Abstract
Introduction:
Young adults who avoid their emotions may be at risk for starting smoking or not quitting smoking. This study investigated whether a preliminary measure of avoidant coping longitudinally predicts young adults’ smoking escalation and cessation.
Methods:
In a sample of the 3,305 participants, originally from Washington State, a preliminary measure of self-reported avoidant coping at age 18 was used to predict both smoking escalation and cessation at ages 20 and 28 with both probability and logistic regression models (10-year retention: 98.5%).
Results:
Individuals who scored high on avoidant coping at 18 were 2.52 (p = .001) times more likely to acquire smoking by 20. However, there was no evidence that avoidant coping at age 18 predicted smoking escalation at 28 or cessation for 20- and 28-year-olds.
Conclusions:
An avoidant coping style may have a short-term effect on young adults’ smoking acquisition. Future research using a precise and well-validated measure of avoidant coping is now needed to test this possibility.
Introduction
Young adult smoking remains at high levels (21%; Centers for Disease Control and Prevention, 2009). Accordingly, understanding why young adults escalate or stop smoking would help identify specific targets for smoking prevention or cessation programs. The purpose of this brief report is to examine whether an avoidant coping style is one factor that may explain why young adults smoke or fail to quit smoking.
The Paradox of Avoidant Coping and Its Implications for Smoking
Recent research has focused on the paradoxical role of avoidant coping in health behavior (Erskine, Georgiou, & Kvavilashvili, 2010; Wegner & Erskine, 2003). Avoidant coping is defined as the tendency to divert attention away from aversive emotions, thoughts, and physical sensations elicited by challenging situations (Krohne & Egloff, 2005). An avoidant coping style may paradoxically increase the very emotions, thoughts, and sensations that an individual is trying to avoid. For example, recent research has demonstrated that efforts to avoid thinking about a topic (e.g., smoking) can actually increase the thinking about that specific topic (e.g., thinking about smoking) and increase behaviors associated with the topic (e.g., smoking; Erskine et al., 2010; Wegner & Erskine, 2003).
We propose that smoking may play an important role in this paradox. Specifically, individuals with avoidant coping styles may use smoking as one way to avoid noticing aversive thoughts, emotions, and sensations. Indeed, we propose that those with avoidant coping styles increase their smoking behavior (e.g., escalate to daily smoking) through this continuous feedback loop: aversive emotional state→smoking in order to avoid aversive emotional state→paradoxical increase in aversive emotional state→smoking in order to avoid aversive emotional state. Furthermore, we posit that a similar feedback loop may impede their success in quitting smoking: withdrawal symptoms and urges→smoking in order to avoid withdrawal symptoms and urges→paradoxical increase in withdrawal symptoms and urges→smoking in order to avoid withdrawal symptoms and urges.
To help empirically establish the basis for these feedback loops, examining the extent to which avoidant coping predicts young adult smoking escalation and cessation would be valuable. Data on such predictions are rare. To date, only one study has examined the role of avoidant coping in adolescent smoking (Dugan, Lloyd, & Lucas, 1999). Specifically, in a 6-month prospective study of 3,542 (74% retention), an avoidant coping style predicted an increase in adolescent smoking acquisition. Regarding the role of avoidant coping in young adulthood, Hussong and Chassin (2004) found no cross-sectional association between avoidant coping and substance use. No prospective studies of the relationships between avoidant coping and young adult smoking have been reported.
Stress as a Moderator
Higher levels of life stress may increase aversive emotions, thereby strengthening the link between smoking to avoid aversive emotions and subsequent paradoxical increases in aversive emotions. The relationship between stress and substance use is well established (Cooper, Wood, Orcutt, & Albino, 2003; Dugan et al., 1999; Wagner et al., 1999; Wills, Sandy, Yaeger, Cleary, & Shinar, 2001). Hussong and Chassin (2004) reported that young adult alcohol use, but not drug use, was cross-sectionally related to an interaction between avoidant coping and young adult transition-related stress. However, no studies to date have examined whether stress moderates the association between an avoidant coping style and smoking.
This Study
Using a large heterogeneous population-based longitudinal sample surveyed at ages 18, 20, and 28 years, we will test these two hypotheses with a preliminary measure of avoidant coping:
Hypothesis 1: The 18-year-olds who score high on avoidant coping will be more likely to escalate to daily smoking and to have not quit smoking between ages 18 and 20 and between ages 20 and 28 years.
Hypothesis 2: Age 18 life stress will moderate the relationship between avoidant coping and these smoking transitions. Specifically, the association between avoidant coping and smoking escalation or cessation will be stronger among those who report high levels of life stress than among those who report low levels of life stress.
Methods
This study used data from the landmark Hutchinson Smoking Prevention Project (HSPP)—a 15-year, 40 school district school-based tobacco use prevention randomized trial (Peterson, Kealey, Mann, Marek, & Sarason, 2000).
Inclusion criteria: (a) provision of age 18 baseline data: the participants’ baseline smoking status, avoidant coping status, and life stress over the past year; (b) provision of age 20 and 28 follow-up data: participants’ smoking status. There were 3,355 18-year-olds who provided baseline data of whom 3,305 (98.5% retention) provided age 20 and 28 follow-up data. The sample was 50.7% male, 90.8% Caucasian, and 23% were at-least-daily smokers at age 18.
Procedures
Participants’ data were collected via self-report at age 18 in a classroom survey or by mail/telephone survey. At ages 20 and 28, the participants reported their smoking status by a mail/telephone follow-up survey. The Fred Hutchinson Cancer Research Center's Institutional Review Board annually approved these procedures.
Measures
Avoidant Coping Style
An avoidant coping style was measured at age 18. A psychometrically validated avoidant coping measure that had high reliability would have been ideal. However, in order to survey a large number of participants with high long-term data retention, the preliminary measure of avoidant coping was limited to only two items: “When I have a problem, I usually just give up” and “If something does not go well, I keep at it until it does” (reverse coded). These items were nearly identical to those of avoidant coping items used in previous studies (Carver, 1997; Carver, Scheier, & Weintraub, 1989). The response options were just like me (coded 0), somewhat like me (coded 1), only a little like me (coded 2), and not like me (coded 3). In a principal-components factor analysis, there was strong evidence for one factor (eigenvalue = 1.42) that explained 71% of the total variance of the two items (α = .59, M = 1.05, SD = 1.09).
Life Stress
Life stress was measured with a single item when the participant was 18 years. The item was “I had a lot of stress in my life last year,” with response options identical to the avoidant coping scale (M = 0.99; SD = 1.01).
Outcome Variables
Smoking datapoints at age 20 and 28 marked the key periods of early young adulthood and late young adulthood. Escalation during the age 18- to 20-year interval transition was defined as increasing from (a) less-than-daily current smoking and not having smoked at least 100 lifetime cigarettes at age 18 to (b) at-least-daily current smoking and having smoked at least 100 lifetime cigarettes at age 20. Escalation during the age 20- to 28-year interval was defined using the same smoking frequency criteria. Escalation to daily smoking is important because it is associated with tobacco dependence and serious short-term and long-term health consequences (Chassin, Presson, Pitts, & Sherman, 2000; Holmen, Barrett-Connor, Holmen, & Bjermer, 2000).
Smoking cessation during the age 18- to 20-year interval was defined as (a) at-least-daily current smoking and having smoked 100 lifetime cigarettes at age 18 and (b) having quit smoking for at least one month at age 20. Cessation during the age 20- to 28-year interval was defined using the same criteria, except that cessation was for at least twelve months at age 28. While a substantial duration of cessation would be ideal (e.g., at least twelve months) for the age 20 outcome, only a small number of individuals had quit for a year because only 2 years had passed since the age 18 assessment. Demographic characteristics by smoking outcomes are shown in Table 1.
Table 1.
Demographic Characteristics by Smoking Outcomes
| Demographic | Smoking interval: 18–20 years |
Smoking interval: 20–28 years |
||
| Acquired | Quit smoking | Acquired | Quit smoking | |
| Analysis sample size | 2,786 | 460 | 2,684 | 541 |
| Gender, n (%) | ||||
| Males | 1,367 (49) | 224 (49) | 1,307 (49) | 267 (49) |
| Females | 1,419 (51) | 236 (51) | 1,377 (51) | 274 (51) |
| Parent's level of education, n (%) | ||||
| ≤High school | 771 (30) | 167 (40) | 731 (30) | 198 (40) |
| >High school | 1799 (70) | 248 (60) | 1,742 (70) | 294 (60) |
| Avoidant coping category, n (%) | ||||
| 1st Quartile (low), score = 0 | 1,128 (26) | 117 (25) | 1,109 (41) | 127 (24) |
| 2nd Quartile (mild), score = 1 | 896 (32) | 159 (34) | 852 (32) | 196 (36) |
| 3rd Quartile (moderate), score = 2 | 499 (18) | 111 (24) | 470 (18) | 133 (25) |
| 4th Quartile (high), score = 3+ | 263 (9) | 74 (16) | 253 (9) | 85 (16) |
Analytic Strategy
We used logistic regression models to examine to what extent avoidant coping predicts the absolute probability that an individual would make escalate or quit smoking. The first two models expressed the absolute probability of escalating to daily smoking during the period ages 18–20 (first model) and 20–28 (second model) as a function of scoring high on avoidant coping at age 18. The second set of two models expressed the absolute probability of quitting smoking during the periods 18–20 (first model) and 20–28 (second model) as a function of the same variable. All probabilities ranged from 0 to 1 and were generated with Stata's prvalue function, which uses the delta method to transform the logistic regression model coefficients of interest into probabilities while holding other adjustment covariates at their mean values. See our prior papers for more information about these probability models (e.g., Bricker et al., 2009). In addition to the probability models, we also provide readers the traditionally reported odds ratios from logistic regression models.
With each model, a Wald test for heterogeneity was used to assess the influence of avoidant coping at the quartiles of this measure. A Wald test for interaction was also used to examine the moderating effect of life stress. A linear test for trend was conducted by including an ordered variable (e.g., avoidant coping or stress) in the regression model as a continuous covariate to demonstrate if any monotonic relationship existed between the degree of avoidant coping and the probability of smoking escalation and cessation.
Covariates
All models adjusted for gender, parents’ highest level of education (less than high school [HS] and greater than or equal to HS), and the condition (i.e., control vs. experimental). In addition, all models accounted for intraclass correlations due to clustering within a school district by using Stata's cluster variance estimation option. Per HSPP trial design specifications, all 40 districts had one HS per district (Peterson et al., 2000). Therefore, clustering by school district was analytically the same as that by HS. All statistical analyses were conducted with Stata Statistical Software (version 10.0).
Results
Probabilities of Smoking Escalation During the 18- to 20-Year Age Interval
As shown in Table 2, column two, participants scoring in the first quartile (i.e., low avoidant coping) had the lowest probability (5.6%) of escalating during the 18- to 20-year age interval, whereas participants scoring in the fourth quartile (i.e., high avoidant coping) had an 11.3% probability of escalating during the 18- to 20-year age interval. The odds ratios indicate that there was a 2.52 (95% CI: 1.46–4.34) times higher odds of escalating for participants in the fourth quartile of avoidant coping than for those in the first quartile of avoidant coping. Supporting these findings, the test for heterogeneity (p = .001) indicated that there was an overall difference in the probabilities across the quartiles, and the test for linear trend (p < .001) indicated that the probabilities increase from the lowest to the highest quartiles.
Table 2.
The Probabilities and Odds of Escalation and Cessation, Given One's Level of Avoidant Coping
| Avoidant coping at age 18 | Smoking interval: 18–20 yearsProbability of influence (95% CI), OR (95% CI) |
Smoking Interval: 20–28 years Probability of influence (95% CI), OR (95% CI) |
||
| Escalation | Quit smoking | Escalation | Quit smoking | |
| 1st Quartile (low) score = 0, n = 1,268 | 5.6% (3.9–7.2), – | 19.2% (11.7–26.7), – | 4.4% (3.1–5.7), – | 26.3% (19.4–33.2), – |
| 2nd Quartile (mild) score = 1, n = 1,068 | 9.1% (6.5–11.6), 1.86 (1.27–2.73) | 16.2% (11.4–21.1), 0.82 (0.46–1.46) | 5.2% (3.4–6.9), 1.18 (0.50–1.91) | 21.0% (16.7–25.3), 0.75 (0.48–1.16) |
| 3rd Quartile (moderate) score = 2, n = 625 | 9.3% (6.4–12.2), 1.86 (1.22–2.84) | 9.7% (2.7–16.6), 0.45 (0.17–1.21) | 4.7% (3.0–6.5), 1.07 (0.66–1.76) | 24.3% (17.7–30.9), 0.90 (0.57–1.42) |
| 4th Quartile (high) score = 3+, n = 344 | 11.3% (6.6–16.0), 2.52 (1.46–4.34) | 22.6% (10.2–35.0), 1.23 (0.52–2.91) | 5.3% (2.4–8.2), 1.21 (0.62–2.39) | 18.9% (10.3–27.4), 0.65 (0.35–1.23) |
| Analysis sample size | 2,786 | 460 | 2,684 | 541 |
| Wald's test | 0.001 | 0.273 | 0.877 | 0.380 |
| Test for trend | <0.001 | 0.859 | 0.582 | 0.320 |
| Test for interaction with stress at age 18 | 0.593 | 0.828 | 0.571 | 0.927 |
Note. Data were included in the acquisition analyses if the study participant was not a daily smoker at the previous timepoint. Similarly, analyses of smoking cessation were conditional upon daily smokers at the previous follow-up timepoint. All models adjusted for the following covariates: gender, parents’ highest level of education, experimental group, and school district. OR = odds ratio.
All Other Probabilities
The probabilities of quitting smoking during the 18- to 20-year age interval ranged from 9.7% to 22.6% (Table 1, column three). The probabilities of escalating during the 20- to 28-year age interval ranged from 4.4% to 5.3% (column four). The probabilities of quitting smoking during the 20- to 28-year age interval ranged from 18.9% to 26.3% (column five). However, the Wald test and trend test showed no evidence of a difference in these probabilities. Finally, as shown across the bottom row, life stress did not have a significant moderating relationship with any of these predictions (all p > .05).
Discussion
Using ten years of longitudinal data (N = 3,305) with a retention rate of 98.5%, this study found support for Hypothesis 1's 18- to 20-year age interval: 18-year-olds who scored high on the preliminary measure of avoidant coping were 2.52 times more likely to make the transition from less-than-daily smoking to at-least-daily smoking by age 20. However, there was no other support for Hypothesis 1. And there was no support for Hypothesis 2, which may be due to the life stress measure's limitations and underpowered interaction tests. Generalizeability is impacted by the sample being primarily Caucasian and originating from Washington State.
There are various explanations as to why the preliminary measure of avoidant coping at age 18 predicted smoking escalation by age 20 but did not predict smoking escalation by age 28. First, the prospective relationship between avoidant coping and smoking may be altered by adult social role changes—for example, marriage and parenthood. Entering into these adult social roles may buffer, or even nullify, the relationship between avoidant coping and smoking. Second, the avoidant coping measure, while showing a promising predictive validity and factorial structure, was preliminary and lacked precision. Future research using a fully validated measure of avoidant coping (e.g., Carver et al., 1989; Herman-Stabl, Stemmler, & Petersen, 1995) is now needed as the next step to determine the prospective role of avoidant coping in young adult smoking.
Funding
This work partially supported by National Cancer Institute grants R01 CA 082569 and R01 CA 109652.
Declaration of Interests
None declared.
Acknowledgments
We gratefully acknowledge the individuals who participated as well as the staff and administrators of the 40 collaborating Washington State school districts. The authors also thank Anya Luke-Killam for editorial assistance in the preparation of this manuscript.
References
- Bricker JB, Rajan BK, Zalewski M, Andersen MR, Ramey M, Peterson AV. Psychological and social risk factors in adolescent smoking transitions: A population-based longitudinal study. Health Psychology. 2009;28:439–447. doi: 10.1037/a0014568. doi:10.1037/a0014568. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Carver CS. You want to measure coping but your protocol's too long: Consider the brief COPE. International Journal of Behavioral Medicine. 1997;4:92–100. doi: 10.1207/s15327558ijbm0401_6. doi:10.1207/s15327558ijbm0401_6. [DOI] [PubMed] [Google Scholar]
- Carver CS, Schneier MF, Weintraub JK. Assessing coping strategies: A theoretically based approach. Journal of Personality and Social Psychology. 1989;56:267–283. doi: 10.1037//0022-3514.56.2.267. doi:10.1037/0022-3514.56.2.267. [DOI] [PubMed] [Google Scholar]
- Centers for Disease Control and Prevention. Cigarette smoking among adults and trends in smoking cessation—United States, 2008. Morbidity and Mortality Weekly Reports. 2009;58:1227–1232. Retrieved from http://www.cdc.gov/mmwr. [PubMed] [Google Scholar]
- Chassin L, Presson CC, Pitts SC, Sherman SJ. The natural history of cigarette smoking from adolescence to adulthood in a midwestern community sample: Multiple trajectories and their psychosocial correlates. Health Psychology. 2000;19:223–231. doi:10.1037/0278-6133.19.3.223. [PubMed] [Google Scholar]
- Cooper ML, Wood PK, Orcutt HK, Albino A. Personality and the predisposition to engage in risky or problem behaviors during adolescence. Journal of Personality and Social Psychology. 2003;84:390–410. doi: 10.1037//0022-3514.84.2.390. doi:10.1037/0022-3514.84.2.390. [DOI] [PubMed] [Google Scholar]
- Dugan S, Lloyd B, Lucas K. Stress and coping as determinants of adolescent smoking behavior. Journal of Applied Social Psychology. 1999;29:870–886. doi:10.1111/j.1559-1816.1999.tb02030.x. [Google Scholar]
- Erskine JAK, Georgiou GJ, Kvavilashvili L. I suppress, therefore I smoke: Effects of thought suppression on smoking behavior. Psychological Science. 2010;21:1225–1230. doi: 10.1177/0956797610378687. doi:10.1177/0956797610378687. [DOI] [PubMed] [Google Scholar]
- Herman-Stabl MA, Stemmler M, Petersen AC. Approach and avoidant coping: Implications for adolescent mental health. Journal of Youth and Adolescence. 1995;24:649–665. doi:10.1007/BF01536949. [Google Scholar]
- Holmen TL, Barrett-Connor E, Holmen J, Bjermer L. Adolescent occasional smokers, a target group for smoking cessation? The Nord-Trondelag Health Study, Norway, 1995–1997. Preventive Medicine. 2000;31:682–690. doi: 10.1006/pmed.2000.0750. doi:10.1006/pmed.2000.0750. [DOI] [PubMed] [Google Scholar]
- Hussong AM, Chassin L. Stress and coping among children of alcoholic parents through the young adult transition. Development and Psychopathology. 2004;16:985–1006. doi: 10.1017/s0954579404040106. doi:10.1017/S0954579404040106. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Krohne HW, Egloff B. Vigilant and avoidant coping: Theory and measurement. In: Spielberg CD, Sarason RC, editors. Stress and emotion: Anxiety, anger, and curiosity. New York: Taylor & Francis Group, LLC; 2005. pp. 97–113. [Google Scholar]
- Peterson AV, Kealey KA, Mann SL, Marek PM, Sarason IG. Hutchinson smoking prevention project: Long-term randomized trial in school-based tobacco use prevention-results on smoking. Journal of the National Cancer Institute. 2000;92:1979–1991. doi: 10.1093/jnci/92.24.1979. doi:10.1093/jnci/92.24.1979. [DOI] [PubMed] [Google Scholar]
- Wagner EF, Myers MG, McIninch JL. Stress-coping and temptation-coping as predictors of adolescent substance use. Addictive Behaviors. 1999;24:769–779. doi: 10.1016/s0306-4603(99)00058-1. doi: 10.1016/S0306-4603(99)00058-1. [DOI] [PubMed] [Google Scholar]
- Wegner DM, Erskine JAK. Voluntary involuntariness: Thought suppression and the regulation of the experience of will. Consciousness and Cognition. 2003;12:684–694. doi: 10.1016/s1053-8100(03)00054-0. doi:10.1016/S1053-8100(03)00054-0. [DOI] [PubMed] [Google Scholar]
- Wills TA, Sandy JM, Yaeger AM, Cleary SD, Shinar O. Coping dimensions, life stress, and adolescent substance use: A latent growth analysis. Journal of Abnormal Psychology. 2001;110:309–323. doi: 10.1037//0021-843x.110.2.309. doi:10.1037/0021-843X.110.2.309. [DOI] [PubMed] [Google Scholar]