An evaluation of pain-related anxiety among daily cigarette smokers in terms of negative and positive reinforcement smoking outcome expectancies

doi:10.1016/j.addbeh.2010.01.005

Addictive Behaviors

Volume 35, Issue 6, June 2010, Pages 553-557

https://doi.org/10.1016/j.addbeh.2010.01.005 Get rights and content

Abstract

The present investigation sought to evaluate the unique explanatory relevance of pain-related anxiety in relation to negative and positive reinforcement smoking outcome expectancies among 135 (40.7% female; M_age = 26.11, SD = 11.23) adult daily cigarette smokers. As predicted, pain-related anxiety was significantly related to greater expectancies that smoking will decrease negative affect, and lesser expectancies that smoking will result in positive outcomes. The observed effects were evident above and beyond the variance accounted for by gender, current level of non-specific bodily pain, daily cigarette use, relations with non-criterion outcome expectancies, and shared variance with anxiety sensitivity. Results suggest that there may be segments of the smoking population who are at relatively greater risk for certain expectancies for tobacco smoking by virtue of individual differences in pain-related anxiety.

Section snippets

Method

Participants included 135 (40.7% female; M_age = 26.11, SD = 11.23) adult daily cigarette smokers recruited from the Burlington, Vermont community for participation in a larger experimental laboratory study on emotion regulation via placement of study flyers throughout various community settings, as well as posting of printed advertisements in local newspapers. The racial distribution of the sample generally reflected that of the Vermont population (State of Vermont Department of Health, 2009):

Results

Means, standard deviations, and zero-order correlations of all variables are reported in Table 1. The PASS-total score was positively and significantly associated with negative reinforcement, appetite/weight control, and negative consequences smoking outcome expectancies (range of observed rs = .26 to .31, see Table 1). The ASI-total score was positively and significantly related to all of the smoking outcome expectancies (range of observed rs = .18 to .25). Females, on average, scored higher in

Discussion

An emerging body of work highlights significant relations between cigarette smoking and the experience of pain and its disorders (Ekholm et al., 2009, Freedman et al., 2008). Despite these observed relations, there is a lack of understanding of the interplay between pain-related anxiety and cognitive-based smoking factors. To fill this gap in the extant literature, the present investigation therefore sought to evaluate the explanatory relevance of pain-related anxiety in relation to certain

Role of Funding Sources

This paper was supported by a National Institute of Mental Health Diversity Supplement (grant number 1 R01 MH076629-01) awarded to Adam Gonzalez and a National Institute of Mental Health research grant (grant number 1 R01 MH076629-01) awarded to Dr. Zvolensky. The National Institute of Mental Health 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.

Contributors

Adam Gonzalez and Michael Zvolensky developed the objectives for the current study, conducted statistical analyses, and led the overall development of the manuscript. Julianna Hogan and Alison McLeish aided equally in the production of the final manuscript. All authors contributed to and have approved the final manuscript.

Conflict of Interest

All other authors declare that they have no conflicts of interest.

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Thus, there was empirical evidence that effects were specific to the hypothesized pathways. Extending prior work on pain and smoking (Gonzalez et al., 2010; LaRowe et al., 2017), the present findings indicate that pain-related anxiety may be related to an array of clinically-relevant smoking processes via dysphoric symptoms. The present findings provide support for a conceptual model wherein smokers with elevated pain-related anxiety endorse more severe dysphoria.
Scientific evidence suggests that pain-related anxiety may contribute to the maintenance of tobacco addiction among smokers with varying levels of pain. Yet, no work has investigated the relation between pain-related anxiety and cognitive-based smoking processes within an indirect effect model. Dysphoria may explain the relation between pain-related anxiety and cigarette smoking, as it is a construct that relates to both pain and smoking outcomes. Thus, the current cross-sectional study examined the indirect effect of pain-related anxiety and three clinically significant smoking processes: perceived barriers to cessation, negative affect reduction motives, and negative mood abstinence expectancies via dysphoria. Participants included 101 (M_age = 32.74 years, SD = 13.60; 35.6% female) adult tobacco cigarette smokers with low cigarette dependence. Results indicated that pain-related anxiety had an indirect effect on all dependent variables through dysphoria. The current findings provide evidence that dysphoria may serve to maintain maladaptive smoking processes in smokers who experience pain-related anxiety. This study furthers research on pain-smoking relations by providing initial evidence for a conceptual model in which smokers with elevated pain-related anxiety endorse greater dysphoric symptoms and use smoking to reduce or escape symptoms of their pain-related anxiety and dysphoria, thus contributing to the maintenance of tobacco dependence.
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Chronic pain is a significant public health concern that imposes substantial burdens on individuals and healthcare systems, and factors that contribute to the development and maintenance of pain-related disability are of increasing empirical and clinical interest. Consistent with the fear-avoidance model of chronic pain, greater pain-related fear has consistently been associated with more severe disability and may predict the progression of disability over time. Recent evidence indicates that treatments designed to reduce pain-related fear are efficacious for improving disability outcomes, and several clinical trials are currently underway to test tailored intervention content and methods of dissemination. Future research in this area is needed to identify factors (e.g., substance use, comorbid psychopathology) that may influence interrelations between pain-related fear, response to treatment, and disability.
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Pain-related anxiety is a risk factor in the transition from acute to chronic pain (Boersma & Linton, 2006; Vlaeyen & Linton, 2000), and greater pain-related anxiety has been related to overestimated appraisals of pain intensity, maladaptive approaches to pain coping, and increased somatic reactivity in anticipation of pain-eliciting physical activity (McCracken, Gross, Sorg, & Edmands, 1993). More recently, pain-related anxiety has been implicated in the maintenance of substance use in general (Hogan, Gonzalez, Howell, Bonn-Miller, & Zvolensky, 2010), and tobacco smoking in particular (Ditre, Zale, Kosiba, & Zvolensky, 2013; Gonzalez, Hogan, McLeish, & Zvolensky, 2010). For example, among a sample of daily smokers who endorsed recent body pain, pain-related anxiety was found to be positively associated with expectancies that smoking decreases negative affect (Gonzalez et al., 2010).
There is increasing recognition that complex and potentially bidirectional relations between pain and smoking may be relevant to the maintenance of tobacco addiction. Pain-related anxiety has been identified as a mechanism in the onset and progression of painful disorders, and initial evidence indicates that pain-related anxiety may be associated with essential features of tobacco dependence among smokers with chronic pain. However, there has not been an empirical study of pain-related anxiety in relation to tobacco dependence and self-reported barriers to quitting among a community-based sample of daily smokers. The current sample was comprised of 122 daily smokers who were recruited from the local community to participate in a larger study that included an initial assessment of pain, smoking history, and pain-related anxiety. Approximately 17% of our sample endorsed moderate or severe past-month pain, nearly half met criteria for current anxiety or mood disorder, and about 30% met criteria for a current substance use disorder, exclusive of tobacco dependence. Results indicated that pain-related anxiety was uniquely and positively associated with both tobacco dependence severity scores and self-reported barriers to quitting. These findings lend support to the notion that pain-related anxiety may contribute to the maintenance of tobacco addiction among smokers who experience varying levels of pain severity.
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Future research is needed to examine other psychological factors such as anxiety specific to pain. Previous research has found that increased pain-specific anxiety is associated with a greater expectancy that smoking will decrease negative affect.20 These data suggest that anxiety about pain may reinforce smoking because smoking is viewed as a tool for reducing negative affect.
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Smoking cigarettes is prevalent among individuals with chronic pain. Some studies indicate nicotine reduces pain and others suggest it may cause or exacerbate pain. Participants in this cross-sectional study were 151 chronic pain patients from a large, urban VA medical center. Patients were divided into 3 groups: 1) nonsmokers; 2) smokers who deny using cigarettes to cope with pain; and 3) smokers who report using cigarettes to cope with pain. Patients who reported smoking as a coping strategy for chronic pain scored significantly worse compared with the other 2 groups on the majority of measures of pain-related outcome. Nonsmokers and smokers who denied smoking to cope did not differ on any variable examined. After controlling for the effects of demographic and clinical factors, smoking cigarettes as a coping strategy for pain was significantly and positively associated with pain intensity (P = .04), pain interference (P = .005), and fear of pain (P = .04). In addition to assessing general smoking status, a more specific assessment of the chronic pain patient’s reasons for smoking may be an important consideration as part of interdisciplinary pain treatment.
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An evaluation of pain-related anxiety among daily cigarette smokers in terms of negative and positive reinforcement smoking outcome expectancies

Abstract

Section snippets

Method

Results

Discussion

Role of Funding Sources

Contributors

Conflict of Interest

Behaviour Research and Therapy

European Journal of Pain

Archives of Physical Medicine and Rehabilitation

Addictive Behaviors

European Journal of Pain

Addictive Behaviors

Journal of Anxiety Disorders

Behaviour Research and Therapy

Pain

Spine Journal

Biological Psychiatry

Behaviour Research and Therapy

Behaviour Research and Therapy

Journal of Anxiety Disorders

Addictive Behaviors

Factors associated with nicotine dependence among African American women cigarette smokers

Research in Nursing & Health

Negative affect as motivation to smoke

Behavior Modification

The Smoking Consequences Questionnaire: The subjective expected utility of smoking in college students

Psychological Assessment

Expectancies for tobacco smoking

Distress tolerance and duration of past smoking cessation attempts

Journal of Abnormal Psychology

A psychometric evaluation of the Smoking Consequences Questionnaire — Adult in smokers with psychiatric conditions

Nicotine & Tobacco Research