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Respiratory problems and anxiety sensitivity in smoking lapse among treatment seeking smokers
Addictive Behaviors 75 (2017) 25–29
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Respiratory problems and anxiety sensitivity in smoking lapse among treatment seeking smokers
MARK
Michael J. Zvolenskya,b,⁎, Rubén Rodríguez-Canoa,c, Daniel J. Paulusa, Roman Kotovd, Evelyn Brometd, Adam Gonzalezd, Kara Manninga, Benjamin J. Lufte a
University of Houston, Department of Psychology, Heyne Building, Suite 104, 77204 Houston, TX, USA The University of Texas MD Anderson Cancer Center, Department of Behavioral Science, 1515 Holcombe Blvd, 77030 Houston, TX, USA c Smoking and Addictive Disorders Unit, University of Santiago de Compostela, Faculty of Psychology, Department of Clinical Psychology and Psychobiology, Campus Vida, 15782 Santiago de Compostela, Spain d Stony Brook University, Department of Psychiatry, Stony Brook, NY, USA e Stony Brook University, Department of Medicine, Stony Brook, NY, USA b
H I G H L I G H T S respiratory symptoms and anxiety sensitivity predicted risk for lapse. • Lower model between lower respiratory symptoms and greater anxiety sensitivity • Interactive • Greater respiratory symptoms and high anxiety sensitivity may relate to early lapse.
A R T I C L E I N F O
A B S T R A C T
Keywords: Smoking Disaster Responder Anxiety sensitivity Respiratory symptoms Posttraumatic stress
Purpose: The current study examined whether the interaction of lower respiratory symptoms and anxiety sensitivity is related to smoking lapse in the context of smoking cessation. Method: Participants were adult daily smokers (N = 60) exposed to the World Trade Center (WTC) disaster who were in a smoking cessation treatment program (75.0% male, 50.6 years old [SD = 9.2], and current smoking rate was 17.6 cigarettes per day (SD = 10.6). Results: Results indicated that the interaction between lower respiratory symptoms and anxiety sensitivity was a significant predictor of greater risk for lapse (i.e., lower survival time; B = 0.005, OR = 1.01, p = 0.039). Follow-up analysis showed that greater respiratory symptoms were a significant predictor of lapse risk among those with high (B = 0.116, OR = 1.12, p = 0.025), but not those with low (B = −0.048, OR = 0.95, p = 0.322), levels of anxiety sensitivity. Discussion: The findings from the current study suggest that smokers with greater respiratory symptoms and higher levels of anxiety sensitivity may be associated with early lapse to smoking following smoking cessation treatment. Future work has the potential to inform the development of tailored cessation interventions for smokers who experience varying levels of lower respiratory symptoms and anxiety sensitivity.
1. Introduction Respiratory illness is a hallmark physical health problem among people exposed to the 2001 World Trade Center (WTC) disaster. For example, research suggests > 40% of individuals exposed to WTC report lower respiratory symptoms (e.g., shortness of breath, chest tightness, wheezing) years after 9/11 (Kotov et al., 2015). Smoking is more common among individuals with respiratory illness compared to those without (Gwynn, 2004; McLeish, Cougle, & Zvolensky, 2011).
⁎
Smoking is also overrepresented among WTC responders and other trauma-exposed individuals (Nandi, Galea, Ahern, & Vlahov, 2005; Vlahov et al., 2002). Smoking negatively impacts respiratory symptoms and illness, as it is related to greater severity, poorer symptom control, more frequent healthcare utilization, and decreased effectiveness of commonly used respiratory medications (e.g., inhaled corticosteroids; Althuis, Sexton, & Prybylski, 1999; Chaudhuri et al., 2008; Eisner & Iribarren, 2007; Lazarus et al., 2007; McLeish & Zvolensky, 2010; Siroux, Pin, Oryszczyn, Le Moual, & Kauffmann, 2000). Yet, there
Corresponding author at: The University of Houston, 126 Heyne Building, Suite 104, Houston, TX 77204-5502, USA. E-mail address: [email protected] (M.J. Zvolensky).
http://dx.doi.org/10.1016/j.addbeh.2017.06.015 Received 10 February 2017; Received in revised form 13 June 2017; Accepted 22 June 2017 Available online 23 June 2017 0306-4603/ © 2017 Elsevier Ltd. All rights reserved.
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is limited empirical data focused on the role of respiratory symptoms in terms of smoking behavior during quit attempts, and of the available work, the data are inconsistent (Fennerty, Banks, Ebden, & Bevan, 1987; Gratziou et al., 2014). Inconsistent findings in past work on respiratory symptoms and smoking cessation outcome may suggest that there are other factors that help explain success in quitting. One such factor might be anxiety sensitivity, the fear of anxiety-relevant sensations (Leventhal & Zvolensky, 2015). This individual difference factor is potentially important because a smoker with respiratory symptoms who has greater compared to lower anxiety sensitivity is more likely to be emotionally reactive to somatic sensations or stressors (e.g., managing medical regimes; Zvolensky, Eifert, Feldner, & Leen-Feldner, 2003). This type of perspective would suggest that respiratory symptoms may be related to earlier smoking behavior (i.e., lapse) in attempts to quit when anxiety sensitivity levels are higher compared to lower. The prediction of early lapse behavior is centrally important from a public health perspective, as a significant percentage of smokers attempting cessation lapse to smoking within a matter of days (e.g., > 50%) and few of these individuals recover to achieve abstinence (e.g., Brown et al., 2001). Past work has found that women report higher levels of anxiety sensitivity (e.g., Schmidt & Koselka, 2000). The present study examined anxiety sensitivity in the context of examining associations between respiratory symptoms and smoking cessation in a sample of treatment-seeking smokers exposed to the WTC disaster. Greater respiratory problems were expected to be related to smoking lapse among those with high, but not those with low, levels of anxiety sensitivity.
relation to 9/11.” Baseline PCL-S scores were used in the current study (α = 0.90).
2. Methods
2.1.6. Anxiety sensitivity index-3 (ASI-3; Taylor et al., 2007) The ASI-3 is an 18-item self-report measure of anxiety sensitivity (Reiss & McNally, 1985). The ASI-3 was administered at baseline (α = 0.93).
2.1.3. Fagerstrom Test of Cigarette Dependence (FTCD; Fagerström, 1978) The FTCD is a 6-item measure of “cigarette dependence” (Fagerström, 2012; Heatherton, Kozlowski, Frecker, & Fagerström, 1991). 2.1.4. Time line follow-back for daily cigarette use (TLFB; Sobell & Sobell, 1996) Retrospective self-report of cigarettes smoked per day was collected from participants, beginning with the period 2 weeks prior to baseline assessment and continuing weekly throughout treatment, and at followups. A lapse was defined as any smoking, even a single puff and relapse was defined as smoking, at least five cigarettes, during 3 consecutive days (Shiffman, 1986; Shiffman et al., 2006). 2.1.5. Biochemical verification Self-reported abstinence on the TLFB was verified using two assays. Saliva cotinine was assessed at 2-weeks post-quit day (session 8) and at each follow-up. Saliva samples were frozen and analyzed by an outside laboratory for cotinine level using radioimmune assay. Carbon monoxide (CO) analysis of breath samples with a Vitalograph Breathco CO monitor (Jarvis, Tunstall-Pedoe, Feyerabend, Vesey, & Saloojee, 1987) was used to assess abstinence at quit day, sessions 7 and 8, and at each follow-up assessment. Detected CO values > 5 ppm or cotinine levels > 15 ng/ml indicated current smoking (Benowitz et al., 2002; Perkins, Karelitz, & Jao, 2013).
Adult daily smokers (n = 60) were enrolled into a smoking cessation treatment study for individuals exposed to the WTC disaster (Gonzalez et al., 2016). Participants were recruited from the WTC Health Program, the New York City Department of Health WTC Health Registry, local newspapers and Craigslist-New York. Study inclusion criteria were smoking five or more cigarettes per day, motivation to quit smoking, interest in smoking cessation treatment, direct exposure to the WTC disaster (e.g., responding to the event or witnessing it in person), and scoring at least in the intermediate range (30 or greater; Andrykowski, Cordova, Studts, & Miller, 1998) on the Post-traumatic Stress Disorder Checklist (PCL-S; Weathers, Litz, Herman, Huska, & Keane, 1993). Participants were ineligible for the study if they were currently participating in other smoking cessation treatment, or were suffering from psychosis, mania, or alcohol dependence. The sample was mostly (n = 45; 75.0%) male, with an average age of 50.6 (SD = 9.2). Regarding race, 66.7% (n = 40) identified as White, 26.7% (n = 16) Black/African American, 1.7% (n = 1) Asian, and 5.0% (n = 3) “other/multi-racial.” Additionally, 16.7% (n = 10) identified ethnically as Hispanic. The current smoking rate was 17.6 cigarettes per day (SD = 10.6). On average, moderate levels of nicotine dependence were reported, as indicated by the Fagerström Test for Cigarette Dependence (FTCD; Fagerström, 1978; M = 5.5; SD = 1.7).
2.1.7. Lower respiratory symptoms (LRS) The severity of six lower respiratory symptoms (shortness of breath, chest tightness, wheezing, dry cough, productive cough, and overall difficulty breathing) was measured using a scale employed successfully in past work (Waszczuk et al., 2017). Participants rated the degree to which each symptom was a problem in the past week on a 5-point Likert-type scale ranging from 0 (none) to 4 (almost a constant problem). For LRS, past work suggests test-retest reliability is high (r = 0.79 for one week retest) and inter-item correlation of r = 0.40 suggests that the items are not redundant (Waszczuk et al., 2017). The LRS scale was administered at baseline (α = 0.80). 2.2. Procedures See Gonzalez et al. (2016) for a detailed description of the procedure. Participants were compensated as follows: $50 for completing the baseline assessment; $50 bonus for attending all sessions; $30 for each follow-up; and $50 bonus for completing all follow-up assessments (i.e., up to $300). The study was approved by the Stony Brook University Institutional Review Board. The current tests represent a secondary analysis of the larger investigation.
2.1. Measures
2.3. Data analytic approach
2.1.1. Structured clinical interview for DSM-IV disorders (SCID-I; First, Spitzer, Gibbon, & Williams, 2007) The SCID is a clinician-administered diagnostic assessment used to assess the presence of psychopathology. It was administered by a trained clinical psychologist at baseline.
A continuous variable (days to lapse) was created based on the numbers of days (via TLFB) from quit-day to first lapse (if present) and from lapse day to relapse day (if present) between baseline and 26-week follow-up. A dependent dichotomous variable was coded for the presence of a lapse after quit day (0 = no lapse; 1 = lapse). The prediction of “survival time” (number of days) before a lapse event occurred was evaluated by a hierarchal Cox proportional-hazard regression model. In the first step, the following covariates were entered: participant sex,
2.1.2. Posttraumatic Stress Disorder Checklist, specific version (PCL-S; Weathers et al., 1993) The PCL-S is a self-report measure of PTSD symptom severity. For the current study, instructions were tailored to capture symptoms “in 26
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3.3. Post hoc tests
age, marital status, racial/ethnic minority, employment, baseline level of cigarette dependence [FTND], and PTSD symptoms [PCL-S]). In the second step, respiratory problems (number of lower respiratory symptoms [LRS]) and anxiety sensitivity (ASI-3) were added. In the third step, the interaction of respiratory problems and anxiety sensitivity (LRS ∗ ASI-3) was entered.
A supplementary analysis was evaluated from time from lapse to relapse. Results indicated there was only a significant main effect of respiratory symptoms (B = 0.080, OR = 1.08, p = 0.025; see Table 1).
4. Discussion 3. Results Results revealed support for an interactive model between lower respiratory symptoms and greater anxiety sensitivity among the studied sample. Specifically, greater lower respiratory symptoms were associated with greater odds of smoking lapse among those with higher, but not those with lower, levels of anxiety sensitivity. The significant interactive effect for smoking lapse remained after controlling for sex, age, marital status, racial/ethnic minority, employment, cigarette dependence, and PTSD symptoms. These findings are consistent with the extant literature showing exacerbating effects of high anxiety sensitivity in the face of somatic and other life stressors (Feldner et al., 2008). Specifically, higher anxiety sensitivity may increase the probability of dysfunctional cognitive-affective responding to threatening situations, which may be related to more rapid negative reinforcement behavior (Farris et al., 2015). Analyses focused on time from lapse to relapse indicated there was no interactive effect between lower respiratory symptoms and anxiety sensitivity for time from lapse to relapse. It is possible that limited statistical power may have influenced this finding. In this same model, it is notable that the main effect of greater lower respiratory symptoms, but not anxiety sensitivity, was associated with an increased risk of relapse. These data are in line with previous work that has reported respiratory illness is related to increased odds of relapse (Gratziou et al., 2014). Several limitations should also be noted. First, the overall sample size was modest and predominately male. It is therefore important that future work replicate these findings among a larger and more diverse sample of tobacco smokers. Second, although duration of abstinence prior to first lapse and relapse has been shown to predict longer-term cessation outcomes (e.g., Brown et al., 2013; Garvey, Bliss, Hitchcock, Heinold, & Rosner, 1992; Gilpin, Pierce, & Farkas, 1997), this period of assessment does not fully capture the dynamic process of quitting (e.g., Velicer, Prochaska, Rossi, & Snow, 1992). Future work should examine the current interactive model in terms of both prolonged and point prevalence as well as tobacco withdrawal to better account for smokers who regain abstinence following an early lapse or relapse (e.g., Hughes et al., 2003; Velicer et al., 1992). Also, there is a need to replicate the findings on a larger sample to help ensure all patterns of the interactions are evident on an independent sample (e.g., combination of lower respiratory symptoms and higher anxiety sensitivity demonstrated a more positive effect for lapse). Finally, the present tests were completed from a secondary analysis of a clinical trial that selected smokers who reported PTSD symptoms of moderate severity from a trauma that occurred over a decade ago (i.e., 9/11 disaster). As such, results may not generalize to all smoking samples.
3.1. Descriptive data ASI-3 and LRS scores did not significantly vary as a function of gender (p's > 0.252). There was no evidence of excess collinearity among predictors/covariates (variance inflation index [VIF] = 1.03–1.65; Mason & Perreault, 1991). ASI-3 and LRS were correlated (r = 0.29, p = 0.024) but shared only 8.5% of variance. Both ASI-3 (r = 0.51, p < 0.001) and LRS (r = 0.42, p = 0.001) were correlated with PCL-S. Neither ASI-3 nor LRS were correlated with FTCD (p's > 0.791).
3.2. Lapse The models with covariates only and with the main effects of anxiety sensitivity and respiratory symptoms did not significantly predict smoking lapse (both χ2, p > 0.05). The addition of the interaction of anxiety sensitivity and respiratory problems yielded a statistically significant change [χ2 (1) = 4.246, p = 0.039; see Table 1]. Specifically, the interaction was a significant predictor of greater risk for lapse (i.e., lower survival time; B = 0.005, OR = 1.01, p = 0.039). Greater respiratory symptoms were a significant predictor of lapse risk among those with high (B = 0.116, OR = 1.12, p = 0.025; see Fig. 1), but not those with low (B = −0.048, OR = 0.95, p = 0.322), levels of anxiety sensitivity.
Table 1 Cox-logistic regression analyses. Step
Lapse
1
2
Lapse to relapse
3 1
2 3
Predictor
Sex Age Marital status Minority Employment FTCD PTSD LRS ASI-total Interaction Sex Age Marital status Minority Employment FTCD PTSD LRS ASI-total Interaction
OR
0.85 1.00 0.97 1.43 1.61 0.99 1.01 1.02 1.01 1.01 0.50 1.02 1.08 0.99 1.56 1.17 0.99 1.08 0.99 1.00
OR (95% CI) Lower
Upper
0.40 0.97 0.48 0.71 0.87 0.80 0.99 0.96 0.99 1.00 0.21 0.98 0.48 0.48 0.83 0.90 0.97 1.01 0.97 0.99
1.83 1.04 1.98 2.89 2.98 1.23 1.03 1.09 1.03 1.01 1.21 1.06 2.43 2.05 2.94 1.53 1.02 1.16 1.02 1.00
p-Value
0.682 0.859 0.938 0.315 0.131 0.935 0.396 0.588 0.359 0.039 0.125 0.245 0.857 0.985 0.169 0.233 0.428 0.025 0.521 0.812
Conflict of interest The authors have no conflict of interest to inform.
Note. Sex (female = 0, male = 1); Age = years at baseline assessment; Marital status (unmarried = 0, married = 1); Minority (Eastern European = 1, others = 0); Employment (unemployed = 1, employed = 0); FTCD = Fagerstrom Test of Cigarette Dependence (Fagerström, 2012); PTSD = Posttraumatic stress disorder (assessed by PCLPosttraumatic Stress Disorder Checklist (Weathers et al., 1993); ASI-total = anxiety sensitivity index total score (Taylor et al., 2007); LRS = lower respiratory symptoms. Interaction = (LSR ∗ ASI-total).
Role of funding sources This work was funded by a CDC200-2011-42057. The funding source had no role in the study design, collection, analysis or interpretation of the data, writing the manuscript, or the decision to submit the paper for publication. 27
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Fig. 1. Interaction of anxiety sensitivity and respiratory problems in terms of time to smoking lapse. Left: low levels of anxiety sensitivity (n = 24). Right: high levels of anxiety sensitivity (n = 25). Data from individuals with moderate anxiety sensitivity (n = 11) was not used for follow-up simple slope analyses. Gibson, L. E. (2008). An examination of anxiety sensitivity as a moderator of the relationship between smoking level and posttraumatic stress symptoms among trauma-exposed adults. Cognitive Therapy and Research, 32(1), 116–132. Fennerty, A., Banks, J., Ebden, P., & Bevan, C. (1987). The effect of cigarette withdrawal on asthmatics who smoke. European Journal of Respiratory Diseases, 71(5), 395–399. First, M. B., Spitzer, R. L., Gibbon, M., & Williams, J. B. (2007). SCID-I/P. Garvey, A. J., Bliss, R. E., Hitchcock, J. L., Heinold, J. W., & Rosner, B. (1992). Predictors of smoking relapse among self-quitters: A report from the Normative Aging Study. Addictive Behaviors, 17(4), 367–377. Gilpin, E. A., Pierce, J. P., & Farkas, A. J. (1997). Duration of smoking abstinence and success in quitting. Journal of the National Cancer Institute, 89(8), 572. Gonzalez, A., Friedberg, F., Li, X., Zvolensky, M. J., Bromet, E. J., Mahaffey, B. L., ... Kotov, R. (2016). Trauma-focused smoking cessation for smokers exposed to the World Trade Center Disaster: A randomized clinical trial. Nicotine & Tobacco Research ntw384. Gratziou, C., Florou, A., Ischaki, E., Eleftheriou, K., Sachlas, A., Bersimis, S., & Zakynthinos, S. (2014). Smoking cessation effectiveness in smokers with COPD and asthma under real life conditions. Respiratory Medicine, 108(4), 577–583. Gwynn, R. C. (2004). Risk factors for asthma in US adults: Results from the 2000 Behavioral Risk Factor Surveillance System. Journal of Asthma, 41(1), 91–98. Heatherton, T. F., Kozlowski, L. T., Frecker, R. C., & Fagerström, K.-O. (1991). The Fagerström test for nicotine dependence: A revision of the Fagerstrom Tolerance Questionnaire. British Journal of Addiction, 86(9), 1119–1127. Hughes, J. R., Keely, J. P., Niaura, R. S., Ossip-Klein, D. J., Richmond, R. L., & Swan, G. E. (2003). Measures of abstinence in clinical trials: Issues and recommendations. Nicotine & Tobacco Research, 5(1), 13–25. Jarvis, M. J., Tunstall-Pedoe, H., Feyerabend, C., Vesey, C., & Saloojee, Y. (1987). Comparison of tests used to distinguish smokers from nonsmokers. American Journal of Public Health, 77(11), 1435–1438. Kotov, R., Bromet, E. J., Schechter, C., Broihier, J., Feder, A., Friedman-Jimenez, G., ... Moline, J. (2015). Posttraumatic stress disorder and the risk of respiratory problems in World Trade Center responders: Longitudinal test of a pathway. Psychosomatic Medicine, 77(4), 438–448. Lazarus, S. C., Chinchilli, V. M., Rollings, N. J., Boushey, H. A., Cherniack, R., Craig, T. J., ... Ford, J. G. (2007). Smoking affects response to inhaled corticosteroids or leukotriene receptor antagonists in asthma. American Journal of Respiratory and Critical Care Medicine, 175(8), 783–790. Leventhal, A. M., & Zvolensky, M. J. (2015). Anxiety, depression, and cigarette smoking: A transdiagnostic vulnerability framework to understanding emotion–smoking comorbidity. Psychological Bulletin, 141(1), 176. Mason, C. H., & Perreault, W. D. (1991). Collinearity, power, and interpretation of multiple regressi. JMR, Journal of Marketing Research, 28(3), 268–280. McLeish, A. C., & Zvolensky, M. J. (2010). Asthma and cigarette smoking: A review of the empirical literature. The Journal of Asthma, 47(4), 345–361. http://dx.doi.org/10. 3109/02770900903556413. McLeish, A. C., Cougle, J. R., & Zvolensky, M. J. (2011). Asthma and cigarette smoking in a representative sample of adults. Journal of Health Psychology, 16(4), 643–652. http://dx.doi.org/10.1177/1359105310386263. Nandi, A., Galea, S., Ahern, J., & Vlahov, D. (2005). Probable cigarette dependence, PTSD, and depression after an urban disaster: Results from a population survey of New York City residents 4 months after September 11, 2001. Psychiatry, 68(4), 299–310. Perkins, K. A., Karelitz, J. L., & Jao, N. C. (2013). Optimal carbon monoxide criteria to confirm 24-hr smoking abstinence. Nicotine & Tobacco Research, 15(5), 978–982. Reiss, S., & McNally, R. (1985). Expectancy model of fear. In S. Reiss, & R. R. Bootzin
Contributors Authors Roman Kotov, Evelyn Bromet, Adam Gonzalez, and Benjamin J. Luft developed the original study protocol. Authors Michael J. Zvolensky, Ruben Rodriguez-Cano, and Daniel J. Paulus formulated the manuscript hypothesis, conducted the statistical analysis, and wrote the first draft of the manuscript. Authors Roman Kotov, Evelyn Bromet, Adam Gonzalez, Kara Manning, and Benjamin J. Luft, assisted with literature reviews and manuscript development. All authors provided substantive feedback on manuscript drafts and have approved the final manuscript. Conflict of interest All authors declare that they have no conflicts of interest. References Althuis, M. D., Sexton, M., & Prybylski, D. (1999). Cigarette smoking and asthma symptom severity among adult asthmatics. Journal of Asthma, 36(3), 257–264. Andrykowski, M. A., Cordova, M. J., Studts, J. L., & Miller, T. W. (1998). Posttraumatic stress disorder after treatment for breast cancer: Prevalence of diagnosis and use of the PTSD Checklist—Civilian Version (PCL—C) as a screening instrument. Journal of Consulting and Clinical Psychology, 66(3), 586. Benowitz, N. L., Jacob, P., III, Ahijevych, K., Jarvis, M. J., Hall, S., LeHouezec, J., ... Tsoh, J. (2002). Biochemical verification of tobacco use and cessation. Nicotine & Tobacco Research, 4(2). Brown, R. A., Kahler, C. W., Niaura, R., Abrams, D. B., Sales, S. D., Ramsey, S. E., ... Miller, I. W. (2001). Cognitive-behavioral treatment for depression in smoking cessation. Journal of Consulting and Clinical Psychology, 69(3), 471–480. Brown, R. A., Reed, K. M. P., Bloom, E. L., Minami, H., Strong, D. R., Lejuez, C. W., ... Hayes, S. C. (2013). Development and preliminary randomized controlled trial of a distress tolerance treatment for smokers with a history of early lapse. Nicotine & Tobacco Research, ntt093. Chaudhuri, R., McSharry, C., McCoard, A., Livingston, E., Hothersall, E., Spears, M., & Thomson, N. (2008). Role of symptoms and lung function in determining asthma control in smokers with asthma. Allergy, 63(1), 132–135. Eisner, M. D., & Iribarren, C. (2007). The influence of cigarette smoking on adult asthma outcomes. Nicotine & Tobacco Research, 9(1), 53–56. Fagerström, K.-O. (1978). Measuring degree of physical dependence to tobacco smoking with reference to individualization of treatment. Addictive Behaviors, 3(3), 235–241. Fagerström, K. (2012). Determinants of tobacco use and renaming the FTND to the Fagerström Test for Cigarette Dependence. Nicotine & Tobacco Research, 14(1), 75–78. Farris, S. G., Paulus, D. J., Gonzalez, A., Mahaffey, B. L., Bromet, E. J., Luft, B. J., ... Zvolensky, M. J. (2015). Anxiety sensitivity mediates the association between posttraumatic stress symptom severity and interoceptive threat-related smoking abstinence expectancies among World Trade Center disaster-exposed smokers. Addictive Behaviors, 51, 204–210. Feldner, M. T., Babson, K. A., Zvolensky, M. J., Monson, C. M., Bonn-Miller, M. O., &
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Respiratory problems and anxiety sensitivity in smoking lapse among treatment seeking smokers
MARK
Michael J. Zvolenskya,b,⁎, Rubén Rodríguez-Canoa,c, Daniel J. Paulusa, Roman Kotovd, Evelyn Brometd, Adam Gonzalezd, Kara Manninga, Benjamin J. Lufte a
University of Houston, Department of Psychology, Heyne Building, Suite 104, 77204 Houston, TX, USA The University of Texas MD Anderson Cancer Center, Department of Behavioral Science, 1515 Holcombe Blvd, 77030 Houston, TX, USA c Smoking and Addictive Disorders Unit, University of Santiago de Compostela, Faculty of Psychology, Department of Clinical Psychology and Psychobiology, Campus Vida, 15782 Santiago de Compostela, Spain d Stony Brook University, Department of Psychiatry, Stony Brook, NY, USA e Stony Brook University, Department of Medicine, Stony Brook, NY, USA b
H I G H L I G H T S respiratory symptoms and anxiety sensitivity predicted risk for lapse. • Lower model between lower respiratory symptoms and greater anxiety sensitivity • Interactive • Greater respiratory symptoms and high anxiety sensitivity may relate to early lapse.
A R T I C L E I N F O
A B S T R A C T
Keywords: Smoking Disaster Responder Anxiety sensitivity Respiratory symptoms Posttraumatic stress
Purpose: The current study examined whether the interaction of lower respiratory symptoms and anxiety sensitivity is related to smoking lapse in the context of smoking cessation. Method: Participants were adult daily smokers (N = 60) exposed to the World Trade Center (WTC) disaster who were in a smoking cessation treatment program (75.0% male, 50.6 years old [SD = 9.2], and current smoking rate was 17.6 cigarettes per day (SD = 10.6). Results: Results indicated that the interaction between lower respiratory symptoms and anxiety sensitivity was a significant predictor of greater risk for lapse (i.e., lower survival time; B = 0.005, OR = 1.01, p = 0.039). Follow-up analysis showed that greater respiratory symptoms were a significant predictor of lapse risk among those with high (B = 0.116, OR = 1.12, p = 0.025), but not those with low (B = −0.048, OR = 0.95, p = 0.322), levels of anxiety sensitivity. Discussion: The findings from the current study suggest that smokers with greater respiratory symptoms and higher levels of anxiety sensitivity may be associated with early lapse to smoking following smoking cessation treatment. Future work has the potential to inform the development of tailored cessation interventions for smokers who experience varying levels of lower respiratory symptoms and anxiety sensitivity.
1. Introduction Respiratory illness is a hallmark physical health problem among people exposed to the 2001 World Trade Center (WTC) disaster. For example, research suggests > 40% of individuals exposed to WTC report lower respiratory symptoms (e.g., shortness of breath, chest tightness, wheezing) years after 9/11 (Kotov et al., 2015). Smoking is more common among individuals with respiratory illness compared to those without (Gwynn, 2004; McLeish, Cougle, & Zvolensky, 2011).
⁎
Smoking is also overrepresented among WTC responders and other trauma-exposed individuals (Nandi, Galea, Ahern, & Vlahov, 2005; Vlahov et al., 2002). Smoking negatively impacts respiratory symptoms and illness, as it is related to greater severity, poorer symptom control, more frequent healthcare utilization, and decreased effectiveness of commonly used respiratory medications (e.g., inhaled corticosteroids; Althuis, Sexton, & Prybylski, 1999; Chaudhuri et al., 2008; Eisner & Iribarren, 2007; Lazarus et al., 2007; McLeish & Zvolensky, 2010; Siroux, Pin, Oryszczyn, Le Moual, & Kauffmann, 2000). Yet, there
Corresponding author at: The University of Houston, 126 Heyne Building, Suite 104, Houston, TX 77204-5502, USA. E-mail address: [email protected] (M.J. Zvolensky).
http://dx.doi.org/10.1016/j.addbeh.2017.06.015 Received 10 February 2017; Received in revised form 13 June 2017; Accepted 22 June 2017 Available online 23 June 2017 0306-4603/ © 2017 Elsevier Ltd. All rights reserved.
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is limited empirical data focused on the role of respiratory symptoms in terms of smoking behavior during quit attempts, and of the available work, the data are inconsistent (Fennerty, Banks, Ebden, & Bevan, 1987; Gratziou et al., 2014). Inconsistent findings in past work on respiratory symptoms and smoking cessation outcome may suggest that there are other factors that help explain success in quitting. One such factor might be anxiety sensitivity, the fear of anxiety-relevant sensations (Leventhal & Zvolensky, 2015). This individual difference factor is potentially important because a smoker with respiratory symptoms who has greater compared to lower anxiety sensitivity is more likely to be emotionally reactive to somatic sensations or stressors (e.g., managing medical regimes; Zvolensky, Eifert, Feldner, & Leen-Feldner, 2003). This type of perspective would suggest that respiratory symptoms may be related to earlier smoking behavior (i.e., lapse) in attempts to quit when anxiety sensitivity levels are higher compared to lower. The prediction of early lapse behavior is centrally important from a public health perspective, as a significant percentage of smokers attempting cessation lapse to smoking within a matter of days (e.g., > 50%) and few of these individuals recover to achieve abstinence (e.g., Brown et al., 2001). Past work has found that women report higher levels of anxiety sensitivity (e.g., Schmidt & Koselka, 2000). The present study examined anxiety sensitivity in the context of examining associations between respiratory symptoms and smoking cessation in a sample of treatment-seeking smokers exposed to the WTC disaster. Greater respiratory problems were expected to be related to smoking lapse among those with high, but not those with low, levels of anxiety sensitivity.
relation to 9/11.” Baseline PCL-S scores were used in the current study (α = 0.90).
2. Methods
2.1.6. Anxiety sensitivity index-3 (ASI-3; Taylor et al., 2007) The ASI-3 is an 18-item self-report measure of anxiety sensitivity (Reiss & McNally, 1985). The ASI-3 was administered at baseline (α = 0.93).
2.1.3. Fagerstrom Test of Cigarette Dependence (FTCD; Fagerström, 1978) The FTCD is a 6-item measure of “cigarette dependence” (Fagerström, 2012; Heatherton, Kozlowski, Frecker, & Fagerström, 1991). 2.1.4. Time line follow-back for daily cigarette use (TLFB; Sobell & Sobell, 1996) Retrospective self-report of cigarettes smoked per day was collected from participants, beginning with the period 2 weeks prior to baseline assessment and continuing weekly throughout treatment, and at followups. A lapse was defined as any smoking, even a single puff and relapse was defined as smoking, at least five cigarettes, during 3 consecutive days (Shiffman, 1986; Shiffman et al., 2006). 2.1.5. Biochemical verification Self-reported abstinence on the TLFB was verified using two assays. Saliva cotinine was assessed at 2-weeks post-quit day (session 8) and at each follow-up. Saliva samples were frozen and analyzed by an outside laboratory for cotinine level using radioimmune assay. Carbon monoxide (CO) analysis of breath samples with a Vitalograph Breathco CO monitor (Jarvis, Tunstall-Pedoe, Feyerabend, Vesey, & Saloojee, 1987) was used to assess abstinence at quit day, sessions 7 and 8, and at each follow-up assessment. Detected CO values > 5 ppm or cotinine levels > 15 ng/ml indicated current smoking (Benowitz et al., 2002; Perkins, Karelitz, & Jao, 2013).
Adult daily smokers (n = 60) were enrolled into a smoking cessation treatment study for individuals exposed to the WTC disaster (Gonzalez et al., 2016). Participants were recruited from the WTC Health Program, the New York City Department of Health WTC Health Registry, local newspapers and Craigslist-New York. Study inclusion criteria were smoking five or more cigarettes per day, motivation to quit smoking, interest in smoking cessation treatment, direct exposure to the WTC disaster (e.g., responding to the event or witnessing it in person), and scoring at least in the intermediate range (30 or greater; Andrykowski, Cordova, Studts, & Miller, 1998) on the Post-traumatic Stress Disorder Checklist (PCL-S; Weathers, Litz, Herman, Huska, & Keane, 1993). Participants were ineligible for the study if they were currently participating in other smoking cessation treatment, or were suffering from psychosis, mania, or alcohol dependence. The sample was mostly (n = 45; 75.0%) male, with an average age of 50.6 (SD = 9.2). Regarding race, 66.7% (n = 40) identified as White, 26.7% (n = 16) Black/African American, 1.7% (n = 1) Asian, and 5.0% (n = 3) “other/multi-racial.” Additionally, 16.7% (n = 10) identified ethnically as Hispanic. The current smoking rate was 17.6 cigarettes per day (SD = 10.6). On average, moderate levels of nicotine dependence were reported, as indicated by the Fagerström Test for Cigarette Dependence (FTCD; Fagerström, 1978; M = 5.5; SD = 1.7).
2.1.7. Lower respiratory symptoms (LRS) The severity of six lower respiratory symptoms (shortness of breath, chest tightness, wheezing, dry cough, productive cough, and overall difficulty breathing) was measured using a scale employed successfully in past work (Waszczuk et al., 2017). Participants rated the degree to which each symptom was a problem in the past week on a 5-point Likert-type scale ranging from 0 (none) to 4 (almost a constant problem). For LRS, past work suggests test-retest reliability is high (r = 0.79 for one week retest) and inter-item correlation of r = 0.40 suggests that the items are not redundant (Waszczuk et al., 2017). The LRS scale was administered at baseline (α = 0.80). 2.2. Procedures See Gonzalez et al. (2016) for a detailed description of the procedure. Participants were compensated as follows: $50 for completing the baseline assessment; $50 bonus for attending all sessions; $30 for each follow-up; and $50 bonus for completing all follow-up assessments (i.e., up to $300). The study was approved by the Stony Brook University Institutional Review Board. The current tests represent a secondary analysis of the larger investigation.
2.1. Measures
2.3. Data analytic approach
2.1.1. Structured clinical interview for DSM-IV disorders (SCID-I; First, Spitzer, Gibbon, & Williams, 2007) The SCID is a clinician-administered diagnostic assessment used to assess the presence of psychopathology. It was administered by a trained clinical psychologist at baseline.
A continuous variable (days to lapse) was created based on the numbers of days (via TLFB) from quit-day to first lapse (if present) and from lapse day to relapse day (if present) between baseline and 26-week follow-up. A dependent dichotomous variable was coded for the presence of a lapse after quit day (0 = no lapse; 1 = lapse). The prediction of “survival time” (number of days) before a lapse event occurred was evaluated by a hierarchal Cox proportional-hazard regression model. In the first step, the following covariates were entered: participant sex,
2.1.2. Posttraumatic Stress Disorder Checklist, specific version (PCL-S; Weathers et al., 1993) The PCL-S is a self-report measure of PTSD symptom severity. For the current study, instructions were tailored to capture symptoms “in 26
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3.3. Post hoc tests
age, marital status, racial/ethnic minority, employment, baseline level of cigarette dependence [FTND], and PTSD symptoms [PCL-S]). In the second step, respiratory problems (number of lower respiratory symptoms [LRS]) and anxiety sensitivity (ASI-3) were added. In the third step, the interaction of respiratory problems and anxiety sensitivity (LRS ∗ ASI-3) was entered.
A supplementary analysis was evaluated from time from lapse to relapse. Results indicated there was only a significant main effect of respiratory symptoms (B = 0.080, OR = 1.08, p = 0.025; see Table 1).
4. Discussion 3. Results Results revealed support for an interactive model between lower respiratory symptoms and greater anxiety sensitivity among the studied sample. Specifically, greater lower respiratory symptoms were associated with greater odds of smoking lapse among those with higher, but not those with lower, levels of anxiety sensitivity. The significant interactive effect for smoking lapse remained after controlling for sex, age, marital status, racial/ethnic minority, employment, cigarette dependence, and PTSD symptoms. These findings are consistent with the extant literature showing exacerbating effects of high anxiety sensitivity in the face of somatic and other life stressors (Feldner et al., 2008). Specifically, higher anxiety sensitivity may increase the probability of dysfunctional cognitive-affective responding to threatening situations, which may be related to more rapid negative reinforcement behavior (Farris et al., 2015). Analyses focused on time from lapse to relapse indicated there was no interactive effect between lower respiratory symptoms and anxiety sensitivity for time from lapse to relapse. It is possible that limited statistical power may have influenced this finding. In this same model, it is notable that the main effect of greater lower respiratory symptoms, but not anxiety sensitivity, was associated with an increased risk of relapse. These data are in line with previous work that has reported respiratory illness is related to increased odds of relapse (Gratziou et al., 2014). Several limitations should also be noted. First, the overall sample size was modest and predominately male. It is therefore important that future work replicate these findings among a larger and more diverse sample of tobacco smokers. Second, although duration of abstinence prior to first lapse and relapse has been shown to predict longer-term cessation outcomes (e.g., Brown et al., 2013; Garvey, Bliss, Hitchcock, Heinold, & Rosner, 1992; Gilpin, Pierce, & Farkas, 1997), this period of assessment does not fully capture the dynamic process of quitting (e.g., Velicer, Prochaska, Rossi, & Snow, 1992). Future work should examine the current interactive model in terms of both prolonged and point prevalence as well as tobacco withdrawal to better account for smokers who regain abstinence following an early lapse or relapse (e.g., Hughes et al., 2003; Velicer et al., 1992). Also, there is a need to replicate the findings on a larger sample to help ensure all patterns of the interactions are evident on an independent sample (e.g., combination of lower respiratory symptoms and higher anxiety sensitivity demonstrated a more positive effect for lapse). Finally, the present tests were completed from a secondary analysis of a clinical trial that selected smokers who reported PTSD symptoms of moderate severity from a trauma that occurred over a decade ago (i.e., 9/11 disaster). As such, results may not generalize to all smoking samples.
3.1. Descriptive data ASI-3 and LRS scores did not significantly vary as a function of gender (p's > 0.252). There was no evidence of excess collinearity among predictors/covariates (variance inflation index [VIF] = 1.03–1.65; Mason & Perreault, 1991). ASI-3 and LRS were correlated (r = 0.29, p = 0.024) but shared only 8.5% of variance. Both ASI-3 (r = 0.51, p < 0.001) and LRS (r = 0.42, p = 0.001) were correlated with PCL-S. Neither ASI-3 nor LRS were correlated with FTCD (p's > 0.791).
3.2. Lapse The models with covariates only and with the main effects of anxiety sensitivity and respiratory symptoms did not significantly predict smoking lapse (both χ2, p > 0.05). The addition of the interaction of anxiety sensitivity and respiratory problems yielded a statistically significant change [χ2 (1) = 4.246, p = 0.039; see Table 1]. Specifically, the interaction was a significant predictor of greater risk for lapse (i.e., lower survival time; B = 0.005, OR = 1.01, p = 0.039). Greater respiratory symptoms were a significant predictor of lapse risk among those with high (B = 0.116, OR = 1.12, p = 0.025; see Fig. 1), but not those with low (B = −0.048, OR = 0.95, p = 0.322), levels of anxiety sensitivity.
Table 1 Cox-logistic regression analyses. Step
Lapse
1
2
Lapse to relapse
3 1
2 3
Predictor
Sex Age Marital status Minority Employment FTCD PTSD LRS ASI-total Interaction Sex Age Marital status Minority Employment FTCD PTSD LRS ASI-total Interaction
OR
0.85 1.00 0.97 1.43 1.61 0.99 1.01 1.02 1.01 1.01 0.50 1.02 1.08 0.99 1.56 1.17 0.99 1.08 0.99 1.00
OR (95% CI) Lower
Upper
0.40 0.97 0.48 0.71 0.87 0.80 0.99 0.96 0.99 1.00 0.21 0.98 0.48 0.48 0.83 0.90 0.97 1.01 0.97 0.99
1.83 1.04 1.98 2.89 2.98 1.23 1.03 1.09 1.03 1.01 1.21 1.06 2.43 2.05 2.94 1.53 1.02 1.16 1.02 1.00
p-Value
0.682 0.859 0.938 0.315 0.131 0.935 0.396 0.588 0.359 0.039 0.125 0.245 0.857 0.985 0.169 0.233 0.428 0.025 0.521 0.812
Conflict of interest The authors have no conflict of interest to inform.
Note. Sex (female = 0, male = 1); Age = years at baseline assessment; Marital status (unmarried = 0, married = 1); Minority (Eastern European = 1, others = 0); Employment (unemployed = 1, employed = 0); FTCD = Fagerstrom Test of Cigarette Dependence (Fagerström, 2012); PTSD = Posttraumatic stress disorder (assessed by PCLPosttraumatic Stress Disorder Checklist (Weathers et al., 1993); ASI-total = anxiety sensitivity index total score (Taylor et al., 2007); LRS = lower respiratory symptoms. Interaction = (LSR ∗ ASI-total).
Role of funding sources This work was funded by a CDC200-2011-42057. The funding source had no role in the study design, collection, analysis or interpretation of the data, writing the manuscript, or the decision to submit the paper for publication. 27
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Fig. 1. Interaction of anxiety sensitivity and respiratory problems in terms of time to smoking lapse. Left: low levels of anxiety sensitivity (n = 24). Right: high levels of anxiety sensitivity (n = 25). Data from individuals with moderate anxiety sensitivity (n = 11) was not used for follow-up simple slope analyses. Gibson, L. E. (2008). An examination of anxiety sensitivity as a moderator of the relationship between smoking level and posttraumatic stress symptoms among trauma-exposed adults. Cognitive Therapy and Research, 32(1), 116–132. Fennerty, A., Banks, J., Ebden, P., & Bevan, C. (1987). The effect of cigarette withdrawal on asthmatics who smoke. European Journal of Respiratory Diseases, 71(5), 395–399. First, M. B., Spitzer, R. L., Gibbon, M., & Williams, J. B. (2007). SCID-I/P. Garvey, A. J., Bliss, R. E., Hitchcock, J. L., Heinold, J. W., & Rosner, B. (1992). Predictors of smoking relapse among self-quitters: A report from the Normative Aging Study. Addictive Behaviors, 17(4), 367–377. Gilpin, E. A., Pierce, J. P., & Farkas, A. J. (1997). Duration of smoking abstinence and success in quitting. Journal of the National Cancer Institute, 89(8), 572. Gonzalez, A., Friedberg, F., Li, X., Zvolensky, M. J., Bromet, E. J., Mahaffey, B. L., ... Kotov, R. (2016). Trauma-focused smoking cessation for smokers exposed to the World Trade Center Disaster: A randomized clinical trial. Nicotine & Tobacco Research ntw384. Gratziou, C., Florou, A., Ischaki, E., Eleftheriou, K., Sachlas, A., Bersimis, S., & Zakynthinos, S. (2014). Smoking cessation effectiveness in smokers with COPD and asthma under real life conditions. Respiratory Medicine, 108(4), 577–583. Gwynn, R. C. (2004). Risk factors for asthma in US adults: Results from the 2000 Behavioral Risk Factor Surveillance System. Journal of Asthma, 41(1), 91–98. Heatherton, T. F., Kozlowski, L. T., Frecker, R. C., & Fagerström, K.-O. (1991). The Fagerström test for nicotine dependence: A revision of the Fagerstrom Tolerance Questionnaire. British Journal of Addiction, 86(9), 1119–1127. Hughes, J. R., Keely, J. P., Niaura, R. S., Ossip-Klein, D. J., Richmond, R. L., & Swan, G. E. (2003). Measures of abstinence in clinical trials: Issues and recommendations. Nicotine & Tobacco Research, 5(1), 13–25. Jarvis, M. J., Tunstall-Pedoe, H., Feyerabend, C., Vesey, C., & Saloojee, Y. (1987). Comparison of tests used to distinguish smokers from nonsmokers. American Journal of Public Health, 77(11), 1435–1438. Kotov, R., Bromet, E. J., Schechter, C., Broihier, J., Feder, A., Friedman-Jimenez, G., ... Moline, J. (2015). Posttraumatic stress disorder and the risk of respiratory problems in World Trade Center responders: Longitudinal test of a pathway. Psychosomatic Medicine, 77(4), 438–448. Lazarus, S. C., Chinchilli, V. M., Rollings, N. J., Boushey, H. A., Cherniack, R., Craig, T. J., ... Ford, J. G. (2007). Smoking affects response to inhaled corticosteroids or leukotriene receptor antagonists in asthma. American Journal of Respiratory and Critical Care Medicine, 175(8), 783–790. Leventhal, A. M., & Zvolensky, M. J. (2015). Anxiety, depression, and cigarette smoking: A transdiagnostic vulnerability framework to understanding emotion–smoking comorbidity. Psychological Bulletin, 141(1), 176. Mason, C. H., & Perreault, W. D. (1991). Collinearity, power, and interpretation of multiple regressi. JMR, Journal of Marketing Research, 28(3), 268–280. McLeish, A. C., & Zvolensky, M. J. (2010). Asthma and cigarette smoking: A review of the empirical literature. The Journal of Asthma, 47(4), 345–361. http://dx.doi.org/10. 3109/02770900903556413. McLeish, A. C., Cougle, J. R., & Zvolensky, M. J. (2011). Asthma and cigarette smoking in a representative sample of adults. Journal of Health Psychology, 16(4), 643–652. http://dx.doi.org/10.1177/1359105310386263. Nandi, A., Galea, S., Ahern, J., & Vlahov, D. (2005). Probable cigarette dependence, PTSD, and depression after an urban disaster: Results from a population survey of New York City residents 4 months after September 11, 2001. Psychiatry, 68(4), 299–310. Perkins, K. A., Karelitz, J. L., & Jao, N. C. (2013). Optimal carbon monoxide criteria to confirm 24-hr smoking abstinence. Nicotine & Tobacco Research, 15(5), 978–982. Reiss, S., & McNally, R. (1985). Expectancy model of fear. In S. Reiss, & R. R. Bootzin
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