Trauma exposure and smoking outcomes: The indirect effects of anxious and depressive symptoms
Introduction
Relative to the general population, trauma-exposed individuals (i.e., individuals who have experienced one or more traumatic events, regardless being diagnosed with posttraumatic stress disorder [PTSD]) are twice as likely to smoke (Feldner, Babson, & Zvolensky, 2007), more likely to smoke heavily (more than 25 cigarettes per day; Beckham et al., 1997) and demonstrate higher levels of nicotine dependence (Beckham et al., 1997, Breslau et al., 2003, Feldner et al., 2007, Fu et al., 2007, Hapke et al., 2005, Koenen et al., 2005, Pietrzak et al., 2011). Further, trauma-exposed smokers experience greater difficulty quitting smoking compared to non-trauma-exposed smokers (Hapke et al., 2005) and PTSD symptoms (clinical and subclinical) contribute to increased perceptions that quitting smoking is difficult (Garey et al., 2015), increase in nicotine withdrawal symptom severity (Beckham et al., 2013), and greater beliefs that quitting smoking will have adverse effects (Farris et al., 2015).
Traumatic load (i.e., the number of traumatic events experienced; Schauer et al., 2003) is an facet of trauma exposure that may contribute to more negative smoking outcomes. For example, nicotine-dependent individuals report a higher than average traumatic load (i.e., 5.53 traumatic events in their lifetime; Lawson et al., 2013) compared to the general population (1.09 events; Kessler et al., 1995). Although numerous studies have linked traumatic stress symptoms to smoking (Farris et al., 2014), traumatic load has been given comparably less attention. There is need to further explore the relation between traumatic load and smoking processes and identify underlying mechanisms that maintain these relations among trauma-exposed smokers to guide the development of smoking cessation programs for trauma-exposed smokers.
Anxious and depressive symptoms may serve as potential mechanisms that indirectly influence the association between traumatic load and smoking beliefs and behavior. Anxious and depressive symptoms often co-occur with posttraumatic stress symptoms in trauma-exposed individuals (Sareen, 2018), and are positively associated with severity of posttraumatic stress symptoms (Wang et al., 2005). Higher traumatic load is associated with increased risk for depressive and anxiety disorders (Fossion et al., 2013) such that traumatic load and depressive symptoms have a dose-dependent relation, such that higher traumatic load relates to more severe depressive symptoms (Agorastos et al., 2014). Additionally, trauma-exposed persons experience elevated anxious symptoms (Cacciaglia et al., 2017) and depression compared to non-trauma exposed persons (Roberts et al., 2009). Further, trauma-exposed smokers with more severe posttraumatic stress symptoms are more apt to smoke to relieve negative affect states, including anxious and depressive symptoms (Feldner et al., 2007, Kearns et al., 2018). Notably, dysphoria has indirectly effects the relation between trauma symptom severity and smoking cessation-related outcomes (Garey et al., 2015).
Exploring how specific facets of anxious and depressive symptoms relate to the relation between traumatic load and smoking outcomes is an important next-step. Indeed, anhedonia and anxious arousal relate to acute affective disturbances associated with withdrawal (Leventhal et al., 2013). Additionally, anhedonia is associated with more unsuccessful smoking quit attempts and higher relapse rates (Leventhal et al., 2009), and anxious arousal is associated with increased perceived barriers for quitting and more severe psychosomatic problems when quitting (Zvolensky et al., 2017). Thus, these components may represent transdiagnostic vulnerabilities which could make smoking cessation more difficult. However, these affective factors and other facets of anxiety/depression have not been explored as unique mechanisms in the relation between traumatic load and smoking outcomes. These limitations hinder comprehensive understanding for the unique role of anxiety and depressive symptoms in smoking models among trauma-exposed smokers.
Theoretically, anxious and depressive symptoms may influence in the relation between traumatic load and maladaptive smoking outcomes among trauma-exposed smokers, given that smokers who experience a greater number of traumatic events may experience more negative affect states (Agorastos et al., 2014, Do et al., 2019, Fossion et al., 2013). Greater anxious and depressive symptoms, in turn, may be related to greater perceived barriers for smoking cessation, more severe quit-related psychosomatic problems, and stronger beliefs for smoking to relieve negative affect. For example, trauma-exposed smokers might cope with increased anxious and depressive symptoms by smoking cigarettes in the absence of other effective coping strategies. As such, trauma-exposed smokers may experience greater challenges related to quitting and endorse maladaptive thinking around the quit process. While emerging work posits that traumatic load may be related to smoking outcomes (Lawson et al., 2013), there is need to disentangle the unique contributions of specific facets of anxious and depressive symptoms in the relation between traumatic load and maladaptive smoking outcomes.
The present study assessed the competing indirect effects of four distinct facets of depression and anxiety (general anxiety, anxious arousal, general depression, and anhedonic depression) in the relationship between traumatic load and perceived barriers for quitting smoking, severity of psychosomatic problems experienced when attempting to quit smoking in the past, and negative reinforcement smoking expectancies among trauma-exposed smokers. Specifically, anhedonic depression concerns inability to enjoy once-pleasurable events and activities, anxious arousal refers to somatic symptoms, general anxiety symptoms captures nonspecific anxiety symptoms (including anxious mood), and general depressive symptoms concerns nonspecific depressive symptoms (including depressed mood; Clark & Watson, 1991). It was hypothesized among trauma-exposed smokers, there would be a significant indirect effect of traumatic load on smoking outcomes through anhedonic depression and anxious arousal, as these particular facets have been linked to greater reports of failed quit attempts (Leventhal et al., 2009), higher relapse rates (Leventhal et al., 2009) and increased quit problems (Zvolensky et al., 2017).
Section snippets
Procedure
Adult daily smokers were recruited from the Houston community through a variety of methods (e.g., flyers, newspaper ads, online posts) to participate in a smoking cessation treatment. Interested participants were scheduled for an in-person baseline assessment to determine study eligibility. Inclusion criteria for the study were: (1) being between 18 and 65 years of age; (2) smoking at least 6 cigarettes per day; and (3) being motivated to quit smoking (reporting a motivation of at least 5 on a
Descriptive analyses
Zero-order correlations among all study variables are presented in Table 2. Traumatic load was positively correlated to quit problems (r = 0.33, p <.001), but not correlated to perceived barriers for smoking cessation or negative reinforcement smoking expectancies. All MASQ subscales positively and significantly correlated with one other (r’s range = 0.40–0.88, all p’s < 0.001), and with dependent variables (r’s range = 0.24–0.70, all p’s < 0.001). All dependent variables significantly
Discussion
Results of the current study indicated traumatic load was indirectly associated with all criterion variables through general anxiety symptoms. These findings were evident after controlling for sex and number of cigarettes smoked per day, and competing mechanisms (i.e., facets of anxiety and depression). These results suggest traumatic load may be related to maladaptive smoking beliefs and psychosomatic symptoms when trying to quit due to its relationship with anxiety symptoms.
General anxiety
Declaration of Competing Interest
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
Acknowledgements
Research reported in this publication was supported by the National Institute on Minority Health and Health Disparities (NIMHD) of the National Institutes of Health (NIH) to the University of Houston. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. This study also was supported by the National Institute of Drug Abuse.
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