Sensations from initial exposure to nicotine predicting adolescent ...

Nicotine & Tobacco Research Volume 5, Number 4 (August 2003) 455–463

Sensations from initial exposure to nicotine predicting adolescent smoking in China: A potential measure of vulnerability to nicotine

Xinguang Chen, Alan Stacy, Hong Zheng, Jianguo Shan, Donna Spruijt-Metz, Jennifer B. Unger, Jie Gong, Peggy Gallaher, Chunhong Liu, Stanley Azen, Sohaila Shakib, C. Anderson Johnson [Received 5 December 2001; accepted 19 August 2002]

Sensations derived from initial exposure to nicotine are a potential indicator of an individual’s vulnerability to nicotine. This study assessed whether sensations experienced during the first lifetime exposure to nicotine could predict current and established cigarette smoking. Data from 210 respondents who reported having ever tried cigarette smoking in Wuhan, China, were obtained for this study from 610 students in 10th grade at two schools. Subjects were participants in a multipurpose pilot survey for an adolescent smoking prevention trial. The survey was administered in a classroom setting using a paper-and-pencil questionnaire. Sensations reported were cigarette smell (59.2%), coughing (54.1%), dizziness (52.1%), nausea (42.5%), relaxation (19.1%), and pleasurable buzz/rush (9.0%). After controlling for confounders, multiple logistic regression analyses identified three sensations significantly associated with smoking: (a) Cigarette smell (OR for days smoked in the past 30 days~2.93, pv.05, OR for number of cigarettes smoked per day~2.69, pv.05, and OR for 100-cigarette smoking~5.40, pv.01), (b) pleasurable buzz/ rush (OR for 100-cigarette smoking~11.09, pv.05), and (c) relaxation (OR for past 30-day smoking measures ranged from 3.69 to 4.48, pv.01, and OR for 100-cigarette smoking~4.12, pv.05). A dose–response relationship was observed between the sensations and cigarette smoking. Self-reported sensations from initial exposure to nicotine may be a useful indicator of an individual’s vulnerability to nicotine. This information can be used for adolescent smoking prevention and cessation interventions.

Introduction Cigarette smoking is the method by which most people experience their first exposure to the effects of nicotine. The quality and strength of the perceived sensations from tobacco and nicotine exposure play an important role in the maintenance of cigarette Xinguang Chen, M.D., Ph.D., Alan Stacy, Ph.D., Hong Zheng, M.P.H., Donna Spruijt-Metz, Ph.D., Jennifer B. Unger, Ph.D., Peggy Gallaher, Ph.D., Stanley Azen, Ph.D., Sohaila Shakib, Ph.D., and C. Anderson Johnson, Ph.D., Institute for Health Promotion and Disease Prevention Research, University of Southern California Keck School of Medicine, Alhambra, CA; Jianguo Shan, M.D., Jie Gong, M.D., M.P.H., and Chunhong Liu, M.D., Wuhan Public Health and Anti-Epidemic Station, Wuhan Public Health Bureau, Wuhan, China. Correspondence: Xinguang (Jim) Chen, M.D., Ph.D., Department of Pediatrics, Wayne State University School of Medicine, 3901 Beaubien Blvd., Detroit, MI 48201, USA. Tel: z1 (313)-745-2400; Fax: z1 (313)993-0390; E-mail: [email protected]

smoking behavior and the development of nicotine dependence (Eissenberg & Balster, 2000; Pomerleau & Pomerleau, 1992; Pomerleau & Pomerleau, 1994; Shadel, Shiffman, Niaura, Nichter, & Abrams, 2000). Although the causal mechanisms are not yet fully understood, cumulative biological, psychological, and behavioral research on cigarette smoking and nicotine dependence suggests that initial sensations from nicotine exposure may provide important indicators of an individual’s vulnerability to nicotine and the subsequent development of nicotine dependence (Eissenberg & Balster, 2000; Hirschman, Leventhal, & Glynn, 1984; Jones, 1986; Pomerleau, 1995; Pomerleau, Pomerleau, & Namenek, 1998; Wang, Fitzhugh, Trucks, Cowdery, & Perko, 1995). These studies suggest that sensations from the first few exposures may be particularly important.

ISSN 1462-2203 print/ISSN 1469-994X online # 2003 Society for Research on Nicotine and Tobacco DOI: 10.1080/1462220031000118603

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SENSATIONS FROM INITIAL EXPOSURE

Sensations from initial nicotine exposure are usually categorized as sensory or emotional responses, and they are frequently described as the experience of a pleasurable buzz/rush; enjoyment of the smell of the cigarettes; and associated feelings of relaxation, nausea, dizziness, and the like (Dessirier, O’Mahony, & Carstens, 1998; Ginzel, 1973; Hirschman et al., 1984; Hummel, Livermore, Hummel, & Kobal, 1992; Pomerleau & Pomerleau, 1992; Pomerleau, Pomerleau, Namenek, & Marks, 1999). Evidence suggests that perceived sensations from initial exposure to nicotine have a physiological basis (Collins & Marks, 1991; Comings & Blum, 2000; Hirschman et al., 1984; Marks, Burch, & Collins, 1983; Pomerleau & Pomerleau, 1992; Shadel et al., 2000; Spurden et al., 1997). The stimulating effect of nicotine on the respiratory and digestive systems elicits coughing (when exposed via cigarette smoking) and nausea (Larson & Silvette, 1968). Nicotine also has been shown to produce muscle relaxation by stimulating sensory nerve endings (Ginzel, 1973). Nicotine intake has been linked with the production of euphoric sensations in the brain. By binding with the nicotinic acetylcholinergic receptors (nAChR), nicotine activates a cascade reaction in the brain reward system (Pomerleau & Pomerleau, 1992; Shadel et al., 2000; Stitzel, Jimenez, Mark, Tritto, & Collins, 2000; Sziraki, Sershen, Benuck, Hashim, & Lajtha, 1998; Yu, Matsubayashi, Amano, Cai, & Sasa, 2000). Increased concentrations of nAChR or sensitivity of this receptor to nicotine in the brain is associated with increased euphoria and relaxation (Collins & Marks, 1991; Comings & Blum, 2000; Marks et al., 1983; Spurden et al., 1997). Several case–control studies indicate that adult regular and heavy smokers retrospectively reported significantly more pleasurable sensations from their first cigarette smoking experience than did light smokers and current nonsmokers who tried smoking a few times in their life (Pomerleau et al., 1998; Pomerleau et al., 1999). One longitudinal study investigated whether sensations derived from the initial cigarette smoking experience predicted smoking progression among 2,043 adolescents in the United States (Wang et al., 1995). This study found that experimenting smokers who experienced sensations of relaxation and dizziness during their initial exposure were at an increased risk of becoming regular smokers (2.5-year risk ratios were 1.77 and 1.69 for relaxation and dizziness, respectively). Cross-sectional studies on adolescent subjects have derived some similar, and some divergent, conclusions. One cross-sectional study on adolescents’ first and most recent use of smokeless tobacco and cigarettes indicated that persistent cigarette experimenters (defined as those who have smoked more than 10 times) reported significantly more positive reactions to their first smoking experience than did minimal

cigarette experimenters (defined as those who smoked less than 10 times) (Hahn et al., 1990). Another crosssectional study found that adolescent regular smokers were more likely to report experiencing pleasurable sensations from their first and second smoking experiences than were smoking experimenters (Middlecamp, Mermelstein, & Flay, 2001). However, no such data are available for adolescent smokers in China, where 25%–45% of the country’s 0.2 billion adolescents may have tried cigarette smoking (Corrao, Guindon, Sharma, & Shokoohi, 2000). If the sensations elicited from nicotine exposure through cigarette smoking are experienced as rewarding, a dose– response relationship could exist between the quality of initial sensations and subsequent cigarette smoking. This hypothesis has not been tested previously among adolescent smokers in China. In addition to the potential physiological mechanisms, cultural and cognitive factors may be associated with self-reported initial sensations. These factors may affect an individual’s perception, construction, storage, and retrieval of the sensations from stimulating drugs such as nicotine (Stacy, Leigh, & Weingardt, 1994; Wise & Bozarth, 1987). For example, the reported sensations from an addictive drug may be constrained by culturally available words or expressions that a subject can choose to describe his or her feelings after exposure to the drug. However, no data are available for a cross-cultural comparison to examine this issue. The purpose of this study was to investigate the associations between initial nicotine sensations and current and established cigarette smoking in an adolescent sample in China. Information derived from the analysis was used to evaluate whether selfreported initial sensations can be used as an indicator of an individual’s vulnerability to nicotine.

Method Data source, samples, and procedure Data for this analysis were obtained from a pilot survey in an ongoing smoking prevention trial in Wuhan, China. The study was conducted by the Wuhan Public Health and Anti-Epidemic Station in China, in collaboration with the University of Southern California Keck School of Medicine in the United States. The survey was approved by the institutional review boards of the University of Southern California and the Wuhan Public Health Bureau. Students in 12 classes at two schools were selected to participate in the survey. The schools were selected for the following reasons: (a) The location of the schools was convenient, (b) the school administrators showed their willingness to participate, (c) the quality of education and the size of enrollment were representative of average schools in Wuhan, and (d ) the schools had

NICOTINE & TOBACCO RESEARCH

experience in collaborative tobacco research. Students were warranted the right not to participate in the study before the survey. Data were collected in June 2000 in a classroom setting with a paper-and-pencil questionnaire. Students completed the questionnaires anonymously, and confidentiality was emphasized during survey administration. Questionnaires were distributed and collected in the envelopes provided; teachers were asked to leave the classroom during the survey. The questionnaire typically took 20–40 min to complete. Only the investigators could gain access to the completed questionnaires. Of the 637 students in 10th grade, aged 15–17 years, who attended the schools, 622 (98%) provided complete data. Respondents who reported that they had ever tried cigarette smoking were included in this analysis, resulting in a final sample of 210 respondents aged 16–17 years. Of the sample, 70% were males.

Sensations from initial nicotine exposure Initial exposure to nicotine or tobacco was defined as the first time a respondent smoked a cigarette, including trying a few puffs. Studies have shown that adolescent smokers self-administrated nicotine early in their smoking history (McNeill, Jarvis, & West, 1987). To measure sensations from initial exposure to nicotine or tobacco, these subjects were asked to respond to a list of six sensory or emotional sensations with yes or no response options (coded as yes~1 and no~0 for statistical analysis). The sensations were cigarette smell, pleasurable buzz/ rush, relaxation, nausea, dizziness, and coughing. The sum of the number of sensations was computed at the individual level as a quantitative measure of sensation intensity from initial exposure to nicotine. Of the six sensations assessed, five (all but cigarette smell) were adopted from previously published studies (Pomerleau et al., 1998; Pomerleau et al., 1999). The sensation cigarette smell was added based on results from preliminary studies with focus groups in Wuhan, China. Adolescent smokers in the focus groups reported cigarette smell as a pleasurable sensation from smoking. The sensation items were translated from English into Chinese (Mandarin). Difficulties were encountered in finding a Chinese equivalent for the English words buzz or rush that were relevant to the age range of the subjects in this study. We decided to use the Chinese equivalent for the word euphoria because this term is commonly used in the Chinese language. In addition, the questions about sensations were carefully reworded to ensure suitability for adolescent smokers. In designing this part of the questionnaire, we emphasized an interest in the sensations from initial cigarette smoking by using the following wording:

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‘‘Please think back to the first time you smoked a cigarette, even a few puffs. Did you experience any of these sensations?’’ In addition to the initial sensations, data for affective responses to the first cigarette smoking experience and expectations of sensations prior to the first experience were included in the analysis. Affective responses to first cigarette smoking experience were assessed using the following question: ‘‘In general, how did you like your first smoking experience?’’ Response options were as follows: (a) Disliked very much, (b) somewhat disliked, (c) neither liked nor disliked, (d ) somewhat liked, (e) liked very much, and ( f ) forget/don’t know. Options (a) and (b) were combined as one category for statistical analysis, as were options (d ) and (e). Expectations of sensations prior to first cigarette smoking experience were assessed using the question ‘‘Before you smoked your first cigarette, had you ever thought that smoking cigarettes was pleasant or unpleasant?’’ Response options were as follows: (a) Pleasant, (b) unpleasant, (c) never thought about it, and (d ) couldn’t remember.

Current and established smoking Measures of current and established cigarette smoking were used as dependent variables for statistical analysis. Current smoking behavior was defined as a positive response to any of the following measures: (a) If smoked in the past 30 days (yes~1; no~0), (b) number of days smoked in the past 30 days (0 days~0; 1–2 days~1; 3–5 days~2; 6–9 days~3; 10–14 days~4; 15–24 days~5; and 25z days~6), and (c) average number of cigarettes smoked per day in the past 30 days (less than 1 cigarette~0; 1 cigarette~1; 2–5 cigarettes~2; 6–10 cigarettes~3; 11–20 cigarettes~4; and 20z cigarettes~5). A positive answer to the question ‘‘Have you smoked at least 100 cigarettes in your life?’’ was defined as 100-cigarette (or established) smoking. This measure was based on findings from studies showing that over 80% of youths who report having smoked over 100 cigarettes during adolescence will become addicted smokers in adulthood (Choi, Gilpin, Farkas, & Pierce, 2001; Choi, Pierce, Gilpin, Farkas, & Berry, 1997). The essential point here is that ‘‘it is not the 100th cigarette that makes them [the subjects] addicted, it is the ‘Yes’ response to the question’’ (Pierce et al., 1998, p. 3-3). Because no girls in this sample reported having smoked 100 cigarettes in their lifetime, only boys were included in statistical analyses that involved the variable 100-cigarette smoking.

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Covariates Numerous studies have shown that adolescent smoking behavior can be predicted by many factors. These factors include but are not limited to smoking peers (Aloise-Young, Graham, & Hansen, 1994; Urberg, Shyu, & Liange, 1990; Wang, Eddy, & Fitzhugh, 2000) and smoking parents (Distefan, Gilpin, Choi, & Pierce, 1998; Lebowitz & Holberg, 1988; Murray, Kiryluk, & Swan, 1985). To test the impact of sensations from initial tobacco or nicotine exposure on cigarette smoking behavior, we included the following control variables in multiple logistic regression models: (a) Three variables measuring cigarette smoking (yes~1; no~0) among significant others in the family (i.e., father, mother, or any siblings), (b) two variables measuring cigarette smoking (yes~1; no~0) among male friends or female friends, (c) three variables measuring perceived acceptance of cigarette smoking (i.e., rejection for smoking) by friends, parents, or teachers, and (d) being male. Because the reported sensations did not differ by age in this sample, age was not included as a control variable.

Statistical analysis For descriptive purposes, prevalence rates were computed for each of the six sensations, overall and stratified by age and gender. Proportions were computed for measures of affective responses to the first smoking experiences and expectations of sensations prior to initial smoking. To test associations between sensations (each separately and the total number) from initial tobacco or nicotine exposure and each of the four cigarette smoking measures, we conducted simple logistic regression analyses. Odds ratios (OR) with Wald 95% confidence intervals were estimated. Chi-square tests were used to assess the statistical significance of the associations. Multiple logistic regression models were applied to detect which of the six sensations were independently associated with smoking behavior. The sensations demonstrated to be associated with smoking behavior were further analyzed using a multiple logistic regression model that included the nine control variables for the adjustment of any potentially confounding effects. Investigators manually entered into the computer the data used for this analysis. For quality assurance, a double-entry protocol was used in data processing. All statistical analyses were conducted using SAS procedures (v. 8.1) on personal computers.

The mean (SD) age was 16.2 (0.44) years. Among the 68 respondents (46.3% of the total sample) who reported having smoked in the past 30 days, 83.7% reported having smoked at least 100 cigarettes in their lifetime. Among the 43 respondents who reported having smoked 100 cigarettes in their lifetime, 88.4% reported having smoked in the past 30 days. Significantly more males than females reported having smoked in the past 30 days (42.9% vs. 7.9%, pv.01) and having smoked over 100 cigarettes in their lifetime (29.0% vs. 0.0%, pv.01). Among the respondents who smoked in the past 30 days, 35% reported having smoked 5 or fewer days, 26% smoked 6–24 days, and 39% smoked 25 or more days. Among these smokers, on average, 42% smoked 1 or fewer cigarettes per day, 42% smoked 2–5 cigarettes per day, and the remainder smoked 6 or more cigarettes per day. Only one subject reported having smoking more than 20 cigarettes in a typical day in the past 30 days.

Self-reported initial sensations and affective responses to the sensations Table 1 presents the self-reported initial sensations. Of the 210 respondents, approximately 40%–60% reported experiencing the following sensations on smoking their first cigarette: Cigarette smell (59.2%), cough (54.1%), dizziness (52.1%), and nausea (42.5%). In addition, 9.0% reported experiencing a pleasurable buzz/rush sensation and 19.1% reported experiencing a relaxation sensation. No significant differences were found in any of the six self-reported sensations by age except for coughing (50.0% for ƒ16 years vs. 69.1% for 17 years, pv.05). More males than females reported having experienced the sensations pleasurable buzz/rush (12.5% vs. none), relaxation (24.4% vs. 5.7%), and dizziness (62.1% vs. 25.9%). Among all the respondents, 42.9% reported that they disliked their first experience with cigarette smoking, 37.4% reported feeling neutral toward it, 16.7% reported forgetting their emotional response to the experience, and 3.0% reported that they liked their first cigarette smoking experience. Regarding expectations of the cigarette smoking experience prior to smoking their first cigarette, 28.0% of respondents reported having never thought about it, 8.0% reported expecting it would be pleasant, 7.0% reported expecting it would be unpleasant, and 57.0% reported that they could not remember whether they had any expectations before trying their first cigarette. No significant age or gender differences were observed for these two variables (Table 1).

Results Sample statistics and cigarette smoking behavior

Sensations and cigarette smoking behavior

Data from 210 respondents were included in the analysis. Of the respondents, 147 (70%) were males.

Simple logistic regression analyses indicated that among the six self-reported sensations, four had an


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Table 1. Self-reported sensations from, affective responses to, and expectations prior to initial cigarette smoking among adolescents in Wuhan, China, who reported having ever smoked a cigarette in their lifetime Stratified by age

Sensation (%) Pleasurable buzz/rush Relaxation Nausea Dizziness Cough Cigarette smell If liking initial smoking experience (%) Dislike Neutral Like Forget/don’t know Expectations prior to initial smoking (%) Smoking would be pleasant Smoking would be unpleasant Couldn’t remember Never thought about it

Stratified by gender

Overall (n~210)

ƒ16 years (n~164)

17 years (n~46)

x 2 test for age differencea

Male (n~147)

Female (n~63)

x 2 test for gender differencea

9.0 19.1 42.5 52.1 54.1 59.2

9.3 17.5 43.9 50.0 50.0 59.1

7.7 25.6 37.1 59.1 69.1 59.5

0.10 1.34 0.52 1.12 4.81* 0.01 14.34

12.5 24.4 46.0 62.1 51.8 56.9

0.0 5.7 33.3 25.9 60.0 64.7

7.28** 8.67** 2.29 20.48** 1.07 0.91 4.13

42.9 37.4 3.0 16.7

41.8 40.5 1.9 15.8

46.7 26.7 6.7 20.0

42.4 37.5 4.2 16.0

43.3 38.3 0.0 18.3

9.30

2.66

8.0

7.1

10.9

7.8

8.3

7.0

5.2

13.0

8.5

3.3

57.0 28.0

59.1 28.6

50.0 26.1

58.9 24.8

51.7 36.7

*pv.05; **pv.01.

OR significantly greater than 1.00 for each of the four smoking behavior measures: If smoked in the past 30 days, number of days smoked in the past 30 days, number of cigarettes smoked per day in the past 30 days, and if smoked over 100 cigarettes in lifetime (Table 2). The four sensations significantly associated with cigarette smoking were cigarette smell (OR from 2.03 to 5.00), pleasurable buzz/rush (OR from 4.23 to 17.09), relaxation (OR from 6.82 to 9.79), and dizziness (OR from 3.01 to 3.81). These results suggest

a positive association between the experience of a sensation from initial nicotine exposure and current or established cigarette smoking. Number of sensations experienced from initial cigarette smoking also was significantly associated with an increased risk for smoking. The OR ranged from 1.90 to 2.22 for the four smoking measures (Table 2). Figure 1 shows the relationship between the number of initial smoking sensations and 30-day and 100-cigarette smoking. The percentage of smokers

Table 2. Associations between self-reported initial smoking sensations and current and 100-cigarette smoking (simple logistic regression analyses)a Smoking in the past 30 days

Sensations, expectations, and affective responses Cigarette smell Pleasurable buzz/rush Relaxation Dizziness Nausea Cough Sum of sensations Smoking could be unpleasant Disliking initial smoking experience

If smoked (n~198–204) OR (95% CI )

Days smoked (n~187–189) OR (95% CI )

Number smoked (n~195–201) OR (95% CI )

2.03* (1.04–3.94) 4.23** (1.49–12.05) 6.82** (3.07–15.15) 3.01** (1.59–5.70) 1.05 (0.56–1.98) 1.51 (0.82–2.78) 1.90** (1.39–2.61) 0.79 (0.24–2.61)

2.64** (1.36–5.15) 7.46** (2.76–20.15) 9.79** (4.60–20.83) 3.60** (1.89–6.82) 1.08 (0.58–2.02) 1.60 (0.88–2.93) 2.12** (1.58–2.84) 0.78 (0.24–2.58)

2.83** (1.50–5.31) 9.41** (3.50–25.33) 9.70** (4.65–20.25) 3.31** (1.87–5.87) 1.03 (0.58–1.82) 1.59 (0.92–2.76) 2.04** (1.54–2.70) 1.28 (0.46–3.53)

0.74 (0.33–1.38)

0.58 (0.28–1.16)

0.60 (0.31–1.14)

Smoked 100 cigarettes If smoked (n~136–138, boys only) OR (95% CI )

5.00** (1.98–12.62) 17.09** (5.18–56.40) 8.53** (3.54–20.55) 3.81** (1.54–9.45) 1.07 (0.50–2.27) 1.66 (0.79–3.50) 2.22** (1.49–3.30) 0.76 (0.20–2.96) 0.91 (0.37–2.19)

*pv.05;**pv.01. a In the simple logistic regression analyses, the four smoking measures each was used as a dependent variable Y; and the six sensations, the sum of sensations, the prior expectation, and the affective response each was used as an independent variables X. Only one X and one Y were used for each logistic regression model. The 95% CI is referred to as the Wald confidence interval of the odds ratios (OR) estimated from the simple logistic regression. The effective sample size n for the logistic regressions is smaller than the total sample size of 210 because subjects with missing data were excluded.

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Figure 1. Number of reported sensations from initial nicotine exposure and smoking prevalence among adolescents who reported having ever tried cigarette smoking in their lifetime—Wuhan, China, 2000. The trend was statistically significant for 30-day smoking (x2~20.88, pv.01) and for 100-cigarette smoking (x2~20.33, pv.01)

increased with the number of reported sensations experienced on initial cigarette smoking. The chisquare test indicated that this dose–response relationship was statistically significant (pv.01). Dislike for the initial cigarette smoking experience and negative prior expectations of smoking were not significantly associated with the four smoking measures included in this analysis (Table 2).

Multiple logistic regression analyses indicated that three sensations (cigarette smell, pleasurable buzz/ rush, and relaxation) were significantly and independently associated with the four smoking measures, with a few exceptions (data not shown). These three sensation variables were analyzed together with the nine control variables in one multiple logistic regression model for each smoking outcome (Table 3). The sensation cigarette smell independently predicted days smoked (OR~2.93, pv.05), number of cigarettes smoked per day (OR~2.69, pv.05) in the past 30 days, and 100-cigarette smoking (OR~5.40, pv.01). The sensation relaxation independently predicted smoking in the past 30 days (OR~3.69, pv.05), days smoked (OR~3.90, pv.01), number of cigarettes smoked per day (OR~4.48, pv.01) in the past 30 days, and 100-cigarette smoking (OR~4.12, pv.05). The sensation buzz/rush (or euphoria) independently predicted 100-cigarette smoking (OR~11.09, pv.01).

Discussion Sensations experienced from initial cigarette smoking The present study used school-based data to examine the relationship between sensations experienced during initial nicotine exposure and current smoking status among adolescents in China. This study is unique because it is one of the few studies to examine this

Table 3. Associations between self-reported initial smoking sensations and current and 100-cigarette smoking (multiple logistic regression analyses controlling for covariates)a Smoking in the past 30 days

Independent variables Control variables Smoking father Smoking mother Smoking siblings Smoking male friends Smoking female friends Rejected by friends for smoking Rejected by parents for smoking Rejected by teachers for smoking Being male Sensation variables Cigarette smell Pleasurable rush/buzz Relaxation

If smoked (n~162) OR (95% CI )

Smoked 100 cigarettes If smoked (n~114, boys only) OR (95% CI )

Days smoked (n~156) OR (95% CI )

Number smoked (n~159) OR (95% CI )

1.13 (0.38–3.35) 0.77 (0.19–3.11) 1.09 (0.47–2.52) 4.51* (1.05–19.43) 1.54 (0.64–3.72) 0.48 (0.12–1.99)

0.72 (0.26–1.95) 0.81 (0.24–2.79) 1.13 (0.51–2.48) 4.13* (1.16–14.78) 1.34 (0.60–3.00) 0.78 (0.24–2.48)

0.46 (0.17–1.19)

0.46 (0.19–1.12)

0.60 (0.26–1.39)

0.17** (0.04–0.65)

1.45 (0.60–3.50)

1.74 (0.75–4.02)

1.69 (0.78–3.66)

1.39 (0.40–4.84)

6.60** (1.88–23.17)

7.61** (2.19–26.45)

4.45** (1.61–12.31)

–

1.68 (0.69–4.08) 1.38 (0.34–10.23) 3.69** (1.33–10.23)

2.93* (1.25–6.91) 2.05 (0.64–6.64) 3.90** (1.59–9.53)

2.69* (1.23–5.88) 2.48 (0.79–7.83) 4.48** (1.86–10.79)

0.67 0.76 0.96 2.44 2.18 0.53

(0.21–2.11) (0.17–3.36) (0.39–2.39) (0.60–9.92) (0.84–5.66) (0.13–2.19)

8.17* (1.19–56.19) 0.18 (0.02–1.56) 0.37 (0.10–1.41) 99.99b (0.00–99.99) 0.80 (0.22–2.89) 1.20 (0.19–7.56)

5.40** (1.40–80.43) 11.09* (1.53–80.43) 4.12* (1.17–14.55)

*pv.05;**pv.01. a In the multiple logistic regression analyses, the four smoking measures each was used as a dependent variable for four regression models. The nine control variables and the three sensation variables all were included in each of the four logistic regression models as independent variables. The 95% CI is referred to as the Wald confidence interval of the odds ratios (OR) estimated from the logistic regression models. The effective sample size n for the logistic regressions is smaller than the total sample size of 210 because subjects with missing data were excluded. b The rather high OR (99.99) of smoking male friends for 100-cigarette smoking is the result of each of the 43 smokers in the 100cigarette smoking category reporting having at least one male smoking friend.


relationship in a school-based adolescent sample. Further, it is one of the few studies to examine sensations derived from smoking with an adolescent sample from China. Findings from this study indicated that approximately half of the Chinese adolescent smokers reported sensations similar to those commonly reported by adolescent and adult smokers in the United States (Eissenberg & Balster, 2000; Hirschman et al., 1984; Pomerleau & Pomerleau, 1992; Pomerleau et al., 1999; Pomerleau et al., 1998; Westman, Behm, & Rose, 1996). The sensations reported were cigarette smell, coughing, nausea, dizziness, relaxation, and pleasurable buzz/rush. Approximately 1/10 adolescents who had ever smoked a cigarette reported an experience of a pleasurable buzz/rush; 2/10 reported an experience of relaxation; and about half (42.5%–59.2%) reported sensations such as dizziness, nausea, or coughing. Although data obtained for this study are not directly comparable with those obtained in the United States, findings from this study suggest more similarities than differences between the United States and China in these self-reported initial nicotine sensations among adolescent smokers (Eissenberg & Balster, 2000). This result may indicate that cultural differences have a limited role in self-reported sensations from initial nicotine exposure in adolescents. If so, such a finding would greatly increase the value of selfreported sensations in tobacco control research and practice in culturally diverse populations in the United States, as well as in tobacco research and control in China, the country with the largest number of smokers in the world. Longitudinal studies are needed to further define the role of cultural and cognitive factors in selfreported initial smoking sensations. In addition to cultural differences, other factors may need to be examined to obtain an optimal measurement of sensations from initial nicotine exposure. For example, individual differences in sensitivity to stimulating sensations may affect a person’s ability to perceive and process, and hence remember, sensations experienced during initial cigarette smoking. An individual with a sensation-seeking personality trait (Zuckerman, 1990) could be more likely than others to perceive and remember sensations from initial cigarette smoking. Gender differences in sensations from initial nicotine exposure also need to be addressed.

Initial sensations as a measure of an individual’s vulnerability to nicotine The positive association between sensations from initial nicotine or tobacco exposure and subsequent cigarette smoking has been reported in various studies (Eissenberg & Balster, 2000). Consistent findings from this and other studies strongly suggest that initial nicotine sensations could be an appropriate measure

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of an individual’s vulnerability to nicotine and nicotine dependence. Although each of the six selfreported sensations in this study may be produced through different physiological, cultural, and cognitive mechanisms, logistic regression analyses demonstrated that most of the sensations were associated with an increased risk of cigarette smoking. A dose–response relationship exists between self-reported sensations and cigarette smoking when both pleasant and unpleasant sensations are combined. The more sensations a person experienced on initial cigarette smoking, the more likely he or she was to report current or established smoking. The vulnerability to nicotine would be the lowest if an individual experienced little or no sensation at all on his or her first cigarette smoking experiences. This finding supports the position that people who experienced something on their first cigarette smoking experience are at an increased risk for picking up a cigarette later (McKay & Schare, 1999; Sofuoglu, Brown, Dudish-Poulsen, & Hatsukami, 2000; Stacy, Galaif, Sussman, & Dent, 1996). Of the six self-reported sensations, cigarette smell, pleasurable buzz/rush, and relaxation appear to be critical for measuring an individual’s vulnerability to nicotine. Multiple logistic regression analyses with and without controls for confounding variables indicated that these three sensations showed the strongest and most consistent associations with current and established smoking. The findings for pleasurable buzz/rush and relaxation sensations are consistent with findings from other studies (Eissenberg & Balster, 2000; Kassel, Shiffman, Gnys, Paty, & Zettler-Segal, 1994; Middlecamp et al., 2001; Shadel et al., 2000; Wang et al., 1995). However, the finding that the sensation cigarette smell is related to current and established smoking is new. This finding suggests that individuals who interpret the smell of the cigarette as enjoyable during the initial cigarette smoking experience are at a greater risk for continuing their nicotine intake in the future and for the development of nicotine dependence. Further, an individual’s vulnerability to nicotine will be high if the individual experiences the sensations cigarette smell, pleasurable buzz/rush, or relaxation on the initial tobacco or nicotine exposure, regardless of the experience of any other sensations.

Sensations from initial exposure to nicotine and adolescent smoking prevention and cessation The significant impact of sensations from initial nicotine exposure on current and established smoking suggests the importance of knowing these initial sensations in adolescent smoking prevention and cessation interventions. To effectively control tobacco use, interventions should consider the initial sensations experienced by adolescents because these sensations are associated with different risk levels for cigarette smoking and nicotine dependence. We

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suggest that data on sensations from initial cigarette smoking be included as part of the basic information used to develop adolescent smoking prevention and cessation programs. To help adolescents in the early stage of smoking behavior to stop smoking, and to help them successfully quit if they become addicted smokers, intervention modalities should incorporate this easily observable difference in vulnerability to nicotine. Sensations from initial exposure to smoking also may be included as routine baseline measures when implementing adolescent smoking intervention programs. For intervention purposes, information about the sensations thus can be used to identify adolescent smokers with different risk levels.

Limitations The present study has several limitations. The data used for this analysis that measured sensations as well as smoking behaviors were obtained through retrospective report; possible biases in memory are unavoidable because of individual differences in smoking experiences, such as length and frequency of cigarette smoking. Sensations reported by subjects who were current smokers and who smoked frequently might be biased by their previous smoking experiences (Stacy et al., 1994). In addition, data from this study were cross-sectional in nature; therefore, a causal relationship cannot be established without further supportive evidence. The ideal approach for this type of research would be to use processdependent measurement techniques such as experiential sampling or real-time monitoring (Campbell, Dollaghan, Needleman, & Janosky, 1997; Delle Fave & Bassi, 2000; Eissenberg & Balster, 2000; Loewenstein, Hamilton, Alagna, Reid, & deVries, 1987). The study also lacked female subjects, which limited investigation of the obvious gender differences in initial sensations and their impacts on later smoking behavior (Friedman, Lichtenstein, & Biglan, 1985; Silverstein, Kelly, Swan, & Kozlowski, 1982). Despite these limitations, results from this study are useful for documenting the predictive effects of individual differences in initial responses to cigarette smoking and nicotine exposure on current cigarette smoking and nicotine dependence. Some of the results were remarkably consistent with those obtained from quite different populations. Self-reported sensations generally were not associated with respondents’ age at survey, indicating no age-related bias. Findings from this study can inform further studies to fully validate sensations from initial nicotine exposure as a measure of an individual’s vulnerability to nicotine, as well as intervention studies to develop more effective smoking prevention and cessation programs.

Acknowledgments This study was supported by the USC junior faculty grant (ACS IRG58-007-41) and NIH Transdisciplinary Tobacco Research Center grant (P 150 CA84735-01). The Wuhan Public Health and Anti-Epidemic Station, China, provided support for field data collection.

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