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Cited by 524Smoking Behavior and CessationAnxiety, Depression, Psychometrics, Treatment, Cognitive ProcessesSubstance Abuse Treatment and Outcomes

Anxiety, depression, and cigarette smoking: a transdiagnostic vulnerability framework to understanding emotion-smoking comorbidity

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Leventhal, Adam M., Zvolensky, Michael J.·2015·Psychological Bulletin
DOI 10.1037/bul0000003PMC PMC4293352
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Abstract

Research into the comorbidity between emotional psychopathology and cigarette smoking has often focused upon anxiety and depression's manifest symptoms and syndromes, with limited theoretical and clinical advancement. This article presents a novel framework to understanding emotion-smoking comorbidity. We propose that transdiagnostic emotional vulnerabilities-core biobehavioral traits reflecting maladaptive responses to emotional states that underpin multiple types of emotional psychopathology-link various anxiety and depressive psychopathologies to smoking. This framework is applied in a review and synthesis of the empirical literature on 3 transdiagnostic emotional vulnerabilities implicated in smoking: (a) anhedonia (Anh; diminished pleasure/interest in response to rewards), (b) anxiety sensitivity (AS; fear of anxiety-related sensations), and (c) distress tolerance (DT; ability to withstand distressing states). We conclude that Anh, AS, and DT collectively (a) underpin multiple emotional psychopathologies, (b) amplify smoking's anticipated and actual affect-enhancing properties and other mechanisms underlying smoking, (c) promote progression across the smoking trajectory (i.e., initiation, escalation/progression, maintenance, cessation/relapse), and (d) are promising targets for smoking intervention. After existing gaps are identified, an integrative model of transdiagnostic processes linking emotional psychopathology to smoking is proposed. The model's key premise is that Anh amplifies smoking's anticipated and actual pleasure-enhancing effects, AS amplifies smoking's anxiolytic effects, and poor DT amplifies smoking's distress terminating effects. Collectively, these processes augment the reinforcing properties of smoking for individuals with emotional psychopathology to heighten risk of smoking initiation, progression, maintenance, cessation avoidance, and relapse. We conclude by drawing clinical and scientific implications from this framework that may generalize to other comorbidities.

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Crossref · 10.1037/bul0000003

Cites

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  • Anxiety sensitivity, distress intolerance, and anhedonia are three of the strongest and most consistent emotion constructs relevant to anxiety/depression and smoking.

    “Scientific efforts have identified anxiety sensitivity, distress intolerance, and anhedonia as three of the strongest and most consistent emotion constructs relevant to anxiety/depression and smoking.24”

    From Evaluation of an integrated treatment to address smoking cessation and anxiety/depressive symptoms among people living with HIV: Study protocol for a randomized controlled trial (2021) · cites this paper as [24]

    In “The Current Paper” and “Conceptual rationale for focusing on Anh, AS, and DT” (pages unavailable), the authors identify anhedonia, anxiety sensitivity, and distress tolerance as three key vulnerabilities relevant to emotional disorders and smoking. Distress intolerance corresponds to low distress tolerance, but the paper does not establish that these are the three strongest and most consistent constructs relative to others. (LLM, conf=0.84)

    Experimental — accuracy not yet measured

  • Exercise may help smoking cessation by reducing anxiety during acute withdrawal, which may be most pronounced after the initial quit attempt.

    “Exercise may assist smoking cessation by mitigating anxiety during acute withdrawal symptoms (Leventhal and Zvolensky, 2015), which may be most pronounced after the initial quit attempt.”

    From Identifying attendance patterns in a smoking cessation treatment and their relationships with quit success (2017) · cites this paper as Leventhal and Zvolensky, 2015

    The Anxiety Sensitivity section (page unavailable) reports that anxiety-related withdrawal symptoms are more pronounced early in abstinence and discusses anxiety-sensitivity interventions that may aid cessation. It does not say that exercise reduces withdrawal anxiety or helps people quit through that mechanism; its mention of vigorous exercise concerns prevention of smoking initiation, not cessation. (LLM, conf=0.78)

    Experimental — accuracy not yet measured

  • Low distress tolerance predicts negative emotional or bodily sensations and also interacts with them to predict poor outcomes.

    “Hence, low DT both predicts negative affective or somatic sensations and interacts with these to predict negative outcomes (Leventhal & Zvolensky, 2015; M. W. Otto et al., 2016).”

    From A randomized controlled trial protocol for engaging distress tolerance and working memory to aid smoking cessation in low socioeconomic status (SES) adults (2020) · cites this paper as Leventhal & Zvolensky, 2015

    The DT and Smoking section reports that negative affect on quit day predicted smoking lapse more strongly among smokers with low distress tolerance. The Distress Tolerance section also suggests low distress tolerance may prolong negative affect. Neither passage establishes that low distress tolerance predicts the occurrence of negative emotional or bodily sensations, or that it interacts with bodily sensations to predict outcomes. (LLM, conf=0.87)

    Experimental — accuracy not yet measured

  • Improvements in one dimension of psychological experiences are associated with improvements in further dimensions of psychological experiences.

    “the concept of the transdiagnostic approach (97, 100–109) reflects the observation that improvements in one dimension of psychological experiences are associated with improvements in further dimensions of psychological experiences.”

    From Sleep disturbances and psychological well-being among military medical doctors of the Swiss Armed Forces: study protocol, rationale and development of a cross-sectional and longitudinal interventional study (2024) · cites this paper as [103]

    The Anxiety Sensitivity section (page unavailable) reports that reducing anxiety sensitivity can promote reductions in emotional symptoms, supporting a specific example of improvement across psychological dimensions. The paper does not establish the citing sentence’s broader claim that improvement in any one dimension is generally associated with improvement in further dimensions; its proposed transdiagnostic treatment framework is described as still needing evaluation. (LLM, conf=0.78)

    Experimental — accuracy not yet measured

  • Anxiety and depressive pathology significantly impair cessation success.

    “anxiety and depressive pathology significantly impair cessation success (Piper et al., 2010; Zvolensky et al., 2008; Leventhal & Zvolensky, 2015; Piper et al., 2011).”

    From A qualitative study of the feasibility and acceptability of a smoking cessation program for people living with HIV and emotional dysregulation. (2019) · cites this paper as Leventhal & Zvolensky, 2015

    The Anxiety Sensitivity and Anhedonia sections (page unavailable) report that these emotional vulnerabilities predict smoking lapse or relapse, supporting a link with poorer cessation outcomes. But the claim generalizes those findings to anxiety and depressive pathology as a whole and states that pathology impairs cessation success; the Anhedonia section notes that a history of major or recurrent depression did not significantly predict cessation after accounting for anhedonia. (LLM, conf=0.87)

    Experimental — accuracy not yet measured

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Cites

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Research works printed but not linked: 6

  1. Centers for Disease Control and Prevention (CDC) 2010 2010 Surgeon General’s Report - How tobacco smoke causes disease: The biology and behavioral basis for smoking-attributable disease Atlanta, Ga 21452462
  2. Raglan GB 2013 Distress tolerance and smoking status: Differences between smokers, former smokers, and never smokers Master’s thesis Retrieved from Washington Reseach Library Contorium
  3. Reiss S McNally RJ Reiss S Bootzin RR 1985 Expectancy model of fear Theoretical issues in behavior therapy 107 121 Orlando, FL, US Academic Press, Inc
  4. Spielberger C 1973 STAIC preliminary manual Palo Alto, CA Consulting Psychologists Press
  5. Zvolensky MJ Forsyth JP Bernstein A Leen-Feldner EW 2007 A concurrent test of the anxiety sensitivity taxon: Its relation to bodily vigilance and perceptions of control over anxiety-related events in a sample of young adults Journal of Cognitive Psychotherapy 21 72 90
  6. Zvolensky MJ Vujanovic AA Bernstein A Leyro T 2010 Distress Tolerance Theory, Measurement, and Relations to Psychopathology Current Directions in Psychological Science 19 6 406 410 PMC7978414 33746374

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Authors
Leventhal, A. M., & Zvolensky, M. J.
Affiliations
  • University of Southern California (US)
  • University of Houston (US)
ORCID
Venue
Psychological Bulletin
Publisher
American Psychological Association (APA)
Published
2015-01
Volume
141
Issue
1
Pages
176-212
ISSN
  • 0033-2909 (ISSN-L)
  • 1939-1455
DOI
10.1037/bul0000003
PMC
PMC4293352
OpenAlex
W2163221923
Semantic Scholar
46afc858babce5200f3c46e1b63f9be614d0e1c9
Cited by
524
References
263
Citations by year
2026: 22 · 2025: 39 · 2024: 33 · 2023: 42 · 2022: 40 · 2021: 47 · 2020: 86 · 2019: 52 · 2018: 54 · 2017: 40 · 2016: 41 · 2015: 27 · 2014: 1
FWCI
24.23
Type
journal article
Language
en
Open access
Locations
  • Psychological Bulletin (publishedVersion)
  • PubMed (publishedVersion)
  • PubMed Central (acceptedVersion)
Funders
National Institute on Drug Abuse (DA025041)
Topics
  • Health Sciences › Medicine › Physiology › Smoking Behavior and Cessation
  • Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
  • Health Sciences › Medicine › Epidemiology › Substance Abuse Treatment and Outcomes
Keywords
cigarette smoking, anxiety, depression, anhedonia, anxiety sensitivity, distress tolerance, smoking initiation, smoking relapse, smoking cessation, smoking maintenance
MeSH terms
Anxiety, Depression, Emotions, Humans, Smoking, Tobacco Use Disorder, Comorbidity

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