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Testing Impulsivity as a Mode rator of Smoking Motivation Following Exposure to Negative Affect and Smoking Cues by Erika B. Litvin 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 Brandon, Ph.D. David Drobes, Ph.D. Geoffrey Potts, Ph.D. Jonathan Rottenberg, Ph.D. Date of Approval: November 16, 2007 Keywords: Tobacco, Cigarettes, Urge, Mood, Reactivity Copyright 2008, Erika B. Litvin
Dedication I dedicate this masters thesis to my pa rents, Susan and Kenneth Litvin, who have supported me unconditionally and in ever y way possible throughout my life and my education.
Acknowledgements I would like to thank everyone who contributed to this research. First, I must acknowledge my advisor, Thomas Brandon, Ph.D He always pushes me to strive for excellence and has contributed immensely to my professional development. I could not ask for a better mentor and I am truly humble d by his confidence in my abilities. I must also thank the other members of my maste rs thesis committee: David Drobes, Ph.D., Geoffrey Potts, Ph.D., and Jonathan Rottenbe rg, Ph.D. for their thoughtful questions and insightful suggestions. Additionally, I woul d like to thank everyone at the Tobacco Research and Intervention Program (TRIP) laboratory, including faculty, graduate students, and staff who were al ways there to help me generate ideas, problem-solve, and just listen when I hit a bump in the roa d. I would like to ack nowledge specifically Brenda Medero for assisting with sc reening and appointment scheduling and undergraduate research assistants Marlee Cea, Danielle Nevitt, Christina Pabon, Riddhi Patel, and Crystal Reels for a ssisting with data co llection. Also, I want to further thank Riddhi, Danielle, and Crystal for coding and ma naging the videotape data and for always maintaining a cheerful and positive attitude during that slow a nd tedious task. I hope that I provided you with valuable experience and I am forever grateful for your many hours of hard work! Last and certainly not least, I would like to thank the individuals who gave their time to participate in this study. W ithout them, this document could not exist.
i Table of Contents List of Tables iv Abstract v Introduction 1 Smoking and Negative Affect 3 Smoking and Impulsivity 8 Impulsivity Questionnaires Derived From Personality Theory 9 Barratt Impulsiveness Scale 9 Grays BAS and BIS 10 Other Self-Report Measures 10 Behavioral Impulsivity Meas uresDelay Discounting Tasks 10 Mechanisms Linking Impulsivity and Smoking 12 Impulsivity and Reactivity to Exte roceptive Cues 13 Impulsivity and Reactivity to Intero ceptive Cues 14 The Current Study 16 Method 18 Experimental Design and Overview 18 Participants 18 Measures 19 Exhaled Carbon Monoxide (CO) 19 Demographic Questionnaire 19 Smoking Status Questionnaire (SSQ) 19 Questionnaire of Smoking Urges-Brie f (QSU-brief) 20 Smoking Consequences QuestionnaireAdult (SCQ-A) 20 Mood Form 21 State-Trait Anxiety Inventory (STAI) 21 Barratt Impulsiveness Scale (BIS-11) 22 BIS/BAS Scales 22 Delay Discounting Task (DDT) 23 Smoking Topography 24 Cigarette Rating Form (CRF) 25 Procedure 25 Recruitment 25 Consent 26 Part I: Baseline Measures 26 Randomization 27
ii Part II: Mood Manipulation 27 Part III: Cue Exposure Manipulation 29 Part IV: Smoking Topography Assessment 30 Debriefing 31 Payment 32 Results 34 Data Screening 34 Self-Report Questionnaire Data 34 Behavioral (Topography) Data 34 Participant Characteristics 35 Mood Manipulation Check 38 Manipulation Effects on Urge and Topography 39 Smoking Urge After The Mood Manipulation 39 Smoking Urge During The Cue Manipulation 40 Smoking Urge After The Cue Manipulation 41 Smoking Topography 42 Moderation Analyses 42 Additional Analyses 43 Discussion 46 Mood Manipulation Manipulation Ch eck Results 47 Manipulation Effects on Urge 51 Mood Manipulation 51 Cue Manipulation 52 Interaction 55 Manipulation Effects on Topography 56 Impulsivity 56 Correlations Among Impulsivity Measures And Other Variables 56 Moderating Effects on Reactivity 57 Summary 58 Conclusion 59 References 61 Appendices 80 Appendix A: Demographic Ques tionnaire 81 Appendix B: Smoking Status Questi onnaire (SSQ) 82 Appendix C: Questionnaire of Smoking Ur ges-Brief (QSU-brief) 83 Appendix D: Smoking Consequences Questio nnaire-Adult (SCQ-A) 84 Appendix E: Mood Form (Trait) 86 Appendix F: Mood Form (State) 87 Appendix G: State-Trait Anxi ety InventoryTrait (STAI Form Y-2) 88 Appendix H: State-Trait Anxi ety Inventory State (STAI Form Y-1) 89 Appendix I: Barratt Impulsiveness Scale (BIS-11) 90
iii Appendix J: BIS/BAS Scales 92 Appendix K: Delay Discounting Task (DDT) 94 Appendix L: Cigarette Rating Form (CRF) 96 Appendix M: Telephone Screening Form 97 Appendix N: Usage Form 100 Appendix O: Art Rating Form 101 Appendix P: 2 nd CO Reading 102 Appendix Q: Debriefing Questions 103 Appendix R: Lottery Results 104
iv List of Tables Table 1 Outline of the Procedure 33 Table 2 Participant Demographic Characteristics (Percentages) 36 Table 3 Participant Baseline Characteristics (Means and Standard Deviations) 37 Table 4 Main Effect of the Mood Mani pulation on QSU-Brief Total Scores 40 Table 5 Main Effects of the Manipul ations on Post-Cue Manipulation QSU-Brief Total Scores 42 Table 6 Intercorrelations Am ong Impulsivity Scales 44 Table 7 Intercorrelations Among Impul sivity Scales, Demographics, and Tobacco Use Variables 44 Table 8 Intercorrelations Among Impulsivity Scales, Baseline Urge, and Trait Affect 44 Table 9 Intercorrelations Among Impulsivity Scales and Smoking Expectancies 45
v Testing Impulsivity as a M oderator of Smoking Motivation Following Exposure to Negative Affect and Smoking Cues Erika B. Litvin ABSTRACT Consistent with classical conditioning theori es of drug use, previous research has demonstrated that presenting smokers with either exteroceptive (e.g., pictures of cigarettes) or interoceptive (e.g., negative aff ect) cues results in increased motivation to smoke, as measured by urge and smoking topography (e.g., shorter latency to begin smoking). However, few studies have presente d both types of cues to determine whether and how they might interact in the producti on of smoking motivation, and little research has focused on identifying potential moderators of cue reactivity. In a randomized 2 x 2 crossed factorial between-subjects desi gn, the current study tested whether an interoceptive cue (anxiety induced via a sp eech preparation task) and an exteroceptive cue (exposure to a lit cigarett e) interacted in the producti on of urge and behavioral reactivity and whether the pers onality trait of impulsivity moderated these effects. Results indicated main effects but no inter active effects for the two cue types on selfreported urge, no main or interactive e ffects on smoking topography, and no moderating effects of impulsivity. However, impulsivity was significantly corre lated with urge to smoke, self-reported negative affect, and exp ectancies that smoking relieves negative
vi affect, suggesting that this tr ait plays an important role in continued tobacco use. Implications for future re search on the relationship be tween impulsivity and smoking behavior are discussed.
1 Introduction Although smoking rates have declined stead ily since the 1960 s, an estimated 20.9 percent of adults in the U.S. continue to smoke (Centers for Disease Control and Prevention, 2005) and tobacco use remains th e leading preventable cause of death (United States Department of Health a nd Human Services, 20 04). A recent study reported that an estimated 70 percent of sm okers want to quit (Centers for Disease Control and Prevention, 2002) but the best cu rrent smoking cessation treatments result in long-term abstinence rates of only 15 to 30% (Fiore et al., 2000). Therefore, it is important that researchers continue to investigate ps ychological and physiological mechanisms that maintain tobacco use. It has been repeatedly ob served that relapse ofte n occurs when drug users encounter stimuli previously paired with drug use (e.g., Shiffman, Paty, Gnys, Kassel, & Hickcox, 1996). Classical conditioning (CC) theories of drug use motivation provide one possible explanation for this phenomenon. They posit that drug-relate d stimuli that are repeatedly paired with drug use become c onditioned stimuli (CSs) capable of eliciting conditioned responses (CRs), and that these responses are subjectiv ely experienced as craving and motivate continued drug use (C arter & Tiffany, 1999; Niau ra et al., 1988). Wikler (1948) hypothesized that stimuli associated with withdrawal symptoms elicit conditioned withdrawal-like res ponses that prompt continued use. Siegel (1975) also proposed that CRs are withdrawal-like, that is, opposite in direction to unconditioned
2 drug responses (UCRs), but that stimuli associ ated with drug administration, rather than drug withdrawal, become CSs. In contrast Stewart, de Wit, and Eikelboom (1984) proposed an incentive model whereby stimuli associated with drug use invoke a positive motivational state and responses that are is odirectional to drug UCRs. Cue reactivity research in the laboratory, which involves e xposing drug users to cues associated with drug administration and measuring their r eactions, has provided general support for CC theories and valuable insight into basic phenomena related to dr ug addiction. A large body of research has demonstrated that exteroce ptive cues, such as pictures of cigarettes, reliably induce self-reported craving or urge, as well as physiological responses, in smokers (Carter & Tiffany, 1999). A smaller number of studies have shown that interoceptive cues, such as negative affect also result in increased urge (e.g., Payne, Schare, Levis, & Colletti, 1991; Tiffany & Drobes, 1990). Outside of the laboratory, smokers are like ly to encounter both exteroceptive and interoceptive cues in close temporal proxi mity. However, to our knowledge, only one laboratory study has investigated reactivity to exteroceptive smoking cues during a negative mood induction (Payne et al., 1991). A dditionally, there is only limited evidence that reactions to smoking cues in the laboratory predict actual drug use behavior (Payne et al., 1991), and relapse following a quit a ttempt (Niaura, Abrams, Demuth, Pinto, & Monti, 1989; Payne, Smith, Adams, & Diefe nbach, 2006). The value of cue-elicited reactions for predicting actual smoking be havior and cessation outcomes may remain uncertain because individuals differ in both response magnitude, with some failing to show any reactions (Rees & H eather, 1995), and their tendency to act on cravings (Tracy, 1994). The need for research on potential moderators of cue reactivity, such as
3 personality traits, has recently been highlig hted (Carter & Tiffany, 1999; Rees & Heather, 1995). Such research has the potential to expl ain individual differen ces in susceptibility to drug conditioning and subsequently aid in refining classical conditioning theories (Rees & Heather, 1995). We will first review the relationship between smoking and negative affect, with a focus on studies that induced negative affect in the laboratory. Second, we will review the construct of impulsivity, a pe rsonality trait that is strongly associated with drug use. We will present evidence to suggest that impulsivity may affect reactivity to both exteroceptive and interoceptive cues. The current study tested experimentally whether these two cue types would in teract in the production of smoking motivation, and whether impulsivity would moderate these effects. Smoking and Negative Affect Many smokers believe that negative affect states, such as stress, anxiety, and depression, motivate them to smoke and that smoking relieves negative affect (NA) (Brandon, 1994; Copeland, Brandon, & Quinn, 1995). Likewise, a number of theorists have also identified NA as a key motivator of drug use behavior (e.g., Baker, Piper, McCarthy, Majeskie, & Fiore, 2004). Wher eas smoking rapidly relieves NA directly caused by nicotine withdrawal, the relationshi p between tobacco use and NA independent of withdrawal is complex, may be reciprocal, and is not yet fully understood (for an extensive review, see Kassel, Stroud, & Paronis, 2003). Corr elational and cross-sectional studies consistently demonstrate a relationshi p between all stages of smoking behavior and NA (Kassel et al., 2003). For example, there is considerable evidence that negative life experiences such as abuse and parental divorce (e.g., Anda et al., 1999), other acute
4 and chronic stressors (e.g., Koval, Peders on, Mills, McGrady, & Carvajal, 2000), and affective disorders such as depression (e.g., Breslau, Peterson, Schultz, Chilcoat, & Andreski, 1998; Brown, Lewinsohn, Seeley, & Wagner, 1996; Dierker, Avenevoli, Merikangas, Flaherty, & Stolar, 2001) are associated with initiation of smoking, progression to daily smoking, and development of nicotine dependence. Regarding smoking maintenance, smokers ge nerally report higher levels of stressful life events and NA (e.g., Hellerstedt & Jeffery, 1997; Jorm et al., 1999b), and are more likely to suffer from depression and some anxiety disord ers (e.g., Anda et al., 1990; Breslau, 1995; Zvolensky, Feldner, Leen-Feldner, & McLe ish, 2005) than non-smokers. NA is even more strongly linked to cessation outcomes. Individuals with a history of depression (Covey, 1999), current depressive symptoms (e .g., Glassman et al., 1990), and relatively higher levels of post-cessation NA (Kenford et al., 2002) are more likely to relapse. In one study, smokers who reported that they were motivated to smoke primarily by NA were also at greater risk of relapse (Pomerleau, Adkins, & Pertschuk, 1978). Most compelling of all, both retrospective and re al-time field studies indicate that a large proportion of relapses are attributable to situational increases in NA (e.g., Brandon, Tiffany, Obremski, & Baker, 1990; Shiffman et al., 1996). Nevertheless, it remains somewhat unclear whether situational increases in NA actually maintain smoking behavior in cont inuing smokers, and consequently, whether smoking relieves NA. Laboratory studies that have investigated these questions have used a variety of different procedures to induce NA, including music (Conklin & Perkins, 2005; Willner & Jones, 1996), images (Conklin & Perkins, 2005), imagery scripts (e.g., Tiffany & Drobes, 1990), exposure to aversive noise (Jarvik, Caskey, Rose, Herskovic, &
5 Sadeghpour, 1989; Payne et al., 1991), watching a stressful movie (Gilbert, Robinson, Chamberlin, & Spielberger, 1989), engaging in a competitive mental arithmetic task (Pomerleau & Pomerleau, 1987), telling particip ants they will need to perform a comedy monologue (Rose, Ananda, & Jarvik, 1983) or give a speech about what they dislike about their body (Juliano & Brandon, 2002; Kassel & Shiffman, 1997; Kassel & Unrod, 2000), and making participants try to solve unsolvable anagrams (Jarvik et al., 1989; Pomerleau, Turk, & Fertig, 1984). Regardi ng whether smoking reduces NA, findings are mixed, depending on the mood induction procedur e used and other situational factors (e.g., engaging in a distracting activity while smoking, see Kassel & Shiffman, 1997; Kassel & Unrod, 2000). For example, a recent study by Conklin and Perkins (2005) that employed a robust music and imagery mood induction, found that smoking did reduce NA, but not more than sipping water. Regarding whether smokers increase their smoking behavior when they experience NA, Shiffman et al. (2002) re ported real-time data that indicated no relationship between situational increases in NA and timing of smoking episodes. Baker et al. (2004) have recently pr esented a negative reinforcem ent model of addiction that may explain these null findings. They have pr oposed that NA is primarily responsible for continued drug use, but that when drugs are freely available, as they are for most smokers, drug users learn to detect intero ceptive, withdrawal-related NA before it becomes conscious. When drug use is inte rrupted, such as during a quit attempt or because drugs are otherwise unavailable, this withdrawal-related NA reaches consciousness and prompts continued use. Ov er time, drug users come to associate drug use with relief not only from withdrawal-related NA, but also from other sources of NA,
6 and NA becomes a potent CS for continued use. However, because the majority of drug use occurs before NA reaches consciousness, Baker et al.s theory w ould actually predict the results that Shif fman et al. obtained. Further supporting Baker et al.s theory, laboratory studies that have induced NA in minimally or moderately-deprived smokers have generally (but not always, see Br andon, Wetter, & Baker, 1996) shown that NA decreases latency to smoke (Conklin & Perkins, 2005) and increases the intensity of smoking behavior, measured by the number of puffs taken and puff volume (Conklin & Perkins, 2005; Payne et al., 1991; Pomerl eau & Pomerleau, 1987; Rose et al., 1983; Willner & Jones, 1996). Whereas numerous studies have presente d smokers with exteroceptive cues to induce craving, many fewer studies have exam ined the effect of NA on craving, despite both theoretical and empirical in terest in the significance of cr aving as a predictor of drug use and its relationship to relapse (e. g., Killen & Fortmann, 1997; Toneatto, 1999). Perkins and Grobe (1992) reporte d that desire to smoke incr eased during a stressful task that involved repeating digit sequences presented at varying speeds tailored for each participant to maintain his/her success rate at approximately 40 percent. Similarly, NA induced by leading participants to believe th ey had performed poorly on an IQ test has also been shown to increase craving (Brandon et al., 1996). Using a musical mood induction procedure, Willner and Jones ( 1996) found that craving increased in a depressed mood condition relative to an el ated mood condition. Employing a similar music and imagery mood induction procedure, Conklin and Perkins (2005) reported that craving increased in a negative mood conditi on relative to a positive mood condition, but not more so than in a neutral mood condition. Tiffany and colleagues have conducted a
7 series of studies using standardized imagery sc ripts. They have dem onstrated that scripts intended to induce NA increase urge to smoke relative to neutral mood scripts (MaudeGriffin & Tiffany, 1996; Tiffany & Drobes, 1990). During everyday life, drug users are likely to encounter both NA and drug cues in close temporal proximity. To investigate how these two cue types might interact, several studies in the alcohol literatu re have investigated the impa ct of NA on urge reactivity to exteroceptive alcohol cues (e.g., sight and smell of an alcoholic beverage) and subsequent alcohol consumption (Cooney, Litt, Morse, Bauer, & Gaupp, 1997; Jansma, Breteler, Schippers, de Jong, & Van Der Staak, 2000; Litt, Cooney, Kadden, & Gaupp, 1990; Nesic & Duka, 2006; Rubonis et al., 1994). Th ese studies have so far produced mixed findings, which may have resulted from different mood induction procedures and participant characterist ics (i.e. social drinke rs vs. alcoholics) (Nesic & Duka, 2006). For example, some studies have failed to find any ef fect for alcohol cues (Litt et al., 1990), or mood (Jansma et al., 2000), while others ha ve found additive effects (Cooney et al., 1997). Gender differences have also been re ported (Nesic & Duka, 2006; Rubonis et al., 1994). Surprisingly, very few studies in the sm oking literature have presented both cue types in the same study. Tiffany and collea gues have reported that imagery scripts containing both NA and urge cues result in greater craving increases than scripts containing either cue type alone (Ma ude-Griffin & Tiffany, 1996; Tiffany & Drobes, 1990). Payne et al. (1991) found that nega tive mood induced via a stressful noise-escape task increased urge to smoke. The presence of smoking cues in the experimental room (i.e. ashtrays with butts, pack s of cigarettes, matches, odor of smoke) while participants
8 completed the task did not affect urge to smoke, but did decrease latency to smoke and increase puff duration for the first cigare tte smoked during a 20 minute ad-lib smoking opportunity following completion of the task. In Tiffany and colleague s as well as in Payne et al.s study, the NA and smoking cues were presented simultaneously. In the Payne et al. study, it is possibl e that the smoking cues did no t affect urge because they were not as salient as the mood induction, considering the attentional demands of the noise-escape task. Additionally, simultaneou s presentation may not reflect the actual experiences of drug users. It seems more likely that drug users experiencing NA would subsequently encounter drug cu es just before use occurs. Consistent with this assumption, the alcohol studies described previously introduced the alcohol cues after participants already had been induced into a negative mood. To our knowledge, no smoking study has presented smoking cues after a negative mood induction, to ensure the salience of the smoking cues and to investigate how NA affects subs equent reactivity to smoking cues. Smoking and Impulsivity Impulsivity, a prominent construct in most theories of personality, encompasses a broad range of traits and behavi or associated with impaired self-regulation, such as poor planning, premature responding before consid ering consequences, sensation-seeking, risk-taking, an inability to inhibit behavior, and a prefer ence for immediate over delayed rewards (Evenden, 1999; Whiteside & Lyna m, 2001). Methods used to assess impulsivity include both self-report and behavior al measures. Factor analytic studies of impulsivity scales have revealed that im pulsivity is not a unitary construct (e.g., Whiteside & Lynam, 2001), and it remains unc lear which measures best capture certain
9 aspects of impulsivity. Nevertheless, a larg e body of research has demonstrated that impulsivity, broadly defined, is associated with some forms of psychopathology (Swann, Bjork, Moeller, & Dougherty, 2002) and many h ealth risk behaviors, including tobacco and other drug use (Bogg & Roberts, 2004). Impulsivity questionnaires deri ved from personality theory. Smoking is associated with impulsivity as measured with a variety of impulsivity-related scales based on the major threeand five-factor models of personality proposed by Cloninger (1987), Eysenck (Eysenck & Eysenck, 1969, 1975; Eyse nck, Pearson, Easting, & Allsoff, 1985), Costa and McRae (Costa & McCrae, 1992; McCrae & Costa, 1990), and Zuckerman (1994). The majority of studi es including these measures have shown that, as a group, adolescent and adult smokers are more im pulsive than nonsmokers (Carton, Jouvent, & Widlocher, 1994; Golding, Harpur, & BrentSmith, 1983; Kassel, Shiffman, Gnys, Paty, & Zettler-Segal, 1994; Mitchell, 1999; Terr acciano & Costa, 2004; Vollrath & Torgersen, 2002; Wills, Vaccaro, & McNamara, 1994; Zuckerman, Ball, & Black, 1990). Two impulsivity-related scales in Cloningers model have also been shown to predict substance use initiation (Masse & Tremblay, 1997). Barratt Impulsiveness Scale. The Barratt Impulsiveness Scale (BIS-11; Patton, Stanford, & Barratt, 1995) is a 30 item scale that consists of three factors labeled attentional impulsiveness, motor impulsiven ess, and nonplanning impulsiveness. Adult smokers report greater impulsivity on the BI S-11 than non-smokers (Mitchell, 1999), and frequency of smoking among adolescent and young adult smokers has been positively associated with BIS-11 scores (Fossati, Barrat t, Acquarini, & Di Ceg lie, 2002; Fossati, Di Ceglie, Acquarini, & Barratt, 2001). Additionally, Dom, Hulstijn, and Sabbe (2006)
10 reported that BIS-11 scores correlated positiv ely with the number of cigarettes smoked daily among a group of alcohol-dependent smokers. Grays BAS and BIS. Grays Reinforcement Sensitivity Theory (RST) of personality (Fowles, 1987; Gray, 1970, 1987) proposes that two systems primarily influence behavior. The Beha vioral Activation or Behavioral Approach System (BAS) motivates reward-seeking behavior and positive affect, while the Behavioral Inhibition System (BIS), motivates avoidance behavior and anxiety reactions Although both an overactive BAS and an underactive BIS may be thought to represent impulsivity, most research has focused on an overactive BAS as a predictor of impulsive behavior. The most commonly used measures associated w ith RST are the BIS/BAS scales (Carver & White, 1994). To our knowledge, no studies have yet determined whether BAS scores of smokers differ from non-smokers, but higher scores on BAS measures are associated with alcohol use (Franken, Muris, & Geor gieva, 2006; Jorm et al., 1999a). Also, Knyazev (2004) reported that a BAS measure predicted substance use (including tobacco use) among a group of adolescents and young adults. Other self-report measures. In addition to the measures described above, a variety of other impulsivity-related s cales predict smoking initiation (Burt, Dinh, Peterson, & Sarason, 2000; Elkins, King, McGue, & Iacono, 2006; Grano, Virtanen, Vahtera, Elovainio, & Kivimaki, 2004; Lipkus Barefoot, Williams, & Siegler, 1994) and discriminate smokers from non-smokers (Geist & Herrmann, 1990; Lewinsohn, Brown, Seeley, & Ramsey, 2000; Lipkus, Barefoot, Feaganes, & Williams, 1994). Behavioral impulsivity measure sdelay discounting tasks. In a delay discounting task, individuals are given a seri es of choices between a small reward that
11 they can receive immediately or a larger rewa rd that is available after a time delay (e.g., one week). Typically, they choose between two monetary amounts (either hypothetical or real). Reward value and delay length are varied such that a discounting rate corresponding to a hyperbolic function can be estimated for each individual. A higher discounting rate reflects a stronger preference for smalle r, immediate rewards and indicates greater impulsivity. Discounting rates from computerized and paper and pencil versions of the task are highly correlated ( r = .82, Epstein et al., 2003). Likewise, versions of the task employing real ve rsus hypothetical rewards have not shown significant differences in discounting pattern s (Madden, Begotka, Raiff, & Kastern, 2003; Madden et al., 2004). Several studies have de monstrated that adult smokers are more impulsive than non-smokers on the delay disc ounting task (Baker, Johnson, & Bickel, 2003; Bickel, Odum, & Madden, 1999; Mitc hell, 1999; Reynolds, Richards, Horn, & Karraker, 2004). Additionally, adult smokers discount the value of cigarette rewards more than monetary rewards (Baker et al., 2003 ; Bickel et al., 1999; Field, Santarcangelo, Sumnall, Goudie, & Cole, 2006), and discountin g rate correlates pos itively with number of cigarettes smoked per day (Epstein et al., 2003; Ohmura, Takahashi, & Kitamura, 2005; Reynolds, 2004). Some rese archers have suggested th at the discounting task assesses state impulsivity, whereas personality measures tap trait impulsivity. Studies that have manipulated nicotine depriva tion state among smokers have shown mixed results, with one study reporting that depriva tion increased discounting rate (Field et al., 2006) and another finding no differences (Mitchell, 2004a). Furthermore, two studies have reported high test-retest reliability ra tes for the discounting task for time periods ranging from one-week ( r = .71 to .90; Baker et al., 2003) to three months ( r = .45 to .75;
12 Ohmura, Takahashi, Kitamura, & Wehr, 2006). However, studies that have administered both discounting tasks and personality measur es have reported only low to moderate correlations between them (e.g., Kirby, Pe try, & Bickel, 1999; Mitchell, 1999). Mechanisms Linking Impulsivity and Smoking Only a handful of studies have inves tigated potential mechanisms that may link impulsivity and tobacco use. Mitchell (2004b ) reviews evidence from the literature on both tobacco and other drugs that suggests a reciprocal relationship: 1) nicotine may cause neuroadaptions that increase impulsive be havior and 2) impulsivity plays a role in the maintenance of smoking behavior. Regard ing the first possibility, studies from the animal literature suggest that nicotine may cause neurological changes that increase impulsivity, or lead individuals to become more impulsive wh en deprived of nicotine (see Mitchell, 2004b). Regarding the second possib ility, impulsivity may be related to both motivation and ability to quit smoking. Mo re impulsive smokers report stronger expectancies for both positive and negative rein forcement benefits from nicotine (Doran, McChargue, & Cohen, 2007). These expectations may reflect actual experience, as more impulsive individuals may receive greater reinforcement from nicotine than less impulsive individuals (Perkins, Gerlac h, Broge, Grobe, & Wilson, 2000), including greater relief from NA (Doran et al., 2006). Additionally, the results of several studies have suggested that impulsivity is asso ciated with smoking relapse (Doran, Spring, McChargue, Pergadia, & Richmond, 2004; Jacobs 1972; Rukstalis, Jepson, Patterson, & Lerman, 2005). Impulsivity has also been implicated to account for individual differences in craving and acting on craving. Zilberman, Tavares, and el-Gue baly (2003) reported that
13 craving in treatment-seeking drug-dependent women was positively related to scores on the BIS-11 and other impulsivity scales. Tr acy (1994) distinguishe d between craving and acting on craving, suggesting that more impulsive individuals may be more likely to act on craving, and that considering variables such as impulsivity may improve the power of craving measures to predict relapse outcomes. Impulsivity and Reactivity to Exteroceptive Cues Given that exteroceptive smoking cues robustly induce craving (Carter & Tiffany, 1999) and commonly prompt relapse (Shiffman et al., 1996), and that impulsivity has been defined as a preference for imme diate rewards and a tendency to respond prematurely, it has been s uggested that perhaps more impulsive smokers are more responsive to smoking cues (Doran et al., 2004 ; Mitchell, 2004b; Rees & Heather, 1995). At the time that the current study was orig inally proposed, no published studies had yet investigated the relationshi p between impulsivity and r eactivity to smoking cues. However, two studies had reported that BAS scores, measured with the BIS/BAS scales (Carver & White, 1994) correlated positively w ith reactivity to alcohol cues (Franken, 2002; Kambouropoulos & Staiger, 2001). A dditionally, Powell, Bradley, and Gray (1992) reported that impulsivity correlated significantly w ith cue-elicited craving among opiate-dependent individuals. Since this study was proposed, two studies examining the relationship between impulsivity and reactivity to exteroceptive smoking cues have been published, with mixed results. Doran, Spring, and McChargue (2007) found that impulsivity was associated with increased cue-elicited craving, while Doran, McChargue, and Spring (2008) reported that impulsivity was associated with increased mean arterial
14 pressure response following cue exposure but not heart rate or cravi ng. Thus, the current study may help clarify this relationship. Impulsivity and Reactivity to Interoceptive Cues Although the hypothesis has not been directly tested, there is al so theoretical and empirical literature to suggest that more impulsive smokers may also be more reactive to affective cues. For example, Tice and Brat slavsky (2000) view emotion regulation as simply one form of general self-regulation, al beit with some special properties. They review evidence to suggest that emotion regula tion takes priority ove r other forms of selfregulation, that negative mood decreases ones capacity for general self-regulation, and that continued attempts at self-control can in turn lead to negative mood, creating a downward spiral. They conclude that many individuals fail at self-regulation (e.g., fail to quit smoking) because they continue to regula te their affect by engaging in the very behaviors they are trying to modify (e.g., sm oking). Because impulsive individuals by definition already have less capacity for self -control in the absence of NA, a negative mood may leave them especially vulnerable to self-control failure. Furthermore, as noted above, two recent studies have shown that more impulsive smokers may derive greater relief from NA through smoking (Doran et al., 2006), and that th ey report stronger expectancies for NA relief from smoking (Doran, McChargue, & Cohen, 2007). As such, more impulsive smokers may be triply hamper ed in their cessation efforts by generally impaired self-regulation, stronger expectati ons that smoking will reduce NA, and greater subjectively experienced reli ef from NA after smoking. Kassel et al. (2003) offer a nother perspective on the pot ential connection between impulsivity and NA-related motivation to sm oke. Citing evidence that externalizing
15 problems predict smoking initiation even more reliably than internalizing problems, they suggest the possibility that the relationship between various indices of NA and smoking initiation is actually spurious and is due to high rates of comorbidity between externalizing and internalizing problems. Deficits in self-regulation that are common to both types of problems, particularly affect regulation, may link them to smoking initation. Furthermore, a growing body of literature suggests that impulsive individuals, including smokers, may show greater respon ses to affectively charged material and deficits in affect regulation compared to peer s. For example, a recent study demonstrated that boys with attention-deficit hyperactivity disorder (ADHD), a disorder characterized by impulsive and hyperactive behavior and a ssociated with tobacco use (e.g., Tercyak, Lerman, & Audrain, 2002), were less able than comparison boys to mask and regulate their emotions during a competitive puzzle task (Walcott & Landau, 2004). In another study examining the interaction between impulsi vity and mood reactivity, Bekker, van de Meerendonk, and Mollerus (2004) reported that more impulsive female college students had a marginally significant tendency to show a greater increase in self-reported emotional eating after a negative mood induction Finally, Doran et al. (2006) found that more impulsive smokers not only reported greater reductions in NA after smoking, as previously noted, but that level of self-reported NA following the negative mood induction correlated positively with impulsivit y. Given the expectan cies that impulsive smokers have (Doran, McChargue, & Cohen, 2007), and the fact that NA correlates positively with craving and with all stages of smoking behavior (Kassel et al., 2003), more impulsive smokers may show greater urge reactivity to a negative mood induction. Additionally, if more impulsive smokers are more likely to act on their cravings, as
16 suggested by Tracy (1994), they may also evidence greater motivation to smoke as indicated by smoking topography assessment. The Current Study More studies are clearly necessary to elucidate the connections between urge, smoking behavior, NA, and exteroceptive smoking cues, and to identify potential moderators of these relationships. The prim ary purpose of the curren t study was to test experimentally the effect of negative mood on urge and behavioral reactivity to exteroceptive smoking cues and subsequent smoking behavior. The smoking cues were presented after the mood induc tion, rather than during it as Payne et al. (1991) did, in order to increase their salienc e, and more precisely assess the effect of a negative mood on reactivity to the smoking cues. As men tioned previously, several studies in the alcohol literature have used simila r methodology (mood induction followed by cue exposure). After exposure to both cue types, participants were given an opportunity to smoke and their smoking behavior was recorded. Additionally, we investigated whether impulsivity moderated urge and behavioral re activity. That is, we examined whether more impulsive smokers, identified from personality and behavioral measures, experienced stronger motivation to smoke in response to these two types of cues, compared to less impulsive smokers. Specific Aim 1: To investigate the effe ct of negative affect on urge and behavioral reactivity to exteroceptive smoking cues and subsequent smoking behavior. We hypothesized that both negative affect and exteroceptive smoking cues would result in increased motivation to smoke, as indicated by increased self-
17 reported craving and smoking topography variables such as decreased latency to smoke. Specific Aim 2: To test the hypothesis that impulsivity moderates reactivity to both affect and smoking cues. Specifica lly, we hypothesized that more impulsive smokers would report stronger urges and sh ow evidence of greater motivation to smoke than less impulsive smok ers, after induction of ne gative affect and exposure to smoking cues.
18 Method Experimental Design and Overview Participants were recruited to participat e in an individual laboratory session to learn more about personality and mood in sm okers. A 2 X 2 crossed factorial betweensubjects design (Negative Mood/Neutral M ood X Smoking Cue/Neutral Cue) was used. First, participants completed baseline meas ures that assessed demographics, nicotine dependence, impulsivity, beliefs about nega tive reinforcement benefits from smoking, trait and state mood, and current urge level. Participants were then randomly assigned to one of four conditions: 1) negative mood induction fo llowed by exposure to smoking cues, 2) negative mood induction followed by exposure to neutral cues, 3) neutral mood induction followed by exposure to smoking cues or 4) neutral mood induction followed by exposure to neutral cues. Following the m ood induction and cue exposure procedures, participants were asked to complete additional questionnaires that assessed urge and state mood. After completing both the mood inducti on and cue exposure procedures, they were given an opportunity to smoke and their smoking behavior was recorded. After smoking, state mood was again assessed and participants were debriefed and paid. Participants Participants included 175 smokers recr uited from the Tampa, Florida area via flyers and newspaper advertisements. All inte rested individuals were screened via phone and were invited to participate if they reported that they were English-speaking, between
19 the ages of 18 and 65, smoked at least 10 cigarettes per day and had smoked for at least one year, were not currently attempting to quit or using pharmacotherapy, were not currently enrolled in a formal cessation tr eatment program, were not pregnant, and had not participated in any recen t TRIP study with similar procedures to the current study (e.g., some manipulation followed by repeat ed measurement of craving, this was determined on a case-by-case basis). Add itionally, upon arrival at the laboratory each participant provided a breath sample to dete rmine exhaled carbon monoxide (CO) level in parts per million. If their CO level was below 8ppm, an accepted cut-off to determine smoking status, they were excluded from the study. Each participant was paid $20 for participation in the study, which la sted approximately 1 to 1.5 hours. Measures Exhaled Carbon Monoxide (CO) Upon arrival at the laboratory, participants provided a breath sample to determine exhaled CO level and verify their smoking status. They were asked to inhale deeply, hold thei r breath for 20 seconds, and then exhale into a disposable tube attached to a CO monitor. Participants were ex cluded from the study if their breath CO level was below 8ppm. Exhale d CO level was also measured at the end of the study, after participan ts had smoked a cigarette. Demographic Questionnaire Single items assessed participants age, marital status, race and ethnicity, education level, and house hold income. (See Appendix A). Smoking Status Questionnaire (SSQ) The SSQ was used to assess participants smoking history and level of nicotine depe ndence. The SSQ incl uded items from the Fagerstrom Test for Nicotine Dependence (F TND), which has been shown reliable and
20 valid for measuring nicotine dependence (Heatherton, Kozlowski, Frecker, & Fagerstrom, 1991). (See Appendix B). Questionnaire of Smoking Urges-Brief (QSU-brief; Cox, Tiffany, & Christen, 2001). The QSU-brief was used to assess participants self-reported urge to smoke at baseline and following the mood and cue ma nipulations. The QSU-brief contains 10 items taken from the original 32-item Qu estionnaire of Smoking Urges (QSU; Tiffany & Drobes, 1991). The items consist of two subscal es that assess both positive (i.e. desire to smoke, pleasure) and negative reinforcement bene fits (i.e. relieve NA). Participants rated each item using a scale that ranged from 1 (very slightly or not at all) to 5 (extremely). Higher scores indicated greater craving. Th e QSU-brief has been shown highly reliable ( = .92-.97) in the measurement of smoking urge s in the laboratory. (See Appendix C). Smoking Consequences Questionnaire Adult (SCQ-A; Copeland et al., 1995). The original Smoking Consequences Questi onnaire (Brandon & Baker, 1991) assesses smokers expectations about the benefits of sm oking, referred to as expectancies, and has been validated in a college student sample. The SCQ-A is a modified version of the SCQ that has been validated in a sample of adult sm okers. Each item is rated on a scale from 0 (completely unlikely) to 9 (com pletely likely). Three of the 10 subscales were included in the proposed study: Negative Affect Reduction (e.g., Smoking calms me down when I feel nervous), Stimulation/St ate Enhancement (e.g., Cigarettes can really make me feel good), and Craving/Addiction (e.g., Smoking will satisfy my nicotine cravings). These three subscales have demonstrat ed high internal consistency ( = .83-.96). (See Appendix D).
21 Mood Form (Diener & Emmons, 1984). The Mood Form was used to assess participants trait and state mood. It consists of 4 items that assess positive affect (e.g., happy, pleased) and 5 items that assess negative affect (e.g., depressed/ blue, frustrated). Each item is rated on a 7 point scale from not at all to extremely much. The ratings for the positive and negative adjectives were summed to produce total Positive Affect and Negative Affect scores. To measure part icipants general mo od (i.e. trait mood), participants were asked to indi cate how much they had experienced each affect state over the past 3 weeks. To measure particip ants state mood before and after the two manipulations and after smoking, participants were asked how much they were currently experiencing each affect state. This measure was chosen for its brevity and high reliability ( = .89 for the positive affect items and = .84 for the negative affect items). (See Appendices E and F) State-Trait Anxiety Inventory (STAI; Spielberger, Gorsuch, Lushene, Vagg, & Jacobs, 1983). The STAI was used to more thoroughly assess partic ipants anxiety, the affect state most likely to be affected by the mood manipulation. The STAI consists of 20 items that assess trait a nxiety (STAI-T) (e.g., I feel ne rvous and restless), and 20 similar items that assess state anxiety (STA I-S) (e.g., I am tense). In the original measure, both the trait and state items are ra ted on a 4-point scale (almost never to almost always for the trait items and not at all to very much so for the state items). However, to obtain more variability towards the high end of the scales recent research in the area of smoking and negative affect has us ed a 7-point scale with the same labels placed at equal intervals (Juliano & Bra ndon, 2002; Kassel & Unrod, 2000). We used the 7-point scale for both the tra it and state versions. Reported alphas for the 7 point scale
22 are .89 for the trait measure (Kassel & Unr od, 2000) and .90 to .96 for the state measure (Juliano & Brandon, 2002; Kassel & Unrod, 2000). (See Appendices G and H). Barratt Impulsiveness Scale (BIS-11; Patton et al., 1995). The BIS-11 is a 30 item self-report measure of impulsivity. It c onsists of three subscales representing three factors: attentional impulsiv eness (difficulty staying on task, racing thoughts), motor impulsiveness (acting without forethought), a nd non-planning impulsiveness (failure to plan and think carefully). E ach item is answered on a 4-point scale from rarely/never to almost always/always, with some items reverse-coded. Higher scores represent greater impulsiveness. Reported alphas for various populations (e.g., undergraduates, substance-abuse patients) are acceptable and have ranged from .79 to .83 (Patton et al. 1995). Smokers have been shown to score higher on this measure than non-smokers (Mitchell, 1999) and this measure has been commonly used in a variety of research related to impulsivity. (See Appendix I). BIS/BAS scales (Carver & White, 1994). The BIS/BAS scales are self-report measures that correspond to anxiety and impul sivity, the two major dimensions of Grays theory of personality (Gray, 1970) Anxiety is associated wi th the behavioral inhibition system (BIS) and impulsivity with the beha vioral activation system (BAS). The BIS scale contains 7 items (e.g., I worry about making mistakes), with a reported alpha of .76 in a large community sample (Jorm et al ., 1999a). The BAS scale (reported alpha of .83, Jorm et al., 1999a) has 3 subscales: Reward Responsiveness (e.g., When I get something I want, I feel excited and energized. ), Drive (e.g., I go out of my way to get things I want.), and Fun Seeking (e.g., I of ten act on the spur of the moment) (Carver & White, 1994). Although its validity as a meas ure of impulsivity remains debatable
23 (Carver & White, 1994), this measure is in cluded in the present study because two previous studies have shown that BAS scores correlate with reactiv ity to alcohol cues (Franken, 2002; Kambouropoulos & St aiger, 2001). (See Appendix J). Delay Discounting Task (DDT; Kirby et al., 1999). In this delay discounting task, participants were given a list of 27 questi ons, each requiring a choice between a smaller, hypothetical monetary reward av ailable immediately, and a larg er reward available after a delay. Immediate amounts ranged from $11 to $80, while delayed amounts ranged from $25 to $85 and were available at delays of 7 to 186 days. Discounting rate ( k ) estimates are derived by fitting an individuals indiffe rence points (point at which an immediate and delayed reward are equally preferre d) into a hyperbolic equation, V=A/1 + k D. V refers to the current value of delayed reward A, and D is the number of days the reward is delayed. More choices for immedi ate rewards results in a higher k value and indicates greater impulsivity. This measure covers eight ranges of discounting rates and two endpoint values for small, medium, and large rewards. Within each reward category, individuals are assigned a value of k corresponding to the geomet ric midpoint of one of the ranges or an endpoint value that is most consistent with their choices. If an individuals choices are equally consis tent with two different values of k the geometric mean of these values is assigned. A persons overall k value is the geometric mean of their assigned k values for the small, medium, and large reward categories. This measure was chosen because it can be completed in a short amount of tim e (approx. 5 minutes) using paper and pencil, and has been shown to correlate highly with other more timeconsuming, computerized discounting tasks in smoking populations (Epste in et al., 2003).
24 To ensure that participants chose the amounts they actually pr eferred, they were given a 1 in 50 chance to win one of the rewards they chose. Participants were given the following instructions for the de lay discounting task: Please answer the following 27 questions in the order they appear Circle the choice you prefer. Please take the choices seriously; they may be for REAL MONEY. At the end of the study, you will choose a marble from a bag that contains 1 green marble and 49 clear marbles. If you choose the green marble, you will win one of your 27 choices. To determine how much money you will win, you will choose another marble from a bag that contains 27 marbles labeled with th e numbers 1 through 27, corresponding to the 27 questions listed below. For example, if you choose the 4 from the bag, you will win whatever you chose on question 4. If you circ led the immediate money on that question ($31 today), you will receive the money today when you leave. If you circled the delayed money on that question ($85 in 7 days), you w ill receive $85 in 7 days. You or another person you designate may return to our facil ity to pick up the money, or you may have the money mailed to you. To make sure th at you get a reward you prefer, you should answer every question as though it were the one you will win. (See Appendix K). Smoking Topography Smoking topography refers to variables that describe an individuals smoking behavior It has been repeated ly shown that laboratory manipulations, such as negative mood i nduction and cue exposure, can produce group differences on various smoki ng topography variables (e.g., Conklin & Perkins, 2005; Payne et al., 1991). After completing the m ood and cue manipulations, each participant was given an opportunity to smoke one of th eir own cigarettes. An unobtrusive video camera recorded participants smoking behavior. Two raters coded each participants
25 tape using a computer program that instructed them to press a key when participants lit their cigarette, began and ended each puff, a nd extinguished their cigarette. The time elapsed between key presses was averaged for the two raters and used to compute latency to begin smoking, mean puff duration, mean in terpuff interval duration, total number of puffs, total time spent puffing, and total time spent smoking. The primary measure of smoking topography was latency, because this variable has been most consistently affected by laboratory manipulations in prev ious research (e.g., Conklin & Perkins, 2005). Cigarette Rating Form (CRF). This form contains 3 items that assess participants opinions about the taste, smell, and enjoyablenes s of their cigarette. Each item is rated from ) not at all to 4) very much. The CRF was administered after participants smoked their ciga rette to mask the true purpose of the smoking topography assessment (see Appendix L). Procedure Recruitment Participants were recruited from the Tampa area via newspaper advertisements and flyers for a study about personality and mood in smokers. They were briefly screened over the phone to make sure they met the requirements previously described (see Appendix M). Those who qua lified and agree to participate were scheduled for an individual appoi ntment expected to last about 1 to 1.5 hours. They were asked to bring a pack of their own cigare ttes to their appointment and were given directions to the Tobacco Res earch and Intervention Program (TRIP) facility. To prevent withdrawal effects and induce a state of mild depriv ation during the stud y, they were told
26 to smoke a cigarette 30 minutes before their appointment (and not smoke for the 30 minutes prior to th eir appointment). Consent Upon arrival at TRIP, a research a ssistant greeted the participants and escorted them to an experimental room. They were given a brief description of the purpose of the study. Next, they were asked to sign an informed consent form that explained the study procedures and their rights as resear ch participants and HIPAA policy. The experimenter then collected thei r pack of cigarettes, which was returned later. Part I: Baseline measures After they signed the c onsent and HIPAA forms and their cigarettes were collecte d, participants exha led CO level was measured to verify their smoking status (must have been 8ppm or greater), and their self-report of the time that they last smoked was recorded on a Us age form (see Appendix N). If they smoked less than 30 minutes before their appointment, they waited until 30 minutes had passed before beginning the study. If they sm oked more than 60 minutes before their appointment, they were asked to go outside, smoke a cigarette and wait 30 minutes before beginning the study, or reschedule for another day. If thei r CO level was below 8ppm, it was explained to them that they did not qua lify for the study and they were paid $5. After their smoking status was verified, partic ipants completed the baseline measures in the following order: demographic questi onnaire, DDT, SSQ, SC Q-A, BIS-11, BIS/BAS scales, Mood Form (trait), STAI-T, QSU-brie f, Mood Form (state), STAI-S. This order was chosen to minimize the salience of th e impulsivity questionnaires and reduce the chance that participants choi ces on the DDT would be influenced by their responses to the other questionnaires.
27 Randomization. After completing the baseline ques tionnaires, participants were randomly assigned to one of the four conditions: 1) negative mood induction + smoking cue, 2) negative mood induction + neutral cue, 3) neutral mood induction + smoking cue, 4) neutral mood induction + neutral cue. Randomization was stratified by gender and conditions were chosen using a co mputerized random number program. Part II: Mood manipulation The negative and neutral mood conditions were matched on time duration. In the negative mood condition (speech condition), the experimenter brought a video camera into th e room and positioned it in front of the participant. Participants were then told th at we wanted to assess their personality in a more open-ended way than was possible with written surveys. They were told that they should imagine they are on a job interview. They were given 3 minutes to prepare a 3-minute speech to answer the question wha t are your greatest personal strengths and weaknesses? (adapted from van Eck, Ni colson, Berkhof, & Sulon, 1996). Participants were also given the following additional instructions: Your speech will be videotaped and evaluated by two other experimenters for various psychological and personality factors. One experimenter is going to rate what you say, while the other is going to rate how you say it, including your body language, to ne of voice, and speaking style. At this point, the experimenter left th e participant alone fo r 3 minutes to think about the speech. Participants were not given any writing utensils or paper during the speech preparation period. After the 3-minut e preparation period, the experimenter reentered the room and explained that a cord needed for the camera was being used in another study and would be available soon. Part icipants were told that in the meantime, they would skip to the next part of the st udy and that they would complete the speech
28 later. They were then given the QSU-brief, Mood Form (state), and STAI-S to complete. In reality, participants in the negative mood condition never gave the speech and were debriefed at the end of the study. However, to sustain their anxiety about the speech throughout the rest of the study, the experimenter repeatedly reminded them that their speech would be taped at some later point. Similar speech tasks are commonly used in psychological research and reliably induce anxiety and related negative emotions (Feldman et al., 1999). Studies have used numerous different topics for the speech task (e.g., what participan ts dislike about their body, presenting a defense for speeding or shop lifting, discussing a controversial political issue). The strengths and w eaknesses topic was chosen for the current study because it fit well with the studys general them e (personality in smokers). This topic also has been shown to increase self-reported negative affect in male adults (van Eck et al., 1996), and therefore we believed it was likely to induce anxiety in the adult community sample we recruited. In contrast, other topics used in past research seem more relevant for the specific populations included in those studies such as women or university students (e.g., body topic, controversial politic al issues). Additionally, some variations of the speech task actually make participants deliver the speech. We chose not to have participants give the speech because we wanted to sustain their negative mood throughout the rest of the study. If they actually gave their sp eech, their mood might become more positive afterward because of feeling relief that the speech is over. Moreover, a recent study employing the speech task demonstrated that anticipation alone increased ratings of negative emotion and induced a cardiovascular (CV) res ponse, and that actually
29 delivering the speech did not further augmen t CV response (Feldman, Cohen, Hamrick, & Lepore, 2004). For the neutral mood condition (art condition), we used a paradigm adapted from Nesic and Duka (2006). Participants in the neutral mood condition were given 3 pictures of paintings with neutral themes (e.g., lands capes). They were told that we were interested in their opinions of the paintings. They rated the paintings using an Art Rating Form (see Appendix O). They were also told that the experimenter needed a few minutes to complete the set-up for the next part of th e study. If they finish ed rating the paintings before the experimenter returned, they just sat quietly in the room After 3 minutes, the experimenter returned and gave participan ts the QSU-brief, Mood Form (state), and STAI-S to complete for the second time. Part III: Cue expos ure manipulation The cue exposure manipulation began immediately after participants completed the second set of ur ge and mood measures. We used an in-vivo cue exposure paradigm ad apted from Sayette, Loewenstein, Kirchner, and Travis (2005) that has successfully produced group differences in several other studies (Sayette & Hufford, 1994; Sayette, Martin, Hull, Wertz, & Perrott, 2003; Sayette, Martin, Wertz, Shiffman, & Perrott, 2001; Wa ters et al., 2004). The experimenter entered the room and placed a covered tray a nd a packet of questi onnaires (face-down) on the table in front of the participants. The e xperimenter told particip ants that they would receive additional instructions via intercom a nd that they should not touch the tray or packet until they were told to do so. The experimenter then left the room to complete the intercom instructions. Participants in the smoking cue condition were instructed via intercom to remove the cover, which revealed a pack of their own cigarettes, a lighter,
30 and an ashtray. They were asked to remove a cigarette from the pack and light it without raising it to their mouth. They were then asked to hold the lit cigarette and look at it for 30 seconds. After 30 seconds, they were asked to rate verbally their urge for a cigarette on a scale from 1-100. Immediately thereaft er, they were asked to extinguish the cigarette in the ashtray and then complete th e QSU-brief, Mood Form (state), and STAI-S for the third time. Participants in the neut ral cue condition received the same instructions to remove the trays cover, but the tray instead revealed a stapler and a roll of tape. They were asked to pick up the tape and then the stapler with their domi nant hand and look at these items for 30 seconds. After 30 seconds, th ey were asked to rate verbally their urge for a cigarette. They then placed the stap ler back on the tray and completed the QSUbrief, Mood Form (state), and STAI-S for the third time. Part IV: Smoking topography assessment. Immediately following the completion of the third set of urge and mood measures, participants we re given an opportunity to smoke one of their own cigarettes. In the smoking cue condition, the experimenter returned to the room carrying an empty bowl. First, the experimenter asked participants to place their extinguished ci garette (from the smoking cue ma nipulation) in the bowl and told them that they would get this cigarette back at the end of the study. They were then told that for the next task, we were interested in their opinions about their cigarettes. They were asked to remove a new cigarette from their pack and place it in the ashtray. In the neutral cue condition, th e experimenter returned to the room carrying a second covered tray that contained participants pack of cigarettes, an asht ray, and a lighter. The experimenter removed the tray with the staple r and tape from view and placed the second tray on the table. Participants were then told that for the next task, we were interested in
31 their opinions about their cigare ttes. The experimenter then removed the tray cover to reveal their cigarettes, ashtray, and lighter. Participants were asked to remove a cigarette from the pack and place it in the ashtray. At this point, all participan ts (regardless of condition) were told that they would now have an opportunity to smoke as much of the cigarette in the ashtray as they wanted, but that they had to take at least one puff. To ensure that participants would not rush through smoking their cigarette because they believed doing so would allow them to complete the study faster, they were also told that because of the way the indoor ventilation system worked, they would need to remain in the room for about 10 minutes and therefore could take their time smoking. Th ey could pick up their cigarette and begin smoking anytime after the experimenter shut the door. While they were smoking, the experimenter left the room and an unobtrusive video camera recorded their smoking behavior. After 10 minutes (or about 30 sec onds after participants extinguished their cigarette, whichever came firs t), the experimenter returned to the room and instructed participants to complete a final set of form s, including the Mood Form (state), STAI-S and the Cigarette Rating Form. After particip ants completed these forms, their exhaled CO level was measured a second time and recorded (see Appendix P). Debriefing After they completed the second CO measurement, participants were debriefed and paid. During debriefing, particip ants were first asked a series of questions to assess their level of insight into the studys purpose (s ee Appendix Q). The experimenter then informed them that the purpose of the study was to evaluate how different moods and personality might affect their responses to the various questionnaires and tasks. Participants in the speech c ondition were told that the speech task was
32 intended to increase feelings of mild stress. Additionally, we told them that smokers often report that smoking helps them deal with stre ss, and we wanted to see how mild stress would affect their responses in this study. Although several participants expressed relief at not having to complete the speech, none became noticeably upset and none continued to display signs of anxiety. Payment. As described earlier, participants th en chose a marble from a bag to determine if they won any additional money. Th e results of this lottery were recorded for each participant (see Appendix R). Six par ticipants won the lotte ry. Five received additional money immediately and one received money after a 30-day delay. Finally, all participants were paid $20 (plus any additional money won in the lottery) for participation.
33 Table 1. Outline of the Procedure 1. Recruitment Individuals screened via phone and scheduled for an individual appointment 2. Consent Informed about the purpose of the study Signed informed consent/HIPAA form Cigarettes collected 3. Part I: Completion of baseline questionnaires in the following order 1. Exhaled CO level measured (must have been above 8 ppm) 2. Demographic questionnaire 3. Delay Discounting Task (DDT) 4. Smoking Status Questionnaire (SSQ) 5. Smoking Consequences Questionnaire-Adult (SCQ-A) 6. Barratt Impulsiveness Scale (BIS-11) 7. BIS/BAS scales 8. Mood Form (trait) 9. State-Trait Anxiety Inventory (Trait version, STAI-T) 10. Questionnaire of Smoking Urges-Brief (QSU-brief) 11. Mood Form (state) 12. State-Trait Anxiety Inventory (State version, STAI-S) 4. Randomization: Participants were randomly assigned to one of four conditions, stratified by gender: Negative mood induction (speech task) + Smoking Cue (cigarettes/lighter) Negative mood induction (speech task) + Neutral Cue (tape/stapler) Neutral mood induction (art rating ta sk) + Smoking Cue (cigarettes/lighter) Neutral mood induction (art rating task) + Neutral Cue (tape/stapler) 5. Part II: Mood manipulation followed by 2 nd QSU-brief, Mood Form (state), and STAI-S 6. Part III: Cue exposure manipulation followed by 3 rd QSU-brief, Mood Form (state), and STAIS 7. Part IV: Smoking topography assessment Told they could smoke as much of one cigarette as they want Told that experimenter would return in about 10 minutes Smoking behavior was recorded by unobtrusive video camera Completion of 4th Mood Form (state) and STAI-S, and Cigarette Rating Form (CRF) When experimenter returned, second breath CO measure was taken 8. Debriefing All participants were informed that the true purpose of the study was to evaluate the effect of mood and personality on smoking behavior Participants in speech condition were told that they would not actually have to give the speech Participants in th e speech condition were assesse d for continuing anxiety Chose marble(s) to determine additional compensation from DDT Paid $20 for participation
34 Results Data screening Self-report questionnaire data. All questionnaire data was checked for completeness during the study a nd participants were prompted to answer any missing items immediately. Any remaining missing items on the QSU-brief, BIS-11, and STAI were imputed using the mean value of the pa rticipants responses to the other items on that questionnaire, provided th at the participant completed at least 90 percent of the items. If a participant answered less than 90 percent of the items, that participant was not included in the analyses involving that que stionnaire. Because the Mood Form and BIS/BAS scales contained less than 10 ite ms each, no missing items were imputed on these measures and participants who did not answer every item were excluded from analyses that involved these measures. In general, the amount of missing questionnaire data was very small and fewer than 5 individuals were not include d in any particular analysis. Behavioral (topography) data. Due to technical problems that prevented coding of the data (e.g., recording started after participant began smoking), 12 participants were missing all topography data. For an additiona l 5 participants, some topography data was dropped or missing due to technical problems or participant idiosyncrasies (e.g., one individual kept the cigarette in his mouth for long periods of time and it was impossible
35 to determine when he was puffing). For 30 par ticipants, the two raters initially disagreed about the number of puffs taken. These tape s were recoded until agreement was reached. Participant Characteristics The final sample included 175 participan ts (91 males, 84 females) who met all inclusion criteria. Demographic characteristic s are presented in Table 2 and mean scores on baseline measures are presented in Tabl e 3. There were no si gnificant differences among the four study conditions (all ps > .05) on any of the demographic variables. There were also no significant differences in other baseline measures (e.g., affect, impulsivity), except that number of cigarett es smoked per day was significantly lower in the neutral cue condition than in the smoking cue condition ( p < .001). Because number of cigarettes per day was significantly corre lated with baseline QSU-brief, BIS-11, and STAI-S scores, this variable was incl uded as a covariate in all analyses. 1 Also, there was a trend toward a difference in baseline QSU-brief scores ( p=.07) such that speech group was somewhat lower than the art group. Because the QSU-brief was the primary dependent measure in this study, baseline QSU-br ief scores were included as a covariate in all analyses involving post-manipulation QSU-brief scores. 1 All analyses were also run without number of cigarettes smoked per day as a covariate. Results that differed depending on the inclusion of this covariate are noted in footnotes.
Table 2. Participant Demographic Characteristics (Percentages) Variable Speech/ Smoking Cue Speech/ Neutral Cue Art/ Smoking Cue Art/ Neutral Cue Overall p (Speech vs. Art; Smoking Cue vs.Neutral Cue) N 45 44 43 43 175 Age (mean) 38.91 (12.46) 40.02 (11.58) 39.33 (11.91) 38.79 (11.47) 39.26 (11.77) ns; ns Race Caucasian Black 72.7 22.7 71.4 23.8 71.4 28.6 69.8 20.9 71.3 24.0 ns; ns Ethnicity Hispanic 15.6 11.4 9.3 16.3 13.1 ns; ns Marital status Single Married Separated Divorced Widowed 68.9 15.6 2.2 11.1 2.2 43.2 18.2 9.1 25.0 4.5 48.8 7.0 16.3 25.6 2.3 53.5 14.0 11.6 18.6 2.3 53.7 13.7 9.7 20.0 2.9 ns; ns Education < HS HS grad Some college 4-yr degree 26.7 24.4 40.0 8.9 25.0 27.3 43.2 4.5 27.9 18.6 51.2 2.3 25.6 16.3 48.8 9.3 26.3 21.7 45.7 6.3 ns; ns Income Under $10,000 45.5 36.4 32.6 39.5 38.5 ns; ns 36
37 Variable Speech/ Smoking Cue Speech/ Neutral Cue Art/ Smoking Cue Art/ Neutral Cue Overall p (Speech vs. Art; Smoking Cue vs.Neutral Cue) N 45 44 43 42 175 Years Smoked 21.33 (12.48) 21.15 (12.44) 22.15 (11.46) 20.38 (10.80) 21.25 (11.74) ns; ns Cigarettes per day 25.53 (10.92) 19.57 (8.68) 24.40 (10.12) 19.74 (7.91) 22.33 (9.79) ns; <.001 FTND score 5.96 (2.54) 5.16 (2.39) 5.84 (2.10) 5.53 (1.94) 5.62 (2.26) ns; ns CO (ppm) 26.72 (18.33) 25.39 (14.37) 23.95 (12.43) 20.33 (8.80) 24.12 (14.03) .07; ns QSU-brief 27.59 (12.13) 24.36 (10.06) 28.71 (11.15) 29.56 (11.62) 27.54 (11.35) .07; ns STAI-Trait 68.96 (27.52) 65.93 (23.75) 73.98 (20.23) 71.67 (23.23) 70.11 (23.86) ns; ns STAI-state 60.12 (32.91) 50.78 (19.37) 59.09 (23.22) 57.65 (27.09) 56.91 (26.22) ns; ns Trait Positive Affect 16.80 (5.44) 17.93 (5.62) 17.12 (5.49) 15.81 (5.05) 16.91 (5.41) ns; ns Trait Negative Affect 18.48 (7.20) 16.44 (6.66) 20.09 (7.19) 18.59 (7.18) 18.40 (7.12) .08; ns State Positive Affect 14.11 (6.73) 16.05 (5.49) 15.14 (6.22) 15.14 (6.28) 15.10 (6.18) ns; ns State Negative Affect 12.04 (7.61) 9.30 (4.73) 10.95 (6.97) 10.93 (7.00) 10.81 (6.69) ns; ns BIS-11 67.62 (15.48) 64.68 (11.03) 70.21 (9.66) 67.67 (11.43) 67.53 (12.19) ns; ns BAS drive 11.53 (2.73) 11.66 (2.47) 11.70 (2.95) 11.33 (2.64) 11.55 (2.68) ns; ns BAS fun-seeking 12.24 (2.81) 12.00 (2.44) 12.70 (2.09) 12.40 (2.63) 12.33 (2.50) ns; ns BAS reward-seeking 17.47 (2.29) 17.77 (2.06) 17.49 (2.28) 18.07 (2.19) 17.70 (2.20) ns; ns BIS total 20.69 (3.79) 19.95 (4.05) 20.58 (4.07) 21.05 (4.21) 20.57 (4.02) ns; ns Table 3. Participant Baseline Characteristics (Means and Standard Deviations)
38 Mood Manipulation Check One of our primary goals in this st udy was to examine changes in smoking motivation following the induction of negative affect. As a manipulation check for the mood induction, we conducted three ANCOVAs using post-mood manipulation STAI-S and Mood Form (state) scores as the dependent variables, condition (speech vs. art) as the independent variable, and cigare ttes per day and baseline ST AI and Mood Form scores as the covariates. For the STAI-S, the mean post-mood manipulation sc ore in the speech condition ( M = 61.34) did not differ from the mean post-mood manipulation score in the art condition ( M = 61.54), F (1, 171) = 1.28, p=.26. Similarly, for the Positive Affect subscale of the Mood Form (state), post-mood manipulation scores did not differ for the two conditions (speech M =14.17, art M =13.87), F (1, 171) = .621, p=.43. Again, the two conditions did not differ on post-mood mani pulation Negative Affect scores, (speech M =11.23, art M =11.28), F (1, 169) = .402, p=.53. We also compared the mean change in STAI-S and Mood Form (state) scores from baseline to post-mood manipulation for the two conditions. STAI-S scores increa sed a mean of 5.84 points in the speech condition and a mean of 3.17 points in the art condition. Although both of these change scores were significantly different from zero, indicating that anxiety increased in both groups, the difference in change scores be tween the two groups was not significant, F (1, 172)=1.469, p = .23. For the Mood Form (state), scores for both groups changed less than one point from baseline to post-mood mani pulation. We also classified participants according to whether their STAI-S scores in creased, decreased, or stayed exactly the same from baseline to post-mood manipulati on. In the speech condition, STAI-S scores decreased in 30.3% of particip ants, stayed the same in 7.9%, and increased in 51.9%. In
39 the art condition, STAI-S scores decreased 31.4% of participants, stayed the same in 9.3%, and increased in 49.1%. Again, these di fferences between the two conditions were not significant. These results seem to indicate that the speech preparation task was not successful at increasing negative affect relative to the ar t rating task. These fi ndings are surprising because the speech task has been used in dozens of previous studies to induce selfreported negative affect reliably. Although both the speech and art tasks significantly increased STAI-S scores, the change scores were modest and well below previous studies using the speech task with smokers, which have reported mean increases in STAI-S scores from 10 to 20 points (Kassel & Un rod, 2000; Juliano & Brandon, 2002). Despite the apparent failure of the speech task to increase self -reported negative affect, we proceeded as planned with the analyses, b ecause we had reason to believe that many participants did in fact beco me more anxious during the speech preparation task. For example, when they were told at the end of the study that their sp eech would not be taped after all, many participants displayed visible signs of relief and also correctly identified that the speech preparation tasks true purpose was to increase their anxiety. Manipulation Effects on Urge and Topography Smoking urge after the mood manipulation. To test for an independent effect of the speech task on self-reported urge, we conducted a single factor ANCOVA, using post-mood manipulation QSU-brief total scor es as the dependent variable, condition (speech vs. art) as the independent variab le, and cigarettes per day and baseline QSUbrief scores as covariates. Results in dicated a significant effect for condition, F (1, 171) = 5.859, p = .02. Examination of the change scores revealed that from baseline to post-
40 mood manipulation, QSU-brief scores increased 1.44 points in the art condition and 3.62 points in the speech condition, indicating that participants in the speech condition experienced a greater increas e in urge (see Table 4). We also conducted similar analyses usi ng the two individual factors of the QSUbrief (anticipation of pleasure anticipation of nega tive affect relief). These analyses revealed that the speech task had a significan t effect on anticipati on of negative affect relief, F (1, 171) = 5.692, p = .02, but there was only a trend for an effect on anticipation of pleasure, F (1, 171) = 2.819, p = .095. Table 4. Main Effect of the Mood Manipul ation on QSU-brief Total Scores Mood Manipulation Baseline QSU Post-mood QSU Difference Speech 25.99 29.61 3.62 Art 29.13 30.57 1.44 Smoking urge during the cue manipulation. While participants held their lit cigarette or the stapler, we asked them to rate verbally their urge to smoke from 1 to 100. To test for main effects and interaction eff ects of the mood and cue manipulations on this verbal urge measure, we conducted a 2 x 2 ANCOVA using verbal urge as the dependent variable, the two manipulations as the factors, and cigarettes pe r day as a covariate. This analysis revealed that the mean urge rating in the sm oking cue condition (M=68.63) was significantly higher than in the neutral cue condition (M=51.58), F (1, 168) = 6.319, p = .01. There was no significant effect of the m ood manipulation on this verbal urge rating, nor was there any significant inter action between the two manipulations.
41 Smoking urge after the cue manipulation To test for main effects and interaction effects of the mood and cue manipulations on self-reported urge immediately following the cue manipulation, we conducted a 2 x 2 ANCOVA, using post-cue manipulation QSU-brief total scores as the dependent vari able, the two manipulations as the factors, and cigarettes per day and base line QSU-brief scores as co variates. This analysis revealed a trend toward the smoking cue result ing in greater urge th an the neutral cue, F (1, 169) = 3.407, p = .07 2 There was no significant main effect for the mood manipulation, nor was there any significant interaction between th e two manipulations (see Table 5). Again, we also conducted similar analyses using the two individual factors of the QSU-brief (anticipation of pl easure, anticipation of negativ e affect relief). These analyses revealed that smoking cue did not significantly increase ur ge relative to the neutral cue on the anticipation of pleasure factor, F (1, 170) = 5.86, p =.12 3 or the anticipation of negative affect relief factor, F (1, 170) = 3.32, p = .15 4 There was no significant effect of the m ood manipulation on the anticipa tion of pleasure factor, but there was a trend toward increased urge in the speech condition for the anticipation of negative affect relief factor, F (1, 170) = 3.51, p = .07. There were no significant interaction effects of the two manipulations on either factor of the QSU-brief. 2 When cigarettes per day was not included as a covariate, this result was significant, p = .02. 3 When cigarettes per day was not included as a covariate, this result was significant, p = .02. 4 When cigarettes per day was not included as a co variate, there was a tre nd toward significance, p= .07.
42 Table 5. Main Effects of the Manipulations on Post-Cue Manipulat ion QSU-Brief Total Scores Cue Manipulation Lit Cigarette Roll of Tape/Stapler Mood Manipulation Baseline QSU Post-cue QSU Difference Baseline QSU Post-cue QSU Difference Speech 27.59 34.41 6.82 24.36 29.23 4.87 Art 28.71 33.91 5.20 29.56 32.49 2.93 Smoking topography. To test for main effects and interaction effects of the mood and cue manipulations on smoking topography va riables, we conducted a series of 2 x 2 ANCOVAs, using latency to begin smoking, mean puff duration, mean interpuff interval duration, total number of puffs, total time spent puffing, and total time spent smoking as the dependent variables, the two manipulations as the factors, and cigarettes per day as a covariate. Results indicated that there were no significant main effect s or interactions of the two manipulations on any of the smoking topography variables (all ps > .05). Moderation Analyses To test whether impulsivity moderated the effects of the manipulations on urge, a series of multiple regression analyses we re conducted (Baron & Kenny, 1986). The two manipulations (mood and cue) were dummy coded, and se parate regressions were performed for each impulsivity meas ure (BIS-11, BIS/BAS scales, and k values from the delay discounting task), using the QSU-brief and the verbal urge measure as dependent measures as appropriate (i.e., where main effects were found, moderation analyses were performed). In each regression, manipulation was entered first, followed by cigarettes per day, an impulsivity measure, and an intera ction term (manipulation x impulsivity). If the QSU-brief was used as the dependent variable, baseline QSU-brief scores were also
43 entered as a predictor. A significant change in R 2 for the interaction term would indicate a moderating effect for impulsivity. Results indicated that none of the impulsivity measures significantly moderated the effects of the mood and cue manipulations on urge (all ps > .05). Additional Analyses We conducted additional analyses to dete rmine whether the impulsivity measures were correlated with each other, and wh ether impulsivity was correlated with other measured variables, such as demographics, smoking history, nicotine dependence, urge, expectancies, and affect. Correlations among the impulsivity measures were weak or absent and are shown in Table 6. The BIS-11, DDT k values, and the BAS fun-seeking scale were significantly correlated with baseli ne urge, as measured by the QSU-brief at baseline. Additionally, at least one impulsiv ity scale was significantly correlated with education, income, cigarettes smoked per da y, urge, affect, and expectancies. These correlations are shown in Tables 7, 8, and 9.
44 Table 6. Intercorrelations Among Impulsivity Scales Scale 1 2 3 4 5 6 7 8 1. Barrett Impulsiveness Scale (BIS-11) -.80** .82** .83** .11 -.05 .36** .08 2. BIS-11 Attentional Impulsiveness -.49** .53** .12 -.02 .28** .04 3. BIS-11 Motor Impulsiveness -.47** .06 .15* .43** .16* 4. BIS-11 Nonplanning Impulsiveness -.10 -.27** .15* -.01 5 k --.004 .09 -.07 6. BAS drive -.34** .37** 7. BAS fun seeking -.35** 8. BAS reward-seeking -* p < .05, **p < .01 Table 7. Intercorrelations Among Im pulsivity Scales, Demographics, and Tobacco Use Scale Education Income Years Smoked Daily Cigarettes Smoked per Day Barrett Impulsiveness Scale (BIS-11) -.21** -.15* -.11 .26** k -.13 -.19* -.003 .13 BAS drive .20** -.03 -.14 -.05 BAS fun seeking -.14 -.08 -.13 .03 BAS reward-seeking .06 -.11 -.03 -.23** p < .05, **p < .01 Table 8. Intercorrelations Among Impul sivity Scales, Baseline Urge, and Trait Affect Scale QSU-brief STAI Positive Affect Negative Affect Barrett Impulsiveness Scale (BIS-11) .36** .59** -.23** .41** k .23** .22** -.14 .09 BAS drive .01 -.08 .24** .02 BAS fun seeking .29** .10 .21** .15* BAS reward-seeking .06 -.04 .18* .06 p < .05, **p < .01
45 Table 9. Intercorrelations Among Impulsivity Scales and Smoking Expectancies Scale SCQ-A Negative Reinforcement SCQ-A Positive Reinforcement SCQ-A Addiction Barrett Impulsiveness Scale (BIS-11) .22** .06 .10 k -.02 .05 -.03 BAS drive .10 .14 -.04 BAS fun seeking .26** .22** .06 BAS reward-seeking .36** .10 .21** p < .05, **p < .01
46 Discussion Previous research has demonstrated that smokers respond to both negative affect and smoking cues with increased self-re ported urge and other physiological and behavioral changes. One primary aim of th is study was to determine whether a negative mood induction would augment urge and behavior al reactivity to subsequently presented smoking cues (i.e. whether there is an interaction effect between these two cue types). For the mood manipulation, participants engage d in either a task that was intended to make them feel anxious (preparing a speech that they believed would be videotaped later) or a neutral task (viewing and rating pict ures of landscape pain tings). For the cue manipulation, which immediately followed th e mood manipulation, participants were exposed to either a lit cigarette or neutral objects (stapler and ro ll of tape). Results indicated a main effect of the mood mani pulation on post-mood manipulation urge, and a main effect of the cue manipulation on verb al urge during the cue manipulation. There were no main effects of the mood or cue ma nipulations on post-cue manipulation urge, nor were there any significan t interactions between the tw o manipulations. There were also no main or interactive effects of the two manipulations on smoking topography. Only limited evidence suggests that cue reactivity predicts actual drug use behavior (Payne et al., 1991) and relapse following a quit attempt (Niaura et al., 1989; Payne et al., 2006), perhaps because individu als vary in both response magnitude and whether they act on cue-elicited urges. However, few studies have systematically
47 examined individual differences in urge and be havioral reactivity. Therefore, the second purpose of this study was to test whether impul sivity, a personality tr ait associated with initiation and maintenance of tobacco use, would mode rate the effects of the manipulations on reactivity. Resu lts indicated that impulsivity was moderately correlated with self-reported urge, but did not moderate the effects of the manipulations on urge reactivity. Mood Manipulation Mani pulation Check Results We chose a speech preparation task for our negative mood induction because similar tasks have reliably increased self-repo rted anxiety and genera l negative affect in many previous studies (Feldman et al., 1999) including studies with smokers (Juliano & Brandon, 2002; Kassel & Unrod, 2000). Howeve r, our manipulation check analyses indicated that the speech task did not signifi cantly increase self-reported anxiety relative to the art task; rather, both tasks increased anxiety by a very small amount. These results are puzzling, and prevent us from confidently concluding that reactiv ity associated with the speech task was a consequence of hei ghtened anxiety or that negative mood and smoking cues do not have interactive effects. After carefully considering the speech task procedure, we have speculat ed on numerous possible explan ations for the manipulation check results, including characte ristics of the sample and featur es of the task itself. Each may account for some portion of our failu re to induce self-reported anxiety. We first considered that our participants did experience an increase in anxiety that was not reflected in their STAI and Mood Fo rm scores, perhaps because they were not accustomed to evaluating themselves in this manner. Several participants commented on the psychological nature of the questionnaires and the difficulty they had in choosing
48 answers. One participant in particular was clearly anxious about the speech and expressed great relief during the debriefing. However, when her STAI scores were later checked, she actually rated herself as less anxious after the speech preparation period than at baseline. Because of this case and other anecdotal evidence that at least some participants did experience a significant incr ease in anxiety following the speech task, we decided to proceed with our planned analyses. The participants in the current study were recruited directly from the community via flyers in shopping centers, bus stops, etc. They were ethnically diverse, and in general middle-aged, unmarried, and very lo w in socioeconomic status (SES). In contrast, most studies that have used speech preparation tasks have included primarily university students or young adu lts recruited from universit y campuses (Feldman et al., 1999). Perhaps some did not experience the spe ech preparation task as aversive because they had not received much exposure to academic and employment environments where speech anxiety typically develops or were unf amiliar with the social norm that giving a speech and being videotaped should provoke anxiety. Additionally, it appears as though our part icipants were al ready experiencing relatively high levels of NA at baseline. Their baseline STAI scores (M=56) were approximately 10 points higher than two pr evious studies with smokers (Kassel & Shiffman, 1997; Kassel & Unrod, 2000). Furthe rmore, some partic ipants specifically mentioned that the study advertisement had caught their attention because they desperately needed $20 (e.g., to eat, to pay overdue bills), and others openly discussed various life stressors they we re experiencing. Perhaps in the context of their already difficult lives, they viewed the speech task as insignificant. Indee d, results of previous
49 studies with smokers suggest that lower anxiet y at baseline is associated with greater anxiety increases following speech preparation tasks. For example, Kassel and Shiffman (1997) and Kassel and Unrod (2000) reporte d STAI increases of 15-20 points from ratings taken just prior to pa rticipants receiving the speech preparation instructions, while Juliano and Brandon (2002), whose pa rticipants baseline STAI scores ( M = 54) were similar to ours (M = 56) reported an average prepreparation to post-preparation task increase of only about 10 points. It is also interesting to note that the mean postspeech task STAI score from Kassel and Unrods study ( M = 57) was nearly identical to our baseline mean ( M = 56). Other features of the speech task may also have influenced our results. We told our participants to imagine they were on a job interview and to discuss their personal strengths and weaknesses because this topi c fit the general theme of the study and a previous study (van Eck et al., 1996) demonstr ated that this topic increased anxiety in adult male employees (as opposed to college stud ents). However, given the low levels of education and income in our sample, many participants may have lacked experience with job interviews and therefore may not have in terpreted this particul ar topic as anxietyprovoking. Indeed, a few participants menti oned during the debrie fing that they had never been on a real job interview before and thus did not know what type of answer was expected. Although this confusion could have increased anxiety as we desired, it could also have attenuated anxiety if it led pa rticipants to just gi ve up on answering the question seriously. There was also anecdotal evidence that a few participants viewed the task as a positive experience. These particip ants told the experimenter that they were
50 looking forward to the opportunity to talk a bout their personality on camera and actually expressed disappointment during debriefing. Another issue relates to our intention to sustain participants anxiety for several minutes in order to determine whether negative mood would a ugment reactivity to subsequently presented smoking cues. Initially, participants were led to believe that their speech would be videotaped immediately follow ing the preparation period. In reality, when the preparation period ended, they were told that another experimenter was using a needed piece of camera equipment and that their speech would be taped later. Immediately after they were told that thei r speech would be delayed, they completed the mood measures, and we continued to remind them about the upcoming speech throughout the rest of the study. It was presumed that participants would continue to experience anxiety until they were told that their speech would not be taped after all. However, perhaps once they were told that the speech would be delayed, their anxiety dissipated and hence would not have been reflected in th eir mood scores. It is also possible that their anxiety disappeared at this point because they did not believe the story about the missing cord and guessed that we would neve r tape the speech. However, during the study few participants explicitly questioned whether they would actually give the speech and during debriefing nearly all participants sa id that they believed that their speech would eventually be recorded. Regardless of why the speech preparati on task did not work as originally intended, the results of this study should inform future research that uses mood induction procedures. Researchers should carefully cons ider the population they plan to recruit and if possible choose a procedure that has been validated with similar populations. These
51 results may also inform research with comm unity samples more generally. Researchers should consider that individuals from the co mmunity may be experiencing significant life stressors that may affect their responses to laboratory manipulations. Study personnel should also take extra care to ensure th at participants unders tand all psychological assessments (e.g., mood scales). Manipulation Effects on Urge Mood manipulation. Consistent with our hypotheses, participants in the speech condition reported increased urge to smoke relative to partic ipants in the art condition immediately following the mood manipulation. Given our manipulation check results, we cannot confidently conclude that NA caused this difference in urge, and we acknowledge that we may have found this re sult by chance. However, when the two factors of the QSU-brief were analyzed separa tely, the effect of th e speech task on postmood manipulation urge was signi ficant only for Factor 2, anti cipation of negative affect relief, suggesting that NA indeed contributed to the increas ed urge. Furthermore, our finding replicates previous research that has employed a variety of negative mood induction procedures (e.g., imagery, Tiffa ny & Drobes, 1990; speech task, Juliano & Brandon, 2002; aversive noise, Payne et al ., 1991; music, Willner & Jones, 1996). Assuming our finding is not chance, other differences in the two tasks seem unlikely to have caused the difference. For example, we c onsidered that, relative to the art task, the speech task may have increased feelings of boredom rather than anxiety, but boredom is also a type of NA. We also considered that perhaps the art ta sk actually increased positive affect, but our results indicated that NA increased slightly in both groups.
52 Despite our efforts to maintain particip ants speech-related anxiety throughout the remainder of the study by repeatedly reminding them of the upcoming speech, there was no significant effect of the mood manipulation when urge wa s assessed a second time via a verbal rating during the cue manipulation or a third time via the QSU-brief immediately after the cue manipulation. However, there was a trend toward an effect of the mood manipulation on post-cue manipulation QSU-br ief Factor 2 (anticipation of negative affect relief) scores, such that participants in the speech condition reported greater urge than those in the art condition. Taken together, these results indicate that the effect of the speech task on urge immediately post-mood manipulation had mostly disappeared several minutes later when urge was assessed during and immediately afte r the cue manipulation. We presented the mood and smoking cues sequentially rather than simultaneously in order to isolate each manipulations effects and avoid task interference that may ha ve affected the results of a previous study (Payne et al., 1991). However, perhaps the novelty and task demands of the cue manipulation (manipulating the tray a pparatus and objects) diverted participants attention away from any anxiety there we re feeling about the upcoming speech and therefore also reduced any associated urge. Alternatively, if indeed the speech did induce anxiety, perhaps our efforts to sustain that anxiety throughout the remainder of the study simply failed. Cue manipulation. In this study, we employed a cu e exposure procedure that has successfully produced urge reac tivity in numerous previous studies (e.g., Sayette et al., 2001). Participants were exposed to either a smoking cue (lit cigarett e) or a neutral cue (stapler and roll of tape) for 30 seconds. Our results indicated that participants in the
53 smoking cue condition reported si gnificantly greater urge ( M = 69 points on a scale of 1 to 100) during cue exposure than partic ipants in the neutral cue condition ( M = 52 points). However, there was only a trend fo r an effect of the smoking cue on QSU-brief scores immediately following the cue manipul ation, with no significant effects on either Factor 1 or Factor 2 of the QSU-brief. Ta ken together, these findings suggest that the smoking cue only had a transient effect on urge. Previous research has demonstrated th at numerous factors may influence the magnitude of urge reactivity to smoking cu es, including deprivation state, nicotine dependence, and opportunity to smoke. Regardin g time elapsed since last cigarette, it has been shown that smokers who are in withdr awal (3-12 hrs abstinence) report greater overall urges than nondeprived or mildly deprived smokers, but they do not report greater increases in urge from baseline to post-cue exposure (e.g., Payne, Smith, Sturges, & Holleran, 1996; Sayette & Hufford, 1994; Saye tte et al., 2001), perhaps because of a ceiling effect (see Sayette et al., 2001). In th is study, participants were told to smoke a cigarette 30 minutes prior to beginning the study, and cue exposure occurred approximately 30-45 minutes into the study. Th us, we expected participants to feel mildly deprived (about 60-75 minutes since la st cigarette) at the tim e of cue exposure. However, our participants baseline urge scores ( M = 27 on a scale of 10-50) and verbal urge ratings (M=52 in the ne utral cue condition) were around the midpoint of the scale, while previous studies have re ported baseline ratings well und er the midpoint of the scale (e.g., Sayette et al., 2001). Furthermore, our participants were highly dependent on nicotine (FTND, M = 5.62; cigarettes per day, M = 22) and most did not have jobs that would require them to refrain from smoking during the day (i.e. because they were all
54 available to participate during normal business hours). Therefore, our participants may have felt more deprived than we anticipat ed when cue exposure occurred, and a ceiling effect may have at tenuated reactivity. Several studies have reported stronger reactivity effects when participants are led to believe that they will have an opportuni ty to smoke soon after cue exposure (for a review, see Wertz & Saye tte, 2001). In this study, we chos e not to give participants any availability information for two primary reasons First, we hypothesized that availability would interact with impulsivity and introdu ce additional unwanted variance in the data. Second, we did not want to make our cue ma nipulation so powerful as to obscure any moderating effect of impulsivity. However, pa rticipants were told that the study would last about 1 to 1.5 hours, and cue exposure occurred approximately 30-45 minutes into the study. Therefore, participan ts knowledge that they would be able to smoke within 15-45 minutes of cue exposure may have at tenuated group differences in reactivity. In summary, based on a review of the cue reactivity literature and careful consideration of factors that affect reactivity magnitude, we chose a paradigm (exposure to a lit cigarette for 30 seconds) that we believed would produce robust, reliable group differences in reactivity, but would not be so powerful as to obscure individual differences and prevent us from detecting a m oderating effect of impulsivity. Our results indicate that our manipulation produced a sign ificant effect on urge during cue exposure but only a trend for an effect immediately afterward. Perhaps the combination of our participant characteristics (highly nicotine dependent, relatively high baseline urge) and our procedure led to a ceiling effect, or th e cue manipulation was simply not powerful enough to produce more than a fleeting effect.
55 Interaction. Few previous studies have incl uded both mood and smoking cues to test for interaction effects, and those studies that have in cluded both have presented them simultaneously (e.g., Payne et al., 1991; Tiffany & Drobes, 1990). However, simultaneous presentation may not reflect the actual experiences of drug users, and prevents analysis of how nega tive mood states affect subseque nt reactivity to drug cues. In the alcohol literature, several recent studies have presented alcohol cues after a negative mood induction (Cooney et al. 1997; Ja nsma et al., 2000; Litt et al., 1990; Nesic & Duka, 2006; Rubonis et al., 1994). These st udies have shown mixed results, with one study finding additive effects (e.g., Cooney et al., 1997), some failing to find any effect of one cue type or the other (e.g., Jansma et al., 2000) and no studies finding an interaction. The current study was modeled on these alcohol cue stud ies, with the cue manipulation immediately following the m ood manipulation. Consistent with this previous alcohol research, our results indicated no significant interaction effects between the mood and cue manipulations. Although it is recommended that future studies continue to explore the effects of mood st ates and smoking cues on motivation to smoke through the use of more robust manipulations and urge measures that are not as susceptible to ceiling effects (see Sayette et al., 2001), it app ears unlikely that interaction effects will be found. Cooney et al. (1997) state that failur e to find interactive effects may indicate that reactivity to affect and drug cues is driv en by independent processes. We also suggest also that perhaps once cu e-elicited urge is ac tivated, attentional resources are diverted toward that part icular cue (see Sayette & Hufford, 1994 for evidence that smoking cues affect reaction tim e), attenuating responses to subsequently presented cues.
56 Manipulation Effects on Topography Neither the mood nor the cue manipulati on significantly affected any of the smoking topography variables (latency, number of puffs, average puff length, average interpuff interval, total time spent puffing, to tal time spent smoking). For the smokers in our study, who were on average highly nicotin e dependent and smoked over 20 cigarettes per day for over 20 years, smoking has likely be come an automatized behavior resistant to manipulation (Tiffany, 1990). Given that ou r manipulations had only transient effects on urge, they may not have been powerful enough to alter our participants normal smoking behavior. Impulsivity The second specific aim of this study was to determine whether impulsivity moderated the effects of the manipulations on urge and behavioral reactivity. We hypothesized that more impulsive individua ls would demonstrate greater urge and behavioral reactivity then less impulsive in dividuals following both manipulations. Our primary measures of impulsivity included a commonly used self-report measure, the Barratt Impulsiveness Scale (BIS-11), and a de lay discounting task (DDT). Participants also completed the BIS/BAS scales, based on Gr ays theory of beha vioral activation and inhibition. We also conducte d additional analyses to dete rmine whether the impulsivity measures were significantly correlated with each other and other baseline variables. Correlations among impulsivity me asures and other variables. The BIS-11 was moderately correlated with the BAS fun-seek ing scale and uncorrela ted with the other BAS subscales. The BIS-11 subscales were st rongly correlated with each other, while the BAS subscales were only moderately correla ted with each other. The personality (i.e.
57 BIS-11, BIS/BAS scales) and behavioral (i.e. DDT k values) impulsivity measures were uncorrelated, a finding generally consistent with previous resear ch reporting weak or absent correlations among these measures (e.g., Mitchell 1999; Reynolds, Ortengren, Richards, & de Wit, 2006). These results also support other recent work that has identified different components of impulsi vity (e.g., Whiteside & Lynam, 2001; for a review, see Evenden, 1999). As a group, the impulsivity measures were moderately correlated with baseline urge, affect, and expectancies for negative reinforcement, confirming a relationship between impulsivity and factors associated with tobacco use. The BIS-11 showed the strongest correlations with these variables, particularly with anxiety and negative affect, a nd also with education, income, and cigarettes smoked per day. Moderating Effects on Reactivity. Contrary to our hypotheses, none of the impulsivity measures moderated the effects of the manipulations on reactivity. Given the small, transient effects of the two manipulations on reactivity for the sample as a whole, the most obvious explanation for our null re sults with respect to impulsivity as a moderator is that the manipulations were not powerful enough to allow us to detect individual differences. Alternatively, a ceiling effect may have occurred because impulsivity was positively correlated with urge and QSU-brief scores were restricted to a range between 10 and 50. Thus, more impulsive individuals simply could not increase their urge score as much as less impulsive i ndividuals. Among the impulsivity measures, scores on the BIS-11 were most strongly correlated with urge. We examined the verbal urge and post-cue manipulation QSU-brief scor es for those particip ants whose BIS-11 score was in the top 25% of the sample and compared their scores to the rest of the
58 sample. Providing evidence that a ceiling e ffect may have occurred, this analysis revealed that in the smoking cue group, 32% of individuals with hi gh BIS-11 scores rated their verbal urge at the maximum (100) a nd 24% scored a 50 (maximum score) on the QSU-brief, compared to only 16% and 5%, respectively, of the re st of the sample. Since this study was originally proposed, two studies have been published that examined whether impulsivity moderated urge reactivity to a smoking cue. In one study (Doran, Spring, & McChargue, 2007), adult smokers were exposed to a lit cigarette and a roll of tape for 5 minutes each. Results indicated that more impulsive smokers evidenced greater urge reactivity th an less impulsive smokers. In a second study (Doran, McChargue, & Spring, 2008), adult smokers were exposed to a lit ciga rette and a roll of tape for 10 minutes each. Results indicated that more impulsive smokers evidenced greater urge reactivity to the ne utral cue (tape), but not to the lit cigarette. It is unclear why Doran and colleagues obtained these di screpant results because their sample characteristics and procedures were very sim ilar for the two studies, except for the age of their participants (Doran, McChargue, & Spring 2008, M = 41; Doran, Spring, & McChargue, 2007, M = 31). Additionally, although Doran, McChargue, & Spring (2008) did not report main effects, thei r preand posturge ratings se em to indicate that they did not find a main effect for the smoking cue. These mixed results, combined with our results, are difficult to interpret and indicate that additional studies are needed to determine whether impulsivity is rela ted to greater urge reactivity. Summary. In summary, our results indicate th at impulsive individuals do not show enhanced urge reactivity. Rather, th ey experience consistently high urge and negative affect, paired with st rong expectations that smoking will relieve negative affect.
59 Given that urge and negative affect contribu te to relapse (Brandon et al., 1990; Shiffman et al., 1996), these findings suggest that th e impulsivity is a pervasive trait that contributes to numerous factor s associated with tobacco use initiation and maintenance, and underscore the importance of conti nued research on how specific aspects of impulsivity affect tobacco use. In their cons tant state of high urge and negative affect, impulsive individuals may feel and act as though cues are always present, which may account for our null results w ith respect to reactivity. Doran, McChargue, & Spring (2008) additionally suggest that impulsive smokers may tend to respond to urges by smoking immediately, which may make them le ss aware of, and have difficulty reporting accurately on, internal states such as craving. Because of other aforementioned issues with our manipulations and the mixed results of previous studies, future research is needed before more definitive conclusions can be drawn. Conclusion Consistent with previous research, th e results of the current study indicated independent effects of a speech preparation ta sk and exposure to a lit cigarette on selfreported urge to smoke. Despite the failure of the speech task to induce self-reported anxiety as intended, our finding adds some support to the relatively small group of experimental studies that have shown an eff ect of negative effect on urge. There were no effects of the two manipulations on smoking topography, and consistent with previous research, no interaction effect s between the two manipulatio ns. The current study also examined whether impulsivity, a trait associated with tobacco use, was related to cue reactivity. Our results extend earlier resear ch on impulsivity, confirming a relationship
60 between impulsivity and overall smoking urge. However, contrary to our hypotheses, we found no evidence for a relationship betw een impulsivity and cue reactivity. Many of the most widely-cited smoking cue reactivity studies have included primarily university students (e.g., Perk ins & Grobe, 1992; Sayette & Hufford, 1994; Tiffany & Drobes, 1990), or young, relatively we ll-educated adults (e.g., Payne et al., 1991; Sayette et al., 2001; also see meta-analysis by Carter & Tiffany, 1999, average age was 27). In contrast, our participants were ethnically diverse, and in general highly dependent on nicotine, middle-aged, and very low in socioeconomic status. Additionally, our inclusion and exclusion criteria were quite liberal; we did not screen for psychological disorders or other drug use as did two previous studies examining impulsivity and cue reactivity (Doran, Mc Chargue, & Spring, 2008; Doran, Spring, & McChargue, 2007). Our unique sample characteristics make our results difficult to compare with previous research and in that regard may be considered a limitation. However, we prefer to view them as a streng th, because it is likely that our participants more closely resemble the current genera l population of smoker s (see Wetter et al., 2005). These smokers may have more difficu lty quitting than those from previous generations (Irvin & Brandon, 2000). Therefor e, it is imperative that researchers prioritize the recruitment of representative samples in research focused on identifying factors that maintain tobacco use and devel oping more effective interventions. Although we found no evidence that more impulsive sm okers were more responsive to negative affect and smoking cues, our resu lts indicate that impulsivity is associated with factors related to smoking initiation, cessation, and relapse, and this warrants further study.
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81 Appendix A: Demographic Questionnaire The following questions are about yourself and your life situation. They are to help us better understand the people we serve. Y ou are under no obligation to answer any question that you find objectionable, however we would appreciate your answering as many as possible. All answers will be kept confidential. Date: _____________________ 1. What is your age? _________________ 2. What is your date of birth?______________ 3. What is your marital status? Single Married Separated Divorced Widowed 4. With which racial category do you most identify yourself? (p lease check one) American Indian/Alaska Native Asian Native Hawaiian or Other Pacific Islander Black or African American White 5. Are you Hispanic/Latino? Yes No 6. What is the highest grade level you have completed? Did not graduate high school High school graduate Some college Technical school/Associates degree 4-year college degree Some school beyond 4-year college degree Professional degree (e.g., MD, JD, PhD) 7. Your household income? Under $10,000 $10,000 $19,999 $20,000 $29,999 $30,000 $39,999 $40,000 $49,999 $50,000 $59,999 $60,000 $69,999 $70,000 $79,999 $80,000 $89,999 Over $90,000
82 Appendix B: Smoking Status Questionnaire (SSQ) 1. Date of Birth:______/______/______ Month Day Year 2. Sex: (check one) Male Female 3. Do you smoke cigarettes everyday? Yes No If No, stop here; If Yes, please continue 4. How many years have you been smoking daily?_________ 5. How many cigarettes do you smoke per day on average?_________ 6. Do you inhale? (circle one) NEVER SOMETIMES ALWAYS 7. Do you smoke more during the first two hours of the day than during the rest of the day? Yes No 8. How soon after you wake up do you smoke your first cigarette? Within 5 minutes 6-30 minutes 31-60 minutes After 60 minutes 9. Which of all the cigarettes you smoke would you most hate to give up? The first one in the morning The one with breakfast The one with lunch The one with dinner The last cigarette before going to bed Other:_________________________ 10. Do you find it difficult to refrain from smoking in places where it is forbidden (eg. in church, at the library) Yes No 11. Do you smoke if you are so ill that you are in bed most of the day? Yes No
83 Appendix C: Questionnaire of Smoking Urges-Brief (QSU-brief) Please rate the statements below using the following scale to record your answers. 1 2 3 4 5 very slightly or not at all a little moderately quite a bit extremely 1. I have a desire for a cigarette right now. 2. Nothing would be better than smoking a cigarette right now. 3. If it were possible, I prob ably would smoke now. 4. I could control things better right now if I could smoke. 5. All I want right now is a cigarette. 6. I have an urge for a cigarette. 7. A cigarette would taste good now. 8. I would do almost anything for a cigarette now. 9. Smoking would make me less depressed. 10. I am going to smoke as soon as possible.
84 Appendix D: Smoking Consequences Questionnaire Adult (SCQ-A) Instructions: This questionnaire is designe d to assess beliefs people have about the consequences of smoking a cigarette. We ar e interested in your general expectations about the consequences of your smoking. Below is a list of statements. Each statement contains a possible consequence of smoking. For each of the statements listed below, please rate how LIKELY or UNLIKELY you believe each consequence is for you when you smoke. If the consequence seems LIKELY to you, circle a number from 5-9. That is, if you believe that a consequence woul d never happen, circle 0; if you believe a consequence would happen every time you smoke, circle 9. Use the guide below to aid you further. For example, if a consequen ce seems completely likely to you, you would circle 9. If it seems a little unlikely to you, you would circle 4. 0 1 2 3 4 5 6 7 8 9 Completely Very A little A little Very Completely Extremely Somewhat Somewhat Extremely -----------------UNLIKELY --------------X--------------------LIKELY ----------------UNLIKELY LIKELY 1. Cigarettes help me deal with anxiety or worry. 0 1 2 3 4 5 6 7 8 9 2. Nicotine fits can be controlled by smoking. 0 1 2 3 4 5 6 7 8 9 3. When Im angry, a cigarette can calm me down. 0 1 2 3 4 5 6 7 8 9 4. I become more addicted the more I smoke. 0 1 2 3 4 5 6 7 8 9 5. If Im tense, a cigarette helps me to relax. 0 1 2 3 4 5 6 7 8 9 6. Smoking a cigarette energizes me. 0 1 2 3 4 5 6 7 8 9 7. Cigarettes help me deal with anger. 0 1 2 3 4 5 6 7 8 9 8. Smoking calms me down when I feel nervous. 0 1 2 3 4 5 6 7 8 9 9. I feel like I do a better job when I am smoking. 0 1 2 3 4 5 6 7 8 9 10. A cigarette can give me energy when Im bored and tired. 0 1 2 3 4 5 6 7 8 9 11. Cigarettes can really make me feel good. 0 1 2 3 4 5 6 7 8 9 12. When Im feeling happy, smoking helps me keep that feeling. 0 1 2 3 4 5 6 7 8 9 13. Smoking will satisfy my nicotine cravings. 0 1 2 3 4 5 6 7 8 9 14. Cigarettes help me reduce or handle tension. 0 1 2 3 4 5 6 7 8 9 15. I feel better physically after having a cigarette. 0 1 2 3 4 5 6 7 8 9 16. A cigarette can satisfy my urge to smoke. 0 1 2 3 4 5 6 7 8 9 17. If Im feeling irritable, a smoke will help me relax. 0 1 2 3 4 5 6 7 8 9 18. I will become more dependent on nicotine if I continue smoking. 0 1 2 3 4 5 6 7 8 9
85 Appendix D: (Continued) 19. When Im upset with someone, a cigarette helps me cope. 0 1 2 3 4 5 6 7 8 9 20. I like the way a cigarette makes me feel physically. 0 1 2 3 4 5 6 7 8 9 21. When I am worrying about something, a cigarette is helpful. 0 1 2 3 4 5 6 7 8 9 22. Smoking temporarily reduces those repe ated urges for cigarettes. 0 1 2 3 4 5 6 7 8 9
86 Appendix E: Mood Form (Trait) Please indicate how much you have experienced each of the following moods during the past three weeks by placing a checkmark on EACH line. Not at Very Some Moderate Much Very Extremely all slight what amount much much Happy |______|______|______ |______|______|______|______| Depressed/Blue |______|___ ___|______|______|______|______|______| Joyful |______|______| ______|______|______|______|______| Unhappy |______|______|______ |______|______|______|______| Pleased |______|______| ______|______|______|______|______| Enjoyment/Fun |______|___ ___|______|______|______|______|______| Frustrated |______|___ ___|______|______|______|______|______| Worried/Anxious |______| ______|______|______|___ ___|______|______| Angry/Hostile |______| ______|______|______|___ ___|______|______|
87 Appendix F: Mood Form (State) Please indicate how much you are expe riencing each of the following moods right now by placing a checkmark on EACH line. Not at Very Some Moderate Much Very Extremely all slight what amount much much Happy |______|______|______ |______|______|______|______| Depressed/Blue |______|___ ___|______|______|______|______|______| Joyful |______|______| ______|______|______|______|______| Unhappy |______|______|______ |______|______|______|______| Pleased |______|______| ______|______|______|______|______| Enjoyment/Fun |______|___ ___|______|______|______|______|______| Frustrated |______|___ ___|______|______|______|______|______| Worried/Anxious |______| ______|______|______|___ ___|______|______| Angry/Hostile |______| ______|______|______|___ ___|______|______|
88 Appendix G: State-Trait Anxiety In ventory Trait (STAI Form Y-2) DIRECTIONS: A number of statements which people have used to describe themselves are given below. Read each statement and th en circle the number to the right of the statement to indicate how you generally feel. There are no right or wrong answers. Do not spend too much time on any one statemen t but give the answer which seems to describe how you generally feel. 1=almost never 3=sometimes 5=often 7=almost always 1. I feel pleasant.. 1 2 3 4 5 6 7 2. I feel nervous and restless... 1 2 3 4 5 6 7 3. I feel satisfied with myself. 1 2 3 4 5 6 7 4. I wish I could be as happy as others seem to be. 1 2 3 4 5 6 7 5. I feel like a failure.. 1 2 3 4 5 6 7 6. I feel rested. ... 1 2 3 4 5 6 7 7. I am calm, cool, and colle cted. ... 1 2 3 4 5 6 7 8. I feel that difficulties are piling up so that I cannot overcome them.. 1 2 3 4 5 6 7 9. I worry too much over something that doesnt really matter. 1 2 3 4 5 6 7 10. I am happy.. 1 2 3 4 5 6 7 11. I have disturbing thoughts. 1 2 3 4 5 6 7 12. I lack self-confidence. ... 1 2 3 4 5 6 7 13. I feel secure. ... 1 2 3 4 5 6 7 14. I make decisions easily. 1 2 3 4 5 6 7 15. I feel inadequate. ... 1 2 3 4 5 6 7 16. I am content... 1 2 3 4 5 6 7 17. Some unimportant thought runs through my mind and bothers me... 1 2 3 4 5 6 7 18. I take disappointments so keenly that I cant put them out of my mind 1 2 3 4 5 6 7 19. I am a steady person... 1 2 3 4 5 6 7 20. I get in a state of tension or turmoil as I think over my recent concerns and interests... 1 2 3 4 5 6 7
89 Appendix H: State-Trait Anxiety In ventory State (STAI Form Y-1) DIRECTIONS: A number of statements which people have used to describe themselves are given below. Read each statement and th en circle the number to the right of the statement to indicate how you feel right now, that is, at this moment. There are no right or wrong answers. Do not spend too much tim e on any one statement but give the answer which seems to describe your present feelings best. 1=not at all 3=somewhat 5=moderately so 7=very much so 1. I feel calm... 1 2 3 4 5 6 7 2. I feel secure. 1 2 3 4 5 6 7 3. I am tense 1 2 3 4 5 6 7 4. I feel strained. 1 2 3 4 5 6 7 5. I feel at ease 1 2 3 4 5 6 7 6. I feel upset. 1 2 3 4 5 6 7 7. I am presently worrying over pos sible misfortunes 1 2 3 4 5 6 7 8. I feel satisfied. 1 2 3 4 5 6 7 9. I feel frightened. 1 2 3 4 5 6 7 10. I feel comfortable 1 2 3 4 5 6 7 11. I feel self-confident 1 2 3 4 5 6 7 12. I feel nervous. 1 2 3 4 5 6 7 13. I am jittery 1 2 3 4 5 6 7 14. I feel indecisive. 1 2 3 4 5 6 7 15. I am relaxed 1 2 3 4 5 6 7 16. I feel content.. 1 2 3 4 5 6 7 17. I am worried 1 2 3 4 5 6 7 18. I feel confused 1 2 3 4 5 6 7 19. I feel steady 1 2 3 4 5 6 7 20. I feel pleasant. 1 2 3 4 5 6 7
90 Appendix I: Barratt Impul siveness Scale (BIS-11) DIRECTIONS: People differ in the ways they ac t and think in different situations. This is a questionnaire to measure some of the ways in which you act and think. Read each statement and record your answer according to the following scale. Do not spend too much time on any statement. Answer quickly and honestly. 1 2 3 4 rarely/never occasionally often almost always/always 1. I plan tasks carefully. ____________ 2. I do things without thinking. 3. I make-up my mind quickly. 4. I am happy-go-lucky. 5. I dont pay attention. 6. I have racing thoughts. 7. I plan trips well ahead of time. 8. I am self-controlled. 9. I concentrate easily. 10. I save regularly. 11. I squirm at plays or lectures. 12. I am a careful thinker. 13. I plan for job security. 14. I say things wit hout thinking. 15. I like to think about complex problems. 16. I change jobs.
91 Appendix I: (Continued) 1 2 3 4 rarely/never occasionally often almost always/always 17. I act on impulse. 18. I get easily bored when so lving thought problems. 19. I act on the spur of the moment. 20. I am a steady thinker. 21. I change residences. 22. I buy things on impulse. 23. I can only think about one thing at a time. 24. I change hobbies. 25. I spend or charge more than I earn. 26. I often have extraneous thoughts when thinking. 27. I am more interested in the present than the future. 28. I am restless at the theater or lectures. 29. I like puzzles. 30. I am future oriented.
92 Appendix J: BIS/BAS Scales Please rate the statements below using the following scale to record your answers. 1 2 3 4 strongly agree agree disa gree strongly disagree 1. If I think something unpleasant is going to happen I usually get pretty worked up. 2. I worry about making mistakes. 3. Criticism or scolding hurts me quit a bit. 4. I feel pretty worried or upset when I think or know someone is angry at me. 5. Even if something bad is about to happen to me, I rarely experience fear or nervousness. 6. I feel worried when I think I ha ve done poorly at something. 7. I have very few fears compared to my friends. 8. When I get something I want, I f eel excited and energized. 9. When Im doing well at something, I love to keep at it. 10. When good things happen to me, it affects me strongly. 11. It would excite me to win a contest. 12. When I see an opportunity for somethi ng I like, I get excited right away. 13. When I want something, I usually go all-out to get it. 14. I go out of my way to get things I want. 15. If I see a chance to get something I want, I move on it right away. 16. When I go after something, I use a no holds barred approach. 17. I will often do things for no other reason than that they might be fun.
93 Appendix J: (Continued) 1 2 3 4 strongly agree agree disa gree strongly disagree 18. I crave excitement and new sensations. 19. Im always willing to try something ne w if I think it will be fun. 20. I often act on the spur of the moment.
94 Appendix K: Delay Discounting Task (DDT) Please answer the following 27 questions in the order they appear Circle the choice you prefer. Please take the choices seriously; they may be for REAL MONEY. At the end of the study, you will choose a marble from a bag that contains 1 green marble and 49 clear marbles. If you choose the green marble, you will win one of your 27 choices. To determine how much money you will win, you will choose another marble from a bag that contains 27 marbles labeled with th e numbers 1 through 27, corresponding to the 27 questions listed below. For example, if you choose the 4 from the bag, you will win whatever you chose on question 4. If you circ led the immediate money on that question ($31 today), you will receive the money today when you leave. If you circled the delayed money on that question ($85 in 7 days), you w ill receive $85 in 7 days. You or another person you designate may return to our facil ity to pick up the money, or you may have the money mailed to you. To make sure th at you get a reward you prefer, you should answer every question as though it were the one you will win. 1. Would you prefer $54 today, or $55 in 117 days? $54 today $55 in 117 days 2. Would you prefer $55 today, or $75 in 61 days? $55 today $75 in 61 days 3. Would you prefer $19 today, or $25 in 53 days? $19 today $25 in 53 days 4. Would you prefer $31 today, or $85 in 7 days? $31 today $85 in 7 days 5. Would you prefer $14 today, or $25 in 19 days? $14 today $25 in 19 days 6. Would you prefer $47 today, or $50 in 160 days? $47 today $50 in 160 days 7. Would you prefer $15 today, or $35 in 13 days? $15 today $35 in 13 days 8. Would you prefer $25 today, or $60 in 14 days? $25 today $60 in 14 days 9. Would you prefer $31 today, or $85 in 7 days? $31 today $85 in 7 days 10. Would you prefer $40 today, or $55 in 62 days? $40 today $55 in 62 days 11. Would you prefer $11 today, or $30 in 7 days? $11 today $30 in 7 days 12. Would you prefer $67 today, or $75 in 119 days? $67 today $75 in 7 days
95 Appendix K: (Continued) 13. Would you prefer $34 today, or $35 in 186 days? $34 today $35 in 186 days 14. Would you prefer $27 today, or $50 in 21 days? $27 today $50 in 21 days 15. Would you prefer $69 today, or $85 in 91 days? $69 today $85 in 91 days 16. Would you prefer $49 today, or $60 in 89 days? $49 today $60 in 89 days 17. Would you prefer $80 today, or $85 in 157 days? $80 today $85 in 157 days 18. Would you prefer $24 today, or $35 in 29 days? $24 today $35 in 29 days 19. Would you prefer $33 today, or $80 in 14 days? $33 today $80 in 14 days 20. Would you prefer $28 today, or $30 in 179 days? $28 today $30 in 179 days 21. Would you prefer $34 today, or $50 in 30 days? $34 today $50 in 30 days 22. Would you prefer $25 today, or $30 in 80 days? $25 today $30 in 80 days 23. Would you prefer $41 today, or $75 in 20 days? $41 today $75 in 20 days 24. Would you prefer $54 today, or $60 in 111 days? $54 today $60 in 111 days 25. Would you prefer $54 today, or $80 in 30 days? $54 today $80 in 30 days 26. Would you prefer $22 today, or $25 in 136 days? $22 today $25 in 136 days 27. Would you prefer $20 today, or $55 in 7 days? $20 today $55 in 7 days
96 Appendix L: Cigarette Rating Form (CRF) Brand of cigarette you smoked: _________________________________________ Please rate the following questions from (1) not at all to (4) very much by circling the number that corresponds to your choice. 1. How much did you like the ta ste of the cigarette? (1) not at all (2) a little (3) somewhat (4) very much 2. How much did you like the smell of the cigarette? (1) not at all (2) a little (3) somewhat (4) very much 3. How enjoyable was the cigarette? (1) not at all (2) a little (3) somewhat (4) very much
97 Appendix M: Telephone Screening Form When potential participant calls regarding project: "Thank you for your interest in this study. First I would like to ask you a few questions. Then I will tell you a little about the study and you can decide if you are interested in participating." Where did you hear about our study from? Indicate response. ad/flyer (ask, Where did you see the flyer? ) location of flyer: _______________________________ word of mouth ( ask, Who told you about it? What is their name? ) Name: _________________________________________ other: ______________________________________________ Question Answer 1. Do you speak and read English well? YES NO 2. How old are you? 18-65 Not 18-65 3. On average, how many cigarettes do you smoke per day? (20 cigarettes = 1 pack) 10 10 4. How long have you been smoking? 1 year 1 year 5. Are you currently enrolled in any formal treatment to quit smoking, like a support group or counseling? NO YES 6. Are you currently using any medication to quit smoking? Examples include: the nicotine patch, nicotine gum, nicotine lozenge, nicotine inhaler, nicotine nasal spray, Zyban, Welbutrin, Bupropion)? NO YES 7. Are you currently actively attempting to quit smoking? NO YES 8. Are you currently pregnant, or is there any possibility that you might currently be pregnant? NO YES 9. Have you ever participated in any other study at our facility? NO YES ( If yes) When? Please describe the study: (Qualified?) YES NO Qualified = YES except for question 9 : Thank you for answering the questions. Please tell me your full name and phone number and you will receive a call back soon about scheduling an appointment.
98 Appendix M: (Continued) Qualified = NO: "Thank you for answering the questio ns. At the current time, you do not qualify for this study. However, if you would like, I can take your name and phone number so we can contact you for any la ter studies that you may qualify for. Do NOT tell them the reasons they didn't qualify! Name: Phone: Thank them and hang up. Qualified = YES: "Thank you for answering the questions. Yo u are qualified for this study. Now I will tell you a little more about it." This is a study to learn more about personality and mood in smokers. This study involves completing some paper measures and a few other tasks. You will be paid $20 for participating in th e study, which is expected to last approximately 1 to 1.5 hours. You will have a chance to win additional money. If you decide to schedule an appointment, when you arrive we will again describe the study to you. We will also give yo u a consent form to read and sign before beginning the study. Are you interested in schedulin g an appointment? (Circle one): YES NO If NO : "Would like us to keep your name an d phone number in case other studies come up?" Name: Phone: If YES : Ok, let me take down your contact information. Collect the following information. Name: Cell Phone: Home Phone: Email Address: Home Address: Ok, lets find a time for you to come in When would be convenient for you? Check appointment book for available slots and schedule an appointment. Date and time of appointment: ________________________________________
99 Appendix M: (Continued) Im going to give you directions to our facili ty and a few reminders. Do you have a pen and paper? Remind them of the followin g (check off each box): Please smoke a cigarette 1/2 hour befo re your appointment. That means you should smoke a cigarette at ________. Please do not smoke again before your appointment, that is, do not smoke between _______ and ______. When you come, please bring a pack of your cigarettes and a lighter. Please call us if you will be late or need to cancel or reschedule your appointment. (Explain how important this is and how mu ch we would appreciate a call). Please call 813-745-1753. If we need to call you is it OK to leave a message on your voicemail? YES NO Give them directions to TRIP (see below) Now Im going to give you directions to our facility. Directions to TRIP Our address is 4115 East Fowler Ave. We are directly across from the main entrance to USF on Fowler Ave on the corner of Fowler and McKinley. We are in the second building at the front of the complex next to Lifetime Cancer Screening. Above our door is a sign that reads T obacco Research and Intervention Program. Park in any space and tell the receptionist that you are here for a research study. If you have any further questio ns, please call 813-745-1753. Remind them again of their appointment date and time. Thank them and hang up.
100 Appendix N: Usage Form Current time: _____________________ Time of last cigarette: _____________________ At least hour since last cigarette? YES NO If NO: Have participant wait until hour has elapsed from last cigarette. CO measure baseline: ______________________
101 Appendix O: Art Rating Form Painting #1 How much do you like the colo rs in this painting? (1) not at all (2) a little (3) somewhat (4) very much How much do you like this painting overall? (1) not at all (2) a little (3) somewhat (4) very much Painting #2 How much do you like the colo rs in this painting? (1) not at all (2) a little (3) somewhat (4) very much How much do you like this painting overall? (1) not at all (2) a little (3) somewhat (4) very much Painting #3 How much do you like the colo rs in this painting? (1) not at all (2) a little (3) somewhat (4) very much How much do you like this painting overall? (1) not at all (2) a little (3) somewhat (4) very much Which painting do you like the best? (1) Painting #1 (2) Pain ting #2 (3) Painting #3
102 Appendix P: 2 nd CO reading CO measure after smoking : _________________________
103 Appendix Q: Debriefing Questions Debriefing Questions (Art Condition) What do you think was the purpose of this study? Do you think there is more to the study than we told you? (If yes, what?) Do you have any questions or concerns a bout participating or about the tasks you completed? For experimenter: Level of insight None Partial Full Debriefing Questions (Speech Condition) Before we told you that you werent going to give your speech, did you believe that you were going to have to give it? What do you think was the purpose of this study? (If not already answered above) Why do you think we told you to prepare a speech but we didnt have you give the speech? Do you have any questions or concerns a bout participating or about the tasks you completed? For experimenter: Level of insight None Partial Full
104 Appendix R: Lottery Results Did the participant win extra money? Yes No If no, this form is complete. If yes, complete the questions below. Which question number did the participant choose? _________ How much extra money did the participant win? _________ Was the amount immediate or delayed? immediate delayed by ______ days If immediate, this form is complete. If delayed, complete the questions below. Pick up or mailed money order? (check desired option and fill out necessary information) Option #1: Pick-up cash Date of pick-up: Name of person picking up cash: Signature of participant: ____________________________ Option #2 Mailed money order Target date of receipt: Name and desired receipt address: Signature of participant: _____________________________ Witness (investigator signature): __________________________
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Litvin, Erika B.
Testing impulsivity as a moderator of smoking motivation following exposure to negative affect and smoking cues
h [electronic resource] /
by Erika B. Litvin.
[Tampa, Fla.] :
b University of South Florida,
ABSTRACT: Consistent with classical conditioning theories of drug use, previous research has demonstrated that presenting smokers with either exteroceptive (e.g., pictures of cigarettes) or interoceptive (e.g., negative affect) cues results in increased motivation to smoke, as measured by urge and smoking topography (e.g., shorter latency to begin smoking). However, few studies have presented both types of cues to determine whether and how they might interact in the production of smoking motivation, and little research has focused on identifying potential moderators of cue reactivity. In a randomized 2 x 2 crossed factorial between-subjects design, the current study tested whether an interoceptive cue (anxiety induced via a speech preparation task) and an exteroceptive cue (exposure to a lit cigarette) interacted in the production of urge and behavioral reactivity and whether the personality trait of impulsivity moderated these effects. Results indicated main effects but no interactive effects for the two cue types on self-reported urge, no main or interactive effects on smoking topography, and no moderating effects of impulsivity. However, impulsivity was significantly correlated with urge to smoke, self-reported negative affect, and expectancies that smoking relieves negative affect, suggesting that this trait plays an important role in continued tobacco use. Implications for future research on the relationship between impulsivity and smoking behavior are discussed.
Thesis (M.A.)--University of South Florida, 2007.
Includes bibliographical references.
Text (Electronic thesis) in PDF format.
System requirements: World Wide Web browser and PDF reader.
Mode of access: World Wide Web.
Title from PDF of title page.
Document formatted into pages; contains 104 pages.
Adviser: Thomas Brandon, Ph.D.
t USF Electronic Theses and Dissertations.