Negative Affect Situations Research Articles

The Relationship Between Negative Affect, State Mindfulness, and the Role of Personality.

ObjectivesAre affective states influencing state mindfulness and can this explain the link between personality and mindfulness? Mindfulness is commonly thought to decrease negative affect, but a number of studies have reported reductions in mindfulness in negative affect situations. This highlights a potential mechanism explaining previously observed negative relationships between individual differences such as Neuroticism and mindfulness, via their shared relationship with negative affect.MethodsIn an experiment, 331 participants were exposed to a negative affect stimulus to investigate whether previously established relationships between Neuroticism, Behavioral Inhibition, and Mindfulness are due to differences in negative affect reactivity. It was expected that participants high on Neuroticism and Behavioral Inhibition to show greater negative affect reactivity which in turn would reduce their state Non-Judgmental Acceptance and Acting with Awareness.ResultsWhile change in negative affect was related to lower Non-Judgmental Acceptance and Acting with Awareness, negative affect reactivity did not mediate the relationship between Neuroticism/BIS and these state mindfulness facets. Importantly, only Non-Judgmental Acceptance and Acting with Awareness facets of mindfulness were affected by negative affect change, but not Attention. This indicates that greater negative affect might require allocation of cognitive resources to stress-related processes such as threat monitoring, reducing mindful emotion processing but not attention.ConclusionsThe current study found that situational mindfulness might be influenced by state affect highlighting the need to more strongly consider the environmental factors which can shape affect in mindfulness interventions.Trial RegistrationOpen Science Framework (https://osf.io/kmyh2).

Trajectories of Situational Temptations in Pregnant Smokers participating in a Scheduled Gradual Reduction Cessation Trial.

The purpose of this paper was to examine changes in situational temptations to smoke among women in early to late pregnancy enrolled in a texting trial to help them quit smoking. We compared changes between (1) intervention arms, (2) those who quit, (3) those who reduced by 50% or more, and (4) those who reduced by less than 50%. We also examined cravings overtime in the intervention arm and the relationship between real-time cravings assessed via text message and situational temptations. This was a secondary analysis of the Baby Steps trial, a randomized controlled trial testing the efficacy of a text-based scheduled gradual reduction (SGR) intervention on cessation. We used t-tests to examine changes across intervention arms and repeated measured proc mixed to explore changes in situational temptations and cravings. Among all women, situational temptations decreased from early to late pregnancy for the positive, negative, and habitual subscales, (ps < 0.001). We found no difference in situational temptations across arms. We found a positive relationship between negative situational temptation and average craving during the Weeks 2 and Weeks 3 of the intervention. Negative ST increased by 0.11 for each unit increase of craving at Week 2. As women progress through pregnancy their temptation to smoke reduces. A different relationship might exist, however with negative affect situations in which women reported higher craving but not in response to other temptations. Future work might have a particular focus on the intersection of negative affect with cravings and temptations to promote cessation during pregnancy. NCT01995097.

Causes of smoking relapse in the 12 months after smoking cessation treatment: Affective and cigarette dependence–related factors

Despite advances in smoking cessation treatments, smoking relapse remains common. Experiencing positive or negative affect and cigarette dependence are the most common causes of relapse; however, little is known about the characteristics that increase the risk of relapse from these causes among current treatment-seeking smokers. Thus, this study aimed to identify the most frequent causes of relapse and the individual characteristics that increase the risk of relapse from these causes during a 12-month period after smoking cessation. Participants included 121 treatment-seeking smokers who quit smoking at the end of treatment and relapsed during a 12-month follow-up period (60.3% female;Mage = 42.57, SD = 11.07). Results indicated that the most frequent smoking relapse situations occurred when smokers experienced positive (e.g., being relaxed; 43.0%) or negative (e.g., being angry; 37.2%) affect or cigarette dependence–related situations (e.g., craving; 19.8%). At an individual level, males with a higher level of education and without a psychopharmaceutical prescription had a higher risk of relapsing in positive-affect situations. Smoking the first cigarette at an older age increased the risk of relapse in negative-affect situations. Finally, being younger and less motivated to quit at pretreatment increased the likelihood of relapse in cigarette dependence–related situations. These findings provide detailed information about smoking relapse situations and identify a set of characteristics that might help to improve current relapse-prevention interventions.

Specific Relapse Predictors: Could Cognitive-Behavioral Treatment for Smoking Cessation Be Improved?

Relapse remains a frequent and complex phenomenon that is not yet well understood. An under-researched area of study that may provide relevant information concerns the assessment of specific post-treatment variables, rather than the composite measures commonly used to predict smoking relapse. The current study sought to examine the effects of post-treatment smoking-related variables, including withdrawal symptomatology, abstinence self-efficacy, and smoking urgency in negative-affect situations and smoking relapse at the 3 month follow-up. The sample comprised 130 participants who achieved abstinence for at least 24 h through a cognitive-behavioral smoking cessation treatment. Regression analysis was conducted for both composite measures and specific subscales and items. Data showed that composite measures of tobacco withdrawal, self-efficacy, and smoking urgency in negative-affect situations were not significant predictors of smoking relapse. However, the analysis including subscales, and specific items showed that lower self-efficacy in negative-affect-related situations (OR = 1.36) and three withdrawal symptoms—irritability/frustration/anger (OR = 2.99), restlessness/impatience (OR = 1.87), and craving (OR = 2.31)—were significant predictors of relapse. These findings offer new insights into the role of different smoking-related post-treatment variables in short-term relapse. Considering and specifically targeting these variables after achieving abstinence may potentially contribute to reducing smoking relapse.

Reducing alcohol-related interpretive bias in negative affect situations: Using a scenario-based Cognitive Bias Modification training paradigm

Problematic alcohol use is associated with drinking alcohol to reduce negative mood states (negative reinforcement motive). Further, heavy drinking individuals tend to interpret ambiguous situations as alcohol-related (interpretive bias). The current experimental study aimed to examine the role of alcohol-related interpretive biases in negative-affect drinking. It was hypothesized that a single-session Cognitive Bias Modification of Interpretation (CBM-I) training condition (compared to a sham condition) would lead to less alcohol-related interpretations of negative affect situations, and less alcohol consumption while being in a negative mood state. The most pronounced effects were expected in individuals who drink alcohol to cope with anxiety. Moderate to heavy drinking university students (N = 134) were randomly assigned to a CBM-I or a sham condition. Interpretations were assessed during and after the training session. Drinking was assessed in a lab-based drink test and one week later using a self-report measure. With respect to alcohol-related interpretative bias, this bias was weaker in the CBM-I compared to the sham condition during the training session. This effect was not moderated by coping-anxiety motives, and did not generalize to another interpretation measure. No training effects were found on drinking behavior in the lab or on self-reported daily-level use. In sum, the CBM-I training condition was associated with lower alcohol-related interpretive bias scores during training. Generalization to another interpretation measure or to drinking behavior was not observed. Future research could explore providing multiple training sessions in order to strengthen the effects of the CBM-I training.

Efficacy of the Life Goal-Focused Brief Intervention among Patients with Alcohol Use Disorder: A Preliminary Study.

ObjectiveThe aim of this study was to examine the efficacy of the life goal-focused brief intervention, or the so-called the goal-focused self-regulation program (GFSRP), for patients with alcohol use disorder (AUD).MethodsThe GFSRP was developed as an 8-week group-program, which is based on a wide range of self-regulation theories, such as goal setting and implementation intentions. Patients with AUD (n=50) took part in the GFSRP and were compared to the control group (n=48). This study examined the changes in outcome measures from baseline to follow-up (12-week) in a mixed design.ResultsThe GFSRP group had higher scores for the abstinence self-efficacy in negative affect situations than the control group at the post-test. In addition, it showed greater scores of optimisms compared to the control group. Furthermore, in the GFSRP group, there was no difference in intrinsic life goals from baseline to the 12-week follow-up, whereas the control group showed a significant decrease.ConclusionThe GFSRP could increase the abstinence self-efficacy and optimism among patients with AUD. Moreover, it might prevent loss of life-goals as core factors in self-regulation among patients with AUD.

Difficulties in emotion regulation in treatment-seeking alcoholics with and without co-occurring mood and anxiety disorders

Emotion regulation difficulties (ERD) are known to underlie mental health conditions including anxiety and depressive disorders and alcohol use disorder (AUD). Although AUD, mood, and anxiety disorders commonly co-occur, no study has examined the association between these disorders and ERD among AUD outpatients. In the current study, emotion regulation (ER) scores of AUD individuals with no co-occurring mental health condition were compared to the ER scores of individuals who met diagnostic criteria for co-occurring mood and/or anxiety disorders. Treatment-seeking AUD individuals (N=77) completed measures of emotion regulation, alcohol use and psychological functioning prior to beginning a 12-week outpatient cognitive-behaviorally oriented alcohol treatment program. Individuals were classified as having no co-occurring mood or anxiety disorder (AUD-0, n=24), one co-occurring disorder (AUD-1, n=34), or two or more co-occurring disorders (AUD-2, n=19). Between-group differences in emotion regulation, quantity/frequency of alcohol consumption, positive and negative affect, affective drinking situations, negative mood regulation expectancies, distress tolerance, alexithymia, trait mindfulness, and psychological symptom severity were examined. Compared with the AUD-0 group, the AUD-2 group reported significantly greater ERD, psychiatric distress and alcohol consumption, more frequent drinking in response to negative affect situations, greater interference from negative emotions, and less use of mindfulness skills. The AUD-1 group differed from AUD-0 group only on the DERS lack of emotional awareness (Aware) subscale. Emotion regulation scores in the AUD-0 group were comparable to those previously reported for general community samples, whereas levels of ERD in the AUD-1 and AUD-2 were similar to those found in other clinical samples. Implications for the inclusion of ER interventions among AUD patients who might most benefit from such an intervention are discussed.

Temptation Minus Self-Efficacy in Alcohol Relapse: A Project MATCH Follow-Up.

Relapse is a crucial event that occurs for many individuals during recovery from alcohol use disorder. This article examines the impact of temptation to drink and self-efficacy to abstain on two distinct aspects of relapse. Causal chain analyses from Project MATCH, a multisite alcoholism treatment trial, provided initial support for the difference between temptation and self-efficacy as a predictor of alcohol use outcomes. In the current study, the Temptation minus Self-Efficacy (T-S) score from the Alcohol Abstinence Self-Efficacy Scale (AASE) is investigated as a predictor of two alcohol use outcomes that were not analyzed in previous Project MATCH reports. This study evaluated the ability of end-of-treatment T-S (calculated as Temptation minus Self-Efficacy scores on AASE) to predict time to first drink and number of drinks on first drinking day. Data were analyzed on 627 participants from Project MATCH who relapsed after completing treatment and achieving a period of abstinence. T-S at end of treatment was a significant predictor of two alcohol use outcomes during the 1-year follow-up period. In addition, situation-specific subscale scores of T-S predicted alcohol use outcomes. T-S in social/positive situations predicted time to first drink. T-S in negative affect situations predicted number of drinks on first drinking day. Results support end-of-treatment measurement discrepancy between AASE scales of Temptation and Abstinence Self-Efficacy as a predictor of time to first drink and number of drinks on first drinking day among individuals who relapse after treatment.

Relationships Between Craving Beliefs and Abstinence Self-Efficacy are Mediated by Smoking Motives and Moderated by Nicotine Dependence.

Decreased abstinence self-efficacy is linked to increased craving and negative affect, as well as poorer smoking outcomes, such as lapse, relapse, and withdrawal symptom severity. Research suggests that beliefs and cognitions concerning ourselves and the world orient us toward specific goals and thus impact our judgments and behavior. This study serves to investigate whether motives for smoking mediate the relationship between beliefs about craving and abstinence self-efficacy judgments and whether this may differ by nicotine dependence. In a sample of 198 smokers (M age = 34.96, 51.8% female, 81.8% Caucasian), self-report measures of craving beliefs, situational abstinence self-efficacy, and smoking motives were measured. We examined the effect of beliefs on abstinence self-efficacy in both craving and negative affect situations, with craving and negative reinforcement smoking motives as mediators, and nicotine dependence as a moderator. Results indicate that craving beliefs predict lower abstinence self-efficacy judgments in craving situations indirectly through increased craving motives. However, this relationship was only significant for less dependent smokers. Additionally, regardless of nicotine dependence, craving beliefs predicted lower abstinence self-efficacy in negative affect situations via increased negative reinforcement smoking motives. These findings suggest that beliefs concerning the specific nature of craving correlate with smoking motives (ie, smoking goals) and thus abstinence self-efficacy judgments. Furthermore, these associations are stronger for less dependent smokers. Such findings suggest the importance of addressing craving beliefs during smoking cessation treatment, especially for less dependent smokers whose craving beliefs are associated with abstinence self-efficacy across multiple situations.

Alcohol-related memory associations in positive and negative affect situations: Drinking motives, working memory capacity, and prospective drinking.

Although studies on explicit alcohol cognitions have identified positive and negative reinforcing drinking motives that are differentially related to drinking indices, such a distinction has received less attention in studies on implicit cognitions. An alcohol-related Word-Sentence Association Task was used to assess implicit alcohol-related memory associations in positive and negative affect situations in 92 participants. Results revealed that enhancement motives were specifically associated with the endorsement of alcohol words in positive affect situations and coping motives were associated with the endorsement of alcohol words in negative affect situations. Furthermore, alcohol associations in positive affect situations predicted prospective alcohol use and number of binges, depending on levels of working memory capacity. The current findings shed more light on the underpinnings of alcohol use and suggest that implicit memory processes and working memory capacity might be important targets for intervention.

"Alcohol-related memory associations in positive and negative affect situations: Drinking motives, working memory capacity, and prospective drinking": Correction to Salemink and Wiers (2013).

"Alcohol-related memory associations in positive and negative affect situations: Drinking motives, working memory capacity, and prospective drinking": Correction to Salemink and Wiers (2013).

Tobacco Cessation Among Low-Income Smokers: Motivational Enhancement and Nicotine Patch Treatment

Despite decades of tobacco use decline among the general population in the United States, tobacco use among low-income populations continues to be a major public health concern. Smoking rates are higher among individuals with less than a high school education, those with no health insurance, and among individuals living below the federal poverty level. Despite these disparities, smoking cessation treatments for low-income populations have not been extensively tested. In the current study, the efficacy of 2 adjunctive smoking cessation interventions was evaluated among low-income smokers who were seen in a primary care setting. A total of 846 participants were randomly assigned either to motivational enhancement treatment plus brief physician advice and 8 weeks of nicotine replacement therapy (NRT) or to standard care, which consisted of brief physician advice and 8 weeks of NRT. Tobacco smoking abstinence was at 1, 2, 6, and 12 months following baseline. The use of the nicotine patch, telephone counseling, and positive decisional balance were predictive of increased abstinence rates, and elevated stress levels and temptation to smoke in both social/habit and negative affect situations decreased abstinence rates across time. Analyses showed intervention effects on smoking temptations, length of patch use, and number of telephone contacts. Direct intervention effects on abstinence rates were not significant, after adjusting for model predictors and selection bias due to perirandomization attrition. Integrating therapeutic approaches that promote use of and adherence to medications for quitting smoking and that target stress management and reducing negative affect may enhance smoking cessation among low-income smokers.

Affect regulation training (ART) for alcohol use disorders: Development of a novel intervention for negative affect drinkers

Although negative affect is a common precipitant of alcohol relapse, there are few interventions for alcohol dependence that specifically target negative affect. In this stage 1a/1b treatment development study, several affect regulation strategies (e.g., mindfulness, prolonged exposure, distress tolerance) were combined to create a new treatment supplement called affect regulation training (ART), which could be added to enhance cognitive–behavioral therapy (CBT) for alcohol dependence. A draft therapy manual was given to therapists and treatment experts before being administered to several patients who also provided input. After two rounds of manual development (stage 1a), a pilot randomized clinical trial (N=77) of alcohol-dependent outpatients who reported drinking often in negative affect situations was conducted (stage 1b). Participants received 12-weekly, 90-minute sessions of either CBT for alcohol dependence plus ART (CBT+ART) or CBT plus a healthy lifestyles control condition (CBT+HLS). Baseline, end-of-treatment, and 3- and 6-month posttreatment interviews were conducted. For both treatment conditions, participant ratings of treatment satisfaction were high, with CBT+ART rated significantly higher. Drinking outcome results indicated greater reductions in alcohol use for CBT+ART when compared to CBT+HLS, with moderate effect sizes for percent days abstinent, drinks per day, drinks per drinking day, and percent heavy drinking days. Overall, findings support further research on affect regulation interventions for negative affect drinkers.

The impact of depression on abstinence self-efficacy and substance use outcomes among emerging adults in residential treatment.

A large proportion of emerging adults treated for substance use disorder (SUD) present with symptoms of negative affect and major depressive disorder (MDD). However, little is known regarding how these comorbidities influence important mechanisms of treatment response, such as increases in abstinence self-efficacy (ASE). This study tested the degree to which MDD and/or depressive symptoms interacted with during-treatment changes in ASE and examined these variables' relation to outcome at 3 months' posttreatment. Participants (N = 302; 74% male) completed measures at intake, midtreatment, end-of-treatment, and at 3-month follow-up. ASE was measured with the Alcohol and Drug Use Self-Efficacy (ADUSE) scale; depressive symptoms were assessed with the Brief Symptom Inventory 18 (BSI 18) Depression scale; and current MDD diagnoses were deduced from the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). Random coefficient regression analyses focused on during-treatment changes in ASE, with BSI 18 scores and MDD diagnosis included as moderators. At intake, individuals with MDD or high levels of depressive symptoms had significantly lower ASE, particularly in negative affect situations. No evidence for moderation was found: ASE significantly increased during treatment regardless of MDD status. There was a main effect of BSI 18 Depression scores: those with lower BSI 18 scores had lower ASE scores at each time point. MDD and BSI 18 Depression did not predict 3-month outcome, but similar to previous findings ASE did predict abstinence status at 3 months. Treatment-seeking emerging adults with MDD merit particular clinical attention because of their lower reported self-efficacy throughout treatment.

Mental Health and Readiness to Change Smoking Behavior in Daily Smoking Primary Care Patients

We examined the association between daily smokers' mental health according to the five-item Mental Health Inventory and the core constructs of the transtheoretical model (TTM): stage of change, processes of change, smoking cessation self-efficacy, and decisional balance. Questionnaire data from 1,334 daily smoking primary care patients were used for multinomial logistic, linear, and ordinal logistic regression analyses controlling for effects of sociodemographic characteristics. Smokers with lower levels of mental health had increased odds to contemplate quitting within the next 6 months compared to not intending to quit at all. In addition, they reported an elevated use of change processes as well as an enhanced endorsement of positive and negative aspects of nonsmoking. However, in a subsample analysis performed on smokers in contemplation stage, low mental health was related to lower self-efficacy expectancies in negative affect situations. Mental health does not appear to constitute a precondition for readiness to change smoking behavior in daily smokers. Nonetheless, smokers with low mental health might require support to deal with negative affect situations.

Alcohol expectancies and drinking motives in college drinkers: Mediating effects on the relationship between generalized anxiety and heavy drinking in negative-affect situations

The current study tested the hypotheses that drinking to cope motives and alcohol expectancies of tension- and worry-reduction mediate the relationship between generalized anxiety (GA) and negative-affect heavy drinking in a cross-sectional sample of 782 college drinkers. As expected, structural equation modeling results indicated that alcohol expectancies mediated the relationship between GA and drinking to cope motives, and drinking to cope motives mediated the relationship between alcohol expectancies and heavy drinking in negative-affect situations. Unexpectedly, drinking to cope motives also mediated the relationship between GA and negative-affect heavy drinking. The model predicting negative-affect heavy drinking was tested in subsamples of 413 hazardous and 366 nonhazardous drinkers and did not differ structurally; however, omnibus measurement of model indirect effects was stronger for hazardous than nonhazardous drinkers. Finally, the results of a similar post-hoc model to predict general problem drinking support the specificity of the interrelationships among GA, cognitive mediators and to negative-affect drinking. These results inform cognitive–behavioral theories and interventions for comorbid GA and alcohol use problems.

Alcohol use, cognitive correlates of drinking and change readiness in hazardous drinkers with high versus low social anxiety.

Prevalence data and theoretical models suggest that socially anxious individuals comprise a significant subset of college hazardous drinkers and may benefit from brief interventions for both alcohol and social anxiety problems. The present study compared hazardous drinkers who have high social anxiety (HD-HSA) with hazardous drinkers who have low social anxiety (HD-LSA) in drinking and psychological characteristics that may distinguish the two drinker groups and inform development of group-specific interventions. After completing a self-report assessment battery, 152 hazardous drinkers (51% men, median age = 19) were selected from an undergraduate volunteer sample on the basis of their scores on an alcohol screen. HD-HSA (n = 76) and HD-LSA (n = 76) were hazardous drinkers who scored in the top third and the bottom third, respectively, of the volunteer sample on a social anxiety measure. HD-HSA reported greater expectancies that alcohol reduces social anxiety and lower alcohol refusal self-efficacy in social drinking situations than HD-LSA did. HD-HSA also tended to report more frequent heavy drinking in negative affect situations, but the groups did not differ in consumption quantity, heavy drinking in positive affect situations or hazardous drinking levels. HD-HSA reported greater interest in attending a social anxiety workshop and showed a trend towards having stronger interest in an alcohol workshop than HD-LSA did, although the sample's overall readiness to change alcohol behaviors was low. Study findings highlight the importance of situational specificity in alcohol assessment and suggest a need to develop group-specific interventions for college hazardous drinkers with high versus low social anxiety.

Depression and smoking: From the Transtheoretical Model of change perspective

This study investigated the associations among history of depression, current depressive symptoms, and constructs of the Transtheoretical Model (TTM) of change: stages of change, decisional balance, temptation, and processes of change for smoking cessation. Participants were 239 current smokers (70.7% male, 49.8% African-American, mean cigarettes per day=19.8, 42.3% were in precontemplation). Results showed that participants with a history of depression reported higher current depressive symptoms. No significant relationship was observed between stages and history or current level of depressive symptoms. Current depressive symptoms, rather than depression history, was related to other TTM constructs: pros of smoking, temptation to smoke under habitual and negative affect situations, and the self-reevaluation process of change.

Smoking and Depression in Chinese Americans

A close link between smoking and depression has been documented by research primarily based on U.S. white populations. This study examined the association between depressive symptoms and smoking behaviors in Chinese American smokers. Analyses were based on baseline data collected from a convenience sample of 199 Chinese smokers who resided in northern California. The sample included 20.6% women, 97% immigrants, with mean age of 40.8 years and mean cigarettes/day of 8.9. Compared with population-based studies of Chinese Americans, the Chinese smokers in the current study reported higher depressive symptoms assessed by the Center for Epidemiologic Studies-Depression Scale [M, 20.4; 95% confidence interval (CI), 18.8-22.2], higher lifetime prevalence rates of major depressive disorders (30.3%; 95% CI, 24.0-37.2%) and dysthymia (11.6%; 95% CI, 7.5-16.9%). Multiple regression analysis suggested female gender, unemployment, major depression or dysthymia within the past year, previous experience with nicotine withdrawal syndrome, and high temptation to smoke under negative affect situations are associated with a higher level of depressive symptoms. The level of depressive symptoms among Chinese American smokers is comparable with that observed in other US populations reported. In the current sample, elevated depressive symptoms were more prominent among women or those who were unemployed, smokers who reported significant nicotine withdrawal at previous quit attempts, and high temptation to smoke when experiencing negative emotions. Findings support further examination of the role of depression in smoking among Chinese Americans and underscore the importance of addressing depressive symptoms when treating tobacco use in Chinese smokers.

History of depression and subsyndromal depression in women smokers

While Major Depressive Disorder (MDD) is associated with difficulty quitting smoking, few studies have examined the role of subsyndromal depression (SubD). We examined pretreatment differences in smoking, weight concerns, and negative affect among three groups of women ( N = 281) enrolling in a smoking cessation program who responded to a self-report questionnaire about the lifetime presence of MDD symptoms: self-report positive for MDD, self-report positive for SubD, and self-report negative for depression (fulfilling either DSM-III-R symptom or duration criteria, but not both). Compared to MDD Subjects (Ss), SubD Ss were more likely to report eating disordered behaviors. Compared to Non-Depressed (Non-Dep) Ss, SubD Ss initiated smoking earlier, and reported greater previous withdrawal symptoms, more eating disordered behaviors, and higher anxiety, depression, and stress. Compared to Non-Dep Ss, MDD Ss reported a greater smoking rate during their heaviest usage period, greater previous withdrawal symptoms, lower self-efficacy to manage food intake (especially during negative affect situations), and greater depression and anxiety. Many of these significant differences disappeared when SubD Ss were combined with Non-Dep Ss and compared with MDD Ss as is done traditionally. SubD does not appear to be on a continuum with Non-Dep and MDD groups, but rather warrants further investigation as a discrete subset of smokers. The implications for assessment and treatment are discussed.