Elsevier

Addictive Behaviors

Volume 32, Issue 2, February 2007, Pages 214-227
Addictive Behaviors

Posttraumatic stress symptoms and smoking to reduce negative affect: An investigation of trauma-exposed daily smokers

https://doi.org/10.1016/j.addbeh.2006.03.032Get rights and content

Abstract

The present investigation examined the relations among posttraumatic stress symptoms and smoking motives. Participants included 100 daily smokers recruited from the community and university settings who reported exposure to at least one traumatic event that met criterion A for posttraumatic stress disorder. Consistent with prediction, higher levels of posttraumatic stress symptoms were associated with smoking to reduce negative affect; this relation was observed after controlling for variance accounted for by number of cigarettes smoked per day and gender. Results are discussed in terms of the implications of smoking to regulate affect among daily smokers who have been exposed to traumatic events.

Introduction

Past research has demonstrated that exposure to traumatic events is associated with increased smoking behavior (Weaver & Etzel, 2003). For example, compared to persons without trauma exposure, higher rates of smoking have been found among individuals exposed to various trauma types, including interpersonal violence (Acierno et al., 1996, Weaver & Etzel, 2003), combat exposure (Beckham et al., 1995, Shalev et al., 1990), and witnessing violence (Acierno et al., 1996). These data highlight the importance of better understanding the nature of the smoking–trauma association.

An important aspect of the relation between smoking and trauma in need of further study is the explication of motivations for smoking among daily smokers who have been exposed to traumatic events. Numerous researchers have theorized that persons who respond symptomatically to trauma exposure may smoke to regulate negative affect to a greater extent than those without such reactions (Acierno et al., 1996, Beckham, 1999, Beckham et al., 1995, Weaver & Etzel, 2003). Additionally, relative to other motivations for smoking, such as relaxation or addictive motives, negative affect reduction motives may be more likely among individuals with trauma symptomatology. Although the anxiety-ameliorating effects are complex and not completely understood (Kalman, 2002), most smokers believe smoking will alleviate negative affective states (Brandon, 1994, Parrott, 1999, Pomerleau & Pomerleau, 1991). Building from such work, some have suggested that, in the absence of other more adaptive coping strategies, smokers who respond symptomatically to trauma may learn to rely on smoking to manage anxiety and other negative mood states (Acierno et al., 1996). This perspective is consistent with other smoking-anxiety work that has shown individuals with pre-morbid panic vulnerability factors (e.g., anxiety sensitivity) or clinically significant panic problems (e.g., panic disorder) tend to smoke to attempt to terminate or avoid nicotine withdrawal or related aversive states such as anxiety (Zvolensky & Bernstein, 2005, Zvolensky et al., 2006, Zvolensky et al., 2005). Indirect evidence, albeit limited, supports this model. First, smoking is associated with greater posttraumatic stress symptomatology (Beckham et al., 1995, Schnurr & Spiro, 1999) and trauma-exposed individuals with, versus without, associated psychopathology are significantly more likely to be current smokers (Acierno et al., 1996), begin smoking (Breslau, Davis, & Schultz, 2003), smoke at higher rates (Beckham et al., 1997), and evidence greater puff volumes (which maximize smoke delivery) while smoking (McClernon et al., 2005). Second, anxiety-inducing situations increase smoking cravings among smokers with trauma-related psychopathology (Beckham et al., 1996). Finally, smokers who fear anxiety-related sensations, such as those with posttraumatic stress disorder (PTSD; Lang et al., 2002, Taylor et al., 1992), expect tobacco use to help alleviate aversive anxiety states (Zvolensky et al., 2004) and these individuals often principally smoke to regulate affect (Zvolensky et al., 2006).

Despite recognition that smoking to reduce negative affect may be integral to understanding the smoking–trauma relation, there have been relatively few direct tests of the model. In one study (Beckham et al., 1995), a sample of 124 daily smoking male Vietnam veterans seeking help for PTSD was examined. Here, several variables, including marital status, race, combat exposure, state and trait anxiety, PTSD symptomatology, and depressive symptoms, were entered as predictors into a stepwise regression model predicting six different motives for smoking (i.e., stimulation, indulgent, psychosocial, sensorimotor, addictive, and automatic) on an abbreviated version of the Motives for Smoking Scale (Russell, Peto, & Patel, 1974). Additionally, an identical regression model was utilized to predict negative affect reduction motives, which were indexed via two (of the six) items that measure such motives on the Reasons for Smoking questionnaire (Ikard, Green, & Horn, 1969) and one item from the Motives for Smoking Scale. Depressive symptoms emerged as the only significant predictor of automatic smoking motives and there were no other significant predictors for other smoking motives. To the best of our knowledge, only one other study tested the relation between PTSD (presence versus absence) and motives for smoking, wherein 445 help-seeking Vietnam combat-exposed veterans were studied (Beckham et al., 1997). The researchers, again, utilized an abbreviated version of the Motives for Smoking Scale, and results were reported for six subscales: stimulation, indulgent, tension reduction, addictive, automatic, and psychosocial. After statistically controlling for age, socioeconomic status, and combat exposure, the presence of PTSD predicted greater indulgent, addictive, automatic, and tension reduction motives for smoking. Smoking status [heavy (≥ 25 cigarettes per day) versus light-moderate (< 25 cigarettes per day)], which significantly predicted all smoking motives except for indulgence, did not moderate the association between PTSD and smoking motives despite persons with PTSD being more likely to be heavy smokers.

There are a number of key limitations to extant research pertaining to smoking motivation among trauma-relevant samples. First, negative affect reduction motives for smoking are of central interest to theory explaining why people who respond to trauma symptomatically evidence high smoking levels, yet the validity of negative affect reduction measures used to date is unclear. Specifically, the scale indexing smoking to reduce negative affect utilized by Beckham et al., 1995, Beckham et al., 1997 was comprised of items from two separate measures and little psychometric data were reported. Second, prior studies have not controlled for number of cigarettes smoked per day, which is unfortunate, as smoking levels relate to smoking motivations (Beckham et al., 1997, Zvolensky et al., 2006). Controlling for number of cigarettes smoked per day would be an important contribution to this literature, as its inclusion would increase confidence that associations between posttraumatic stress symptomatology and smoking motivations are due to trauma-related psychopathology, and not differing smoking levels between those with, versus without, posttraumatic stress psychopathology. Third, the stepwise regression approach utilized by Beckham et al. (1995) may have underestimated the relation between trauma-related symptomatology and motives for smoking. Specifically, statistically controlling for variance accounted for by depressive symptoms in these analyses may be problematic because of the high degree of overlap between depressive and posttraumatic stress symptomatology (see Acierno et al., 2000). And finally, it is noteworthy that prior studies have focused on persons suffering from combat-related chronic and severe PTSD. The degree to which the findings from these studies generalize to trauma-exposed persons more generally is not clear. Instead, these findings may be specific to factors that relate to long-term maintenance of PTSD among this chronic subgroup.

The present study sought to address these limitations by examining the relations between posttraumatic stress symptomatology and smoking motives among trauma-exposed young adults. The current study sampled younger adults than those studied in previous research (Mages = 45 and 47 years; Beckham et al., 1995, Beckham et al., 1997), which was advantageous for two reasons: (1) this represents a novel extension to prior research on trauma and smoking motives and (2) smoking generally peaks among young adults between the ages of 18 and 25, and smoking prevalence among this age group has risen in recent years (Presley et al., 2002, Wechsler et al., 1998). The primary hypothesis tested was that greater levels of posttraumatic stress symptoms would predict greater negative affect reduction smoking motives above and beyond number of cigarettes smoked per day and gender, both of which relate to smoking motives (Beckham et al., 1997, Ikard et al., 1969, Zvolensky et al., 2006). For instance, in a national probability sample of 2094 smokers, habitual, addictive, and negative affect reduction motives demonstrated moderate-sized correlations with daily smoking levels among both males (r's 0.27–0.41) and females (r's 0.40–0.53); also, males endorsed significantly higher levels of habitual and addictive motives than females and females endorsed higher levels of smoking to reduce negative affect than males (Ikard et al., 1969). Similarly, among 151 young adult daily smokers, women were significantly more likely to smoke to reduce negative affect than males (Zvolensky et al., 2006). This hypothesis was driven by conceptual models and empirical work suggesting that anxiety risk factors and symptoms are related to greater motivations to smoke to cope with negative affect states (Zvolensky & Bernstein, 2005). It also was expected that posttraumatic stress symptom levels would relate to habitual and addictive smoking motives, but it was not expected that this relation would be observed above and beyond cigarettes smoked per day and gender, as smoking level was expected to account for this relation. Finally, consistent with previous research, we did not expect posttraumatic stress symptoms would relate to relaxation or sensorimotor manipulation motives for smoking.

Section snippets

Participants

The sample consisted of 100 (49 females) daily cigarette smokers who reported exposure to at least one traumatic event. The sample ranged in age from 18 to 61 (M = 24.52; S.D. = 9.95) years, which can be contrasted to the mean participant ages of 45 (S.D. = 2.9; Beckham et al., 1995) and 47 (S.D. = 4.3; Beckham et al., 1997) years in previous investigations of the relation between smoking motives and PTSD symptoms. Participants were screened from a larger sample of participants (n = 627) recruited via

Descriptive data and zero-order correlations

First, in terms of descriptive information regarding smoking characteristics, on average participants were smoking 16.18 (S.D. = 7.04) cigarettes per day, began smoking at age 15.58 (S.D. = 2.54), and reported regularly smoking for an average of 10.14 (S.D. = 11.96) years. Mean scores on the subscales of the RFS (Ikard et al., 1969) were as follows: 19.79 (S.D. = 5.49) for negative affect reduction; 7.03 (S.D. = 2.59) for stimulation; 8.37 (S.D. = 2.92) for habitual reasons; 15.33 (S.D. = 4.12) for addictive

Discussion

Consistent with prediction, greater posttraumatic stress symptom levels predicted greater smoking to reduce negative affect. Moreover, this relation was observed above-and-beyond variance accounted for by the theoretically relevant factors of gender and cigarettes smoked per day, both of which have been linked to smoking to reduce negative affect (Ikard et al., 1969, Wetter et al., 1999, Zvolensky et al., 2006). That is, trauma-exposed individuals with higher levels of posttraumatic stress

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