Addictive Behaviors 39 (2014) 1784–1788
Contents lists available at ScienceDirect
Addictive Behaviors
Comparing college smokers' and dual users' expectancies towards cigarette smoking Joshua C. Gottlieb ⁎, Lee M. Cohen, Aaron K. Haslam Texas Tech University, USA
a r t i c l e
i n f o
Available online 17 July 2014 Keywords: Dual users Expectancies Tobacco College students
a b s t r a c t Background: As no agreed upon definition exists for dual use (i.e., individuals who concurrently use more than one form of tobacco), this population remains largely unstudied in the substance use literature, despite increases in smokeless tobacco use among young adults. Individuals 18–25 years of age report the highest rates of smokeless tobacco use, dual use, and cigarette use. The current study compared the smoking outcome expectancies of college student dual users to those who reported only smoking cigarettes. Methods: The Short Form of the Smoking Consequences Questionnaire was used to examine potential differences in positive or negative expectations regarding cigarette use. Results: Data from this study suggest that smokers believe that smoking will lead to greater positive consequences (“cigarettes taste good”), negative reinforcement (“cigarettes help me deal with anger”), and weight/appetite reduction (“smoking controls my appetite”) when compared to dual users. Conversely, dual users believed that smoking would lead to greater negative consequences (e.g., “smoking is taking years off of my life”). Discussion: These results may help to explain why some smokers choose not to use smokeless tobacco products for harm reduction or smoking cessation purposes, as well as why increases are being observed in smokeless tobacco rates among young adults. © 2014 Elsevier Ltd. All rights reserved.
1. Introduction The use of tobacco products is a major public health concern in the United States and abroad. It remains the leading cause of preventable death worldwide and is associated with several serious illnesses including lung cancer, ischemic heart disease, and emphysema (Adhikari, Kahende, Malarcher, Pechacek, & Tong, 2008; World Health Organization [WHO], 2011). Despite the well-known health risks associated with tobacco use, many continue to smoke cigarettes and/or use smokeless tobacco products (e.g., chewing tobacco, snuff, snus). In 2012, an estimated 22.0% of Americans 18 years or older reported current cigarette use, while 3.6% reported current use of one or more smokeless tobacco products (Centers for Disease Control & Prevention [CDC], 2014). Current use is defined as having smoked or used smokeless tobacco in the past 30 days. While adult smoking rates have declined over the past 15 years, individuals 18–25 years of age have the highest rates of tobacco use. In 2012, nearly early one-third of young adults 18–25 were smokers (31.8%) and 5.5% used smokeless tobacco (CDC, 2014). Males tended to smoke more than females (36.6% and 27.1%, respectively), and use more smokeless tobacco (10.5% of males and 0.5% of females; CDC, ⁎ Corresponding author at: Department of Psychology, Texas Tech University, Box 42051, Lubbock, TX 79409, USA. Tel.: +1 806 834 3644. E-mail address: [email protected] (J.C. Gottlieb).
http://dx.doi.org/10.1016/j.addbeh.2014.07.015 0306-4603/© 2014 Elsevier Ltd. All rights reserved.
2014). Alarmingly, nearly half (46.1%) of all new smokeless tobacco users and over three-fourths (86.9%) of smokers initiate use before age 18 (CDC, 2014; Substance Abuse & Mental Health Services Administration [SAMHSA], 2011). Several explanations may account for the increase in smokeless tobacco use among teens and young adults including, smoking bans and new flavors of smokeless tobacco products (e.g., cherry, apple blend, peach, and grape) clearly targeting this group (Alpert, Koh, & Connolly, 2008; Oliver, Jensen, Vogel, Anderson, & Hatsukami, 2013; Widome, Brock, Klein, & Forster, 2012). Furthermore, the addition of snus to the American market has made tobacco use significantly easier to conceal given that the user swallows saliva produced by the product rather than spit it out (Foulds, Ramstrom, Burke, & Fagerström, 2003; Galanti, Wickholm, & Gilljam, 2001). The advertising of smokeless tobacco products (including snus) has also increased, so larger numbers of our youth are being introduced to an addictive product where use can be easily hidden from authority figures (Curry, Pederson, & Stryker, 2011). These trends are disturbing as individuals are becoming dependent on nicotine earlier and are less likely to successfully quit after a cessation attempt (Lando, Haddock, Robinson, Klesges, & Talcott, 2000). One reason for this is that young smokers have been substituting their cigarettes with smokeless tobacco products (rather than turning to a non-tobacco alternative), or they become dual users, thereby increasing their overall nicotine intake (Hatsukami, Ebbert, Feuer, Stepanov, & Hecht, 2007; Tomar, Alpert, & Connolly, 2010).
J.C. Gottlieb et al. / Addictive Behaviors 39 (2014) 1784–1788
Dual users are those who concurrently use more than one form of tobacco. Aside from the well-known risks of tobacco use, dual users face additional risks when compared to those who use either of the tobacco products in isolation including, heavier alcohol consumption, and greater levels of risk taking behavior (Klesges et al., 2011). Demographically, dual users tend to be Caucasian males, between the age of 18 and 25 years, who live in the southern United States (McClave-Regan & Berkowitz, 2011). In 2012, prevalence estimates for dual use were 10.1% of young adults 18–25 years old and 3.7% of all adults (CDC, 2014). One study examining smokers, smokeless tobacco users, and dual users, found that dual users reported the greatest severity of nicotine withdrawal symptoms, followed by smokers, and smokeless tobacco users (Post, Gilljam, Rosendahl, Bremberg, & Galanti, 2010). Furthermore, the same research group found that smokeless tobacco and dual users reported symptoms of tobacco dependence that were 2–5 times greater than cigarette smokers (Post et al., 2010). 1.1. Tobacco outcome expectancies Smoking outcome expectancies are important to consider when studying an individual's smoking behavior, motivation to continue smoking, and the likelihood of successful smoking cessation (Brandon, Juliano, & Copeland, 1999; Copeland & Brandon, 2000). Additionally, they are predictive of initiation, relapse, and levels of consumption (Brandon & Baker, 1991; Brandon et al., 1999; Copeland, Brandon, & Quinn, 1995; Rose, Chassin, Presson, & Sherman, 1996). Smoking outcome expectancies can generally be grouped into the following categories: 1) positive reinforcement smoking expectancies, 2) negative consequences smoking expectancies, 3) negative reinforcement smoking expectancies, and 4) appetite/weight control smoking expectancies (Brandon & Baker, 1991). Positive smoking expectancies include the facilitation of social situations, and enjoyment of the flavor of the product used (Hendricks & Brandon, 2005; Morrell, Song, & Halpern-Felsher, 2010; Mullennix, Kilbey, Fisicaro, Farnsworth, & Torrento, 2003; Myers, McCarthy, MacPherson, & Brown, 2003). While smokers may enjoy the positive effects of smoking they are also aware of the negative consequences associated with continued use including the numerous health consequences, smelling like smoke, and having bad breath (Glock, Unz, & Kovacs, 2012; Hendricks & Brandon, 2005). Smokers are able to rationalize continued use via the positive expectancies they hold, despite concurrently holding negative expectancies (Glock et al., 2012). There are also smoking outcome expectancies relevant to negative reinforcement. These expectancies have been found to be associated with trait worry and the expectation that smoking will reduce overall negative affect. Furthermore, negative affect reduction expectancies are also thought to induce a positive mood and are associated with smoking behavior as well as nicotine dependence (Brandon, Wetter, & Baker, 1996; Downey & Kilbey, 1995; Peasley-Miklus, McLeish, Schmidt, & Zvolensky, 2012). Finally, expectancies regarding appetite/weight reduction from smoking have been shown to be a motivating factor for individuals to smoke as well, especially among young women (Adams, Baillie, & Copeland, 2011; Brandon & Baker, 1991). Women tend to initiate smoking for weight control reasons and have stronger beliefs regarding the appetite suppressing properties of nicotine when compared to men (Copeland & Carney, 2003; Copeland et al., 1995; French & Jeffery, 1995). Much less is known regarding the role of smokeless tobacco outcome expectancies. A recent study found that positive expectancies towards smokeless tobacco are predictors of current use (Gottlieb, Cohen, Demarree, Treloar, & McCarthy, 2013). Health consequences related to smokeless tobacco use were also found to be lower among smokeless tobacco users when compared to non-tobacco users and smokers (Gottlieb et al., 2013). Another research group found that smokeless tobacco use was positively correlated with expectations that smokeless tobacco could control one's mood, as well as curb the
1785
need to smoke (Wiium & Aarø, 2011). Given that nicotine is the primary psychoactive substance present in both products it makes sense that there is a substantial overlap between smoking and smokeless tobacco outcome expectancies, but differences also exist. One primary difference is that while weight loss is a significant concern for many smokers, smokeless tobacco does not appear to be used for this purpose (Gerend, Boyle, Peterson, & Hatsukami, 1998). While it is evident that little is known regarding the role of smokeless tobacco outcome expectancies, even less is known about the expectancies of dual users of cigarettes and smokeless tobacco. Taking into consideration that dual use can be significantly more harmful to the individual (McClave-Regan & Berkowitz, 2011; Noonan & Duffy, 2014) and dual users appear to be more difficult to treat when compared to users of either product alone (Post et al., 2010; Rosendahl, Galanti, & Gilljam, 2008; Wetter et al., 2002), it is important to gain a better understanding of this largely understudied group. Thus, the present study is designed to examine any differences between smokers and dual users' responses to a measure of smoking outcome expectancies. It is hypothesized that smokers will report higher positive reinforcement outcome expectancies for smoking when compared to dual users, given that smokers use only one tobacco product, whereas dual users may experience as much (or more) positive reinforcement from smokeless tobacco. Regarding negative consequence as a result of smoking, it is predicted that dual users will expect greater negative outcomes when compared to smokers, as the former may chose to use smokeless tobacco as a means of harm reduction and substitute such use a portion of the time they have urges to smoke. We also hypothesize that smokers will display greater negative reinforcement outcome expectancies when compared to dual users as smoking may be used as the only method for reducing negative affect, where dual users may decide to use a smokeless tobacco product instead of smoking. Finally, considering that a relationship between smokeless tobacco use and appetite/weight reduction has not yet been established and significantly more men than women use smokeless tobacco, it is hypothesized that smokers will report higher outcome expectancies related to appetite/weight reduction. 2. Method 2.1. Participants This analysis was part of a larger study (N = 968) that developed a measure for smokeless tobacco outcome expectancies among young adults (Gottlieb et al., 2013). Participants in the current study were 306 undergraduate students enrolled a large, public university in the southern United States. The other 662 students were not included in the analyses for the current study due to the fact that not all phases of data collection for the development of the measure asked about frequency of use. Of the 306 students included, there was a fairly even distribution of dual users (n = 140) and those who reported use of cigarettes, but not smokeless tobacco (n = 166). Cigar and pipe tobacco users were excluded from participation, and electronic cigarette use was not assessed for, as these devices were not commonly used at the time of assessment. The mean age was found to be just under 20 years old (M = 19.89; SD = 3.70) and more females (58.2%) than males. The sample self-identified as 71.2% Caucasian, 16.3% Hispanic or Latino, 3.9% African American, 2.9% Asian American or Pacific Islander, 0.7% Native American, and 4.9% identified as biracial or “other.” The noted demographic data are generally representative of the city in which the study was conducted, however it is important to mention that African Americans are underrepresented in this sample. See Table 1 for complete demographic information. 2.2. Procedure The Human Research Protection Program (Institutional Review Board) of the university where the study was conducted approved the
1786
J.C. Gottlieb et al. / Addictive Behaviors 39 (2014) 1784–1788
2.4. Data analysis
Table 1 Participant demographics. Smokers (n = 166)
Dual users (n = 140)
Combined (N = 306)
% Male % Female
13.9 86.1
75.0 25.0
41.8 58.2
Mean age (Standard Deviation) % African American % Asian American % Caucasian % Hispanic % Native American % Biracial or other
19.36 (2.51) 3.0 1.2 67.5 21.7 .6 6.0
20.52 (4.67) 5.0 5.0 75.7 10.0 .7 3.5
19.89 (3.70) 3.9 2.9 71.2 16.3 0.7 4.9
procedures used for this study and all who participated did so voluntarily. Potential participants were able to choose from a variety of studies available in the Department of Psychology via Sona Experiment Management System, a web-based human subject pool management system. Students who signed up for the current study were given a link to an on-line questionnaire that included the measures described below. Data reported for the current study were collected in 2012. Following completion of the on-line questionnaire, students were directed to another link where they entered their name so that course credit could be awarded for their participation while also keeping their responses anonymous. The on-line questionnaire consisted of a background questionnaire that collected information regarding age, gender, race/ethnicity, and information related to their tobacco use (e.g., type of tobacco product used). The questionnaire also included the Short Form of the Smoking Consequences Questionnaire. Based on past 30-day use, participants were assigned to one of two groups according to the type of tobacco product(s) used (i.e., dual users or cigarette smokers). 2.3. Measures 2.3.1. Background questionnaire A questionnaire designed for the present study was used in order to collect personal information relevant to the purposes of the study. All information was asked in a manner so that participants could not be identified via their responses in order to assure anonymity and participant honesty. Basic demographic questions were asked including participant age, gender, and race/ethnic background. Additionally, frequency of tobacco use was assessed.
The data that were used to test the hypotheses were not normally distributed, indicating that there were both ceiling and floor effects depending on the subscale used in the S-SCQ. As a result, non-parametric Mann–Whitney U tests with continuity correction were used for assessing all hypotheses. This statistical procedure does not examine the group mean locations as is done in a t-test or analysis of variance (ANOVA), but instead examines the rank order of score values from within each group without assuming an underlying distribution. Mann–Whitney U tests were conducted using R (V 3.0.2; R Development Core Team, 2013). Measures of effect sizes were calculated by hand using the following equation: θ ¼ U=ðn1 n2 Þ
ðEq:1Þ
where θ can be interpreted as the overlap between the two distributions. When θ approaches 0 or 1 it is indicative of a little overlap between the populations and suggests differences between groups. If θ approaches .5 then there is little evidence that any true difference exists between the groups (Newcombe, 2006). 3. Results 3.1. Gender and ethnic make up Given that only 0.5% of females aged 18–25 years are current smokeless tobacco users (compared to 10.5% of males), we expected that there would be a significant difference in gender between dual users and smokers (CDC, 2014) which was found to be the case. Results indicated that there were significantly more males than females in the group of dual users, and more females than males in the smoking group (χ2 = 116.69, p b .001) which may suggest that a greater number of female smokers have never used a smokeless tobacco product when compared to their male counterparts. The racial makeup of the dual user and smoker groups were also found to be significantly different (χ2 = 12.62, p = .05). These findings are consistent with national demographic data indicating that the vast majority of those who report use of smokeless tobacco identify as Caucasian (CDC, 2014). Given the observed national prevalence rates, it is not surprising that our sample of dual users were more likely to identify as Caucasian when compared to our sample of cigarette smokers. 3.2. Smoking expectancies
2.3.2. Smoking expectancies The Short Form of the Smoking Consequences Questionnaire (SSCQ; Myers et al., 2003) was developed as a brief measure to determine smoking outcome expectancies in young adult and adolescent populations. The S-SCQ consists of 21-items and four factors: 1) negative consequences, 2) positive reinforcement, 3) negative reinforcement, and 4) appetite-weight control. The original Smoking Consequences Questionnaire (SCQ; Brandon & Baker, 1991) consists of 50-items and contains the same four factors as the short form. Items are rated based on likelihood of occurrence if the individual smoked on a 10-point Likert-type scale (0 = completely unlikely to 9 = completely likely). The purpose of the SCQ is to measure an individual's subjective expected utility of smoking (Brandon & Baker, 1991). When compared to the SCQ (α = .96), internal consistency for the S-SCQ is excellent (α = .93). The S-SCQ was also found to correlate highly with the full scale (r = .94, p b .01). This was also found to be the case for each factor as well: negative consequences (r = .78, p b .01), positive reinforcement (r = .86, p b .01), negative reinforcement (r = .99, p b .01), while the appetite/weight control factor included the same five items as the full SCQ. Confirmatory factor analyses show good fit for the four-factor structure of the S-SCQ (χ2 = 338.12 (183), SRMSR = .08, CFI = .92, TLI = .92).
As stated, Mann–Whitney U tests were conducted for the primary hypotheses, as the data collected from the S-SCQ was not normally distributed. We hypothesized that smokers would report greater positive reinforcement outcome expectancies when compared to dual users, and that dual users would expect greater negative consequences when compared to smokers. Both of these hypotheses were confirmed (U = 9894, p = .988, θ = .426; U = 13462.5, p = .993, θ = .579, respectively). Further, we expected to observe that smokers would report greater negative reinforcement outcome expectancies and greater appetite/weight control expectancies when compared to dual users. Once again, both of these hypotheses were confirmed (U = 9316, p = .001, θ = .401; U = 10,053, p = .02, θ = .433, respectively). See Table 2 for descriptive statistics by factor. To assess the relationship between number of days smoked and number of days smokeless tobacco products were used and the S-SCQ subscale scores, Spearman's rho and Kendall tau correlations were conducted given the ordinal nature of the data and the fact that the data were not normally distributed. The number of days smoked per week was not correlated with any of the S-SCQ expectancy subscales at the p b .05 level. There was, however, a significant positive relationship
J.C. Gottlieb et al. / Addictive Behaviors 39 (2014) 1784–1788 Table 2 Statistics for dual users and smokers on the S-SCQ (by factor). First quartile Positive reinforcement Dual users 0 Smokers 0.8 Negative consequences Dual users 7 Smokers 6.25 Appetite–weight control Dual users 0 Smokers 0 Negative reinforcement Dual users 0 Smokers 1.25
Median
Third quartile
2.1 3.9
5.2 6
8.75 7.875
9 9
0 1.6
3.9 4.25
1.571 4.714
5.714 6.714
observed between number of days participants reported using smokeless tobacco and the positive reinforcement factor score (ρ = .35, p b .001; τ = .299, p b .001, n = 306), indicating that as positive expectancies increased so did the number of days used. Additionally, a significant negative relationship was observed between the number of days participants reported using smokeless tobacco and the negative reinforcement factor score (ρ = −.363, p b .001; τ = −.3, p b .001, n = 282) indicating that as negative expectancies increased, the number of days used decreased. Twenty-four participants who did not provide complete data regarding the frequency of their smokeless tobacco use were excluded from these analyses.
4. Discussion The current study sought to examine the smoking outcome expectancies of college students who use different tobacco products. By studying tobacco users' expectancies, we may gain insight into why college students initiate and maintain a behavior that is known globally to compromise an individual's health status. Dual users are especially important to study given the lack of research among this group and since many are using smokeless tobacco products to replace (or at least help them reduce) cigarette smoking. Gaining insight as to why substituting smokeless tobacco for cigarettes does not work for some college students (but does for others) may prove useful in the development of improved treatment packages for tobacco use disorder. We examined positive and negative outcome expectancies of dual users regarding the use of cigarettes when compared to those who only smoke using the S-SCQ, a valid and reliable measure (Myers et al., 2003). It was predicted that smokers would report greater positive reinforcement, negative reinforcement, and appetite/weight control outcome expectancies when compared to dual users. Conversely, it was predicted that dual users would report a greater likelihood of negative consequences as a result of their cigarette smoking when compared to smokers. All of our predictions were confirmed. Data from this study suggest that smokers believe that smoking will lead to greater positive consequences (e.g., “when I smoke, the taste is pleasant”) when compared to their dual using counterparts. This makes sense conceptually since smokers only use cigarettes while dual users may shift between products. It also appears that dual users believe that smoking will lead to greater negative consequences (e.g., “smoking is taking years off of my life”) when compared to their smoking counterparts. This may be indicative of the fact that some dual users are trying to reduce their use of cigarettes and switch exclusively to smokeless tobacco products as a means of harm reduction (Rodu & Phillips, 2008). Additionally, smokers were found to hold stronger beliefs that smoking would relieve negative affect (e.g., “cigarettes help me deal with anger”) when compared to dual users. It is possible that smokers believe this more strongly because they turn to only one tobacco product to cope with negative affect. Conversely, dual users may use
1787
cigarettes or a smokeless tobacco product to combat their negative affect. Finally, it was not surprising to observe that smokers held a stronger belief that smoking would lead to appetite/weight reduction (e.g., “smoking controls my appetite”) when compared to dual users. Since there is no evidence to support that smokeless tobacco users use in order to control weight, it may be that this observation is best accounted for by a gender effect (i.e., the smoking only group was predominately female, whereas the dual user group was predominately male). This notion is consistent with prior research indicating that women, more than men, smoke for this reason (Adams et al., 2011; Copeland & Carney, 2003). Despite the potential utility of the findings, certain limitations should be considered when interpreting the results. First, and as alluded to earlier, groups differed significantly by gender and race. As such, it is possible that the differences observed are at least partially accounted for by the gender or racial makeup of each group rather than the tobacco product used. In the future, studies should take these factors into account when recruiting participants. This said, the demographics of the group of dual users in the present study resembled rates of dual use nationally, however, it is unclear why the smoking group predominately consisted of female participants. One potential explanation is that university populations tend to consist of more females than males (Morrell, Cohen, & Dempsey, 2008). Another limitation is that we did not assess participants' reasons for being a dual user. Specifically, we did not assess which tobacco product was preferred by the dual users who participated in the current study, nor did we assess the reasons for the use of multiple products. In addition, we did not assess for how long individuals have been using tobacco products or assess which individuals primarily smoked cigarettes compared to those who primarily use smokeless tobacco. This information may better elucidate the findings from this study. Future studies should examine the specific roles for the use of each tobacco product among dual users, as well as why college students who choose to use a single tobacco product have the preference they do. Further, differences between dual users who primarily use smokeless tobacco versus those who primarily smoke cigarettes should be examined, including any differences in expectancies across levels of use. Gaining a better understanding of such differences may help treatment providers distinguish whether an individual will be better suited for participation in a smoking cessation group, a smokeless tobacco cessation program, or a protocol designed to addresses dual use. In sum, we found that dual users were more likely to believe that smoking cigarettes would lead to negative consequences when compared to smokers. We also found that smokers believe that smoking will lead to greater positive reinforcement, negative reinforcement, and hold a greater belief that smoking will serve as an appetite/weight suppressant when compared to dual users. Overall the findings of the present study suggest that because smokers choose to use only one form of tobacco, they are more likely to have favorable expectancies regarding smoking than college students who use multiple tobacco products. It is feasible that those who use two or more forms of tobacco hold less favorable expectancies regarding smoking since they have one or more alternate tobacco products to turn to in order to satisfy their cravings for nicotine, while still receiving the positive sensations that are associated with tobacco use. By examining tobacco users' outcome expectancies, researchers can better understand what ultimately leads an individual to use the substance, which can lead to improved treatment programs and outcomes specifically tailored for college students. Role of funding sources There were no funding sources for the research leading to the current manuscript. Contributors Joshua C. Gottlieb and Lee M. Cohen designed the study. Joshua C. Gottlieb conducted literatures searches relevant to the study and prepared articles for the various sections of the manuscript. Aaron K. Haslam conducted the statistical analyses. Joshua C. Gottlieb and Lee M. Cohen wrote the first draft of the manuscript, and Aaron K. Haslam helped edit the
1788
J.C. Gottlieb et al. / Addictive Behaviors 39 (2014) 1784–1788
final document. All three authors: Joshua C. Gottlieb, Lee M. Cohen, and Aaron K. Haslam contributed to and have approved the final version of the manuscript. Conflict of interest Joshua C. Gottlieb, Lee M. Cohen, and Aaron K. Haslam have no conflicts of interest, financial or otherwise.
References Adams, C. E., Baillie, L. E., & Copeland, A. L. (2011). The smoking-related weight and eating episodes test (SWEET): Development and preliminary validation. Nicotine & Tobacco Research, 13(11), 1123–1131. http://dx.doi.org/10.1093/ntr/ntr162. Adhikari, B., Kahende, J., Malarcher, A., Pechacek, T., & Tong, V. (2008). Smokingattributable mortality, years of potential life lost, and productivity losses — United States, 2000–2004. Morbidity and Mortality Weekly Report, 57(45), 1226–1228. Alpert, H. R., Koh, H., & Connolly, G. N. (2008). Free nicotine content and strategic marketing of moist snuff tobacco products in the United States: 2000–2006. Tobacco Control, 17(5), 332–338. http://dx.doi.org/10.1136/tc.2008.025247. Brandon, T. H., & Baker, T. B. (1991). The Smoking Consequences Questionnaire: The subjective expected utility of smoking in college students. Psychological Assessment, 3(3), 484–491. http://dx.doi.org/10.1037/1040-3590.3.3.484. Brandon, T. H., Juliano, L. M., & Copeland, A. L. (1999). Expectancies in tobacco smoking. In I. Kirsch (Ed.), How expectancies shape experience (pp. 263–299). Washington, DC: American Psychological Association. Brandon, T. H., Wetter, D. W., & Baker, T. B. (1996). Affect, expectancies, urges, and smoking: Do they conform to models of drug motivation and relapse? Experimental and Clinical Psychopharmacology, 4(1), 29–36. http://dx.doi.org/10.1037/1064-1297. 4.1.29. Centers for Disease Control and Prevention (2014). The health consequences of smoking — 50 years of progress. A report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services. Copeland, A. L., & Brandon, T. H. (2000). Testing the causal role of expectancies in smoking motivation and behavior. Addictive Behaviors, 25(3), 445–449. http://dx.doi.org/10. 1037/1040-3590.7.4.484. Copeland, A. L., Brandon, T. H., & Quinn, E. P. (1995). The Smoking Consequences Questionnaire-Adult: Measurement of smoking outcome expectancies of experienced smokers. Psychological Assessment, 7(4), 484–494. http://dx.doi.org/10.1037/ 1040-3590.7.4.484. Copeland, A. L., & Carney, C. E. (2003). Smoking expectancies as mediators between dietary restraint and disinhibition and smoking in college women. Experimental and Clinical Psychopharmacology, 11(3), 247–251. http://dx.doi.org/10.1037/1064-1297. 11.3.247. Curry, L. E., Pederson, L. L., & Stryker, J. E. (2011). The changing marketing of smokeless tobacco in magazine advertisements. Nicotine & Tobacco Research, 13(7), 540–547. http://dx.doi.org/10.1093/ntr/ntr038. Downey, K. K., & Kilbey, M. M. (1995). Relationship between nicotine and alcohol expectancies and substance dependence. Experimental and Clinical Psychopharmacology, 3(2), 174–182. http://dx.doi.org/10.1037/1064-1297.3.2.174. Foulds, J., Ramstrom, L., Burke, M., & Fagerström, K. (2003). Effect of smokeless tobacco (snus) on smoking and public health in Sweden. Tobacco Control, 12(4), 349–359. http://dx.doi.org/10.1136/tc.12.4.349. French, S. A., & Jeffery, R. W. (1995). Weight concerns and smoking: A literature review. Annals of Behavioral Medicine, 17(3), 234–244. http://dx.doi.org/10.1007/ BF02903918. Galanti, M. R., Wickholm, S., & Gilljam, H. (2001). Between harm and dangers: Oral snuff use, cigarette smoking and problem behaviours in a survey of Swedish male adolescents. European Journal of Public Health, 11(3), 340–345. http://dx.doi.org/10.1093/ eurpub/11.3.340. Gerend, M.A., Boyle, R. G., Peterson, C. B., & Hatsukami, D. K. (1998). Behavior and weight control among women using smokeless tobacco, cigarettes, and normal controls. Addictive Behaviors, 23(2), 171–178. http://dx.doi.org/10.1016/S0306-4603(97) 00023-3. Glock, S., Unz, D., & Kovacs, C. (2012). Beyond fear appeals: Contradicting positive smoking outcome expectancies to influence smokers' implicit attitudes, perception, and behavior. Addictive Behaviors, 37(4), 548–551. http://dx.doi.org/10.1016/j. addbeh.2011.11.032. Gottlieb, J. C., Cohen, L. M., Demarree, K. G., Treloar, H. R., & McCarthy, D.M. (2013). The Development and Psychometric Evaluation of the Smokeless Tobacco Expectancies Scale (STES). Psychological Assessment, 25(3), 997–1001. http://dx.doi.org/10.1037/ a0032256. Hatsukami, D. K., Ebbert, J. O., Feuer, R. M., Stepanov, I., & Hecht, S. S. (2007). Changing smokeless tobacco products new tobacco-delivery systems. American Journal of Preventive Medicine, 33(6 Suppl.), S368–S378. http://dx.doi.org/10.1016/j.amepre.2007. 09.005. Hendricks, P.S., & Brandon, T. H. (2005). Smoking expectancy associates among college smokers. Addictive Behaviors, 30(2), 235–245. http://dx.doi.org/10.1016/j.addbeh. 2004.05.006.
Klesges, R. C., Ebbert, J. O., Morgan, G. D., Sherrill-Mittleman, D., Asfar, T., Talcott, W. G., et al. (2011). Impact of differing definitions of dual tobacco use: Implications for studying dual use and a call for operational definitions. Nicotine & Tobacco Research, 13(7), 523–531. http://dx.doi.org/10.1093/ntr/ntr032. Lando, H. A., Haddock, C. K., Robinson, L. A., Klesges, R. C., & Talcott, G. W. (2000). Ethnic differences in patterns and correlates of age of initiation in a population of Air Force recruits. Nicotine & Tobacco Research, 2, 337–344. http://dx.doi.org/10.1080/ 14622200020028065. McClave-Regan, A. K., & Berkowitz, J. (2011). Smokers who are also using smokeless tobacco products in the US: A national assessment of characteristics, behaviours and beliefs of ‘dual users’. Tobacco Control, 20(3), 239–242. http://dx.doi.org/10.1136/tc. 2010.039115. Morrell, H. E. R., Cohen, L. M., & Dempsey, J. P. (2008). Smoking prevalence and awareness among undergraduate and health care students. American Journal on Addictions, 17(3), 181–186. http://dx.doi.org/10.1080/10550490802019899. Morrell, H. E., Song, A. V., & Halpern-Felsher, B.L. (2010). Predicting adolescent perceptions of the risks and benefits of cigarette smoking: A longitudinal investigation. Health Psychology, 29(6), 610–617. http://dx.doi.org/10.1037/a0021237. Mullennix, J. W., Kilbey, M. M., Fisicaro, S. A., Farnsworth, L. M., & Torrento, R. (2003). The representation of smoking expectancies by single-word adjectives and their relationship to smoking characteristics. Nicotine & Tobacco Research, 5(5), 681–694. http://dx. doi.org/10.1080/1462220031000158654. Myers, M. G., McCarthy, D.M., MacPherson, L., & Brown, S. A. (2003). Constructing a short form of the Smoking Consequences Questionnaire with adolescents and young adults. Psychological Assessment, 15(2), 163–172. http://dx.doi.org/10.1037/10403590.15.2.163. Newcombe, R. G. (2006). Confidence intervals for an effect size measure based on the Mann–Whitney statistic. Part 1: General issues and tail-area-based methods. Statistics in Medicine, 25(4), 543–557. http://dx.doi.org/10.1002/sim.2323. Noonan, D., & Duffy, S. A. (2014). Factors associated with smokeless tobacco use and dual use among blue collar workers. Public Health Nursing, 31(1), 19–27. http://dx.doi.org/ 10.1111/phn.12095. Oliver, A. J., Jensen, J. A., Vogel, R. I., Anderson, A. J., & Hatsukami, D. K. (2013). Flavored and nonflavored smokeless tobacco products: Rate, pattern of use, and effects. Nicotine & Tobacco Research, 15(1), 88–92. http://dx.doi.org/10.1093/ntr/nts093. Peasley-Miklus, C. E., McLeish, A.C., Schmidt, N.B., & Zvolensky, M. J. (2012). An examination of smoking outcome expectancies, smoking motives and trait worry in a sample of treatment-seeking smokers. Addictive Behaviors, 37(4), 407–413. http://dx.doi.org/ 10.1016/j.addbeh.2011.11.037. Post, A., Gilljam, H., Rosendahl, I., Bremberg, S., & Galanti, M. R. (2010). Symptoms of nicotine dependence in a cohort of Swedish youths: A comparison between smokers, smokeless tobacco users and dual tobacco users. Addiction, 105(4), 740–746. http:// dx.doi.org/10.1111/j.1360-0443.2009.02852.x. R Development Core Team (2013). R: A language and environment for statistical computing (version 3.0.2). Vienna, Austria: R Foundation for Statistical Computing (Retrieved from http://www.R-project.org). Rodu, B., & Phillips, C. V. (2008). Switching to smokeless tobacco as a smoking cessation method: Evidence from the 2000 National Health Interview Survey. Harm Reduction Journal, 5, 18. http://dx.doi.org/10.1186/1477-7517-5-18. Rose, J. S., Chassin, L., Presson, C. C., & Sherman, S. J. (1996). Prospective predictors of quit attempts and smoking cessation in young adults. Health Psychology, 15(4), 261–268. http://dx.doi.org/10.1037/0278-6133.15.4.261. Rosendahl, K. I., Galanti, M. R., & Gilljam, H. (2008). Trajectories of smokeless tobacco use and of cigarette smoking in a cohort of Swedish adolescents: Differences and implications. Nicotine & Tobacco Research, 10(6), 1021–1027. http://dx.doi.org/10.1080/ 14622200802097522. Substance Abuse and Mental Health Services Administration (2011). Results from the 2010 National Survey on Drug Use and Health: Summary of national findings. HHS Publication No. 11-46580. Rockville, MD: Substance Abuse and Mental Health Services Administration. Tomar, S. L., Alpert, H. R., & Connolly, G. N. (2010). Patterns of dual use of cigarettes and smokeless tobacco among US males: Findings from national surveys. Tobacco Control, 19(2), 104–109. http://dx.doi.org/10.1136/tc.2009.031070. Wetter, D. W., McClure, J. B., de Moor, C., Cofta-Gunn, L., Cummings, S., Cinciripini, P.M., et al. (2002). Concomitant use of cigarettes and smokeless tobacco: Prevalence, correlates, and predictors of tobacco cessation. Preventive Medicine, 34(6), 638–648. http://dx.doi.org/10.1006/pmed.2002.1032. Widome, R., Brock, B., Klein, E. G., & Forster, J. L. (2012). Smokeless tobacco advertising at the point of sale: Prevalence, placement, and demographic correlates. Nicotine & Tobacco Research, 14(2), 217–223. http://dx.doi.org/10.1093/ntr/ntr188. Wiium, N., & Aarø, L. E. (2011). Outcome expectations and use of smokeless tobacco (snus): A cross-sectional study among young Norwegian snus users. Scandinavian Journal of Psychology, 52(1), 64–70. http://dx.doi.org/10.1111/j.1467-9450.2010. 00823.x. World Health Organization (2011). WHO report on the global tobacco epidemic, 2011: Warning about the dangers of tobacco. (Geneva, Switzerland).
Contents lists available at ScienceDirect
Addictive Behaviors
Comparing college smokers' and dual users' expectancies towards cigarette smoking Joshua C. Gottlieb ⁎, Lee M. Cohen, Aaron K. Haslam Texas Tech University, USA
a r t i c l e
i n f o
Available online 17 July 2014 Keywords: Dual users Expectancies Tobacco College students
a b s t r a c t Background: As no agreed upon definition exists for dual use (i.e., individuals who concurrently use more than one form of tobacco), this population remains largely unstudied in the substance use literature, despite increases in smokeless tobacco use among young adults. Individuals 18–25 years of age report the highest rates of smokeless tobacco use, dual use, and cigarette use. The current study compared the smoking outcome expectancies of college student dual users to those who reported only smoking cigarettes. Methods: The Short Form of the Smoking Consequences Questionnaire was used to examine potential differences in positive or negative expectations regarding cigarette use. Results: Data from this study suggest that smokers believe that smoking will lead to greater positive consequences (“cigarettes taste good”), negative reinforcement (“cigarettes help me deal with anger”), and weight/appetite reduction (“smoking controls my appetite”) when compared to dual users. Conversely, dual users believed that smoking would lead to greater negative consequences (e.g., “smoking is taking years off of my life”). Discussion: These results may help to explain why some smokers choose not to use smokeless tobacco products for harm reduction or smoking cessation purposes, as well as why increases are being observed in smokeless tobacco rates among young adults. © 2014 Elsevier Ltd. All rights reserved.
1. Introduction The use of tobacco products is a major public health concern in the United States and abroad. It remains the leading cause of preventable death worldwide and is associated with several serious illnesses including lung cancer, ischemic heart disease, and emphysema (Adhikari, Kahende, Malarcher, Pechacek, & Tong, 2008; World Health Organization [WHO], 2011). Despite the well-known health risks associated with tobacco use, many continue to smoke cigarettes and/or use smokeless tobacco products (e.g., chewing tobacco, snuff, snus). In 2012, an estimated 22.0% of Americans 18 years or older reported current cigarette use, while 3.6% reported current use of one or more smokeless tobacco products (Centers for Disease Control & Prevention [CDC], 2014). Current use is defined as having smoked or used smokeless tobacco in the past 30 days. While adult smoking rates have declined over the past 15 years, individuals 18–25 years of age have the highest rates of tobacco use. In 2012, nearly early one-third of young adults 18–25 were smokers (31.8%) and 5.5% used smokeless tobacco (CDC, 2014). Males tended to smoke more than females (36.6% and 27.1%, respectively), and use more smokeless tobacco (10.5% of males and 0.5% of females; CDC, ⁎ Corresponding author at: Department of Psychology, Texas Tech University, Box 42051, Lubbock, TX 79409, USA. Tel.: +1 806 834 3644. E-mail address: [email protected] (J.C. Gottlieb).
http://dx.doi.org/10.1016/j.addbeh.2014.07.015 0306-4603/© 2014 Elsevier Ltd. All rights reserved.
2014). Alarmingly, nearly half (46.1%) of all new smokeless tobacco users and over three-fourths (86.9%) of smokers initiate use before age 18 (CDC, 2014; Substance Abuse & Mental Health Services Administration [SAMHSA], 2011). Several explanations may account for the increase in smokeless tobacco use among teens and young adults including, smoking bans and new flavors of smokeless tobacco products (e.g., cherry, apple blend, peach, and grape) clearly targeting this group (Alpert, Koh, & Connolly, 2008; Oliver, Jensen, Vogel, Anderson, & Hatsukami, 2013; Widome, Brock, Klein, & Forster, 2012). Furthermore, the addition of snus to the American market has made tobacco use significantly easier to conceal given that the user swallows saliva produced by the product rather than spit it out (Foulds, Ramstrom, Burke, & Fagerström, 2003; Galanti, Wickholm, & Gilljam, 2001). The advertising of smokeless tobacco products (including snus) has also increased, so larger numbers of our youth are being introduced to an addictive product where use can be easily hidden from authority figures (Curry, Pederson, & Stryker, 2011). These trends are disturbing as individuals are becoming dependent on nicotine earlier and are less likely to successfully quit after a cessation attempt (Lando, Haddock, Robinson, Klesges, & Talcott, 2000). One reason for this is that young smokers have been substituting their cigarettes with smokeless tobacco products (rather than turning to a non-tobacco alternative), or they become dual users, thereby increasing their overall nicotine intake (Hatsukami, Ebbert, Feuer, Stepanov, & Hecht, 2007; Tomar, Alpert, & Connolly, 2010).
J.C. Gottlieb et al. / Addictive Behaviors 39 (2014) 1784–1788
Dual users are those who concurrently use more than one form of tobacco. Aside from the well-known risks of tobacco use, dual users face additional risks when compared to those who use either of the tobacco products in isolation including, heavier alcohol consumption, and greater levels of risk taking behavior (Klesges et al., 2011). Demographically, dual users tend to be Caucasian males, between the age of 18 and 25 years, who live in the southern United States (McClave-Regan & Berkowitz, 2011). In 2012, prevalence estimates for dual use were 10.1% of young adults 18–25 years old and 3.7% of all adults (CDC, 2014). One study examining smokers, smokeless tobacco users, and dual users, found that dual users reported the greatest severity of nicotine withdrawal symptoms, followed by smokers, and smokeless tobacco users (Post, Gilljam, Rosendahl, Bremberg, & Galanti, 2010). Furthermore, the same research group found that smokeless tobacco and dual users reported symptoms of tobacco dependence that were 2–5 times greater than cigarette smokers (Post et al., 2010). 1.1. Tobacco outcome expectancies Smoking outcome expectancies are important to consider when studying an individual's smoking behavior, motivation to continue smoking, and the likelihood of successful smoking cessation (Brandon, Juliano, & Copeland, 1999; Copeland & Brandon, 2000). Additionally, they are predictive of initiation, relapse, and levels of consumption (Brandon & Baker, 1991; Brandon et al., 1999; Copeland, Brandon, & Quinn, 1995; Rose, Chassin, Presson, & Sherman, 1996). Smoking outcome expectancies can generally be grouped into the following categories: 1) positive reinforcement smoking expectancies, 2) negative consequences smoking expectancies, 3) negative reinforcement smoking expectancies, and 4) appetite/weight control smoking expectancies (Brandon & Baker, 1991). Positive smoking expectancies include the facilitation of social situations, and enjoyment of the flavor of the product used (Hendricks & Brandon, 2005; Morrell, Song, & Halpern-Felsher, 2010; Mullennix, Kilbey, Fisicaro, Farnsworth, & Torrento, 2003; Myers, McCarthy, MacPherson, & Brown, 2003). While smokers may enjoy the positive effects of smoking they are also aware of the negative consequences associated with continued use including the numerous health consequences, smelling like smoke, and having bad breath (Glock, Unz, & Kovacs, 2012; Hendricks & Brandon, 2005). Smokers are able to rationalize continued use via the positive expectancies they hold, despite concurrently holding negative expectancies (Glock et al., 2012). There are also smoking outcome expectancies relevant to negative reinforcement. These expectancies have been found to be associated with trait worry and the expectation that smoking will reduce overall negative affect. Furthermore, negative affect reduction expectancies are also thought to induce a positive mood and are associated with smoking behavior as well as nicotine dependence (Brandon, Wetter, & Baker, 1996; Downey & Kilbey, 1995; Peasley-Miklus, McLeish, Schmidt, & Zvolensky, 2012). Finally, expectancies regarding appetite/weight reduction from smoking have been shown to be a motivating factor for individuals to smoke as well, especially among young women (Adams, Baillie, & Copeland, 2011; Brandon & Baker, 1991). Women tend to initiate smoking for weight control reasons and have stronger beliefs regarding the appetite suppressing properties of nicotine when compared to men (Copeland & Carney, 2003; Copeland et al., 1995; French & Jeffery, 1995). Much less is known regarding the role of smokeless tobacco outcome expectancies. A recent study found that positive expectancies towards smokeless tobacco are predictors of current use (Gottlieb, Cohen, Demarree, Treloar, & McCarthy, 2013). Health consequences related to smokeless tobacco use were also found to be lower among smokeless tobacco users when compared to non-tobacco users and smokers (Gottlieb et al., 2013). Another research group found that smokeless tobacco use was positively correlated with expectations that smokeless tobacco could control one's mood, as well as curb the
1785
need to smoke (Wiium & Aarø, 2011). Given that nicotine is the primary psychoactive substance present in both products it makes sense that there is a substantial overlap between smoking and smokeless tobacco outcome expectancies, but differences also exist. One primary difference is that while weight loss is a significant concern for many smokers, smokeless tobacco does not appear to be used for this purpose (Gerend, Boyle, Peterson, & Hatsukami, 1998). While it is evident that little is known regarding the role of smokeless tobacco outcome expectancies, even less is known about the expectancies of dual users of cigarettes and smokeless tobacco. Taking into consideration that dual use can be significantly more harmful to the individual (McClave-Regan & Berkowitz, 2011; Noonan & Duffy, 2014) and dual users appear to be more difficult to treat when compared to users of either product alone (Post et al., 2010; Rosendahl, Galanti, & Gilljam, 2008; Wetter et al., 2002), it is important to gain a better understanding of this largely understudied group. Thus, the present study is designed to examine any differences between smokers and dual users' responses to a measure of smoking outcome expectancies. It is hypothesized that smokers will report higher positive reinforcement outcome expectancies for smoking when compared to dual users, given that smokers use only one tobacco product, whereas dual users may experience as much (or more) positive reinforcement from smokeless tobacco. Regarding negative consequence as a result of smoking, it is predicted that dual users will expect greater negative outcomes when compared to smokers, as the former may chose to use smokeless tobacco as a means of harm reduction and substitute such use a portion of the time they have urges to smoke. We also hypothesize that smokers will display greater negative reinforcement outcome expectancies when compared to dual users as smoking may be used as the only method for reducing negative affect, where dual users may decide to use a smokeless tobacco product instead of smoking. Finally, considering that a relationship between smokeless tobacco use and appetite/weight reduction has not yet been established and significantly more men than women use smokeless tobacco, it is hypothesized that smokers will report higher outcome expectancies related to appetite/weight reduction. 2. Method 2.1. Participants This analysis was part of a larger study (N = 968) that developed a measure for smokeless tobacco outcome expectancies among young adults (Gottlieb et al., 2013). Participants in the current study were 306 undergraduate students enrolled a large, public university in the southern United States. The other 662 students were not included in the analyses for the current study due to the fact that not all phases of data collection for the development of the measure asked about frequency of use. Of the 306 students included, there was a fairly even distribution of dual users (n = 140) and those who reported use of cigarettes, but not smokeless tobacco (n = 166). Cigar and pipe tobacco users were excluded from participation, and electronic cigarette use was not assessed for, as these devices were not commonly used at the time of assessment. The mean age was found to be just under 20 years old (M = 19.89; SD = 3.70) and more females (58.2%) than males. The sample self-identified as 71.2% Caucasian, 16.3% Hispanic or Latino, 3.9% African American, 2.9% Asian American or Pacific Islander, 0.7% Native American, and 4.9% identified as biracial or “other.” The noted demographic data are generally representative of the city in which the study was conducted, however it is important to mention that African Americans are underrepresented in this sample. See Table 1 for complete demographic information. 2.2. Procedure The Human Research Protection Program (Institutional Review Board) of the university where the study was conducted approved the
1786
J.C. Gottlieb et al. / Addictive Behaviors 39 (2014) 1784–1788
2.4. Data analysis
Table 1 Participant demographics. Smokers (n = 166)
Dual users (n = 140)
Combined (N = 306)
% Male % Female
13.9 86.1
75.0 25.0
41.8 58.2
Mean age (Standard Deviation) % African American % Asian American % Caucasian % Hispanic % Native American % Biracial or other
19.36 (2.51) 3.0 1.2 67.5 21.7 .6 6.0
20.52 (4.67) 5.0 5.0 75.7 10.0 .7 3.5
19.89 (3.70) 3.9 2.9 71.2 16.3 0.7 4.9
procedures used for this study and all who participated did so voluntarily. Potential participants were able to choose from a variety of studies available in the Department of Psychology via Sona Experiment Management System, a web-based human subject pool management system. Students who signed up for the current study were given a link to an on-line questionnaire that included the measures described below. Data reported for the current study were collected in 2012. Following completion of the on-line questionnaire, students were directed to another link where they entered their name so that course credit could be awarded for their participation while also keeping their responses anonymous. The on-line questionnaire consisted of a background questionnaire that collected information regarding age, gender, race/ethnicity, and information related to their tobacco use (e.g., type of tobacco product used). The questionnaire also included the Short Form of the Smoking Consequences Questionnaire. Based on past 30-day use, participants were assigned to one of two groups according to the type of tobacco product(s) used (i.e., dual users or cigarette smokers). 2.3. Measures 2.3.1. Background questionnaire A questionnaire designed for the present study was used in order to collect personal information relevant to the purposes of the study. All information was asked in a manner so that participants could not be identified via their responses in order to assure anonymity and participant honesty. Basic demographic questions were asked including participant age, gender, and race/ethnic background. Additionally, frequency of tobacco use was assessed.
The data that were used to test the hypotheses were not normally distributed, indicating that there were both ceiling and floor effects depending on the subscale used in the S-SCQ. As a result, non-parametric Mann–Whitney U tests with continuity correction were used for assessing all hypotheses. This statistical procedure does not examine the group mean locations as is done in a t-test or analysis of variance (ANOVA), but instead examines the rank order of score values from within each group without assuming an underlying distribution. Mann–Whitney U tests were conducted using R (V 3.0.2; R Development Core Team, 2013). Measures of effect sizes were calculated by hand using the following equation: θ ¼ U=ðn1 n2 Þ
ðEq:1Þ
where θ can be interpreted as the overlap between the two distributions. When θ approaches 0 or 1 it is indicative of a little overlap between the populations and suggests differences between groups. If θ approaches .5 then there is little evidence that any true difference exists between the groups (Newcombe, 2006). 3. Results 3.1. Gender and ethnic make up Given that only 0.5% of females aged 18–25 years are current smokeless tobacco users (compared to 10.5% of males), we expected that there would be a significant difference in gender between dual users and smokers (CDC, 2014) which was found to be the case. Results indicated that there were significantly more males than females in the group of dual users, and more females than males in the smoking group (χ2 = 116.69, p b .001) which may suggest that a greater number of female smokers have never used a smokeless tobacco product when compared to their male counterparts. The racial makeup of the dual user and smoker groups were also found to be significantly different (χ2 = 12.62, p = .05). These findings are consistent with national demographic data indicating that the vast majority of those who report use of smokeless tobacco identify as Caucasian (CDC, 2014). Given the observed national prevalence rates, it is not surprising that our sample of dual users were more likely to identify as Caucasian when compared to our sample of cigarette smokers. 3.2. Smoking expectancies
2.3.2. Smoking expectancies The Short Form of the Smoking Consequences Questionnaire (SSCQ; Myers et al., 2003) was developed as a brief measure to determine smoking outcome expectancies in young adult and adolescent populations. The S-SCQ consists of 21-items and four factors: 1) negative consequences, 2) positive reinforcement, 3) negative reinforcement, and 4) appetite-weight control. The original Smoking Consequences Questionnaire (SCQ; Brandon & Baker, 1991) consists of 50-items and contains the same four factors as the short form. Items are rated based on likelihood of occurrence if the individual smoked on a 10-point Likert-type scale (0 = completely unlikely to 9 = completely likely). The purpose of the SCQ is to measure an individual's subjective expected utility of smoking (Brandon & Baker, 1991). When compared to the SCQ (α = .96), internal consistency for the S-SCQ is excellent (α = .93). The S-SCQ was also found to correlate highly with the full scale (r = .94, p b .01). This was also found to be the case for each factor as well: negative consequences (r = .78, p b .01), positive reinforcement (r = .86, p b .01), negative reinforcement (r = .99, p b .01), while the appetite/weight control factor included the same five items as the full SCQ. Confirmatory factor analyses show good fit for the four-factor structure of the S-SCQ (χ2 = 338.12 (183), SRMSR = .08, CFI = .92, TLI = .92).
As stated, Mann–Whitney U tests were conducted for the primary hypotheses, as the data collected from the S-SCQ was not normally distributed. We hypothesized that smokers would report greater positive reinforcement outcome expectancies when compared to dual users, and that dual users would expect greater negative consequences when compared to smokers. Both of these hypotheses were confirmed (U = 9894, p = .988, θ = .426; U = 13462.5, p = .993, θ = .579, respectively). Further, we expected to observe that smokers would report greater negative reinforcement outcome expectancies and greater appetite/weight control expectancies when compared to dual users. Once again, both of these hypotheses were confirmed (U = 9316, p = .001, θ = .401; U = 10,053, p = .02, θ = .433, respectively). See Table 2 for descriptive statistics by factor. To assess the relationship between number of days smoked and number of days smokeless tobacco products were used and the S-SCQ subscale scores, Spearman's rho and Kendall tau correlations were conducted given the ordinal nature of the data and the fact that the data were not normally distributed. The number of days smoked per week was not correlated with any of the S-SCQ expectancy subscales at the p b .05 level. There was, however, a significant positive relationship
J.C. Gottlieb et al. / Addictive Behaviors 39 (2014) 1784–1788 Table 2 Statistics for dual users and smokers on the S-SCQ (by factor). First quartile Positive reinforcement Dual users 0 Smokers 0.8 Negative consequences Dual users 7 Smokers 6.25 Appetite–weight control Dual users 0 Smokers 0 Negative reinforcement Dual users 0 Smokers 1.25
Median
Third quartile
2.1 3.9
5.2 6
8.75 7.875
9 9
0 1.6
3.9 4.25
1.571 4.714
5.714 6.714
observed between number of days participants reported using smokeless tobacco and the positive reinforcement factor score (ρ = .35, p b .001; τ = .299, p b .001, n = 306), indicating that as positive expectancies increased so did the number of days used. Additionally, a significant negative relationship was observed between the number of days participants reported using smokeless tobacco and the negative reinforcement factor score (ρ = −.363, p b .001; τ = −.3, p b .001, n = 282) indicating that as negative expectancies increased, the number of days used decreased. Twenty-four participants who did not provide complete data regarding the frequency of their smokeless tobacco use were excluded from these analyses.
4. Discussion The current study sought to examine the smoking outcome expectancies of college students who use different tobacco products. By studying tobacco users' expectancies, we may gain insight into why college students initiate and maintain a behavior that is known globally to compromise an individual's health status. Dual users are especially important to study given the lack of research among this group and since many are using smokeless tobacco products to replace (or at least help them reduce) cigarette smoking. Gaining insight as to why substituting smokeless tobacco for cigarettes does not work for some college students (but does for others) may prove useful in the development of improved treatment packages for tobacco use disorder. We examined positive and negative outcome expectancies of dual users regarding the use of cigarettes when compared to those who only smoke using the S-SCQ, a valid and reliable measure (Myers et al., 2003). It was predicted that smokers would report greater positive reinforcement, negative reinforcement, and appetite/weight control outcome expectancies when compared to dual users. Conversely, it was predicted that dual users would report a greater likelihood of negative consequences as a result of their cigarette smoking when compared to smokers. All of our predictions were confirmed. Data from this study suggest that smokers believe that smoking will lead to greater positive consequences (e.g., “when I smoke, the taste is pleasant”) when compared to their dual using counterparts. This makes sense conceptually since smokers only use cigarettes while dual users may shift between products. It also appears that dual users believe that smoking will lead to greater negative consequences (e.g., “smoking is taking years off of my life”) when compared to their smoking counterparts. This may be indicative of the fact that some dual users are trying to reduce their use of cigarettes and switch exclusively to smokeless tobacco products as a means of harm reduction (Rodu & Phillips, 2008). Additionally, smokers were found to hold stronger beliefs that smoking would relieve negative affect (e.g., “cigarettes help me deal with anger”) when compared to dual users. It is possible that smokers believe this more strongly because they turn to only one tobacco product to cope with negative affect. Conversely, dual users may use
1787
cigarettes or a smokeless tobacco product to combat their negative affect. Finally, it was not surprising to observe that smokers held a stronger belief that smoking would lead to appetite/weight reduction (e.g., “smoking controls my appetite”) when compared to dual users. Since there is no evidence to support that smokeless tobacco users use in order to control weight, it may be that this observation is best accounted for by a gender effect (i.e., the smoking only group was predominately female, whereas the dual user group was predominately male). This notion is consistent with prior research indicating that women, more than men, smoke for this reason (Adams et al., 2011; Copeland & Carney, 2003). Despite the potential utility of the findings, certain limitations should be considered when interpreting the results. First, and as alluded to earlier, groups differed significantly by gender and race. As such, it is possible that the differences observed are at least partially accounted for by the gender or racial makeup of each group rather than the tobacco product used. In the future, studies should take these factors into account when recruiting participants. This said, the demographics of the group of dual users in the present study resembled rates of dual use nationally, however, it is unclear why the smoking group predominately consisted of female participants. One potential explanation is that university populations tend to consist of more females than males (Morrell, Cohen, & Dempsey, 2008). Another limitation is that we did not assess participants' reasons for being a dual user. Specifically, we did not assess which tobacco product was preferred by the dual users who participated in the current study, nor did we assess the reasons for the use of multiple products. In addition, we did not assess for how long individuals have been using tobacco products or assess which individuals primarily smoked cigarettes compared to those who primarily use smokeless tobacco. This information may better elucidate the findings from this study. Future studies should examine the specific roles for the use of each tobacco product among dual users, as well as why college students who choose to use a single tobacco product have the preference they do. Further, differences between dual users who primarily use smokeless tobacco versus those who primarily smoke cigarettes should be examined, including any differences in expectancies across levels of use. Gaining a better understanding of such differences may help treatment providers distinguish whether an individual will be better suited for participation in a smoking cessation group, a smokeless tobacco cessation program, or a protocol designed to addresses dual use. In sum, we found that dual users were more likely to believe that smoking cigarettes would lead to negative consequences when compared to smokers. We also found that smokers believe that smoking will lead to greater positive reinforcement, negative reinforcement, and hold a greater belief that smoking will serve as an appetite/weight suppressant when compared to dual users. Overall the findings of the present study suggest that because smokers choose to use only one form of tobacco, they are more likely to have favorable expectancies regarding smoking than college students who use multiple tobacco products. It is feasible that those who use two or more forms of tobacco hold less favorable expectancies regarding smoking since they have one or more alternate tobacco products to turn to in order to satisfy their cravings for nicotine, while still receiving the positive sensations that are associated with tobacco use. By examining tobacco users' outcome expectancies, researchers can better understand what ultimately leads an individual to use the substance, which can lead to improved treatment programs and outcomes specifically tailored for college students. Role of funding sources There were no funding sources for the research leading to the current manuscript. Contributors Joshua C. Gottlieb and Lee M. Cohen designed the study. Joshua C. Gottlieb conducted literatures searches relevant to the study and prepared articles for the various sections of the manuscript. Aaron K. Haslam conducted the statistical analyses. Joshua C. Gottlieb and Lee M. Cohen wrote the first draft of the manuscript, and Aaron K. Haslam helped edit the
1788
J.C. Gottlieb et al. / Addictive Behaviors 39 (2014) 1784–1788
final document. All three authors: Joshua C. Gottlieb, Lee M. Cohen, and Aaron K. Haslam contributed to and have approved the final version of the manuscript. Conflict of interest Joshua C. Gottlieb, Lee M. Cohen, and Aaron K. Haslam have no conflicts of interest, financial or otherwise.
References Adams, C. E., Baillie, L. E., & Copeland, A. L. (2011). The smoking-related weight and eating episodes test (SWEET): Development and preliminary validation. Nicotine & Tobacco Research, 13(11), 1123–1131. http://dx.doi.org/10.1093/ntr/ntr162. Adhikari, B., Kahende, J., Malarcher, A., Pechacek, T., & Tong, V. (2008). Smokingattributable mortality, years of potential life lost, and productivity losses — United States, 2000–2004. Morbidity and Mortality Weekly Report, 57(45), 1226–1228. Alpert, H. R., Koh, H., & Connolly, G. N. (2008). Free nicotine content and strategic marketing of moist snuff tobacco products in the United States: 2000–2006. Tobacco Control, 17(5), 332–338. http://dx.doi.org/10.1136/tc.2008.025247. Brandon, T. H., & Baker, T. B. (1991). The Smoking Consequences Questionnaire: The subjective expected utility of smoking in college students. Psychological Assessment, 3(3), 484–491. http://dx.doi.org/10.1037/1040-3590.3.3.484. Brandon, T. H., Juliano, L. M., & Copeland, A. L. (1999). Expectancies in tobacco smoking. In I. Kirsch (Ed.), How expectancies shape experience (pp. 263–299). Washington, DC: American Psychological Association. Brandon, T. H., Wetter, D. W., & Baker, T. B. (1996). Affect, expectancies, urges, and smoking: Do they conform to models of drug motivation and relapse? Experimental and Clinical Psychopharmacology, 4(1), 29–36. http://dx.doi.org/10.1037/1064-1297. 4.1.29. Centers for Disease Control and Prevention (2014). The health consequences of smoking — 50 years of progress. A report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services. Copeland, A. L., & Brandon, T. H. (2000). Testing the causal role of expectancies in smoking motivation and behavior. Addictive Behaviors, 25(3), 445–449. http://dx.doi.org/10. 1037/1040-3590.7.4.484. Copeland, A. L., Brandon, T. H., & Quinn, E. P. (1995). The Smoking Consequences Questionnaire-Adult: Measurement of smoking outcome expectancies of experienced smokers. Psychological Assessment, 7(4), 484–494. http://dx.doi.org/10.1037/ 1040-3590.7.4.484. Copeland, A. L., & Carney, C. E. (2003). Smoking expectancies as mediators between dietary restraint and disinhibition and smoking in college women. Experimental and Clinical Psychopharmacology, 11(3), 247–251. http://dx.doi.org/10.1037/1064-1297. 11.3.247. Curry, L. E., Pederson, L. L., & Stryker, J. E. (2011). The changing marketing of smokeless tobacco in magazine advertisements. Nicotine & Tobacco Research, 13(7), 540–547. http://dx.doi.org/10.1093/ntr/ntr038. Downey, K. K., & Kilbey, M. M. (1995). Relationship between nicotine and alcohol expectancies and substance dependence. Experimental and Clinical Psychopharmacology, 3(2), 174–182. http://dx.doi.org/10.1037/1064-1297.3.2.174. Foulds, J., Ramstrom, L., Burke, M., & Fagerström, K. (2003). Effect of smokeless tobacco (snus) on smoking and public health in Sweden. Tobacco Control, 12(4), 349–359. http://dx.doi.org/10.1136/tc.12.4.349. French, S. A., & Jeffery, R. W. (1995). Weight concerns and smoking: A literature review. Annals of Behavioral Medicine, 17(3), 234–244. http://dx.doi.org/10.1007/ BF02903918. Galanti, M. R., Wickholm, S., & Gilljam, H. (2001). Between harm and dangers: Oral snuff use, cigarette smoking and problem behaviours in a survey of Swedish male adolescents. European Journal of Public Health, 11(3), 340–345. http://dx.doi.org/10.1093/ eurpub/11.3.340. Gerend, M.A., Boyle, R. G., Peterson, C. B., & Hatsukami, D. K. (1998). Behavior and weight control among women using smokeless tobacco, cigarettes, and normal controls. Addictive Behaviors, 23(2), 171–178. http://dx.doi.org/10.1016/S0306-4603(97) 00023-3. Glock, S., Unz, D., & Kovacs, C. (2012). Beyond fear appeals: Contradicting positive smoking outcome expectancies to influence smokers' implicit attitudes, perception, and behavior. Addictive Behaviors, 37(4), 548–551. http://dx.doi.org/10.1016/j. addbeh.2011.11.032. Gottlieb, J. C., Cohen, L. M., Demarree, K. G., Treloar, H. R., & McCarthy, D.M. (2013). The Development and Psychometric Evaluation of the Smokeless Tobacco Expectancies Scale (STES). Psychological Assessment, 25(3), 997–1001. http://dx.doi.org/10.1037/ a0032256. Hatsukami, D. K., Ebbert, J. O., Feuer, R. M., Stepanov, I., & Hecht, S. S. (2007). Changing smokeless tobacco products new tobacco-delivery systems. American Journal of Preventive Medicine, 33(6 Suppl.), S368–S378. http://dx.doi.org/10.1016/j.amepre.2007. 09.005. Hendricks, P.S., & Brandon, T. H. (2005). Smoking expectancy associates among college smokers. Addictive Behaviors, 30(2), 235–245. http://dx.doi.org/10.1016/j.addbeh. 2004.05.006.
Klesges, R. C., Ebbert, J. O., Morgan, G. D., Sherrill-Mittleman, D., Asfar, T., Talcott, W. G., et al. (2011). Impact of differing definitions of dual tobacco use: Implications for studying dual use and a call for operational definitions. Nicotine & Tobacco Research, 13(7), 523–531. http://dx.doi.org/10.1093/ntr/ntr032. Lando, H. A., Haddock, C. K., Robinson, L. A., Klesges, R. C., & Talcott, G. W. (2000). Ethnic differences in patterns and correlates of age of initiation in a population of Air Force recruits. Nicotine & Tobacco Research, 2, 337–344. http://dx.doi.org/10.1080/ 14622200020028065. McClave-Regan, A. K., & Berkowitz, J. (2011). Smokers who are also using smokeless tobacco products in the US: A national assessment of characteristics, behaviours and beliefs of ‘dual users’. Tobacco Control, 20(3), 239–242. http://dx.doi.org/10.1136/tc. 2010.039115. Morrell, H. E. R., Cohen, L. M., & Dempsey, J. P. (2008). Smoking prevalence and awareness among undergraduate and health care students. American Journal on Addictions, 17(3), 181–186. http://dx.doi.org/10.1080/10550490802019899. Morrell, H. E., Song, A. V., & Halpern-Felsher, B.L. (2010). Predicting adolescent perceptions of the risks and benefits of cigarette smoking: A longitudinal investigation. Health Psychology, 29(6), 610–617. http://dx.doi.org/10.1037/a0021237. Mullennix, J. W., Kilbey, M. M., Fisicaro, S. A., Farnsworth, L. M., & Torrento, R. (2003). The representation of smoking expectancies by single-word adjectives and their relationship to smoking characteristics. Nicotine & Tobacco Research, 5(5), 681–694. http://dx. doi.org/10.1080/1462220031000158654. Myers, M. G., McCarthy, D.M., MacPherson, L., & Brown, S. A. (2003). Constructing a short form of the Smoking Consequences Questionnaire with adolescents and young adults. Psychological Assessment, 15(2), 163–172. http://dx.doi.org/10.1037/10403590.15.2.163. Newcombe, R. G. (2006). Confidence intervals for an effect size measure based on the Mann–Whitney statistic. Part 1: General issues and tail-area-based methods. Statistics in Medicine, 25(4), 543–557. http://dx.doi.org/10.1002/sim.2323. Noonan, D., & Duffy, S. A. (2014). Factors associated with smokeless tobacco use and dual use among blue collar workers. Public Health Nursing, 31(1), 19–27. http://dx.doi.org/ 10.1111/phn.12095. Oliver, A. J., Jensen, J. A., Vogel, R. I., Anderson, A. J., & Hatsukami, D. K. (2013). Flavored and nonflavored smokeless tobacco products: Rate, pattern of use, and effects. Nicotine & Tobacco Research, 15(1), 88–92. http://dx.doi.org/10.1093/ntr/nts093. Peasley-Miklus, C. E., McLeish, A.C., Schmidt, N.B., & Zvolensky, M. J. (2012). An examination of smoking outcome expectancies, smoking motives and trait worry in a sample of treatment-seeking smokers. Addictive Behaviors, 37(4), 407–413. http://dx.doi.org/ 10.1016/j.addbeh.2011.11.037. Post, A., Gilljam, H., Rosendahl, I., Bremberg, S., & Galanti, M. R. (2010). Symptoms of nicotine dependence in a cohort of Swedish youths: A comparison between smokers, smokeless tobacco users and dual tobacco users. Addiction, 105(4), 740–746. http:// dx.doi.org/10.1111/j.1360-0443.2009.02852.x. R Development Core Team (2013). R: A language and environment for statistical computing (version 3.0.2). Vienna, Austria: R Foundation for Statistical Computing (Retrieved from http://www.R-project.org). Rodu, B., & Phillips, C. V. (2008). Switching to smokeless tobacco as a smoking cessation method: Evidence from the 2000 National Health Interview Survey. Harm Reduction Journal, 5, 18. http://dx.doi.org/10.1186/1477-7517-5-18. Rose, J. S., Chassin, L., Presson, C. C., & Sherman, S. J. (1996). Prospective predictors of quit attempts and smoking cessation in young adults. Health Psychology, 15(4), 261–268. http://dx.doi.org/10.1037/0278-6133.15.4.261. Rosendahl, K. I., Galanti, M. R., & Gilljam, H. (2008). Trajectories of smokeless tobacco use and of cigarette smoking in a cohort of Swedish adolescents: Differences and implications. Nicotine & Tobacco Research, 10(6), 1021–1027. http://dx.doi.org/10.1080/ 14622200802097522. Substance Abuse and Mental Health Services Administration (2011). Results from the 2010 National Survey on Drug Use and Health: Summary of national findings. HHS Publication No. 11-46580. Rockville, MD: Substance Abuse and Mental Health Services Administration. Tomar, S. L., Alpert, H. R., & Connolly, G. N. (2010). Patterns of dual use of cigarettes and smokeless tobacco among US males: Findings from national surveys. Tobacco Control, 19(2), 104–109. http://dx.doi.org/10.1136/tc.2009.031070. Wetter, D. W., McClure, J. B., de Moor, C., Cofta-Gunn, L., Cummings, S., Cinciripini, P.M., et al. (2002). Concomitant use of cigarettes and smokeless tobacco: Prevalence, correlates, and predictors of tobacco cessation. Preventive Medicine, 34(6), 638–648. http://dx.doi.org/10.1006/pmed.2002.1032. Widome, R., Brock, B., Klein, E. G., & Forster, J. L. (2012). Smokeless tobacco advertising at the point of sale: Prevalence, placement, and demographic correlates. Nicotine & Tobacco Research, 14(2), 217–223. http://dx.doi.org/10.1093/ntr/ntr188. Wiium, N., & Aarø, L. E. (2011). Outcome expectations and use of smokeless tobacco (snus): A cross-sectional study among young Norwegian snus users. Scandinavian Journal of Psychology, 52(1), 64–70. http://dx.doi.org/10.1111/j.1467-9450.2010. 00823.x. World Health Organization (2011). WHO report on the global tobacco epidemic, 2011: Warning about the dangers of tobacco. (Geneva, Switzerland).
