
==== Front
Psychiatr Q
Psychiatr Q
The Psychiatric Quarterly
0033-2720
1573-6709
Springer US New York

39008153
10080
10.1007/s11126-024-10080-z
Original Paper
Emotion Regulation Difficulties and Smoking Behavior among Adults with Chronic Obstructive Pulmonary Diseases
Schadegg Mary J. 2
Dixon Laura J. 1
http://orcid.org/0000-0003-0493-8509
Lee Aaron A. aalee2@olemiss.edu

1
1 https://ror.org/02teq1165 grid.251313.7 0000 0001 2169 2489 Department of Psychology, University of Mississippi, P.O. Box 1848, University, MS 38677 USA
2 grid.137628.9 0000 0004 1936 8753 Department of Psychiatry, NYU Grossman School of Medicine, One Park Ave, New York, NY 10016 USA
15 7 2024
15 7 2024
2024
95 3 433445
7 6 2024
© The Author(s) 2024
2024
https://creativecommons.org/licenses/by/4.0/ Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.
COPD is one of the leading causes of death in the United States and results in increased healthcare costs and disability. Smoking is the main determinant of COPD development and continued use increases mortality as compared to those who have stopped smoking. Research has indicated that cigarette smoking may play a role in attempts to regulate distressing emotional experiences and thus, may be an important transdiagnostic process underlying continued smoking behavior among adults with COPD. The current study investigated the role of ER difficulties in relation to smoking status and cigarettes smoked per day among adults with COPD. This cross-sectional study included a sample was adults with COPD (N = 320). Participants self-reported current smoking status, daily smoking, and the Difficulties in Emotion Regulation Scale. All analyses were adjusted for age, sex, probable depression, probable anxiety, and dyspnea severity. DERS total scores were associated with greater odds of current smoking. With the exception of impulsivity, all other dimensions of emotion regulation were significantly associated with current smoking. Greater difficulties in emotional awareness were associated with greater cigarettes smoked per day. However, neither the DERS total score nor any other dimensions of emotional regulation were significantly associated with cigarettes smoked per day. The present study provides preliminary data linking ER difficulties to smoking behavior among adults with COPD. If corroborated by future research, these findings suggest that ER might be a potential target for smoking cessation programs among adults with COPD.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11126-024-10080-z.

Keywords

Emotion regulation
Smoking
COPD
Respiratory disease
University of Mississippi College of Liberal Arts Research Grant for Faculty Research and Creative AchievementUniversity of Mississippi College of Liberal Arts Research Grant for Faculty Research and Creative Achievement None Askwith Foundation through the University of Michigan Center for Managing Chronic Disease None issue-copyright-statement© Springer Science+Business Media, LLC, part of Springer Nature 2024
==== Body
pmcIntroduction

Chronic obstructive pulmonary diseases (COPD) are a class of chronic progressive respiratory conditions characterized by obstructed airflow and breathing difficulties that contribute to diminished capacity for physical activity [1]. Globally, COPD is a leading cause of death [2], and in the United States (U.S.), COPD is a major source of healthcare costs and disability [3]. Cigarette smoking is the primary cause of COPD disease in the U.S., with 15.2% of current cigarette smokers having COPD compared to 7.6% former smokers, and 2.8% of adults who had never smoked [4]. Individuals with COPD who smoke have accelerated declines in pulmonary function and greater odds of early mortality compared to those who stop smoking [5, 6]. Further, smoking causes eight out of ten COPD-related deaths [7]. Yet, alarmingly, 38% of the approximately 16 million U.S. adults diagnosed with COPD are current smokers [4].

Among adults with COPD, those with comorbid mental health diagnoses are more likely to smoke cigarettes [8]. While research has not specifically investigated the effect of negative affect on smoking behaviors among those with COPD, prior studies have found that smoking is frequently used as a strategy to mitigate the experience of negative affect [9], suggesting a direct connection between smoking and negative emotional experiences. A recent meta-analysis found negative affect has been consistently linked with smoking behavior with small pooled effect sizes (rs = 0.06–0.20) [10]. Negative affect has also been associated with greater difficulties in smoking cessation– particularly among individuals struggling with a comorbid emotional disorder [11]. Together, these findings suggest that individuals’ ability to modulate negative affect may be an important risk factor for cigarette smoking among adults with COPD.

Emotion regulation (ER) is a transdiagnostic process that includes the ability to adaptively manage emotional responses [12]. Difficulties in ER can occur across several domains, including awareness and understanding of emotions, acceptance of emotions, ability to control impulses and engage in goal-directed behaviors when experiencing negative affect, and accessing effective strategies that can be used to regulate emotions [13]. Emotion dysregulation has been found to be a stable, trait-like factor that contributes to a range of psychopathology [13, 14], chronic health conditions [15], and substance use disorders [16].

Engagement in substance use to regulate or cope with one’s emotions is well-documented [17], with more recent studies demonstrating the connection between emotion dysregulation and smoking behaviors. Compared to non-smokers, smokers report greater difficulties in ER [18], which is associated with greater negative affect [19, 20]. Among current smokers, emotion dysregulation has been associated with smoking behaviors [21] and the use of cigarettes in an attempt to reduce negative affect [19]. One prior study also found that expectations about the effectiveness of cigarette use for regulating emotions mediated the relationship between depressive symptoms and number of cigarettes smoked per day [22], suggesting that individuals who smoke perceive smoking to be an effective means by which to manage distressing emotional experiences. Past research demonstrates that the association between cravings to smoke and intense negative or positive affect were attenuated when controlling for self-efficacy of ER ability [15]. Further, prior work suggests that ER difficulties increase the risk of relapse among adults who recently quit smoking [23], whereas the use of adaptive ER strategies, such as cognitive reappraisal, results in decreased cravings, lower negative affect, greater positive affect, and increased tolerance for distress [24–26]. Taken together the research suggests that ER difficulties might be a viable treatment target for improving smoking-related outcomes.

Cumulatively, extensive research indicates smoking behaviors are associated with the inability to modulate unpleasant emotional experiences; yet research has not yet elucidated the contribution of ER difficulties in smoking behaviors among adults with COPD. To further understand ER as a potential mechanism in smoking behaviors for this high-risk group, the current study investigated the role of ER difficulties in relation to smoking status and cigarettes smoked per day among adults with COPD. Compared to non-smokers with COPD, we predicted current smokers with COPD would evidence significantly greater difficulties with ER. In addition, overall difficulties in regulating emotions were expected to differentiate smoking status, after adjusting for established predictors such as age, sex, anxiety, depression, and dyspnea severity [1, 8, 27]. With regard to cigarettes smoked per day, we hypothesized greater difficulties with ER would be associated with a higher number of cigarettes smoked per day among smokers with COPD. Finally, exploratory analyses were conducted to identify specific domains of ER difficulties that affected smoking behaviors in this sample.

Methods

Participants

Participants were recruited from a large web-based panel of U.S. adults with chronic respiratory disease maintained by Qualtrics. All panel members had previously reported a diagnosis of asthma and/or COPD. Qualtrics panel members were invited to participate by email. To be eligible for this study, interested panel members had to indicate that they were: (1) 18 years of age or older and (2) endorse a current diagnosis of chronic bronchitis, emphysema, or COPD.

A total of 911 adults initiated the survey and 838 (92.0%) provided informed consent to participate in the study. Of those who provided informed consent, 145 reported having no respiratory condition, 229 (27.3%) reported having current asthma only, and 217 reported having a COPD and comorbid asthma. The present study used data from the remaining 320 respondents who reported having one or more COPDs, (i.e., emphysema, chronic bronchitis, or “COPD”) without comorbid asthma.

Compliance with Ethical Standards

The authors declare that they have no conflicts of interest. This research was supported by funding from Askwith Foundation through the University of Michigan Center for Managing Chronic Disease awarded to AL. The funder did not have any role in the study design; data collection, management, analysis, or interpretation; manuscript writing; or submission for publication. AL and LD’s effort on this paper was supported by the University of Mississippi College of Liberal Arts Research Grant for Faculty Research and Creative Achievement.

This study included human research participants. All study methods and procedures were consistent with the Declaration of Helsinki and approved by the University of Michigan Medical School Institutional Review Board. All participants provided informed consent to participate in this study. Data will be shared by the corresponding author upon reasonable request.

Measures

Emotion Regulation Difficulties

The Difficulties with Emotion Regulation Scale (DERS) [13] is comprised of 36 self-report items that measures a person’s perceived emotional awareness, acceptance of emotions, and ability to regulate emotions. Participants rate each item on a 5-point scale, ranging 1 (almost never) to 5 (almost always). The total, as well as the six subscales, were separately examined in this study to assess: (a) non-acceptance of emotional experiences (non-acceptance), (b) difficulties in goal-directed behaviors (goals), (c) difficulties controlling impulses when experiencing negative affect (impulse), (d) level of emotional awareness (awareness), (e) access to ER strategies (strategy), (f) level of emotional clarity (clarity), and (g) overall difficulties in perceived ER ability (total). Item responses are summed to compute subscales and the total score with higher scores indicating greater ER difficulties. The DERS has demonstrated good internal consistency (α = 0.93), and good construct validity [13]. In the current study the total and six subscales demonstrated good to excellent internal consistency (αs = 0.80 − 0.95).

Smoking Behavior

All participants were asked to indicate their current smoking status using a single item from the National Health Interview Survey (i.e., “Do you now smoke cigarettes, every day, some days, or not at all?”) [28]. Response options included “Yes, every day or some days” or “no, not at all”. Participants who reported smoking every day or some days were asked to indicate the average number of cigarettes they smoke per day (“How many cigarettes do you now smoke on average each day?”).

Control Variables

All participants reported their sex and age on a demographic measure to be used as control variables in the present study. The Patient Health Questionnaire-2 (PHQ-2) [29] and the Generalized Anxiety Disorder-2 (GAD-2) [30] were used to determine probable depression and anxiety. The PHQ-2 and GAD-2 each consist of two items which assess critical symptoms of depression and generalized anxiety. Participants rate the extent to which they have experienced each symptom of depression or anxiety on a 4-point scale ranging from 0 (Not at all) to 3 (Nearly every day). Total scores, ranging from 0 to 6, are computed by summing the responses for each item. A cutoff score of 3 has demonstrated good sensitivity and specificity for accurately identify depression [29, 30] or probable anxiety [31]. Accordingly, in the current study, individuals with total scores 3 on the PHQ-2 or GAD-2 were categorized as having probable depression or anxiety. Dyspnea related impairment was measured using the Modified Medical Research Council (mMRC) Dyspnea Scale [32]. Participants indicate their degree of disability caused by breathlessness during activities by choosing from five responses of increasing severity from 0 (I only get breathless with strenuous exercise) to 4 (I am too breathless to leave the house). Consistent with previous, mMRC Dyspnea Scale scores were used to classify patients as having mild (< 2) vs. moderate or severe (2) disability [33]. Prior studies suggest that mMRC Dyspnea Scale scores 2 predict lower physical activity [34] and greater risk of early mortality [35].

Data Analytic Plan

All analyses were performed using SPSS version 27. Descriptive statistics were used to characterize the sample. A series of independent samples t-tests were used to compare DERS total and subscale scores among non-smokers and smokers with COPD. Examination of univariate distributions for each DERS total and subscale did not indicate significant skew or outlying data points. Levene’s test demonstrated equality of variance between groups. Cohen’s d was computed as a measure of effect size for each comparison to quantify the difference in DERS total and subscale scores among smokers and non-smokers. Next, we used separate two-step logistic regression models to examine the association between the DERS total and subscales scores with odds of smoking. Finally, we used separate two-step hierarchical linear regression models to examine the association between DERS total and each subscale with total number of cigarettes per day among current smokers. For each multivariable model, control variables, including respondents’ age, sex male = 0, female = 1), probable depression (no = 0, yes = 1), probable anxiety (no = 0, yes = 1), and dyspnea related disability (mild = 0 vs. moderate or severe = 1) were entered in step one and DERS subscales were entered in step two. All tests were two-tailed with alpha = 0.05.

Results

Sample Characteristics

Table 1 includes the descriptive statistics for the sample. Most of the sample was male, White, and non-Latinx with an average age of approximately 60 years. Most of the sample had at least some college education and reported an annual income between $15,000 and $55,000. A small portion of the sample screened positive for probable depression (7.2%) or probable anxiety (4.7%). The modal MRC Dyspnea scale score was in the mild range (“I get short of breath when hurrying on the level or up a slight hill”); yet, 45.0% indicated moderate or severe disability. Lastly, approximately half of the sample (n = 152) were current smokers who averaged 16 cigarettes per day, which is higher than the prevalence of smoking (38%) among adults with COPD reported by one prior study [36].

Table 1 Descriptive statistics of the sample (N = 320)

Variable	% or Mean (SD)	
Age	61.17 (13.57)	
Male	61.9%	
Race		
 White	88.4%	
 Black	7.8%	
 Other	3.8%	
Ethnicity (Non-Latino)	92.5%	
Education		
 < High school	3.4%	
 High school	25.6%	
 ≥ Some college	70.9%	
Income		
 < 15,000	14.7%	
 15,000 to 30,000	30.6%	
 30,000 to 55,000	29.4%	
 ≥ 55,000	25.3%	
MRC Dyspnea Scale		
 0	15.0%	
 1	40.0%	
 2	30.0%	
 3	14.1%	
 4	0.9%	
Current smoker	47.2%	
Cigarettes/day	15.6 (10.6)	
DERS total (n = 309)	74.1 (23.5)	
 Nonacceptance	12.6 (5.8)	
 Goals	12.0 (4.6)	
 Impulse	10.6 (4.8)	
 Awareness	14.3 (4.7)	
 Strategies	15.4 (6.7)	
 Clarity	9.1 (3.6)	
SD = Standard Deviation

Emotion Regulation Difficulties and Smoking Status

Table 2 depicts the results of t-tests comparing DERS total and subscales scores for smokers and non-smokers. As hypothesized, smokers with COPD had significantly higher DERS total scores compared to non-smokers with COPD. Additionally, all subscales for the DERS had significantly higher means for smokers as compared to non-smokers. The difference in DERS scores between smokers and non-smokers were characterized by medium effect sizes (Cohen’s d = 0.39–0.67).

Table 2 Means, standard deviations, and results of t-tests comparing DERS total and subscale scores among smokers and non-smokers with COPD (n = 309)

DERS	Non-Smokers
n = 160	Smokers
n = 149				
M	SD	M	SD	t	p	Cohen’s d	
Total	66.84	19.32	81.96	25.17	-5.89	<.001	0.67	
Non-acceptance	11.29	5.19	14.07	6.16	-4.29	<.001	0.49	
Goals	11.13	4.55	13.03	4.45	-3.70	<.001	0.42	
Impulse	9.50	3.77	11.88	5.37	-4.48	<.001	0.51	
Awareness	13.42	4.41	15.22	4.90	-3.39	.001	0.39	
Strategies	13.45	5.36	17.46	7.36	-5.44	<.001	0.62	
Clarity	8.06	2.81	10.30	4.03	-5.63	<.001	0.64	
Notes. DERS = Difficulties in Emotion Regulation Scale, M = Mean, SD = Standard Deviation

Adjusted Associations between Emotion Regulation Difficulties and Smoking Status

Table 3 depicts the associations between ER difficulties (DERS total and subscale scores) and the adjusted odds of current smoking among adults with COPD, controlling for age, sex, depression, anxiety, and dyspnea severity. Consistent with prediction, DERS total scores were significantly associated with greater odds of current smoking (p <.001), after adjusting for all control variables. Each 10-point increase in DERS total scores (range 36 to 180) was associated with an approximately 20% increase in odds of current smoking. Of the DERS subscales, greater non-acceptance of emotions (p =.006), greater difficulties engaging in goal directed behaviors (p =.046), greater difficulties in emotional awareness (p =.014), greater difficulties accessing adaptive regulation strategies (p =.002), and greater difficulties in emotional clarity (p =.001) were associated with greater odds of current smoking.

Table 3 Results of adjusted logistic regression models examining the relationship between DERS total and subscales with smoking status (n = 309)

	AOR	SE	95% CI	p	
Step 1: Controls					
 Age	0.94	0.01	0.92, 0.96	<.001	
 Female sex	1.08	0.26	0.65, 1.79	.767	
 Depression	2.20	0.61	0.66, 7.32	.196	
 Anxiety	0.65	0.75	0.15, 2.80	.563	
 Dyspnea severity	1.16	0.13	0.89, 1.50	.271	
Step 2: DERS					
 Total	1.02	0.01	1.01, 1.04	.001	
 Non-acceptance	1.07	0.02	1.02, 1.12	.006	
 Goals	1.06	0.03	1.00, 1.13	.046	
 Impulse	1.05	0.03	0.99, 1.12	.096	
 Awareness	1.07	0.03	1.01, 1.13	.014	
 Strategies	1.08	0.03	1.03, 1.13	.002	
 Clarity	1.15	0.04	1.06, 1.24	.001	
Notes. DERS = Difficulties in Emotion Regulation Scale, AOR = Adjusted Odds Ratio, SE = Standard Error, 95% CI = 95% Confidence interval. Separate logistic regression models were used to evaluate DERS total and subscale scores in relation to smoking status adjusted for age, sex, probable depression, probable anxiety, and dyspnea severity

Adjusted Association between Emotion Regulation Difficulties and Daily Cigarette Use

Table 4 depicts the associations between ER difficulties (DERS total and subscale scores) and cigarettes smoked per day among adults with COPD, controlling for age, sex, depression, anxiety, and dyspnea severity. Contrary to our hypothesis, DERS total scores were not significantly associated with daily cigarette use (ΔF (1, 142) = 1.86, p =.175). Greater difficulties in awareness of emotions was associated with significantly more cigarettes smoked per day (ΔF (1, 142) = 5.00, p =.027), accounting for an additional 3.3% of the variance is cigarettes smoked per day. However, no other ER difficulties were significantly associated with cigarettes smoked per day in adjusted models (ps \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$ \ge $$\end{document} 0.05).

Table 4 Results of adjusted hierarchical linear regression models examining the relationship between DERS total and subscales with number of cigarettes smoked per day among smokers (n = 149)

	B	SE	95%CI	p	
Step 1: Controls					
 Age	0.10	0.06	-0.03, 0.22	.120	
 Female sex	-1.31	1.81	-4.88, 2.27	.472	
 Depression	-0.11	3.71	-7.44, 7.22	.976	
 Anxiety	0.33	4.50	-8.55, 9.22	.941	
 Dyspnea severity	-0.57	1.77	-4.07, 2.92	.746	
Step 2: DERS					
 Total	0.06	0.04	-0.03, 0.15	.175	
 Non-acceptance	-0.46	0.16	-0.36, 0.27	.775	
 Goals	0.16	0.23	-0.29, 0.62	.478	
 Impulse	0.12	0.20	-0.27, 0.51	.550	
 Awareness	0.42	0.18	0.05, 0.76	.027	
 Strategies	0.16	0.15	-0.14, 0.47	.290	
 Clarity	0.49	0.25	0.00, 0.98	.050	
Notes. DERS = Difficulties in Emotion Regulation Scale, SE = Standard Error, 95% CI = 95% Confidence interval. Separate linear regression models were conducted to evaluate DERS total and subscale scores in relation to cigarettes smoked per day among smokers. All results are adjusted for age, sex, probable depression, probable anxiety, and dyspnea severity

Discussion

The current study adds to the existing body of research on emotion dysregulation and smoking behaviors by examining difficulties in ER between smokers and non-smokers with COPD. Current smokers with COPD are particularly vulnerable to the negative health consequence of smoking and may represent a subgroup of cigarette-users who have been resistant to quitting smoking or who have been unsuccessful in their previous quit attempts. Consequently, these findings have the potential to facilitate smoking cessation efforts in COPD patients.

Consistent with hypotheses, smokers with COPD reported significantly greater overall ER difficulties compared to non-smokers with COPD. In relation to our exploratory aims, the results indicated significantly greater difficulties in each dimension of ER among smokers with COPD. In addition, the adjusted models revealed a robust association between overall ER difficulties and the odds of current smoking among adults with COPD. For example, in the current sample, individuals scoring one standard deviation above the mean on the DERS had approximately 47% greater odds of current smoking, even after controlling for age, sex, probable depression, probable anxiety, and dyspnea severity. This finding suggests that overall ER difficulties represents an important factor associated with smoking among adults with COPD, after accounting for well-established risk factors.

With the exception of the impulsivity dimension of ER, each facet of ER difficulties was associated with higher odds of smoking, even after controlling for age, sex, probable anxiety, probable depression, and dyspnea severity. These results are consistent with past research that suggests smoking is used as a method for regulating emotions [9, 21]. Additionally, the current study is one of few studies showing that specific dimensions of ER difficulties, including non-acceptance of emotions [21], lack of emotional clarity [18], difficulty engaging in goal-directed behaviors and limited access to ER strategies [37], contribute to smoking behaviors. Impulsivity may be less important in the maintenance of smoking behavior among adults who continue to smoke even after being diagnosed with a serious chronic respiratory disease. For example, the habitual nature of smoking across emotional experiences and the extent of nicotine dependence may play comparatively more important roles in the persistence of smoking in this population. The present findings inform ongoing research efforts designed to identify transdiagnostic processes in COPD [38] and specifically, provide the first indication that ER abilities might be implicated in smoking behaviors for those with COPD.

Contrary to our hypotheses, overall ER difficulties did not predict the number of cigarettes smoked per day among smokers with COPD. Among the specific domains of ER difficulties, only limited awareness of emotions predicted number of cigarettes smoked per day among smokers. These findings diverge from one study showing a direct association between negative affect regulation and number of cigarettes smoked [22]. However, our findings are consistent with prior substance use research. For example, while pre-use affect is associated with alcohol use in general it is not associated with the number of drinks consumed [39]. Additionally, a prior study found that only the impulse subscale of the DERS was associated with number of alcoholic drinks consumed, whereas ER deficits overall and subscales were associated with alcohol use more generally [40]. These might indicate that the amount of substance used is less dependent on ER. Past research has found that emotion dysregulation is predictive of cigarette dependency in a general [41] and substance use treatment seeking populations [37]. In consideration of these prior and current findings, our findings indicate that ER is generally associated with smoking dependency but not with daily smoking frequency.

Smoking remains one of the most significant health risks among individuals with COPD. Adults with COPD are at risk of detrimental functional outcomes [42] and comorbid mental health diagnoses [8]; with continuation of smoking being a particularly high-risk behavior among those with COPD, compounding negative outcomes. For example, individuals with COPD who smoke cigarettes have lower physical functioning, as well as greater risk of hospitalization and early mortality [5, 6, 43]. Despite these negative health consequences, many adults with COPD have difficulty quitting smoking. Indeed, this study and one previous study have reported high rates of current smoking (38 and 48%) among adults with COPD [4]. Prior studies have highlighted numerous barriers to smoking cessation, including beliefs about association between COPD and smoking [44], low motivation to change [45], and minimal hope of success [46]. Results of prior studies as well as the present findings suggest that ER may represent a viable treatment target for smoking cessation interventions among adults with COPD.

The present findings should be interpreted in the context of several important limitations. First, the present study used a cross-sectional design which precludes causal interpretation of the associations among study variables. For example, adults with COPD who have greater difficulties in ER may be more likely to smoke cigarettes to manage negative emotional experiences. Conversely, smoking may contribute to greater difficulties in ER. Second, although the present sample was recruited from a panel of individuals with chronic respiratory disease, the diagnosis of COPD was not confirmed with by a provider diagnosis or spirometry. Third, we assessed respondents’ current smoking status (smoking vs. not smoking) but did not assess smoking history. Consequently, we are not able to examine differences in ER difficulties among ever vs. never smokers. If evident, greater ER deficits among adults with a history of smoking compared to adults who have never smoked would further support the role ER deficits in smoking behavior. Last, cigarette consumption was assessed using a global self-report of daily cigarette smoking. Albeit a standard approach to assessment, future research should consider the inclusion of additional measures of smoking dependence, history of quit attempts, or intention to discontinue smoking to further elucidate the relation between emotion dysregulation and clinically relevant smoking indicators among current smokers with chronic lung conditions.

Conclusions

Smoking is among the most important risk factors for medical complications and early mortality among adults with COPD [4]. Accordingly, smoking cessation is the primary target for medical and behavioral interventions among smokers with COPD. The present study provides preliminary data linking specific ER difficulties to smoking behavior among individuals with COPD. If corroborated by future research, these findings suggest that ER might be a potential target of interventions for smoking cessation among individuals with COPD. In light of the current findings, a critical first step would be increasing emotional awareness to help such individuals recognize the need for ER strategies, followed by equipping them with the abilities to access, select, and implement effective ER strategies. Specifically, prior research among smokers has indicated that targeting the use of adaptive ER strategies, and specifically, the use of cognitive reappraisal, resulted in reduction of cravings, increased willingness to experience smoking related thoughts, and longer periods before relapse [25]. ER treatment enhanced CBT has yielded high rates of abstinence and decreased daily cigarette smoking among individuals without chronic respiratory disease [47]. Future studies should examine the effectiveness of ER based interventions for current smokers with COPD.

Electronic Supplementary Material

Below is the link to the electronic supplementary material.

Supplementary Material 1

Author Contributions

All authors contributed to the study conception. Data collection was performed by AL. Data analysis was performed by AL and MS. The first draft of the manuscript was written by MS and all authors edited and reviewed subsequent drafts of the manuscript. All authors read and approved the final manuscript.

Funding

This research was supported by funding from Askwith Foundation through the University of Michigan Center for Managing Chronic Disease awarded to AL. The funder did not have any role in the study design; data collection, management, analysis, or interpretation; manuscript writing; or submission for publication. LD’s effort on this paper was supported by the University of Mississippi College of Liberal Arts Research Grant for Faculty Research and Creative Achievement.

Declarations

Conflict of interest

The authors declare that they have no conflicts of interest.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
==== Refs
References

1. Vogelmeier CF Criner GJ Martinez FJ Anzueto A Barnes PJ Bourbeau J Global strategy for the diagnosis, Management and Prevention of Chronic Obstructive Lung Disease 2017 Report Respirology 2017 22 3 575 601 10.1164/rccm.201701-0218PP 28150362
Vogelmeier CF, Criner GJ, Martinez FJ, Anzueto A, Barnes PJ, Bourbeau J, et al. Global strategy for the diagnosis, Management and Prevention of Chronic Obstructive Lung Disease 2017 Report. Respirology. 2017;22(3):575–601. 10.1164/rccm.201701-0218PP.28150362
2. Mathers C, Stevens G, Hogan D, Mahanani WR, Ho J et al. Global and Regional Causes of Death: Patterns and Trends, 2000–15. In: Jamison DT, Gelband H, Horton S, Jha P, Laxminarayan R, Mock CN, editors. Disease Control Priorities: Improving Health and Reducing Poverty. 3rd Edition ed. Washington, D.C.2017.
3. Iheanacho I Zhang S King D Rizzo M Ismaila AS Economic burden of chronic obstructive pulmonary disease (COPD): a systematic literature review Int J Chronic Obstr Pulm Dis 2020 15 439 60 10.2147/COPD.S234942
Iheanacho I, Zhang S, King D, Rizzo M, Ismaila AS. Economic burden of chronic obstructive pulmonary disease (COPD): a systematic literature review. Int J Chronic Obstr Pulm Dis. 2020;15:439–60. 10.2147/COPD.S234942.
4. Wheaton AG Liu Y Croft JB VanFrank B Croxton TL Punturieri A Chronic obstructive pulmonary disease and smoking status—United States, 2017 Morb Mortal Wkly Rep 2019 68 24 533 8 10.15585/mmwr.mm6824a1
Wheaton AG, Liu Y, Croft JB, VanFrank B, Croxton TL, Punturieri A, et al. Chronic obstructive pulmonary disease and smoking status—United States, 2017. Morb Mortal Wkly Rep. 2019;68(24):533–8.
5. Godtfredsen NS Lam TH Hansel TT Leon M Gray N Dresler C COPD-related morbidity and mortality after smoking cessation: Status of the evidence Eur Respir J 2008 32 4 844 53 10.1183/09031936.00160007 18827152
Godtfredsen NS, Lam TH, Hansel TT, Leon M, Gray N, Dresler C, et al. COPD-related morbidity and mortality after smoking cessation: Status of the evidence. Eur Respir J. 2008;32(4):844–53. 10.1183/09031936.00160007.18827152
6. Thun MJ Carter BD Feskanich D Freedman ND Prentice R Lopez AD 50-year trends in smoking-related mortality in the United States N Engl J Med 2013 368 351 64 10.1056/NEJMsa1211127 23343064
Thun MJ, Carter BD, Feskanich D, Freedman ND, Prentice R, Lopez AD, et al. 50-year trends in smoking-related mortality in the United States. N Engl J Med. 2013;368:351–64. 10.1056/NEJMsa1211127.23343064
7. U.S. Department of Health and Human Services The health consequences of smoking — 50 years of progress: a report of the Surgeon General 2014 Atlanta, GA U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health
U.S. Department of Health and Human Services. The health consequences of smoking — 50 years of progress: a report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2014.
8. Phan T Carter O Waterer G Chung LP Hawkins M Rudd C Determinants for concomitant anxiety and depression in people living with chronic obstructive pulmonary disease J Psychosom Res 2019 120 60 5 10.1016/j.jpsychores.2019.03.004 30929709
Phan T, Carter O, Waterer G, Chung LP, Hawkins M, Rudd C, et al. Determinants for concomitant anxiety and depression in people living with chronic obstructive pulmonary disease. J Psychosom Res. 2019;120:60–5. 10.1016/j.jpsychores.2019.03.004.30929709
9. Vinci C Kinsaul J Carrigan MH Copeland AL The relationship between smoking motives and smoking urges experienced in response to a negative affect induction Addict Behav 2015 40 96 101 10.1016/j.addbeh.2014.09.007 25241308
Vinci C, Kinsaul J, Carrigan MH, Copeland AL. The relationship between smoking motives and smoking urges experienced in response to a negative affect induction. Addict Behav. 2015;40:96–101. 10.1016/j.addbeh.2014.09.007.25241308
10. Akbari M Hasani J Seydavi M Negative affect among daily smokers: a systematic review and meta-analysis J Affect Disord 2020 274 553 67 10.1016/j.jad.2020.05.063 32663988
Akbari M, Hasani J, Seydavi M. Negative affect among daily smokers: a systematic review and meta-analysis. J Affect Disord. 2020;274:553–67. 10.1016/j.jad.2020.05.063.32663988
11. Mahaffey BL Gonzalez A Farris SG Zvolensky MJ Bromet EJ Luft BJ Smoking to regulate negative affect: disentangling the relationship between posttraumatic stress and emotional disorder symptoms, nicotine dependence, and cessation-related problems Nicotine Tob Res 2016 18 6 1471 8 10.1093/ntr/ntv175 26304694
Mahaffey BL, Gonzalez A, Farris SG, Zvolensky MJ, Bromet EJ, Luft BJ, et al. Smoking to regulate negative affect: disentangling the relationship between posttraumatic stress and emotional disorder symptoms, nicotine dependence, and cessation-related problems. Nicotine Tob Res. 2016;18(6):1471–8. 10.1093/ntr/ntv175.26304694
12. Gratz KL, Dixon LJ, Kiel EJ, Tull MT. Emotion regulation: Theoretical models, associated outcomes and recent advances. In: Zeigler-Hill V, Shackelford TK, editors. The SAGE handbook of personality and individual differences: Applications of personality and individual differences 2018. pp. 63–89.
13. Gratz KL Roemer L Multidimensional assessment of emotion regulation and dysregulation: development, factor structure, and initial validation of the difficulties in emotion regulation scale J Psychopathol Behav Assess 2004 26 1 41 54 10.1023/B:JOBA.0000007455.08539.94
Gratz KL, Roemer L. Multidimensional assessment of emotion regulation and dysregulation: development, factor structure, and initial validation of the difficulties in emotion regulation scale. J Psychopathol Behav Assess. 2004;26(1):41–54. 10.1023/B:JOBA.0000007455.08539.94.
14. Gross J, Muñoz RF. Emotion regulation and mental health. Clinical psychology: Science and practice. 1995;2:151– 64. 10.1111/j.1468-2850.1995.tb00036.x.
15. Wierenga KL Lehto RH Given B Emotion regulation in chronic disease populations: an integrative review Res Theory Nurs Pract 2017 31 3 247 71 10.1891/1541-6577.31.3.247 28793948
Wierenga KL, Lehto RH, Given B. Emotion regulation in chronic disease populations: an integrative review. Res Theory Nurs Pract. 2017;31(3):247–71. 10.1891/1541-6577.31.3.247.28793948
16. Kober H. Emotion regulation in substance use disorders. Gross JJ, editor 2014.
17. Turner S Mota N Bolton J Sareen J Self-medication with alcohol or drugs for mood and anxiety disorders: a narrative review of the epidemiological literature Depress Anxiety 2018 35 9 851 60 10.1002/da.22771 29999576
Turner S, Mota N, Bolton J, Sareen J. Self-medication with alcohol or drugs for mood and anxiety disorders: a narrative review of the epidemiological literature. Depress Anxiety. 2018;35(9):851–60. 10.1002/da.22771.29999576
18. Faulkner P Dean AC Ghahremani DG London ED Neural basis of smoking-related difficulties in emotion regulation Int J Neuropsychopharmacol 2020 23 7 409 16 10.1093/ijnp/pyaa015 32221527
Faulkner P, Dean AC, Ghahremani DG, London ED. Neural basis of smoking-related difficulties in emotion regulation. Int J Neuropsychopharmacol. 2020;23(7):409–16. 10.1093/ijnp/pyaa015.32221527
19. Johnson AL, McLeish AC. The indirect effect of emotion dysregulation in terms of negative affect and smoking-related cognitive processes. Addict Behav. 2016;53. 10.1016/j.addbeh.2015.10.023.:187– 92.
20. MacIntyre JM Ruscio AC Brede E Waters AJ Emotion dysregulation and negative affect: Laboratory and EMA investigations in smokers Addict Behav Rep 2018 7 65 70 10.1016/j.abrep.2018.01.001 29687075
MacIntyre JM, Ruscio AC, Brede E, Waters AJ. Emotion dysregulation and negative affect: Laboratory and EMA investigations in smokers. Addict Behav Rep. 2018;7:65–70. 10.1016/j.abrep.2018.01.001.29687075
21. Adams CE Tull MT Gratz KL The role of emotional nonacceptance in the relation between depression and recent cigarette smoking Am J Addictions 2012 21 4 293 301 10.1111/j.1521-0391.2012.00238.x
Adams CE, Tull MT, Gratz KL. The role of emotional nonacceptance in the relation between depression and recent cigarette smoking. Am J Addictions. 2012;21(4):293–301. 10.1111/j.1521-0391.2012.00238.x.
22. Schleicher HE Harris KJ Catley D Nazir N The role of depression and negative affect regulation expectancies in tobacco smoking among college students J Am Coll Health 2009 57 5 507 12 10.3200/JACH.57.5.507-512 19254891
Schleicher HE, Harris KJ, Catley D, Nazir N. The role of depression and negative affect regulation expectancies in tobacco smoking among college students. J Am Coll Health. 2009;57(5):507–12. 10.3200/JACH.57.5.507-512.19254891
23. Farris SG Zvolensky MJ Schmidt NB Difficulties with emotion regulation and psychopathology interact to predict early smoking cessation lapse Cogn Therapy Res 2016 40 3 357 67 10.1007/s10608-015-9705-5
Farris SG, Zvolensky MJ, Schmidt NB. Difficulties with emotion regulation and psychopathology interact to predict early smoking cessation lapse. Cogn Therapy Res. 2016;40(3):357–67. 10.1007/s10608-015-9705-5.
24. Kober H Kross EF Mischel W Hart CL Ochsner KN Regulation of craving by cognitive strategies in cigarette smokers Drug Alcohol Depend 2010 106 1 52 5 10.1016/j.drugalcdep.2009.07.017 19748191
Kober H, Kross EF, Mischel W, Hart CL, Ochsner KN. Regulation of craving by cognitive strategies in cigarette smokers. Drug Alcohol Depend. 2010;106(1):52–5. 10.1016/j.drugalcdep.2009.07.017.19748191
25. Szasz PL Szentagotai A Hofmann SG Effects of emotion regulation strategies on smoking craving, attentional bias, and task persistence Behav Res Ther 2012 50 5 333 40 10.1016/j.brat.2012.02.010 22459732
Szasz PL, Szentagotai A, Hofmann SG. Effects of emotion regulation strategies on smoking craving, attentional bias, and task persistence. Behav Res Ther. 2012;50(5):333–40. 10.1016/j.brat.2012.02.010.22459732
26. Dixon LJ Lee AA Gratz KL Tull MT Anxiety sensitivity and sleep disturbance: investigating associations among patients with co-occurring anxiety and substance use disorders J Anxiety Disord 2018 53 9 15 10.1016/j.janxdis.2017.10.009 29127882
Dixon LJ, Lee AA, Gratz KL, Tull MT. Anxiety sensitivity and sleep disturbance: investigating associations among patients with co-occurring anxiety and substance use disorders. J Anxiety Disord. 2018;53:9–15.29127882
27. Fucito LM Juliano LM Toll BA Cognitive reappraisal and expressive suppression emotion regulation strategies in cigarette smokers Nicotine Tob Res 2010 12 11 1156 61 10.1093/ntr/ntq146 20829326
Fucito LM, Juliano LM, Toll BA. Cognitive reappraisal and expressive suppression emotion regulation strategies in cigarette smokers. Nicotine Tob Res. 2010;12(11):1156–61. 10.1093/ntr/ntq146.20829326
28. National Center for Health Statistics. National Health Interview Survey dataset documentation and questionnaires.
29. Kroenke K Spitzer RL Williams JB The Patient Health Questionnaire-2: validity of a two-item depression screener Med Care 2003 41 11 1284 92 10.1097/01.MLR.0000093487.78664.3C 14583691
Kroenke K, Spitzer RL, Williams JB. The Patient Health Questionnaire-2: validity of a two-item depression screener. Med Care. 2003;41(11):1284–92. 10.1097/01.MLR.0000093487.78664.3C.14583691
30. Kroenke K Spitzer RL Williams JB Monahan PO Löwe B Anxiety disorders in primary care: prevalence, impairment, comorbidity, and detection Ann Intern Med 2007 146 5 317 25 10.7326/0003-4819-146-5-200703060-00004 17339617
Kroenke K, Spitzer RL, Williams JB, Monahan PO, Löwe B. Anxiety disorders in primary care: prevalence, impairment, comorbidity, and detection. Ann Intern Med. 2007;146(5):317–25. 10.7326/0003-4819-146-5-200703060-00004.17339617
31. Plummer F Manea L Trepel D McMillan D Screening for anxiety disorders with the GAD-7 and GAD-2: a systematic review and diagnostic metaanalysis Gen Hosp Psychiatry 2016 39 24 31 10.1016/j.genhosppsych.2015.11.005 26719105
Plummer F, Manea L, Trepel D, McMillan D. Screening for anxiety disorders with the GAD-7 and GAD-2: a systematic review and diagnostic metaanalysis. Gen Hosp Psychiatry. 2016;39:24–31. 10.1016/j.genhosppsych.2015.11.005.26719105
32. Bestall J Paul E Garrod R Garnham R Jones P Wedzicha J Usefulness of the Medical Research Council (MRC) dyspnoea scale as a measure of disability in patients with chronic obstructive pulmonary disease Thorax 1999 54 7 581 6 10.1136/thx.54.7.581 10377201
Bestall J, Paul E, Garrod R, Garnham R, Jones P, Wedzicha J. Usefulness of the Medical Research Council (MRC) dyspnoea scale as a measure of disability in patients with chronic obstructive pulmonary disease. Thorax. 1999;54(7):581–6. 10.1136/thx.54.7.581.10377201
33. Gupta D Agarwal R Aggarwal AN Maturu V Dhooria S Prasad K Guidelines for diagnosis and management of chronic obstructive pulmonary disease: joint ICS/NCCP (I) recommendations Lung India 2013 30 3 228 10.4103/0970-2113.116248 24049265
Gupta D, Agarwal R, Aggarwal AN, Maturu V, Dhooria S, Prasad K, et al. Guidelines for diagnosis and management of chronic obstructive pulmonary disease: joint ICS/NCCP (I) recommendations. Lung India. 2013;30(3):228. 10.4103/0970-2113.116248.24049265
34. Munari AB Gulart AA Dos Santos K Venâncio RS Karloh M Mayer AF Modified Medical Research Council dyspnea scale in GOLD classification better reflects physical activities of daily living Respir Care 2018 63 1 77 85 10.4187/respcare.05636 28874609
Munari AB, Gulart AA, Dos Santos K, Venâncio RS, Karloh M, Mayer AF. Modified Medical Research Council dyspnea scale in GOLD classification better reflects physical activities of daily living. Respir Care. 2018;63(1):77–85. 10.4187/respcare.05636.28874609
35. Casanova C Marin JM Martinez-Gonzalez C de Lucas-Ramos P Mir-Viladrich I Cosio B Differential effect of modified medical research council dyspnea, COPD assessment test, and clinical COPD questionnaire for symptoms evaluation within the new GOLD staging and mortality in COPD Chest 2015 148 1 159 68 10.1378/chest.14-2449 25612228
Casanova C, Marin JM, Martinez-Gonzalez C, de Lucas-Ramos P, Mir-Viladrich I, Cosio B, et al. Differential effect of modified medical research council dyspnea, COPD assessment test, and clinical COPD questionnaire for symptoms evaluation within the new GOLD staging and mortality in COPD. Chest. 2015;148(1):159–68. 10.1378/chest.14-2449.25612228
36. Wheaton AG Cunningham TJ Ford ES Croft JB Employment and activity limitations among adults with chronic obstructive pulmonary disease—United States, 2013 MMWR Morbidity Mortal Wkly Rep 2015 64 11 289
Wheaton AG, Cunningham TJ, Ford ES, Croft JB. Employment and activity limitations among adults with chronic obstructive pulmonary disease—United States, 2013. MMWR Morbidity Mortal Wkly Rep. 2015;64(11):289.
37. Rogers AH Bakhshaie J Viana AG Manning K Mayorga NA Garey L Emotion dysregulation and smoking among treatment-seeking smokers Addict Behav 2018 79 124 30 10.1016/j.addbeh.2017.12.025 29289851
Rogers AH, Bakhshaie J, Viana AG, Manning K, Mayorga NA, Garey L, et al. Emotion dysregulation and smoking among treatment-seeking smokers. Addict Behav. 2018;79:124–30. 10.1016/j.addbeh.2017.12.025.29289851
38. Mathew AR Yount SE Kalhan R Hitsman B Psychological functioning in patients with chronic obstructive pulmonary disease: a preliminary study of relations with smoking status and disease impact Nicotine Tob Res 2019 21 5 686 90 10.1093/ntr/nty102 29788395
Mathew AR, Yount SE, Kalhan R, Hitsman B. Psychological functioning in patients with chronic obstructive pulmonary disease: a preliminary study of relations with smoking status and disease impact. Nicotine Tob Res. 2019;21(5):686–90. 10.1093/ntr/nty102.29788395
39. Courtney JB Russell MA Testing affect regulation models of drinking prior to and after drinking initiation using ecological momentary assessment Psychol Addict Behav 2021 35 5 597 608 10.1037/adb0000763 34138595
Courtney JB, Russell MA. Testing affect regulation models of drinking prior to and after drinking initiation using ecological momentary assessment. Psychol Addict Behav. 2021;35(5):597–608. 10.1037/adb0000763.34138595
40. Dvorak RD Sargent EM Kilwein TM Stevenson BL Kuvaas NJ Williams TJ Alcohol use and alcohol-related consequences: associations with emotion regulation difficulties Am J Drug Alcohol Abus 2014 40 2 125 30 10.3109/00952990.2013.877920
Dvorak RD, Sargent EM, Kilwein TM, Stevenson BL, Kuvaas NJ, Williams TJ. Alcohol use and alcohol-related consequences: associations with emotion regulation difficulties. Am J Drug Alcohol Abus. 2014;40(2):125–30. 10.3109/00952990.2013.877920.
41. Zvolensky MJ Shepherd JM Bakhshaie J Garey L Viana AG Peraza N Emotion dysregulation and cigarette dependence, perceptions of quitting, and problems during quit attempts among spanish-speaking Latinx adult smokers Addict Behav 2019 96 127 32 10.1016/j.addbeh.2019.05.002 31077888
Zvolensky MJ, Shepherd JM, Bakhshaie J, Garey L, Viana AG, Peraza N. Emotion dysregulation and cigarette dependence, perceptions of quitting, and problems during quit attempts among spanish-speaking Latinx adult smokers. Addict Behav. 2019;96:127–32. 10.1016/j.addbeh.2019.05.002.31077888
42. Montserrat-Capdevila J Godoy P Marsal JR Ortega M Pifarré J Alsedà M Mental disorders in chronic obstructive pulmonary diseases Perspect Psychiatr Care 2018 54 3 398 404 10.1111/ppc.12274 29577318
Montserrat-Capdevila J, Godoy P, Marsal JR, Ortega M, Pifarré J, Alsedà M, et al. Mental disorders in chronic obstructive pulmonary diseases. Perspect Psychiatr Care. 2018;54(3):398–404. 10.1111/ppc.12274.29577318
43. Godtfredsen N Vestbo J Osler M Prescott E Risk of hospital admission for COPD following smoking cessation and reduction: a Danish population study Thorax 2002 57 11 967 72 10.1136/thorax.57.11.967 12403880
Godtfredsen N, Vestbo J, Osler M, Prescott E. Risk of hospital admission for COPD following smoking cessation and reduction: a Danish population study. Thorax. 2002;57(11):967–72. 10.1136/thorax.57.11.967.12403880
44. Bjarnason NH Mikkelsen KL Tønnesen P Smoking habits and beliefs about smoking in elderly patients with COPD during hospitalisation J Smok Cessat 2010 5 1 15 21 10.1375/jsc.5.1.15
Bjarnason NH, Mikkelsen KL, Tønnesen P. Smoking habits and beliefs about smoking in elderly patients with COPD during hospitalisation. J Smok Cessat. 2010;5(1):15–21. 10.1375/jsc.5.1.15.
45. Hilberink SR Jacobs JE Schlösser M Grol RP de Vries H Characteristics of patients with COPD in three motivational stages related to smoking cessation Patient Educ Couns 2006 61 3 449 57 10.1016/j.pec.2005.05.012 16157462
Hilberink SR, Jacobs JE, Schlösser M, Grol RP, de Vries H. Characteristics of patients with COPD in three motivational stages related to smoking cessation. Patient Educ Couns. 2006;61(3):449–57. 10.1016/j.pec.2005.05.012.16157462
46. Lundh L Hylander I Törnkvist L The process of trying to quit smoking from the perspective of patients with chronic obstructive pulmonary disease Scand J Caring Sci 2012 26 3 485 93 10.1111/j.1471-6712.2011.00953.x 22117588
Lundh L, Hylander I, Törnkvist L. The process of trying to quit smoking from the perspective of patients with chronic obstructive pulmonary disease. Scand J Caring Sci. 2012;26(3):485–93. 10.1111/j.1471-6712.2011.00953.x.22117588
47. Bradizza CM Stasiewicz PR Zhuo Y Ruszczyk M Maisto SA Lucke JF Smoking cessation for pregnant smokers: development and pilot test of an emotion regulation treatment supplement to standard smoking cessation for negative affect smokers Nicotine Tob Res 2017 19 5 578 84 10.1093/ntr/ntw398 28403472
Bradizza CM, Stasiewicz PR, Zhuo Y, Ruszczyk M, Maisto SA, Lucke JF, et al. Smoking cessation for pregnant smokers: development and pilot test of an emotion regulation treatment supplement to standard smoking cessation for negative affect smokers. Nicotine Tob Res. 2017;19(5):578–84. 10.1093/ntr/ntw398.28403472
