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Effects of Weight-Related Cues on Smoking Motivation by Elena Nicole Lopez A thesis submitted in partial fulfillment of the requirements for the degree of Master of Arts Department of Psychology College of Arts and Sciences University of South Florida Major Professor: Thomas H. Brandon, Ph.D. David J. Drobes, Ph.D. J. Kevin Thompson, Ph.D. Michael T. Brannick, Ph.D. Date of Approval: September 15, 2004 Keywords: cue reactivity, body image, a ddiction, college students, females Copyright 2004, Elena Nicole Lopez
Dedication This thesis is dedicated to all those who have helped make it possible, such as all my friends within the department, incl uding Hazel Anne Johns on, Haitham Khoury, and Sherecce Fields. Thank you for providing me with whatever I needed, whether it were support, advice, study notes, good food, a good wo rkout, an awesome mix CD, or merely comic relief. Thanks also go to my far away friends, Michelle Naggar, Robert Reisman, Eben Alsberg, Susan Borja, and Jason Owen for their support, patience, understanding, and encouragement beginning long before I entere d graduate school. I appreciate their constant forgiveness when things became hectic and I forgot to call. I hope they know that they are always in my thoughts. Thanks to my boyfriend, Wael Khoury, fo r making me smile and laugh no matter what is going on in my world. Thanks for also reminding me that there even is a world beyond my graduate studies! You are a continua l reminder that there is more to life than just work and that having some playtime actually makes work much easier. Bahhibbak. Thanks go to my grandparents, Jack and Jane Gottschalk, my aunt, Conchy Lopez, and the rest of my family for always supporting me in my choices and expressing interest in my work, even if they didnt qui te understand it all. Thanks to Lightning and Habib Grover for their unconditi onal love and stress relief. But most importantly, I want to dedicate this thesis to my parents, Carlos and Janis Lopez, for their never-end ing support in all that I do. I appreciate their invaluable advice to help me make my decisions as well as the sense of confidence theyve instilled in me to achieve whatever I desire. They are always there to help me and cheer me on, and I am thankful for their love and encour agement. And although this is only one of many accomplishments I will have in my life, and only a stepping stone in my graduate career, I am glad that they are with me to share in this achievement and to be with me through the ups and downs of all aspects of my life. I am who I am because of them. Thank you for everything I love you both very much.
Acknowledgements I would like to thank my research ad visor, Thomas Brandon, Ph.D., for all his support, advice, and encouragement, not only on th is project but also in all aspects of my graduate career. I appreciate his willingness to always help and his patience with my endless questions. I would also like to tha nk the other members of my committee: David Drobes, Ph.D., who brought my project into the twenty-first cen tury; Kevin Thompson, Ph.D., who has helped me develop my seconda ry area of interest; and Michael Brannick, Ph.D., who is always there with a smile to help with my never-ending statistical questions. I appreciate all their insights and suggestions which has made my thesis better and has made me a better researcher. My gratitude is further extended to everyone in my lab for helping me at all stages of this project from brainstorming to data collection to analyses and for always giving me the encouragement I needed to keep going.
i Table of Contents List of Tables................................................................................................................. ....iii List of Figures................................................................................................................ ....iv Abstract....................................................................................................................... .........v Chapter One: Introduction..................................................................................................1 Body Image Dissatisfaction.....................................................................................4 Cue Reactivity..........................................................................................................5 The Current Study....................................................................................................7 Chapter Two: Methods.......................................................................................................9 Experimental Design and Overview........................................................................9 Participants...............................................................................................................9 Measures................................................................................................................10 Demographic Questionnaire......................................................................10 Smoking Status Questionnaire (SSQ)........................................................10 Short Smoking Consequences Questionnaire (Short-SCQ).......................10 Eating Disorders Examinati on Self-Report Questionnaire Version (EDE-Q)....................................................................................11 The Eating Disorders Inventory (EDI)......................................................11 Visual Analogue Scales (VAS)..................................................................11 Object Desirability Form...........................................................................12 Materials................................................................................................................12 Carbon monoxide (CO) monitor................................................................12 Body-related images..................................................................................12 Smoking cue reactivity images..................................................................13 Neutral images...........................................................................................13 Physiological measures..............................................................................14
ii Computers..................................................................................................14 Weight........................................................................................................14 Procedure...............................................................................................................16 Recruitment................................................................................................16 Pre-manipulation........................................................................................16 Manipulation..............................................................................................17 Post-manipulation......................................................................................18 Chapter Three: Results......................................................................................................19 Participant Characteristics.....................................................................................19 Manipulation Check...............................................................................................19 Primary Analyses...................................................................................................21 Moderators.............................................................................................................21 Mediators...............................................................................................................23 Chapter Four: Discussion..................................................................................................26 Treatment Implications..........................................................................................29 Limitations.............................................................................................................29 References..................................................................................................................... .....33
iii List of Tables Table 1 Summary of Procedure..............................................................................15 Table 2 Participant Characteristics.........................................................................20 Table 3 Means (Standard Deviations) of Smoking Urge Ratings...........................21 Table 4 Correlations between Four Meas ures of Body Dissatisfaction and BMI..22
iv List of Figures Figure 1 This shows that TBD mode rates the body image manipulation only when the smoking cue is absent ....................................................23
v Effects of Weight-Related Cues on Smoking Motivation Elena Nicole Lopez ABSTRACT Smoking is now the leading cause of prev entable death and disease in women. Understanding womens motivations to smoke is important in developing effective cessation and relapse prevention programs. Women, more so than men, appear to associate their smoking behavior to issues of weight. Although a general relationship between weight concerns and smoking has been found among women, a causal relationship had not been demonstrated. This study tested whether act ivation of negative body image cognitions would produce greate r urges to smoke and whether the relationship would be modera ted by trait body dissatisfaction and mediated by state body dissatisfaction. A randomized 2 X 2 crossed factorial, w ithin-subjects design (body image cues X smoking cues) was conducted with 62 female college smokers. The body image manipulation comprised an image of either a thin model or a ne utral object, and the smoking manipulation comprised an image of e ither a smoking cue or a neutral object. Participants completed pre-intervention m easures assessing smoking history and body image dissatisfaction. Urge to smoke, mood state, and weight and appearance satisfaction were assessed during the experiment. It was hypothesized that main effects on reported urge to smoke would be found for both manipulations, with body dissa tisfaction moderating the body image manipulation. Results indicated that both sm oking cues and thin model images increased reported urges to smoke. Additionally, in the absence of smoking cues, the effect of the body image manipulation was moderated by ba seline body dissatisfaction, with those women with greater body dissati sfaction reacting str onger to the thin model image. The effect on smoking urges by the body image mani pulation was partially mediated by both state measures of affect and body satisfaction.
vi Thus, this study is the first to demonstrate through an experimental design that the presentation of images portraying thin women increased smoking urge, which is consistent with a causal influence of body image affecting their smoking motivation.
1 Chapter One Introduction According to the latest Surgeon Gene rals Report on Smoking, cigarette smoking has been found to cause diseases in near ly every organ of the body (USDHHS, 2004). Despite widespread knowledge of the heal th risks associated with tobacco smoking, almost a quarter of the U.S. population c ontinues to smoke (CDC, 2004) Although this statistic reflects a decline in the past few decades of the prevalence of smoking, this decline is not as great in women as it is in men (Escobedo & Peddicord, 1996, 1997; National Center for Health Statistics, 1993; Ockene, 1993). Young females seem to be initiating at higher rates than their male counterparts (CDC, 1994), and among older adolescents, the females are more nicotine de pendent than the males (Young et al., 2002). Women also seem to have more difficulties in quitting and remaining abstinent than men (Bjornson, Rand, Connett, Lindgren, & et al., 1995; Blake et al., 1989; CDC, 1994; Cepeda-Benito, Reynoso, & Erath, 2004; Ocke ne, 1993; Ortner, Schindler, Kraigher, Mendelsohn, & Fischer, 2002; Swan, Ward, Carmelli, & Jack, 1993; Ward, Klesges, Zbikowski, Bliss, & Garvey, 1997; Wetter et al., 1999). Smoking is now the leading cause of pr eventable death and disease in women (Husten, 1998; USDHHS, 2001), with 20% of women smoking as of 2002 (CDC, 2004). And while the lung cancer mortality rate in men is now beginning to level off, it continues to rise in females (Husten, 1998). This rise led lung cancer to become the United States leading cause of female can cer death, surpassing breast cancer in 1987 (USDHHS, 2001). Although both men and wome n are susceptible to smoking-related illnesses, such as cancer and heart disease, it is believed that women may be at an even greater risk than men (Baldini & Strau ss, 1997; Langhammer, Johnsen, Holmen, Gulsvik, & Bjermer, 2000; Ortner et al., 2002; Zang & Wynder, 1996). Women are also susceptible to other smoking-related diseases uni que to females, such as those related to
2 cervical cancer and reproductive function (USDHHS, 2001). In general, women who smoke lose more years off their lives than men who smoke (14.5 years versus 13.2 years; USDHHS, 2004). In addition, women seem to be less aware of th e significant dangers posed to them by continuing to smoke as seen in their less frequent reporting of health concerns as compared to men when discus sing their motivations to quit smoking (Curry, Grothaus, & McBride, 1997). These findings illustrate the ex treme importance of understanding smoking behavior w ithin the female population. We must be aware, however, of other gender differences. Past research has demonstrated that, in general, individua ls report greater urges to smoke when experiencing negative affect (Brandon, Wetter, & Baker, 1996); however, women, more than men, report that they smoke to manage their mood (Cepeda-Benito & Reig Ferrer, 2000; Ward et al., 1997). Women also report we ight control as another perceived benefit of smoking (Cepeda-Benito & Reig Ferrer, 2000; Ward et al., 1997) These differences in outcome expectancies may reflect the motivations underlying gender differences in smoking initiation, maintenance, and cessation. Women, more so than men, appear to tie their smoking behavior to reas ons of weight control (Kille n, 1998; Klesges et al., 1998; Ogden, 1994; Ward et al., 1997), weight loss (Klesges & Klesges, 1988; Ogden, 1994; Perkins, Levine, Marcus, & Shiffman, 1997), and/or fear of or actual post-cessation weight gain (Klesges & Klesge s, 1988; Levine, Perkins, & Marcus, 2001; Perkins et al., 1997). Females are also more likely than male s to diet (Klesges et al., 1998) and use inappropriate and even dangerous methods to control their weight, such as smoking (Cavallo & Pinto, 2001; Kles ges et al., 1998; Mitchell & Perkins, 1998; Polivy & McFarlane, 1998; Wiseman, Turco, Sunday, & Halmi, 1998). With regard to initiation, it is known that adolescent gi rls tend to have concerns about their weight and body shape (Killen, 1998), are more dissatisfied with their bodies than males, and are more inclined to activel y engage in behaviors to lose weight than males. Moreover, this concern about wei ght and body shape has been increasing among pre-teenage girls (Polivy & McFarlane, 1998). Killen (1998) found that thoughts about weight, eating disorder symptoms and weight control attempts were prospectively related to females but not males initiating sm oking. This finding was supported by French,
3 Perry, Leon, and Fulkerson (1994) who found th at general weight concerns predicted initiation of smoking in adolescent females but not in adolescent males. Stice and Shaw (2003) also found that body image disturbanc es greatly increased the risk for smoking initiation in adolescent girls. Although smoking for weight control is prevalent in both males and females in many different race/eth nic groups, it appears th at girls are more influenced than boys by the desire to smoke for weight control or weight loss (Fulkerson & French, 2003; USDHHS, 2001). Klesges et al. (1998) also found that weightconscious females, particularly Whites, may be initiating smoking in an attempt to control weight, believing that sm oking has anorexic effects. Many of these smoking expect ancies may be based on t obacco advertising, which has been marketing cigarettes as a weight control device since the 1920s with ads such ones from as Lucky Strike, which invited women to Reach for a Lucky instead of a sweet. Although the tobacco companies have been warned by the Federal Trade Commission not to market cigarettes as r educing devices ("Looking back: Who was the original Lucky Strike girl?," 1999, Fall), they still infuse their advertisements with this message by suggesting that women who smoke are slim, athletic, and sexually attractive (USDHHS, 2001). The focus on weight and body image is not limited to adolescent girls, but instead affects women across the life span. In f act, in a national survey conducted by Cash, Winstead, and Janda (1986), fewer than 10% of the women reported having only minor concerns about their appearance, whereas the re st reported greater concerns. It is this focus on weight and body image that is a recurring theme when querying women about their smoking behavior. Compared to nonsm oking women, smokers are more likely to be concerned about their weight (Feldman, Hodgson, & Corber 1985), to use diet pills (Gritz & Crane, 1991), to view their body weight as impor tant to their self-esteem (Bruckner, Spring, & Pingitore, 1994), to be dissatisfied with their weight (Bruckner et al., 1994), to be higher in diet ary restraint (Bruckner et al ., 1994; Meyers et al., 1997), and to feel unattractive (King, Matacin, Ma rcus, Bock, & Tripolone, 2000). Of women who are currently smoking, young women have the l east intention to quit (Perkins et al., 2001) and they are up to 4 times more likely than men to report weight gain as a cause of
4 relapse (Swan et al., 1993). Womens fear of post-cessation weight ga in appears to have a factual basis (Williamson et al., 1991). Women are more likely to self-report greater eating and weight gain after qu itting (Perkins et al., 2001), and, indeed, they do appear to gain more than men, either as a percentage of their initial weight or in absolute pounds (Williamson et al., 1991). It is, therefore, not surprising that women hold expectancies that smoking controls body weight and cessatio n leads to weight gain (Meyers et al., 1997). In fact, women hold higher expectations than men of cigarettes utility when it comes to controlling appetite and weight (Brandon & Baker, 1991) Although a general relationship between smoking and weight co ncerns has been found among women, what is unclear and untested is whether phasic fluc tuations in body image influence situational cravings for cigarettes, and if this relati onship is moderated by a womans general body satisfaction. Such a relationship would pr ovide evidence of a causal influence of body image on smoking motivation. Body Image Dissatisfaction Body image is a persons perception of his or her outer appearance (Thompson, Heinberg, Altabe, & Tantleff-Dunn, 1999). It is believed that dysfunctional body image is caused by socio-environmental variables (e.g., parents, peers, and media) that provide comparison standards, as well as by events th at activate self-appraisa l, such as viewing thin models (Cash, 1998; Thompson et al., 1999 ). Before the 1980s, the focus of body image research was on patients suffering from anorexia nervosa and bulimia. It was not until the 1980s that research began to demonstrate that individuals who do not have eating disorders experience body dissatisfaction (for a review see Thompson et al., 1999). Women are generally less satisfied with thei r bodies than men (Turner, Hamilton, Jacobs, Angood, & Dwyer, 1997). In fact, this phenom enon is so prevalent in the general population of women that the widespread di ssatisfaction with one s body has now been labeled normative discontent (Rodin, Silb erstein, & Striegel-Moore, 1984; Tiggemann & Wilson-Barrett, 1998). The mass media are thought to be am ong the greatest influences of womens desire for thinness. Over the past three decades in Western culture, the models in magazines, movies, and television have beco me increasingly thin. This promotes a
5 modern ideal of feminine attractiveness that is a thin body (Owen & Laurel-Seller, 2000; Polivy & McFarlane, 1998). There is, conse quently, a great deal of pressure on women to achieve an unhealthy level of body wei ght, which ranges from below-normal to a weight approaching the crit eria for anorexia nervosa (Owen & Laurel-Seller, 2000; Polivy & McFarlane, 1998). Experimental studies have examined the immediate impact of viewing images of thin models versus normal-weight models, obese models, or neutral images. These studies have found that women, following imme diate exposure to thin models, report greater depression (Pinhas, Toner, Ali, Ga rfinkel, & Stuckless, 1999; Stice & Shaw, 1994), stress (Stice & Shaw, 1994), sham e (Stice & Shaw, 1994), body and weight dissatisfaction (Irving, 1990; Kalodner, 1997; Ogden & Mundray, 1996; Shaw, 1995; Stice & Shaw, 1994; Turner et al., 1997), wei ght concern (Posavac, Posavac, & Posavac, 1998) and anger (Pinhas et al., 1999), especi ally among women who ar e more responsive to personal cues (Wilcox & Laird, 2000). In terms of self-reported body satisfaction, Groesz and colleagues (2002), in their meta-analytic review, found an overall d value of 0.31, indicating body satisfaction decreased with th e viewing of thin models as compared to viewing the control images. These studi es support the conclusion by Turner et al. (1997) that the media shape societal percep tions, rather than just reflecting those perceptions. Cue Reactivity It is believed that classical conditioning may play a key role in drug use behavior. Under this general paradigm, it is thought that external stimuli, such as drug paraphernalia and situations, and interoceptive stimuli, such as cognition and affect, that accompany drug administration become paired w ith the drug itself. Over time, with repeated and reliable pairings, these conditioned stimuli can elicit conditioned responses. Many studies have been able to demonstrat e this phenomenon in a laboratory setting, with smokers having subjective, physiological and behavioral responses to either external or internal cues (Brandon, Piaseck i, Quinn, & Baker, 1995; Carter & Tiffany, 1999; Niaura, Rohsenow, Binkoff, Monti, & et al., 1988; Rohsenow, Niaura, Childress,
6 Abrams, & et al., 1990). Cue reactivity can help identify the motivations behind drug use, including the stimuli and situations that provoke ongoing smoking and relapse. Different theoretical models have been developed to account for cue reactivity (for a summary of theoretical models, s ee Tiffany, 1995). Two models are based on the idea of conditioned withdrawal, i.e. that cert ain stimuli evoke aversive, withdrawal-like responses, and the individual relapses to avoi d these negative effects. The first such model was proposed by Wikler (1948). This conditioned withdrawal model stated that the environmental stimuli associated with a drug users withdrawal becomes a conditioned stimuli (CS) eliciting the conditi oned withdrawal response. Siegel and his associates (Poulos, Hinson, & Siegel, 1981; Siegel, 1983) proposed an alternate model, known as the conditioned compensatory res ponse model, which was still based on the notion of conditioned withdrawal. This model stated that a stimulus paired with drug administration becomes the CS that elicits compensatory withdrawal-like response. Research has not consistently supported thes e models, and thus new theoretical models have been introduced. One such model is the conditioned incentive model proposed by Stewart, de Wit, and Eikelboom (1984). This model hypothesizes that environmental stimuli associated with drug administrati on become positive incentives by mimicking the appetitive effects of the drug, which motivates an individual to use the drug. This model has also faced some shortcomings in being able to predict an addicts behavior and response to drug-paired stimuli. Although th ese specific theoretical models have not completely explained how classical conditioni ng is involved in a drug users craving, there is consensus that this general concept has a great deal of u tility in helping to understand addictive behavi ors (Drummond, Tiffany, Glauti er, & Remington, 1995). A common element of all the models is that cond itioned stimuli should elicit responses that include cravings to smoke. In a meta-analysis conducted by Carter and Tiffany (1999), ther e were consistent findings indicating that exposur e to smoking cues, as compared to neutral cues, increased heart rate and skin conduct ance responding. The average effect sizes in Cohens d were .21 and .44 for each of those physiological measures respectfully. Self-report of cravings had a much larger effect size ( d = 1.18). These cues include d the induction of negative
7 affect, the imagining of a drug-related situ ation, the viewing of smoking images, or the presentation of real cigarettes. These resu lts found in the smoking literature paralleled those found for other addictive substances (Brandon et al., 1995; Carter & Tiffany, 1999). The Current Study The overarching purpose of this study was to test if state body satisfaction plays a causal role in smoking motivation. Thus, we manipulated body image satisfaction to test whether activation of nega tive body image cognitions would produce greater urges to smoke. A smoking cue manipulation was incl uded to test whet her the body image manipulation was sufficient to evoke cravings to smoke or if both f actors were necessary to have that effect. Add itionally, the simultaneous presen tation of the two factors allowed us to test whether there was a syne rgistic effect of the two manipulations on smoking urges. This study drew upon two areas of res earch body dissatisfaction and cue reactivity and used methodology already estab lished within each of these areas. The experimental condition of the body image manipu lation displayed stimuli of thin fashion models, intended to threaten the womans self-image, whereas the experimental condition of the smoking cue manipulation displayed smoki ng stimuli, intended to induce cravings. The control conditions of bot h manipulations were of neutral images of inanimate objects. Although there were two modes of assessment of smoking motivation, selfreport measures of craving and physiologi cal measures of heart rate and skin conductance, the self-report measures were th e primary dependent variables of interest, as they have shown the greatest effect size in other research. The psychophysiological data were not analyzed for th is thesis. For the dependent measures, it was hypothesized that main effects would be found for bot h the smoking cue manipulation and the body image manipulation, and the effects would be at least additive with in the condition that includes both experimental manipulations. In past research on body image satisfaction, greater effects for thin model images were found for participants with greater body dissatisfac tion (Groesz et al., 2002). Therefore, our second aim was to evaluate level of body satisfac tion as a moderating variable in the body image manipulation. A secondary hypothesis was that those
8 individuals with higher scor es on the measure of body dissatisfaction would demonstrate the greatest impact from the body image manipulation.
9 Chapter Two Methods Experimental Design and Overview Participants were recruited under the guise of a study interested in smokers reactions to different images. The experiment was a randomized 2 X 2 crossed factorial, within-subjects design (body image manipulation X smoking cue manipulation). Thus, the four conditions were thin models/smoking cu es (T/S), thin models /neutral cues (T/N), neutral cues/smoking cues (N/S ), and neutral cues/neutral cues (N/N). Participants completed measures assessing basic demographics, smoking history, smoking expectancies, body image dissatisfaction, mood st ate, and urge to smoke, as well as had their heart rate and skin conductance assessed. The dependent measures were the reported smoking urges. Participants Participants were 62 college females. University students were used due to findings from the CDC (2002) indicating that, nationally from 1993-2000, individuals in the age group of 18-24 have not decreased th eir prevalence of smoking and continue to have one of the highest rates of prevalen ce. In addition, the prevalence of current smoking increased among those aged 20-24 w ith 13 or more years of education. A nationwide study by Wechsler, Rigotti, Gledhi ll-Hoyt, and Lee (1998) indicated that the prevalence of smoking among all types of co llege students was increasing, and the increase was much greater among those students at public schools than at private schools. Klesges (1988) research i ndicated that college student s have an increased smoking incidence and rate, especially in the female population. There is also evidence suggesting that university females report a greater leve l of body dissatisfaction and increased beliefs of being overweight than they had as hi gh school seniors (Vohs, Heatherton, & Herrin, 2001). It has been shown that within the uni versity population, it is a high priority to
10 achieve and maintain an ideal weight, and that the use of dieting strategies of all types are extremely high in this group (Klesges & Klesges, 1988). Participants were recruited from the Un iversity of South Florida through fliers posted on campus, freshman orientation sc reenings, classroom recruitment, and psychology courses that offered extra credit fo r courses by participating in research. Potential participants were screened over the telephone, w ith participation limited to those women currently attending college, between the ages of 18 and 24, and who smoked at least 10 cigarettes per day for at leas t 1 year. Participants recruited within the undergraduate psychology pool received two extr a credit points, and all others were paid $20.00. All participants had their names entered into a lottery to win $50.00. Measures Demographic Questionnaire. Single items assessed the age, education, marital status, and ethnicity of the pa rticipants, and as well as thei r parents level of education and household income. Smoking Status Questionnaire (SSQ). This form was used to assess the participants smoking status and nicotine depe ndence. This questionnaire contains items from the Fagerstrm Test for Nicotine Dependence (FTND). The FTND is a reliable and valid measure of nicotine dependence (Heat herton, Kozlowski, Frecker, & Fagerstrm, 1991). Short Smoking Consequences Questionnaire (Short-SCQ; Myers, McCarthy, MacPherson, & Brown, 2003). This is a 21-ite m version of the orig inal 50-item Smoking Consequences Questionnaire (SCQ; Brandon & Baker, 1991), a standard instrument for measuring smoking expectancies among college students. The internal consistency for the full Short-SCQ was high (.93) and it correlated highly with the original ( r = .94). Both questionnaires have four factors on wh ich outcome expectancies can be measured: Positive Reinforcement/Sensory Satisfacti on, Negative Reinforcement/Negative Affect Reduction, Appetite/Weight Control, and Nega tive Consequences. The Appetite/Weight Control factor is the same fo r both the SCQ and the Short-SCQ. The other three factors on the Short-SCQ correlated well with the factors of the SCQ (PR: r = .86, NR: r = .99,
11 NC: r = .78). This study was only interested in the Appetite/Weight Control factor, but the complete form was administered. Eating Disorders Examination Self-Report Questionnaire Version (EDE-Q; Fairburn & Beglin, 1994). The EDE-Q is a 41-item self-report measure based on the Eating Disorders Examination clinical in terview (EDE; Cooper & Fairburn, 1987), the latter of which has excellent psychometric properties. Good to adequate correspondence was found between the two assessments on th e different subscales indicating the EDEQs acceptability as a self-report measure (Fairburn & Be glin, 1994). All the subscales have excellent internal consistency and two w eek test-retest reliability. This study used only the Shape Concerns and Weight Concer ns subscales, totaling 12 items, to measure body dissatisfaction at baseline. The EDE-Q subscales are scor ed in the same manner as the original EDE: items are rated on a 7point forced-choice format ranging from 0-6. Higher scores reflect greater frequency or seve rity. The total score of the subscales, as opposed to the mean, were used in this study. The Eating Disorders Inventory (EDI; David M. Garner Olmstead, & Polivy, 1983). The EDI is a widely used self-report m easure of symptoms associated with eating disorders, such as body dissatisfaction, perfec tionism, and weight concern. This study used the 7-item Drive for Thinness (DFT) s ubscale, which assesses concern with dieting, fear of weight gain, and pr eoccupation with weight, and th e 9-item Body Dissatisfaction (BD) subscale, which assesses satisfaction with weight-related body sites. The subscales have shown good to excellent internal consistency (DFT: = .87-.91; BD: = .92-.93) in a nonpatient female group (D. M. Garner, Olms ted, Polivy, & Garfinkel, 1984; Raciti & Norcross, 1987; Vanderheyden & Boland, 1987). Excellent to good test -retest reliability in nonpatient college students has been demonstrated at three weeks (DFT: r = .92; BD: r = .97; Wear & Pratz, 1987) and at one year (DFT: r = .72; BD: r = .75; Crowther, Lilly, Crawford, Shepherd, & Oliver, 1990; Ti ggemann & Wilson-Barrett, 1998). The subscales are usually scored on a 0-3 scori ng system, but for the present study the items were scored with a 1-6 scoring system to increase the range of response. Visual Analogue Scales (VAS). These were 4 scales displayed on a computer screen following each trial. The four statements asked the participant to rate how they
12 felt at that exact moment. They a ssessed urge to smoke a cigarette ( not strong at all to very strong ), affect ( very unhappy to very happy ), overall body weight satisfaction ( very dissatisfied to very satisfied ), and overall appearance satisfaction ( very dissatisfied to very satisfied ). The scales had a range of 21 points (0 to 20), but the participant only saw the anchors 0 and 10 with a line marking the middle of th e scale. The participant used a trackball mouse to move the marker along the line and then clicked the mouse key when she felt the marker best represented how she felt. These scales assessed participants state characteristics following the experiment al trials. The weight and appearance satisfaction scales also served as manipula tion checks to determine if the thin images induced body dissatisfaction. Object Desirability Form. This form was used to encourage social comparison to the thin model images and to reinforce the be lief that the study was solely interested in smokers opinions and feelings following different images. This form provided spaces for each image for the participant to mark wh ether or not she wanted to own the items displayed in the image. The instructions, gi ven both verbally and in written form, asked the participant to imagine owning the item and using the item. Those instructions were especially relevant in encouraging the so cial comparison to the thin images. Materials Carbon monoxide (CO) monitor. A BreathCo carbon monoxide recorder by Vitalograph was used to measure the participan ts level of CO in parts per million (ppm). This measurement was taken immediately following informed consent and HIPPA consent. The participant wa s instructed to hold her breath for 20 seconds and then breathe into a disposable cardboa rd tube. (This measure was not available for the first 7 participants.) Body-related images. Media images have been us ed in previous studies with success. The images of thin models used for this study were taken from websites that contained fashion images similar to thos e found in popular womens fashion magazines such as Cosmopolitan and Vogue These fashion magazines have been mentioned on various websites as being the most popular among women ( Amazon Booksellers' women's interest page. n.d.; Top magazines by category. n.d.). They are considered to be at the
13 cutting edge of fashion and beauty, part of which encompasses the thin-ideal. One such on-line announcement stated that the magazine lives by the maxim that you cant be too rich or too thin and describes the models as being broomstick-thin ( Amazon Booksellers' women's interest page. n.d.). A total of six images were used in the experimental condition of the body image manipu lation. All models appeared to be in the age group of the participants, and a samp ling of ethnically/racially diverse individuals was chosen. Smoking cue reactivity images. The smoking cue images were devoid of complete human models so as to not confound th e results. Six images were used in the experimental condition of the smoking cue ma nipulation. Three of the images were of burning cigarettes alone, and the other thre e images contained a gender-neutral hand holding the cigarette. Neutral images. These images were devoid of any human models that may have influenced the participant. Past body image research has used control images of normal weight models, obese models, or inanimate obj ects. Although there is some concern that the inanimate stimuli may confound the body imag e manipulation with effects of seeing an attractive person (regardless of thinness of the model), similar effects sizes have been found for comparison to average models and inanimate objects (Groesz et al., 2002). This lends support to the notion that it is th e slenderness of the model and not the viewing of an attractive person that prov ides the hypothesized effects. To maximize the differences between the experimental and control images, this study used inanimate objects as control images. Images chosen had no obvious relation to eating, grooming, body weight, physical body image, or smoking and thus were not expected to trigger any body or weight evaluation or smoking urges. A sample of Peter Langs collection of neutral images (e.g., hous ehold appliances, furniture), which have been previously demonstrated to show low arousal, were used (CSEA-NIMH, 1995). Also used were comparable images taken w ith a digital camera of similar objects (e.g., office supplies, household objects). These 36 neutral images were shown as control images for the body image manipulation a nd the smoking cue manipulation, and they were also the images used in the distractor trials. The distractor trials, with the same
14 layout as the experimental trials, allowed the data collection to be a fluid process, while offering a recovery period between the experi mental trials. These images also allowed for some distraction to reduce carry-over effects from one experimental trial to the next. Physiological measures. Heart rate and skin con ductance are both fairly robust measures of physiological responding and are no t very invasive. Heart rate is a measure of cardiovascular function that varies in re sponse to emotional arousal or cognitive effort (e.g., Schwartz, Weinberger, & Singer, 1981). Skin conductance responses provide an index of sympathetic arousal (e.g., Raskin, 1973) Electrodes were attached according to established guidelines to measure both heart rate and skin conductan ce. For heart rate, one large (8mm) electrode filled with saline electrode gel was placed on each forearm, and one ground electrode was also placed on the non-dominant forearm. To measure skin conductance, two large (8mm) electrodes fi lled with K-Y Jelly were attached to the hypothemar eminence on the partic ipants non-dominant hand. The data were directly inputted into a computer. For the initial baseline of 2 minutes, echocardiogram (EKG) and skin conductance was monitored continuous ly. For each trial, a two second baseline was recorded prior to the picture viewing a nd then 10 seconds were recorded from the beginning of the picture viewing. Heart rate was recorded as interbeat intervals, which were triggered by R-waves detected by a Schmitt trigger. Stored interbeat intervals were edited offline to correct for ar tifacts and then converted to beats per minute for each halfsecond value. Skin conductance was sampled at 20 Hz and stored as the medians of each half-second value. These data were not analyzed fo r this thesis. C omputers. One computer controlled the reco rding of the psychophysiology data. A second computer controlled the presentati on of the images and the VAS questions. The second computer also recorded th e responses to the VAS measures. Weight A professional, medical scale was us ed to measure weight to the nearest pound and height to the nearest inch, wh ich were used to calculate the Body Mass Index (BMI).
15 Table 1 Summary of Procedure Pre-Manipulation Informed consent and HIPPA authorization CO measured Participant smoked one cigarette Participant completed baseline measures o Demographic questionnaire o SSQ o Short-SCQ o PANAS o EDE-Q (Weight Concerns and Shape Concerns subscales) o EDI (Drive for Thinness and Body Dissatisfaction subscales) Baseline measure of heart rate and skin conductance Manipulation Shown three blocks, each block comprised of one each of four experimental trials o Thin models/smoking cues (T/S) o Thin models/neutral cues (T/N) o Neutral images/smoking cues (N/S) o Neutral images/neutral cues (N/N) Shown a distractor trial after each experimental trial Given the Object Desirability Form to complete for each trial Heart rate and skin conductance measured at the beginning of each image VAS for urge, mood, weight satisfaction, and appearance satisfaction measured after each trial Post-Manipulation Deception check Height and weight measured Debriefed Compensated for participation
16 Procedure Recruitment. Some participants were recruite d through the University of South Floridas undergraduate psychol ogy pool. These individuals regi stered to participate in the study through an on-line registration site where they were screened on-line and received credit for courses after the completion of the experiment. Other participants were recruited through flyers and/or newspaper ads, th rough courses, and through a freshman orientation screening questionnaire. These individuals were screened over the phone and received monetary compensation afte r the completion of the experiment. All participants who were qualified were schedul ed for an individual appointment in the afternoon or evening to be held in a room at the Tobacco Research and Intervention Program at the H. Lee Moffitt Cancer Center and Research Institute. The late scheduling time was established with the hope that most of the participants would have smoked at least one cigarette before arriving and thus would not be in a state of over-night abstinence. The participants we re tested individually. They were instructed to bring their cigarettes to the appointment. Pre-manipulation. Upon their arrival, participants were informed that they were participating in a study to understand smokers f eelings and reactions to different images. They were told that the experiment woul d involve their viewing and rating different stimuli while we assessed their reactions. Informed consent and HIPPA authorization were obtained at this time. A breath sample was collected for the CO analysis. The participant was then instructed to go outside to smoke one cigarette. This allowed for standardization across participan ts and to avoid having the ur ge ratings be influenced by high withdrawal levels. After finishing smoking her cigarette, the participant was asked to complete the demographic questionnaire, the SSQ, the S hort-SCQ, the PANAS, the EDI (Drive for Thinness and Body Dissatisfaction subscales ), and the EDE-Q (Weight and Shape Concerns subscales). The participant was told that the information obtained from the measures would be used to better understa nd college students in general and consumers who are smokers. The participant was also informed that the measures assessed her current feelings before beginning the experime nt to be able to control for individual
17 differences. This information was given to minimize suspicion of the body image questionnaires. Manipulation. The participant was seated in a comfortable chair about 2 feet in front of a high-resolution color computer mon itor. The female experimenter attached the five physiological electrodes to the participant and then left the room to begin recording 2 minutes of baseline heart rate and skin conductance. The experimenter returned to the experime ntal room and read a script informing the participant that she would see many diffe rent pairs of images, each one shown for only a brief amount of time. The participant was instructed to imagine using each object displayed, and then decide whether or not sh e would like to own the object, recording her decision on the Object Desirability Form. She was given two examples, one of a chair and another of a clothing outfit, to explai n how to think about each object shown. The participant was given instru ctions on how to complete the VAS measures on the computer using the mouse, after which she was then left alone to complete the session. The participant was exposed to one of six or ders of trials. The orders were based on a random categorization of three blocks of trials. Each block was comprised of four experimental trials (one of each experimental condition), each separated by a distractor trial (i.e. eight trials per block). Within the block, the order of the e xperimental trials was randomly established. Each experimental tr ial contained a photo representing the body image manipulation displayed side-by-side an image representing the smoking cue manipulation. The side of the sm oking cues and body image photos were counterbalanced. The distractor trials cont ained two neutral images displayed side-byside to mimic the appearance of the experimental trials. Each trial slide (i.e., image pair) was shown for 17 seconds, followed by three seconds of black screen. The participant was instructed to watch each slide for the entire time that it was displayed. Psychophysiologi cal measures were collected throughout the first 10 seconds of the slide-vi ewing interval. The participant was instructed to remain still until hearing a tone, which was presented 10 seconds into the trial. At this time, the participant was allowed to move to make her ratings on the Object Desirability Form. At the end of the trial, the four VAS ratings were completed. After the completion of the
18 last VAS, there were two seconds of bl ack screen, during which the baseline physiological measurements for the upcoming trial were recorded. Post-manipulation Upon completion of the study, each participant was asked to guess the purpose of the experiment, so as to assess whether the manipulations were adequately concealed. The experimenter then weighed her and measured her height to calculate her BMI. Lastly, the participant wa s debriefed and asked not to tell anyone else about her experience. The part icipant was then awarded eith er experimental points or money for participation and wa s entered into the lottery.
19 Chapter Three Results Participant Characteristics Demographic and smoking history characte ristics are presented in Table 2. Although all participants me t the inclusion criteria of smoking a minimum of 10 cigarettes per day for at least one year, the mean score on the FTND (3.29) indicates a low level of nicotine dependence. Manipulation Check VAS measures of urge, mood, weight satisfaction, and appearance satisfaction ratings were averaged across same trials type s (e.g., the mean of the urge ratings for the three T/S trials) for use in subsequent anal yses. As expected, th e ratings for overall weight satisfaction and overall appearance sati sfaction were highly in tercorrelated in all four conditions (T/S: r = .84, p < .001; N/S: r = .84, p < .001; T/N: r = .84, p < .001; N/N: r = .83, p < .001). Therefore, the mean of the we ight and appearance satisfaction ratings for each condition was calculated creating a new variable, state body satisfaction The experimental design required that th e thin images induce body dissatisfaction. We conducted a 2 X 2 Repeated Measure Anal yses of Variance (ANOVA) using the state body satisfaction ratings. The means of the ratings show that the thin images ( M = 10.16, SE = .72) produced less satisfacti on than the neutral images ( M = 10.73, SE = .68), indicating that the mani pulation was successful, F (1, 61) = 21.98, p < .001. The smoking images also had a significant effect on state body satisfaction, F (1, 61) = 4.71, p < .05, with the smoking images ( M = 10.37, SE = .71) producing lower body satisfaction ratings than the neutral images ( M = 10.53, SE = .70). No interaction was found.
20 Table 2 Participant Characteristics Variable % M SD Age 20.03 1.50 Smoking History Years smoked 4.58 2.37 Cigarettes smoked per day 15.65 4.89 Fagerstrm score 3.29 2.00 Carbon monoxide level* 15.16 8.74 Ethnicity Caucasian 91.9 Black 3.2 Other 4.8 Hispanic Yes 8.1 No 91.9 Year in school Freshman 32.3 Sophomore 29.0 Junior 22.6 Senior 16.1 Marital Status Single 100 Married 0 Does/did Father Smoke Yes 69.4 No 27.4 I dont know 3.2 Does/did Mother Smoke Yes 45.2 No 51.6 I dont know 3.2 *Based on only 55 subjects from whom this was collected.
21 Primary Analyses A 2 X 2 Repeated Measures ANOVA was c onducted to test the effects of the manipulations on the VAS smoking urge rati ngs. A main effect of the smoking cue manipulation was found, F (1, 61) = 17.13, p < .001. Smoking images produced greater urges to smoke ( M = 8.97, SE = .77) than neutral images ( M = 8.00, SE = .69), replicating previous cue-reactivity research. A main effect, although smaller, was al so found for the body image manipulation, F (1, 61) = 5.80, p = .02. Consistent with our primar y hypothesis, the th in model images produced greater urges to smoke ( M = 8.62, SE = .73) than neutral images ( M = 8.35, SE = .72). Although both the smoking and body image ma nipulations produced significant main effects, there was no inter action between the two manipulations, F (1, 61) = .65, p = .42. This indicates that the two manipulations had additive but not synergistic effects (see Table 3). Table 3 Means (Standard Deviations) of Smoking Urge Ratings Body image manipulation Smoking image manipulation Thin Neutral Smoking 9.06 (6.10) 8.88 (6.13) Neutral 8.19 (5.57) 7.82 (5.36) Note. Urge rating scale ranged from 0 to 20. Moderators Given a main effect for the body image manipulation, our second aim was to analyze level of trait body dissatisfaction as a possible moderator of the effect. Four measures of body dissatisfaction were coll ected, the EDI-Drive for Thinness, EDI-Body Dissatisfaction, EDE-Weight Concerns, and ED E-Shape Concerns. As expected, they were highly intercorrelated (see Table 4). Th erefore, a combined score was computed to encompass the body dissatisfaction cons truct. This new variable, called Trait Body Dissatisfaction (TBD) was created by summing the z-scor es of the four measures. TBD
22 was not correlated with smoking urge ratings in any of the experimental conditions (T/S: r = .05, p = .69; N/S: r = .06, p = .63; T/N: r = .07, p = .57; N/N: r = -.01, p = .92). Table 4 Correlations between Four Measures of Body Dissatisfaction and BMI Measure 1 2 3 4 5 1. EDI Body Dissatisfaction 2. EDI Drive for Thinness .62** 3. EDE Weight Concerns .74** .80** 4. EDE Shape Concerns .78** .80** .93** 5. BMI .45** .20 .38** .42** Note. EDI = Eating Disorders Inventory; EDE = Eating Disorders Examination. ** p < .01. To test for a moderating effect on smoki ng urge, a generalized linear model was established with the smoking and body image manipulations as with in-subjects factors and the TBD as a continuous between-subj ects factor. The hypothesized two-way interaction between the body image manipulation and the TBD approached significance, F (1, 60) = 3.41, p = .07. Moreover, a significant three-way interaction was found between the two within-subj ects factors and the TBD, F (1, 60) = 5.72, p = .02. To determine the nature of the threeway interaction, separate ANOVAs were conducted to assess for a main effect of the body image manipulation both in the presence of the smoking image and without th e presence of the smoking image. In the absence of the smoking image, there was not only a significant main effect of the body image manipulation, F (1, 60) = 5.04, p = .03, but also a significan t interaction effect with TBD, F (1, 60) = 8.42, p < .01. This indicates that the TBD moderated the effect of the body manipulation. In the presence of the sm oking image, there was no main effect of the body image manipulation, F (1, 60) = 1.36, p = .25, nor an interact ion with the TBD, F (1, 60) = .18, p = .67. Thus, only when smoking images were not present did thin images induce urges, and this effect wa s moderated by body dissatisfaction. Figure 1 displays this relationship usi ng a median split of TBD.
23 LowHighTrait Body Dissatisfaction 6.5 7.0 7.5 8.0 8.5 9.0 9.5 10.0Smoking Urge Rating Body Image ManipulationThin image present Thin image absent Smoking Manipulation: Smoking Cue Present LowHighTrait Body Dissatisfaction Body Imag e Manipulatio n Thin ima g e p r Thin ima g e a b Smoking Manipulation: Smoking Cue Absent Figure 1. This shows that Trait Body Dissatisfaction moderates the body image manipulation only when the smoking cue is absent. TBD categories are based on a median split of that variable. Ratings were made on a 21-point scale (0 = urge to smoke a cigarette is not strong at all 20 = urge to smoke a cigarette is very strong ). Because BMI is highly correlated with most of the measures of body dissatisfaction (Table 4), we analyzed BMI as a continuous between-subjects factor to assess for its moderating effects. However, it did not show any significant interactions with the manipulations (i.e., body image manipulation X BMI, F (1, 60) = .64, p = .43; smoking cue manipulation X BMI, F (1, 60) = .12, p = .73; body image manipulation X smoking cue manipulation X BMI, F (1, 60) = .47, p = .50). The Appetite/Weight Control factor of the Short-SCQ was used as a continuous between-subjects factor to examine whet her those expectancies moderated the relationship between the body image manipula tion and smoking urges. There were no significant interactions with the manipula tions (i.e., body image manipulation X BMI, F (1, 60) = .01, p = .91; smoking cue manipulation X BMI, F (1, 60) = .34, p = .56; body image manipulation X smoking cue manipulation X BMI, F (1, 60) = .37, p = .55). Moreover this variable was not correlated with TBD ( r = .19, p = .14). Mediators Mediators were tested using the logi c of Baron and Kennys (1986) recommended procedures. To test the possibility that negative affect may me diate the relationship between the body image manipulation and ur ges to smoke, a repeated measures ANOVA
24 with the VAS mood ratings as the depende nt variable was fi rst conducted. Although there was a trend for the thin model image to produce greater negative affect than the neutral image ( M = 10.92, SE = .42 and M = 11.18, SE = .42, respectively), the difference did not reach significance, F (1, 61) = 2.87, p = .10. There was also no significant effect for the viewing of the smoking factor, F (1, 61) = .71, p = .40, nor was there an interaction between the two types of factors, F (1,61) = .001, p =.98. However, because there was a trend toward significance with the body image manipulation, a continued evalua tion of the mediational relati onship was explored. First, a mean of the smoking urge ratings was calcula ted for both the trials with thin images (i.e. T/S and T/N) and the trials without th in images (i.e. N/S and N/N). A difference score between these two means was computed. The same was done for the mood ratings. These two difference scores were correlated ( r = -.28, p < .05), indicating that as the thin image produced lower positive affect, it also produced greater smoking urges. Finally, a 2 X 2 Repeated Measures ANCOVA was conducte d to test the effects of the body image manipulation on the urge ratin gs with the mood ratings for each trial as covariates. No longer did the body image mani pulation produce significant differences in urge, F (1, 57) = .65, p = .42. This supports the hypothesis that state affect did mediate the relationship. A caveat is th at the one step in the media tional analysis only approached significance. Because the body image manipulation decreased state body satisfaction and increased smoking urges, state body satisfac tion was tested as a mediator of the body image manipulations effect on smoking urges. A mean of the st ate body satisfaction ratings was calculated in the same way as the smoking urge ratings described above, and a difference score between these two means wa s computed. The difference scores for the state body satisfaction ratings and the sm oking urge ratings were correlated ( r = -.51, p < .001), indicating that the magnitude of the body image manipulations effect on state body satisfaction was associated with the manipul ations effect on urge ratings. That is, as the thin image produced lower body sa tisfaction, it also produced greater smoking urges.
25 To continue the test for mediation, a 2 X 2 Repeated Measures ANCOVA was conducted again to test the effects of the manipulations on the smoking urge ratings, but this time with the state body satisfaction rati ngs for each trial as covariates. There was no longer a main effect of the body image manipulation, F (1, 57) = .23, p = .64, indicating that state body satisfaction did al so mediate the relationship. State body satisfaction was also tested as a mediator of the smoking cue manipulations effect on smoking urges. The smoking cue manipulation decreased state body satisfaction and increased smoking urges, therefore, a mean of the smoking urge ratings was calculated for both the trials with smoking images (i.e. T/S and N/S) and the trials without thin images (i.e. T/N and N/N). A difference score between these two means was computed. The same was done for the state body satisfaction ratings. The two difference scores were not correlated ( r = .09, p = .49), indicating that state body satisfaction did not mediate the relati onship for the smoking cue manipulation.
26 Chapter Four Discussion With many women claiming they smoke to manage their weight, it is imperative to understand how this motivati on affects the phasic fluctuations in urges to smoke that perpetuate smoking behavior. To date, there have been no systematic studies to address how body dissatisfaction and concerns about we ight can affect urge to smoke. The current study was designed to address th is question among college student women, the key demographic group for body image distortion. This study had two principle aims: to assess the effect of a smoking cue manipulation and a body image manipulation on self-reported urges to smoke; and to assess if body dissatisfaction moderated the re lationship between that manipulation and the reported urge to smoke. With the sm oking cue manipulation, we hypothesized that we would replicate past studi es that showed smoking cues produced greater urges to smoke than neutral images. Our results s upported this hypothesis. With the body image manipulation, we hypothesized that thin mode l images would produce greater urges to smoke than neutral images. As hypothesized, we found a smaller, but still significant, main effect of the body image manipulation w ith thin images evoking greater urges. Because the two factors were displayed simu ltaneously, we hypothesized that exposure to the two experimental conditions would produce at least an additive effect if not a synergistic effect on the reported urge to smoke. The two main effects without an interaction indicated that there was an additi ve effect of the two experimental images shown together but no synergistic effect betw een them. These results indicate that not only can smoking cues evoke urges to smoke, but so, too, can images of thin models. Because a main effect for the body imag e manipulation was found, we explored body dissatisfaction as a potential moderating variable. Other studies have demonstrated that women with greater baseline body di ssatisfaction are more affected by body image
27 manipulations (Groesz et al., 2002). We hypothesized that those women with higher body dissatisfaction would be most affected by the thin model image and thus show greater urge responses. This hypothesis was supported; how ever, this effect was only observed in the absence of the smoking image. It appears as though the smoking images are much more potent than the thin images in producing an urge response and thus the smoking image overpowers the more subtle eff ect of the thin image as moderated by body dissatisfaction. However, the effect of the body image manipulation is still very important as women are constantly being bom barded with images of the thin-ideal through magazines, television, and movies, and usually they are pres ented in the absence of smoking cues. Thus for women high in body di ssatisfaction, they are at a great risk of continuous cueing, which can make quitting a challenge and relaps e, among those who do quit, a high probability. Because body dissatisfaction was highly correlated with BMI, we examined whether womens actual body mass moderated the relationship between the body image manipulation and the reported urges to smoke. This was not found, i ndicating that it was not the actual weight of the individual, but rather her perception of her body that influenced her urge to smoke. This findi ng is consistent with a treatment study for women smokers concerned with weight gain (Perkins et al., 2001). The study compared three types of adjunct treatments to a smoking cessation counseli ng group: a standard program, which did not address weight gain; a behavioral weight control program, to prevent weight gain; and a cognitive-behav ioral therapy (CBT) program, to directly reduce weight concerns but not weight. Results indicated the CBT adjunct and not the behavioral weight contro l adjunct, improved smoking cessation outcome beyond that produced by the standard couns eling. Our study provides addi tional support to the idea of focusing on cognitive therapy for body im age in addressing post-cessation weight concerns, rather than on the weight itself. Expectancies can be thought of as dete rminants of behavior, with a stimulus activating an expectancy that di rectly leads to an initiation of a behavioral response that has been previously associated with that stimulus (for a review see Kirsch, 1999). Within smoking research, expectancies have been found to be associated with many measures of
28 smoking motivation (Brandon, Julia no, & Copeland, 1999). Prev ious research has found that expectancy for negative affect relief m oderated the effects of a negative affect manipulation on urges to smoke (Brandon et al., 1996). However, we failed to find that womens expectancies of cigarettes ability to control their a ppetite and weight moderated the relationship between the body image manipulation and reported smoking urges. It is possible that these expectancies may need to be primed or activated prior to measurement for them to act as predictors or moderators of smoking urge. In a study that tested the effect of an im plicit prime for body image on we ight control expectancies, women were asked to participate in a bogus task of rating slides (McKee, Hinson, & Nhean, 2004). Half the women were shown imag es of thin models while the other half were shown neutral images. After the viewi ng of the slides, they were assessed on their smoking expectancies and eating restraint. Women who were high in dietary restraint endorsed more smoking expectancies when they had been primed initially with the thin model images than when they had been primed with the neutral images. It is possible that in the present study, similar post-primi ng assessment of expectancies, might have shown greater predictive power. Some studies have demonstrated that vi ewing thin models ca n increase negative affect (Stice & Shaw, 1994), and other stud ies have found negative affect to produce smoking urges (Brandon et al., 1996; Payne, Schare Levis, & Colletti, 1991). Thus, we examined whether the effect of the body im age manipulation on smoking urge might be mediated by negative affect. This was supported, although a caveat was that the relationship between the body image manipula tion and state affect only approached significance. Significance of this one re lationship may be due to psychometric and statistical limitations. The trend, however, was in the expected direc tion, with the thin images producing greater negative affect than neutral images. Because a main effect was found for the body image manipulation for both state body satisfaction and smoking urges, an anal ysis was conducted to determine whether state body satisfaction mediated the effect of that manipulation on smoking urges. This indeed was found. There no doubt are additi onal mediators between body dissatisfaction
29 and smoking motivation. State appetite/weight control expectancies come to mind, but it was not tested in the present study. Treatment Implications Overall, the results suggest that images of thin models can act as cues to smoke among women who are dissatisfie d with their bodies. Stud ies of actual smoking relapse suggest that cue reactivity may be related to relapse (Niaura et al., 1988) and thus cue exposure therapy should have clinical efficac y. This type of treatment is based on Pavlovian extinction: repeated presentation of drug-related cues (e.g., the drug itself, drug paraphernalia) in the absence of drug admi nistration should eventually extinguish the cravings to the stimuli. Unfortunately, a meta-analysis by Conklin and Tiffany (2002) showed poor results for cue exposure therapy for a variety of drug addictions, including cigarette smoking. One explanation given for the poor outcomes was the lack of extinction to the actual drug ad ministration. However, it has also been suggested that cue-exposure paradigms should be expanded to include extinction to upstream cues and to interoceptive (cognitive a nd affective) cues. Findings from the present study suggest that exposure stimuli might also include im ages that induce body dissatisfaction, as well as the dysfunctional cognitions themselves. Also, as noted earlie r, body dissatisfaction and weight concerns could be direct targ ets of other forms of cognitive-behavioral treatments for smoking cessation (c.f. Perkins et al., 2001). Limitations There were several methodological limita tions of this study that should be considered when interpreting the results. An ethically and racially diverse sampling of thin models was chosen as stimuli for the body image manipulation. However, the sample of participants was quite homogeneous. This might have decreased the effect of the manipulation due to the Cau casian participants not socially comparing themselves to those models of other ethnic and racial groups. Social comparison theory states that an individual usually will make comparisons to others who share similar relevant dimensions, such as skin color (Festinger, 1954). Greater effects on self-evaluations are usually seen when social comparison occurs with members of meani ngful in-groups than with members of out-groups (Brewer & Weber, 1994; Major, Sciacchitano, & Crocker,
30 1993; Miller, Turnbull, & McFarland, 1988). In a study conducted by Frisby (2004) there was no effect to African American women on their mood or body satisfaction from idealized media images when the model wa s of a dissimilar ethnic background. This suggests that similarity to the model in the images may play a role in how the images affect body satisfaction. It is unclear as to whether this applies acr oss all ethnic groups or only minorities, but future studies should be aware of this and tailor the stimuli to the characteristics of individual participants. The experimental effects may have also been influenced by whether participants actually engaged in a comparison with the model. According to Wilcox and Laird (2000), an individual can choose either to soci ally compare herself to the model or to identify with the model. Our manipulati on depended upon social comparison occurring. If instead, identification with the model occu rred in some participants, body satisfaction may have been enhanced rather than challe nged, reducing the impact of the manipulation. It is also possible that ba sed on the instructions, some participants may have overly focused on the models clothing to the exclusi on of the model herself, thus limiting social comparison. Future studies may wish to be ei ther more explicit in their instructions for the image viewing (although this can increase demand effects) or include some measure of social comparison at th e end of the image viewing. Another limitation was that, although the differences in urge ratings among the different trials were statistically significant, the differences were quite small and may not be clinically significant. Th is might have been due to having the participants smoke about 30 minutes before beginning the expos ure to the trials. This was done to standardize all the participants with regard to level of nicotine withdrawal. However, because many of the participants were li ght smokers, smoking that one cigarette may have prevented a greater urge response from occurring. Future studies might increase the time between the participant smoking her cigarette and beginning the experiment. Another modification may be to use a highe r smoking rate inclusion criterion. An increase in smoking rate may increase the le vel of nicotine dependence of the sample and provide participants with greater conditioning histories, which could lead to a greater responses to the stimuli (Niaura et al., 1988).
31 The smaller than expected effect size may also be a function of the withinsubjects design. In their meta-analysis, Groesz, Levine, and Murnen (2002) found a greater effect size for body image manipulati ons that used between-subjects designs. Although their meta-analysis did not discuss ex planations for the relative weakness of within-subjects designs, a reason able explanation is that ca rry-over effects occur across trials and conditions, even when distractor trials are used between experimental trials. The half-life of body image th reats is unknown and may be l onger than the inter-trial interval of this study. Nevertheless, the w ithin-subjects design offered us the advantages of relatively high statistical power with a small sample size for the initial test of the causal role of body dissatisfaction on smoking urges. Our design was unique in that we paired s timuli together to test for additive and synergistic effects. However, the use of the side-by-side image design may also have reduced effect sizes by diffusing the particip ants attention to a ny given stimuli. The trials containing the smoking images elicited greater smoking urges, and thus this greater salience of the smoking images may have redu ced the focus and social comparison to the thin model. Future studies could use a s ubtler smoking cue, such as an ashtray by the computer, which would not consciously take aw ay from the focus of examining the thin images, but would allow for an exploration of additive effects of the dual manipulations. Additionally, future studies c ould just present single, unpair ed stimuli, eliminating the issues of the dual-stimuli design. Another limitation of this study is the lack of a beha vioral measure of smoking motivation. In their study, Brandon, Wette r, and Baker (1996) found no covariance between measures of self-reported urge and smoking consumption, which is consistent with Tiffanys (1990) model of drug motiv ation, viewing urge and administration behavior as functionally inde pendent. However, other dr ug motivation models (Baker, Morse, & Sherman, 1987; e.g., Heather & Stal lard, 1989; Marlatt, 1985; Niaura et al., 1988) view urge as an integr al aspect of self-administr ation behavior. Multi-modal assessment is essential, and therefore fu ture studies should include behavioral assessments in addition to self-reported urge ratings. The as-yet-unanalyzed psychophysiological measures included in this study will also serve a similar function.
32 Despite the limitations, the results ar e promising. This study builds upon past descriptive and correlational research that has indicat ed a relationship between body dissatisfaction and smoking behavior by util izing an experimental paradigm. The presentation of images depict ing thin women increased smoking urge, which is consistent with a causal influence of body image. Although many women report smoking for weight control reasons in a global sense, this study is the first to show that images of thin women, which have been show to threaten body image, can affect situ ational cravings to smoke. This is important to know for wome n of all ages, because the concept of body dissatisfaction is quite prevalent in the gene ral population. Howeve r, these results are especially important in the college-aged female population, with whom this study was conducted. Because these women are in a tran sitory period of their smoking behavior, it is important to learn the motivations of thei r smoking behavior, so that interventions can be developed before these women become chronically dependent on tobacco.
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Lopez, Elena Nicole.
Effects of weight-related cues on smoking motivation
h [electronic resource] /
by Elena Nicole Lopez.
[Tampa, Fla.] :
University of South Florida,
Thesis (M.A.)--University of South Florida, 2004.
Includes bibliographical references.
Text (Electronic thesis) in PDF format.
System requirements: World Wide Web browser and PDF reader.
Mode of access: World Wide Web.
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ABSTRACT: Smoking is now the leading cause of preventable death and disease in women. Understanding women's motivations to smoke is important in developing effective cessation and relapse prevention programs. Women, more so than men, appear to associate their smoking behavior to issues of weight. Although a general relationship between weight concerns and smoking has been found among women, a causal relationship had not been demonstrated. This study tested whether activation of negative body image cognitions would produce greater urges to smoke and whether the relationship would be moderated by trait body dissatisfaction and mediated by state body dissatisfaction. A randomized 2 X 2 crossed factorial, within-subjects design (body image cues X smoking cues) was conducted with 62 female college smokers.The body image manipulation comprised an image of either a thin model or a neutral object, and the smoking manipulation comprised an image of either a smoking cue or a neutral object. Participants completed pre-intervention measures assessing smoking history and body image dissatisfaction. Urge to smoke, mood state, and weight and appearance satisfaction were assessed during the experiment. It was hypothesized that main effects on reported urge to smoke would be found for both manipulations, with body dissatisfaction moderating the body image manipulation. Results indicated that both smoking cues and thin model images increased reported urges to smoke. Additionally, in the absence of smoking cues, the effect of the body image manipulation was moderated by baseline body dissatisfaction, with those women with greater body dissatisfaction reacting more strongly to the thin model image.The effect on smoking urges by the body image manipulation was partially mediated by both state measures of affect and body satisfaction. Thus,this study is the first to demonstrate through an experimental design that the presentation of images portraying thin women increased smoking urge, which is consistent with a causal influence of body image affecting their smoking motivation.
Adviser: Brandon, Thomas H.
t USF Electronic Theses and Dissertations.