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. Author manuscript; available in PMC: 2019 Sep 1.
Published in final edited form as: Health Psychol. 2018 Jul 26;37(9):814–819. doi: 10.1037/hea0000633

Anhedonia and smoking cessation among Spanish-speaking Mexican-Americans

Aaron K Haslam 1,2, Virmarie Correa-Fernández 3, Diana S Hoover 4, Liang Li 5, Cho Lam 6, David W Wetter 6
PMCID: PMC6504546  NIHMSID: NIHMS978293  PMID: 30047750

Abstract

Objective:

Smoking cessation is associated with improved health and reduced risk of disease. Understanding specific factors that are associated with smoking cessation is important both for identifying those who may have the greatest difficulty quitting smoking and tailoring smoking cessation interventions accordingly. Low positive affect/anhedonia, a key transdiagnostic symptom of several psychiatric disorders, is associated with lower levels of smoking cessation in the general population, but to date, few studies have examined factors influencing smoking cessation among Spanish-speaking Mexican-American smokers.

Methods:

The current study examined whether low positive affect/anhedonia was inversely related to cessation status across three time points among Spanish-speaking Mexican-American smokers (N=199) who were making a smoking quit attempt.

Results:

Using multilevel modeling, the between person low positive affect/anhedonia score was found to be inversely associated with smoking at quit day, three and 26 weeks post quit, while controlling for relevant covariates (i.e., age, gender, education, income, relationship status, heaviness of smoking index), but not when controlling for other symptoms of depression.

Conclusions:

Contrary to prior research, the results of this study did not confirm the unique predictive role of low positive affect/anhedonia among Mexican-Americans, suggesting that risk factors for this group may be different than other populations and cessation approaches may also need to differ.

Keywords: low positive affect/anhedonia, smoking cessation, Latino health, transdiagnostic symptoms, longitudinal design

Smoking is the leading cause of preventable morbidity and mortality in the United States (U.S.), accounting for approximately 480,000 deaths each year (US Department of Health and Human Services, 2014). Compared to most other racial/ethnic groups, Latinos have lower smoking prevalence rates, are less likely to smoke daily, and tend to smoke fewer cigarettes per day on the days they do smoke (Trinidad, Perez-Stable, Emery, & Messer, 2011; Trinidad et al., 2009; Zhu, Pulvers, Zhuang, & Baesconde-Garbanati, 2007). Nevertheless, smoking is a major risk factor for the two leading causes of death among Latinos (i.e., cancer and heart disease; (Heron, 2016; Kochanek, Xu, Murphy, Miniño, & Kung, 2011). As such, smoking remains a huge public health concern in this population. Among Latino subgroups, Mexican-Americans have lower smoking prevalence rates than Cubans or Puerto Ricans (Daviglus, Talavera, Aviles-Santa, et al., 2012).

Although smoking patterns among Latinos suggest that they may have lower levels of dependence on nicotine/tobacco and should have an easier time quitting, their cessation rates are similar to non-Latino White smokers (Babb, Malarcher, Schauer, Asman, & Jamal, 2017). Furthermore, Latinos have less access to evidence-based cessation resources and are less likely to use such resources (Babb et al., 2017; Trinidad et al., 2011). Similarly, Mexican-Americans are less likely to report that they receive physician advice to quit smoking than do their White counterparts (Levinson, Perez-Stable, Espinoza, Flores, & Byers 2004). Unfortunately, a recent review highlights the significant gaps in research on the correlates and determinants of smoking cessation among Latinos overall, as well as the paucity of data on Latino subgroups in the U.S. (Castro, 2016).

In the general population, psychiatric disorders and symptoms are associated with higher smoking prevalence and worse cessation outcomes (Ziedonis et al., 2008). Furthermore, recent literature examining depressive symptoms and anxiety symptoms support the validity of transdiagnostic symptoms, like low positive affect/anhedonia, as potential predictors of smoking cessation failure (Wienberger, Pilver, Desai, Mazure, & McKee, 2013; Jiang, Li, Pan, Zhang, & Jia, 2014). Anhedonia is a key transdiagnostic symptom for several psychiatric disorders (Leventhal, Ramsey, Brown, LaChance, & Kahler, 2008; Leventhal & Zvolensky, 2015), and refers to a reduced ability to experience pleasure (Ribot, 1897). Typically, individuals who are anhedonic also experience low positive affect and show greater increases in positive affect when nicotine is administered (Cook, Spring, & McChargue, 2007). Leventhal and colleagues have conducted a series of studies examining the role of low positive affect/anhedonia in smoking motivation and cessation (Ameringer & Leventhal, 2010; Leventhal et al., 2008; Leventhal et al., 2014), and concluded that low positive affect/anhedonia is related to lower rates of smoking cessation. Low positive affect/anhedonia is hypothesized to reduce cessation rates by reducing sensitivity to the hedonic properties of other more adaptive reinforcers (Leventhal, Waters, Kahler, Ray, & Sussman, 2009). To the best of our knowledge, no prior studies have investigated the role of low positive affect/anhedonia in predicting smoking cessation among Latinos or specific Latino subgroups like Mexican-Americans.

The current study examined the associations between low positive affect/anhedonia and smoking cessation in a sample of Spanish-speaking Mexican-Americans. Low positive affect/anhedonia was hypothesized to be negatively associated with smoking cessation. Gaining a better understanding of the role of low positive affect/anhedonia in smoking cessation failure could inform treatments targeted at Spanish-speaking Mexican-American smokers.

Method

Study Design and Participants

Data were from a longitudinal cohort study examining smoking cessation in Spanish-speaking Mexican-American adults. Specifically, the study was designed to examine the influence of neighborhood- and individual-level factors on the acute intrapersonal and contextual precipitants of smoking cessation among Spanish speaking Mexican-Americans. Previous papers from the parent study have found that discrimination and lower levels of mindfulness increase the risk for cessation failure (e.g., Kendzor, et al., 2014; Spears et. Al., 2015). The study was approved by the Institutional Review Board at The University of Texas MD Anderson Cancer Center. All participants (N=199) received smoking cessation treatment, which included six brief evidence-based in-person and telephone-based counseling sessions beginning one week prior to quit date and ending three weeks after the quit date (Cofta-Woerpel, Wright, & Wetter, 2007), four weeks of nicotine replacement therapy, and self-help materials. During the quit day and week three assessment points, participants received in-person counseling. All treatment and study procedures were in Spanish. Individuals were eligible if they: (a) self-reported Mexican heritage; (b) preferred to speak Spanish; (c) were 18–65 years old; (d) smoked > 5 cigarettes per day during the past year; (d) had an expired carbon monoxide (CO) level of > 8 ppm; (f) were motivated to quit smoking in the next month; and (g) had a valid home address and telephone number. Exclusion criteria included: (a) contraindications for nicotine patch use; (b) current substance use disorder; (c) regular use of tobacco products other than cigarettes; (d) use of other pharmacological smoking cessation aids (e.g., bupropion); (e) pregnancy or lactation; (f) another household member enrolled in the study; and (g) participation in any other smoking cessation program in the past 90 days. All participants underwent an informed consent procedure and signed an informed consent prior to providing any research data.

Measures

Demographics and tobacco-related variables.

At baseline, participants indicated their gender, age, educational attainment (no high school diploma or general education diploma, high school diploma/general education diploma, some college, some kind of college degree), income (< $12,000, $12,001–30,000, $30,001–54,000, >$54,001), relationship status (married/living with partner vs. not married), and Heaviness of Smoking Index. The education variable was dichotomized to be less than high school vs. at least a high school degree in the multivariate analyses. All other variables were untransformed.

Low positive affect/anhedonia and other depressive symptoms.

The four subscales of the Center for Epidemiologic Studies-Depression Scale (CES-D; Radloff, 1977) assessed low positive affect/anhedonia, depressed affect, somatic symptoms, and interpersonal disturbance. The CES-D has shown good psychometric properties in the general population and among Spanish-speaking smokers (Shafer, 2006; Leykin, Torres, Aguilera, & Muñoz, 2011). The CES-D was assessed on quit day and at three and 26 weeks post quit day, with instructions asking about symptoms during the past week. The factor structure presented in Shafer (2006) was used with the mean score being calculated from the respective items from each subscale with a possible range of 0–3. The items loading on the low positive affect/anhedonia subscale (i.e., “just as good as other people”, “hopeful about future”, “happy”, and “enjoyed life”) were reverse coded with high scores indicating low positive affect/anhedonia. This scoring has been used in other research to assess the relation between low positive affect/anhedonia and smoking cessation (Leventhal, et al., 2008). Furthermore, in other populations there does appear to be at least a moderate correlation between the low positive affect/anhedonia score and the Snaith-Hamilton Pleasure Scale (e.g., Leventhal, Unger, Audrain-McGovern, Sussman, Volk, & Strong, 2015). The low positive affect/anhedonia, somatic, and depressed affect factors of the CES-D displayed acceptable internal consistency in the current study at baseline (Cronbach’s alpha = 0.72, 0.78, 0.89, respectively). However, the interpersonal disturbance factor showed weak internal consistency at baseline (Cronbach’s alpha = 0.44). Confirmatory factor analyses indicated that the model fit for the four factor structure of the CES-D was acceptable for each time point in the current study (quit day: CFI=0.996, TLI=0.988; three weeks post quit: CFI=0.994, TLI=0.981; 26 weeks post quit: CFI=0.985, TLI=0.956).

Smoking cessation.

Smoking cessation at three and 26 weeks post-quit was determined by participant self-reported complete cessation from smoking for the previous seven days, and verified by either expired carbon monoxide (CO; < 8 ppm) or salivary cotinine (< 20ng/ml). Cessation on quit day was determined by self-report of no smoking on that day and expired CO. The concordance between the biochemical verification and self-report was very high and ranged from 0.98 to 0.99 across the different time points. Participants with missing cessation data were assumed to be non-abstinent (i.e. intent to treat [ITT]).

Data Analytic Strategy

The study assessed if low positive affect/anhedonia was related to smoking cessation status measured at the same time point (i.e. quit day, three weeks, and 26 weeks post quit day) using a longitudinal analysis. Generalized linear mixed models assessed the study hypotheses using the R package lme4 (version 1.1.11; Bates, Maechler, & Bolker, 2015). Person centering transformations disaggregated the between- and within-person effects. The between-person effect of low positive affect/anhedonia assessed the relationship of participants’ mean low positive affect/anhedonia score across all time points and cessation status across all follow-up points. The within-person effect for low positive affect/anhedonia assessed the relationship of participants’ deviation from their mean low positive affect/anhedonia score at a given time point and cessation status at the same time point. The model intercept and linear coefficient for within-person low positive affect/anhedonia were estimated as random coefficients. A model adjusting for the other subscales of the CES-D assessed if low positive affect/anhedonia was uniquely related to smoking cessation. A post hoc analysis using generalized linear mixed models examined the relation of the between- and within-person effects of the CES-D total score and cessation across time. An additional post hoc analysis using generalized linear models examined the relationship between baseline (i.e. pre-quit) low positive affect/anhedonia and cessation at each of the three follow-up points. The analysis controlled for heaviness of smoking index, age, gender, educational attainment, income, and relationship status (all covariates were assessed at baseline), as these are commonly reported variables that are related to smoking cessation (Caponnetto, & Polosa, 2008).

Results

Participant Characteristics

Of the 199 participants, most were male (63.3%; n=126) and had a mean age of 38.7 years (SD=10.42). Approximately 58% (n = 116) had less than a high school diploma/General Education Diploma and 69% (n = 138) were married/living with a partner. Fifteen percent of participants (n = 30) earned < $12,000, 34% (n = 68) earned between $12,001 and $30,000, 27% (n=54) earned between $30,001 and $54,000, 10% (n = 20) earned more than $54,001, and 14% (n=27) had missing income data. At baseline, participants reported smoking a mean of 15.8 (SD=9.56) cigarettes per day. Follow-up rates were 83% on quit day, 84% at three weeks post quit, and 57% at 26 weeks post quit. Cessation rates were 47% (n=93) on quit day, 39% (n=77) at three weeks, and 14% (n=27) at 26 weeks post quit day. The mean low positive affect/anhedonia scores were 0.96 (SD=0.81), 0.97 (0.85), and 1.07 (0.91) for quit day, week 3 and week 26, respectively.

Anhedonia and Smoking Cessation Status

As hypothesized, at the between-subjects level, low positive affect/anhedonia was inversely associated with cessation (OR=0.48, 95% CI [0.26, 0.87]) while controlling for the effects of gender, age, education, income, relationship status, and Heaviness of Smoking Index. Participants with higher mean levels of low positive affect/anhedonia during a quit attempt were less likely to be abstinent. The within-person deviation of low positive affect/anhedonia was not related to cessation. Table 1 summarizes the results. The results for the between person component of low positive affect/anhedonia were no longer significant when controlling for the other subscales of the CES-D. However, the between person level of the depressed affect subscale was related to cessation status (OR = 0.25, 95% CI [0.07, 0.87]; see Table 2). A post hoc analysis found that baseline low positive affect/anhedonia was not related to later smoking cessation at Quit Day (OR = 1.06, 95% CI [0.67, 1.67]), Week Three (OR = 0.92, 95% CI [0.57, 1.45]), or Week 26 (OR = 0.63, 95% CI [0.32, 1.18]). A sensitivity analyses conducted using completers only (i.e., individuals with follow-up cessation data) yielded similar findings in which the between-person level of low positive affect/anhedonia was significantly related to cessation after controlling for demographic covariates and the heaviness of smoking, but was no longer significant after additionally controlling for the other CES-D subscales. An additional post hoc analysis indicated that the person centered mean for the overall CES-D score was inversely related to cessation (OR = 0.66, 95% CI [0.11, 0.72]), but the within person overall CES-D score was not associated with cessation (OR = 1.05, 95% CI [0.13, 1.37])

Table 1.

Association between low positive affect/anhedonia and smoking cessation

Odds/OR 95% CI
Intercept 3.28 1.12 – 9.58
PM PA/An 0.48 0.26 – 0.87
WPD PA/An 0.81 0.50 – 1.33
HSI 0.76 0.61 – 0.95
Age 1.07 0.76 – 1.51
Income 0.71 0.34 – 1.46
Relationship Status 0.80 0.39 – 1.65
Gender 2.06 0.96 – 4.41
Education 0.46 0.21 – 1.01
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OR = odds ratio PM = Person centered mean, WPD = within person deviation, PA/An = low positive affect/anhedonia, and HSI = Heaviness of Smoking Index. The reference groups for dichotomous covariates were below 30,000 for income, not living with partner for relationship status, male for gender, and < high school for education.

Table 2.

Association between low positive affect/anhedonia and smoking cessation adjusting for all CES-D subscales

Odds/OR 95% CI
Intercept 4.59 1.48 – 14.25
PM PA/An 0.62 0.32 – 1.18
WPD PA/An 0.82 0.48 – 1.39
HSI 0.72 0.57 – 0.91
Age 1.05 0.74 – 1.48
Income 0.67 0.32 – 1.37
Relationship Status 0.66 0.31 – 1.37
Gender 1.68 0.72 – 3.95
Education 0.49 0.22 – 1.09
PM Depression 0.25 0.07 – 0.87
PM Interpersonal Disturbance 0.88 0.29 – 2.67
PM Somatic 2.90 0.65 – 12.96
WPD Depression 1.18 0.34 – 4.03
WPD Somatic 0.45 0.10 – 1.93
WPD Interpersonal Disturbance 0.89 0.36 – 2.21
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OR = odds ratio PM = Person centered mean, WPD = within person deviation, PA/An = low positive affect/anhedonia, and HSI = Heaviness of Smoking Index. The reference groups for dichotomous covariates were below 30,000 for income, not living with partner for relationship status, male for gender, and < high school for education.

Discussion

Low positive affect/anhedonia has been posited to be a transdiagnostic vulnerability underlying several psychiatric disorders and is inversely related to smoking cessation in the general population (for discussion see Leventhal & Zvolensky, 2015). The current study expands this work by demonstrating that low positive affect/anhedonia was associated with higher rates of cessation failure among Spanish-speaking Mexican-American smokers before controlling for other depressive symptoms. However, contrary to the findings of Leventhal, et al. (2008), low positive affect/anhedonia was not related to cessation status after controlling for the other subscales of the CES-D, indicating some redundancy among the subscales. Thus, low positive affect/anhedonia was not confirmed to be a unique transdiagnostic factor related to smoking cessation in the Spanish-speaking Mexican-American population. This study adds to the sparse literature on correlates of smoking cessation among Mexican-Americans (e.g., Kendzor et al., 2014), the largest Latino subgroup in the U.S.

Even though Latinos tend to smoke fewer cigarettes per day than the general population of smokers, they appear to have similar or even less success at quitting (Centers for Disease Control and Prevention, 2002, 2011; Stahre, Okuyemi, Joseph, & Fu, 2010; Trinidad et al., 2011). However, there are very few data addressing differences across Latino subgroups, and further research is clearly needed to better understand the unique factors that may differentially impact cessation among Latinos in general, and Mexican-Americans more specifically.

It is important to note that a more specific measure of low positive affect/anhedonia may yield different results. Furthermore, the null findings for within person changes in low positive affect/anhedonia may suggest that only the overall post-quit severity of low positive affect/anhedonia is important for smoking cessation failure and not changes over time. Finally, the significant relation of between person depressive affect with cessation also conflicts with some prior research in an English-speaking Mexican-American sample, which failed to find an association between global depressive symptoms and cessation (e.g., Castro, et al., 2011), and may highlight the importance of separating these symptoms and clearly differentiating among Latino subgroups and language.

The current study cannot disentangle the direction of effects between low positive affect/anhedonia and smoking cessation, but only that they were correlated across time, although not uniquely when considering other depressive symptoms. Thus, future research is needed to determine whether low positive affect/anhedonia increases the risk for smoking cessation failure among Spanish speaking Mexican-Americans. Careful attention to treatment approaches that influence low positive affect/anhedonia could help elucidate these relationships. For example, prior research indicates that low positive affect/anhedonia is associated with lower neural activation in the striatum (Der-Avakian & Markou, 2012), whereas administration of nicotine is associated with increased activation of this area (Barrett, Boileau, Okker, Pihl, & Dagher, 2004). Moreover, neural activation in the striatum is enhanced with behavioral activation treatment (Dichter et al., 2009), which has shown promise for treating tobacco dependence, perhaps because it mitigates the reward deficits inherent in low positive affect/anhedonia (MacPherson et al., 2010). Future research should more fully examine this possibility as well as other treatment approaches that impact the ability to experience pleasure or reinforcement from more adaptive behaviors. Furthermore, low positive affect/anhedonia may be an important construct for future research among other Latino groups as well as Spanish speaking Mexican-Americans given it is endorsed more frequently in this group than in other racial/ethnic groups (Huang et al., 2006).

This study has several other limitations. First, although the CES-D has been previously used to assess low positive affect/anhedonia and its impact on smoking cessation, it does not distinguish specific facets of anhedonia (e.g., consummatory, anticipatory) that may be important in better understanding the association. More comprehensive and specific measures of anhedonia are needed in future research. Second, because being motivated to quit was an eligibility criteria, the generalizability of the findings is limited to only those smokers who are motivated to quit. Furthermore, smokers in the current study received behavioral counseling and nicotine replacement therapy, thus, the results may not generalize to smokers using other treatments or to unaided quit attempts. Finally, this study included only Spanish-speaking Mexican-Americans. Thus, our findings might not apply to other racial/ethnic groups, including other Latino subgroups.

Despite its limitations, this study had notable strengths. It is the first to examine the relation between low positive affect/anhedonia and smoking cessation during a quit attempt among Spanish speaking Mexican-American smokers. In addition, cessation status was biochemically-verified at all time points. Another strength of this research is that it examined smoking cessation and low positive affect/anhedonia longitudinally over three separate time-points.

In sum, this is the first known study to demonstrate inverse associations of low positive affect/anhedonia with smoking cessation among Spanish-speaking Mexican-American smokers, although that relationship was no longer significant after controlling for other depressive symptoms. Future research is needed to clarify mixed findings across different racial/ethnic groups.

Supplementary Material

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Funding Statement:

This study was funded by the National Center on Minority Health and Health Disparities through Grant P60MD000503 and by the National Cancer Institute through The University of Texas MD Anderson Cancer Center’s Support Grant CA016672. Aaron Haslam was supported by a cancer prevention fellowship through the National Cancer Institute (R25T CA57730; PI: Dr. Shine Chang), Dr. Virmarie Correa-Fernández was supported by the American Cancer Society (MRSG-15-018-01-CPPB; PI: Dr. Virmarie Correa-Fernández), and Dr. Diana Hoover was supported by the National Institute on Drug Abuse (K23 DA040933; PI: Diana Hoover).

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NIHMS978293-supplement-1.docx (41.3KB, docx)
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