An experimental investigation of the functional relationship between social phobia and cigarette smoking
Introduction
Individuals with psychological disorders are overrepresented among U.S. smokers, experience a disproportionate amount of the smoking-related public health burden, and, as such, are an important target for prevention and intervention efforts (Schroeder & Morris, 2010). Psychological comorbidities for which cigarette smoking may be used to cope with or manage psychological symptoms may be the most problematic for smoking outcomes (Gehricke et al., 2007). A growing body of research suggests that Social Phobia (SP), a highly prevalent disorder for which 12.1% of the population meets diagnostic criteria (Ruscio et al., 2008), exhibits this relationship with tobacco use such that SP symptoms predict the initiation of cigarette smoking (Johnson et al., 2000), nicotine dependence (Sonntag, Wittchen, Höfler, Kessler, & Stein, 2000), and poor cessation outcomes (Lasser et al., 2000, Ruscio et al., 2008). Moreover, there are significantly greater rates of smoking among individuals with SP than among individuals without psychological comorbidities; specifically, 54.0% of individuals with SP are lifetime smokers and 35.9% of individuals with SP are current smokers (Lasser et al., 2000, Ruscio et al., 2008).
In teasing apart potential mechanisms underlying the relationship between cigarette smoking and SP, a negative reinforcement model is relevant. From a negative reinforcement framework, individuals with SP would smoke cigarettes in order to reduce or avoid feelings of distress in relation to social situations or in anticipation of social situations. There has been some support for this negative reinforcement link between SP and cigarette smoking in early adolescence prior to the onset of regular smoking such that adolescents high in SP report greater urge to smoke during peer interactions than adolescents without elevated SP symptoms (Henry, Jamner, & Whalen, 2012), suggesting that tobacco use may develop and escalate as a method to regulate social anxiety.
Strong theory and etiological data suggest the temporal ordering of SP, cigarette smoking onset, and nicotine dependence (e.g., Sonntag et al., 2000). However, there are only a few studies that have examined the functional utility of cigarette smoking for individuals with SP symptomatology. The studies that have examined smoking and SP suggest that SP symptoms are positively related to self-reported smoking to cope behaviors during social situations as well as to cigarette craving when deprived of nicotine (Watson, VanderVeen, Cohen, DeMarree, & Morrell, 2012). Furthermore, the relationship between SP symptoms and nicotine dependence is mediated by affiliative attachment motives, suggesting that among individuals with elevated SP symptomatology, cigarette smoking may help to cope with the feelings of loneliness or social rejection associated with SP (Buckner & Vinci, 2013). Other studies have not specifically assessed SP symptomatology, but have utilized experimental manipulations to induce social stress among samples of smokers and have found that in response to social stress, the urge to smoke is positively associated with self-reported and observer-reported anxiety (Niaura, Shadel, Britt, & Abrams, 2002) and that, in turn, smoking a cigarette is related to lower levels of self-reported anxiety (Gilbert & Spielberger, 1987). Taken together, these studies further support a unique negative reinforcement relationship between SP and tobacco use.
There are several remaining gaps in the literature on SP and cigarette smoking. Although self-report data from Watson et al. (2012) suggests that SP is related to smoking to cope with social situations, this relationship has yet to be experimentally examined and it remains unclear whether cigarette smoking modulates negative affect (NA) associated with social stress for socially phobic smokers. Additionally, no studies to date have assessed smoking behavior (i.e., via smoking topography) among socially phobic smokers in response to social stress. Thus, it remains unknown whether self-reported smoking to cope translates to differential smoking in response to a social stressor as compared to in response to a neutral mood.
Towards addressing these gaps in the extant literature, the primary aims of the current study were two-fold: 1) to examine the relationship between levels of SP (high SP, healthy control with average SP) and cigarette smoking-related outcomes (smoking topography) as a function of induced social stress (neutral, stress) and 2) to examine the relationship between levels of SP (high SP, healthy control with average SP) and NA as a function of induced social stress (neutral, stress). We hypothesized that in response to a social stressor, high SP smokers as compared to average SP smokers, would have: 1) greater smoking outcomes (greater puff number, greater puff volume, shorter interpuff interval (IPI) on measures of smoking topography) and 2) greater NA modulation as a function of smoking evidenced by significant increases in NA in anticipation of a social stressor followed by significant decreases in NA after smoking a cigarette.
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Participants
Participants were recruited from the University of Maryland, College Park campus using flyers and postings online. Interested individuals were advised to contact the study by phone or e-mail to complete an online screening to determine eligibility. Inclusion criteria for the study were as follows: 1) ages 18–21, 2) current regular smoking defined as smoking ≥ 5 cigarettes/smoking day (CPSD) for the past 6 months and smoking on ≥ 20 out of the last 30 days, and 3) a score of either > 35 or between 9
Descriptive findings
Average CPSD for the sample was M(SD) = 7.67(4.36). On average, participants first smoked at age 15.59(2.62), began smoking weekly at age 17.46(1.63), and began smoking daily at age 18.19(1.35). mFTQ levels were relatively low (M(SD) = 4.04(1.27)). High SP individuals reported smoking significantly more CPSD (M(SD) = 9.02(4.74)) than average SP (M(SD) = 6.51(3.69)) individuals [F(1,52) = 4.76, p = .03].
Summary of main findings
The present study provides an experimental examination of the relationship between SP, social stress, cigarette smoking, and affect in order to understand the functional role of cigarette smoking for individuals with SP symptomatology. Regarding the first study aim, we did not find significant SP group by condition effects on smoking topography outcomes. There are two plausible explanations for this finding. First, we were interested in individuals between the ages of 18 and 21 and recruited a
Role of funding sources
This research was supported by NIDA grant F31DA034999 to Jennifer Dahne. The sponsor had no role in the design and conduct of the study; or in the preparation, review, or approval of the manuscript.
Contributors
Jennifer Dahne conceptualized and designed the study, conducted the statistical analyses, and was the lead in the manuscript preparation. Leanne Hise and Misha Brenner assisted in running the study and in manuscript revisions. C.W. Lejuez and Laura MacPherson supervised all aspects of the study and extensively edited and revised the manuscript. All authors contributed to and have approved the final manuscript.
Conflict of interest
The authors have no conflicts of interest to declare.
Acknowledgments
The authors acknowledge Dr. Thomas Eissenberg for generously lending smoking topography devices.
References (23)
- et al.
Smoking and social anxiety: The roles of gender and smoking motives
Addictive Behaviors
(2013) - et al.
Development and validation of measures of social phobia scrutiny fear and social interaction anxiety
Behaviour Research and Therapy
(1998) - et al.
Response to social stress, urge to smoke, and smoking cessation
Addictive Behaviors
(2002) - et al.
Acute negative affect relief from smoking depends on the affect situation and measure but not on nicotine
Biological Psychiatry
(2010) - et al.
Validation of the modified Fagerström Tolerance Questionnaire with salivary cotinine among adolescents
Addictive Behaviors
(2000) - et al.
Influence of social stress on risk-taking behavior in adolescents
Journal of Anxiety Disorders
(2013) - et al.
Are social fears and DSM-IV social anxiety disorder associated with smoking and nicotine dependence in adolescents and young adults?
European Psychiatry
(2000) - et al.
Examining the interrelationships between social anxiety, smoking to cope, and cigarette craving
Addictive Behaviors
(2012) - et al.
Reliability and validity of a smoking timeline follow-back interview
Psychology of Addictive Behaviors
(1998) - et al.
Depression moderates smoking behavior in response to a sad mood induction
Psychology of Addictive Behaviors
(2009)
Smoking to self-medicate attentional and emotional dysfunctions
Nicotine & Tobacco Research
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