The Effect of Asthma on Smoking Behavior and Smoking-Related Cognitive Processes among Adult Smokers A thesis submitted to the Division of Graduate Education and Research of the University of Cincinnati in partial fulfillment of the requirements for the degree of Master of Arts in the Department of Psychology of the College of Arts and Sciences July 2011 by Kimberly M. Avallone B.S., University of Florida, 2008 Committee: Alison C. McLeish, Ph.D. (chair) Christine A. Hovanitz, Ph.D. Farrah Jacquez, Ph.D. Abstract Despite the negative effects of smoking on lung functioning and overall health, smoking is more prevalent among individuals with asthma compared to those without. The purpose of the current study was to replicate and extend past work on asthma and smoking by examining the unique predictive ability of asthma diagnosis in terms of smoking behavior and smoking-related cognitive processes among adult daily smokers. Participants were 251 regular daily smokers: 125 smokers with self-reported, physician-diagnosed asthma (54% male; Mage = 37.66 years, SD = 12.12) and 126 smokers without asthma (70.4% male; Mage = 36.51 years, SD = 13.05) who completed a battery of self-report measures. Partially consistent with hypotheses, after controlling for gender, race, number of medical problems, and alcohol consumption, asthma diagnosis was a significant predictor of age of regular smoking onset (1.9% unique variance), number of quit attempts (2.5% unique variance), and self-control reasons for quitting (2.6% unique variance). Results for nicotine dependence and daily smoking rate approached significance. Contrary to prediction, asthma diagnosis did not significantly predict smoking motives, reasons for quitting related to health concerns, or barriers to cessation. The primary implication of the present findings is that while there are few differences between smokers with and without asthma in terms of smoking behaviors and smoking-related cognitive processes, the differences that do exist suggest that current smoking cessation interventions may not be as effective for smokers with asthma and targeted, specialized interventions need to be developed. Keywords: asthma, cigarette smoking, smoking motives, smoking cessation ii Page Intentionally Left Blank iii Table of Contents Abstract ................................................................................................................................................... ii Table of Contents................................................................................................................................. iv List of Tables...........................................................................................................................................v Introduction........................................................................................................................................... 1 Asthma ............................................................................................................................................................... 1 Cigarette Smoking......................................................................................................................................... 3 Asthma and Smoking Co-occurrence ................................................................................................... 4 Effects of Smoking on Asthma Severity............................................................................................... 5 Smoking-Related Cognitive Processes ................................................................................................ 6 Smoking-Related Cognitive Processes Among Smokers with Asthma.................................. 8 Conclusions and Limitations of Previous Research.....................................................................10 Present Study................................................................................................................................................11 Method...................................................................................................................................................11 Participants ....................................................................................................................................................11 Measures .........................................................................................................................................................14 Procedure........................................................................................................................................................18 Results....................................................................................................................................................18 Analytic Approach.......................................................................................................................................18 Bivariate Correlations among Covariates and Predictor Variable...........................................20 Bivariate Correlations among Covariates and Criterion Variables .........................................20 Bivariate Correlations among Predictor and Criterion Variables ............................................20 Hierarchical Multiple Regression Analyses......................................................................................21 Discussion.............................................................................................................................................24 Asthma Diagnosis and Smoking Behavior .......................................................................................24 Asthma Diagnosis and Smoking-Related Cognitive Processes...............................................26 Limitations and Future Directions ........................................................................................................28 Conclusions ...................................................................................................................................................31 References ............................................................................................................................................33 iv List of Tables Table 1: Asthma Severity Classification………………………………………………………….44 Table 2: Descriptive Data for Covariates, Predictor, and Criterion Variables……………..45 Table 3: Intercorrelations among Covariates, Predictor, and Criterion Variables………..46 Table 4: Asthma Diagnosis Predicting Smoking Behavior……………………………………47 Table 5: Asthma Diagnosis Predicting Reasons for Smoking (RFS)………………………..48 Table 6: Asthma Diagnosis Predicting Reasons for Quitting (RFQ) and Barriers to Cessation……………………………………………………………………………………………….49 v Introduction Asthma Over 20 million individuals in the United States currently suffer from asthma, a reversible obstructive airway disease that consists of chronic airway inflammation and episodes of exacerbations in response to certain stimuli (America Lung Association [ALA], 2010a). These airway exacerbations, or asthma attacks, include swelling of the airway lining, tightening of the muscles around the airways, and increased mucus production, resulting in symptoms of wheezing, coughing, chest tightness, and shortness of breath (ALA, 2010b). Common triggers for an asthma attack include allergens and irritants, such as dust mites, pollen, cockroaches, outdoor air pollution, pets, mold, environmental tobacco smoke, exercise, and changes in weather (e.g., increased humidity, cold temperatures; ALA, 2008). Asthma attacks are common among those with asthma; approximately 56% of individuals with asthma experience one or more asthma attacks per year (Center for Disease Control [CDC], 2007). If not well controlled through medical intervention, asthma can result in significant rates of morbidity and mortality (ALA, 2008). For example, individuals with asthma are at greater risk for experiencing complications from respiratory illnesses (e.g., influenza, bronchitis, pneumonia) due to the chronic airway inflammation associated with the disease (ALA, 2008). The lifetime prevalence rate of asthma among adults in the United States (U.S.) is 13.3%, and females are 10.5% more likely than males to have ever received an asthma diagnosis (ALA, 2010c). Females also have consistently higher prevalence rates of asthma attacks per year than males (ALA, 2010c). Asthma is generally diagnosed by physician determination of the presence of recurrent episodes of airflow obstruction (usually at least partially reversible) or airway hyperresponsiveness (National Heart, Lung, and Blood Institute [NHLBI], 2007). The classification of asthma severity is typically completed through physical exam to assess an individual’s lung functioning, frequency of symptoms, and frequency of rescue inhaler use. Lung functioning is assessed via spirometry, which measures peak 1 expiratory flow rates and forced expiratory volume in one second (FEV; Sims, 2006). In both cases, the lower the number, the more severe the level of impairment. Based on the findings from this assessment, patients can be placed into one of the following categories of severity: intermittent, mild persistent, moderate persistent, or severe persistent (NHLBI, 2007). Please see Table 1 for a more detailed description of asthma severity classification for individuals over 12 years of age. Although the exact etiology of asthma is currently unknown, a great deal of information is currently available about