The Influence of Attachment Phenomena on Alcohol and Tobacco Use by Thao Lan Le A thesis submitted in conformity with the requirements for the degree of Doctor of Philosophy Institute of Medical Science University of Toronto © Copyright by Thao Lan Le 2017 The Influence of Attachment Phenomena on Alcohol and Tobacco Use Thao Lan Le Doctor of Philosophy Institute of Medical Science University of Toronto 2017 Abstract Alcohol and tobacco use are leading causes of preventable death. Studying novel determinants of substance use may inform prevention and cessation. Attachment insecurity (attachment avoidance and attachment anxiety) describes interactions between adults and their attachment figures, which may influence substance use. This thesis assessed how attachment may be relevant in understanding and addressing substance use. Study 1, a cross-sectional survey study of 348 adult primary care patients, tested hypothesized associations between childhood adversity, attachment insecurity and substance use; if attachment insecurity could mediate between childhood adversity and substance use; and hypothesized sex differences in these associations. In Study 2, 38 smokers participated in experiments designed to assess the influence of cigarette cues and an attachment figure photo on craving and affect. In Study 1, 61% of participants reported childhood adversity, 11% reported harmful drinking and 20% reported current smoking. Attachment anxiety was associated with harmful drinking in ii women and men. Attachment anxiety was a statistical mediator between childhood adversity and harmful drinking (95% CI 0.09 to 0.30). Sex did not moderate the relationship between attachment anxiety and hazardous drinking in this mediation model. In women, attachment anxiety was associated with both childhood adversity (p=.002) and current smoking (p=.04), and was a statistical mediator between childhood adversity and smoking (95% CI 0.003 to 0.236). In Study 2, 56% of participants reported decreased craving after seeing an attachment figure photo (Neutral photo = 50.9 (SD 29.8), Attachment figure photo = 38.2 (SD 31.6), t(35)= -2.661, p=0.01). Cigarette cues (d=.50) and the attachment figure photo (d=.42) had similar effect sizes. Cigarette cue reactivity and attachment figure smoking status did not influence responses to photo exposures. Attachment anxiety was associated with alcohol and tobacco use, and may mediate between childhood adversity and substance use. Viewing an attachment figure photo decreased craving in smokers, with an effect that is comparable to the increase caused by cigarette cues. These studies indicate that attachment phenomena may play a role in substance use. Childhood adversity, attachment anxiety, and the presence of an attachment figure are factors to consider in the design of prevention and cessation strategies. iii Acknowledgments Jeff, thank you for being my sounding board, for helping me refine my thinking and for building my confidence. Ba, thank you for your encouragement in the form of kind words and comforting homemade food. Dr. Robert Maunder, thank you for your supervision. You have taught me that an orchid, under certain conditions, can also be a sunflower. Dr. Robert Mann, Dr. Robert Levitan, Dr. Tony George, thank you for your personal and scientific support over the last 6 years as members of my program advisory committee. I am glad to have gotten to know you and look forward to future collaborations. Dr. Souraya Sidani, while you are no longer formally involved with my committee, you have been always willing, able and available when I sought support. Your generosity has been immensely appreciated and inspiring. Dr. Hayley Hamilton, Dr. Cynthia Conklin, thank you for your help and time as members of my examination committee. Thank you to the sources of funding: Ashley Studentships for Tobacco Research (Ontario Tobacco Research Unit), The Queen Elizabeth II/H. David Archibald Graduate Scholarships in Science and Technology (QEII-GSST), Intersections of Mental Health Perspectives in Addictions Research Training Fellowship (CIHR), Malka and Al Green Fellowship in Psychiatry, July and Samuel Pencer Studentship in Psychiatry, Bernard Ghert Fellowship in Psychiatry (Mount Sinai Hospital, Psychiatry). Last, but not least, thank you to all the participants who made this body of work possible. Each one of you has taught me something. iv Contributions Chapter 1: Introduction & Chapter 2: Research Aims and hypotheses Contribution statement and acknowledgements: The content of these chapters was conceived, drafted, and revised by me. Robert Maunder provided comments and suggested revisions. Chapter 3: Childhood adversity and alcohol consumption: the mediating role of attachment insecurity & Chapter 4: Sex differences in the relationships between childhood adversity, attachment insecurity and current smoking Citation: Le, T.L., Levitan, R.D., Mann, R. E., & Maunder, R.G. (2017). Childhood adversity and alcohol consumption: the mediating role of attachment insecurity. Revisions under review in American Journal of Drug and Alcohol Abuse. Citation: Le, T.L., Mann, R. E., Levitan, R.D., George, T.P., & Maunder, R.G. (2017). Sex differences in the relationships between childhood adversity, attachment anxiety and smoking. Addiction Research and Theory, 25(2), 146-153. Contribution statement and acknowledgements: My roles in this study included the following: 1) conceiving and designing the study, 2) recruiting participants, 3) implementing surveys, 4) designing and managing the database, 5) statistical analyses, 6) writing the manuscript, 7) submitting and revising the manuscript for publication, and 8) communicating results through conference presentations. I thus played a primary role in every aspect of this study. Robert Maunder supervised all aspects of my involvement in this study, and made contributions to the study design, data interpretation, and writing the manuscript. All authors provided critical revision of the manuscript for important intellectual content. We thank the participants who made this study possible, Yves Talbot, Cleo Haber and the Granovsky Gluskin Family Medicine Center at Mount Sinai Hospital for their support with the study. In addition, we would like to acknowledge Souraya Sidani for her statistical guidance. v Chapter 5: A Photo Of An Attachment Figure Decreases Craving in Smokers Citation: Le, T.L., George, T. P, Levitan, R.D., Mann, R. E., & Maunder, R.G. (2017). A Photo Of An Attachment Figure Decreases Craving in Smokers. Submitted to Addictive Behaviors. Contribution statement and acknowledgements: My roles in this study included the following: 1) conceiving and designing the study, 2) recruiting participants, 3) conducting experiments, 4) designing and managing the database, 5) statistical analyses, 6) writing the manuscript, 7) submitting and revising the manuscript for publication. I thus played a primary role in every aspect of this study. Robert Maunder supervised all aspects of my involvement in this study, and made contributions to the study design, data interpretation, and writing the manuscript. All authors provided critical revision of the manuscript for important intellectual content. We thank the participants who made this study possible. In addition, we would like to acknowledge Souraya Sidani for her statistical guidance. Chapter 6: General discussion and Chapter 7: Conclusions and Implications Contribution statement and acknowledgements: The content of this chapter was conceived, drafted, and revised by me. Robert Maunder provided comments and suggested revisions. vi Table of Contents Acknowledgments .......................................................................................................................... iv Contributions ................................................................................................................................... v Table of Contents .......................................................................................................................... vii List of Tables ................................................................................................................................. xii List of Figures ............................................................................................................................... xiv Abbreviations ............................................................................................................................... xvi Chapter 1 Introduction ................................................................................................................... 17 1 Overview ................................................................................................................................... 17 1.1 Substance Use .................................................................................................................... 17 1.1.1 Determinants of Alcohol and Tobacco Use ........................................................... 18 1.1.2 Measures of substance use ..................................................................................... 18 1.1.3 Studying cue reactivity in smokers ........................................................................ 23 1.2 Childhood Adversity ......................................................................................................... 28 1.2.1 Issues in researching childhood adversity ............................................................. 28 1.2.2 Reliability and validity