J Relig Health (2018) 57:1211–1223

https://doi.org/10.1007/s10943-017-0399-8

ORIGINAL PAPER

Depressive Symptoms and Tobacco Use: Does Religious

Orientation Play a Protective Role?

Stacy C. Parenteau1

Published online: 21 April 2017

Ó Springer Science+Business Media New York 2017

Abstract Many studies have established an association between depression and smoking.
The main objective of this study was to determine whether religious orientation moderates
the relationship between depressive symptoms and tobacco use. This study utilized a cross-
sectional data collection strategy to examine the relationship among depressive symptoms,
religious orientation, and tobacco use among undergraduate students (N = 349) at a
midsize southeastern university. Participants completed a demographic questionnaire, the
Center for Epidemiologic Studies Depression Scale, the Extrinsic/Intrinsic Religious
Orientation Scale-Revised and the Drinking and Drug Habits Questionnaire. Analyses
using hierarchical linear regression indicate a significant interaction effect (depressive
symptoms 9 extrinsic religious orientation) on tobacco use. Additional moderation anal-
yses reveal a significant interaction effect between depressive symptoms and the extrinsic-
personal religious orientation on tobacco use. Results suggest that having an extrinsic
religious orientation, and specifically, the extrinsic-personal subtype, can protect against
the effects of depressive symptoms. In this regard, individuals who turn to religion for
solace or comfort may be less likely to engage in tobacco use when experiencing
depressive symptoms. Limitations, future directions, and implications are discussed.

Keywords Depressive symptoms
Religious orientation
Tobacco use

& Stacy C. Parenteau

sparente@aum.edu
1
Department of Psychology, Auburn University at Montgomery, 210I Goodwyn Hall, Montgomery,
AL 36117, USA

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Introduction

Smoking is a concerning health behavior on many college campuses. Johnston et al. (2015)
reported an annual prevalence rate of 23% for cigarette use among college students in
2014. The pernicious effects of tobacco use have been well documented; in this regard,
Danaei and colleagues (2005) have established smoking as a leading risk factor in cancer
mortality worldwide. Given the health risks associated with smoking, it is important to
identify factors associated with this particular health behavior. Depression and smoking
have long been empirical bedfellows, with a plethora of studies establishing an association
between these two variables (Berg et al. 2009; Fergusson et al. 2003; Glassman et al.
1990). Few studies, however, have identified variables that moderate the association
between depression and smoking. Given that studies have identified a link between reli-
giosity and both depression (for reviews, see McCullough and Larson 1999; Smith et al.
2003) and smoking (Kendler and Myers 2009; Klassen et al. 2013), it is pertinent to
explore religiosity as a potential moderator in the depression-smoking relationship. This
study will explore the interactive effect of depressive symptoms and religious orientation
on tobacco use.

Depression and Tobacco Use

The outgrowth of studies examining depression and smoking (Berg et al. 2009; Glassman
et al. 1990; Ludman et al. 2002) consists mainly of correlational studies that fail to
delineate the direction of the depression-smoking relationship: Does smoking lead to
depression, or does being depressed cause one to smoke more? Some researchers have
suggested that individuals may smoke in an attempt to alleviate depressive symptoms
(Glassman et al. 1990; Lerman et al. 1998). Although causality cannot be determined, the
present study will establish whether religious orientation buffers the impact of depressive
symptoms on tobacco use.
Some researchers have extended this empirical arena to examine variables that may
underlie the depression-smoking link. In this regard, Leventhal and Zvolensky (2015)
propose that three transdiagnostic emotional vulnerabilities may serve as theoretical
bridges that link anxiety/depressive psychopathologies to smoking. Specifically relevant to
the depression-smoking association, Leventhal and Zvolensky posit that anhedonia—the
diminished pleasure in response to rewards—amplifies the pleasure-enhancing effects of
smoking. Despite theoretical advances that have elucidated the link between depression
and smoking, more research is needed to identify variables that may modify this
association.

Religious Orientation and Health Outcomes

A plethora of research has illuminated the relationship between religiosity and health
outcomes (McCullough et al. 2000). The early focus on church attendance as a measure of
religiosity has flowered into a broader focus on more personal and multidimensional
aspects of the religious experience (Pargament et al. 1998). In this regard, the influence of
religious orientation in health outcomes has received increasing attention in the religion–
health literature.
Religious orientation has been conceptualized as a motivational construct; individuals
with an intrinsic religious orientation embrace religion for its inherent value and are

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genuinely committed to the tenets of their religion, while individuals with an extrinsic
religious orientation are guided by ulterior motives (Allport and Ross 1967; Gorsuch
1997). Kirkpatrick (1989) demarcated between extrinsic-social, a motivation for the social
rewards reaped from religious involvement (e.g., going to church to make friends), and
extrinsic-personal, a motivation to gain a sense of peace or comfort from religion.
It has long been established that intrinsic religious orientation is generally associated
with more positive outcomes (Donahue 1985; Masters and Bergin 1992). This empirical
domain is checkered, however, by studies illuminating an association between extrinsic
religious orientation and better health indices. In this regard, Turner-Musa and Wilson
(2006), using a fourfold typology categorizing individuals based on their degree of intrinsic
and extrinsic religious orientation (Allport and Ross 1967), found that African-American
college students with intrinsic, extrinsic, and pro-religious (high intrinsic/high extrinsic)
orientations were more likely to engage in health-promoting behaviors, compared to those
with a nonreligious (low intrinsic/low extrinsic) orientation.

The Present Study

Considering the empirical evidence suggesting that religious orientation appears to be

associated with positive outcomes (Donahue 1985; Masters and Bergin 1992), it is rea-
sonable to project that intrinsic and extrinsic religious orientation will mitigate the effects
of depressive symptoms on tobacco use. Horton and Loukas (2013) found that both pos-
itive and negative religious coping exacerbated the impact of depressive symptoms on
smoking for females. To the author’s knowledge, no other studies have examined reli-
giosity as a moderating factor in the depression-smoking association.
Why might religious orientation buffer against the effects of depressive symptoms, and
hence, be associated with less tobacco use? Many studies reveal a negative association
between meaning in life and depression (Blackburn and Owens 2015). Because the
intrinsic religious orientation is characterized by a strong commitment to one’s religion, it
would be reasonable to expect that such an orientation would be associated with a greater
sense of life meaning; indeed, studies have established a positive association between
intrinsic religious orientation and purpose and meaning in life (Donahue 1985; Masters
and Bergin 1992). Hence, intrinsic religious orientation may serve as a protective agent,
intercepting the influence of depressive symptoms on tobacco use.
While extrinsic religious orientation has traditionally been associated with negative
outcomes (Donahue 1985; Masters and Bergin 1992), it is possible that an extrinsic
motivation may also buffer the effects of depression. Individuals who use their religion to
gain comfort or social rewards may cushion the slings and arrows of depression; in this
regard, numerous studies have cited the ameliorative effects of social support in regard to
depression (George et al. 1989; Harris et al. 1999). The present study will determine
whether both intrinsic and extrinsic religious orientation temper the effects of depressive
symptoms on tobacco use.
It is pertinent to note sex differences that have emerged in the literature on religiosity
and health outcomes. Women generally report using religious coping more than men
(Tamres et al. 2002). In regard specifically to health behaviors, positive religious coping
has been found to buffer the impact of daily hassles on alcohol use only for females
(Stoltzfus and Farkas 2012). Moreover, women are more inclined to smoke when expe-
riencing negative affect (Brandon and Baker 1991). The present study also will examine
sex as another moderator in the relationship between depressive symptoms and tobacco
use.

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This study was conducted to determine whether (1) depressive symptoms are associated
with tobacco use; (2) religious orientation moderates the depressive symptoms-tobacco use
relationship; and (3) sex differences exist in regard to the moderating effect of religious
orientation on the depressive symptoms-tobacco use association. It was expected that (1)
depressive symptoms would be positively associated with tobacco use; (2) both intrinsic
and extrinsic religious orientation would buffer the impact of depressive symptoms on
tobacco use; and (3) intrinsic and extrinsic religious orientation would protect against the
impact of depressive symptoms on tobacco use for females only.

Method

Participants

Data presented in this manuscript were collected as part of a study examining discrimi-
nation, religiosity, and health outcomes. Participants (N = 349, mean age = 20.45,
SD = 4.77) were recruited from introductory psychology courses at a midsize southeastern
university. As can be seen in Table 1, the majority of the sample was female, single, and
Protestant. Forty-eight percent of the sample was white and 51% nonwhite.

Procedure

Institutional Review Board (IRB) approval was attained prior to data collection. The
students registered for the study through an online site. After signing an informed consent
form, participants completed a series of counterbalanced self-report questionnaires.

Measures

Demographic Questionnaire

Participants provided basic demographic information, including age, sex, race, academic
class, marital status, family income, and religious affiliation.

Center for Epidemiological Studies Depression Scale (Radloff 1977)

The CES-D scale is a 20-item questionnaire assessing depressive symptomology, on a

4-point Likert scale (0 = rarely or none of the time to 3 = most or all of the time). Sample
items include ‘‘I felt that everything I did was an effort.’’, and ‘‘I had crying spells.’’ The
scale has demonstrated excellent reliability ([.85) (Hann et al. 1999).

Intrinsic/Extrinsic Religious Orientation Scale-Revised (I/E Scale-Revised; Gorsuch

and McPherson 1989)

This revised scale based on Allport and Ross’s (1967) original scale consists of 8 items
assessing intrinsic religious orientation (e.g., ‘‘My whole approach to life is based on my
religion.’’) and 6 items assessing extrinsic religious orientation (e.g., ‘‘What religion offers
me most is comfort in times of trouble and sorrow.’’), on a 5-point Likert scale
(1 = strongly agree to 5 = strongly disagree). The extrinsic scale is subcategorized into

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Table 1 Participant
Percent (%)
Demographics
Gender
Males 29.5
Females 70.5
Race
Caucasian 48
African-American 42
Asian 5
American Indian/Alaskan Native .9
Native Hawaiian/Pacific Islander .6
Biracial 2.6
Not revealed .9
Academic class
Freshman 73
Sophomore 16
Junior 6
Senior 4
Not revealed 2
Marital status
Single 90
Married 8
Divorced 2
Family income
$0–20,000 21
$20,001–40,000 17
$40,001–60,000 22
$60,001–80,000 18
$80,001–100,000 10
[ $100,000 6
Not revealed 6
Religious affiliation
Catholic 6
Protestanta 58
Other Christian 23
Muslim 1.4
Hindu .3
a
Includes participants who Atheist/agnostic 7
identified as ‘‘Protestant,’’ as well Other faith tradition 3
as Methodist, Baptist, Lutheran, Not revealed 1.4
Evangelical, and Episcopal

the extrinsic-social (e.g., ‘‘I go to church mostly to spend time with my friends.’’), and the
extrinsic-personal (e.g., ‘‘I pray mainly to gain relief and protection.’’) scales. Items were
reverse coded, with higher scores indicating higher levels of intrinsic and extrinsic reli-
giosity. Three questions were reverse coded a second time, per scale instructions. This
scale has demonstrated solid reliability (.83) for the intrinsic scale and fair reliability (.65)

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for the extrinsic scale, as well as fair reliability for the extrinsic-personal (.57) and
extrinsic-social (.58) subscales (Gorsuch and McPherson 1989).

Drinking and Drug Habits Questionnaire (DDHQ; Collins et al. 1985; Turchik
and Garske 2009)

The DDHQ is an inventory modified by Turchik and Garske (2009) from a general
information questionnaire originally developed by Collins et al. (1985). The inventory
assesses weekly drinking, problem drinking, and substance use. Tobacco use was assessed
by using one question from the substance use subscale. This question asked participants to
rate how frequently they used tobacco (cigarettes, cigars, chew) on a 4-point Likert scale
(1 = never used to 4 = frequently use). Refer to Table 2 for descriptive statistics for all
variables in the present study.

Results

Preliminary Analyses

Associations among demographic variables and tobacco use were examined using bivariate
correlational analyses. Demographic variables with more than one category were converted
into dichotomous variables prior to analysis. Marital status was recoded into single
(‘‘0’’)/married (‘‘1’’); race was recoded into white (‘‘0’’)/nonwhite (‘‘1’’); and religious
affiliation was recoded into Christian (‘‘0’’)/non-Christian (‘‘1’’) (see Tables 3 and 4).
Family income was not recoded into a dichotomous variable, since higher values indicate
higher income brackets (0 = $20,000/year through 5 = [ $100,000). Academic class was
also coded with higher values indicating higher class (0 = freshman; 1 = sophomore;
2 = junior; 3 = senior). Among the demographic variables examined, sex (r = -.19,
p \ .01, using Spearman’s rho), race (r = -.19, p \ .01, using Spearman’s rho), family
income (r = .13, p \ .05), and religious affiliation (r = .12, p \ .05, using Spearman’s

Table 2 Means, standard deviations, and bivariate correlations for depressive symptoms, religious orien-
tation, and tobacco use variables
1. 2. 3. 4. 5. 6. M SD Cronbach
alpha

1. Depressive – -.19** .02 .06 -.05 .08 16.22 10.27 .89

symptoms
2. IRO .27** .35** .03 -.15** 27.54 6.71 .78
3. ERO .82* .69** -.17** 16.16 4.32 .69
4. E-P .15** -.17** 10.43 3.16 .78
5. E-S -.08 5.73 2.51 .76
6. Tobacco use – 1.64 1.02
IRO intrinsic religious orientation, ERO extrinsic religious orientation, E-P extrinsic-personal religious
orientation, E-S extrinsic-social religious orientation
** p \ .01
* p \ .05

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Table 3 Moderation of depres-

b t R2 DR2
sive symptoms and tobacco use
by religious orientation
Outcome variable: tobacco use
Block 1
Age .07 1.27 .125
Sex (0 = male; 1 = female) -.19 -3.31**
Race (0 = white; 1 = nonwhite) -.24 -4.08**
Family income .02 .36
Religious affiliationW .07 1.19
DS depressive symptoms, ERO Block 2
extrinsic religious orientation, Depressive symptoms .09 1.55 .145 .020
IRO intrinsic religious orientation ERO -.07 -1.20
N = 282 IRO -.07 -1.07
** p \ .01 Block 3
* p \ .05 DS 9 ERO -.16 -2.81** .172 .027
W
0 = Christian, 1 = non- DS 9 IRO -.01 -.17
Christian

Table 4 Moderation of depres-

b t R2 DR2
sive symptoms and tobacco use
by extrinsic religious orientation
subtypes Outcome variable: tobacco use
Block 1
Age .08 1.33 .125
Sex (0 = male; 1 = female) -.18 -3.19**
Race (0 = white; 1 = nonwhite) -.24 -4.14**
Family income .03 .56
Religious orientationW .07 1.15
DS depressive symptoms, E-P
extrinsic-personal religious Block 2
orientation, E-S extrinsic-social Depressive symptoms .10 1.72 .140 .015
religious orientation Extrinsic-personal -.03 -.49
** p \ .01 Extrinsic-social -.06 -1.10
* p \ .05 Block 3
W
0 = Christian, 1 = non- DS 9 E-P -.15 -2.63** .172 .032
Christian
DS 9 E-S -.08 -1.39
N = 285

rho) were significantly associated with tobacco use, and thus, were controlled for in
regression analyses. Age also was controlled for, as this variable was marginally associated
with tobacco use (r = .10, p = .06, using Spearman’s rho).
Bivariate correlational analyses were conducted to analyze first-order correlations
among depressive symptoms, religious orientation, and tobacco use. As can be seen in
Table 2, depressive symptoms were not associated with tobacco use. Both intrinsic and
extrinsic religious orientations were negatively associated with tobacco use. Even though
depressive symptoms and tobacco use were not significantly associated, regression anal-
yses were run to examine the moderating effects of religious orientation.

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Moderation Analyses

Hierarchical regression analyses were conducted to determine whether religious orientation

moderated the relationship between depressive symptoms and tobacco use. Prior to anal-
yses, depressive symptoms and the religious orientation predictor variables were mean
centered, consistent with recommendations by Aiken and West (1991), and the 2-way
interaction terms were created from these centered variables.
As can be seen in Table 3, age (centered), race, sex, family income, and religious
affiliation were entered in the first block, followed by depressive symptoms, extrinsic
religious orientation and intrinsic religious orientation in the second block, and the two
2-way interaction terms (depressive symptoms 9 extrinsic religious orientation; depres-
sive symptoms 9 intrinsic religious orientation) in the third block.
There were no significant main effects for depressive symptoms (b = .09, p [ .05),
extrinsic religious orientation (b = -.07, p [ .05), or intrinsic religious orientation
(b = -.07, p [ .05) on tobacco use. There was a significant interaction effect (b = -.16,
p \ .01) between depressive symptoms and extrinsic religious orientation on tobacco use.
ModGraph-I (Jose 2013) was used to visually demonstrate this moderation effect (see
Fig. 1). Probing this significant interaction effect further, it was found that depressive
symptoms were positively associated with tobacco use at low (t = 2.70, p \ .01), but not
medium (t = 1.38, p [ .05) or high (t = -.60, p [ .05), levels of extrinsic religious
orientation. As seen in Table 3, the interaction between depressive symptoms and intrinsic
religious orientation was not significant, and thus, was not further analyzed.
A second set of regression analyses was conducted to examine the moderating effects of
the extrinsic-personal and extrinsic-social religious orientations. There were no significant
main effects for depressive symptoms (b = .10, p [ .05), extrinsic-personal religious
orientation (b = -.03, p [ .05), or extrinsic-social religious orientation (b = -.06,
p [ .05) on tobacco use. There was a significant interaction (b = -15, p \ .01) between
depressive symptoms and extrinsic-personal religious orientation on tobacco use. Mod-
Graph-I (Jose 2013) was again used to visually demonstrate this interaction (see Fig. 2).
Probing this interaction effect further, it was found that depressive symptoms were

Fig. 1 Moderation of depressive symptoms and tobacco use by extrinsic religious orientation (ERO)

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Fig. 2 Moderation of depressive symptoms and tobacco use by extrinsic-personal religious orientation
(E-P)

positively associated with tobacco use at low (t = 2.88, p \ .01), but not medium
(t = 1.60, p [ .05) or high (t = -.46, p [ .05), levels of extrinsic-personal religious
orientation. As can be seen in Table 4, the interaction between depressive symptoms and
extrinsic-social religious orientation was not significant, and thus, was not further explored.
A series of 3-way interactions were regressed on tobacco use to determine whether the
purported associations among depressive symptoms, religious orientation, and tobacco use
differed by sex. None of the 3-way interactions (sex 9 depressive symptoms 9 intrinsic
religious orientation; sex 9 depressive symptoms 9 extrinsic religious orientation;
sex 9 depressive symptoms 9 extrinsic-personal religious orientation; sex 9 depressive
symptoms 9 extrinsic-social religious orientation) were significantly associated with
tobacco use; thus, the sample was not stratified by sex, and regression analyses were not
run separately for males and females.

Discussion

The main goals of this study were to determine whether depressive symptoms are asso-
ciated with tobacco use, and whether religious orientation moderates this relationship.
Although there was no direct association between depressive symptoms and tobacco use,
results revealed that extrinsic, and specifically, extrinsic-personal, religious orientation
moderates this relationship, such that depressive symptoms are positively associated with
tobacco use for those lacking perceived support or comfort from their religion.
It is unclear as to why depressive symptoms were not directly associated with tobacco
use in the present study, a relationship affirmed by other studies (Berg et al. 2009;
Glassman et al. 1990; Lerman et al. 1998; Ludman et al. 2002). One possible explanation is
that religiosity plays such a strong role in the lives of southeastern Americans that indi-
viduals experiencing depressive symptoms will turn to tobacco use only when deficient in a
certain aspect of religiosity—in this case, extrinsic-personal religious orientation. In fact,
southeastern states like Alabama, Mississippi, Tennessee, Louisiana, and Arkansas occupy

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the top spots on the 2014 Religious Landscape Study, which ranked states on religiosity, as
measured by an overall combined index of four measures of religiosity, including self-
reported importance of religion in one’s life, religious attendance, frequency of prayer, and
belief in God (Pew Research Center 2015). In other words, individuals in the Southeastern
United States who do not experience comfort or support from religion may be more
vulnerable to engaging in tobacco use to salve their depressive symptoms.
Studies have generally established an association between intrinsic religious orientation
and positive outcomes (Donahue 1985; Masters and Bergin 1992). Moreover, intrinsic
religious orientation has been found to have protective benefits; in this regard, intrinsic
religious orientation buffered the effects of uncontrollable life stress on depression for
Protestants (Park et al. 1990). Only extrinsic religious orientation, however, protected
against depressive symptoms in the present study. Why does intrinsic religious orientation
not offer similar benefits?
It may be that extrinsic religious orientation confers a protective benefit against tobacco
use, and other health behaviors, for specific populations with depressive symptoms. In his
binary model of depression, Blatt (1974) distinguishes between anaclictic and introjective
depression. Anaclictic depression is grounded in dependence in interpersonal relationships
and fears of abandonment, while introjective depression centers on harsh self-criticism and
feelings of failure and guilt with regard to not meeting internalized standards. It is possible
that these two subtypes of depression interact differently with intrinsic and extrinsic
religious orientation; future studies could examine the protective effects of religious ori-
entation against both types of depression.
On a broader level, future research should explore for which individuals, and under
what circumstances, extrinsic religious orientation is more beneficial. The present study
buttresses previous findings that identified extrinsic, and specifically extrinsic-personal,
religious orientation as a protective factor against the stress of racial discrimina-
tion (Parenteau et al. 2017). It may be that different types of religious orientation are more
or less protective depending on the life situation one is dealing with.
Another intriguing finding from the present study is that extrinsic-personal, not
extrinsic-social, religious orientation harnessed the impact of depressive symptoms on
tobacco use. It may seem likely that seeing friends at church would have salubrious effects,
as social support has long been associated with mood-enhancing benefits (George et al.
1989; Harris et al. 1999). If one only sees certain friends at church, however, it is possible
that these ‘‘church friendships’’ are not profound enough to provide substantial support.
Church-based social ties, in other words, may be too tenuous or erratic to be of any
consequence for individuals dealing with depressive symptoms. Extrinsic-personal reli-
gious orientation, however, does provide some protection against tobacco use for indi-
viduals experiencing depressive symptoms. Such individuals gain a sense of peace and
comfort from prayer or other religious activities, which may reduce their need to smoke to
alleviate their distress by smoking.
The present study makes an important contribution to the literature examining the
depression-smoking association. A previous study revealed that both positive and negative
religious coping exacerbated the impact of depressive symptoms on smoking for females
(Horton and Loukas 2013). The current study, in contrast, provides evidence that reli-
giosity—in this case, extrinsic-personal religious orientation—can provide comfort for
individuals experiencing depressive symptoms and deter them from engaging in tobacco
use to alleviate their negative mood. These discrepant findings suggest that positive reli-
gious coping and an extrinsic religious orientation reflect two different aspects of the
religious experience, and may differ in their ability to protect against the effects of

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depressive symptoms. Positive religious coping encompasses efforts such as asking for
forgiveness, seeking a stronger connection with God, and both seeking and providing
comfort from and to others, in response to stressful life situations (Pargament 2007;
Pargament et al. 1998, 2000). The extrinsic-personal orientation subscale on the revised
questionnaire developed by Gorsuch and McPherson (1989) reflects a general motivation
to seek comfort through one’s religion. Although two of the questions specify the use of
prayer, this subscale does not include the diverse sampling of positive religious coping
methods included in the Brief RCOPE (Pargament et al. 1998). It is possible that a general
motivation to gain peace and comfort through religion provides the best protection against
the effects of depression, and some specific positive religious coping strategies may have a
more detrimental effect. More research is needed to determine which aspects of religiosity
will provide the optimal benefit for individuals experiencing depression.
Finally, although it has been found that women are more likely than men to seek
comfort through religion (Ferraro and Kelley-Moore 2000), and thus, may be expected to
emotionally profit from an extrinsic religious orientation, which orients individuals to seek
the benefits of religious engagement, the present study did not find a significant interaction
among sex, depressive symptoms, and religious orientation. While the lack of significance
may be due to power issues, it also is possible that religiosity is so deeply ingrained in the
lives of Southeastern Americans (Pew Research Center 2015) that all individuals in this
area of the country will derive benefits from their religious faith, irrespective of gender.

Limitations, Future Directions, and Implications

There are limitations that must be taken into consideration regarding the present findings.
First, the cross-sectional design precludes our ability to observe changes in the targeted
variables over time, or to establish causality among the variables. More longitudinal
studies are needed to examine temporal associations among depressive symptoms, reli-
gious orientation, and tobacco use. Second, the sample was limited in demographic scope,
as most participants endorsed a Christian denomination. Future studies need to examine the
role of religiosity in non-Christian populations, and in a nationally representative sample.
Furthermore, as previously noted, future studies should take into account the type of
depression, and examine whether intrinsic and extrinsic religious orientation interact dif-
ferently with anaclictic and introjective depression (Blatt 1974). Other religious factors,
such as religious commitment (Worthington 1988; Worthington et al. 2003), should also be
examined for their potential moderating influence in the depression-smoking association.
Future studies should also examine gender as an additional moderating variable.
In conclusion, the current findings are not to suggest that an intrinsic religious orien-
tation is detrimental, and that valuing religion for its inherent value and being strongly
committed to one’s religious tenets is misguided or maladaptive. Rather, the present
findings illuminate the redemptive power of turning to one’s religion for solace and
comfort, which can serve a protective function for those experiencing depressive symp-
toms who might otherwise engage in an unhealthy behavior to ameliorate those symptoms.
Extrinsic religious orientation has long been identified with more negative outcomes
compared to intrinsic religious orientation (Donahue 1985; Masters and Bergin 1992). The
present study challenges the somewhat negative reputation of extrinsic religious orienta-
tion by providing evidence that the extrinsic-personal dimension of this orientation also
can have value in people’s lives.

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Acknowledgments I would like to thank Heather Culpepper, Philip Hughes, Megan Horton, Jessica
Chadwick and Ashley Weston for assistance with data collection.

Compliance with Ethical Standards

Conflict of interest The author declares that she has no conflict of interest.

Human and Animal Rights Statement All procedures performed in studies involving human participants
were in accordance with the ethical standards of the institutional and/or national research committee and
with the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards. This article
does not contain any studies with animals performed by any of the authors.

Informed Consent Informed consent was obtained from all individual participants included in the study.

References
Aiken, L. S., & West, S. G. (1991). Multiple regression: Testing and interpreting interactions. Newbury
Park: Sage.
Allport, G. W., & Ross, J. M. (1967). Personal religious orientation and prejudice. Journal of Personality
and Social Psychology, 5, 432–443.
Berg, C., Choi, W. S., Kaur, H., Nollen, N., & Ahluwalia, J. S. (2009). The roles of parenting, church
attendance, and depression in adolescent smoking. Journal of Community Health, 34, 56–63.
Blackburn, L., & Owens, G. P. (2015). The effect of self efficacy and meaning in life on posttraumatic stress
disorder and depression severity among veterans. Journal of Clinical Psychology, 71, 219–228.
Blatt, S. J. (1974). Levels of object representation in anaclitic and introjective depression. Psychoanalytic
Study of the Child, 29, 107–157.
Brandon, T. H., & Baker, T. B. (1991). The smoking consequences questionnaire: The subjective expected
utility of smoking in college students. Psychological Assessment, 3, 484–491.
Collins, R. L., Parks, G. A., & Marlatt, G. A. (1985). Social determinants of alcohol consumption: The
effects of social interaction and model status on the self-administration of alcohol. Journal of Con-
sulting and Clinical Psychology, 53, 189–200.
Danaei, G., Vander Hoorn, S., Lopez, A. D., Murray, C. J. L., & Ezzati, M. (2005). Causes of cancer in the
world: Comparative risk assessment of nine behavioural and environmental risk factors. Lancet, 366,
1784–1793.
Donahue, M. J. (1985). Intrinsic and extrinsic religiousness: Review and meta-analysis. Journal of Per-
sonality and Social Psychology, 48, 400–419.
Fergusson, D. M., Goodwin, R. D., & Horwood, L. J. (2003). Major depression and cigarette smoking:
Results of a 21-year longitudinal study. Psychological Medicine, 33, 1357–1367.
Ferraro, K. F., & Kelley-Moore, J. A. (2000). Religious consolation among men and women: Do health
problems spur seeking? Journal for the Scientific Study of Religion, 39, 220–234.
George, L. K., Blazer, D. G., Hughes, D. C., & Fowlier, N. (1989). Social support and the outcome of major
depression. British Journal of Psychiatry, 154, 478–485.
Glassman, A. H., Helzer, J. E., Covey, L. S., Cottler, L. B., Stetner, F., Tipp, J. E., et al. (1990). Smoking,
smoking cessation, and major depression. Journal of the American Medication Association, 264,
1546–1549.
Gorsuch, R. (1997). Toward motivational theories of intrinsic religious commitment. In B. Spilka & D.
N. McIntosh (Eds.), The psychology of religion: Theoretical approaches (pp. 11–22). Boulder, CO:
Westview.
Gorsuch, R. L., & McPherson, S. E. (1989). Intrinsic/extrinsic measurement: I/E-revised and single-item
scales. Journal for the Scientific Study of Religion, 28, 348–354.
Hann, D., Winter, K., & Jacobsen, P. (1999). Measurement of depressive symptoms in cancer patients.
Evaluation of the Center Epidemiological Studies Depression Scale (CES-D). Journal of Psychoso-
matic Research, 46, 437–443.
Harris, T., Brown, G. W., & Robinson, R. (1999). Befriending as an intervention for chronic depression
among women in an inner city. 1: Randomised controlled trial. The British Journal of Psychiatry, 174,
219–224.
Horton, K. D., & Loukas, A. (2013). Depressive symptoms, religious coping, and cigarette smoking among
post-secondary vocational students. Psychology of Addictive Behaviors, 27, 705–713.

123
J Relig Health (2018) 57:1211–1223 1223

Johnston, L. D., O’Malley, P. M., Bachman, J. G., Schulenberg, J. E., & Miech, R. A. (2015). Monitoring
the future national survey results on drug use, 1975–2014: volume 2: College students and adults ages
19–55. Ann Arbor: Institute for Social Research, The University of Michigan.
Jose, P. E. (2013). ModGraph-I: A programme to compute cell means for the graphical display of mod-
erational analyses: The internet/Excel version, Version 3.0. Victoria University of Wellington,
Wellington, New Zealand. Retrieved [date] from http://pavlov.psyc.vuw.ac.nz/paul-jose/modgraph/.
Kendler, K. S., & Myers, J. (2009). A developmental twin study of church attendance and alcohol and
nicotine consumption: A model for analyzing the changing impact of genes and environment. The
American Journal of Psychiatry, 166, 1150–1155.
Kirkpatrick, L. A. (1989). A psychometric analysis of the Allport-Ross and Feagin measures of intrinsic–
extrinsic religious orientation. In M. L. Lynn, D. O. Moberg, M. L. Lynn, & D. O. Moberg (Eds.),
Research in the social scientific study of religion: A research annual (Vol. 1, pp. 1–31). US: Elsevier
Science/JAI Press.
Klassen, B. J., Smith, K. Z., & Grekin, E. R. (2013). Differential relationships between religiosity, cigarette
smoking, and waterpipe use. Journal of American College Health, 61, 381–385.
Lerman, C., Caporaso, N., Main, D., Andrain, J., Boyd, N. R., Bowman, E. D., et al. (1998). Depression and
self-medication with nicotine: The modifying experience of the dopamine D4 receptor gene. Health
Psychology, 17, 56–67.
Leventhal, A. M., & Zvolensky, M. J. (2015). Anxiety, depression, and cigarette smoking: A transdiagnostic
vulnerability framework to understanding emotion-smoking comorbidity. Psychological Bulletin, 141,
176–212.
Ludman, E. J., Curry, S. J., Grothaus, L. C., Graham, E., Stout, J., & Lozano, P. (2002). Depressive
symptoms, stress, and weight concerns among African American and European American low-income
female smokers. Psychology of Addictive Behaviors, 16, 68–71.
Masters, K. S., & Bergin, A. E. (1992). Religious orientation and mental health. In J. F. Schumaker (Ed.),
Religion and mental health (pp. 221–232). New York: Oxford University Press.
McCullough, M. E., Hoyt, W. T., Larson, D., Koenig, H. G., & Thoresen, C. (2000). Religious involvement
and mortality: A meta-analytic review. Health Psychology, 19, 211–222.
McCullough, M. E., & Larson, D. B. (1999). Religion and depression: A review of the literature. Twin
Research and Human Genetics, 2, 126–136.
Parenteau, S. C., Waters, K., Cox, B., Patterson, T., & Carr, R. (2017). Racial discrimination and alcohol
use: The moderating role of religious orientation. Substance Use and Misuse, 52, 1–9.
Pargament, K. I. (2007). The psychology of religion and coping: Theory, research practice. New York: The
Guilford Press.
Pargament, K. I., Koenig, H. G., & Perez, L. M. (2000). The many methods of religious coping: Devel-
opment and initial validation of the ROCPE. Journal of Clinical Psychology, 56, 519–543.
Pargament, K. I., Smith, B. W., Koenig, H. G., & Perez, L. (1998). Patterns of positive and negative
religious coping with major life stressors. Journal for the Scientific Study of Religion, 37, 710–724.
Park, C., Cohen, L. H., & Herb, L. (1990). Intrinsic religiousness and religious coping as life stress
moderators for Catholics and Protestants. Journal of Personality and Social Psychology, 59, 562–574.
Pew Research Center. (2015). U.S. public becoming less religious.
Radloff, L. S. (1977). The CES-D scale: A self-report depression scale for research in the general popu-
lation. Applied Psychological Measurement, 1, 385–401.
Smith, T. B., McCullough, M. E., & Poll, J. (2003). Religiousness and depression: Evidence for a main
effect and the moderating influence of stressful life events. Psychological Bulletin, 129, 614–636.
Stoltzfus, K. M., & Farkas, K. (2012). Alcohol use, daily hassles, and religious coping among students at a
religiously affiliated college. Substance Use and Misuse, 47, 1134–1142.
Tamres, L. K., Janicki, D., & Helgeson, V. S. (2002). Sex differences in coping behavior: A meta-analytic
review and an examination of relative coping. Personality and Social Psychology Review, 6(1), 2–30.
Turchik, J. A., & Garske, J. P. (2009). Measurement of sexual risk taking among college students. Archives
of Sexual Behavior, 38, 936–948.
Turner-Musa, J. O., & Wilson, S. A. (2006). Religious orientation and social support on health promoting
behaviors of African American students. Journal of Community Psychology, 34, 105–115.
Worthington, E. L., Jr. (1988). Understanding the values of religious clients: A model and its application to
counseling. Journal of Counseling Psychology, 35, 166–174.
Worthington, E. L., Wade, N. G., Hight, T. L., Ripley, J. S., McCullough, M. E., Berry, J. W., et al. (2003).
The religious commitment inventory-10: Development, refinement, and validation of a brief scale for
research and counseling. Journal of Counseling Psychology, 50, 84–96.

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