An examination of smoking outcome expectancies, smoking motives and trait worry in a sample of treatment-seeking smokers

Over 50% of daily smokers have a lifetime history of a psychiatric disorder and such persons consume a disproportionately large percentage of overall cigarettes (Ziedonis et al., 2008; Lasser et al., 2000). Although smoking has historically been studied in relation to co-occurring schizophrenia, substance use and mood disorders (Ziedonis et al., 2008), comparatively less scholarly attention has been focused on anxiety and its disorders. Anxiety disorders are among the most common psychiatric conditions (Kessler, Chiu, Demler, & Walters, 2005), and some studies indicate higher rates of smoking among the anxiety-disorder population relative to both persons with no psychiatric illness as well as many other psychiatric conditions (McCabe et al., 2004; Lasser et al., 2000). Notably, little research to date has examined the potential explanatory value of trait worry in the context of smoking and anxiety, despite the fact that this construct is a common component of anxiety psychopathology (Barlow, 2002; Brown, Antony & Barlow, 1992) and is the core feature of generalized anxiety disorder (GAD; American Psychiatric Association, 2000). Worry has been operationalized as thoughts focused on the possibility of future negative events (Borkovec, 1994; Borkovec, Alcaine & Behar, 2004). This mental activity is theorized to sometimes create cognitive avoidance that interferes with emotional processing (Borkovec, 1994; Borkovec, Ray, & Stober, 1998) and is considered to be a ‘formative element’ to many types of anxiety psychopathology (Barlow, 2002). Although trait worry is related to other negative mood states, there is both theoretical and empirical evidence that it is a distinct psychological construct (Borkovec et al., 1998). The vast majority of the work relating to worry in terms of smoking has focused on worry specific to tobacco use. For example, smokers tend to worry about a lack of smoking-related self-control (e.g., worry whether they are addicted to nicotine) and the health consequences of smoking (Koblitz et al., 2009; McCaul et al, 2006). Smoking-focused worry also has often been associated with an increased level of current motivation to quit smoking and a greater number of quit attempts (Dijkstra & Brosschot, 2003; Magnan, Koblitz, Zielke, & McCaul, 2009; McCaul, Mullens, Romanek, Erickson, & Gatheridge, 2007), though this support is not entirely consistent (Klein, Zajac, & Monin, 2009). In one test of daily smokers, Spada, Nikcevic, Moneta & Wells (2007) examined whether metacognitive knowledge (i.e., information about one’s own thoughts and emotions) mediated the relationship between emotion and smoking dependence. Spada and colleagues (2007) found that two facets of metacognition related to worry--positive beliefs about worry and its usefulness and negative beliefs about worry related to uncontrollability--were positively associated with smoking dependence (Spada et al., 2007). Also, in a study examing smokers thoughts and worries about their smoking behavior using ecolocical momentary assessment procedures, Koblitz et al. (2009) found a positive correlation between baseline trait worry scores and intensity of worry regarding thoughts specific to smoking. The present study sought to explicate the relationship between chronic, excessive worry and important smoking-related processes believed to influence smoking behavior, such as smoking outcome expectancies and motives. Although no prior research has examined associations between trait worry per se and cognitive-based smoking processes or smoking behavior, studies have recently begun to examine GAD diagnostic status and smoking. These studies have primarily documented an association between GAD and smoking prevalence; specifically, individuals diagnosed with GAD are twice as likely to smoke relative to individuals without this diagnosis (Cranford, Eisenberg, & Serras, 2009) or with no psychiatric illness (Lasser et al, 2000; Ziedonis et al, 2008). In addition to high rates of tobacco use, a GAD diagnosis is significantly related to decreased success in quitting smoking (Lasser et al., 2000; McCabe et al., 2004; Piper, Cook, Schlam, Jorenby & Baker, 2010). Data examining the temporal relationship between GAD and tobacco use suggests that smoking 20 or more cigarettes per day in adolescence is related to an increased risk for developing GAD in early adulthood (Johnson et al, 2000). Similarly, using data from the National Comorbidity Survey-Replication, Cougle, Zvolensky, Fitch, & Sachs-Ericcson (2010) found that approximately 68% of individuals with a lifetime history of ‘regular smoking’ reported smoking prior to the onset of their GAD diagnosis. This GAD-smoking work, although only indirectly related to trait worry, provides empirical support for exploring the potential explanatory relevance of trait worry in terms of smoking-based cognitive processes (e.g., outcome expectancies for smoking, motives for smoking, and perceived barriers to quitting). Smoking outcome expectancies have been defined as one’s expectations or beliefs about the outcome of smoking (Brandon & Baker, 1991) while smoking motives have been conceptualized as one’s specific reasons for smoking (Ikard, Green, & Horn, 1969). Perceived barriers to quitting reflect one’s perception of personal obstacles associated with the quitting process (MacNee & Talsma, 1995). Theoretical models of GAD and worry such as the Avoidance Theory of Worry (Borkovec, 1994; Borkovec, Alcaine, & Behar, 2004) and the Emotion Dysregulation Model (Mennin, Heimberg, Turk, & Fresco, 2002) emphasize the role of emotional avoidance in response to perceived threat (see Behar, DiMarco, Hekler, Mohlam, & Staples, 2009, for a review). Specifically, trait worry is viewed as a tactic of avoiding negative mental images and subsequent autonomic activation (Borkovec, 1994; Borkovec et al, 2004), or of coping with or avoiding strong emotions (Mennin et al, 2002). Given the link between worry and avoidance (Borkovec, 1994), smokers higher in trait worry may be more apt to smoke for negative affect reduction reasons, maintain beliefs that smoking can down regulate negative mood, and perceive more challenges or barriers in succesfully quitting. Indeed, Cougle et al. (2010) suggest that the act of smoking among individuals with GAD may function as a “safety seeking behavior” used to avoid and/or alleviate anxiety but one that may ultimately worsen anxiety or possibly interfere with its successful treatment. Together, the purpose of the current study was to examine the predictive value of trait worry with regard to the cognitive-based smoking processes of tobacco smoking motives, outcome expectancies, and perceived barriers to cessation. It was hypothesized that after controlling for daily smoking rate, negative affectivity, gender, and a composite health score for tobacco-related disease as well as other (non-criterion) smoking motives and expectancies, trait worry would be significantly and uniquely associated with negative affect reduction smoking motives, mood-based outcome expectancies, and greater perceived barriers in quitting. These hypotheses were globally guided by extant smoking-GAD research as well as theoretical models of trait worry suggesting this construct may confer increased risk for avoidant coping and negative evaluations about the ability to manage life events (Borkovec, 1994), and therefore, may be associated with greater reasons for mood-based smoking beliefs and expectancies, and perceived barriers for quitting smoking.