This article was downloaded by: [New York University] On: 12 June 2015, At: 00:16 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK

Psychology, Health & Medicine Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/cphm20

Evaluating the role of anxiety sensitivity in barriers to cessation and reasons for quitting among smokers with asthma a

a

a

Alison C. McLeish , Adrienne L. Johnson , Kimberly M. Avallone & Michael J. Zvolensky

bc

a

Department of Psychology, University of Cincinnati, P.O. Box 210376, Cincinnati, OH 45221-0376, USA b

Department of Psychology, University of Houston, TX, USA

c

Click for updates

MD Anderson Cancer Center, The University of Texas, Houston, TX, USA Published online: 02 Jun 2015.

To cite this article: Alison C. McLeish, Adrienne L. Johnson, Kimberly M. Avallone & Michael J. Zvolensky (2015): Evaluating the role of anxiety sensitivity in barriers to cessation and reasons for quitting among smokers with asthma, Psychology, Health & Medicine, DOI: 10.1080/13548506.2015.1051058 To link to this article: http://dx.doi.org/10.1080/13548506.2015.1051058

PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms &

Downloaded by [New York University] at 00:16 12 June 2015

Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions

Psychology, Health & Medicine, 2015 http://dx.doi.org/10.1080/13548506.2015.1051058

Evaluating the role of anxiety sensitivity in barriers to cessation and reasons for quitting among smokers with asthma Alison C. McLeisha*, Adrienne L. Johnsona, Kimberly M. Avallonea and Michael J. Zvolenskyb,c

Downloaded by [New York University] at 00:16 12 June 2015

a Department of Psychology, University of Cincinnati, P.O. Box 210376, Cincinnati, OH 45221-0376, USA; bDepartment of Psychology, University of Houston, TX, USA; c MD Anderson Cancer Center, The University of Texas, Houston, TX, USA

(Received 1 October 2014; accepted 8 May 2015) The aim of the present study was to examine the unique predictive ability of anxiety sensitivity (AS) in terms of perceived barriers to cessation and smoking cessation motives among daily smokers with asthma (n = 125, 54% male, Mage = 37.7 years, SD = 12.1). As hypothesized, after controlling for the effects of race, asthma control, negative affect, and smoking rate, AS significantly predicted greater barriers to cessation, and reasons for quitting related to health concerns and self-control. Contrary to hypotheses, AS did not significantly predict external reasons for quitting. These findings suggest that smokers with asthma who are fearful of physiological arousal may be a particularly ‘at-risk’ population for smoking cessation difficulties due, in part, to greater perceived barriers to cessation. Interventions focused on enhancing intrinsic motivation for quitting and reducing AS may be most effective for this population. Keywords: asthma; anxiety sensitivity; smoking; smoking cessation barriers; smoking cessation motives

Approximately 28% of individuals with asthma in the US are current smokers (Yun, Chanetsa, Kelsey, & Zhu, 2006) compared to a smoking rate of approximately 18% in the general US population (Center for Disease Control and Prevention, 2014). Smokers with asthma also report poorer asthma control and more frequent and severe asthma exacerbations compared to non-smokers with asthma (Mccoy et al., 2006; McLeish & Zvolensky, 2010; Schatz, Zeiger, Vollmer, Mosen, & Cook, 2006). Although smokers with asthma appear to be as motivated to quit smoking as smokers without asthma (Avallone et al., 2013; Precht, Keiding, & Madsen, 2003; Siroux, Pin, Oryszczyn, Le Moual, & Kauffmann, 2000), abstinence rates during cessation attempts among individuals with asthma are significantly lower than those observed among smokers without asthma (Fennerty, Banks, Ebden, & Bevan, 1987; Tønnesen et al., 2005). Currently, there is little empirical understanding of the factors among smokers with asthma that govern perceptions of, and reasons for, quitting. This lack of attention is unfortunate as both factors play an important role in smoking cessation. Reasons for quitting smoking fall along two broad dimensions: (1) intrinsic motives, which include health concerns (e.g. worry about shorter life) and self-control (e.g. to like one’s self better), and (2) extrinsic motives, which include immediate reinforcement (e.g. save *Corresponding author. Email: [email protected] © 2015 Taylor & Francis

Downloaded by [New York University] at 00:16 12 June 2015

2

A.C. McLeish et al.

money) and social influence (e.g. to get others to stop nagging; Curry, Wagner, & Grothaus, 1990). Research indicates that individuals with extrinsic reasons for quitting are less successful in quitting, and those who are high in intrinsic reasons for quitting and low in extrinsic reasons are ultimately the most successful in quitting (Curry et al., 1990; Halpern & Warner, 1993). Similarly, in terms of perceptions of quitting, greater perceived barriers to smoking cessation are associated with increased chance of relapse during a quit attempt (Macnee & Talsma, 1995). Recent work suggests that anxiety sensitivity (AS), defined as the fear of arousalrelated physical and psychological sensations (McNally, 2002; Reiss & McNally, 1985), may be an important explanatory construct in terms of better understanding the smoking–asthma relation. AS reflects a relatively stable, albeit malleable, cognitive predisposition that results in an amplification of pre-existing anxiety levels such that a person who is high in AS will be more reactive to any personally relevant threat stimulus. For example, an individual who is high in AS who experiences heart palpitations will experience an increase in fear because of concerns about having a heart attack and a further amplification in this fear due to this anxious responding to such sensations. AS is distinct from trait or state anxiety symptoms and other negative affect states (e.g. depression; Rapee & Medoro, 1994; Zvolensky, Kotov, Antipova, & Schmidt, 2003). Whereas trait anxiety denotes one’s anxiety proneness and state anxiety denotes how anxious one is in a particular moment or situation, AS denotes a fear of this anxiety or the symptoms one experiences when anxious. In the case of smoking, there is basic and applied research to suggest AS is associated with smoking maintenance and relapse by heightening adverse emotional responsitivity to interoceptive cues (Farris, Langdon, DiBello, & Zvolensky, 2015; Leventhal & Zvolensky, 2015). Extant AS research suggests that it serves as a transdiagnostic risk factor for both smoking and asthma, resulting in poorer outcomes in both domains. For example, higher levels of AS are related to greater odds of early lapse (Brown, Kahler, Zvolensky, Lejuez, & Ramsey, 2001) and relapse during quit attempts (Zvolensky et al., 2007; Zvolensky, Bonn-Miller, Bernstein, & Marshall, 2006; Zvolensky, Stewart, Vujanovic, Gavric, & Steeves, 2009) as well as decreased asthma control and asthma-related quality of life (Avallone, McLeish, Luberto, & Bernstein, 2012; McLeish, Zvolensky, & Luberto, 2011). Among smokers without asthma, AS is associated with greater barriers for cessation (Gonzalez, Zvolensky, Vujanovic, Leyro, & Marshall, 2008; Gregor, Zvolensky, McLeish, Bernstein, & Morissette, 2008; Johnson, Farris, Schmidt, Smits, & Zvolensky, 2013) as well as both intrinsic (i.e. health concerns) and extrinsic (i.e. immediate reinforcement, social influence) reasons for quitting smoking (Zvolensky et al., 2007). However, there is no empirical knowledge of AS and smoking cessation processes among smokers with asthma. Thus, despite its transdiagnostic relevance, it remains unclear if AS is similarily important to better understanding perceptions of, and reasons for, quitting among smokers with asthma. Therefore, the aim of the present study was to examine the unique predictive ability of AS in terms of perceived barriers to cessation and smoking cessation motives among a sample of daily smokers with asthma. It was hypothesized that after adjusting for race, asthma control, negative affectivity, and daily smoking rate, AS would be significantly predictive of greater barriers to cessation and both intrinsic (i.e. health concerns, self-control) and extrinsic (i.e. immediate reinforcement, social influence) reasons for quitting smoking. The covariates were chosen on an a priori basis due to their known associations with both smoking and asthma (Grant, Lyttle, & Weiss, 2000; Kassel, Stroud, & Paronis, 2003; Kullowatz et al., 2008; McLeish & Zvolensky, 2010; Nathan et al., 2004; U.S. Department of Health & Human Services [USDHHS], 1998).

Psychology, Health & Medicine

3

Downloaded by [New York University] at 00:16 12 June 2015

Method Participants Participants were 125 daily cigarette smokers with self-reported, physician-diagnosed asthma (54% male, Mage = 37.7 years, SD = 12.1) recruited from the greater Cincinnati, Ohio community. The racial composition of the sample was 40.8% White and 57.6% Non-white. 7.2% of the sample had at least a four-year college degree, 3.2% had a twoyear college degree, 28.8% had completed some college education, 36.8% had a high school degree, and 24% had less than a high school degree. On average, participants smoked 20.8 (SD = 12.8) cigarettes per day and had been regular smokers for 20.6 years (SD = 11.8). The average level of nicotine dependence, as indexed by the Fagerström test for nicotine dependence (FTND) (Heatherton, Kozlowski, Frecker, & Fagerström, 1991) was 6.1 (SD = 2.2), indicating a moderate level of nicotine dependence. Participants were approximately 17.46 (SD = 12.92) years of age when diagnosed with asthma and reported 1.62 (SD = .49) asthma-related hospitalizations. In terms of asthma control, 27.2% of smokers with asthma reported troubling asthma symptoms most or all days/nights during the previous two weeks and a mean Asthma control test (ACT) (Nathan et al., 2004) score of 15.48 (SD = 4.21), indicating difficulties with asthma control.

Measures Expired carbon monoxide Biochemical verification of smoking status was completed by carbon monoxide (CO) analysis of breath samples assessed using a Bedfont Micro 4 Smokerlyzer CO Monitor (Model EC50; coVita, Haddonfield, NJ). Research indicates that 10 ppm is an optimal cut-off score for reliably discriminating smoking status (Cocores, 1993). Obtained values at or above this cut-off were considered indicative of regular smoking. The average expired CO level for the current sample was 21.8 ppm (SD = 11.4). Fagerström test for nicotine dependence The FTND (Heatherton et al., 1991) is a six-item measure designed to assess gradations in nicotine dependence. The FTND has shown good internal consistency, positive relations with key smoking variables (e.g. cotinine; Heatherton et al., 1991; Payne, Smith, McCracken, McSherry, & Antony, 1994) as well as high degrees of test–retest reliability (Pomerleau, Carton, Lutzke, Flessland, & Pomerleau, 1994). Smoking history questionnaire The smoking history questionnaire (Brown, Lejuez, Kahler, & Strong, 2002) was used to assess smoking pattern and history, including items pertaining to smoking rate, age of onset at initiation, and number of serious quit attempts. Asthma diagnosis To identify individuals with an asthma diagnosis, participants were first asked whether or not a physician has ever diagnosed them with asthma. Those who endorsed (1) an asthma diagnosis; (2) having a current prescription for an asthma-related medication;

4

A.C. McLeish et al.

and (3) experiencing asthma-related symptoms within the past 12 months were considered to have ‘current asthma.’ This strategy has been successfully employed in previous research (e.g. Avallone et al., 2013; McLeish et al., 2011). Information was also gathered regarding age at diagnosis, number of hospitalizations, and recent symptoms and medication use.

Downloaded by [New York University] at 00:16 12 June 2015

Asthma control test The ACT (Nathan et al., 2004) is a five-item self-report measure that assesses asthma control. The ACT measures frequency of symptoms (e.g. ‘How often have you had shortness of breath?’) and functional impairment due to symptoms (e.g. ‘How much of the time did your asthma keep you from getting as much done at work or at home?’) within the past four weeks. Items are rated on a five-point Likert-type scale with anchors specific to each question. The items are then summed to produce a total score with higher scores reflecting better asthma control. The ACT shows good reliability and is able to discriminate between groups of patients with different levels of asthma control (Nathan et al., 2004). Internal consistency for the ACT in the current sample was acceptable (α = .78). Positive affect negative affect schedule The positive affect negative affect schedule (PANAS) (Watson, Clark, & Tellegen, 1988) is a measure of general positive and negative emotional states commonly used in psychopathology research (Watson, 2000). Items are rated on a five-point Likert-type scale (1 = very slightly or not at all to 5 = extremely) and then summed such that higher scores indicate greater levels of positive or negative affect. In the present study, we used only the negative affect subscale (PANAS-NA) as an index of the broad-based disposition to experience negative affective states (e.g. anger, anxiety, depression, guilt). Internal consistency for the PANAS-NA in the current sample was excellent (α = .91). Anxiety sensitivity index-3 The anxiety sensitivity index-3 (ASI-3) (Taylor et al., 2007) is an 18-item self-report measure that assesses the degree to which participants fear negative consequences stemming from anxiety symptoms. Items are rated on a five-point Likert-type scale (0 = very little to 4 = very much) and then summed such that higher scores indicate greater levels of AS. The ASI-3 is comprised of one higher order AS factor and three specific lower order factors (Taylor et al., 2007). The three lower order factors consist of physical (e.g. ‘It scares me when my heart beats rapidly’), social (e.g. ‘I worry that other people will notice my anxiety’), and cognitive (e.g. ‘When my thoughts seem to speed up, I worry that I might be going crazy’) concerns. The ASI-3 has demonstrated the strongest psychometric properties of any current measure of AS (Taylor et al., 2007). Internal consistency for the ASI-3 total score in the current sample was excellent (α = .94). Barriers to cessation scale The barriers to cessation scale (BCS) (Macnee & Talsma, 1995) is a 19-item self-report measure that assesses one’s perceived barriers to quitting smoking. Items are rated on a

Psychology, Health & Medicine

5

four-point Likert-type scale (0 = not a barrier/not applicable to 3 = large barrier) and then summed such that higher scores reflect greater perceived barriers to cessation. The BCS assesses cessation barriers across three domains: internal (e.g. ‘feeling less in control of your moods’), external (e.g. ‘no encouragement or help from friends’), and addiction-related barriers (e.g. ‘withdrawal symptoms’). Internal consistency for the BCS in the current sample was excellent (α = .90).

Downloaded by [New York University] at 00:16 12 June 2015

Reasons for quitting questionnaire The reasons for quitting questionnaire (RFQ) (Curry et al., 1990) is a 20-item self-report measure that assesses motivation to quit smoking. Participants are asked to indicate, on a four-point Likert-type scale ranging from 1 (not at all true) to 4 (extremely true), the extent to which different reasons for smoking apply to them. Items are then summed with higher scores reflecting stronger motivation for quitting. The RFQ assesses four domains of motivation to quit smoking, which fall along two broad domains: intrinsic and extrinsic. The dimensions that fall under intrinsic motivation to quit smoking are health concerns (e.g. ‘I am concerned about illness’) and self-control (e.g. ‘I want to show myself or others I can quit’). The remaining two subscales, immediate reinforcement (e.g. ‘I will save money on cigarettes’) and social influence (e.g. ‘I want people to stop nagging me’) are extrinsic reasons to quit smoking. The RFQ has demonstrated good internal consistency, adequate convergent and discriminant validity, and satisfactory predictive validity (Curry et al., 1990). Internal consistency for the RFQ subscales was acceptable (range: .71–.82).

Procedure Participants responding to community-based advertisements for a research study focused on smoking and emotions were scheduled for an individual appointment by a trained research assistant. Individuals were eligible to participate if they: (1) were between the ages of 18 and 65; (2) smoked at least 10 cigarettes per day; (3) had been regular smokers for at least one year; (4) had received a physician diagnosis of asthma; (5) had a current prescription for at least one asthma medication; and (6) reported experiencing asthma symptoms within the past year. After providing informed, written consent, participants’ smoking status was biochemically verified via CO analysis. Participants then completed a self-report battery to assess smoking and affect-related variables. Participants were compensated $30 for their time and effort. The Institutional Review Board approved all study procedures and materials prior to data collection.

Analytic approach First, bivariate correlations were computed to examine the relationship among all study variables. The main effect of AS for barriers to cessation and the four reasons for quitting subscales (i.e. health concerns, self-control, immediate reinforcement, social influence) was evaluated using a hierarchical multiple regression procedure (Cohen & Cohen, 1983). Separate models were constructed for the dependent variables. Race, asthma control, daily smoking rate (i.e. cigarettes per day), and negative affectivity were entered as covariates at step one of each regression, and AS was entered at the second step.

6

A.C. McLeish et al.

Downloaded by [New York University] at 00:16 12 June 2015

Results See Table 1 for associations among predictor and criterion variables. Race was significantly correlated with negative affectivity (r = −.28, p < .01) and barriers to cessation (r = −.20, p < .05). Specifically, Whites reported greater negative affectivity and barriers to cessation. Asthma control was significantly negatively associated with all of the variables except for smoking rate and RFQ-social influence (range: −.18 to −.25). Negative affectivity was significantly associated with AS (r = .69, p < .01), barriers to cessation (r = .44, p < .01), RFQ-health concerns (r = .21, p < .05), and RFQ-self-control (r = .25, p < .01). Smoking rate was not significantly associated with any of the variables. AS was significantly associated with all of the criterion variables (range: .25–.52). Results for the regression analyses are presented in Table 2. Examination of tolerance statistics indicated no issues with multicollinearity in any of the regression models (all tolerances > .20). For barriers to cessation, the first step accounted for 24.9% of the variance. Negative affectivity (β = .42, t = 4.03, p < .01) was the only significant predictor at step one. Step two of the model predicted 3.6% of unique variance, and, as hypothesized, AS was a significant predictor (β = .26, t = 2.07, p < .05). In terms of reasons for quitting related to health concerns, the first step accounted for 12.3% of the variance. Asthma control (β = −.25, t = −2.51, p < .05) was the only significant predictor at step one. Step two of the model predicted 6.3% of unique variance, and, as hypothesized, there was a significant main effect for AS (β = .35, t = 2.63, p = .01). For reasons for quitting related to self-control, step one was not significant. As hypothesized, there was a main effect for AS, accounting for 4.4% of unique variance (β = .29, t = 2.12, p < .05). Neither regression models significantly predicted reasons for quitting related to immediate reinforcement or reasons for quitting related to social influence.1 Discussion The current study sought to examine the role of AS in terms of smoking cessation factors among smokers with asthma. As hypothesized, higher AS was significantly predictive of greater barriers to cessation (3.6% unique variance) and reasons for quitting related to health concerns (6.1% unique variance) and self-control (4.5% unique variance). These significant effects were above and beyond the variance accounted for by asthma control, negative affect, and daily smoking rate. Contrary to hypothesis, AS was not significantly predictive of immediate reinforcement and social influence reasons for quitting smoking. These findings suggest that smokers with asthma who fear anxiety-related sensations are intrinsically, rather than extrinsically, motivated to quit smoking and perceive greater barriers to quitting smoking compared to individuals without such fears. It should be noted, however, that AS was significantly correlated with both extrinsic motives for quitting at the zero-order level, indicating that other constructs that were included in our regression model, but not in the correlational analyses, partially accounted for this significant association. The current findings are similar to what has been found among smokers without asthma in terms of barriers to cessation and intrinsic motives for quitting (Gonzalez et al., 2008; Gregor et al., 2008; Johnson et al., 2013; Zvolensky et al., 2007). Nicotine withdrawal produces a number of arousal-related sensations, including somatic shakiness, increased heart rate, and nausea. Smokers with asthma experience such symptoms in the context of a pre-existing lung disease that manifests in chronic breathing difficulty coupled with episodic symptom exacerbations. Moreover, smokers with asthma sometimes experience a brief exacerbation of their asthma symptoms upon quitting (Fennerty et al.,

.14 – – – – – – – – –

– – – – – – – – – –

−.28** −.20* – – – – – – – –

3 −.04 −.08 .14 – – – – – – –

4 −.15 −.20* .69** .19 – – – – – –

5 −.20* −.23* .44** .16 .52** – – – – –

6 −.18 −.25** .21* −.03 .33** .34** – – – –

7 .02 −.22* .25** −.08 .33** .35** .48** – – –

8 −.13 −.18* .17 .08 .25** .41** .38** .47** – –

9 .14 −.05 .13 .05 .26** .34** .22* .43** .41** –

10

– 7–25 10–50 5–81 0–68 0–57 1–4 1–4 1–4 1–4

Range

– 15.48 22.42 20.78 26.08 26.89 2.82 3.06 3.12 2.02

M

– 4.21 9.15 12.84 17.32 13.02 .84 .79 .77 .89

SD

Notes: Race: 0 = White, 1 = Non-white; ACT: asthma control test (Nathan et al., 2004); PANAS-NA: positive and negative affect schedule-negative affect subscale (Watson et al., 1988); CPD: cigarettes per day; AS: anxiety sensitivity index-3 (Taylor et al., 2007); BCS: barriers to cessation scale (Macnee & Talsma, 1995); RFQ-HC: reasons for quitting questionnaire-health concerns subscale (Curry et al., 1990); RFQ-SC: reasons for quitting questionnaire-self control subscale (Curry et al., 1990); RFQ-IR: reasons for quitting questionnaire-immediate reinforcement subscale (Curry et al., 1990); RFQ-SI: reasons for quitting questionnaire-social influence subscale (Curry et al., 1990). *p < .05; **p < .01.

2

1

Descriptive data and intercorrelations among predictor and criterion variables.

1. Race 2. ACT 3. PANAS-NA 4. CPD 5. AS 6. BCS 7. RFQ-HC 8. RFQ-SC 9. RFQ-IR 10. RFQ-SI

Table 1.

Downloaded by [New York University] at 00:16 12 June 2015

Psychology, Health & Medicine 7

8

A.C. McLeish et al.

Table 2.

AS predicting barriers to cessation and reasons for quitting.

Downloaded by [New York University] at 00:16 12 June 2015

ΔR2

t (each predictor)

β

sr2

Criterion variable: barriers to cessation Step 1 .25 Race ACT PANAS-NA CPD Step 2 .04 AS

−.27 −1.39 4.03 1.23

−.03 −.13 .42 .12

.00 .02 .14 .01

2.07

.26

.04

Criterion variable: RFQ-health concerns Step 1 .12 Race ACT PANAS-NA CPD Step 2 .06 AS

−1.65 −2.51 .59 −1.18

−.18 −.25 .06 −.12

.03 .06 .00 .01

2.63

.35

.06

Criterion variable: RFQ-self control Step 1 .08 Race ACT PANAS-NA CPD Step 2 .04 AS

1.24 −1.57 1.86 −1.28

.13 −.16 .20 −.13

.02 .02 .03 .02

2.12

.29

.04

Criterion variable: RFQ-immediate reinforcement Step 1 .04 Race −1.12 ACT −.89 PANAS-NA .29 CPD .84 Step 2 .01 AS .82

−.12 −.09 .03 .09

.01 .01 .00 .01

.12

.01

Criterion variable: RFQ-social influence Step 1 .04 Race ACT PANAS-NA CPD Step 2 .04 AS

1.78 −.35 1.12 .26

.20 −.04 .13 .03

.03 .00 .01 .00

1.84

.26

.04

p

Evaluating the role of anxiety sensitivity in barriers to cessation and reasons for quitting among smokers with asthma.

The aim of the present study was to examine the unique predictive ability of anxiety sensitivity (AS) in terms of perceived barriers to cessation and ...
140KB Sizes 0 Downloads 3 Views