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. Author manuscript; available in PMC: 2023 Jan 1.
Published in final edited form as: J Subst Abuse Treat. 2021 May 31;132:108508. doi: 10.1016/j.jsat.2021.108508

Emotion Dysregulation and Hazardous Drinking in relation to Suicidal Ideation among Spanish-Speaking Latinx Daily-Smokers

Ruben Rodriguez-Cano 1, Daniel J Paulus 2, Jaye L Derrick 3, Janice A Blalock 4, Michael J Zvolensky 3,4,5
PMCID: PMC8630077  NIHMSID: NIHMS1709933  PMID: 34098209

Abstract

Objective:

Suicidal ideation has increased among Latinx individuals in the last decade. Smoking increases the likelihood of suicidal ideation but work on Latinx smokers is minimal. Hazardous drinking and emotion dysregulation could be factors related to suicidal ideation among Latinx smokers, as has been evident in non-Latinx White samples. The current study sought to examine the main and interactive effects of emotion dysregulation and hazardous drinking in relation to suicidal ideation among Latinx daily-smokers.

Methods:

Participants were 371 Spanish-speaking daily-smokers (58.8% female; Mage=33.3; SDage = 9.8) recruited from the United States through Qualtrics. We used structural equation modeling (SEM) to test an interactive model of emotion dysregulation and hazardous alcohol consumption in relation to suicidal ideation; we also tested the effect of emotion dysregulation on suicidal ideation as a function of hazardous drinking status.

Results:

Results indicated that latent emotional dysregulation was associated with greater suicidal ideation (p<0.001); however, hazardous drinking was not related to suicidal ideation (p=0.186). The interactive term of emotional dysregulation and hazardous drinking was significantly related to suicidal ideation (p=0.017). Specifically, greater emotion dysregulation was significantly related to suicidal ideation among Latinx smokers who engaged in hazardous drinking (p<0.001) but not those who did not engage in hazardous drinking (p=0.123).

Conclusions:

The current findings suggest that smoking combined with hazardous drinking may be related to increased suicidal ideation among Latinx smokers. Findings are discussed in relation to the potential role of intervention strategies that focus on emotion dysregulation and hazardous drinking among Latinx current daily smokers to mitigate suicidal risk among this established health disparities population.

Keywords: Emotion Dysregulation, Hazardous Drinking, Suicidal Ideation/Risk, Latinx Smokers, Health disparities

1. Introduction

Latinx individuals comprise the most rapidly growing racial/ethnic group in the United States (US), accounting for 17% of the total population and is expected to become 30% of the total population by 2060 (US Census Bureau, 2019). Although Latinx individuals have evidenced lower suicide rates than other ethnicities (US Department of Health and Human Services, 2020), suicide remains an important cause of death among Latinx Americans (Centers for Disease Control and Prevention [CDC], 2020). For example, suicide and suicidal ideation have increased among Latinx persons in the last decade, particularly among females and young adults (Silva & Van Orden, 2018). Indeed, suicide ranks as the 3rd most prevalent cause of death among Latinx young adults (CDC, 2020), underscoring the need for increased research into both risk factors and potential prevention of suicide in Latinx communities.

Smokers are one subgroup of the population that is at increased risk for suicide/suicidal ideation (Clarke et al., 2010). Meta-analytic evidence indicates a strong association between smoking and suicidal ideation (OR = [1.65–2.45]; Poorolajal & Darvishi, 2016). For example, suicidal ideation is associated with greater craving during quit attempts (Albanese et al., 2016). Other work suggests that smoking may adversely impact negative mood and increase suicidal ideation (Brandt et al., 2017; Capron et al., 2012; Green et al., 2017). Further, quitting smoking has been related to decreased suicidal ideation (Capron et al., 2014). Despite the known relation between smoking and suicidal ideation, the study of both smoking and suicidal ideation among US Latinx smokers is lacking. Consequently, there is a need to understand what factors are related to suicidal ideation among Latinx smokers in the US.

One construct studied extensively in relation to suicide is emotion dysregulation (Hatkevich et al., 2019; Lynch et al., 2004; Neacsiu et al., 2018). Emotion dysregulation is a multidimensional and maladaptive mechanism reflecting responses to emotional distress (Gratz & Tull, 2010). In Latinx populations, emotion dysregulation has been linked to suicidal ideation among adolescents (Alonzo et al., 2016), as well as suicidal ideation and suicide attempts among adults (Mayorga et al., 2018; Paulus et al., 2016). Despite these observations, existing studies have not yet evaluated the relationship between emotion dysregulation and suicidal ideation among Latinx smokers to our knowledge, which is essential given smokers report greater emotion dysregulation relative to nonsmokers (Lyvers et al., 2013).

One additional factor linked to suicidal ideation is alcohol misuse (Borges et al., 2017; Pompili et al., 2010). Hazardous drinking, a form of alcohol misuse that increases one’s risk for alcohol-related problems (Rehm, 2011), has been previously linked to suicide (Luk et al., 2020). For example, hazardous drinkers are more than twice as likely to screen positively for suicide risk relative to those who do not engage in hazardous drinking (Paulus et al., 2020). Indeed, excessive alcohol consumption is associated with increased intensity of suicidal ideation during the 24 hours prior to a suicide attempt (Bagge et al., 2014). The relationship between hazardous drinking and suicidal ideation ostensibly occurs when alcohol is used as a coping strategy for negative mood states (Gonzalez et al., 2009). Among Latinx persons, there is evidence suggesting that alcohol abuse may contribute to the escalating incidence of suicide (Baca-Garcia et al., 2011). Given the strong and positive relationship between hazardous drinking and smoking among Latinx individuals (Bandiera et al., 2019), it is important to evaluate hazardous drinking and suicide relations among Latinx smokers.

Beyond the unique relations that emotion dysregulation and hazardous drinking demonstrate with suicidal ideation, it is worthwhile to explore a potential interactive effect to elucidate suicidal ideation among Latinx smokers. Previous literature has documented that greater alcohol problems might influence suicidal behavior when alcohol is used as a maladaptive emotion regulation strategy (Darvishi et al., 2015; Pompili et al., 2010). Indeed, alcohol consumption can function as a coping strategy to regulate negative affect (Kober, 2014), which can increase the probability of suicidal ideation (Yamokoski et al., 2011). Thus, individuals who misuse alcohol (such as hazardous drinkers) may tend to engage in maladaptive emotion regulation strategies (e.g., drinking to regulate emotions) more than non-hazardous drinkers. Such emotion dysregulation may be more strongly related to maladaptive thoughts and behaviors (e.g., suicide) among hazardous drinkers. In addition, among hazardous drinkers, emotion regulation might be particularly impaired by the deleterious effect of chronic alcohol misuse on neural regions modulating emotion regulation (Kober, 2014). Theoretically, the effect of emotion dysregulation on suicidal ideation could be influenced by the influence of alcohol consumption on cognition, affect, and social processes (Sayette, 2017). In particular, Latinx persons might use alcohol to cope with minority related stress (e.g., poverty, migration stress, discrimination; Berger-Cardoso et al., 2018). Consequently, exploring the role of emotion dysregulation in the context of hazardous drinking and suicidal ideation among Latinx smokers would help to identify subgroups of Latinx smokers (e.g., those who also engage in hazardous drinking) who may be particularly vulnerable to the effects of emotion dysregulation on suicidal ideation.

Among Latinx individuals, it is important to account for other variables that may influence suicidal ideation. For example, sociodemographic factors such as identifying as female, being younger and having higher levels of US acculturation as well as experiencing psychological stress increase the risk of suicidal ideation (Fortuna et al., 2007; Perez-Rodriguez et al., 2014; Silva & Van Orden, 2018). Also, higher rates of metal health problems (Fortuna et al., 2007), such as depression and anxiety (Odafe et al., 2016), increase suicide vulnerability among Latinx persons. Furthermore, when examining emotion dysregulation, it is important to control for factors indicative of distress/negative affect (e.g., stress, depression, anxiety) to assure that observed associations are due to emotion dysregulation and not general distress (e.g., Paulus et al., 2021).

The current study sought to examine the main and interactive effects of emotion dysregulation and hazardous drinking in relation to suicidal ideation among Latinx daily smokers. We hypothesized that greater emotional dysregulation and hazardous drinking would each be uniquely associated with suicidal ideation. Furthermore, we expected an interactive effect, such that the association between emotional dysregulation and suicidal ideation would be stronger for hazardous drinkers relative to non-hazardous drinkers. These associations were expected to be evident after accounting for variance attributed to theoretical and clinical variables known to influence suicide and smoking among Latinx individuals (e.g., sex, age, years in the US, cigarettes per day, anxiety, depression, culturally-related stress, social status; Fortuna et al., 2007; Odafe et al., 2016; O’Donnell et al., 2004; Perez-Rodriguez et al., 2014; Silva & Van Orden, 2018). Given the multidimensional nature of emotion dysregulation (Gratz & Roemer, 2004), post-hoc tests were conducted to explore emotion dysregulation sub-facets to better understand which aspect(s) of emotion dysregulation may be most relevant to suicidal ideation.

2. Method

2.1. Participants

The sample consisted of 371 Spanish-speaking daily smokers (58.8% female; Mage=33.3; SDage=9.8) who reported smoking an average of 9.3 cigarettes per day (SD=8.6). Approximately one third (35.6%) identified their nationality as Mexican, 22.9% “American/Born in the United States,” 17.3% Puerto Rican, 8.9% Cuban, 5.7% South American, 2.2% Central American, 2.2% Dominican, and 5.4% “other.” A majority (62.8%) reported full-time (40+ hours per week) employment, with 14.0% employed half-time (approximately 20 hours per week), 5.9% with less than 20 hours per week, and 17.2% unemployed or looking for work.

2.2. Procedure

Participants were recruited from the United States through Qualtrics. Adults with a Qualtrics Panels account who reported current daily smoking received an invitation survey to participate in the study. Participants with a Qualtrics Panels account agreed in advance to receive research surveys in an ongoing basis. We used this method because it increases the likelihood of response for the studies that includes in-depth questionnaires (since participants already agreed to received research questionaries). Eligibility criteria were: (1) 18 years of age or older, (2) fluent in Spanish, and (3) current daily smoker, including smoking in the past week. Eligible participants were then directed to an anonymous online survey and provided informed consent electronically. The survey took approximately 20 minutes. Participants could opt to receive their compensation ($7.50) in one of several forms (e.g., gift cards, rewards miles/points).

2.3. Measures

2.3.1. Demographics.

Descriptive information (e.g., sex, age, years in the US, cigarettes per day) was gathered with a demographic questionnaire.

2.3.2. Brief Difficulties in Emotion Regulation Scale (DERS-16; Bjureberg et al., 2016).

The DERS-16 is an abbreviated version of the original 36-item DERS (Gratz & Roemer, 2004). Sixteen items (e.g., “I have difficulty making sense out of my feelings”) are rated on a scale from 1 (almost never, 0–10%) to 5 (almost always, 91–100%) and summed to a total score. In addition, a five-factor model (nonacceptance of emotional responses [DERS-NON], difficulties engaging in goal-directed behavior [DERS-GOA], impulse control difficulties [DERS-IMP], limited access to emotion regulation strategies [DERS-STR], and lack of emotional clarity [DERS-CLA]) has been shown to fit the data (Charak et al., 2019). In the current sample, internal consistency was excellent for the DERS-16 total score (α=0.97) consistent with past work among Spanish-speaking Latinx individuals (Zvolensky et al., 2019). Internal consistency was good to excellent for DERS-16 subscales: DERS-NON (α=0.89), DERS-GOA (α=0.89), DERS-IMP (α=0.90), DERS-STR (α=0.93), and DERS-CLA (α=0.83). The DERS-16 subscales were used as indicators of a latent emotion dysregulation variable, which was included as the predictor in the current study.

2.3.3. Alcohol Use Disorders Identification Test-Consumption (AUDIT-C; Bush et al., 1998).

The AUDIT-C is a three-item measure of hazardous drinking. Items (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) and summed to a total score; scores of 4+ for men or 3+ for women indicate hazardous drinking (Reinert & Allen, 2007). Previous studies successfully used the AUDIT-C to screen for hazardous drinking with good psychometric properties (Barry et al., 2015; Kelly et al., 2009). Past work has also shown that the AUDIT-C performs similarly well across Latinx, Black, and White respondents (Frank et al., 2008) and well among Spanish-speakers (Cremonte et al., 2010). In the current sample, internal consistency was good (α=0.81). Hazardous drinking status (0=nonhazardous; 1=hazardous) was used as a moderator in the current study.

2.3.4. Beck Depression Inventory-II (BDI-II; Beck et al., 1996).

The BDI-II is a reliable and valid assessment of depressive symptoms and previously successfully translated to Spanish (Sanz and Vazquez, 2011). In the current study, item 9 (BDI-II-9; “Suicidal Thoughts or Wishes”) from the BDI-II was used to assess suicidal ideation in the past week.1 This single item can serve as an evidenced based method for suicide screening (Green et al., 2015).

2.3.5. Hispanic Stress Inventory (HSI; Cervantes et al., 1990, 1991).

As in past work (Hong, 2014), three items (e.g., “job difficulties because of Latinx descent”) from the HSI (i.e., HSI-3) were used to index culturally-related stress. Items are rated as 0 (no) or 1 (yes) and summed together. HSI-3 internal consistency was good (α=0.81).

2.3.6. The MacArthur Scale for Subjective Social Status (SSS; Adler, 2009; Singh-Manoux et al., 2005).

Participants were presented with an image of a ladder with ten rungs representing where people in the US stand. Participants select the rung that best represents their perceived standing relative to others in the US, where 1 is the lowest and 10 is the highest (e.g., more money, better jobs, higher education). The measure has demonstrated adequate reliability and validity (Franzini & Fernandez-Esquer, 2006; Ostrove et al., 2000; Reitzel et al., 2010, 2014).

2.3.7. The Hospital Anxiety and Depression Scale (HADS; Zigmond & Snaith, 1983).

The HADS consists of 14 items (e.g., “Worrying thoughts go through my mind”) rated on various scales from 0 (e.g., not at all) to 3 (e.g., most of the time). Seven items assess anxiety (HADS-A) and seven items assess depression (HADS-D). The Spanish version of the HADS has demonstrated good psychometric properties among Spanish-speakers (Herrero et al., 2003). In the current study, internal consistencies were acceptable for the HADS-A (α0.77) and HADS-D (α0.70).

2.4. Analytic Strategy

We conducted descriptive analyses (e.g., correlations) in SPSS version 24. Next, we conducted a structural equation modeling (SEM) using MPlus 8.5 (Muthén & Muthén, 2017) to test primary hypotheses. First, a measurement model was fit examining DERS-16 subscales as indicators of a latent emotion dysregulation variable using confirmatory factor analysis (CFA). Next, regression analyses examined main and interactive effects of the latent emotion dysregulation variable and hazardous drinking status (based on AUDIT-C cut-offs) in relation to suicidal ideation (BDI-II-9). Covariates (sex, age, years in the US, cigarettes per day, anxiety [HADS-A], depression [HADS-D], culturally-related stress [HSI-3], subjective social status [SSS]) were first examined as predictors of suicidal ideation. Next, emotion dysregulation and hazardous drinking status were added to the model to examine main effects. Then, the interaction of emotion dysregulation and hazardous drinking was added. In the presence of a statistically significant interaction (p < .05), we examined the effect of emotion dysregulation on suicidal ideation as a function of hazardous drinking status (i.e., among non-hazardous vs. hazardous drinkers; Holmbeck, 2002). Finally, follow-up tests examined each of the five sub-facets of emotion dysregulation in relation to suicidal ideation. We provided fully standardized coefficients (β) and 95% confidence intervals. Model fit was assessed using root mean square error of approximation (RMSEA), Comparative Fit Index (CFI), and Tucker-Lewis Index (TLI). RMSEA values of .06 or lower, CFI and TLI values of 0.95 or greater, indicate good model fit (Hu & Bentler, 1999). When estimating interactions with latent variable, MPlus does not generate traditional model fit statistics. Therefore, the final model was evaluated by comparing the Akaike Information Criterion (AIC) and sample size adjusted Bayesian Information Criterion (BIC) statistics in the model with the interaction term to that of the model with without the interaction term (i.e., main effects/covariates only); AIC and BIC are comparative fit statistics with lower AIC/BIC values in one model indicative of better model fit relative to another model.

3. Results

3.1. Descriptive Statistics

Correlations, means, and standard deviations, are presented in Table 1. Approximately two-thirds of the sample (69.0%) screened positive for hazardous drinking, and 42.3% endorsed some level of suicidal ideation. Data were normally distributed (e.g., suicidal ideation skewness=1.4). On average, the sample reported drinking 2–4 times per month and consuming 3–4 drinks per occasion.

Table 1:

Correlations and Descriptive Statistics (n=371)

1 2 3 4 5 6 7 8 9 12 11 12
1. Sex -
2. Age 0.09 -
3.Income −0.17** 0.08 -
4. Years in US. −0.03 0.02 −0.09 -
5. CPD 0.02 0.20** 0.02 0.04 -
6.HADS-A −0.03 −0.10 −0.09 0.07 −0.04 -
7.HADS-D −0.07 −0.07 −0.13* 0.03 0.07 0.60** -
8. HSI-3 −0.14** −0.07 −0.03 0.06 −0.06 0.49** 0.34** -
9. SSS −0.01 0.03 0.26** −0.04 −0.16** −0.17** −0.23** −0.04 -
10.DERS-16 −0.11* −0.11* 0.12* 0.05 −0.02 0.52** 0.30** 0.42** −0.06 -
11.Hazardous Drinking −0.08 −0.09 0.18** 0.05 −0.11* 0.15** 0.05 0.20** 0.12* 0.24** -
12. BDI-II-9 −0.11* −0.18** 0.07 0.03 −0.03 0.48** 0.31** 0.33** −0.08 0.45** 0.19** -
M/[n] [218] [135] 5.68 37.62 9.25 9.15 7.66 1.11 6.14 39.68 [256] 1.60
SD/[%] [58.80] [36.40] 2.35 178.07 8.64 4.50 4.07 1.23 2.46 17.87 [6.90] 0.83
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Notes: Sex (male=0; female=1); Age (34 or less=0; 35 or greater=1); Income=annual household income; Years in U.S.=number of years living in the U.S.; CPD=cigarettes per day; HADS=Hospital Anxiety and Depression Scale; HADS-A=Anxiety subscale; HADS-D=Depression Subscale; HSI-3=Hispanic Stress Inventory-3; SSS=Subjective Social Status; DERS-16=Difficulties in Emotion Regulation Scale-16 total score; Hazardous Drinking (nonhazardous=0; hazardous=1); BDI-II-9=Beck Depression Inventory-II, item 9.

*

p<0.05

**

p<0.01

3.2. Primary Analysis

The measurement CFA model examined the latent structure of emotion dysregulation (CFI=1.00, TLI=1.00, RMSEA=0.00), showing that all five DERS-16 subscales loaded significantly and strongly onto the latent factor (β’s ranged from 0.81 to 0.97; all p’s<0.001). Next, we ran a model examining covariates in relation to suicidal ideation (see Table 2; [CFI=1.00, TLI=1.00, RMSEA=0.00]). Then, emotion dysregulation (as a latent variable) and hazardous drinking status were added as predictors (CFI=0.94, TLI=0.92, RMSEA=0.09, AIC=8605.55, BIC=8626.37). There was a positive, statistically significant main effect of emotion dysregulation (β=0.23, 95% CI [0.12, 0.35], p<0.001) but no significant effect of hazardous drinking status (β=0.06, 95% CI [−0.03, 0.16], p=0.186) on suicidal ideation. Finally, we added the interaction of emotion dysregulation and hazardous drinking to the model (AIC=8601.99, BIC=8623.55), which resulted in lower AIC (Δ3.56) and BIC (Δ2.82), suggesting improved model fit by including the interaction. There was a statistically significant interaction of emotion dysregulation and hazardous drinking status (β=0.11, 95% CI [0.02, 0.20], p=0.017); emotion dysregulation was significantly related to suicidal ideation among hazardous drinkers (β=0.25, 95% CI [0.11, 0.38], p<0.001) but not those below the hazardous drinking cutoff (β=0.17, 95% CI [−0.05, 0.35], p=0.123).

Table 2:

Main and Interactive Effects of Latent Emotion Dysregulation and Hazardous Drinking Status in Relation to Suicidal Ideation (n=371)

β LL UL P
Covariates
 Sex −0.03 −0.12 0.06 0.452
 Age −0.13 −0.22 −0.04 0.003
 Income 0.13 0.04 0.22 0.007
 Years in US. 0.01 −0.08 0.10 0.853
 Cigarettes Per Day 0.001 −0.09 0.09 0.987
 Anxiety (HADS-A) 0.38 0.27 0.49 <0.001
 Depression (HADS-D) 0.02 −0.09 0.14 0.670
 Culturally-related Stress (HSI-3) 0.12 0.02 0.22 0.017
 Subjective Social Status (SSS) −0.03 −0.12 0.07 0.576
Main effects
 Latent Emotion Dysregulation (DERS-16) 0.23 0.12 0.35 <0.001
 Hazardous Drinking Status (AUDIT-C) 0.06 −0.03 0.16 0.186
Interactive effects
 Latent Emotion Dysregulation*Hazardous Drinking Status 0.11 0.02 0.20 0.017
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Note: β=fully standardized regression coefficient; LL=lower limit of 95% confidence interval for β; UL=upper limit of 95% confidence interval for β. Sex (male=0; female=1); Age (34 or less=0; 35 or greater=1); Income=annual household income; Years in U.S.=number of years living in the U.S.; HADS=Hospital Anxiety and Depression Scale; HADS-A=Anxiety subscale; HADS-D=Depression Subscale; HSI-3=Hispanic Stress Inventory-3; SSS=Subjective Social Status; DERS-16=Difficulties in Emotion Regulation Scale-16; Hazardous Drinking (nonhazardous=0; hazardous=1); BDI-II-9=Beck Depression Inventory-II, item 9;

3.3. Follow-up Tests

To examine which facets of emotion dysregulation are uniquely associated with suicidal ideation among hazardous drinking participations, we ran a model examining each of the five DERS-16 facets as separate predictors of suicidal ideation after accounting for covariates. No individual DERS-16 subscale was significantly associated with suicidal ideation (β’s ranged from −0.05 to 0.16; p’s ranged from 0.063 to 0.941). The same pattern resulted when examining DERS-16 subscales in the full sample (β’s ranged from −0.07 to 0.12; p’s ranged from 0.099 to 0.631).

4. Discussion

The current study is the first investigation, to our knowledge, of the moderating role of hazardous drinking in the relation between emotional dysregulation and suicidal ideation among US Latinx daily-smokers. Somewhat unexpectedly, there was no main effect of hazardous drinking on suicidal ideation, contrasting with prediction. As expected, emotional dysregulation was significantly associated with an increased risk of suicidal ideation. However, this effect of emotion dysregulation was qualified by the presence of a statistically significant interaction between emotion dysregulation and hazardous drinking in relation to suicidal ideation. Specifically, emotion dysregulation was significantly related to suicide ideation only among hazardous drinking Latinx smokers (i.e., not among those who did not engage in hazardous drinking). This effect was evident after controlling for theoretically and empirically relevant variables related to suicidal ideation among Latinx individuals (e.g., sex, age, year in the US, cigarettes per day, anxiety, depression, culturally-relevant stress, and social status; Fortuna et al., 2007; Odafe et al., 2016; O’Donnell et al., 2004; Perez-Rodriguez et al., 2014; Silva & Van Orden, 2018), possibly suggesting a synergistic role of hazardous drinking on the relationship between emotion dysregulation and suicide ideation among Latinx smokers.

The association between emotion dysregulation and suicidal ideation may be more pronounced among hazardous drinkers relative individuals not engaging in hazardous drinking given known effects that chronic alcohol misuse has on aggressiveness, psychological distress, and repertoires of alternative coping strategies (Hufford, 2001). Furthermore, individuals who habitually misuse alcohol (e.g., hazardous drinkers) may be more vulnerable to emotion dysregulation (e.g., Paulus et al., 2021) and its effects on mood and suicide. Of note, because we conducted a latent examination of emotion dysregulation, we were able to control for the measurement error of emotion dysregulation instrument in our sample (DERS-16). Thus, we can more confidently presume that emotion dysregulation (as a construct) was associated with greater suicide ideation and that this effect was evident only among those who engaged in hazardous drinking. Future work should investigate mechanisms whereby emotion dysregulation may increase suicidal ideation among hazardous drinkers, particularly Latinx smokers who engage in hazardous drinking.

Despite the clear association that emotion dysregulation demonstrated in relation to suicidal ideation, follow-up analyses indicated that no subdimensions of emotion dysregulation (i.e., nonacceptance of emotional responses, difficulties engaging in goal-directed behavior, impulse control difficulties, limited access to emotion regulation strategies, and lack of emotional clarity) demonstrated unique associations with suicidal ideation, after accounting for the effects of each of the other subdimensions. Thus, it appears that emotion dysregulation more globally is related to suicidal ideation among Latinx smokers who also engage in hazardous drinking. Although previous studies among non-Latinx individuals found that specific emotion regulation difficulties, such as problems with emotional characteristics (Neacsiu et al., 2018) and perceived limited emotion regulation strategies (Hatkevich et al., 2019), were related to greater suicidal ideation, the former work did not simultaneously examine emotion dysregulation facets and the latter assessed them on an adolescent sample. The current findings suggest potential therapeutic targets based on emotion regulation may aid in the reduction of suicide ideation risk among Latinx smokers who engage in hazardous drinking. For example, interventions aiming to increase the repertoire of emotion regulation strategies contrary to hazardous drinking (i.e., call a friend or a family member instead of drinking to regulate emotions) might ameliorate suicidal ideation among Latinx smokers.

Regarding the covariates included in our models, similar to previous studies younger Latinx with higher anxiety and depression had higher risk on suicidal ideation (Odafe et al., 2016; Silva & Van Orden, 2018). Contrary to other studies, sex, year in the US, cigarette dependence (assessed by number of cigarettes per day), culturally-related stress, social status did not have influence on suicide ideation risk in the final models (Eaton et al., 2011; Fortuna et al., 2007; O’Donnell et al., 2004; Perez-Rodriguez et al., 2014; Silva & Van Orden, 2018). Our results may be partially explained due to our sample being comprised of relatively younger Latinx (Mean age = 33.3 years old) that might be more acculturated than an older Latinx sample (Chrisman et al., 2017). Although we are not able to disentangle the levels of acculturation in our sample, our results indicated that Latinx with higher income, which has been related with greater acculturation levels (Zambrana et al., 1999), have greater likelihood of suicidal ideation risk. Previous studies also indicated that more acculturated Latinx, those who assimilate the mainstream culture lead higher suicide rates, has greater suicidal ideation because they suffer a disintegration of their traditional values and social networks (Silva & Van Orden, 2018). In the context of emotion dysregulation and hazardous drinking, acculturation stress is a factor related with hazardous drinking among those Latinx with higher emotion dysregulation levels (Paulus et al., 2019). Along with these findings, our results indicated that emotion dysregulation and hazardous drinking are two fundamental variables to understand suicide ideation among Latinx.

There are limitations to the current study. First, due to the limited sample size, we did not test moderation by Latinx national origin. Since recent work has indicated differences in alcohol consumption (Bandiera et al., 2019) and suicide ideation (Baca-Garcia et al., 2011) among specific Latinx ethnic groups, future studies should include larger sample sizes for potential comparisons by nationality. Second, the use of AUDIT-C is limited to its nature as a brief screening tool for hazardous alcohol consumption; the AUDIT-C does not assess alcohol problems and neither the AUDIT nor the AUDIT-C can indicate diagnoses such as alcohol use disorder (AUD). Future studies should include more robust measures of alcohol consumption that control wider aspects of alcohol drinking and clinically-defined AUD. Third, our results can only directly reflect findings for Latinx smokers. Future studies should seek to examine the interplay of emotion dysregulation and hazardous drinking in terms of suicide ideation among Latinx non-smokers. Fourth, our cross-sectional design characterizes the studied relations between variables only at one time point. Longitudinal designs are needed to identify potential causal relations between emotion dysregulation and suicide ideation among Latinx smokers with hazardous alcohol use. Fifth, our findings were based on an online recruitment system, a validated method for survey assessment (i.e., Wainwright et al., 2019); however, future studies should replicate current results in other samples of smokers (i.e., treatment seeking-smokers or primary care patients). Sixth, all measures were based on self-report. Future work would benefit from a multimethod assessment protocol to reduce potential shared variance between constructs. Finally, social- and cultural-specific factors related to suicidal ideation among Latinx, such as social discrimination (Kwon & Han, 2019), low levels of belonging, and higher levels of perceived burdensomeness (perceived liability to others) (Silva & Van Orden, 2018) should be explored in the context of emotion regulation and hazardous alcohol use as an effort to broaden our understanding of suicidal ideation among Latinx smokers.

Overall, the current results suggest that among Latinx smokers, emotion dysregulation is related to suicidal ideation for those who are also hazardous drinkers but not among non-hazardous drinkers. For Latinx smokers who also engage in hazardous alcohol use, improving adaptive emotion regulation strategies (e.g., cognitive reappraisals) might help lessen suicidal ideation.

Highlights.

  • Suicidal ideation is higher among Latinx smokers with poorer emotion regulation.

  • Suicidal ideation is not related to emotion dysregulation among Latinx smokers who are not hazardous drinkers.

  • Emotion dysregulation is related to greater suicidal ideation only among Latinx smokers who are hazardous drinkers.

  • No individual facet of emotion dysregulation appears to demonstrate unique associations with suicidal ideation.

Acknowledgments

Research reported in this publication was supported by the National Institute on Minority Health and Health Disparities (NIMHD) of the National Institutes of Health (NIH) to the University of Houston under Award Number U54MD015946. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Ruben Rodriguez-Cano was supported by a Postdoctoral Fellowship by The Cancer Prevention and Research Institute of Texas (CPRIT) (ID RP170259) and by the MD Anderson’s Cancer Center Support Grant (P30 CA016672) funded by the National Cancer Institute. He also was supported by the Research Council of Norway (288083; 300816). Daniel Paulus was supported by a Postdoctoral Fellowship by the National Institute of Alcohol Abuse and Alcoholism (T32AA007453).

Footnotes

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Conflict of interest

None to declare.

1

Additionally, the BDI-II suicidal ideation item was dichotomized as 0 (“I don’t have any thoughts of killing myself”) and 1 (“I have thoughts of killing myself, but I would not carry them out”; “I would like to kill myself”; or “I would kill myself if I had the chance”). All analyses were conducted using this dichotomized outcome and the pattern of findings did not change. These results can be obtained by contacting the first author.

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