot shock) stimulus produced an approach-avoidance conflict (subjects exhibited "retreat behaviors" in which they would approach the goal box, stop, and then retreat back towards the start box). Once retreats were established, their sensitivity to nicotine pretreatment (0.0, 0.03, 0.045, 0.06, or 0.075 mg/kg, i.v.) was compared to saline. In subsequent tests, the effects of nicotine (0.06 or 0.03 mg/kg) were examined on spontaneous activity (locomotion) and center-square entries in an open field (anxiety).

RESULTS

Doses of 0.06 and 0.075 mg/kg, but not lower doses of nicotine, reduced the number of runway retreats, and 0.06 mg/kg nicotine increased the number of open-field center entries relative to saline. No effects on locomotion were observed.

CONCLUSIONS

Nicotine reduced approach-avoidance conflict and increased the rats' willingness to enter the center of an open field, suggesting that the drug can produce anxiolytic properties and that such effects may serve as an important factor in the persistence of smoking behavior.

Nicotine dependence mediates the relations between insomnia and both panic and posttraumatic stress disorder in the NCS-R sample

Although a growing literature has demonstrated elevations in insomnia symptoms among persons with either panic disorder (PD) or posttraumatic stress disorder (PTSD) relative to people without psychopathology, comparably little is known about processes underlying these associations. In recognition of this important gap in the literature, this study tested nicotine dependence as a partial mediator of the relations between insomnia symptoms and both PD and PTSD among a nationally representative sample of 5,692 (3,311 females; M(age)=43.33, SD=16.55) adults from the National Comorbidity Survey-Replication. Consistent with hypotheses, nicotine dependence partially mediated the relations between insomnia and both PD and PTSD after controlling for variance accounted for by diagnoses of major depressive episodes, drug and alcohol dependence, and gender. Overall, results suggest nicotine dependence may be a possible mechanism that underlies insomnia among those with PD and PTSD.

Test of the role of nicotine dependence in the relation between posttraumatic stress disorder and panic spectrum problems

Posttraumatic stress disorder (PTSD) frequently co-occurs with panic spectrum problems. Relatively little empirical work has tested possible mechanisms accounting for this association. Nicotine dependence often ensues subsequent to PTSD onset and research suggests smoking high numbers of cigarettes daily may lead to panic problems. The current study tested the hypotheses that nicotine dependence partially mediates the relations between PTSD and both panic attacks and panic disorder within a nationally representative sample of 5,692 (3,020 women; M(Age) = 45, SD = 18) adults from the National Comorbidity Survey-Replication. Results were consistent with hypotheses. These findings support the theory suggesting smoking among people with PTSD may be involved in the development of panic problems.

An evaluation of anxiety sensitivity, emotional dysregulation, and negative affectivity among daily cigarette smokers: relation to smoking motives and barriers to quitting

The present investigation evaluated the relations between anxiety sensitivity and motivational bases of cigarette smoking, as well as barriers to quitting smoking, above and beyond concurrent substance use, negative affectivity, and emotional dysregulation among a community sample of 189 daily cigarette smokers (46% women; M(age)=24.97 years, SD=9.78). Results indicated that anxiety sensitivity was significantly related to coping, addictive, and habitual smoking motives, as well as greater perceived barriers to quitting. These effects were evident above and beyond the variance accounted for by concurrent tobacco, alcohol, and marijuana use and discernable from shared variance with negative affectivity and emotional dysregulation. Emotional dysregulation was significantly related to stimulation, habitual, and sensorimotor smoking motives and greater perceived barriers to quitting, whereas negative affectivity was only significantly related to smoking for relaxation. These findings uniquely add to a growing literature suggesting anxiety sensitivity is an important and unique cognitive factor for better understanding clinically-relevant psychological processes related to cigarette smoking.

Anxiety sensitivity and smoking motives and outcome expectancies among adult daily smokers: replication and extension

The present investigation examined the incremental validity of anxiety sensitivity in the context of distress intolerance in terms of predicting smoking motives and outcome expectancies. Participants were a community sample of 144 daily smokers (85 women, M (age) = 29.72 years, SD = 11.96). Results indicated that above and beyond discomfort intolerance, Axis I diagnoses, gender, volume of alcohol consumption, and average number of cigarettes smoked per day, anxiety sensitivity significantly incrementally predicted habitual, addictive, and negative affect reduction motives to smoke, as well as negative reinforcement outcome expectancies. No such incremental effects were similarly evident for distress intolerance. Findings are discussed in relation to the role of anxiety sensitivity in smoking motives and outcome expectancies.

Smoking and posttraumatic stress symptoms among adolescents: does anxiety sensitivity matter?

The present study examined the hypothesized moderating role of anxiety sensitivity (AS) in the relationship between lifetime smoking history and posttraumatic stress symptoms among 64 traumatic event-exposed adolescents. As predicted, the relationship between smoking status and posttraumatic stress symptom levels was moderated by AS. Specific facets of AS also were examined. Disease concerns, but not unsteady, mental illness, or social concerns, moderated the association between smoking and symptom level. These findings are generally consistent with findings from adult samples, but importantly extend this area of research to another phase of the lifespan.

Trauma exposure influences cue elicited affective responses among smokers with and without a history of major depression

The current study tested the emotional reactivity of smokers with and without histories of major depression (MDD Hx) and trauma exposure (TE). Four counterbalanced conditions nested negative (e.g., dysphoric) or neutral mood inductions with in vivo versus control smoking paraphernalia cues (Neutral+Control; Neutral+Cigarette; Neg+Control; Neg+Cigarette). Mixed model analysis of covariance (ANCOVA) tested between and within subjects differences in negative affective symptoms pre- to post-exposure across four groups (TE+MDD Hx; TE only; MDD Hx only; no history). Results produced two notable effects. First, TE only individuals endorsed the greatest increase in depressive symptoms across both negative mood induction conditions (regardless of smoking paraphernalia) compared with other groups. Second, dual history participants (TE+MDD Hx) show a potentiated depressive response to the Neg+Cigarette condition compared with the Neg+Control condition. Implications to a depression-specific negative affective vulnerability among TE only smokers that is independent of MDD Hx and greater than smokers with a MDD Hx are discussed.

Smoking in help-seeking veterans with PTSD returning from Afghanistan and Iraq

Past research has shown that veterans and individuals with posttraumatic stress disorder (PTSD) have increased rates of smoking. However, the rates of smoking in younger help-seeking veterans returning from Afghanistan and Iraq, and possible correlates of smoking among this population are unknown. In this study, we evaluated the rate of lifetime and current smoking among a sample of 90 returning male veterans diagnosed with PTSD. Fifty-nine percent reported a lifetime history of smoking including 32% that were current smokers. Current smokers were significantly younger than non-smokers. Current smokers (mean age=31) reported a mean age of smoking onset as 15.86 with a pack year history of 8.89. These smokers reported on average five previous quit attempts. According to a stages of change model, one-half of the smokers were in the contemplation phase of stopping smoking (50%), 29% were in the pre-contemplation phase and 21% were in the preparation phase. The results are placed in the context of non-psychiatric and psychiatric smokers.

Relationship between PTSD symptomatology and nicotine dependence severity in crime victims

Smoking rates are higher and cessation rates are lower among individuals with posttraumatic stress disorder (PTSD) compared to the general population, thus understanding the relationship between PTSD and nicotine dependence is important. In a sample of 213 participants with a crime-related trauma (109 with PTSD), the relationship between PTSD status, smoking status (smoker vs. non-smoker), substance abuse diagnosis (SUD), PTSD symptoms, and sex was assessed. SUD diagnosis was significantly related to smoking status, but PTSD symptomatology and sex were not. Among smokers (n=117), increased nicotine dependence severity was associated with being male and with increased level of PTSD avoidance symptoms. Correlations indicated that PTSD avoidance and hyperarousal symptom clusters and total PTSD symptom scores were significantly related to nicotine dependence severity in males, while PTSD symptomatology in general did not correlate with dependence severity for females. The results suggest that level of PTSD symptomatology, particularly avoidance symptoms, may be important targets for smoking cessation treatment among male smokers who have experienced a traumatic event.

Evaluation of smoking characteristics among community-recruited daily smokers with and without posttraumatic stress disorder and panic psychopathology

The present investigation compared 123 community-recruited daily smokers with posttraumatic stress disorder (PTSD), panic disorder (PD), nonclinical panic attacks (PA), or no current Axis I psychopathology (controls; C) in terms of nicotine dependence, smoking rate, quit history, severity of symptoms during past quit attempts, and motivation for and expectancies about smoking. No differences were observed between groups in regard to smoking rate or nicotine dependence. The PTSD group reported making more lifetime quit attempts than the other groups, and the PTSD and PD groups perceived more severe symptoms during past quit attempts. The PD and PTSD groups reported greater motivation to smoke to reduce negative affect. Individuals with PTSD endorsed a stronger expectation that smoking would alleviate negative mood states and would produce negative consequences. Overall, results suggest that smokers with PD or PTSD differ from other smoking groups in a number of clinically significant ways.

Nicotine dependence and mental disorders among adults in the USA: evaluating the role of the mode of administration

BACKGROUND

To investigate the association between nicotine dependence (ND), by cigarette smoking and use of smokeless tobacco (UST), and mental disorders.

METHOD

Face-to-face surveys (n=43 093) were conducted in the 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). Nicotine use, ND, and mental disorders were assessed using DSM-IV criteria.

RESULTS

UST-ND was associated with a significantly increased likelihood of any anxiety disorder, specific phobia, alcohol abuse and dependence. Consistent with previous findings, cigarette smoking-ND was associated with an increased likelihood of all mental disorders examined. Among those without ND, cigarette smoking was specifically associated with panic attacks and panic disorder; non-dependent UST was not associated with mental disorders.

CONCLUSIONS

Our findings suggest that the association between ND and mental disorders is relatively specific to the mode of nicotine administration. Among those who are nicotine dependent, cigarette use is associated with most major psychiatric disorders, whereas UST is associated with dysthymia and specific phobia. Among those who use tobacco but are not nicotine dependent, cigarette use is associated with dysthymia and panic disorder; UST is not associated with any major mood or anxiety disorders. The link between mental disorders and nicotine is complex, and is associated primarily with dependence, and not with non-dependent use.

Does number of lifetime traumas explain the relationship between PTSD and chronic medical conditions? Answers from the National Comorbidity Survey-Replication (NCS-R)

The present study sought to extend prior research by using data from the National Comorbidity Survey-Replication (NCS-R) to examine the relationship between number of lifetime traumas, posttraumatic stress disorder (PTSD) and 15 self-reported chronic medical conditions. The goal was to determine whether the commonly found relationship between PTSD symptomatology and physical health were better explained by the number of lifetime traumas experienced. The NCS-R is a representative US household survey that assessed lifetime experience of a variety of traumas, lifetime diagnosis of PTSD and 15 chronic medical conditions (e.g. pain conditions, cardiovascular disorders, etc.). Two major findings emerged: (1) there was a graded relationship between trauma exposure, PTSD, and the majority of chronic medical conditions where individuals with PTSD had the highest likelihood of chronic medical condition and non-traumatized individuals had the lowest risk and; (2) with the exception of headaches, the relationship between PTSD and chronic medical conditions was explained by the number of lifetime traumas experienced when analyses were subset to traumatized individuals. The present study supports prior research suggesting that multiple traumas have a cumulative effect on physical health. The impact of trauma on health may be independent of PTSD symptomatology.

Gender differences in immediate antecedents of ad lib cigarette smoking in smokers with and without posttraumatic stress disorder: a preliminary report

Using ambulatory methods for monitoring, this study investigated gender differences regarding the association between smoking and situational cues in 63 smokers with posttraumatic stress disorder (PTSD) and 32 smokers without PTSD. Smokers were instructed to complete a diary entry each time an ambulatory blood pressure monitor took a reading and each time they prepared to smoke. Generalized estimating equations contrasted 682 smoking and 444 nonsmoking situations by group status. For all smokers, ad lib smoking was strongly related to craving. For women with PTSD, ad lib smoking was strongly related to total PTSD symptoms, PTSD reexperiencing symptoms, and PTSD hyperarousal symptoms. For men with PTSD, ad lib smoking was significantly related to negative affect, PTSD reexperiencing symptoms, restlessness, and worry. No other mood antecedents were significant for women or men smokers without PTSD. These results are consistent with previous studies documenting gender differences in smoking behavior, and underscore the importance of examining gender differences in psychiatric samples.

Smoking predicts posttraumatic stress symptoms among rescue workers: a prospective study of ambulance personnel involved in the Enschede Fireworks Disaster

BACKGROUND

Examining whether smoking is a risk factor for posttraumatic stress disorder (PTSD) symptoms among rescue workers affected by a disaster.

METHODS

Ambulance personnel (N=66) participated in surveys 2-3 weeks (T1) and 18 months after a fireworks disaster (T2). Hierarchical multiple regression analyses were conducted with cigarette consumption at T1 as a predictor of PTSD symptoms at T2. Demographic characteristics, disaster experiences, peritraumatic dissociation, intrusions and avoidance, psychological distress and alcohol consumption assessed at T1 were included as covariates.

RESULTS

Regression analyses showed that smoking at T1 independently predicted intrusions, avoidance, hostility, and depression symptoms at T2. Results were not affected by controlling for post-disaster critical incidents at work.

CONCLUSIONS

This is the first prospective study among rescue workers demonstrating that smoking soon after a disaster predicts PTSD symptoms in the intermediate term. Findings substantiate results of previous studies indicating that smoking is a relevant risk factor. Future research on how changes in cigarettes consumption post-trauma affect risk of PTSD is required.

Posttraumatic stress disorder and smoking relapse: A theoretical model

Posttraumatic stress disorder (PTSD) is associated with a high prevalence of cigarette smoking, heavy cigarette consumption, and low cessation rates. To date, little is known about mechanisms impeding smoking cessation among this recalcitrant group of smokers. An important first step in improving smoking cessation treatment efficacy is the assessment of knowledge about mechanisms pertinent to relapse. This theoretical study addresses the gap in the literature regarding factors potentially influencing smoking relapse among individuals with PTSD. Mechanisms reviewed that may be particularly relevant to smoking relapse among PTSD smokers include negative affect, positive affect, attention, anxiety sensitivity, distress tolerance, and self-efficacy. Treatment implications as well as methodological advances that may be relevant to examining the proposed relapse model are discussed.

Childbirth, abortion and subsequent substance use in young women: a population-based longitudinal study

AIMS

To investigate the possible linkages between deliveries, abortions and subsequent nicotine dependence, alcohol problems and use of cannabis and other illegal drugs from the ages of 15-27 years.

METHODS

Data were gathered as part of the Young in Norway Longitudinal Study, an 11-year follow-up of a representative sample of Norwegian adolescents and young adults.

DESIGN, SETTING AND PARTICIPANTS

Information was obtained on (i) the history of childbirths and induced abortions for the participants between the ages of 15-27 years; (ii) measures of nicotine dependence, alcohol problems and use of cannabis and other illegal drugs; and (iii) socio-demographic, family and individual confounding factors.

RESULTS

Those who had had an abortion had elevated rates of substance use and problems. Those who gave birth to a child had reduced rates of alcohol problems and cannabis use. These associations persisted after control for confounders. However, those women who still lived with the father of the aborted fetus were not at increased risk.

CONCLUSIONS

Abortion in women may, under some circumstances, be associated with increased risk of nicotine dependence, alcohol problems and use of cannabis and other illegal drugs. The birth of a child may reduce the use of some substances.

Posttraumatic stress symptom severity predicts marijuana use coping motives among traumatic event-exposed marijuana users

The present study examines the relation between posttraumatic stress symptom severity and motives for marijuana use among 103 (55 women) young adult marijuana users (current) who reported experiencing at least one traumatic event in their lifetime. As expected, after covarying for the theoretically relevant variables of frequency of past 30-day marijuana use, number of cigarettes smoked per day, and volume of alcohol consumed, posttraumatic stress symptom severity was significantly related to marijuana use coping motives, but no other motives for marijuana use. Results are discussed in relation to better understanding the role of coping-motivated marijuana use among young adults experiencing posttraumatic stress.