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Understanding sex differences in physical activity behavior: The role of anxiety

sensitivity

Gloria J. Gomez, Emily K. Burr, Angelo M. DiBello, Samantha G. Farris

PII: S1755-2966(21)00012-0
DOI: https://doi.org/10.1016/j.mhpa.2021.100392
Reference: MHPA 100392

To appear in: Mental Health and Physical Activity

Received Date: 23 May 2020

Revised Date: 18 March 2021
Accepted Date: 19 March 2021

Please cite this article as: Gomez, G.J., Burr, E.K., DiBello, A.M., Farris, S.G., Understanding sex
differences in physical activity behavior: The role of anxiety sensitivity, Mental Health and Physical
Activity (2021), doi: https://doi.org/10.1016/j.mhpa.2021.100392.

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Running Head: ANXIETY SENSITIVITY AND PHYSICAL ACTIVITY

Understanding Sex Differences in Physical Activity Behavior:

The Role of Anxiety Sensitivity

Gloria J. Gomez, B.A. a

of
Emily K. Burr, B.A.a

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Angelo M. DiBello, Ph.D.b

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Samantha G. Farris, Ph.D.a*
re
a
Rutgers, the State University of New Jersey, Department of Psychology, Piscataway,
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NJ 08854 USA
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b
University of New York, Brooklyn College, Department of Psychology, Brooklyn, NY
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11210, USA
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*Corresponding author: Samantha G. Farris, Ph.D. at Rutgers, the State University of

New Jersey, Department of Psychology, 53 Avenue E, Piscataway NJ 08854 USA;

Phone: (848) 445-2174; Fax: (732) 445-0036; Email: samantha.farris@rutgers.edu

Funding: This research was supported by a Qualtrics Behavioral Research Grant to the

last author.

Disclosures: All authors have read and approved of the manuscript.

Declarations of interest: None.

 Abstract

Problem: There is a well-evidenced sex-disparity in physical activity (PA), such that

females are significantly less active than males. Anxiety sensitivity, the fear of anxiety-

related bodily sensations, is a cognitive-affective vulnerability associated with increased

negative affect during PA and lower levels of PA. The current study examined anxiety

sensitivity as a potential sex-specific, psychological factor related to sex differences in

past-week PA behavior in daily cigarette smokers. Method: Participants (n = 527;

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53.3% female) completed an anonymous online survey on emotion and health. Anxiety

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sensitivity was assessed with the Anxiety Sensitivity Index-3. Past-week, self-reported
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PA minutes were measured across four intensities (e.g. walking, moderate, vigorous,
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and total PA) using the International Physical Activity Questionnaire-Short. Four zero-
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inflated negative binomial regression models were constructed to test the main and
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interactive effects of sex and anxiety sensitivity on PA outcomes. Results: Females

reported significantly fewer past-week PA minutes relative to males across all domains.
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At higher levels of anxiety sensitivity, males reported significantly fewer total PA

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minutes; whereas, total PA levels in females were not dependent on anxiety sensitivity

level. Additionally, females with elevated anxiety sensitivity reported significantly more

past-week walking minutes relative to females with low anxiety sensitivity, whereas the

opposite pattern was observed in males. Conclusion: This is the first study to our knowledge

to examine sex-differences in anxiety sensitivity and PA, at varying PA intensities, among

smokers. These data have the potential to inform sex-specific models of anxiety, PA, and

smoking.
ANXIETY SENSITIVITY AND PHYSICAL ACTIVITY 1

Introduction

There is a well-documented sex disparity in physical activity (PA) such that females

engage in significantly less PA than males (Armstrong et al., 2018; Caspersen et al., 2000;

Guthold et al., 2018; U.S. Department of Health and Human Services, 2013). Many

psychosocial factors may drive this disparity. Females, compared to males, have lower average

income levels that may limit financial access to exercise facilities, often occupy demanding

domestic roles that may reduce availability for PA, and receive less social support for exercise

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from friends and family (Eyler et al., 2002; Speck & Harrell, 2003; World Health Organization,

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2017). Psychological distress like anxiety and depression also occur disproportionately in

females (Bandelow & Michaelis, 2015; Brody et al., 2018), and have been linked to maladaptive
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health behaviors like low PA engagement and cigarette smoking. (Leventhal & Zvolensky, 2015;
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Schuch et al., 2017; Stubbs et al., 2017). Indeed, while cigarette smoking is more prevalent in
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males than females (Jamal et al., 2016), females are more likely to smoke to cope with negative
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affect and stress relative to males (Weinberger & McKee, 2012; Wray et al., 2015). Additionally,

cigarette smoking is a behavioral risk factor of low PA engagement, regardless of psychological

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correlates (Heydari et al., 2015; Papathanasiou et al., 2012). Therefore, given that females tend
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to express greater vulnerabilities relevant to anxiety and lower PA engagement (which is also

associated with smoking behavior), it is important to address sex differences in regard to anxiety

vulnerabilities and PA engagement within a smoking population.

One psychological factor that may underlie the sex-disparity in PA behavior in cigarette

smokers is anxiety sensitivity: a fear of anxiety-related bodily sensations (e.g., increased heart

rate) and the belief that these sensations have damaging physical, cognitive, or social

consequences (Reiss, 1991). Anxiety sensitivity has been implicated in the development and

maintenance of anxiety and mood disorders (Naragon-Gainey, 2010) as well as problematic

health behaviors like physical inactivity and cigarette smoking (Otto et al., 2016). Moreover,

females report higher levels of anxiety sensitivity than males (Deacon et al., 2003; Noël et al.,
ANXIETY SENSITIVITY AND PHYSICAL ACTIVITY 2

2013; Norr et al., 2015; Stewart et al., 1997), a disparity that is believed to contribute to the

greater prevalence of anxiety and depressive symptoms in females relative to males (Norr et al.,

2015), and although not yet examined, may also contribute to lower levels of PA in females

compared to males.

Theoretically, individuals with elevated anxiety sensitivity may experience greater bodily

distress and negative affect during PA, especially at higher intensities (Asmundson et al., 2013),

which can undermine future PA engagement due to its aversiveness (Otto et al., 2016). Given

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that females report higher levels of anxiety sensitivity than males, it can be inferred that females

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are more likely to attend to physiological changes in arousal and interpret the physical

sensations experienced during PA (e.g., increased sweating) as highly threatening and, thus,
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may avoid future PA to prevent anxious arousal (Smits et al., 2010). Notably, smokers are less
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physically active and report higher levels of anxiety sensitivity than non-smokers (Heydari et al.,
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2015; Leventhal & Zvolensky, 2015; Papathanasiou et al., 2012), thus, anxiety sensitivity may
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be a key cognitive-affective vulnerability that influences PA levels in smokers. Evidence to-date

suggests that anxiety sensitivity is related to lower engagement in retrospectively- and

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prospectively-measured PA (Hearon et al., 2014; Moshier et al., 2016), particularly with

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vigorous-intensity exercise (Moshier et al., 2013). Elevated anxiety sensitivity is also linked to

greater fear prior to and during moderate-intensity exercise (Farris, Legasse, et al., 2018; Smits

et al., 2010), greater perceived exertion during moderate-intensity exercise (Farris et al., 2017),

and lower PA enjoyment in cigarette smokers (Farris, Legasse, et al., 2018).

Given that anxiety sensitivity is linked to lower PA levels and is generally higher in

females (versus males), anxiety sensitivity may be a critical female-specific risk factor that

contributes to the sex-disparity in PA. However, we are aware of only one study to date that

evaluated the interplay between anxiety sensitivity, sex, and PA in a sample of undergraduate

students (DeWolfe et al., 2018). Results indicated that females had significantly lower levels of

self-reported past 30-day PA than males, and that this sex disparity was explained by anxiety
ANXIETY SENSITIVITY AND PHYSICAL ACTIVITY 3

sensitivity. Therefore, there is preliminary evidence for the inverse association between anxiety

sensitivity and PA, especially in females (DeWolfe et al., 2018). These findings are important to

further extend for several reasons: (a) this study relied on an undergraduate sample (78%

female) which limits generalizability of the findings; (b) PA was assessed with a non-validated

questionnaire (i.e., author generated questions), which raises concern about the reliability and

validity of these data; (c) the intensity of PA was not considered despite evidence that elevated

anxiety sensitivity is related to decreased engagement in higher-intensity PA (Farris et al., 2019;

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Hearon et al., 2014; Moshier et al., 2013, 2016); and (d) walking-based PA was not included

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although walking is the most commonly reported form of PA (Dai et al., 2015), particularly in

females (Abrantes et al., 2011; Daley et al., 2011).

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Thus, the present study was designed to extend upon on preliminary findings from
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DeWolfe et al. (2018) by assessing anxiety sensitivity in relation to sex differences in PA using
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(a) a more gender-balanced, community sample of adults, (b) a population of smokers, (c) a
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well-validated self-report measure of PA, while (d) accounting for PA intensity and walking-

based PA, and to (e) examining how varying levels of anxiety sensitivity influence PA by sex.
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Specifically, we examined the anxiety sensitivity-PA association in a sample of male and female
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smokers to further examine the relationship between anxiety sensitivity and PA in this sub-group

known to have elevated anxiety sensitivity and lower PA levels than non-smokers. We

hypothesized that: (a) anxiety sensitivity would be associated with lower levels of past-week PA

for all PA outcomes (walking, total, moderate- and -vigorous-intensity PA) in smokers; (b)

female smokers would report lower levels of past-week PA in all four domains than male

smokers; and (c) elevated anxiety sensitivity would be associated with lower levels of past-week

PA in each PA domain, particularly for female smokers when compared to male smokers.

Method

Participants
ANXIETY SENSITIVITY AND PHYSICAL ACTIVITY 4

Participants were daily smokers who completed an anonymous online survey via

Qualtrics Panels, an online research participation platform. Eligibility criteria include: (a) being a

daily smoker for ≥ 1 year, (b) smoking ≥ 5 cigarettes per day, (c) use of combustible cigarettes

as the primary tobacco product, and (d) stable smoking (e.g., cigarette use not reduced by > ½

in the past month).

Measures

Demographics and Medical History. Biological sex was self-reported by participants

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and was one of the primary predictor variables in this study (coded male = 0 and female = 1).

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Model covariates were self-reported, including age, body mass index (BMI), number of medical

conditions, and level of cigarette dependence. Age was self-reported on a demographics form.
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BMI was calculated based on self-reported height and weight ([weight (lbs.)] / [height (in.)] ² ×
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703), but only participants who reported ≥ 70% confidence in their self-calculated BMI rating
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were retained in this study (n=12 cases excluded). A medical history form was used to evaluate
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the presence of 33 different medical conditions such as respiratory illnesses (e.g., asthma),

cardiovascular diseases (e.g., heart failure), and neurological disorders (e.g., epilepsy).
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Although specific psychological conditions were not evaluated, one item assessed for prior or
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present diagnosis of any psychological condition. A sum of endorsed conditions was derived

given evidence that the presence of one or more chronic health conditions can confer risk for

elevated anxiety sensitivity and reduced participation in PA (Asmundson et al., 2000; Murphy et

al., 2011). Level of cigarette dependence was measured using the Fagerström Test for

Cigarette Dependence (FTCD; Fagerström, 2011), a 6-item self-report questionnaire where

higher scores (possible range: 0-10) reflect greater physical dependence on cigarettes. The

internal consistency for the FTCD was poor in the current sample (α = 0.56), which is often

found for this measure likely due to the dichotomous response options (e.g., yes, no) of some of

the items (Korte et al., 2013).

ANXIETY SENSITIVITY AND PHYSICAL ACTIVITY 5

Anxiety Sensitivity. Anxiety sensitivity was the other primary predictor variable in this

study. Anxiety sensitivity was assessed with the Anxiety Sensitivity Index-3 (ASI-3; Taylor et al.,

2007). The ASI-3 is an 18-item self-report measure that evaluates the extent to which

individuals are concerned about the potential consequences of anxiety-related bodily symptoms

(e.g., “When my stomach is upset, I worry that I might be seriously ill.”) Items are scored on a 5-

point Likert scale ranging from 0 (very little) to 4 (very much), with higher scores reflecting

greater anxiety sensitivity. The ASI-3 has strong psychometric properties in non-clinical samples

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(Osman et al., 2010) and in smokers (Farris et al., 2015). Internal consistency was α = 0.96 in

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the current sample.

Physical Activity (PA). PA behavior was the outcome variable in this study and was
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evaluated using the International Physical Activity Questionnaire-Short (IPAQ-S; Craig et al.,
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2003). The IPAQ-S is a reliable and well-validated 7-item self-report measure that measures the
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past-week frequency and duration of PA, including moderate-intensity PA (“activities that take
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moderate physical effort and make you breathe somewhat harder than normal”), vigorous-

intensity PA (“activities that take hard physical effort and make you breathe much harder than
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normal”), and walking. The duration (minutes) × frequency (days) of PA were used to derive an
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index of past-week PA behavior. Internal consistency was low in the present sample (α = 0.63),

which is likely due to the small number of items in this measure (Taber, 2018) .

Procedure

The current study was a secondary data analysis of baseline data from a study that

evaluated the validity of a contextual-behavioral persistence task in smokers (Farris, DiBello, et

al., 2018). Participants were recruited online through Qualtrics Panel Services and completed

the study in July 2015. Eligible participants completed baseline self-report questionnaires prior

to an experimental task. The protocol was approved by the Institutional Review Board where the

study was conducted.

Data Analytic Strategy

ANXIETY SENSITIVITY AND PHYSICAL ACTIVITY 6

Data were analyzed using SPSS Statistics v. 26 and Stata v. 16. A histogram was used

to inspect the normality of data and examine skewness and kurtosis. Due to the non-normal

distribution of PA data, a data analytic procedure that allows for non-normal distributions was

employed (e.g., zero-inflated probability distribution). Descriptive and inferential statistics were

used to describe the sample in terms of sex, anxiety sensitivity, and PA. Independent samples t-

tests were used to characterize any significant differences between males and females on study

variables without controlling for other variables relevant to PA. To test the primary study aims,

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four zero-inflated negative binomial (ZINB) regression models were used to examine the main

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and interactive effects of anxiety sensitivity and sex for each PA outcome (total PA, vigorous-

intensity PA, moderate-intensity PA, and walking). Compared to the t-tests, the ZINB regression
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models test for sex differences among the primary PA outcomes while accounting for covariates
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implicated in lower PA engagement. The ZINB distribution is a negative binomial distribution
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that also has an excess number of zeros. Thus, the ZINB procedure is a mixture model that
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accounts for the non-normal distribution of the PA outcome variables by simultaneously

estimating two distributions of the model: the zero-inflated component (e.g., a logistic
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regression) is a model that evaluates the log likelihood of being an excess zero and a count
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component (e.g., the count outcome) evaluates the negative binomial distribution, including a

proportion of zeros that would be expected in a negative binomial distribution with the given

mean and dispersion (Atkins et al., 2013). The count component of each model, relative to the

zero-inflated portion of the model, was interpreted given interest in predicted PA level rather

than the presence/absence of PA. Current research suggests that increasing age, elevated BMI,

and presence of chronic disease (≥ 1) are implicated in physical inactivity (Murphy et al., 2011;

Watson et al., 2016), and greater cigarette dependence in smokers (vs. low) is related to

decreased engagement in PA (Azagba & Asbridge, 2013). Therefore, model covariates in the

current study included age, BMI, number of medical conditions, and level of cigarette

dependence due to their relevance to PA. Consistent with previous approaches to graphing
ANXIETY SENSITIVITY AND PHYSICAL ACTIVITY 7

negative binomial regression, the interaction in Figures 1 and 2 were examined by graphing the

relationship between total PA activity/walking minutes and anxiety sensitivity at actual levels of

anxiety sensitivity across both sexes (Bernstein et al., 2018; Wang et al., 2020). This approach

is different than the probing interactions at high/low values of the standard deviation which is

common in linear regression as negative binomial regression is inherently non-linear, so that

approach does not apply to the current analytic framework being employed.

Results

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Descriptive Overview

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Participants (n=527; M age = 44.80, SD = 13.58; 53.3% female) predominantly self-

identified as white (89.8%) and were primarily non-Hispanic or Latino (93.4%). The current
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sample also reported elevated levels of anxiety sensitivity (M = 22.22; SD = 18.33) based on
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clinical cut-scores of ≥ 17 on the Anxiety Sensitivity Index-3 that are used to identify moderate-
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to-high levels of anxiety sensitivity in smoking and non-smoking specific populations alike (Allan,
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Korte, et al., 2014; Allan, Raines, et al., 2014). Sample characteristics and t-test results are

presented in Table 1.
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Regression Results
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Results from both the logistic and counts portions of the zero-inflated negative binomial

regression results are displayed in Table 2. The coefficients in the count portion of the models

are log-linked. Thus, when exponentiated, the coefficients can de directly interpreted as incident

rate ratios (IRR). IRRs are the expected proportional change in the outcome for each unit

change in the predictor variable. An IRR value that is greater than 1 indicates that the outcome

mean is higher given a 1 unit increase in the predictor variable. Conversely, an IRR value that is

less than 1 indicates that the outcome mean is lower given a 1 unit increase in the predictor

variable.

Total PA mins/day. Results revealed a significant main effect of anxiety sensitivity on

total PA engagement (b = -0.01, IRR = .99, p = 0.002), such that higher levels of anxiety
ANXIETY SENSITIVITY AND PHYSICAL ACTIVITY 8

sensitivity were associated with fewer total past-week PA minutes. The main effect of sex on

total PA engagement was also significant (b = -0.27, IRR = .69, p = 0.015), indicating that

females reported significantly lower past-week total PA. There was also a significant sex by

anxiety sensitivity interaction on total PA (b = 0.01, IRR = 1.01, p = 0.041), such that the impact

of anxiety sensitivity on total PA varied as a function of sex. Females reported significantly fewer

total PA minutes regardless of anxiety sensitivity level. Meanwhile, males with higher levels of

anxiety sensitivity reported significantly fewer total PA minutes relative to males with lower

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anxiety sensitivity levels (Figure 1).

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Vigorous-Intensity PA mins/day. The main effect of anxiety sensitivity on vigorous-

intensity PA minutes was significant (b = -0.02, IRR = .98, p < 0.001), as was the main effect of
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sex on vigorous-intensity PA (b = -0.55, IRR = .27, p < 0.001), such that females reported
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significantly fewer minutes of vigorous-intensity PA than males. However, the sex by anxiety
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sensitivity interaction on vigorous-intensity PA minutes was not significant (b = 0.01, IRR =

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1.101, p = .257).

Moderate-Intensity PA mins/day. There was a significant and negative main effect of

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anxiety sensitivity in terms of past-week moderate-intensity PA engagement (b = -0.02, IRR =

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.98, p = 0.001), and a significant main effect of sex on moderate-intensity PA (b = -0.34, IRR =

.60, p = 0.012), such that females reported significantly lower engagement in moderate-intensity

PA. The interactive effect of sex and anxiety sensitivity on moderate-intensity PA minutes was

non-significant (b = 0.01, IRR = 1.01, p = 0.400).

Walking mins/day. Results revealed a significant and negative main effect of anxiety

sensitivity in terms of walking mins/day (b = -0.01, IRR = ,99, p = 0.006), but the main effect of

sex on walking minutes was not significant (b = -0.09, IRR = .91, p = 0.414). The interactive

effect between anxiety sensitivity and sex on walking was also significant (b = 0.02, IRR =1.02,

p < 0.001), such that the impact of anxiety sensitivity on walking mins/day varied as a function

of sex. Consistent with the findings with respect to total PA minutes, males with higher levels of
ANXIETY SENSITIVITY AND PHYSICAL ACTIVITY 9

anxiety sensitivity reported significantly fewer walking mins/day relative to males with lower

anxiety sensitivity levels. Conversely, higher levels of anxiety sensitivity in females, relative to

lower levels of anxiety sensitivity, were associated with significantly more past-week walking

minutes (Figure 2).

Discussion

The present study evaluated anxiety sensitivity as a psychological vulnerability

associated with sex differences in PA behavior. As hypothesized, elevated anxiety sensitivity

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was uniquely related to lower past-week PA levels across all four outcomes. Findings also

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revealed that female smokers reported significantly less past-week total, moderate- and

vigorous-intensity PA relative to male smokers. These findings corroborate prior evidence that
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(1) anxiety sensitivity is associated with lower PA levels, and (2) females report lower PA
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engagement than males (DeWolfe et al., 2018). However, contrary to expectation, higher levels
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of anxiety sensitivity were only associated with lower past-week total PA minutes in male
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smokers, while female smokers’ total PA levels were not conditional on level of anxiety

sensitivity. This finding is likely inconsistent with results from DeWolfe et al. (2018) due to the
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present study’s use of a self-report measure that assesses varying PA domains vs. general PA
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engagement, as well as potential differences in each sample population’s PA behavior (college

students vs. cigarette smokers).

Although speculative, given that male smokers reported greater engagement in total,

vigorous- and moderate-intensity PA, it is possible that this population is generally more willing

and likely to maintain regular engagement in PA. Indeed, prior research indicates that while

female smokers are more likely to report lower levels of PA, this inverse relationship between

smoking status and PA is attenuated in male smokers (Kaczynski et al., 2008). However,

elevated anxiety sensitivity in male smokers may result in an increased risk for reduced PA

because this psychological vulnerability likely produces an aversive PA experience for males by

reducing exercise tolerance and increasing levels of fear, perceived exertion, and negative
ANXIETY SENSITIVITY AND PHYSICAL ACTIVITY 10

affect during exercise (Farris et al., 2016, 2017; Farris, Legasse, et al., 2018; Smits et al., 2010).

In contrast, females may not demonstrate the same reductions in PA because they already

report significantly lower levels of PA relative to males, indicating that females generally avoid

PA independent from the presence of risk factors like anxiety sensitivity. Female smokers do not

exhibit a significant change in how often they engage in PA as anxiety sensitivity levels

increase, but rather remain consistently avoidant of PA across intensity levels. Future work is

needed to identify potential factors that may contribute to females’ predisposition for lower PA

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levels, as well as mechanisms unique to males with elevated anxiety sensitivity that may

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exacerbate their risk for reduced PA engagement.

Inconsistent with our expectation, we found that female smokers high (vs. low) in anxiety
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sensitivity reported significantly more time spent walking, whereas the opposite pattern was
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observed in males. This set of findings suggests that walking may be a more preferable form of
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PA for females with elevated anxiety sensitivity given that it involves less physical exertion than
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moderate- and vigorous-intensity PA and, therefore, may produce less distress. Indeed, walking

is commonly reported as the most preferable form of PA in females relative to other forms of PA
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(Abrantes et al., 2011; Daley et al., 2011), and is related to increases in positive affect
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(Ekkekakis et al., 2000) compared to higher-intensity exercises, which are associated with

elevated negative affect (Hall et al., 2002). Future studies are needed to corroborate whether

females with elevated anxiety sensitivity do engage in more walking activity than females with

lower anxiety sensitivity, and the potential mechanisms (e.g., positive affect) that may underlie

the preference for walking relative to higher-intensity PA.

This is the first study to our knowledge to examine sex differences in anxiety sensitivity

and PA, at varying PA intensities, among smokers. Results from the current study must be

interpreted considering a few limitations. First, individuals tend to overreport their PA levels on

self-report questionnaires compared to objective measures of PA (Dyrstad et al., 2014). Follow-

up research is needed using objective measures of PA (e.g., accelerometers) to assess PA in

ANXIETY SENSITIVITY AND PHYSICAL ACTIVITY 11

real-time with greater accuracy (Bassett & John, 2010). However, prior work using objectively

measured PA has found that females engage in lower levels of PA than males (Hagströmer et

al., 2010; Hawkins et al., 2009), and that individuals with higher anxiety sensitivity levels

participate in lower levels of PA (Hearon & Harrison, 2020), findings of which are comparable to

the results from our self-reported PA data. Second, the current study was cross-sectional in

nature, which precludes the ability to analyze questions related to temporal changes in PA as a

function of anxiety sensitivity and sex. Future research is needed to evaluate these associations

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over time. Third, the study sample of focus was daily cigarette smokers with moderate levels of

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cigarette dependence. The associations between anxiety sensitivity, PA and sex are not

proposed to be specific to smokers; indeed, the effect of cigarette dependence was a non-
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specific predictor in the statistical models. Additionally, although cigarette dependence and
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other relevant factors (e.g., BMI, sex, medical conditions) were statistically controlled for, future
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research is needed to understand how these processes interplay with sex and anxiety sensitivity
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(e.g., Smits et al., 2008) to potentially undermine PA engagement for a more comprehensive

and nuanced risk model.

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The current findings highlight anxiety sensitivity as a psychological vulnerability that may
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offer insights into the unique patterning of PA as a function of biological sex. Given that

moderate-to-vigorous-intensity aerobic exercise is also a commonly used form of interoceptive

exposure to attenuate anxiety sensitivity (Broman-Fulks et al., 2004; LeBouthillier &

Asmundson, 2015; Sabourin et al., 2015), which can also promote early smoking abstinence

(Zvolensky et al., 2018), the efficacy of such an intervention may be enhanced by tailoring the

application of interoceptive exposures based on sex-specific differences. For example, female

smokers may benefit from lower-intensity bouts of aerobic exercise for interoceptive exposures

at the beginning of treatment to gradually build tolerance and acceptance of exposure and

minimize the risk of early dropout or non-compliance. More empirical research is needed to

inform such tailoring and other treatment modification approaches.

ANXIETY SENSITIVITY AND PHYSICAL ACTIVITY 12

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ANXIETY SENSITIVITY AND PHYSICAL ACTIVITY 22

Table 1. Sample characteristics and sex differences in PA.

Total Sample Females Males

(n = 527) (n = 281, 53.3%) (n = 246, 46.7%)
Variables M (SD) M (SD) M (SD) t, p
Age 44.80 (13.58) 44.95 (12.78) 44.64 (14.56) -0.257, 0.799
Body Mass Index (BMI) 27.89 (7.33) 28.10 (7.90) 27.65 (6.62) -0.701, 0.484

Cigarette Dependence (FTCD) 5.41 (2.00) 5.52 (2.03) 5.27 (1.95) -1.503, 0.133

# Medical Conditions 1.69 (2.07) 1.92 (2.20) 1.42 (1.87) -2.83, 0.005

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Anxiety Sensitivity (ASI-3) 22.22 (18.03) 21.69 (17.99) 22.83 (18.08) 0.726, 0.468

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IPAQ-S Total (min/week) 417.64 (674.49) 371.79 (725.32) 470.02 (624.32) 1.671, 0.095

IPAQ-S Vigorous-Intensity PA 103.95 (222.00) -p 75.71 (168.54) 136.20 (267.19) 3.147, 0.002
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IPAQ-S Moderate-Intensity PA 146.79 (302.67) 127.46 (282.07) 168.88 (323.77) 1.570, 0.117

IPAQ-S Walking 166.91 (300.90) 168.63 (305.69) 164.94 (295.94) -0.140, 0.888
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Note: BMI = Body Mass Index; FTCD = Fagerström Test for Cigarette Dependence. # Medical
Conditions = Count of self-reported medical conditions, out of 33 possible conditions; ASI-3 =
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Anxiety-Sensitivity Index-3. IPAQ-S = International Physical Activity Questionnaire-Short.

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ANXIETY SENSITIVITY AND PHYSICAL ACTIVITY 1

Table 2.
Main and interactive effects of sex and anxiety sensitivity on count PA outcomes.1
Count Portion of Model Logistic Portion of Model
Outcome: Total PA Min/Day b SE p 95% CI IRR b SE p 95% CI
Intercept 6.26 0.08 <.001 6.104, 6.422 523.22 -2.04 0.21 <.001 -2.452, -1.630
Sex [female] ‐0.27 0.11 .015 ‐0.491, ‐0.052 0.69 -0.06 0.29 .837 -0.629, 0.509
Anxiety Sensitivity ‐0.01 0.00 .002 ‐0.023, ‐0.005 0.99 -0.003 0.01 .798 -0.028, 0.021
Sex ✕ Anxiety Sensitivity 0.01 0.01 .041 0.001, 0.025 1.01 -0.001 0.17 .958 -0.033, 0.032

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Outcome: Vigorous-Intensity PA

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b SE p 95% CI IRR b SE p 95% CI
Min/Day

pr
Intercept 5.44 0.01 <.001 5.271, 5.611 230.44 -0.34 0.13 .009 -0.604, -0.085
Sex [female] ‐0.55 0.12 <.001 ‐0.788, ‐0.310 0.27 0.26 0.18 .148 -0.093, 0.619

e-
Anxiety Sensitivity ‐0.02 0.00 <.001 ‐0.028, ‐0.010 0.98 -0.002 0.01 .845 -0.017, 0.014

Pr
Sex ✕ Anxiety Sensitivity 0.01 0.01 .257 -0.005, 0.020 1.01 -0.003 0.01 .784 -0.023, 0.017
Outcome: Moderate-Intensity PA
b SE p 95% CI IRR b SE p 95% CI

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Min/Day

rn
Intercept 5.57 0.10 <.001 5.377, 5.765 262.43 -0.56 0.14 <.001 -0.833, -0.291
Sex [female] -0.34 0.14 .012 -0.613, -0.074 0.60 -0.03 0.19 .882 -0.400, 0.344
Anxiety Sensitivity u -0.02 0.01 .001 -0.029, -0.007 0.98 -0.002 0.01 .975 -0.016, 0.016
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Sex ✕ Anxiety Sensitivity 0.01 0.01 .400 -0.008, 0.021 1.01 .001 0.01 .887 -0.019, 0.022
Outcome: Walking Min/Day b SE p 95% CI IRR b SE p 95% CI
Intercept 5.41 0.08 <.001 5.246, 5.580 223.63 -1.057 0.15 <.001 -1.355, -0.759
Sex [female] ‐0.09 0.11 .414 ‐0.318, 0.131 0.91 -0.26 0.21 .226 -0.681, 0.0161
Anxiety Sensitivity ‐0.01 0.00 .006 ‐0.021, ‐0.004 0.99 -0.01 0.01 .349 -0.027, 0.009
Sex ✕ Anxiety Sensitivity 0.02 0.01 <.001 0.011, 0.036 1.02 .019 0.01 .119 -0.005, 0.042
Note: Anxiety Sensitivity (ASI-3); Physical Activity (PA per the IPAQ-S); b: unstandardized beta coefficient; SE: standard error for
unstandardized beta; p: p-value; CI: confidence interval; IRR: incidence rate ratio. 1 Controlling for age, BMI, number of medical
conditions, and cigarette dependence.
ANXIETY SENSITIVITY AND PHYSICAL ACTIVITY 1

Figure 1.
Interaction between sex, anxiety sensitivity, and total PA minutes.

Male
800 Female

700
Total PA Minutes

600

500

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400

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300

200
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100
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0
0 10 20 30 40 50 60 70
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Anxiety Sensitivity (ASI-3)

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ANXIETY SENSITIVITY AND PHYSICAL ACTIVITY 2

Figure 2.
Interaction between sex, anxiety Sensitivity, and walking minutes.

Male
400 Female

350
Walking Minutes

300

250

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200

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150

100 -p
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50

0
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0 10 20 30 40 50 60 70
Anxiety Sensitivity (ASI-3)
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 Highlights

• Anxiety sensitivity, female sex, and smoking are risk factors for physical inactivity

• Higher anxiety sensitivity levels were related to lower total physical activity levels

in males

• Females' total physical activity levels were not dependent on anxiety sensitivity

levels

• High levels of anxiety sensitivity were related to more time spent walking for

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females but not males

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Keywords: exercise; physical activity; anxiety sensitivity; sex differences; smokers
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 Conflict of Interests

Declarations of interest: Given their role as Editorial Board Member, Dr. Samantha

Farris had no involvement in the peer-review of this article and has no access to

information regarding its peer-review. Full responsibility for the editorial process for this

article was delegated to Editor in Chief, Adrian Taylor.

Role of the funding source: No role.

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