Anxiety sensitivity and perceived control over anxiety-related events: associations with smoking outcome expectancies and perceived cessation barriers among daily smokers.

The present investigation examined the extent to which the cognitive factors of anxiety sensitivity (AS) and perceived control over anxiety-related events are independently related to smoking outcome expectancies and perceived barriers to quitting. Participants were 125 community-recruited adult, daily smokers. Consistent with hypotheses, AS and perceived control over anxiety-related events independently and significantly predicted smokers' expectancies for negative affect reduction from smoking, whereas only AS predicted expectancies for negative personal consequences from smoking. Also as hypothesized, AS and perceived control over anxiety-related events each independently and significantly predicted level of general perceived barriers to quitting smoking. All of the observed significant effects were evident above and beyond the variance accounted for by gender, alcohol consumption, number of cigarettes smoked per day, and negative affectivity. Together, these findings further the literature on the relation between anxiety-relevant cognitive factors and psychological smoking processes.     

Development and validation of an adolescent smoking consequences questionnaire.

Several researchers have investigated the role of outcome expectancies in the initiation and maintenance of smoking behavior. Empirical studies with adults, using a validated self-report instrument, have shown that smokers identify higher levels of positive smoking expectancies and lower levels of negative smoking expectancies compared with nonsmokers and ex-smokers. Studies examining smoking outcome expectancies among adolescents have yielded similar findings, but many of these studies did not use a self-report expectancy measure validated with teens. Therefore, the present study sought to modify a well-known adult smoking expectancy instrument, the Smoking Consequences Questionnaire (SCQ), and to validate its factor structure with a community sample of adolescent nonsmokers and current smokers (aged 11-19 years). Results of a confirmatory factor analysis provided support for a seven-latent-factor structure modeled after the SCQ-Adult. As expected, smoking behavior and the intent to smoke in the future were associated with the endorsement of positive and negative smoking outcome expectancies. The psychometric data provide early support for the validity and reliability of this modified SCQ, renamed the Adolescent Smoking Consequences Questionnaire, for the assessment of smoking expectancies among smoking inexperienced and experienced teens.     

Effects of smoking abstinence and alcohol consumption on smoking-related outcome expectancies in heavy smokers and tobacco chippers.

Smoking cessation interventions often target expectancies about the consequences of smoking. Yet little is known about the way smoking-related expectancies vary across different contexts. Two internal contexts that are often linked with smoking relapse are states associated with smoking abstinence and alcohol consumption. This report presents a secondary analysis of data from two experiments designed to examine the influence of smoking abstinence, and smoking abstinence combined with alcohol consumption, on smoking-related outcome expectancies among heavy smokers and tobacco chippers (smokers who had consistently smoked no more than 5 cigarettes/day for at least 2 years). Across both experiments, smoking abstinence and alcohol consumption increased expectancies of positive reinforcement from smoking. In addition, alcohol consumption increased negative reinforcement expectancies among tobacco chippers, such that the expectancies became more similar to those of heavy smokers as tobacco chippers' level of subjective alcohol intoxication increased. Findings suggest that these altered states influence the way smokers evaluate the consequences of smoking, and provide insight into the link between smoking abstinence, alcohol consumption, and smoking behavior.     

Incremental validity of anxiety sensitivity in terms of motivation to quit, reasons for quitting, and barriers to quitting among community-recruited daily smokers.

The present investigation examined the relationships between anxiety sensitivity and motivation to quit smoking, barriers to smoking cessation, and reasons for quitting smoking among 329 adult daily smokers (160 females; M (age) = 26.08 years, SD = 10.92). As expected, after covarying for the theoretically relevant variables of negative affectivity, gender, Axis I psychopathology, nonclinical panic attack history, number of cigarettes smoked per day, and current levels of alcohol consumption, we found that anxiety sensitivity was significantly incrementally related to level of motivation to quit smoking as well as current barriers to quitting smoking. Partially consistent with the hypotheses, after accounting for the variance explained by other theoretically relevant variables, we found that anxiety sensitivity was significantly associated with self-control reasons for quitting smoking (intrinsic factors) as well as immediate reinforcement and social influence reasons for quitting (extrinsic factors). Results are discussed in relation to better understanding the role of anxiety sensitivity in psychological processes associated with smoking cessation.     

Adolescents' smoking expectancies: psychometric properties and prediction of behavior change.

Outcome expectancies have been related to smoking behavior among adults, but less attention has been given to expectancies about smoking among adolescents at differing levels of smoking experience. The present study reports the psychometric properties and predictive validity of a brief expectancy scale across two samples of adolescents. Sample 1 (N = 349) consisted of high school students (54% female) who were regular smokers enrolled in a cessation program. Sample 2 (N = 273) consisted of 8th- and 10th-grade early experimenters (54% female) involved in a natural history study of smoking trajectories. In both samples, a principal component analysis of a 13-item expectancy scale yielded four factors (taste, weight control, boredom relief, and negative affect management), each with high internal consistency (coefficient alphas >.77) and accounting for 73% and 80% of the total variance for each sample, respectively. Expectancies were significantly higher among current smokers than among early initiators. In Sample 1, boredom relief and weight management expectancies predicted smoking status 6 months later. In Sample 2, students whose smoking increased over 18 months had higher overall expectancies at baseline compared with those who tried smoking and did not escalate. These findings support the predictive validity of expectancies in predicting escalation and cessation. Implications for the importance of expectancies in understanding adolescent smoking behavior are considered.     

Smokers' expectancies for nicotine replacement therapy vs. cigarettes.

Smokers (N=188) recruited from the local community completed a questionnaire that measured expected outcomes of using cigarettes, nicotine gum, nicotine patch, and nicotine nasal spray. Expectancy questions relating to negative affect, craving, weight, and health risks were derived from the Smoking Consequences Questionnaire-Adult. As predicted, smokers held much greater expectancies that cigarettes help control negative affect, craving, and weight relative to nicotine replacement therapy (NRT). All NRT products were expected to cause fewer health risks than cigarette smoking. As predicted, smokers held strong negative affect reduction expectancies for cigarette smoking. For NRT, although still relatively low, craving reduction was the strongest expectancy. Individuals who had experience using the nicotine patch had greater positive expectancies for NRT. Greater positive expectancies for NRT were correlated with more immediate plans to quit smoking. In summary, cigarette smokers' positive expectancies about cigarettes do not appear to generalize to NRT products, which may limit their use and effectiveness.     

Dimensions of depressive symptoms and smoking cessation.

Because different psychopathologic components of depressive symptoms may have distinct etiologies, examining their differential effects on smoking cessation may elucidate mechanisms underlying the smoking-depression relationship. Negative affect (NA), somatic features (SF), low positive affect/anhedonia (PA), and interpersonal disturbance (IP) have been identified as unique dimensions of depression that can be measured using the Center for Epidemiologic Studies Depression Scale (CESD). This study examined common and unique associations between CESD subscales and baseline smoking characteristics, nicotine withdrawal, and relapse in 157 participants enrolled in a smoking cessation trial for heavy social drinkers. Each dimension was univariately associated with negative and positive reinforcement smoking motives. Only SF had unique relations with tolerance smoking motives and univariate associations with nicotine dependence severity. Only PA predicted cessation-related changes in withdrawal symptoms on quit day. Analyses predicting abstinence at 8, 16, and 26 weeks post quit date showed that NA, SF, and PA each univariately predicted relapse, ps< or =.0083. Only low PA predicted poorer outcomes incrementally to the other dimensions, even when controlling for level of nicotine dependence, smoking frequency, and history of major depression, p = .0018. Interventions targeting anhedonia and low positive affect may be useful for smokers trying to quit.     

Motives for smoking and their correlates in clients attending Stop Smoking treatment services.

This study investigated smokers' ratings of putative smoking motives and how these relate to smoking patterns, withdrawal symptoms, and short-term abstinence in clients attending smokers' clinics. Data were collected from 2,727 clients from two London Stop Smoking Services that offered behavioral support combined with pharmacotherapy. On a scale of 1 to 5, stress relief (M = 3.9), boredom relief (3.7), and enjoyment (3.6) were rated highest. Uses as an aid to concentration (2.9), for relief of withdrawal discomfort (2.8), and as an aid to socialization (2.8) received moderate ratings. Weight control was rated low (2.0). These ratings were found to be largely independent of each other. Ratings of enjoyment, boredom relief, improvement in concentration, and relief of withdrawal discomfort were positively correlated with daily cigarette consumption (p<.001). Ratings of smoking for withdrawal relief, enjoyment, improvement in concentration, stress relief, and boredom relief were positively correlated with nicotine dependence as measured by the Fagerstr?m Test for Nicotine Dependence (p<.001). Strength of urges to smoke and time spent with urges to smoke in the first week of abstinence were positively correlated with smoking for withdrawal relief, to stay alert, to improve concentration, and with enjoyment of smoking (p<.01). Relapse to smoking within 4 weeks was not associated with ratings of any of the smoking motives, including enjoyment. Although correlated with a measure of dependence, no strong connection appears to exist between relapse and any of the smoking motives, suggesting that the mechanisms underlying nicotine dependence lie at a deeper level, outside the ability of smokers to be introspective regarding their motivations.     

Smoking and education: Do psychosocial variables explain the relationship between education and smoking behavior?

The effect of education, depressive symptoms, trait anxiety, and coping traits (approach-belief, monitoring-creating-executing, and self-regulating) were tested on smoking behavior among 574 young adult males. We hypothesized that depression, anxiety, and coping traits were mediators in the relationship between education and smoking. Univariate analyses showed a significant association between smoking behavior and depressive symptoms, higher trait anxiety score, and lower scores on approach-belief and self-regulating traits. Education was significantly associated with depressive symptoms and coping traits. Although we found significant associations between smoking and education, smoking and depression, and education and depression, the hypothesis was not supported. A similar pattern was found in the case of coping traits. A multivariate logistic regression showed that low education (OR = 4.29), severe depression (OR = 1.84), and low self-regulating coping traits (OR = 2.19) were independent risk factors for smoking. The relationship between education and smoking cannot be explained by these individual variables.     

Impact of Posttraumatic Stress Disorder on early smoking lapse and relapse during a self-guided quit attempt among community-recruited daily smokers

The present investigation examined whether daily smokers with posttraumatic stress disorder (PTSD), as compared to daily smokers with either anxiety psychopathology or no current Axis I psychopathology, have decreased success in the early phases of a self-guided smoking quit attempt. Participants were 140 daily smokers (81 women; M (age) = 29.5; SD = 11.9; range = 18-65 years); approximately one-third of the sample met criteria for current PTSD (n = 47), one-third met criteria for other current anxiety disorders (without PTSD; n = 33), and one-third did not meet criteria for any current Axis I disorder (n = 60). Consistent with prediction, membership in the PTSD group, compared to membership in the other anxiety disorders group and the group with no current Axis I psychopathology, was associated with increased risk of lapse during the first week following quit day. Additionally, daily smokers with PTSD and other anxiety disorders were at significantly increased risk of relapse during the first week post-cessation compared to persons without Axis I psychopathology. However, the PTSD group and the other anxiety disorders group did not differ from one another in terms of relapse. Results suggest that PTSD is associated with increased risk of smoking lapse and relapse compared to smokers with no current Axis I psychiatric problems, and increased risk of early smoking lapse but not relapse, as compared to those with other anxiety disorders. Findings provide novel evidence that PTSD, and perhaps anxiety disorders more generally, may be important factors in reducing the odds of successful unaided quit attempts in the early phases of cessation.     

The role of impulsivity on smoking maintenance.

In order to better understand why those higher in impulsivity experience more difficulties during smoking abstinence, the current study examined the possible mechanisms contributing to cigarette smoking relapse. Fifty dependent cigarette smokers completed measures designed to assess craving, tobacco withdrawal severity, and negative affect during 48 hours of nicotine abstinence. Using a series of multilevel models (SAS Proc Mixed Procedure), significant impulsivity x time analyses revealed differences in craving, F(2, 96) = 3.74, p<.05, and anxiety, F(2, 96) = 3.23, p<.05. Simple slopes analyses indicated that heightened trait-impulsivity predicted greater increases in craving and anxiety during a 48-hour abstinence period. These findings suggest that smokers with higher levels of impulsivity may lack the ability to find an accessible and comparable substitute for cigarette smoking during a cessation attempt. This study also highlights the importance of considering individual differences when treating those who wish to quit smoking.     

Ad lib smoking in post-traumatic stress disorder: an electronic diary study

Using ambulatory methods for 1 week of monitoring, this study investigated the association between smoking and situational cues in 22 smokers with post-traumatic stress disorder (PTSD) and 23 smokers without PTSD. Generalized estimating equations contrasted 1,759 smoking and 1,088 nonsmoking situations by group status controlling for multiple covariates. PTSD smokers reported higher stress and PTSD symptoms across daily activities. For all smokers, higher nicotine dependence, craving, food and caffeine consumption, and being outside were related to smoking. PTSD smokers were more likely to smoke when experiencing PTSD symptoms, anxiety, and stress. Following smoking, smokers with PTSD reported a significant reduction in negative affect. These results are consistent with previous ambulatory findings regarding mood in smokers, and underscore that in smokers with PTSD, PTSD symptom variables as well as stress and anxiety are significantly associated with ad lib smoking.     

Tobacco use and readiness to quit smoking in low-income HIV-infected persons.

The study aim was to identify covariates of smoking status and readiness to quit that encompassed key sociodemographic and health status variables, health-related quality of life, drug use and unprotected sex, and tobacco use variables in a cohort of low-income persons living with HIV. We also examined the impact of HIV diagnosis on smoking cessation. The sample (N = 428) was mostly male (59%) and Black (53%) or Hispanic (30%), and had a high school education or less (87%). Mean age was 40 years. Two-thirds of participants were current smokers, 19% former smokers, and 16% never smokers. Current smokers smoked a mean of 16 cigarettes/day for 22 years; 42% were in the precontemplation stage of readiness to quit smoking, 40% were contemplators, and 18% were in preparation. Most current smokers (81%) reported receiving medical advice to quit smoking. Multivariate logistic regression analyses indicated that current smokers, compared with former smokers, were more likely to use illicit drugs, perceive a lower health risk for continued smoking, and report less pain. Current smokers, compared with nonsmokers (former and never smokers), were more likely to report greater illicit drug use in their lifetime, current illicit drug use, and less pain. A multiple linear regression indicated that greater current illicit drug use, greater emotional distress, and a lower number of quit attempts were associated with lower stage of readiness to quit smoking. These findings confirm a high prevalence of smoking among HIV-infected persons and suggest a complex interplay among drug use, pain, and emotional distress that impact smoking status and, among smokers, readiness to quit. Tobacco control programs for HIV-infected persons should build motivation to quit smoking and address salient barriers to cessation--such as comorbid drug use, emotional distress, pain, and access to and coverage for treatment--and should educate smokers regarding the HIV-specific health benefits of cessation.     

Recommendation for the assessment of tobacco craving and withdrawal in smoking cessation trials.

This paper addresses methodological issues in the assessment of nicotine withdrawal and craving in clinical trials of smoking cessation therapies. We define withdrawal as a syndrome of behavioral, affective, cognitive, and physiological symptoms, typically transient, emerging upon cessation or reduction of tobacco use and causing distress or impairment of behavioral function. Offset effects (effects related to removal of a direct nicotine effect) are sustained effects of cessation or reduction of tobacco use that cause distress or impairment. Withdrawal and craving are important as potential predictors of relapse, as mediators and markers of treatment effects, and as clinical phenomena in their own right. Symptoms recommended for assessment include craving, irritability, depression, restlessness, sleep disturbance, difficulty concentrating, increased appetite, and weight gain; anxiety deserves further study. We recommend reporting of data on each of these individual symptoms, and use of multiple-item assessments. Although some standardized measures of withdrawal have promising psychometric properties, no measure has yet fully established its reliability, validity, and broad applicability and, therefore, we do not currently favor universal adoption of any one measure. Assessment of objective indices of withdrawal (e.g., hormonal changes) is currently technically challenging and of unknown value. Although weekly assessment may suffice in some large trials, more intensive measurement can provide better sensitivity. Analyses of withdrawal should include baseline measures and be sensitive to potential instability in baseline. Analytic approaches should take into account potential bias when only abstinent subjects are examined. Conversely, heterogeneity should be considered when smoking subjects are included in intent-to-treat analyses. Withdrawal data from clinical trials focused on assessing abstinence rates may be biased because of progressive subject loss to dropout and relapse; different designs and approaches are needed to investigate the process and natural history of craving and withdrawal.     

Real-time craving and mood assessments before and after smoking.

This study explored some quandaries concerning craving and mood as motivators to smoke. Craving and negative mood have long been associated with day-to-day smoking as two of the primary motivational forces behind the maintenance of the behavior, as well as significant barriers in smokers' attempts to quit. Craving remains a clinically relevant phenomenon, with most smokers describing craving as a troublesome problem when quitting. Smokers' self-reports of negative mood, as an antecedent for smoking, are so robustly reported that many models of nicotine dependence have incorporated a critical role for negative mood in maintaining smoking behavior. However, several naturalistic studies that collected mood ratings with hand held computers from smokers in real time, just before smoking a cigarette, have provided scant evidence that negative mood plays a major role in motivation to smoke. No study to date has examined craving and mood data as a consequence of smoking, that is, collecting the same data immediately after smoking. This study used personal digital assistants (PDAs) to collect craving and mood data immediately before smoking, immediately after smoking, and at random times of day. Nontreatment seeking smokers (N = 72) carried a PDA for an average of 10 days while they recorded their smoking behavior. Results showed that craving and negative mood ratings were lowest immediately after smoking compared with immediately before smoking and at random times of day. These findings suggest that smokers may be at least partially motivated to smoke to lower their craving and improve their mood states.     

Clinical significance of tobacco withdrawal.

To estimate the clinical significance of tobacco withdrawal, this review located six experimental studies that reported Profile of Mood States (POMS) scores after stopping smoking in untreated smokers and compared them with scores in psychiatric outpatients. The pre-cessation POMS Total Mood Disturbance scores (median = 13.6) were similar to adult norms (mean, M = 17.8) but during abstinence (M = 5 days), the scores had increased (M = 27.4) to be similar to that of psychiatric outpatient norms (M = 25.1). These results and others suggest stopping smoking causes clinically significant distress.     

Smoking behavior among hospital staff still influences attitudes and counseling on smoking.

Smoking among health professionals has been shown to influence smoking-related knowledge and counseling in clinical practice. The evidence regarding smoking as a risk factor has increased in the past decade. The present study was carried out in 2000 and investigated the associations between individual smoking behavior among hospital staff and (a). smoking-related knowledge, (b). attitudes toward counseling on smoking, and (c). self-reported smoking-related counseling provided by the staff. The study was based on a survey using self-administered questionnaires given to all hospital staff in a large university hospital in Denmark. Altogether, 82% of staff (2561) returned a completed questionnaire. Analyses focused on a subsample consisting of health professionals in the clinical wards (1429). Multivariate analyses were performed in which smoking-related knowledge, attitudes toward smoking-related counseling, smoking-related counseling practices, and self-rated qualifications for counseling were main outcome measures. Health professionals who were current smokers systematically underestimated the health consequences of smoking and differed significantly from nonsmokers in their assessments of smoking as a risk factor. Nonsmokers might overestimate smoking as a risk factor. Nonsmokers gave patients advice on smoking cessation significantly more often than did current smokers (ex-smokers, OR=2.5, 95% CI=1.8-3.4; never-smokers, OR=1.5, 95% CI=1.1-2.0). Ex-smokers and smokers felt significantly more qualified to counsel patients about smoking than did never-smokers (ex-smokers, OR=1.8, 95% CI=1.3-2.5; smokers, OR=1.4, 95% CI=1.0-1.9). Individual smoking behavior among hospital staff was strongly associated with smoking-related knowledge, attitudes, and counseling practices. Lack of self-rated qualifications was a major barrier to professional counseling on smoking in a hospital framework.     

Smokeless Tobacco Use and Its Relation to Panic Disorder, Major Depression, and Posttraumatic Stress Disorder in American Indians

INTRODUCTION: Rates of nicotine use are high in American Indians. Anxiety and depression tend to be associated with cigarette use, but the association of anxiety and depression with smokeless tobacco (ST) is less clear. We asked if panic disorder, major depression, and posttraumatic stress disorder (PTSD) are related to lifetime ST use in 2 American Indian tribes. METHODS: Logistic regression analyses examined the association between lifetime panic disorder, major depression, and PTSD and the odds of lifetime ST use status after controlling for sociodemographic characteristics, smoking status, and alcohol use disorders in 1,506 Northern Plains and 1,268 Southwest tribal members. RESULTS: Odds of lifetime ST use was 1.6 times higher in Northern Plains tribal members with a lifetime history of PTSD after controlling for sociodemographic variables and smoking (95% CI: 1.1, 2.3; p = .01). This association remained significant after further adjustment for panic disorder and major depression (odds ratio [OR] = 1.5; 95% CI: 1.0, 2.2; p = .04) but was diminished after accounting for alcohol use (OR = 1.3; 95% CI: 0.9, 1.9; p = .23). In the Southwest, lifetime psychiatric disorders were not associated with lifetime ST use status. Increasing psychiatric comorbidity was significantly linked to increased odds of ST use in both tribes. Conclusions: This study is the first to examine psychiatric conditions and lifetime ST use in a large, geographically diverse American Indian community sample. Although approximately 30% of tribal members were lifetime users of ST, the association with lifetime psychiatric disorders was not as strong as those observed with cigarette smoking. Understanding shared mechanisms between all forms of tobacco use with anxiety and depressive disorders remains an important area for investigation.     

A randomized, open-label pilot comparison of gabapentin and bupropion SR for smoking cessation.

This 6-week, randomized, open-label pilot study estimated the treatment effect size of gabapentin (n = 17) compared with bupropion SR (n = 19) for smoking cessation, thereby allowing sample size calculations for a definitive comparison study. The primary outcome measure was smoking cessation. Secondary outcome measures included smoking reduction and withdrawal severity. Gabapentin was less efficacious than bupropion for smoking cessation but was associated with fewer dropouts from adverse effects. Withdrawal severity was less with bupropion. Bupropion remains the first-line non-nicotine pharmacotherapy for smoking cessation. Further study is required to determine if gabapentin has any useful role in smoking cessation. Based on our primary outcome measure, 79 subjects would be required in each treatment group of a two-armed study to achieve 90% power for detecting a difference in efficacy between gabapentin and bupropion.     

Association of post-treatment smoking change with future smoking and cessation efforts among adolescents with psychiatric comorbidity.

Little is known about how initial change following a smoking intervention relates to longer-term smoking outcomes among adolescent smokers with psychiatric comorbidity. The present study investigated this relationship among psychiatrically hospitalized adolescents (N = 183) who participated in a controlled trial comparing motivational interviewing to brief advice. Quit attempters (n = 37), reducers (n = 45), and maintainers (n = 101) were assembled based on, respectively, having made a quit attempt, having reduced smoking by at least 50%, and having reduced smoking by less than 50% in the first week after hospital discharge. Hierarchical linear models and generalized estimating equations were conducted to test group differences in average number of cigarettes per smoking day and odds of making a quit attempt during subsequent weeks of a 12-month continuous follow-up, and in cotinine-verified abstinence rates at 1, 6, and 12 months posthospitalization. Baseline smoking levels and presence of a substance use disorder or anxiety disorder were predictive of outcomes. After controlling for covariates, we found that quit attempters smoked less during follow-up than did the other change groups and that reducers smoked less than maintainers. Quit attempters evidenced a higher percentage of quit attempts during follow-up than did the other change groups. Reducers had a greater average percentage of quit attempts during follow-up than did maintainers. However, groups did not differ on cotinine-verified abstinence rates across the follow-up period. Findings have implications for initial post-treatment change as it relates to subsequent smoking and cessation outcomes among adolescent smokers at especially high risk for smoking persistence.