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Psychosocial Processes Underlying Smoking: Still More to Learn

May 2008
27(3S):S185-S186

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As reflected in the articles in this special issue of Health Psychology, numerous questions remain to be answered concerning the complex psychological processes that determine tobacco use and cessation. Furthermore, the articles exemplify the value of employing a variety of research designs to address the myriad of unanswered questions. The challenge we face as scientists is how best to imbed the study of psychosocial processes underlying tobacco use into a dynamic and complex media and policy environment that influences and reflects how society at large construes the problem of tobacco use. For despite the remarkable advances in our understanding of the genomics of nicotine dependence and tobacco-related disease, progress at the ground level of this public health battle must continue to pass through changes in beliefs, attitudes, and behaviors. (PsycINFO Database Record (c) 2013 APA, all rights reserved)

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COMMENTARIES

Psychosocial Processes Underlying Smoking: Still More to Learn

Robert T. Croyle and Cathy L. Backinger

National Cancer Institute

The emergence of transdisciplinary research and models of

tobacco use over the past decade greatly expanded the diversity of

disciplines and methods employed to understand smoking initia-

tion and cessation (Morgan et al., 2003). A field that was primarily

focused on psychological processes in the 1970s now includes

important and ongoing work in genomics, genetics, neuroscience,

imaging, pharmacology, communication science, economics, pol-

icy studies, and systems analysis (Abrams et al., 2003). The

remarkable range of levels of analysis utilized in contemporary

smoking research is exemplified by two recent studies that lie at

the molecular and societal ends of this continuum. Thorgeirsson et

al. (2008) conducted a whole genome scan on biospecimens ob-

tained from research participants in seven countries and identified

a common variant in the nicotinic acetylcholine receptor gene

cluster that was associated with smoking quantity and nicotine

dependence. Farrelly, Loomis, and Mann (2007), utilizing super-

market scanner data on cigarette prices and sales from across the

United States, found that higher prices and taxes are associated

with an increased consumption of higher-yield cigarettes by smok-

ers. The expansion of smoking research into the domains of

genomics and economics clearly strengthens our understanding of

the many determinants of tobacco use, but does it also reflect the

completion of research on psychosocial processes underlying this

life-threatening addictive behavior? We don’t think so.

As reflected in the articles in this special issue of Health

Psychology, numerous questions remain to be answered concern-

ing the complex psychological processes that determine tobacco

use and cessation. Furthermore, the articles exemplify the value of

employing a variety of research designs to address the myriad of

unanswered questions. In the domain of the health cognition,

laboratory experiments continue to play an essential role in teasing

apart causal mechanisms and pathways to persuasion and motiva-

tion (Lopez et al., 2008; Rhodes et al., 2008). These phenomena

can then be studied in the field to validate and replicate the

findings in naturalistic contexts (Catley & Grobe, 2008). Theoret-

ically derived hypotheses can also be tested within the context of

interventions (Fuglestad, Rothman, & Jeffery, 2008; Hertel et al.,

2008; Schumann et al., 2008). Cohort studies that include exten-

sive measures of psychosocial functioning and social relationships,

such as the National Longitudinal Study of Adolescent Health,

have been especially important in understanding risk factors, path-

ways, and comorbidities associated with multiple health risk be-

haviors, including smoking (McCaffery et al., 2008). The impor-

tance of social, political and cultural context on individual-level

behavior is reflected in studies of low-income populations (Nollen

et al., 2008) and in international surveys (Yong & Borland, 2008).

Finally, it is critical that systematic evidence reviews continue to

be supported and conducted to ensure that interventions and public

health policies are informed by the current state of the science

(Webb, 2008). Webb’s (2008) review of research concerning ces-

sation in African American smokers complements the recent re-

lease of the new Public Health Service clinical guideline on

smoking cessation (Fiore et al., 2008), which relied on a broad

review of the enormous literature on cessation, and should be

required reading for every clinical practitioner.

The National Cancer Institute (NCI), along with its partner

institutes and agencies, has made a special effort to expand the

breadth of disciplines engaged in tobacco use research while not

sacrificing research on fundamental psychosocial mechanisms.

The Transdisciplinary Tobacco Use Research Centers (TTURCs)

initiative, which was cofunded by the National Institute on Drug

Abuse, the Robert Wood Johnson Foundation, and the National

Institute on Alcohol Abuse and Alcoholism, was the cornerstone of

this effort (Turkkan, Kaufman, & Rimer, 2000). In addition, we

continue to support a wide range of big and small science projects

in epidemiology, statistical modeling, chemoprevention, and the

early detection of tobacco-related disease. So given the scale and

diversity of tobacco-related research, in what domains is there a

need for more research on psychosocial processes?

Although effective strategies for smoking prevention and ces-

sation exist, there is much room for improvement. As new medi-

cations continue to be developed and tested, it is also essential to

improve counseling and other behavioral methods to support ces-

sation and its maintenance. In addition to new medication devel-

opment, we believe that two other contexts provide important

opportunities for health psychologists to contribute to the literature

on smoking by examining relevant psychosocial processes and

mechanisms. Within the United States, the expanding implemen-

tation of clean indoor air laws, increased taxes on tobacco prod-

ucts, tobacco control media, new tobacco products, and tobacco

product marketing and advertising provide a natural experiment

for understanding how prices, legal constraints, communications

and social norms impact individuals’ beliefs and behaviors. Inter-

nationally, the implementation of provisions of the Framework

Convention on Tobacco Control (World Health Organization,

2005) allow for unique, between-country comparisons of the ef-

fects of new taxes, warning labels, and marketing restrictions that

can inform both psychological theory and public health policy. If

Robert T. Croyle and Cathy L. Backinger, National Cancer Institute.

Correspondence concerning this article should be addressed to Robert T.

Croyle, National Cancer Institute, 6130 Executive Blvd., Room 6138,

Bethesda, MD 20892. E-mail: croyler@mail.nih.gov

Health Psychology In the public domain

2008, Vol. 27, No. 3(Suppl.), S185–S186 DOI: 10.1037/a0012916

S185

Time since smoke-free law and smoking cessation behaviors

Article

Jul 2009
NICOTINE TOB RES

We examined the association between time since implementation of a smoke-free law and cessation behaviors among current and former smokers. A quasiexperimental, three-group design assessed smoking and cessation behaviors via brief telephone interviews with 295 randomly selected current and former smokers who had quit since a smoke-free law took effect in their community. Participants lived in one of four communities that had implemented a smoke-free law in the preceding 6-8 months (n = 106), 18 months (n = 87), or 36 months (n = 102). Compared with those living in communities with relatively new smoke-free laws (6-8 months), those in communities with more established laws (18 and 36 months) were more likely to (a) be former smokers and (b) report a longer time since smoking their last cigarette. Compared with the 6- to 8-month group, those in the 36-month group were more likely to have tried to quit since the law was implemented. Smoke-free laws may have a delayed effect on cessation among adults. The longer a smoke-free law is in effect, the more likely adults will attempt to quit smoking and become former smokers. Maintaining the integrity of smoke-free laws over time is an important population-based quit strategy.

Treating Tobacco Dependence Among African Americans: A Meta-Analytic Review

Article

Full-text available

May 2008

Monica Webb Hooper

Objective: African Americans suffer disproportionately from smoking-related morbidity and mortality; yet it is unclear whether existing treatments benefit this population. The purposes of this meta-analysis were to evaluate the overall efficacy of smoking cessation interventions (SCIs) among African American adults and to examine specific study characteristics and methods that influence treatment outcome. Design: Twenty published and unpublished studies representing 32 hypothesis tests and 12,743 smokers compared SCIs to control conditions. Main Outcome Measures: (1) Smoking abstinence post-treatment; (2) abstinence at the first follow-up assessment; and (3) 11 potential moderators of treatment effects. Results: Overall, SCIs increased the odds of cessation by 40% at posttest and 30% at follow-up. Treatment type, setting, cultural specificity, unit of analysis, outcome measure, nature of control group, and biochemical verification moderated the overall treatment effect size. Conclusion: SCIs are efficacious among African Americans. Theoretical, clinical, and future research implications are discussed.

Getting There and Hanging on: The Effect of Regulatory Focus on Performance in Smoking and Weight Loss Interventions

Article

Full-text available

May 2008

Our primary objective was to determine whether individual differences in regulatory focus (Higgins, 1998) would differentially predict the initiation and maintenance of behavioral change. We hypothesized that people high in promotion focus because they eagerly pursue new positive end-states, would be better able to initiate behavioral change, whereas people higher in prevention focus because they tend to be vigilant in avoiding losses as a means to preserve desired end-states, would be better able to maintain change. We examined our hypotheses in longitudinal studies of smoking cessation and weight loss. Our outcome measures were smoking status and weight. In both interventions, promotion focus, but not prevention focus, predicted successful initiation; people higher in promotion focus had higher quit rates and lost more weight through the first 6 months of follow-up. Of participants who had initial success, prevention focus, but not promotion focus, predicted successful maintenance; people higher in prevention focus were more likely to remain smoke-free and maintain weight loss over the next year. A fit between behavioral task and regulatory focus can facilitate the successful performance of meaningful behaviors over time.

Demographic and Psychosocial Factors Associated With Increased Fruit and Vegetable Consumption Among Smokers in Public Housing Enrolled in a Randomized Trial

Article

Full-text available

May 2008

To examine the demographic and psychosocial factors associated with increased fruit and vegetable (FV) consumption among smokers residing in public housing. Cluster randomized trial of 20 public housing developments (HDs). Ten housing developments were randomly assigned to a FV intervention and 10 to a smoking cessation intervention. Change in daily FV intake over the past 7 days at 8 weeks postbaseline. Above the effect of treatment, baseline confidence for vegetable consumption (model coefficient = 0.19, SE = 0.07, p = .01), decreased barriers (model coefficient = -0.12, SE = 0.04, p = .002) and increased agency (model coefficient = 0.08, SE = 0.04, p = .03) were significantly associated with week 8 FV consumption. Although the intervention produced significant change in FV consumption, the majority of individual psychosocial factors were not associated with this change. Future studies examining the dynamic interaction between interventions and individual, social, and environmental factors are needed to more fully explain dietary change among public housing residents.

Effects of a Body Image Challenge on Smoking Motivation Among College Females

Article

Full-text available

May 2008

Previous correlational and quasi-experimental research has established that weight concerns and negative body image are associated with tobacco smoking, cessation, and relapse, particularly among young women. This study examined the causal influence of body image upon smoking motivation by merging methodologies from the addiction and body image literatures. Using a cue-reactivity paradigm, the study tested whether an experimental manipulation designed to challenge women's body image-specifically, their weight dissatisfaction-influenced their motivation to smoke. Female college smokers (N= 62) were included in a 2 X 2 factorial, within-subjects design (body image cues X smoking cues). Self-reported urge to smoke was the primary dependent measure, with skin conductance as a secondary measure. As hypothesized, the presentation of smoking images and thin model images produced greater urges to smoke than control images. Additionally, trait weight concerns moderated the effect of the body image manipulation such that those women with greater weight concerns produced greater craving to the thin model image (when smoking cues were not present). These findings provide initial evidence that situational challenges to body image are causally related to smoking motivation.

Patterns and Predictors of Change in a Smoking Intervention Study: Latent Growth Analysis of a Multivariate Outcome Model

Article

Full-text available

May 2008

This study reports the outcome of a smoking intervention study in a general population setting in Germany. A randomized, controlled trial, with a sample of 719 current daily cigarette smokers. The authors tested a criterion measurement model that is related to the transtheoretical model and that proposes multivariate outcome measures with positive and negative attitudes about smoking and habit strength. The authors analyzed patterns and predictors of change in self-efficacy and in the pros and cons of nonsmoking using latent growth models. Participation in the intervention groups did not predict average mean levels or growth trajectories in the multivariate outcome model. Accounting for attrition in multisample missing-data procedures and accounting for demographic and smoking behavior variables did not alter this result. Thus, the intervention was ineffective. However, endorsement of self-efficacy and the pros of nonsmoking increased linearly over time in all study groups, which may be attributable to historical or societal changes or to repeated, comprehensive smoking assessments. In addition to reporting the outcome of a smoking intervention trial, the current study also illustrates a modeling approach to the measurement of change.

Attitude and Norm Accessibility Affect Processing of Anti-Smoking Messages

Article

Full-text available

May 2008

Anti-smoking PSAs are not always effective in reducing cigarette smoking, and there is a lack of research into mechanisms through which PSAs affect the attitudes and behaviors of viewers. The present research was designed to better understand how smokers and non-smokers process anti-smoking ads. In a repeated measures design, the accessibility of smokers' (N = 70) and non-smokers' (N = 96) attitudes toward and norms concerning smoking were assessed and then their reactions to four anti-smoking PSAs were measured. The accessibility of smokers' attitudes toward smoking-how quickly they bring their attitudes to mind-predicted their central processing of ad content, and smokers who counterargued in response to the ads were not persuaded by them. The accessibility of smokers' norms for smoking-how quickly they bring to mind social support for smoking-predicted their peripheral processing of the ads, and imbued resistance to persuasion. In contrast, non-smokers' attitude and norm accessibility were unrelated to ad processing. These results suggest that anti-smoking ads may have paradoxical effects on smokers and may actually undermine anti-smoking efforts. Furthermore, smokers who can readily access a pro-smoking norm are unlikely to process anti-smoking messages, which may further hinder anti-smoking efforts.

Functional Beliefs About Smoking and Quitting Activity Among Adult Smokers in Four Countries: Findings From the International Tobacco Control Four-Country Survey

Article

Full-text available

May 2008

To examine the psychometric properties, distributions, and predictive utility for quitting behavior of six functional beliefs about smoking among adult smokers. Data was from the first three waves of the International Tobacco Control Four-Country Survey (ITC-4), a random-digit dialed telephone survey of a cohort of over 8,000 adult current smokers from the United Kingdom, United States, Canada, and Australia followed up annually. Quitting attempts and the success of such attempts at the next wave. The six functional belief measures are modestly correlated with each other and are moderately stable over time. Smoking for enjoyment and life enhancement were significantly negatively related to quitting attempts, at least partly mediated by quitting intention and dependence. Smoking for stress management appeared to reduce quit success among those who tried, an effect mediated by quitting self-efficacy and dependence. Smoking for weight control, social facilitation, and as an aid to concentration were not independently associated with cessation. Positive reasons for smoking may discourage quitting, but stress management is the only function that appears to prospectively predict quit success. Interventions should target those beliefs, and review the value of intervening on beliefs that are unrelated to cessation outcomes.

Depressive Symptoms and Cigarette Smoking in Twins From the National Longitudinal Study of Adolescent Health

Article

Full-text available

May 2008

To our knowledge, no prior twin studies have examined genetic and environmental contributions to the association of depressive symptoms and cigarette smoking in adolescence. Genetic and environmental contributions to the covariation of depressive symptoms and cigarette smoking were estimated among 287 monozygotic and 441 dizygotic adolescent twin pairs from the National Longitudinal Study of Adolescent Health. Depressive symptoms were measured using an 18-item modified version of the Center for Epidemiologic Studies-Depression Scale (CES-D; Radloff, 1977). Smoking involvement was defined using an ordinal scale based on smoking recency and frequency. Depressive symptoms and smoking were significantly correlated in both males and females. Twin modeling indicated that, in females, the correlation was attributable in part to common genetic factors and in part to environmental factors not shared among twins, or nonshared environment. In males, the correlation between depressive symptoms and smoking was solely attributable to nonshared environment. Nonshared environmental correlations in males and females lend support to a direct causal relationship between depressive symptoms and smoking in adolescence. However, the additional common genetic vulnerability in females suggested that common genetic factors also contribute, particularly among adolescent females.

The Impact of Expectations and Satisfaction on the Initiation and Maintenance of Smoking Cessation: An Experimental Test

Article

Full-text available

May 2008

Our primary objective was to test the thesis that the initiation of behavior change is dependent on favorable expectations, whereas maintaining a change in behavior is dependent on satisfaction with the outcomes afforded by behavior change. These hypotheses were tested in the context of a smoking cessation intervention. Adult smokers were randomized to an 8-week smoking cessation program designed to induce either optimistic or modest expectations about cessation. Participants were encouraged to quit smoking after Week 4 and were followed for 15 months after the end of the program. MAIN PROCESS AND OUTCOME MEASURES: The authors focused on participants' expectations about cessation, satisfaction with cessation, and smoking status. The effect of the expectation manipulation on smokers' beliefs about cessation was moderated by their prior cessation success. Those led to hold favorable expectations about cessation were more likely to initiate cessation. Although satisfaction was not affected by initial expectations, it predicted maintained cessation. Conclusions: Results highlight the challenge of altering how smokers think about cessation and the need for further research on intervention strategies that target different factors for the initiation and maintenance of cessation.

Using Basic Laboratory Research to Understand Scheduled Smoking: A Field Investigation of the Effects of Manipulating Controllability on Subjective Responses to Smoking

Article

Full-text available

May 2008

To examine, in a naturalistic context, the effect of manipulating smokers' control over their smoking behavior on subjective responses to smoking. A within-subjects yoking design was used in which 23 participants (45% female) first engaged in ad-lib or controllable smoking for 3 days during which a hand-held computer was used to record the timing of every cigarette smoked. This was followed by a 3-day scheduled or uncontrollable smoking phase in which participants were prompted to smoke by the hand-held computer on the same schedule that they had previously recorded. Participants used an 11-point visual analog scale presented on the hand-held computer to report reward from smoking and other subjective responses (craving, mood, etc.) immediately after smoking and also at other times (unrelated to smoking) through the day. During the scheduled or uncontrollable phase participants experienced significantly lower rewarding effects from smoking, poorer mood, less reduction in craving, and less improvement in overall feeling immediately after smoking. The findings suggest the effect of reduced controllability may partly underlie the effect of scheduled reduced smoking interventions. Results also point to the potential benefit of translating basic laboratory research to the field for developing clinical interventions.