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

doi:10.1016/j.addbeh.2008.02.015

Addictive Behaviors

Volume 33, Issue 11, November 2008, Pages 1470-1476

https://doi.org/10.1016/j.addbeh.2008.02.015 Get rights and content

Abstract

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.

Section snippets

Participants

The sample consisted of 64 (40 females) adolescents (M_age = 15 years, 0 months; SD = 2 years, 4 months; range = 10 years, 6 months to 17 years, 11 months) who reported exposure to at least one Diagnostic and Statistical Manual of Mental Disorders — Fourth Edition (DSM-IV; APA, 1994) defined traumatic event (see below for details). Participants were selected from a larger sample (n = 225) who were recruited via announcements and flyers placed throughout the local community. Education level was as

Zero-order correlations

First, associations among theoretically and empirically-relevant factors were examined. Posttraumatic stress symptom level was not related to age (r = .19, ns) and did not differ as a function of gender (t = .83, ns) or alcohol use history (t = 1.93, ns). However, PANAS-C negative affectivity scores were significantly related to symptom levels (r = .24, p < .05). Accordingly, PANAS-C scores were included at step 1 of each regression model.

Consistent with hypothesis one, adolescents with positive smoking

Discussion

The current study contributes to the growing literature on the relationship between smoking and posttraumatic stress symptoms among youth, and uniquely examined AS as a moderator of this association. Consistent with prediction, traumatic event-exposed adolescents with positive smoking histories reported higher levels of posttraumatic stress symptoms and this relationship was moderated by AS. In terms of specific facets of the global AS construct, as predicted, the Disease Concerns factor

Acknowledgments

This project was supported, in part, by an Arkansas Biosciences Institute grant and a Centers for Disease Control and Prevention grant (U49 CE001248) awarded to Dr. Feldner and a National Institutes of Health grant awarded to Dr. Leen-Feldner (grant # 1 R03 MH077692-01A1).

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Collectively, these studies suggest that trauma exposure and/or PTSD diagnosis may be associated with elevated AS in substance using samples. The bivariate associations between AS and smoking frequency and/or tobacco dependence were examined in eight studies (across 5 unique samples), and these studies reported non-significant associations correlations between AS and smoking (r's < 0.20; (Bakshaie et al., 2015; Bakshaie et al., 2016; Farris et al., 2014; Farris et al., 2016; Feldner, Babson et al., 2008; Mathew et al., 2015; Rellini et al., 2010). However, one study of treatment-seeking smokers with PTSD found that AS demonstrated small-sized associations with expired carbon monoxide breath samples (r = 0.29), an index of smoking recency (Asnaani et al., 2015).
Posttraumatic stress disorder (PTSD) and substance use disorders (SUD) are complex psychiatric conditions that commonly co-occur. No evidence-based, “gold standard” treatments for PTSD/SUD comorbidity are currently available. Thus, it is imperative to better understand cognitive-affective mechanisms, targetable via cognitive-behavioral intervention (i.e., malleable), that may be related to both disorders in order to improve the theory and treatment of PTSD/SUD. Anxiety sensitivity is a malleable cognitive-affective factor with relevance to both PTSD and SUD. This systematic review focused on the published literature on anxiety sensitivity and trauma/PTSD and substance use/SUD from 1966 – May 1, 2018, and includes a total of 35 manuscripts. The state of the literature, limitations, and future research directions are discussed.
Anxiety sensitivity mediates the association between post-traumatic stress symptom severity and interoceptive threat-related smoking abstinence expectancies among World Trade Center disaster-exposed smokers
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Although the size of this effect was small in size, these data are conceptually relevant given the physiological nature of some nicotine withdrawal symptoms (e.g., restlessness, sleep disturbances, coughing, dizziness; Hughes, 2007) and physical health consequences of smoking. Indeed, previous work has also found specificity for the physical concerns sub-factor of anxiety sensitivity in terms of predicting smoking heaviness among treatment-seeking smokers (Farris et al., 2015) and more severe PTSD symptoms (Feldner, Babson, Zvolensky, Monson, et al., 2007; Feldner, Leen-Feldner, Trainor, Blanchard, & Monson, 2008). A post-hoc mediation model was conducted to further explicate the nature of the associations between PTSD symptom severity, anxiety sensitivity, and threat-based abstinence expectancies.
Anxiety sensitivity (fear of internal anxiety-relevant bodily sensations) is an individual difference variable that is associated with the development and maintenance of posttraumatic stress disorder (PTSD) and is also involved in the maintenance/relapse of smoking. Abstinence expectancies are crucial to smoking maintenance, yet, past work has not explored how PTSD symptom severity and anxiety sensitivity contribute to them.
Participants were 122 treatment-seeking daily smokers (36.1% female; M_age = 49.2, SD = 9.7; cigarettes per day: M = 18.3, SD = 15.2) who were exposed to the World Trade Center disaster on September 11, 2001 and responded to an advertisement for a clinical smoking cessation trial. The indirect effect of anxiety sensitivity was tested in terms of the effect of PTSD symptom severity on smoking abstinence expectancies (i.e., anxiety sensitivity as a statistical mediator).
PTSD symptom severity was positively associated with interoceptive threat-related smoking abstinence expectancies: expecting harmful consequences (β = .33, p < .001) and somatic symptoms (β = .26, p = .007). PTSD symptom severity was also significantly associated with anxiety sensitivity (β = .27, p = .003). Anxiety sensitivity mediated the association between PTSD symptom severity and expectancies about the harmful consequences (β = .09, CI_95% = .02–.21; ΔR² = .076) and somatic symptoms (β = .11, CI_95% = .02–.24; ΔR² = .123) from smoking abstinence, with medium effect sizes (Κ² = .08 and .10, respectively).
These data document the role of PTSD symptoms in threat-based expectancies about smoking abstinence and suggest anxiety sensitivity may underlie the associations between PTSD symptom severity and abstinence expectancies.
A social operational model of urban adolescents' tobacco and substance use: A mediational analysis
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A substantial body of research documents the relationship between mental health and the use of substances among adolescents (Costello, Erkanli, & Federman, 1999; Grella, Hser, Joshi, & Rounds-Bryant, 2001; Kandel et al., 1999). Of particular relevance to the present study, many urban youth are disproportionately exposed to trauma (e.g., violence, crime), which increases vulnerability to tobacco use (Feldner, Leen-Feldner, Trainor, Blanchard, & Monson, 2008; Hebert, 2008) and to other substance use (Acierno, Kilpatrick, Resnick, Saunders, Arellano, Best, 2003; Costello, Erkanli, Fairbank, & Angold, 2002). Specifically, early exposure to trauma and subsequent development of PTSD symptoms can interfere with emotional regulatory tasks and lead to further internalizing problems (Lubit, 2005; Mayes & Suchman, 2006).
This study tested a mediation model of the relationship with tobacco use, social network quality (level of risk or protection in a network), and substance use (alcohol and/or illicit drugs) with a sample of 301 urban adolescents. It was theorized that social network quality would mediate the effect of tobacco use, accounting for PTSD symptoms and parent-teen relationships, on substance use. Results of path modeling with AMOS showed that the model provided an overall very good fit to the data and demonstrated partial mediation effects of social network quality on substance use. An effect-size measure was applied to determine what proportion of the total effect was mediated by the intervening (social network) variable and produced a moderate effect size (0.31). Results highlight the mediating role of social network quality on risk factors for adolescent substance use and are informative to prevention science in advancing social operational models of substance use.
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While some individuals develop PTSD subsequent to traumatic experiences, many individuals resume prior functioning naturally. Diathesis-stress models suggest that stable individual differences present in individuals prior to trauma may serve as vulnerability factors to symptom development. The high levels of comorbidity and symptom similarity suggest that established vulnerability factors for anxiety and depression may also serve as vulnerability factors for PTSD. The examination of multiple vulnerability factors simultaneously may increase understanding of the etiology of PTSD and comorbid post-trauma symptomatology and account for a greater percentage of variance in PTSD symptoms. In addition, the vulnerability factors may be related to distinct sets of symptoms, with vulnerabilities predicting the PTSD symptoms most similar to their associated disorders. Research examining the relations between attributional style, rumination, anxiety sensitivity, and the looming cognitive style and the development of PTSD after trauma exposure is reviewed and suggestions for future research are provided.
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Smoking and posttraumatic stress symptoms among adolescents: Does anxiety sensitivity matter?

Abstract

Section snippets

Participants

Zero-order correlations

Discussion

Acknowledgments

Journal of Anxiety Disorders

Clinical Psychology Review

Journal of the American Academy of Child and Adolescent Psychiatry

Journal of Affective Disorders

Assault, PTSD, family substance use, and depression as risk factors for cigarette use in youth: Findings from the national survey of adolescents

Journal of Traumatic Stress

Multiple regression: Testing and interpreting interactions

Diagnostic and statistical manual of mental disorders

Adverse childhood experiences and smoking during adolescence and adulthood

Journal of the American Medical Association

The moderator–mediator variable distinction in social psychological research: Conceptual, strategic, and statistical considerations

Journal of Personality and Social Psychology

Nicotine dependence in the United States

Archives of General Psychiatry

A developmental psychopathology perspective on adolescence

Journal of Consulting and Clinical Psychology

Temperament, personality and the mood and anxiety Disorders

Journal of Abnormal Psychology

Applied multiple regression/correlation analysis for the behavioral sciences

Traumatic events and posttraumatic stress in childhood

Archives of General Psychiatry

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

Anxiety sensitivity as a moderator of the relation between trauma exposure frequency and posttraumatic stress symptomatology

Journal of Cognitive Psychotherapy: An International Quarterly

The Child PTSD Symptom Scale: A preliminary examination of its psychometric properties

Journal of Clinical Child Psychology

Post-hoc probing of significant moderational and mediational effects in studies of pediatric populations

Journal of Pediatric Psychology