Do ethnicity and gender moderate the influence of posttraumatic stress disorder on time to smoking lapse?
Introduction
Posttraumatic stress disorder (PTSD) presents a significant barrier to smoking cessation in the general population (Hapke et al., 2005). Around 45% of individuals with PTSD are current smokers, and PTSD is associated with an increased likelihood of being a smoker (Feldner, Babson, & Zvolensky, 2007). Evidence suggests that smoking increases the risk of developing PTSD (Breslau et al., 2004, Koenen et al., 2005). Moreover, PTSD smokers are less able to quit smoking and have a shorter time to first smoking lapse within the first week of a quit attempt (Zvolensky et al., 2008). It is theorized that core features of PTSD, including trauma symptoms and increased negative affect, represent key risk factors for smoking lapse and relapse (Beckham et al., 2013, Beckham et al., 2007, Cook et al., 2007). Additionally, individuals with PTSD experience more intense withdrawal symptoms during smoking cessation, which could also increase the risk for smoking relapse (Dedert et al., 2012). Since smoking is related to PTSD symptoms and PTSD symptoms can in turn increase the risk for smoking relapse, it is essential to further investigate early lapse in PTSD smokers.
Rates of smoking relapse within the general population are also affected by gender and ethnicity (Japuntich et al., 2011). In a large-scale clinical trial testing the efficacy and effectiveness of different types of smoking cessation treatment, both females (compared to males) and Black smokers (compared to White smokers) were more likely to relapse following a quit attempt, largely regardless of treatment used (Piper et al., 2010). It is theorized that ethnic and gender differences in nicotine metabolism (Hukkanen, Jacob, & Benowitz, 2005) – possibly related in part to genetic polymorphism of the CYP2A6 gene (Derby et al., 2008) – significantly contribute to increased susceptibility of smoking relapse. Specifically, females may be more highly addicted to nicotine due to their faster nicotine metabolism, which likely increases their level of dependence (Benowitz, Lessov-Schlaggar, Swan, & Jacob, 2006). In contrast, smokers of African and Asian descent generally metabolize nicotine more slowly than smokers of European descent (Nakajima et al., 2006); yet Black smokers take in significantly more nicotine per cigarette and are more highly addicted compared to White smokers (Benowitz, 2008, Perez-Stable et al., 1998). These data, taken together, suggest that women and Black smokers have increased risk for smoking lapse following a quit attempt.
In addition to main effects of ethnicity and PTSD on smoking cessation, ethnicity may moderate the effect of PTSD on smoking cessation. Differences in smoking rates between ethnicities are likely influenced by several societal and cultural factors, as well as individual differences. A nationally representative study found that for minorities (defined as Black and Hispanic respondents) there was no significant relationship between past-30-day psychological distress and current smoking status or cigarettes smoked per day. However, there was a significant association of psychological distress with smoking status in White respondents (Kiviniemi, Orom, & Giovino, 2011). While an association between general distress and smoking status has clinical relevance, it is important to determine whether the same relationship may or may not be present when considering an interaction between ethnicity and specific psychiatric diagnoses. Another nationally representative study of Black Americans found that the presence of a lifetime or current psychiatric disorder was significantly associated with current smoking status. In addition, past year and past month psychiatric disorders were significantly associated with lower odds of being at least one year abstinent (Hickman, Delucchi, & Prochaska, 2010). Existing knowledge regarding the interaction between ethnicity and psychiatric disorders is limited because previous research has relied on retrospective report and has not examined specific psychiatric disorders, such as PTSD. There is a need for research that utilizes prospective methodology to monitor post-quit lapse events as they occur.
The effects of major sociodemographic factors such as ethnicity and gender on smoking cessation in PTSD are particularly important because women and Black Americans are more likely to have PTSD, and are more likely to have difficulty quitting smoking (Benowitz, 2008, Brewin et al., 2000). As these groups are overrepresented among PTSD smokers, it is important to investigate how ethnicity and gender influence cessation behaviors in smokers with PTSD. The aim of the current study is to provide the first prospective investigation of the moderating effect of ethnicity on PTSD with regard to smoking lapse following a quit attempt. The study hypotheses were: 1) ethnicity will significantly predict lapse after quitting, with Black smokers exhibiting a faster lapse rate compared to Whites; 2) female gender will be associated with faster lapse rate; 3) ethnicity will moderate the effect of PTSD on lapse rate, such that Black smokers will exhibit a smaller effect of PTSD on lapse rate; and 4) gender will also moderate the effect of PTSD on lapse rate, such that women will have a larger effect of PTSD on lapse rate.
Section snippets
Participants
Data for the current study were taken from a larger study investigating early smoking lapse in smokers with and without PTSD (Beckham et al., 2013). Participants were Black and White smokers with PTSD (n = 48) and a comparison group with no current Axis I psychiatric disorders (n = 56). Eligibility criteria included smoking at least 10 cigarettes daily for the past year, willingness to make a smoking cessation attempt, and aged 18–65. One hundred ninety-nine individuals were recruited and screened
Results
Descriptive characteristics are presented in Table 1. At baseline, individuals with PTSD had a higher level of nicotine dependence as measured by the FTND, and a higher incidence of lifetime major depressive disorder, current anxiety disorder other than PTSD, and lifetime alcohol dependence. Overall, rates of lifetime alcohol and drug dependence in the sample were high (see Table 1). Of the 104 participants who initiated a quit attempt, 91 participants (88%) had at least one smoking lapse
Discussion
This study yielded several findings with relevance for clinical treatment and provided the first prospective examination of how the effect of PTSD on time to lapse is moderated by ethnicity. In considering intervention in the early course of a smoking cessation attempt, the presence of PTSD is an established risk factor for early lapse. This report provided data suggesting that the effect of PTSD on early lapse is particularly evident in White smokers.
Results indicated that for Black smokers,
Conclusions
The data presented in the current report are consistent with previous empirical research (Kiviniemi et al., 2011), suggesting that PTSD is not as closely related to smoking cessation success in Black smokers. As a result, biological and sociocultural factors influencing the cessation process in Black smokers are in need of further research. There is a need to go beyond previously identified sociocultural barriers to smoking cessation (e.g., low income and discrimination) in order to evaluate
Role of funding sources
This work was supported primarily by the National Institutes of Health Grants R01CA081595, R01CA81595-07S1, K24DA016388, R21DA019704, and R21CA128965; the Department of Veterans Affairs Office of Research and Development, Clinical Science; and the Mid-Atlantic Mental Illness Research Education and Clinical Center.
Contributors
Drs. Beckham and Calhoun designed the parent study and wrote the protocol. Ms. Wilson conducted the literature searches and devised specific hypotheses relevant to the current study. Ms. Dennis and Ms. Kirby oversaw data collection and prepared the dataset for analysis. Dr. Dennis conducted the statistical analysis. Ms. Wilson and Dr. Dedert wrote the first draft of the manuscript and all authors contributed to and have approved the final manuscript.
Conflict of interest
All authors declare that they have no conflicts of interest.
Acknowledgments
This work was supported primarily by the National Cancer Institute grant 2R01 CA091595 and the National Institute on Drug Abuse grant 2K24 DA016388, and the Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development Clinical Science. The authors would like to thank the participants who volunteered to participate in this study. The views expressed in this presentation are those of the authors and do not necessarily represent the views of the National
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