Smoking Patterns and Dependence: Contrasting Chippers and Heavy Smokers
By: Saul Shiffman
Department of Psychology, University of Pittsburgh;
Jean Paty
Department of Psychology, University of Pittsburgh
Acknowledgement: Jean Paty is now at
invivodata, inc., Pittsburgh, Pennsylvania.
This research was
supported by Grant DA04281 from the National Institute on Drug Abuse. The research served as a
master's thesis in psychology for Jean Paty, under the direction of the Saul Shiffman. Saul
Shiffman and Jean Paty are cofounders and shareholders of invivodata, inc., which provides
electronic diaries for clinical research.
We are grateful for
comments on the statistical analysis from Linda Collins and Joseph Schwartz and for general
comments from Michael Sayette, the assistance of Maryann Gnys and Jon Kassel in conducting the
study, the assistance of Stuart Ferguson and Qianyu Dang in data analysis, and the editorial
assistance of Yolanda DiBucci.
Nicotine dependence is
typically the driving motive behind tobacco use and cigarette smoking, and most current smokers
are dependent (U.S. Department of Health and Human
Services, 1988). However, studies have documented that some people are able
to engage in stable patterns of light smoking without progressing to dependence
(Hajek, West, & Wilson, 1995;
Shiffman, 1989; Shiffman, Paty, Kassel, Gnys, & Zettler-Segal,
1994). Most people who smoke regularly progress to dependence
(Shiffman & Paton, 1999);
intermittent smoking is generally an unstable pattern leading either to progression to regular
smoking or to desistence (e.g., Zhu, Sun, Hawkins,
Pierce, & Cunningham, 2003). However, we have demonstrated that some
intermittent smokers can demonstrate substantial resistance to dependence, sustaining a regular
pattern of light smoking for years without developing dependence (Shiffman, Paty, et al., 1994). These smokers—dubbed
“chippers” (CHs)—absorb nicotine from cigarettes in normal amounts and
metabolize nicotine normally (Brauer, Hatsukami, Hanson,
& Shiffman, 1996; Shiffman,
Fischer, Zettler-Segal, & Benowitz, 1990; Shiffman et al., 1992) but, despite having smoked tens of
thousands of cigarettes, show few signs of nicotine dependence (Shiffman, 1989; Shiffman, Paty, et al., 1994) and no sign of withdrawal even after several
days of abstinence (Shiffman, Paty, Gnys, Kassel, &
Elash, 1995). CHs do not seem to smoke to avoid nicotine depletion or to
stave off withdrawal. These findings suggest that repeated exposure to smoking may not in itself
inevitably lead to nicotine dependence. Low-rate smoking and less-than-daily smoking are common
among teen smokers early in their smoking careers, but this pattern is typically subsequently
displaced by daily and higher-rate smoking as smoking progresses (Gilpin et al., 2001). However, CHs seem to have failed to
progress or “mature” into heavier and more consistent smoking; we have hypothesized
that they may display patterns of smoking associated with earlier stages of the smoking career
(Shiffman, 1991;
Shiffman, Paty, et al., 1994).
Smoking patterns can provide
some clues to smoking motives. For example, if smokers smoke when stressed, this would bolster
the notion that they are smoking to mitigate negative affect (Shiffman et al., 2002; Shiffman, Kassel, Paty, Gnys, & Zettler-Segal, 1994). In recent
analyses of heavy smokers' (HSs') smoking patterns, we found that their ad lib smoking was not
substantially associated with affective state (Shiffman
et al., 2002; Shiffman, Paty,
Gwaltney, & Dang, 2004). This lack of association between smoking and
situational stimuli was explained in terms of HSs' addictive drive to smoke regularly to
maintain blood nicotine levels and avoid lapsing into nicotine withdrawal (Shiffman et al., 2002), thus overriding any
association between smoking and other stimuli. Contrasting HSs' smoking patterns with those of
CHs may help test this hypothesis. If this explanation of HSs' smoking is valid, then we would
expect CHs' smoking to demonstrate much stronger association with situational stimuli (which we
refer to as “stimulus control”).
Several studies
(Chassin, Presson, & Sherman,
1984; Hajek et al.,
1995; Jarvik, Killen, Varady,
& Fortman, 1993; Shiffman,
Kassel, et al., 1994) have used global retrospective self-report
questionnaires (“smoking typology scales”) to ask CHs about their smoking patterns
and motives. Compared with HSs, CHs tend to emphasize social motives, those related to the
sensory pleasure of smoking and those associated with pleasant relaxation or smoking after meals
(as opposed to motives associated with craving, relief of negative affect, stimulation, and
habitual or automatic smoking). Thus, CHs may be what M. A. H. Russell, Peto, and Patel (1974) called “indulgent”
smokers. However, questionnaires assessing smoking patterns are fraught with psychometric
problems and do not accurately reflect smoking patterns (Shiffman, 1993; Shiffman & Prange, 1988; Tate, Schmitz, & Stanton, 1991). CHs may also fit the pattern
described by Moran, Wechsler, and Rigotti,
(2004) as “social smoking,” defined as smoking primarily with
others and primarily as a social activity, implying smoking driven by external social motives
rather than by internal or pharmacological motives.
In this study, we used data
on smoking and nonsmoking situations collected in real time in real-world settings with
ecological momentary assessment (EMA; Shiffman,
1993; Shiffman et al.,
2002; Shiffman, Paty, et al.,
2004; Stone & Shiffman,
1994) to analyze CHs' smoking patterns. In an extreme-groups design, we
contrasted CHs' patterns with those of closely matched HSs. We examined the hypothesis that CHs
would be particularly likely to smoke when with others (Moran et al., 2004) and when drinking alcohol (Istvan & Matarazzo, 1984; Shiffman & Balabanis, 1995), a pattern resembling
the behavior of smokers early in their smoking careers (McKee, Hinson, Roundsaville, & Petrelli, 2004).
We also assessed CHs' urges
to smoke, both when smoking and when not smoking. Whereas some studies have suggested that CHs
experience little craving (Davies, Willner, &
Morgan, 2000; Sayette, Wilson,
& Elias, 1992; Shiffman et
al., 1995), others have suggested that CHs do experience craving,
especially when exposed to smoking cues (Davies et al.,
2000; Sayette et al.,
1992, 2003),
suggesting that CHs' craving might vary considerably according to the circumstances. We expected
that CHs might experience craving in the occasional situation when they smoke but not when not
smoking, whereas HSs may report craving even when not smoking (indicating their dependence).
We focused on stimulus
control of smoking as a key differentiator of chipping versus heavy smoking. As dependence
develops, smoking is expected to become increasingly driven by the ebb and flow of blood
nicotine levels. In particular, because nicotine is cleared quickly from the body and thus has
to be “topped off” frequently, for dependent smokers, the need to regularly
replenish nicotine would tend to override and erode the stimulus control that might otherwise be
exercised by situational stimuli. Whereas even dependent smokers are expected to have some
discretion in when they smoke (Kozlowski & Herman,
1984), the diminution of stimulus control and the development of stereotypy
may be a hallmark of dependence, as use of the drug shifts from being a purely discretionary
pleasure that accompanies certain activities, but which the smoker can take or leave, to a
compulsive pattern of regular and stereotypic self-administration (Edwards, 1986; Shiffman, Waters, & Hickcox, 2004). Thus, we hypothesized that HSs'
smoking would demonstrate less stimulus control than would CHs' smoking.
Whereas an analysis of
particular antecedents can examine the association of smoking with particular situational
variables, an analysis of overall stimulus control must look past associations with particular
variables and the direction of those associations. For example, some CHs may tend to smoke when
working and stressed, whereas others smoke when eating and relaxed. Both patterns demonstrate
stimulus control over smoking, but a groupwise nomothetic analysis might show no effect. To
assess the degree of stimulus control, we performed idiographic analyses, in which we modeled
stimulus associations separately for each smoker and statistically estimated the overall
magnitude of the associations across a range of situational stimuli. We then entered these
estimates into a second-level analysis, which contrasted the average levels of stimulus control
among CHs and HSs.
In our assessment, we
avoided relying on global assessments or recall of smoking patterns (Hammersley, 1994; Shiffman, 1993); instead, we used EMA (Stone & Shiffman, 1994) methods to collect
real-time data about smoking and nonsmoking episodes in subjects' natural environments. Subjects
noted (with a palmtop computer that time tagged records to document timely entry; see
Stone, Shiffman, Schwartz, Broderick, & Hufford,
2002) when they were smoking and completed a situational and affective
assessment. As a control or contrast for smoking occasions (Paty, Kassel, & Shiffman, 1992; Shiffman, 2004), the computer beeped subjects for a
similar assessment at randomly selected nonsmoking times (Csikszentmihalyi & Larson, 1987; Shiffman et al., 2002).
Methods
Design
This was an extreme-groups
case-control design, contrasting smoking patterns in a group of CHs selected to demonstrate
resistance to nicotine dependence with a matched group of relatively HSs.
Participants
Participants were 26 CHs
and 28 HSs recruited through the media (Shiffman,
Paty, et al., 1994). CHs were highly selected to demonstrate a pattern of
regular smoking without progression. They had to average no more than 5 cigarettes per day
while smoking at least 4 days per week. HSs smoked 20 to 40 cigarettes daily. The inclusion
criteria were confirmed by collateral reports and by biochemical assays where possible
(Shiffman, Paty, et al., 1994).
HSs were recruited to closely match CHs on gender, age, number of years of smoking (and,
consequently, on age at initiation), and the nominal nicotine delivery of their cigarettes
(Federal Trade Commission method).
Shiffman, Paty, et al. (1994)
described and justified the selection criteria in detail. The emphasis was on identifying
smokers whose smoking was stable rather than transitional. Subjects were included only if they
were not planning to quit or cut back smoking, were over 23 years old, were Caucasian, did not
use tobacco products other than cigarettes, and had smoked for at least 4 years with no
substantial changes in the past 2 years, no more than three quit efforts in the past 2 years,
and no cessation of smoking for 2 days or more in the past 6 months. Table 1 shows the
demographics and smoking history of CHs and HSs.
![Demographic and Smoking History Characteristics of Chippers (CHs) and Heavy Smokers
(HSs) abn-115-3-509-tbl1a.gif](https://imageserver.ebscohost.com/img/embimages/pdh/abn/abn-115-3-509-tbl1a.gif?ephost1=dGJyMMvl7ESepq84yOvqOLCmsEyepq5Srqa4SK6WxWXS)
Procedure
The methods of the study
have been described in Shiffman, Paty, et al.
(2004) and Shiffman et al.
(2002). The study was conducted in 1988 in Pittsburgh, PA, at a time when
few regulations restricting smoking were in place. Participants were trained to use a handheld
computer designed to allow data collection in near real time. The electronic diary (ED; see
Shiffman et al., 1995) was a
PSION Organizer II palmtop (5.6″ × 3.1′ × 1.1″; 8.8 oz; PSION,
Ltd., London, England) with a 2-line, 16-character LCD screen. For 2 weeks, participants
monitored their ad libitum smoking throughout the waking day by recording each cigarette on the
ED immediately before smoking. All cigarettes recorded by CHs were assessed. Because HSs smoked
often, ED was programmed not to administer assessments for all their cigarettes but instead to
select smoking occasions at random, such that approximately 5 cigarettes per day were assessed
(smoking). The appropriate sampling ratio was based on subjects' self-reported smoking
frequency; for example, for a subject who reported smoking 20 cigarettes per day, a random 25%
of cigarette entries were selected for assessment. Even when no assessment was administered,
the ED made a record of each cigarette. In addition, participants were beeped by the ED four to
five times daily at random times to complete a similar assessment while they were not smoking
(nonsmoking).
ED Assessments
Identical assessments of
smoking and nonsmoking situations were completed on the screen, one item at a time.
Participants rated mood and urge to smoke on a 4-point scale ranging from 1
(NO!!) to 4 (YES!!). Mood ratings were made for adjectives
(listed below) derived from the circumplex model of affect (J. Russell, 1980) as well as bipolar items on overall affect
and arousal. We used exploratory factor analysis and multidimensional scaling to score the
affect items into three scales: Negative Affect (high-loading items, in descending order of
factor loadings, with italics indicating reverse scoring: happy,
calm, tense, delighted, frustrated, overall
affect; Cronbach's alpha = .80), Arousal (arousal, tired, overall
arousal; α = .75), and Low Mood (sad, miserable, bored, frustrated; α = .75). We used
factor scores (standardized scores, with M = 0 and SD = 1.0
over the whole sample) derived from varimax rotation because they yield uncorrelated scale
scores. The Negative Affect and Arousal factors were bipolar, with low scores representing
positive affect and low arousal, respectively. Participants also noted current activities and
location (see Table 2).
![Characteristics of Smoking and Nonsmoking Situations in Chippers (CHs) and Heavy Smokers
(HSs) abn-115-3-509-tbl2a.gif](https://imageserver.ebscohost.com/img/embimages/pdh/abn/abn-115-3-509-tbl2a.gif?ephost1=dGJyMMvl7ESepq84yOvqOLCmsEyepq5Srqa4SK6WxWXS)
![Characteristics of Smoking and Nonsmoking Situations in Chippers (CHs) and Heavy Smokers
(HSs) abn-115-3-509-tbl2b.gif](https://imageserver.ebscohost.com/img/embimages/pdh/abn/abn-115-3-509-tbl2b.gif?ephost1=dGJyMMvl7ESepq84yOvqOLCmsEyepq5Srqa4SK6WxWXS)
Data Reduction and Analysis
Participants contributed
data from a total of 831 days (CHs: 395; HSs: 436), encompassing 8,496 assessments (CHs: 3,889;
HSs: 4,597)—4,971 nonsmoking assessments (CHs: 2,591; HSs: 2,380) and 3,525 smoking
assessments (CHs: 1,308; HSs: 2,217). Individual smoking and nonsmoking observations were
analyzed and were not aggregated (see Shiffman et al.,
2002). We used generalized estimating equations (GEE) to account for the
nesting of multiple observations within subjects and the autocorrelations among them,
specifying an AR(1) autocorrelation structure (Zeger,
Liang, & Albert, 1988). We have previously presented an analysis of
HSs' smoking patterns (Shiffman, Paty, et al.,
2004). The analysis of CHs' data, essentially a logistic regression,
treated observation type (smoking vs. nonsmoking) as a categorical dependent variable modeled
as a function of a situational variable (mood, activity, situation). We report odds
ratios, confidence intervals,
and statistical significance. Given the number of tests, we emphasize relationships where
p < .01. We used point-biserial or phi correlation coefficients to
calculate for each participant the degree of association between smoking and its antecedents,
and we report the average within-subject correlation coefficient as another effect-size
estimate. Comparison of situational associations between CHs and HSs also used GEE analysis but
extended the models to include a Group effect and a Group × Antecedent interaction. The
interaction, which was the focus of the analysis, essentially tests the ratio of the two odds
ratios seen among CHs and those seen among HSs.
To assess the degree to
which smoking was under stimulus control of various stimuli, by subject, we performed a
two-level analysis, starting with an idiographic analysis with each subject (Bryk & Raudenbush, 1992). For each subject, we
constructed a logistic regression equation predicting smoking (vs. nonsmoking) from a set of
situational antecedents. Separate analyses were conducted for blocks of variables, as defined
in Table 2: activity, eating and
drinking, location, social setting, mood, and time. (Models combining all variables could not
be estimated because of collinearity.) For each subject's equation, we estimated the area under
the curve (AUC) for the receiver operating characteristic (ROC) curve characterizing the degree
of prediction of smoking from the independent variables. The magnitude of AUC-ROC reflects the
degree to which smoking is predictable, independent of which particular variables (antecedents)
were predictive. To compare the
degree to which smoking was predictable from situational variables for CHs and HSs, we entered
the individually computed AUC-ROC values into a second-level, between-groups analysis
(Bryk & Raudenbush, 1992),
using t tests and nonparametric median tests. To account for the fact that
some AUC-ROC values may have been more reliably estimated than others (on the basis of the
number of observations and the estimated AUC-ROC value itself), we weighted the cases by the
inverse of the standard error of AUC-ROC, which was computed with the approach of
Hanley & McNeil (1982).
Weighted and unweighted analyses yielded identical results; we report the weighted values.
An important virtue of the
AUC-ROC as an indicator of the magnitude of the relationship is that AUC-ROC has a conceptually
meaningful interpretation. AUC-ROC is interpretable as the probability of correctly identifying
a smoking observation from a randomly chosen pair of smoking and nonsmoking observations, given
the predictor variables (Hanley & McNeil,
1982). That is, if AUC-ROC is 0.75, this means that in all possible
pairwise comparisons of a smoking and nonsmoking observation, the model would enable one to
correctly identify the smoking observation 75% of the time. AUC-ROC ranges from 0.5 (chance
identification) to 1.0 (perfect identification).
Results
Description
Table 1 shows the characteristics of
the samples. The groups closely resemble each other on many variables because of matching and
differ systematically in smoking behavior and history because of selection as CHs and HSs.
Whereas CHs smoked an average of 3.9 (SD = 1.2) cigarettes per day, 6 days a
week, the HSs smoked an average of 31.4 (SD = 6.6) cigarettes daily.
Protocol, Compliance, and Reactivity Data
Subjects provided data for
an average of 15.4 days. On average, CHs contributed 100 random assessments and 50 smoking
assessments. HSs contributed 85 random assessments and 79 smoking assessments; in addition,
each HS recorded an average of 275 cigarettes that were not assessed.
Compliance with protocol
instructions was first assessed by self-report, with questions phrased to encourage admission
of noncompliance. Despite the permissive set, the subjects reported carrying the ED 94% of the
time and recording 97% of cigarettes smoked. More objectively, half the subjects responded to
at least 89% of all random prompts within the 2 min allotted; only 1 out of 4 subjects missed
even one prompt per day. Compliance with recording of cigarettes was assessed by correlating
the number recorded to exhaled levels of carbon monoxide (CO), a biochemical marker of recent
smoking (Vogt, Selvin, Widdowson, & Hulley,
1977). Afternoon CO levels correlated with the number of cigarettes
recorded in the preceding 4 hr among both CHs (r = .56, p
< .01) and HSs (r = .52, p < .01). The number of
cigarettes recorded did not change significantly between the first 2 and last 2 days of the
study for CHs (3.3 vs. 3.7; ns) but did drop modestly for HSs (28.7 vs. 24.6;
p < .005), at an average rate of 0.33 cigarettes per day. CO levels showed
no change (CHs: Day 2 = 7.6 ppm [SD = 2.9], last day = 7.25 ppm
[SD = 3.0], ns; HSs: Day 2 = 27.6 ppm [SD =
11.8], last day = 27.3 ppm [SD = 7.5], ns).
Smoking Patterns of CHs
Table 2 summarizes the data obtained
from CHs when they were smoking and when sampled at random when not smoking, comparing the
antecedents of those two contexts. The analysis evaluates the change in the odds of smoking
with changes in the situational antecedent, expressed as an odds ratio. In other words, it
evaluates whether the probability of smoking (vs. not smoking) differed in a particular
circumstance (e.g., drinking alcohol) compared with its complement (not drinking alcohol). CHs
were more likely to smoke in certain locations; the odds of smoking increased when CHs were at
home or at a bar or restaurant (compared with all other locations). They were less likely to
smoke in situations they characterized as “other” (including outdoors). Being at
work, at others' homes, and in a car did not significantly affect the probability of
smoking.
CHs' smoking also was
associated with concurrent activities. The probability of smoking increased when they were
relaxing, socializing, or doing nothing and decreased when they were working or when they were
engaged in activities classified as “other.” CHs were also more likely to smoke
when eating, drinking coffee, or drinking alcohol. The relationship with alcohol was
particularly strong: Drinking alcohol increased the odds of smoking nearly fivefold.
Collectively, the
activities associated with CHs' smoking suggested that CHs were more likely to smoke in those
activities that M. A. H. Russell et al.
(1974) described as “indulgent.” To capture this, we coded
situations as indulgent if they involved eating, drinking alcohol, relaxing, socializing, or
doing nothing and did not involve working. Such situations accounted for 75% of CHs' cigarette
smoking; the odds of smoking were more than 4 times greater in indulgent settings than in
others (see Table 2).
CHs' smoking also seemed to
be influenced by others' smoking. They were more likely to smoke when others were smoking and
less likely to smoke when others were not smoking. However, these data do not support the
hypothetical characterization of CHs as social smokers. CHs smoked almost half their cigarettes
when they were alone and were actually more likely to be alone when they were smoking than when
they were not smoking.
The probability of CHs'
smoking was not influenced by their affective state. There was no linear association between
smoking and negative affect. We considered that CHs might smoke under both negative and
positive affect, which would “wash out” in a linear analysis of a bipolar affect
scale. Accordingly, we evaluated the quadratic trend in affect, which would capture a tendency
to smoke when either feeling good or feeling bad. No significant association was found. One
minor finding was that a single item rating current arousal indicated that smoking was more
likely under low arousal. However, this effect appears to be related to CHs' tendency to smoke
later in the day and disappeared when we restricted the analysis to the evening hours. (We also
tested individual affect items and the negative affect by arousal interaction; these were
unrelated to smoking.)
CHs did report urges to
smoke; 16% of their ratings indicated an intensity of 4, the highest value on the scale. These
were strongly associated with smoking: 89% of these high-urge occasions were recorded when CHs
were smoking. The odds of smoking increased more than eightfold for every 1-point increase in
urge intensity. Examination of the probability of smoking at each urge level shows that the
likelihood of smoking rises steeply as one crosses the midpoint of the urge scale. On average,
CHs reported moderate to strong urges when smoking (3.3 on a 4-point scale), but they denied
urges (the average of 1.5 lies between the response options labeled “no??” and
those labeled “NO!!”) when not smoking.
Comparing Smoking Patterns of CHs and HSs
Table 2 also shows the data associated
with HSs' smoking (from Shiffman, Paty, et al.,
2004). A set of analyses evaluated the interaction of group differences
with smoking versus nonsmoking differences. A significant interaction indicates significant
differences between CHs and HSs in the odds ratios for antecedents. In other words, these
analyses ask whether the association between an antecedent (e.g., alcohol) and smoking (vs.
nonsmoking) differs for CHs and HSs.
There were several
significant differences, some of which are graphed in Figure 1. The activity of relaxing had
a stronger association with CHs' smoking than with HSs' smoking. Also, whereas CHs were less
likely to be smoking when engaged in “other” activities, the trend among HSs was
reversed. There was also a trend for CHs' smoking, compared with HSs' smoking, to be more
suppressed when working.
![Figure 1. Significant interactions in stimuli associated with smoking for chippers (CHs) and heavy
smokers (HSs). The y-axis represents the percentage of momentary observations
when an antecedent was reported in smoking or nonsmoking occasions. Data for eating and drinking
exclude cases where only alcohol was consumed. Note the differences in y-axis
scaling across graph panels. (Interactions regarding “other” activity and
“other” locations are not graphed, as the interactions are difficult to interpret,
particularly as CHs and HSs may mark different activities and locations as
“other.”) abn-115-3-509-fig1a.gif](https://imageserver.ebscohost.com/img/embimages/pdh/abn/abn-115-3-509-fig1a.gif?ephost1=dGJyMMvl7ESepq84yOvqOLCmsEyepq5Srqa4SK6WxWXS)
Eating or drinking (food,
coffee, and/or alcohol) was associated with a greater increase in the probability of smoking
among CHs than among HSs. The differences in response to alcohol were the most striking: CHs
showed a much stronger association between drinking and smoking than did HSs. However, the
association between smoking and eating was stronger for CHs than for HSs, even when alcohol
situations were excluded, suggesting that CHs' smoking was also more associated with other
types of consumption. With the omnibus coding of indulgent situations, we found that CHs'
smoking was much more associated with indulgent activities than was HSs' ( Figure 2, left
panel) smoking.
![Figure 2. Proportion of smoking and nonsmoking occasions that are classified as indulgent (see text)
for chippers and heavy smokers. Indulgent settings were defined as those where the subject was
not working, but was relaxing, socializing, eating or drinking, or doing nothing. Left-hand panel
shows all data. The right-hand panel shows data collected in the evening only (after 5
p.m.) abn-115-3-509-fig2a.gif](https://imageserver.ebscohost.com/img/embimages/pdh/abn/abn-115-3-509-fig2a.gif?ephost1=dGJyMMvl7ESepq84yOvqOLCmsEyepq5Srqa4SK6WxWXS)
CHs were less likely to
smoke when engaged in “other” activities and in “other” locations
(which included outdoors), whereas HSs showed no such relationships. CHs were also less likely
to smoke in vehicles, which was positively associated with smoking among HSs. Compared with
HSs, CHs were more responsive to others' smoking. The proportion of cigarettes they smoked when
others were smoking was similar, but CHs generally spent less time where others were smoking,
so their smoking was proportionately more influenced by others' smoking (see Figure 1). There were no group differences in the
proportion of cigarettes smoked while alone or in the likelihood of smoking alone.
There were no group
differences in the association between affect and smoking, whether for negative affect,
arousal, or depressed affect. (We also tested individual affect items and the negative affect
by arousal interaction; these showed no interactions between group and smoking.) However, there
were significant differences in the relationship between urge and smoking. When smoking, CHs
and HSs gave very similar urge ratings, with the majority of ratings indicating the presence of
urges ( Figure 3, right panel). However, differences emerged in nonsmoking
situations (left panel). Whereas HSs' ratings were generally in the neutral range, with 53%
indicating some degree of urge even when not smoking, in these nonsmoking situations, CHs
indicated very low urges or even an aversion to smoking (only 15% indicated some degree of
urge).
![Figure 3. Distribution of urge ratings in smoking (right panel) and nonsmoking (left panel)
occasions, for chippers and heavy smokers. The y-axis represents the percentage
of occasions falling into each urge-rating category abn-115-3-509-fig3a.gif](https://imageserver.ebscohost.com/img/embimages/pdh/abn/abn-115-3-509-fig3a.gif?ephost1=dGJyMMvl7ESepq84yOvqOLCmsEyepq5Srqa4SK6WxWXS)
Time
Figure 4 shows the distribution of smoking times for CHs and HSs. It is evident that CHs'
smoking is skewed toward later in the day, with most occurring after 5 p.m. (This was not
universally true, however: A quarter of CHs smoked the majority of their cigarettes before 5
p.m. Altogether, two thirds of CHs' cigarettes were smoked after 5 p.m., compared with 43% of
HSs' cigarettes.) To control for this difference in time of day, we repeated the between-groups
analysis with only data collected after 5 p.m. The results were largely identical, with a few
exceptions. Two Group × Smoking interactions were no longer significant in the
time-controlled analysis: The tendency of CHs' smoking to be more promoted than that of HSs by
others' smoking was eliminated and became nonsignificant (from OR = 1.57 to OR = 1.07). Also,
the difference in overall arousal went from OR = 0.78 to OR = 0.86, indicating that the arousal
effects were due to CHs not smoking earlier in the day. Conversely, two previously
nonsignificant interaction effects became significant in the after-5-p.m. data: CHs' smoking
was more closely associated with being in bars or restaurants than was HSs' smoking (OR went
from 1.66 [all day] to 2.29 [after 5]), and CHs' smoking was also significantly more closely
associated with coffee drinking than was HSs' smoking (OR = 1.81 to 2.61). Otherwise,
restricting the analysis to observations after 5 p.m. had little directional effect: The ORs
varied slightly, of course, but the between-groups differences were equally likely to
strengthen or weaken, and there was little change in the average OR. In Figure 2, we illustrate the relative stability of the
results with the relationship between smoking and indulgence, as the indulgence variable
appears to capture many of the group differences in smoking. Whereas the indulgent settings
occur more often in the evening than they do earlier in the day (illustrated by the greater
height of the points in the right panel), the differential impact of indulgence on CHs'
smoking, compared with that of HSs, is almost unchanged when we limit observations to those
after 5 p.m. (The OR went from 3.06 for all day to 2.86 for after 5 p.m.)
![Figure 4. The distribution of smoking occasions by time of day. Bars represent the percentage of
cigarettes smoked in that time period. The graph shows that chippers' (CHs) smoking is
disproportionately concentrated in the evening hours; 67% of CHs' cigarettes are smoked after 5
p.m abn-115-3-509-fig4a.gif](https://imageserver.ebscohost.com/img/embimages/pdh/abn/abn-115-3-509-fig4a.gif?ephost1=dGJyMMvl7ESepq84yOvqOLCmsEyepq5Srqa4SK6WxWXS)
Indulgent Smoking and Affect
We observed that much of
CHs' smoking took place during indulgent activities; such situations accounted for 75% of CHs'
cigarette smoking but only 55% of HSs' smoking. We speculated that, perhaps, smoking cigarettes
in these indulgent situations might be motivated by these situational cues, whereas smoking
outside of these situations might be influenced by negative affect. Accordingly, we conducted a
GEE analysis that tested the Group (CHs vs. HSs) × Indulgence × Affect in predicting
smoking. This interaction test asks whether the difference between CHs and HSs in the
relationship of affect and smoking is moderated by being in an indulgent or nonindulgent
setting. (In other words, it tests whether the interaction of group and affect, predicting
smoking, differs between indulgent and nonindulgent settings. Note that, as expected, indulgent
settings are associated with more positive affect, as evident in Figure 5, but this main
effect does not bias the evaluation of the interaction of interest.)
![Figure 5. The association between affect and smoking in indulgent situations (see text) and others,
for chippers (CHs; right panel) and heavy smokers (HSs; left panel). Indulgent settings were
defined as those where the subject was not working, but was relaxing, socializing, eating or
drinking, or doing nothing. Interaction effects indicate that, for CHs, smoking was associated
with negative affect only in nonindulgent situations. For HSs, smoking was associated with more
positive affect only in nonindulgent situations abn-115-3-509-fig5a.gif](https://imageserver.ebscohost.com/img/embimages/pdh/abn/abn-115-3-509-fig5a.gif?ephost1=dGJyMMvl7ESepq84yOvqOLCmsEyepq5Srqa4SK6WxWXS)
The interaction was
significant (OR = 1.79, 1.28–2.50, p < .001) and is illustrated in
Figure 5, which graphs the mean
negative affect score for occasions varying by setting (indulgent vs. not) and smoking, for
each group. Analyses within groups were informative. For CHs, there was a strong and
significant Indulgence × Affect interaction: In nonindulgent situations, smoking was
associated with more negative affect (OR = 1.47, 1.10–1.97, p <
.001). Among HSs, there was a modest but significant interaction, but in the opposite direction
(OR = 0.84, 0.72–0.98, p < .05): In nonindulgent situations (but not
in indulgent situations), smoking was associated with more positive affect. In both cases,
affect was related to smoking only outside indulgent settings.
Stimulus Control of Smoking Among CHs and HSs
The preceding analyses
examined groupwise trends in associations between smoking and situational antecedents. However,
these analyses do not completely capture stimulus associations with smoking because they miss
idiographic or idiosyncratic associations that vary subject to subject. To capture these, we
performed logistic regressions separately for each subject, predicting smoking from situational
antecedents. We used the AUC-ROC to quantify the strength of the multivariate association for
each within-subject logistic regression and then compared the average strength of association
for CHs and HSs by using simple t tests and the nonparametric Wilcoxon's test.
Figure 6 shows the resulting average AUC-ROC values for the domains of activity,
consumption, affect, social setting, location, and time. CHs' smoking was under significantly
greater stimulus control for each category of situational antecedents. (This was true
irrespective of whether tested parametrically or nonparametrically and regardless of whether
the analysis was weighted.) The association of CHs' smoking with activities was especially
evident. Among CHs, knowing current activity would enable one to predict smoking almost 83% of
the time (based on an AUC-ROC of 0.83); the parallel figure for HSs was about 65% (recall that
50% correct identification is expected at random). CH-HS differences accounted for 68% of the
variance in the AUC-ROC for activities. In view of the fact that there were no systematic
associations between affect and smoking in group-aggregate analyses of either group (or the
interaction), it is particularly striking that current affect allows one to predict smoking 75%
of the time for CHs and 64% of the time for HSs. This illustrates how the AUC-ROC analysis
picks up idiographic associations, even when no aggregate group trend is present. Although time
of day was related to smoking, these analyses were essentially unchanged when we limited the
data to observations collected after 5 p.m.
![Figure 6. The area under the receiver operating characteristic curve (AUC-ROC), describing the
association between a set of stimuli and smoking, for subjects in each group. The AUC-ROC values
were derived from logistic regression equations for each individual subject, in which the stimuli
(e.g., variables describing eating and drinking in the situation) were independent variables and
smoking (vs. nonsmoking) was the dependent variable. The figure shows average AUC-ROC values
across subjects in each group. See the text for interpretation of AUC-ROC. *p
< .001. **p < .0001 abn-115-3-509-fig6a.gif](https://imageserver.ebscohost.com/img/embimages/pdh/abn/abn-115-3-509-fig6a.gif?ephost1=dGJyMMvl7ESepq84yOvqOLCmsEyepq5Srqa4SK6WxWXS)
Discussion
This is the first study to
contrast the smoking patterns of dependent and nondependent smokers. Although we have previously
documented HSs' smoking patterns in two studies (Shiffman et al., 2002; Shiffman,
Paty, et al., 2004), this is the first study to examine smoking patterns in
nondependent smokers. Smoking patterns of CHs selected to demonstrate resistance to nicotine
dependence suggested that they were indulgent smokers (M. A. H. Russell et al., 1974) who smoked in relaxing, undemanding
situations, and when eating and drinking, but not when working. However, contrary to
expectations, they were neither positive affect smokers (affect was not associated with smoking)
nor social smokers (they smoked alone often—as often as did the HSs). CHs' smoking
patterns distinguished them from HSs, but the nomothetic group differences understated the
differences in stimulus control over smoking. When we considered idiographic measures of
stimulus control, CHs' smoking proved to be under considerable stimulus control, particularly in
association with concurrent activities. In every situational dimension we examined, CHs' smoking
was under greater stimulus control than was that of HSs.
One issue in contrasting
CHs' and HSs' smoking patterns is that CHs tend to concentrate their smoking later in the day.
However, controlling for this by analyzing evening smoking made relatively little difference in
the comparisons. This suggests that time of day, per se, does not matter as much in CHs' smoking
as do the situations associated with relaxation, eating, drinking, and leisure time, which
happen to concentrate in the evening hours. Controlling for time of day did, however, eliminate
the initial finding that CHs (more than HSs) tended to smoke when experiencing low arousal; this
was apparently due to CHs' tendency to smoke in the evening.
Our data show that CHs are
not social smokers (as defined by Moran et al.,
2004). If anything, CHs tended to smoke more when alone than with others.
CHs smoked almost half their cigarettes when alone—the same as did the HSs. Moreover, even
when others were present while CHs were smoking, more often than not, they were not smoking.
Less than a quarter of all CHs' cigarettes were smoked in the presence of others who were
smoking, and CHs' and HSs' smoking were equally likely to smoke when others were smoking (with
no difference in the influence of others' smoking, after time of day was accounted for).
Clearly, then, even though CHs sometimes smoked with others, their smoking is not just
maintained by a desire to fit in or join other smokers, which suggests it is intrinsically
motivated.
The picture of the typical
chipper is what M. A. H. Russell et al.
(1974) labeled an indulgent smoker—one who smokes when relaxed or
socializing, and over meals, coffee, and drinks, but not when working. In fact, three quarters
of CHs' cigarettes were smoked under such circumstances. CHs differed from HSs in this respect,
though the difference was more quantitative than qualitative: HSs showed similar associations,
but they were much weaker and often nonsignificant (Shiffman, Paty, et al., 2004). It is striking that CHs' pattern of smoking
appears to resemble patterns associated with early in smokers' careers, before they have
progressed to regular daily smoking and to dependence (McKennel & Thomas, 1967; M.
A. H. Russell, 1971). This is consistent with our hypothesis that CHs
represent smokers who simply have not progressed developmentally into adult forms of dependent
smoking (Shiffman, 1991;
Shiffman, Paty, et al., 1994).
Despite their pattern of
indulgent smoking, CHs' smoking was not associated with positive affect; in general, CHs'
affective state did not seem to matter, paralleling our findings for HSs (Shiffman et al., 2002; Shiffman, Paty, et al., 2004). However, when CHs were smoking
outside of indulgent situations, smoking was associated with negative affect. This could
represent an attempt by CHs to cope with distress in these settings. Whether smoking in fact has
any impact on affect cannot be discerned from these data, because we looked at the antecedents
of smoking and not the consequences. In contrast to CHs, HSs were not more likely to smoke under
negative affect in nonindulgent settings; their smoking was actually slightly more likely to
occur under positive affect. It is not clear how to explain these differences. In any case, our
analysis suggests and illustrates an analytic strategy of going beyond analysis of overall
relationships to partition situations into different categories that may display different
smoking dynamics, looking for complex interactions among settings, activities, and affect. This
approach has some parallels in studies of relapse episodes, where some episodes are associated
with negative affect and others are associated with positive affect, smoking cues, and drinking
(Shiffman, 1986), and certain
associations with prior negative affect are seen only for a subset of relapse episodes
(Shiffman & Waters, 2004).
Our largely negative
findings on ad lib smoking and affect (in this and other studies; Shiffman et al., 2002) contrast strikingly with findings on
cues that promote smoking under conditions of abstinence, that is, in relapse episodes. In that
setting, negative affect appears to play a very powerful role in triggering temptation to smoke
and actual smoking (O'Connell & Martin,
1987; Shiffman,
1982; Shiffman, Paty, Kassel,
& Hickcox, 1996). During ad lib smoking, smokers may smoke on a regular
schedule unconsciously designed to avoid withdrawal, thus blunting the association of smoking
and negative affect. Moreover, proprioceptive cues associated with low nicotine levels
(Kozlowski & Herman, 1984) or
subtle increases in negative affect (Baker, Piper,
McCarthy, Majeskie, & Fiore, 2004) might by quite subtle and operate
below the level of consciousness, making them unavailable to self-report. During ad lib smoking,
these subtle cues may quickly trigger smoking without rising to consciousness. In abstinence,
however, smokers are motivated to hold off smoking, and negative affect and craving can build to
levels that are not only conscious but also intense. In addition, in abstinence,
withdrawal-related negative affect, or withdrawal-related sensitization to negative affect from
other sources, may also intensify affect and make it more important and more prominent as a
driver of smoking. Finally, negative affect may also become particularly important in relapse
because it disrupts smokers' attempts to cope with craving (Muraven & Baumeister, 2000); this dynamic would not
influence ad lib smoking.
We also note that the
assessment and analysis of affect is controversial (Larsen & Diener, 1992), with some theories viewing negative and
positive affect as opposite poles of a single dimension (J. Russell, 1980), as our assessment implies, and others
viewing positive and negative affect as independent dimensions (Watson, Clark, & Tellegen, 1988). The difference between
the two positions turns on a difference in factor rotation, with a positive affect factor
defined by a contrast of positive affect and high arousal versus negative affect and low arousal
(Barrett & Russell, 1998;
Yik, Russell, & Barrett,
1999). Accordingly, the fact that we failed to find affect by arousal
interactions suggests that the findings are not an artifact of the scoring affect according to
the circumplex model. It is also notable that we have repeatedly found no relationship between
smoking and affect, even when examining individual affect items, suggesting that the finding is
not an artifact of how the items are aggregated into factors.
Whereas some laboratory
studies have examined how affect may influence how intensely people smoke after they have lit up
(e.g., Payne, Schare, Levis, & Colletti,
1991), our study examines only the variables associated with initially
lighting up the cigarette. It has been pointed out that the stimuli associated with lighting up
itself, and with the effects of the initial nicotine intake from the first puffs (called
“intraadministration cues”; McDonald &
Siegel, 2004), might come to acquire potent value as conditioned stimuli
and may promote continued smoking after smoking has been initiated. Because our method focuses
on stimuli that precede, and perhaps trigger, the act of smoking in the first place, these
influences (which, in any case, cannot explain why an act of smoking is initiated) were not
within the scope of our methods. Likewise, because our focus was on the most immediate
antecedents or triggers of smoking, less acute phenomena (e.g., if having a bad day increases
smoking over the whole day, even when feeling better) would not be seen in these analyses
because the negative affect would pervade both smoking and nonsmoking occasions. Thus, our
findings address the stimuli that cue smoking but not other kinds of stimulus influences.
What do these data tell us
about CHs' motivation for smoking? We can rule out a number of motives for CHs' smoking. Because
CHs do not experience withdrawal (Shiffman, Kassel, et
al., 1994) and do not maintain steady-state nicotine levels
(Shiffman, Paty, et al., 1994),
withdrawal relief cannot be an important motive. The fact that CHs smoke when alone, and are no
more likely than HSs to smoke when others are smoking, rules out purely social motives. That CHs
do not seek out smoking when working, but instead avoid it, suggests that they are not motivated
by performance enhancement. The fact that CHs are most likely to smoke in indulgent situations
that are already positively reinforcing suggests that smoking might enhance the reinforcing
value of already-reinforcing stimuli. This is consistent with the recent suggestions by
Donny et al. (2003), who, in an
experiment with rodents taught to self-administer nicotine, found that getting nicotine appeared
to make accompanying stimuli reinforcing. In their work, stimuli previously paired with nicotine
facilitated self-administration and were sufficient to maintain lever pressing on their own. In
other words, nicotine, in addition to being reinforcing in itself, might lend reinforcement
value to other stimuli. This suggests that CHs might smoke in circumstances that are already
reinforcing to enhance the reinforcement value of those “natural” rewards. This
hypothesis should be tested more systematically, both in CHs and in HSs.
This
reinforcement-enhancement hypothesis might also explain the very striking relationship between
smoking and drinking among CHs (but see Rose et al.,
2004). Alcohol consumption was the single best predictor of smoking among
CHs. Nevertheless, alcohol can explain only a small fraction of CHs' smoking; only one out of
six cigarettes was smoked within 5 min of drinking. Just as CHs are not social smokers, they
also are not just drinking smokers.
Our analysis of urges to
smoke shows that CHs do express strong desire to smoke at the times they elect to smoke. Indeed,
their urge levels at those times are essentially identical to those of HSs. This quantification
could be misleading if CHs and HSs were using different scales to assess their craving relative
to their range of craving experience. Having never experienced the intense craving that
characterizes addictive smokers, CHs might rate cravings as intense that HSs consider to be mild
(relatively speaking; see Sayette et al.,
2000). Alternatively, CHs may infer craving from the fact that they are
smoking (“I am about to smoke, so I must be having an urge”). Taking the craving ratings at face value, the data
suggest that CHs and HSs differ dramatically in the frequency and pervasiveness of craving.
Whereas the urge intensity associated with smoking occasions was similar for CHs and HSs (
Figure 3, right-hand panel), HSs
experienced this heightened craving state every 30 min (crudely, 32 occasions in 16 waking
hours), whereas CHs were in this state only about once every 240 min (crudely, 4 occasions in 16
waking hours). Thus, CHs spend much less time in a craving state. Now consider the remaining
part of the day, when subjects were not smoking. Whereas HSs were in craving states 53% of the
remaining time, CHs were in craving states only 15% of the remaining time. In other words, HSs'
craving is pervasive despite a high volume of smoking; CHs' craving is tightly confined despite
smoking only rarely.
Whereas craving has
typically been linked to dependence, the mere presence of an urge need not implicate dependence
processes any more than a social drinker's desire (urge) to have a glass of wine with dinner.
Urges become pathological when they become pervasive and become detached from stimulus control.
Thus, the difference we see between CHs and HSs is in the frequency and intensity of their urges
when they are not smoking. (In other analyses, we found that other measures of dependence
correlated best with urge levels when not smoking; Shiffman, Waters, et al., 2004.)
One might say that CHs'
cravings demonstrate situational specificity, appearing only in limited situations. The
situational specificity of CHs' smoking was similarly demonstrated by our analysis of smoking in
each group. The analysis demonstrated that CHs' smoking was under considerable stimulus control,
much more so than HSs' smoking. Concurrent activities exercised the greatest influence over CHs'
smoking, so much so that knowing what activity a chipper was engaged in would allow one to
correctly predict smoking 85% of the time (vs. 67% for HSs). In every stimulus
domain—affect, location, activity, eating and drinking, and social setting—CHs'
smoking showed significantly more linkage to situational stimuli; it was under greater stimulus
control. The fading of stimulus control may well be a hallmark of the development of dependence.
A key transition in tobacco use (and other drug use) may occur when users transition from using
drugs for particular recreational, or even medicinal, effects in particular contexts to needing
and using the drug all the time, regardless of context (M. A. H. Russell et al., 1974). Consistent, regular, and stereotyped
patterns of use are hallmarks of dependence (Edwards,
1986; Shadel, Shiffman, Niaura,
Nichter, & Abrams, 2000; Shiffman, Waters, & Hickcox, 2004). Thus, the loosening of stimulus
control over smoking may be an important process in the development of dependence. We
hypothesize that this loosening occurs over time as smokers proceed on a developmental
trajectory toward dependence.
This discussion implicitly
contrasts two patterns of smoking: one in which smoking is stimulus bound and largely
concentrated in indulgent situations and one that is pervasive and relatively free of external
stimulus control. We speculate that the situationally limited, indulgent pattern characterizes
an early stage in the development of smoking. Smoking is initially triggered by social
inducements and, for a time, is socially motivated and tied to social situations
(M. A. H. Russell et al., 1974;
Shiffman, 1991). As young smokers
(like the rodents in Donny's studies) learn that nicotine can enhance the value of other
reinforcers, smoking concentrates in indulgent situations where the smoker has access to other
reinforcement. CHs, having failed to progress beyond this stage, represent the
“fossilized” form of this pattern. Most smokers, however, progress to more frequent
and less stimulus-bound smoking, as dependence begins to emerge and smoking comes to be
dominated by the motives of craving and withdrawal relief (or avoidance). Research is needed on smoking patterns that emerge
as young smokers traverse developmental trajectories of smoking toward dependence
(Shadel et al., 2000).
Our interpretation rests on
the observation that CHs' smoking showed consistently stronger associations with a variety of
situational variables. One might argue that HSs' heavier smoking makes it inherently more
difficult to demonstrate associations with situational stimuli; if one is to smoke 30 times a
day, one has little discretion about where or when to smoke. However, it is notable that HSs
actually showed situational associations as strong as or stronger than did CHs for some
variables, such as being in a vehicle or waiting (see Table 2). This demonstrates that even heavy HSs still have “room”
to allocate their smoking differentially across contexts, as suggested by the boundary model of
nicotine regulation (Kozlowski & Herman,
1984). Conceptually, the fact that heavy, continuous smoking tends to
obliterate stimulus associations is in fact consistent with the key point: As a smoker is driven
to smoke frequently, stimulus control over the behavior is lost. Conversely, stimulus control
must be relaxed to allow smoking to reach the high levels seen in dependent smokers.
Our findings on stimulus
control may have implications for prevention and treatment. Our observations on CHs' smoking
suggest that stimulus control may be able to act as a strong brake on smoking. Interventions
that promote stimulus control of smoking (e.g., restrictions on where one can smoke) could
conceivably impede progression toward heavy and dependent smoking. Indeed, it is striking that
occasional smoking is more common in states that have strong smoking regulations
(Tauras, 2004). Stimulus control
interventions might also help promote successful cessation. Cinciripini (Cinciripini, Wetter, & McClure, 1997) has
demonstrated that imposing artificial stimulus control on smoking (during a structured reduction
phase) can promote cessation, and the data on the stimulus specificity of relapse episodes
suggest that exercising stimulus control by avoiding certain situational stimuli could prove
effective in preventing relapse. More research is needed on stimulus control of smoking.
Our statistical approach to
assessing stimulus control of smoking seemed to provide useful insight into smoking patterns.
The analysis of group differences in associations with particular stimuli requires that many of
the group members share the same pattern of associations, thus shifting the group means.
However, this does not allow for idiographic differences in smoking patterns, which would be
expected to affect stimulus control. In our ROC analysis, rather than assuming that smokers in
each group would share particular stimulus associations (e.g., that all CHs would smoke more at
home), we allowed for idiographic stimulus associations with smoking, such that some individuals
might smoke more at home, others when at others' homes, and others at work. The difference in
approaches was illustrated by our analysis of affect. When assessed nomothetically, by
traditional analysis that required that subjects share similar associations between smoking and
particular affects, there were no systematic associations between smoking and affect in either
group and no differences between groups. However, the idiographic approach, which allowed
associations to vary by individuals, indicated that smoking was under partial control of
affective stimuli.
The finding that affect
exercises some control over HSs' smoking, when assessed idiographically, may help explain why
HSs report that their smoking is prompted by mood changes, even though nomothetic analyses have
repeatedly shown no differences in mood between smoking and nonsmoking occasions
(Shiffman, 1993;
Shiffman, et al., 2002;
Shiffman, Paty, et al., 2004);
smokers' self-reports may pick up on the idiographic associations between smoking and mood.
However, the magnitude of the associations between mood and smoking seen even in idiographic
analyses does not approach that which smokers report on global questionnaires
(Shiffman, 1993), suggesting that
there is still a discrepancy between global retrospective reports and the detailed
self-monitoring in this study. The fact that subjectively experienced affect plays such a
prominent role in relapse (Shiffman et al.,
1996; Shiffman & Waters,
2004) may leave smokers with a broad impression that their smoking is
linked to negative affect.
In any case, the study
suggests that it is important to allow for idiographic associations in analyzing smoking
patterns, particularly because stimulus associations with smoking might develop through
accidental conditioning to certain stimuli and thus should be expected to vary across
individuals, perhaps even randomly.
Although we have made
considerable progress in understanding dependent smoking, relatively little attention has been
paid to understanding nondependent or situation-bound smoking. Although heavy and dependent
smoking is still the predominant smoking pattern in the United States and Western Europe, it may
be important, for several reasons, to understand the patterns, motives, and reinforcers that
drive and maintain low-level smoking. First, although heavier smoking leads to increased health
risks (U.S. Department of Health and Human Services, 1998), even low-level smoking has adverse
health consequences; Luoto (Luoto, Uutela, & Puska,
2000) reported that even nondaily smoking increases the risk of heart
disease by 50%. Second, contrasting these patterns of smoking with more typical heavy or
dependent smoking can help improve our understanding of how smoking develops and is maintained.
Finally, low-level and occasional smoking is becoming an increasingly common pattern, with 24%
of U.S. smokers engaging in less-than-daily smoking, an increase of almost 50% between 1996 and
2001 (Centers for Disease Control,
2003). Our sample of CHs was selected to represent an extreme of resistance
to dependence (i.e., we recruited smokers who maintained low levels of smoking despite smoking
on most days over many years) and thus was not representative of this growing group, many of
whom smoke at lower levels and with less stability than seen in our CHs sample
(Gilpin, Cavin, & Pierce,
1997). Studies of smoking patterns among the full representative range of
intermittent or nondependent smokers are needed.
Our study's conclusions are
bounded by certain limitations. The study was done at a time when restrictions on smoking were
relatively modest (see Shiffman, Paty, et al.,
2004). The current climate of smoking regulations may have imposed some
stimulus control on smokers while disrupting other associations (see Shiffman et al., 2002). Our samples of CHs and HSs
were small and arguably not representative. Very stringent criteria were applied for inclusion
of CHs, and HSs were systematically selected to match the CHs sample. The validity of the
results also depends on the validity of the EMA data on smoking situations. To the extent that
these were biased by reactivity or by some kinds of systematic noncompliance (e.g., not
recording cigarettes when very upset), the data could be misleading. However, analyses suggested
that compliance was very good and that the data were valid. The use of EMA methods, relying on
real-time entry of real-world data regarding smoking situations, and the contrast to randomly
sampled nonsmoking situations, was a significant strength of our methodology. The large number
of observations per person may help compensate for the small sample of persons, and the
observation of each person over 2 weeks of ad lib smoking helped ensure that each person's
smoking patterns were adequately sampled. Finally, the use of a palmtop computer to collect the
data helped ensure that data were recorded in a timely manner (Stone et al., 2002) and enabled analysis of temporal
patterns.
This study documents the
smoking patterns of nondependent smokers and contrasts them to those of HSs. The study
demonstrates that CHs are not social smokers but that their smoking is concentrated in
situations associated with relaxation and consumption of food, coffee, and alcohol. An
idiographic analysis demonstrated that CHs' smoking was under stronger stimulus control than was
HSs' smoking, with specific patterns of stimulus associations being individual and
idiosyncratic. Understanding how smoking is brought under stimulus control, and how it breaks
out of such control as dependence develops, is an urgent agenda for the study of smoking and the
development of nicotine dependence, with implications for prevention and cessation
interventions.
Footnotes
1
The term stimulus
control is commonly used to describe stimulus-behavior contingencies. As our analyses
are observational and do not involve manipulation of antecedent stimuli to observe their effect
on smoking, the causal implications of “control” may not apply. However, we use the
term to link to the existing literature on stimulus control, including stimulus control of
smoking.
2
The analysis follows a
case-control design, in which the antecedents of cases (smoking episodes) and controls
(nonsmoking episodes) are described. From these data, it is not possible to say how likely a
subject is to smoke, for example, when working, but it is possible to say that the likelihood of
smoking is increased when working and to quantify, on the basis of the odds ratio, the degree to
which the odds of smoking are increased (Rudas,
1998).
3
Conceptually, then, the
AUC-ROC expresses the overall predictability of smoking, as does the R2 statistic in a linear regression. An alternative
statistic that has been offered as an analogue for R2 in logistic regression is the reduction in the
log-likelihood statistic due to the model fit (essentially, the reduction in uncertainty;
Menard, 1995). The two statistics
capture similar information and were very highly correlated (average = 0.95) in our data. We also
tested our models with the reduction in log-likelihood and observed the same results. We prefer
the AUC-ROC statistic for presentation because of its interpretation as the probability of
correct identification.
4
HSs contributed more smoking
assessments because we collected five smoking assessments per day, whereas most CHs did not smoke
five times daily. Regular smokers had fewer random assessments than did CHs because they smoke
more and spend less time not smoking, thus providing fewer opportunities for random
assessments.
5
This explanation is made less
plausible by the fact that exploratory analyses reveal that CHs' craving (as observed in randomly
scheduled assessments) starts to rise about a half hour or so before they smoke.
6
It is not necessary to posit
that the original pattern of smoking in indulgent situations disappears; rather, it is covered
over by more pervasive smoking patterns. This explains why similar situational associations are
seen in HSs in a much weaker, more diluted form.
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Submitted: September 3, 2004 Revised: May 23, 2005 Accepted: May 24, 2005