Perceived health moderates the association between smoking rate and panic vulnerability variables among daily smokers

Body Mass Index and functional impairment: the explanatory role of anxiety sensitivity among treatment-seeking smokers

Obesity and smoking are highly prevalent public health concerns in the United States. Data indicate that elevated Body Mass Index (BMI) is related to functional impairment. However, there is limited understanding of mechanisms that may explain their comorbidity among smokers. The current study sought to test whether anxiety sensitivity explained the relation between BMI and functional impairment among 420 (46.9% females; M_age = 38 years, SD = 13.42) treatment-seeking, adult smokers. Results indicated that BMI yielded a significant indirect effect through anxiety sensitivity for functional impairment, b = 0.01, SE = .01, 95% CI = [.002, .021]. These findings remained significant after controlling for participant sex, negative affectivity, tobacco dependence, psychopathology, and medical conditions (i.e. hypertension, heart problems, respiratory disease, asthma). Such data provide novel empirical evidence that, among smokers, BMI may be a risk factor for functional impairment indirectly through anxiety sensitivity. Overall, such findings could potentially inform the development of personalized interventions among this particularly vulnerable segment of the smoking population.

Does successful smoking cessation reduce anxious arousal among treatment-seeking smokers?

INTRODUCTION

There is limited work that has examined the effect of quitting smoking on anxious arousal, an underlying dimension of anxiety symptoms and psychopathology.

METHOD

Smokers (n=185, 54.1% female) enrolled in a smoking cessation treatment trial were monitored post-cessation in terms of abstinence status (biochemically verified; at Weeks 1, 2, and Month 1 post-quit) and severity of panic-relevant symptoms (self-reported; at Month 1 and 3 post-quit). Structural equation models were conducted, adjusting for participant sex, age, treatment condition, and pre-cessation nicotine dependence, presence of depressive/anxiety disorders, anxious arousal, and anxiety sensitivity.

RESULTS

After adjusting for covariates, participants who remained abstinent for one month (n=80; 43.2%) relative to those who did not (n=105; 56.8%) demonstrated significant reductions in anxious arousal at Month 1 (β=-.26, p=.04) and Month 3 post-quit (β=-.36, p=.006); abstinence status had a non-significant effect on anxious arousal severity at Month 3 after controlling for Month 1 anxious arousal (β=-.18, p=.09).

DISCUSSION

Findings align with theoretical models of smoking-anxiety interplay and suggest that smoking cessation can result in reductions in anxious arousal.

Anxiety, depression, and cigarette smoking: a transdiagnostic vulnerability framework to understanding emotion-smoking comorbidity

Research into the comorbidity between emotional psychopathology and cigarette smoking has often focused upon anxiety and depression's manifest symptoms and syndromes, with limited theoretical and clinical advancement. This article presents a novel framework to understanding emotion-smoking comorbidity. We propose that transdiagnostic emotional vulnerabilities-core biobehavioral traits reflecting maladaptive responses to emotional states that underpin multiple types of emotional psychopathology-link various anxiety and depressive psychopathologies to smoking. This framework is applied in a review and synthesis of the empirical literature on 3 transdiagnostic emotional vulnerabilities implicated in smoking: (a) anhedonia (Anh; diminished pleasure/interest in response to rewards), (b) anxiety sensitivity (AS; fear of anxiety-related sensations), and (c) distress tolerance (DT; ability to withstand distressing states). We conclude that Anh, AS, and DT collectively (a) underpin multiple emotional psychopathologies, (b) amplify smoking's anticipated and actual affect-enhancing properties and other mechanisms underlying smoking, (c) promote progression across the smoking trajectory (i.e., initiation, escalation/progression, maintenance, cessation/relapse), and (d) are promising targets for smoking intervention. After existing gaps are identified, an integrative model of transdiagnostic processes linking emotional psychopathology to smoking is proposed. The model's key premise is that Anh amplifies smoking's anticipated and actual pleasure-enhancing effects, AS amplifies smoking's anxiolytic effects, and poor DT amplifies smoking's distress terminating effects. Collectively, these processes augment the reinforcing properties of smoking for individuals with emotional psychopathology to heighten risk of smoking initiation, progression, maintenance, cessation avoidance, and relapse. We conclude by drawing clinical and scientific implications from this framework that may generalize to other comorbidities.

Anhedonia in obsessive-compulsive disorder: beyond comorbid depression

Obsessive-compulsive disorder (OCD) has been linked to reward dysfunctions, highlighting a possible role of anhedonia in OCD. Surprisingly, anhedonia in OCD has never been evaluated. Moreover, although nicotine typically has anti-anhedonic effects, anecdotal reports suggest low prevalence rates of smoking in OCD. To address these two phenomena, 113 individuals with OCD completed a battery of questionnaires assessing symptom severity, anhedonia, and smoking. 28.3% of the sample met criteria for clinically significant anhedonia, which correlated with Y-BOCS scores (r=0.44), even when controlling for depressive symptoms. 13.3% of the sample endorsed current smoking, a lower rate than seen in psychiatric disorders (40-90%) and the general adult population (19%). Results highlight high rates of anhedonia and yet reduced prevalence of smoking in OCD. In contrast to the known positive association between anhedonia and smoking, a negative association emerged. Future research is needed to address the unique interface between anhedonia and reward responsiveness in OCD. Potential clinical implications are discussed.

Mental disorders and cigarette use among adults in the United States

BACKGROUND

The goal of this study was to determine the association between mental disorders and cigarette consumption and nicotine dependence.

METHODS

Data were drawn from the National Epidemiologic Survey of Alcohol and Related Conditions (NESARC), a nationally representative survey of adults (N = 43,093) aged 18 and older. Relationships between specific anxiety disorders, mood disorders, nondependent cigarette use, nicotine dependence among the whole sample, and nicotine dependence among cigarette users were examined.

RESULTS

After adjusting for demographics and comorbid mental disorders, generalized anxiety disorder (OR = 1.16 (1.29-1.51)), specific phobia (OR = 1.35 (1.21-1.51)), panic disorder (PD) (OR = 1.90 (1.62-2.23)), major depression (MDD) (OR = 1.31 (1.16-1.48)), and bipolar disorder (OR = 1.30 (1.09-1.54)) were associated with increased likelihood of nondependent cigarette use. Specific phobia (OR = 1.69 (1.49-1.91)), PD (OR = 1.82 (1.50-2.21)), MDD (OR = 1.59 (1.38-1.84)), and bipolar disorder (OR = 1.71 (1.39-2.09)) were associated with increased odds of nicotine dependence among the whole sample; social phobia (OR = 1.69 (1.19-2.40)), specific phobia (OR = 1.69 (1.43-2.01)), MDD (OR = 1.65 (1.34-2.02)), and bipolar disorder (OR = 2.38 (1.74-3.24)) were associated with increased risk of nicotine dependence among cigarette users.

CONCLUSIONS

Specific anxiety disorders and mood disorders were uniquely associated with nondependent cigarette use, nicotine dependence among the whole sample, and the risk of nicotine dependence among cigarette users in the United States. Findings suggest that demographic differences, comorbid mood, anxiety, substance, and personality disorders all contributed to previously observed associations between mental disorders and nicotine dependence, explaining these links in some but not all cases.

The association between panic disorder and coronary artery disease among primary care patients presenting with chest pain: an updated literature review

CONTEXT

Although panic disorder is linked to hypertension and smoking, the relationship between panic disorder and coronary artery disease (CAD) is unclear.

OBJECTIVE

To extend our understanding about the strength of the association between panic disorder and coronary artery disease and known cardiovascular risk factors.

DATA SOURCES

Potential studies were identified via a computerized search of MEDLINE and PsycINFO databases and review of bibliographies. MeSH headings used included panic disorder with chest pain, panic disorder with coronary disease or cardiovascular disorders or heart disorders, and panic disorder with cholesterol or essential hypertension or tobacco smoking.

STUDY SELECTION

The diagnosis of panic disorder in eligible studies was based on DSM-IV criteria, and studies must have used objective criteria for CAD and risk factors. Only case-control and cohort studies were included.

DATA SYNTHESIS

Concerning the relationship between panic disorder and CAD, studies conducted in emergency departments found a relative risk [RR] of 1.25 (95% CI = 0.87 to 1.80), while those conducted in cardiology settings found an inverse relationship (RR = 0.19, 95% CI = 0.10 to 0.37). However, there is an inverse relationship between the prevalence of CAD in the study and the RR (r = -.554, p = .097), suggesting that, in primary care settings in which the prevalence of CAD is low, there may be a significant association between panic disorder and CAD.

CONCLUSION

The association between panic disorder and CAD has several implications for primary care physicians managing patients with chest pain. When comorbid, the panic attacks may cause the patient with coronary disease to seek care but could also provoke a cardiac event. If one condition is recognized, a search for the other may be warranted because of the potential consequences if left undetected. The treatment approach to the panic disorder should be adjusted in the presence of comorbid CAD.

Applying the tripartite model of anxiety and depression to cigarette smoking: an integrative review

INTRODUCTION

Research on the relationship between emotional disorders and smoking often characterizes anxiety and depression at the broad syndrome level. Because of the complex concordance and discordance across and within anxiety and depressive symptoms, research using this approach may be limited. Watson and Clark developed the tripartite model of anxiety and depression, which identifies negative affect (NA), anhedonia and low positive affect (PA), and anxious arousal (AA) as traits that characterize the underlying heterogeneity in emotional symptoms. An emerging literature has examined the relation between the affective constructs in the tripartite model and smoking; however, these findings have not been summarized and integrated. The aim of this report reviews the literature on the association between tripartite affective dimensions (anhedonia and low PA, NA, and AA) and smoking variables (smoking status, heaviness, chronicity, dependence, cessation, craving/urge).

METHODS

Qualitative summarization and integration of findings.

RESULTS

All three dimensions were consistently associated with smoking status but demonstrated mixed or no relationship with smoking heaviness, chronicity, and dependence. Low PA and anhedonia consistently associated with craving and relapse, even in studies that controlled for other dimensions. Emotional disturbance on multiple dimensions (e.g., low PA + high NA) was associated with disproportionate increases in smoking risk in several studies.

CONCLUSIONS

Tripartite dimensions may each have differential effects on smoking. Anhedonic and low PA individuals (especially those with concurrent NA or AA) may be a high-risk group worthy of targeting for interventions. Continued research of the affective dimensions linked with smoking could inform the etiology of tobacco dependence and lead to more effective smoking interventions that target affect.

Negative affectivity in smokers applying to smoking cessation clinics: a case-control study

OBJECTIVE

The objective of this study was to assess whether subjects applying to smoking cessation clinics display a higher level of affective symptoms than smokers recruited from the general population.

METHODS

The study was conducted according to a cross-sectional, case-control design. Cases were smokers applying to public smoking cessation clinics for the first time and controls were smokers recruited from the general population. Socio-demographic data and clinical information were collected. Self- (Hospital Anxiety Depression Scale, Beck Depression Inventory, State-Trait Anxiety Inventory) and hetero-administered (Montgomery Asberg Depression Rating Scale, Hamilton Anxiety scale) rating scales were used to assess anxious and depressive symptoms. Nicotine dependence was measured via a self-administered questionnaire (Fagerström Tolerance Questionnaire).

RESULTS

Sixty-eight cases were recruited, individually matched, and compared to controls. Overall, cases had significantly higher scores than controls when the rating scales assessing anxious and depressive symptoms were evaluated.

CONCLUSIONS

Smokers applying to smoking cessation clinics for the first time have a higher level of negative affectivity than smokers from the general population. An evaluation of the level of negative affectivity could be introduced into clinical practice to have a complete assessment of the patient. We propose adding psychological or pharmacological support to complement the smoking cessation program.

The moderating role of health fear on the relation between smoking status and panic symptoms among adolescents

The present study examined the moderating role of health fear on the concurrent relation between smoking status and panic attack symptoms among 249 adolescents (132 females, M(age)=14.86 years). As hypothesized, youth high in health fear reported elevations in panic attack symptoms, whereas this relation was relatively weak among those low in health fear. Importantly, these associations were significant after controlling for age, gender, negative affectivity, and anxiety sensitivity. Also as expected, health fear did not moderate the association between smoking status and depressive symptoms, supporting model specificity. Results are discussed in terms of implications for the panic-smoking association among youth.

Anxiety sensitivity as a moderator of the association between smoking status and anxiety symptoms and bodily vigilance: replication and extension in a young adult sample

The present investigation evaluated the moderational role of the physical concerns dimension of anxiety sensitivity (fear of anxiety and anxiety-related states) in the relation between smoking status and panic-relevant symptoms in a young adult sample (n=222; 123 females; M(age)=22.45 years, SD=8.08). Consistent with prediction, anxiety sensitivity physical concerns moderated the association of smoking status with body vigilance and anxious arousal symptoms, such that greater anxiety sensitivity physical concerns was associated with greater panic symptoms among smokers. The observed effects were evident even after controlling for the variance accounted for by alcohol use problems and gender. Also consistent with prediction, there was no interactive effect apparent for depressive symptoms, providing evidence of explanatory specificity with respect to the anxiety variables examined. Findings are discussed with regard to the role of anxiety sensitivity in the relation between smoking and panic processes.

Anxiety sensitivity as a moderator of association between smoking status and panic-related processes in a representative sample of adults

The present investigation evaluated a moderational role of anxiety sensitivity (fear of anxiety and anxiety-related states; [McNally RJ. Anxiety sensitivity and panic disorder. Biological Psychiatry 2002; 52:938-946.]) in the relation between smoking status and anxiety/depressive symptoms in a Russian epidemiological sample (n = 390; 197 females, Mean age = 43.55). Consistent with prediction, anxiety sensitivity moderated the association of smoking status with indices of anxiety and depressive symptoms; the effects were evident after controlling for the variance accounted for by alcohol use problems, environmental stress (past month), and gender. These findings are discussed with regard to the role of anxiety sensitivity in etiologic connection between smoking and panic-related processes.

Mental disorders and nicotine dependence among pregnant women in the United States

OBJECTIVE

To investigate the association between mental disorders and cigarette use and nicotine dependence among pregnant women in the United States.

METHODS

A face-to-face general population survey was conducted on participants in the 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions. One thousand five hundred sixteen women reporting a pregnancy in the past year were captured. Primary outcomes were seven Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition-defined mood and anxiety disorders and eight personality disorders, which were measured with the Alcohol Use Disorder and Associated Disabilities Interview Schedule.

RESULTS

Among pregnant women, 21.7% reported cigarette use and 12.4% met the criteria for nicotine dependence. Among pregnant women with cigarette use, 45.1% met criteria for at least one mental disorder, and among those with nicotine dependence, 57.5% met criteria for at least one other mental disorder. After adjusting for demographics and comorbidity, nicotine dependence during pregnancy significantly predicted any mental disorder (odds ratio [OR] 3.3, 95% confidence interval [CI] 2.1-5.1), any mood disorder (OR 2.5, 95% CI 1.5-4.0), major depression (OR 2.07, 95% CI 1.3-3.4), dysthymia (OR 6.2, 95% CI 2.9-13.1), and panic disorder (OR 3.1, 95% CI 1.6-6.1) in the past year. No significant associations were found between nondependent cigarette use and mental disorders.

CONCLUSION

Our results suggest an association between mental disorders and nicotine dependence among pregnant women in the United States. This association has far-reaching implications for both the mental and physical health of women and potentially for their children.

LEVEL OF EVIDENCE

III.

Risk-factor research and prevention programs for anxiety disorders: A translational research framework

The aim of the present essay is to discuss the interconnection between risk-factor research and prevention program development for panic-spectrum psychopathology. We argue that prevention of panic-spectrum psychopathology specifically, and anxiety disorders more generally, is likely to be best advanced through active, systematic translation of basic, risk-factor research. After operationalizing key terminology, we present some exemplar risk-factor candidates for panic-spectrum psychopathology, summarize research related to their role as risk-factors for panic problems, and link this discussion to risk-factor nomenclature. We then present a translational framework for extrapolating extant knowledge on these and other potential risk-factors for panic-spectrum psychopathology with respect to the development of preventative interventions. The proposed translational framework is intended to describe a forward-feeding process by which risk-factor research could be used by clinical researchers to inform prevention programs; and reciprocally, how such prevention knowledge could be most effectively utilized to drive new, clinically focused risk-factor research.

Panic attacks, panic disorder, and agoraphobia: associations with substance use, abuse, and dependence

Anxiety and substance use disorders frequently co-occur. Despite the clinical importance of this co-occurrence, theory and research addressing the relations between anxiety-substance use disorder comorbidity remain limited. The present commentary is intended to briefly review and summarize key aspects of this literature, with a specific focus on panic-spectrum psychopathology (panic attacks, panic disorder, and agoraphobia) and its associations with tobacco, alcohol, and marijuana use, abuse, and dependence. A heuristic theoretical model for better understanding the panic-substance use relations also is offered. Extant data suggest clinically meaningful bidirectional associations are evident between panic problems and premorbid risk factors for such problems and various forms of tobacco, alcohol, and marijuana use. Key clinical implications and future directions are outlined based upon the review.