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. Author manuscript; available in PMC: 2018 Mar 1.
Published in final edited form as: Psychol Addict Behav. 2017 Jan 12;31(2):189–199. doi: 10.1037/adb0000252

Emotion Dysregulation Explains Associations between Anxiety Sensitivity and Hazardous Drinking and Drinking Motives among Adult Treatment-Seeking Smokers

Daniel J Paulus 1,*, Jaclyn Valadka 1, Michael S Businelle 2, Matthew W Gallagher 1,3, Andres G Viana 1,3, Norman B Schmidt 4, Michael J Zvolensky 1,5,*
PMCID: PMC5344750  NIHMSID: NIHMS836193  PMID: 28080096

Abstract

Smoking and drinking frequently co-occur. For example, alcohol use is associated with lapses during quit attempts. However, little is known regarding psychological factors explaining drinking among smokers. Anxiety sensitivity is a risk factor associated with hazardous drinking and drinking to cope and/or conform, although little is known about mechanisms underlying such associations. One potential explanatory factor is emotion dysregulation. The current study examined emotion dysregulation as an explanatory factor underlying anxiety sensitivity and five alcohol-related outcomes: hazardous drinking, alcohol consumption, alcohol problems coping-oriented drinking and drinking to conform. Participants for this study were 467 treatment-seeking adult daily smokers (48.2% female; Mage=36.7 years, SD = 13.6) who reported smoking an average of 16.5 cigarettes per day. Results indicated significant indirect effects of anxiety sensitivity via emotion dysregulation in relation to hazardous drinking, alcohol consumption, alcohol problems, drinking to cope, and drinking to conform. Effects were medium sized. Alternative models testing indirect effects of emotion dysregulation via anxiety sensitivity in relation to outcomes and anxiety sensitivity via outcomes in relation to emotion dysregulation were non-significant with small effect sizes. Follow-up tests examined effects of anxiety sensitivity via specific emotion dysregulation sub-factors. Thus, among treatment-seeking smokers, emotion dysregulation may explain the associations of anxiety sensitivity with alcohol-related outcomes. This pattern of findings highlights the potential importance of interventions targeting emotion dysregulation among hazardous drinking smokers.

Keywords: comorbidity, smoking, alcohol, transdiagnostic, vulnerabilities

Research has consistently documented the association between alcohol use and smoking (Anthony & Echeagaray-Wagner, 2000; Falk, Yi, & Hiller-Sturmhöfel, 2006; Kahler et al., 2008; Palfai, Monti, Ostafin, & Hutchison, 2000). For example, a majority of smokers drink alcohol, and drinkers are more likely to smoke relative to non-drinkers (Harrison, Hinson, & McKee, 2009; Krukowski, Solomon, & Naud, 2005; Reed, Wang, Shillington, Clapp, & Lange, 2007). Among smokers, rates of drinking and hazardous drinking (i.e., drinking that increases the risk of harmful consequences; World Health Organization [WHO], 2015) are elevated (Dawson, 2000). Past work has shown that smokers with alcohol problems report lower tobacco quit rates, are more dependent on nicotine (Hughes & Kalman, 2006), and die at higher rates due to smoking-related illness relative to smokers without alcohol problems (Hurt et al., 1996). Concurrent use of alcohol and tobacco is associated with additive health risk greater than the independent risk alcohol or tobacco use alone (B. Taylor & Rehm, 2006). Further, drinking alcohol is associated with greater risk for relapse following a quit attempt (Humfleet, Muñoz, Sees, Reus, & Hall, 1999). Thus, hazardous drinking smokers represent an ‘at risk’ group, although little is known regarding psychological factors underlying hazardous drinking among smokers.

One promising theoretically relevant factor to consider in relation to hazardous drinking among smokers is anxiety sensitivity. Anxiety sensitivity is a trait-like tendency to evaluate physiological arousal as harmful or dangerous (Reiss, 1991; Reiss & McNally, 1985). Anxiety sensitivity is a well-established risk factor for anxiety and depression (Naragon-Gainey, 2010) and has been consistently related to hazardous drinking in community samples (DeMartini & Carey, 2011; Schmidt, Buckner, & Keough, 2007; Stewart, Peterson, & Pihl, 1995; Stewart, Samoluk, & MacDonald, 1999). Individuals with elevated anxiety sensitivity report greater alcohol-related problems (Conrod, Stewart, & Pihl, 1997; Stewart et al., 1999), more frequent drinking to intoxication (Stewart et al., 1995; Stewart, Zvolensky, & Eifert, 2001), and higher rates of alcohol dependence (Lewis & Vogeltanz-Holm, 2002). Longitudinally, anxiety sensitivity has been shown to predict development of alcohol use disorder (Schmidt et al., 2007). Research also suggests that those with elevated anxiety sensitivity experience greater arousal-dampening effects of alcohol relative to those with lower anxiety sensitivity (e.g., Stewart et al., 2001; Zack, Poulos, Aramakis, Khamba, & MacLeod, 2007). A growing body of work has linked anxiety sensitivity to negative reinforcement (i.e., coping and conformity) motives for alcohol use (for review, see; DeMartini & Carey, 2011; Stewart et al., 2001). However, little is known about the relationship between anxiety sensitivity and hazardous drinking/motives for use among smokers. Such associations may be particularly important among smokers, as high anxiety sensitivity is evident in approximately 33% of all smokers (Allan et al., 2014) and relates strongly to numerous factors maintaining smoking (Leventhal & Zvolensky, 2015).

There is a need to examine potential mechanisms underlying associations of anxiety sensitivity and alcohol use among smokers to better understand how anxiety sensitivity may influence hazardous drinking and drinking to cope/conform. Such work is necessary in order to translate research into practice and inform existing interventions (Kazdin, 2008). One potential mechanism underlying anxiety sensitivity-alcohol associations is emotion dysregulation, defined as difficulties engaging a set of abilities wherein one can observe, understand, evaluate, and differentiate one’s emotions and subsequently access strategies to regulate emotions and control behavioral responses (Gratz & Roemer, 2004; Tull & Aldao, 2015). Emotion dysregulation is associated with increased alcohol consumption (Berking et al., 2011), greater alcohol-related problems (Dvorak et al., 2014), and coping/conformity motives for alcohol use (Aurora & Klanecky, 2016). Importantly, past work has found that emotion dysregulation is associated with, albeit distinct from, anxiety sensitivity (Vujanovic, Zvolensky, & Bernstein, 2008), with emotion dysregulation demonstrating incremental predictive validity over anxiety sensitivity (McDermott, Tull, Gratz, Daughters, & Lejuez, 2009; Sippel et al., 2015).

Theoretically, a smoker with elevated anxiety sensitivity may negatively interpret common physiological arousal (e.g., chest tightness, craving) as catastrophic, and as a result, have difficulty regulating emotions. The individual may then be more prone to engage in hazardous drinking, drinking to conform, and drinking to cope with distress in an effort to regulate negative affect. Partial support for this hypothesis comes from past work examining indirect associations of anxiety sensitivity via emotion dysregulation in relation to alcohol consumption and problems among psychiatric inpatients (Paulus, Vujanovic, & Wardle, 2016) and persons living with HIV (Paulus, Jardin, et al., 2016). Importantly, this past work has found non-significant indirect effects of anxiety sensitivity via emotion dysregulation, adding support for the theoretical model posited here. However, to date, such associations have not been examined among smokers or in relation to motives for alcohol use.

Together, the current study evaluated the indirect association of anxiety sensitivity via emotion dysregulation in relation to alcohol-related criterion variables among adult daily smokers (see Figure 1). Specifically, anxiety sensitivity was expected to positively predict emotion dysregulation, which, in turn, would be associated with hazardous drinking, alcohol consumption, and alcohol problems, as well as coping and conformity motives for alcohol use. It was expected that the indirect effect of anxiety sensitivity via emotion dysregulation would be present over and above variance accounted for by theoretically relevant covariates of gender, racial/ethnic minority status, cigarettes per day, and negative affectivity. These covariates were selected as past work has shown significant associations of each with alcohol consumption (Batel, Pessione, Maître, & Rueff, 1995; Grant et al., 2012; Nolen-Hoeksema, 2004; Witkiewitz & Villarroel, 2009).

Figure 1.

Figure 1

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Proposed model examining the indirect effect of Anxiety Sensitivity on Alcohol Use criterion variables (Hazardous Drinking, Alcohol Consumption, Alcohol Problems, Drinking to Cope, and Drinking to Conform) via Difficulties with Emotion Regulation.

Method

Participants

Participants included 467 adult daily smokers seeking treatment for smoking (51.8% male; Mage=36.7 years, SDage = 13.6) who reported smoking eight or more cigarettes per day. Regarding ethnicity, 85.2% of participants identified as White/Caucasian, 8.5% as Black, 3.4% as Hispanic, 1.1% as Asian, and 2.4% as “mixed race/other.” In terms of sexual orientation, 80.7% of participants identified as heterosexual, 3.9% as homosexual, 2.8% as bisexual, and 1.1% as “other.” The remaining 11.6% of participants did not disclose their sexual orientation. A majority (95.3%) of participants completed high school or received further education, and most (86.7%) reported current employment. On average, participants reported smoking 16.5 cigarettes per day (SD=10.0) and had been smoking regularly for an average of 18.4 years (SD=13.4).

The rates of psychiatric disorders were as follows (determined via Structured Clinical Interview for DSM-IV): social anxiety disorder (14.1%), non-tobacco substance use disorder (8.4%), generalized anxiety disorder (8.4%), specific phobia (8.1%), alcohol use disorder (7.7%), major depressive disorder (7.1%), posttraumatic stress disorder (PTSD; 5.1%), dysthymic disorder (4.1%), panic disorder (3.2%), obsessive-compulsive disorder (OCD; 2.1%), anxiety disorder not otherwise specified (1.7%), “other” (1.7%), agoraphobia (1.3%), depressive disorder not otherwise specified (1.1%), bipolar I/II disorder (0.4%), anorexia (0.2%), bulimia (0.2%), and body dysmorphic disorder (0.2%). Broadly, approximately one third (33.2%) met criteria for any anxiety disorder (including PTSD and OCD) and 12.2% met criteria for a mood disorder.

Measures

Structured Clinical Interview for DSM-IV (SCID; First, Spitzer, Gibbon, & Williams, 2002)

The SCID was administered by trained doctoral-level therapists to assess for Axis I psychopathology in the past year. The interviews were audiotaped, and 12.5% of the interviews were randomly checked for reliability by a clinical psychologist. There were no disagreements in diagnostic coding.

Smoking History Questionnaire (SHQ; Brown et al., 2002)

The SHQ is a self-report measure that assesses a participant’s smoking history and current use patterns. Items include age of first cigarette, smoking rate (number of cigarettes smoked daily in the past week), and years of daily smoking. The SHQ was used in the present study to measure participants’ smoking rates.

Positive and Negative Affect Schedule (PANAS; Watson, Clark, & Tellegen, 1988)

The PANAS is a self-report measure of positive and negative affectivity. Participants rate the extent to which they experience each emotion (e.g., upset) on a Likert scale from 1 (“ very slightly or not at all”) to 5 (“extremely”) in the previous two weeks. The negative affectivity scale (PANAS-NA) was used in the present study as a covariate and had good internal consistency in the current sample (α=.84).

Anxiety Sensitivity Index-3 (ASI-3; S. Taylor et al., 2007)

The ASI-3 is a self-report measure of anxiety sensitivity comprised of 18 statements (e.g., “It scares me when my heart beats rapidly”). Participants rate each statement on a Likert scale from 0 (“very little”) to 4 (“very much”). The items sum to a total score. The ASI-3 is a reliable and valid measure of anxiety sensitivity (Taylor et al., 2007). Additionally, the ASI-3 has strong psychometric properties among samples of smokers (Farris et al., 2015). In the current sample, internal consistency was excellent for the ASI-3 (α=.93).

Difficulties in Emotion Regulation Scale (DERS; Gratz & Roemer, 2004)

The DERS is a 36-item self-report measure of emotion regulation difficulties. Each item is rated on a Likert scale from 1 (“almost never”) to 5 (“almost always”). The sum of the scores (including 11 reverse-scored items) yields the total score. Additionally, the DERS yields six sub-factor scores: Nonacceptance of Emotional Responses (DERS-Non; e.g., “When I’m upset, I feel like I am weak”), Difficulties Engaging in Goal-Directed Behavior (DERS-Goa; e.g., “When I’m upset, I have difficulty thinking about anything else”), Impulse Control Difficulties (DERS-Imp; e.g., “I experience my emotions as overwhelming, and out of control”), Lack of Emotional Awareness (DERS-Awa; e.g., “I pay attention to how I feel”, which is reverse-scored), Limited Access to Emotion Regulation Strategies (DERS-Str; e.g., “When I’m upset, I believe that there is nothing I can do to make myself feel better”), and Lack of Emotional Clarity (DERS-Cla; e.g., “I have no idea how I’m feeling”). The DERS has strong psychometric properties, including high test-retest reliability and construct and predictive validity (Gratz & Roemer, 2004). The DERS has been shown to be reliable in samples of smokers (Brandt, Johnson, Schmidt, & Zvolensky, 2012). In the current sample, internal consistency was excellent for the DERS total score (α=.95) and good to excellent for each of the sub-factors (α=.91, .88, .87, 84, .90, and .83 for the DERS-Non, -Goa, -Imp, -Awa, -Str, and -Cla scales, respectively).

The Alcohol Use Disorders Identification Test (AUDIT; Saunders, Aasland, Babor, de la Fuente, & Grant, 1993)

The AUDIT is a self-report measure of hazardous drinking consisting of 10 questions. The questions (e.g., “How often do you have a drink containing alcohol”) are rated on various scales from 0 (e.g., “never”) to 4 (e.g., “4 or more times a week”); the sum of these scores is the total score (AUDIT-Total), used in the current study. The AUDIT is a reliable and valid measure of hazardous drinking (Babor, Higgins-Biddle, Saunders, & Monteiro, 2001; Saunders et al., 1993). The present study used the scores of two subscales of the AUDIT: frequency of alcohol consumption (AUDIT-Consumption; e.g., “How often do you have a drink containing alcohol?”) and alcohol-related problems (AUDIT-Problems; e.g., “Have you or someone else been injured because of your drinking?”). The two-factor structure of the AUDIT has been previously validated (Maisto, Conigliaro, McNeil, Kraemer, & Kelley, 2000) and used among smokers (Chavarria et al., 2015). In the current sample, internal consistency was good for the total score as well as the subscales assessing consumption and problems (α=.84, .80, .82, respectively).

Drinking Motives Questionnaire-Revised (DMQ-R; Cooper, 1994)

The DMQ-R is a self-report measure comprised of 20 items related to reasons for drinking alcohol rated on a Likert scale from 1 (“almost never/never”) to 5 (“almost always/always”). There are four subscales: coping (e.g., “To forget about your problems”), conformity (e.g. “To fit in with a group you like”), social (e.g., “To be sociable”), and enhancement (e.g., “Because it improves parties and celebrations”). In the current study, the coping motives (DMQ-R-Coping) and conformity motives (DMQ-R-Conformity) were used as they are considered ‘risky’ drinking motives (e.g., Allan, Albanese, Norr, Zvolensky, & Schmidt, 2015; DeMartini & Carey, 2011). The four factor structure of the DMQ-R has been shown to be valid (Cooper, 1994) with past work demonstrating structural invariance as well as strong convergent and divergent validity of the various sub-factors (Kuntsche, Stewart, & Cooper, 2008). The internal consistency in the present sample was good to excellent for the coping (α=.91) and conformity (α=.85) subscales.

Procedure

Daily smoking adults were recruited from the community to participate in a large multisite randomized controlled trial examining two smoking cessation interventions (for full protocol, see Schmidt, Raines, Allan, & Zvolensky, 2016). Individuals responded to study advertisements and were invited to participate in an in-person baseline assessment to determine eligibility for the trial. Individuals were eligible if they were 18+ years of age, daily cigarette users (8+ per day for 1+ years), and reported a motivation to quit smoking (5+ or greater on a 10-point scale). Individuals with psychotic spectrum disorders, uncontrolled bipolar disorder, serious suicidal intent (i.e., immediate attention required) or undergoing other smoking cessation programs were excluded. All participants provided informed written consent and were then assessed using the SCID-I and completed a battery of self-report questionnaires. The study was approved by the Institutional Review Board at each study site. The current study is based on secondary analysis of the baseline data.

Data Analytic Strategy

First, correlations were conducted on study variables. Analyses were conducted using the PROCESS macro for SPSS 22 (Hayes, 2012), which calculates the indirect effect of a predictor (X) on an outcome (Y) through one or more intermediary factors (Mi; West & Aiken, 1997). Bootstrapping with 10,000 re-samples was performed to obtain confidence intervals around the indirect effect, which is the preferred method for testing significance (MacKinnon, Lockwood, & Williams, 2004; Shrout & Bolger, 2002). The association of anxiety sensitivity via emotion dysregulation was examined with five variables: hazardous drinking (AUDIT-Total), alcohol consumption (AUDIT-Consumption), alcohol problems (AUDIT-Problems), coping motives for alcohol use (DMQ-R-Coping), and conformity motives for alcohol use (DMQ-R-Conformity). Commonly, 95% confidence intervals are used, which correspond to a Type I error rate of 5% (i.e., that the indirect effect differs from zero at p < .05; Preacher & Hayes, 2004). However, due to the five dependent variables tested, more conservative 99% confidence intervals were utilized to determine significance for the indirect effects (i.e., that the indirect effect differs from zero at p < .01; Preacher & Hayes, 2004) and p < .01 was used as the threshold of significance for total and direct effects. Effect sizes (κ2) were calculated for the indirect effects (Preacher & Kelley, 2011). Covariates included gender, racial/ethnic minority status, cigarettes per day, and negative affectivity. For each model, two planned comparison models were also evaluated. First, the predictor and intermediary factor were reversed to examine effects of emotion dysregulation via anxiety sensitivity in relation to each dependent variable. Next, each dependent variable and intermediary factor were reversed to evaluate the possibility of anxiety sensitivity predicting emotion dysregulation via the alcohol-related outcomes. Finally, post-hoc analyses evaluated the six sub-factors of the DERS, concurrently, as intermediary variables (M1–6) to determine the unique explanatory effects of emotion dysregulation sub-factors. For post-hoc analyses, 95% confidence intervals were used to detect specific indirect effects of anxiety sensitivity via DERS sub-factors.

Results

Descriptive Statistics

Means, standard deviations, and correlations between study variables are presented in Table 1. Data were normally distributed with skewness within acceptable range (−0.36–2.69; George & Mallery, 2003). Approximately one quarter of participants (24.0%) had elevated anxiety sensitivity per the ASI-3 (23 or greater; Allan et al., 2014) and one third (33.8%) had DERS scores greater than average values reported in past work among smokers (M=33.8; Gonzalez, Zvolensky, Vujanovic, Leyro, & Marshall, 2008).

Table 1.

Zero-order correlations among study variables (N = 467)

Variable 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
1. Gender (female) a -
2. CPD a −.12* -
3. Minority a .01 −.09* -
4. PANAS-NA a .12* .01 −.01 -
5. ASI-3 b .07 .05 .01 .60** -
6. DERS-Tot c .09 .01 −.01 .68** .66** -
7. DERS-Non c .15** .02 .01 .57** .62** .76** -
8. DERS-Goa c .11* −.06 −.03 .52** .52** .77** .51** -
9. DERS-Imp c .07 −.02 .01 .55** .57** .78** .51** .63** -
10. DERS-Awa c −.12* .13** −.05 .18** .15** .53** .22** .19** .22** -
11. DERS-Str c .12** −.03 .01 .69** .64** .88** .65** .67** .70** .26** -
12. DERS-Cla c .05 −.06 .01 .52** .43** .79** .47** .48** .52** .56** .62** -
13. AUDIT-Total d −.11* −.09* −.13** .22** .21** .30** .17** .26** .27** .13** .27** .27** -
14. AUDIT-Consumption d −.16** −.12** −.11* .10* .11* .19** .06 .21** .18** .11* .14** .17** .83** -
15. AUDIT-Problems d −.06 −.08 −.10* .26** .24** .31** .21** .25** .30** .10* .30** .29** .87** .49** -
16. DMQ-R-Coping d −.04 .06 −.15** .26** .26** .33** .24** .27** .29** .11* .33** .23** .58** .34** .59** -
17. DMQ-R-Conformity d −.14** .01 −.08 .16** .24** .28** .25** .19** .21** .16** .24** .22** .29** .16** .34** .52** -
Range - - - 11–44 0–57 37–162 6–30 5–25 6–29 6–26 8–38 5–24 0–30 0–12 0–20 5–25 5–23
Mean/N 225 16.5 69 20.3 15.1 74.7 11.9 12.9 10.2 14.8 14.7 10.2 6.2 3.9 1.7 8.5 6.3
SD/% 48.2% 10.0 14.8% 6.2 12.2 21.8 5.3 4.7 4.2 5.0 6.1 3.7 6.0 3.1 3.1 4.6 2.7
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Note: Gender (coded as Female = 1); CPD = cigarettes per day; Minority (coded as racial/ethnic minority = 1); PANAS-NA = Positive and Negative Affect Schedule, Negative Affectivity Subscale; ASI-3 = Anxiety Sensitivity Index-3; DERS = Difficulties with Emotion Regulation Scale; Tot = Total score; Non = Nonacceptance of Emotional Responses; Goa=Difficulties Engaging in Goal-Directed Behaviors; Imp=Impulse control Difficulties; Awa=Lack of emotional Awareness; Str=Limited Access to Emotion Regulation Strategies; Cla=Lack of Emotional Clarity; AUDIT-Total= Alcohol Use Disorders Identification Test, Total Score; AUDIT-Consumption= Alcohol Use Disorders Identification Test, Consumption Subscale; AUDIT-Problems = Alcohol Use Disorders Identification Test, Alcohol Problems Subscale; DMQ-R-Coping = Drinking Motives Questionnaire Revised, Coping Motives Subscale; DMQ-R-Conformity = Drinking Motives Questionnaire Revised, Conformity Motives Subscale;

a

Covariates.

b

Predictor.

c

Intermediary Factor.

d

Outcome.

*

p < .05.

**

p < .01.

Hazardous Drinking

In relation to hazardous drinking (AUDIT-Total), there was a non-significant, albeit trending, total effect of anxiety sensitivity (B=.06, p=.018; Table 2). However, there was a significant indirect effect of anxiety sensitivity via emotion dysregulation (B=.05, 99% CI [.02, .10], completely standardized indirect effect β=.09), which was medium in effect size (κ2=.15). After accounting for the indirect effect, the direct effect of anxiety sensitivity was not significant (B=.01, p=.663). For the alternative models, there was non-significant effect of emotion dysregulation via anxiety sensitivity (B=.01, 99% CI [−.02, .03], completely standardized indirect β=.01) and a non-significant indirect effect of anxiety sensitivity via hazardous drinking (B=.03, 99% CI [−.01, .09], completely standardized indirect β=.02), which were small (κ2=.01, and .05, respectively).

Table 2.

Direct and Total Effects

N = 467
Predictor (X)		 path Consequent
Intermediary (M)
DERS		 path Outcome (Y)
AUDIT-Total
B SE t p B SE t p
Constant 32.74 3.30 9.92 < .001 4.02 1.40 2.87 .004
ASI-3 a .69 .07 10.08 < .001 c’ .01 .03 0.44 .663
DERS - - - - - b .07 .02 4.12 <.001
Gender .28 1.37 0.21 .836 −1.87 .53 −3.55 <.001
CPD −.05 .07 −0.66 .510 −.07 .03 −2.79 .006
Minority −.73 1.91 −0.38 .702 −2.30 .74 −3.13 .002
PANAS-NA 1.57 .14 11.51 <. 001 .04 .06 0.65 .513
R2 = .56
F(5, 461) = 116.82, p < .001		 R2 = .14
F(6, 460) = 12.55, p < .001
N = 467
Predictor (X)		 path Consequent
Intermediary (M)
DERS		 path Outcome (Y)
AUDIT-Consumption
B SE t p B SE T p
Constant 32.74 3.30 9.92 < .001 4.63 .73 6.37 <.001
ASI-3 a .69 .07 10.08 < .001 c’ .01 .02 0.26 .798
DERS - - - - - b .03 .01 3.29 .001
Gender .28 1.37 0.21 .836 −1.17 .27 −4.29 <.001
CPD −.05 .07 −0.66 .510 −.05 .01 −3.45 <.001
Minority −.73 1.91 −0.38 .702 −1.06 .38 −2.78 .006
PANAS-NA 1.57 .14 11.51 <. 001 −.02 .03 −0.64 .525
R2 = .56
F(5, 461) = 116.82, p < .001		 R2 = .10
F(6, 460) = 8.67, p < .001
N = 467
Predictor (X)		 path
Intermediary (M)
DERS		 path Outcome (Y)
AUDIT-Problems
B SE t p B SE t p
Constant 32.74 3.30 9.92 < .001 −.10 .73 −0.13 .894
ASI-3 a .69 .07 10.08 < .001 c’ .01 .02 0.95 .343
DERS - - - - - b .03 .01 3.60 <.001
Gender .28 1.37 0.21 .836 −.66 .27 −2.42 .016
CPD −.05 .07 −0.66 .510 −.03 .01 −2.37 .018
Minority −.73 1.91 −0.38 .702 −.91 .38 −2.39 .017
PANAS-NA 1.57 .14 11.51 <. 001 .04 .03 1.17 .244
R2 = .56
F(5, 461) = 116.82, p < .001		 R2 = .13
F(6, 460) = 11.59, p < .001
N = 467
Predictor (X)		 path
Intermediary (M)
DERS		 path Outcome (Y)
DMQ-R-Coping
B SE t p B SE t p
Constant 32.74 3.30 9.92 < .001 4.32 1.07 4.04 <.001
ASI-3 a .69 .07 10.08 < .001 c’ .02 .02 1.05 .294
DERS - - - - - b .05 .01 3.72 <.001
Gender .28 1.37 0.21 .836 −.68 .40 −1.70 .090
CPD −.05 .07 −0.66 .510 .02 .02 0.76 .449
Minority −.73 1.91 −0.38 .702 −1.84 .56 −3.28 .001
PANAS-NA 1.57 .14 11.51 <. 001 .05 .05 1.12 .262
R2 = .56
F(5, 461) = 116.82, p < .001		 R2 = .14
F(6, 460) = 12.45, p < .001
N = 467
Predictor (X)		 path
Intermediary (M)
DERS		 path Outcome (Y)
DMQ-R-Conformity
B SE t p B SE t p
Constant 32.74 3.30 9.92 < .001 5.63 .63 9.00 <.001
ASI-3 a .69 .07 10.08 < .001 c’ .03 .01 2.12 .034
DERS - - - - - b .03 .01 4.01 <.001
Gender .28 1.37 0.21 .836 −.87 .24 −3.69 <.001
CPD −.05 .07 −0.66 .510 −.07 .01 −0.57 .572
Minority −.73 1.91 −0.38 .702 −.63 .33 −1.92 .056
PANAS-NA 1.57 .14 11.51 <. 001 −.03 .03 −1.20 .229
R2 = .56
F(5, 461) = 116.82, p < .001		 R2 = .12
F(6, 460) = 10.75, p < .001
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Alcohol Consumption

There was a non-significant total effect of anxiety sensitivity in relation to alcohol consumption (AUDIT-Consumption; B=.03, p=.071). The indirect effect of anxiety sensitivity via emotion dysregulation was significant (B=.02, 99% CI [.01, .04], completely standardized indirect β=.07) and medium-sized (κ2=.10). The direct effect of anxiety sensitivity was not significant (B=.01, p=.798). Both alternative models yielded non-significant indirect effects: emotion dysregulation via anxiety sensitivity (B=.01, 99% CI [−.01, .01], completely standardized indirect β=.01) and anxiety sensitivity via alcohol consumption (B=.02, 99% CI [−.01, .07], completely standardized indirect β=.01), which were small (κ2=.01, and .02, respectively).

Alcohol Problems

For alcohol problems (AUDIT-Problems) there was a significant total effect of anxiety sensitivity (B=.04, p=.007) as well as an indirect effect of anxiety sensitivity via emotion dysregulation (B=.02, 99% CI [.01, .05], completely standardized indirect β=.08) of medium size (κ2=.14). The direct effect of anxiety sensitivity was not significant (B=.01, p=.343). Both alternative models yielded non-significant indirect effects: emotion dysregulation via anxiety sensitivity (B=.01, 99% CI [−.01, .02], completely standardized indirect β=.02) and anxiety sensitivity via alcohol problems (B=.03, 99% CI [−.01, .09], completely standardized indirect β=.02), which were small (κ2=.03, and .06, respectively).

Drinking to Cope

With regard to coping motives for alcohol use (DMQ-R-Coping), there was a significant total effect of anxiety sensitivity (B=.06, p=.004) as well as an indirect effect of anxiety sensitivity via emotion dysregulation (B=.04, 99% CI [.01, .07], completely standardized indirect β=.08), which was medium (κ2=.14). There was a non-significant direct effect of anxiety sensitivity (B=.02, p=.294). There were non-significant indirect effects of emotion dysregulation via anxiety sensitivity (B=.01, 99% CI [−.01, .03], completely standardized indirect β=.02) and anxiety sensitivity via coping motives for alcohol use (B=.03, 99% CI [−.01, .10], completely standardized indirect β=.02), which were small (κ2=.04, and .06, respectively)

Drinking to Conform

The total effect of anxiety sensitivity in relation to conformity motives for alcohol use (DMQ-R-Conformity) was significant (B=.05, p<.001). There was a significant indirect effect of anxiety sensitivity via emotion dysregulation (B=.02, 99% CI [.01, .04], completely standardized indirect β=.08), which was medium (κ2=.14). The direct effect of anxiety sensitivity was not significant, using p <.01 as the cutoff (B=.03, p=.034). The comparison models were rejected with non-significant indirect effects of emotion dysregulation via anxiety sensitivity (B=.01, 99% CI [−.01, .03], completely standardized indirect β=.02) and anxiety sensitivity via conformity motives (B=.03, 99% CI [−.01, .10], completely standardized indirect β=.02), which were small (κ2=.05, and .05, respectively).

Post-hoc analyses

There was a specific indirect effect of anxiety sensitivity via lack of emotional clarity (DERS-Cla) in relation to hazardous drinking (B=.01, 95% CI [.002, .03], completely standardized indirect effect β=.02) and alcohol problems (B=.01, 95% CI [.002, .02], completely standardized indirect effect β=.03). For alcohol consumption, there was a specific indirect effect of anxiety sensitivity via difficulties engaging in goal-directed behaviors (DERS-Goa; B=.01, 95% CI [.003, .03], completely standardized indirect effect β=.04). There were no specific indirect effects of anxiety sensitivity via DERS sub-factors in relation to coping motives. For conformity motives, there was an indirect effect of anxiety sensitivity via nonacceptance of emotional responses (DERS-Non; B=.01, 95% CI [.003, .03], completely standardized indirect effect β=.05).

Discussion

The present study evaluated the association of anxiety sensitivity with an array of clinically significant alcohol use variables among adult treatment-seeking smokers. As expected, anxiety sensitivity was indirectly associated with hazardous drinking, alcohol consumption, alcohol problems, drinking to cope, and drinking to conform, via emotion dysregulation. Indeed, anxiety sensitivity was a robust predictor of emotion dysregulation and emotion dysregulation was a robust predictor of all alcohol-related outcomes. The indirect effects of anxiety sensitivity via emotion dysregulation were evident after accounting for variance explained by participant gender, racial/ethnic minority status, cigarettes per day, and negative affectivity. Importantly, two alternative models were evaluated for each outcome. These alternative models evaluated indirect associations of emotion dysregulation via anxiety sensitivity in relation to alcohol outcomes and anxiety sensitivity via alcohol outcome in relation to emotion dysregulation. These models yielded non-significant indirect associations in each case, adding confidence to the hypothesized association of anxiety sensitivity via emotion dysregulation in relation to alcohol-related outcomes. In addition to being statistically non-significant, the alternative models yielded small indirect effects (κ2=.01–.06), further adding support for the indirect effects of anxiety sensitivity via emotion dysregulation, which were medium in each case (κ2=.10–.15). Taken together, difficulty regulating emotions may serve as one potential explanation for how anxiety sensitivity relates to hazardous drinking and motives for alcohol use among treatment-seeking smokers. As such, anxiety sensitivity may impact emotion regulatory capacity, which, in turn, may impact hazardous drinking, coping-oriented drinking, and drinking to conform, although longitudinal work is needed to extend the current cross-sectional findings.

Of note, this study documents the ‘total effect’ of anxiety sensitivity with alcohol outcomes among treatment-seeking smokers (i.e., the association of anxiety sensitivity with each outcome). Specifically, although anxiety sensitivity was significantly associated with alcohol problems, coping motives, and conformity motives, the associations of anxiety sensitivity with hazardous drinking and alcohol consumption only trended towards significance, using the more stringent Type I error cut-off of .01. These findings are consistent with emerging work suggesting that anxiety sensitivity is more strongly associated with alcohol problems relative to alcohol consumption (e.g., Chavarria et al., 2015; Paulus, Vujanovic, et al., 2016) and extend such work to treatment-seeking smokers. After accounting for emotion dysregulation, there were no significant direct effects of anxiety sensitivity with any dependent variable. These findings highlight the importance of considering additional factors, such as emotion dysregulation, among well-established associations such as those between anxiety sensitivity and alcohol (for review, see DeMartini & Carey, 2011).

Post-hoc tests evaluated sub-factors of emotion dysregulation in the associations between anxiety sensitivity and hazardous drinking, alcohol consumption, alcohol problems, and motives for use. These tests revealed specific indirect effects of anxiety sensitivity via lack of emotional clarity in relation to hazardous drinking and alcohol problems. Such findings are consistent with past work linking deficits in emotional clarity to increased affective (e.g., anxiety and depression) symptoms, greater alcohol use (Vine & Aldao, 2014), and alcohol-related consequences (Dvorak et al., 2014) and other work demonstrating the mediating role of emotional clarity in the associations between trauma symptoms and alcohol misuse (Tripp & McDevitt-Murphy, 2015). Additionally, there was a specific indirect effect of anxiety sensitivity via difficulties engaging in goal-directed behavior in relation to alcohol consumption, consistent with past work suggesting that difficulties with goals underlie associations between negative affectivity and alcohol use (Paulus, Bakhshaie, et al., 2016) and between posttraumatic stress symptoms and alcohol-related outcomes (Goldstein, Bradley, Ressler, & Powers, 2016; Tripp, McDevitt-Murphy, Avery, & Bracken, 2015). Regarding motives for use, there was a specific indirect effect of anxiety sensitivity via nonacceptance of emotional responses in relation to conformity motives for alcohol use. We are unaware of prior work demonstrating associations of emotion regulation to conformity motives. No specific indirect effects were significantly associated with coping motives for alcohol use. However, past work has found lack of emotional clarity and limited access to emotion regulation strategies to mediate associations between negative affectivity and drinking to cope (Veilleux, Skinner, Reese, & Shaver, 2014), which was controlled for in the current analyses. Interestingly, impulse control difficulties, although correlated with anxiety sensitivity and all alcohol-related outcomes (Table 1) did not underlie associations of anxiety sensitivity and any outcome.

The current results suggest that targeting emotion regulation may be a promising treatment avenue among treatment-seeking smokers using alcohol in terms of addressing alcohol use behavior. Although yet to be tested among smokers, there is a growing interest in therapies targeting emotion dysregulation (Gratz, Weiss, & Tull, 2015) with some encouraging findings for emotion regulation treatments among those with alcohol use disorders and comorbid anxiety/alcohol use disorders (Berking et al., 2011; Conklin et al., 2015). Specifically, targeting emotional clarity may have clinical benefit as improvements in emotional clarity have been observed following abstinence from alcohol (Fox, Hong, & Sinha, 2008). Further, given interest in anxiety sensitivity reduction interventions for both smoking (Zvolensky, Bogiaizian, Salazar, Farris, & Bakhshaie, 2014) and alcohol/substance use (Worden, Davis, Genova, & Tolin, 2015), the current results highlight the importance of potentially implementing emotion regulation treatments within anxiety sensitivity reduction paradigms. Further, the indirect effects documented here are consistent with recent intervention work targeting anxiety sensitivity (e.g., Schmidt, Capron, Raines, & Allan, 2014), demonstrating that changes in anxiety sensitivity indirectly impact mental health outcomes. Theoretically, this indirect association occurs because anxiety sensitivity itself impacts sensitivity to internal physiological sensations and requires other intervening variables (e.g., emotion dysregulation) to progress that change in sensitivity into change in other outcomes (e.g., alcohol use, anxiety).

There are a number of limitations that must be noted. First, the study was limited to a cross sectional design and temporal association of variables was not evaluated. Although attempts were made to evaluate alternative pathways (i.e., alternative models), future work will need to evaluate the longitudinal impact of anxiety sensitivity on emotion dysregulation and, in turn, the effect of emotion dysregulation on alcohol-related outcomes. Second, although stringent criteria were used to determine significance and alternative models were tested, method variance due to the exclusive use of self-report data and measurement error may have impacted findings. Future work should utilize multi-method approaches, where available. Third, participants were daily smokers recruited for a smoking cessation trial. As such, future work should examine the current models among individuals at risk for alcohol problems (or with alcohol-use disorders) in order to generalize beyond treatment-seeking smokers. Further, future work might consider evaluating the current findings as a function of smoking status (e.g., daily vs. non-daily smoker), which we were unable to do in the current evaluation due to inclusion criteria requiring regular daily smoking. Finally, although the study benefited from a large sample of smokers with good gender diversity (48.2% female), there was a lack of racial/ethnic diversity. Future work should examine the current findings specifically among underserved and low-income minority samples.

Overall, the results of the current study document the indirect association of anxiety sensitivity via emotion dysregulation with five alcohol-relevant outcomes in a large sample of treatment-seeking smokers: hazardous drinking, alcohol consumption, alcohol problems, drinking to cope, and drinking to conform. There was consistent evidence for the hypothesized indirect effects with regards to each outcome along with converging evidence obtained from alternative models, which were rejected. The current results suggest that treatments aiming to target drinking among treatment-seeking smokers may benefit from assessing and addressing emotion dysregulation.

Table 3.

Post-Hoc Specific Indirect Effects

Y Model B SE LLCI ULCI
1:AUDIT-Total M1–6:Total Indirect Effect 0.05 0.02 0.01 0.09
M1:DERS-Non (a1*b1) −0.01 0.01 −0.04 0.02
M2:DERS-Goa (a2*b2) 0.01 0.01 −0.01 0.04
M3:DERS-Imp (a3*b3) 0.02 0.01 −0.01 0.05
M4:DERS-Awa (a4*b4) −0.0004 0.002 −0.01 0.003
M5:DERS-Str (a5*b5) 0.01 0.02 −0.02 0.04
M6:DERS-Cla (a6*b6) 0.01 0.01 0.002 0.03
2:AUDIT-Consumption M1–6:Total Indirect Effect 0.02 0.01 −0.002 0.04
M1:DERS-Non (a1*b1) −0.01 0.01 −0.02 0.01
M2:DERS-Goa (a2*b2) 0.01 0.01 0.003 0.03
M3:DERS-Imp (a3*b3) 0.01 0.01 −0.005 0.02
M4:DERS-Awa (a4*b4) 0.0004 0.001 −0.001 0.005
M5:DERS-Str (a5*b5) −0.002 0.01 −0.02 0.01
M6:DERS-Cla (a6*b6) 0.004 0.004 −0.002 0.01
3:AUDIT-Problems M1–6:Total Indirect Effect 0.03 0.01 0.01 0.05
M1:DERS-Non (a1*b1) −0.001 0.01 −0.02 0.01
M2:DERS-Goa (a2*b2) 0.001 0.01 −0.01 0.01
M3:DERS-Imp (a3*b3) 0.01 0.01 −0.004 0.03
M4:DERS-Awa (a4*b4) −0.001 0.002 −0.01 0.001
M5:DERS-Str (a5*b5) 0.01 0.01 −0.01 0.02
M6:DERS-Cla (a6*b6) 0.01 0.004 0.002 0.02
4:DMQ-R-Coping M1–6:Total Indirect Effect 0.04 0.01 0.02 0.07
M1:DERS-Non (a1*b1) 0.002 0.01 −0.02 0.02
M2:DERS-Goa (a2*b2) 0.01 0.01 −0.01 0.02
M3:DERS-Imp (a3*b3) 0.01 0.01 −0.01 0.03
M4:DERS-Awa (a4*b4) −0.001 0.002 −0.01 0.002
M5:DERS-Str (a5*b5) 0.02 0.01 −0.001 0.05
M6:DERS-Cla (a6*b6) 0.003 0.005 −0.01 0.01
5:DMQ-R-Conformity M1–6:Total Indirect Effect 0.03 0.01 0.01 0.04
M1:DERS-Non (a1*b1) 0.01 0.01 0.003 0.03
M2:DERS-Goa (a2*b2) 0.001 0.004 −0.01 0.01
M3:DERS-Imp (a3*b3) 0.001 0.01 −0.01 0.01
M4:DERS-Awa (a4*b4) 0.001 0.001 −0.001 0.01
M5:DERS-Str (a5*b5) 0.01 0.01 −0.01 0.02
M6:DERS-Cla (a6*b6) 0.003 0.003 −0.002 0.01
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Note. ASI-3 (anxiety sensitivity index-3) is the predictor in all models; DERS (difficulties in emotion regulation scale); Non=nonnacceptance of emotional responses; Goa=difficulties engaging in goal-directed behavior; Imp=impulse control difficulties; Awa=lack of emotional awareness; Str=limited access to emotion regulation strategies; Cla=lack of emotional clarity are the explanatory variables; AUDIT (Alcohol Use Disorders Identification Test) -Total, -Consumption, and -Problems subscales and DMQR (Drinking Motives Questionnaire-Revised) -Coping and -Conformity subscales are the outcome variables in models 1–5, respectively. The standard error and 95% CI for the indirect effects are obtained through bootstrapping with 10,000 re-samples. LLCI = lower bound of a 95% confidence interval; ULCI = upper bound.

Acknowledgments

This study was funded by the National Institutes of Health: National Institute of Mental Health grant number R01 MH076629-0 awarded to Drs. Schmidt and Zvolensky. Data from this manuscript has not been presented or disseminated elsewhere in any form.

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