Addictive Behaviors 33 (2008) 1441–1447

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Addictive Behaviors

Relationship between PTSD symptomatology and nicotine dependenceseverity in crime victims

Joseph S. Baschnagel a,⁎, Scott F. Coffey a, Julie A. Schumacher a, David J. Drobes b,Michael E. Saladin c,d

a The University at Mississippi Medical Center, Department of Psychiatry and Human Behavior, 2500 North State St. Jackson, MS 39216, USAb University of South Florida, H. Lee Cancer Center and Research Institute, 4115 E. Fowler Ave., Tampa, FL 33617, USAc Medical University of South Carolina, Department of Rehabilitation Sciences Suite 17, PO Box 250700, 77 President St., Charleston, SC 29425 USAd Medical University of South Carolina, Department of Psychiatry, USA

a r t i c l e i n f o

⁎ Corresponding author. Tel.: +1 601 984 5957; fax:E-mail addresses: jbaschnagel@psychiatry.umsmed

(J.A. Schumacher), david.drobes@moffitt.org (D.J. Drob

0306-4603/$ – see front matter © 2008 Elsevier Ltd.doi:10.1016/j.addbeh.2008.03.004

a b s t r a c t

Keywords:

Smoking rates are higher and cessation rates are lower among individuals with posttraumaticstress disorder (PTSD) compared to the general population, thus understanding the relationshipbetweenPTSDandnicotine dependence is important. In a sample of 213 participantswith a crime-related trauma (109with PTSD), the relationship between PTSD status, smoking status (smoker vs.non-smoker), substance abuse diagnosis (SUD), PTSD symptoms, and sex was assessed. SUDdiagnosiswas significantly related to smoking status, but PTSD symptomatology and sexwere not.Among smokers (n=117), increased nicotine dependence severity was associatedwith beingmaleandwith increased level of PTSD avoidance symptoms. Correlations indicated that PTSD avoidanceand hyperarousal symptom clusters and total PTSD symptom scores were significantly related tonicotine dependence severity in males, while PTSD symptomatology in general did not correlatewith dependence severity for females. The results suggest that level of PTSD symptomatology,particularly avoidance symptoms, may be important targets for smoking cessation treatmentamong male smokers who have experienced a traumatic event.

© 2008 Elsevier Ltd. All rights reserved.

PTSDSmokingNicotine dependenceAvoidanceHyperarousal

1. Introduction

Smoking is associated with increasedmorbidity andmortality, with smoking related disease remaining one of the top causes ofall premature deaths in the US (CDC, 2005). Despite efforts to reduce smoking prevalence, the national prevalence rate of smokingremains about 21% among adults (CDC, 2006). One reason for the continued high prevalence rates may be due to the ‘hardening’ ofthe smoking population. The hardening concept suggests that smoking rates have remained steady over the past few years due to asubset of ‘hard-core’ smokers who are unwilling or unable to quit and that current approaches to treatment may not be as effectivefor this subset (see Warner & Burns, 2003).

Subsumed by this hardening concept are smokers who suffer from a comorbid psychiatric condition. Individuals diagnosedwith a mental illness are twice as likely to smoke and less likely to quit compared to those without a mental illness diagnosis(Lasser et al., 2000). Posttraumatic stress disorder (PTSD) is a psychiatric illness associated with substantially higher rates ofsmoking than the national average (45%, Lasser et al., 2000). Moreover, the quit rate among individuals with co-occurring PTSD issubstantially lower than the rate among individuals without mental illness (32% vs. 43% respectively, Lasser et al., 2000; see alsoHapke et al., 2005). Given smoking's impact on health, knowing the factors thatmaintain higher smoking rates and lower quit ratesamong individuals with PTSD is important in order to better treat this population.

+1 601 984 5885..edu (J.S. Baschnagel), scoffey@psychiatry.umsmed.edu (S.F. Coffey), jschumacher@psychiatry.umsmed.edues), saladinm@musc.edu (M.E. Saladin).

All rights reserved.

1442 J.S. Baschnagel et al. / Addictive Behaviors 33 (2008) 1441–1447

It has been suggested that substance use among individuals with PTSD is motivated by a desire to self-medicate traumasymptoms, and that the substance of choice reflects the predominant PTSD symptom type(s) an individual suffers (Brown &Wolfe,1994). Consistent with this hypothesis, McFall, Mackay, and Donovan (1992) have shown that drug abuse is more stronglyassociated with avoidance and re-experiencing symptom clusters and alcohol use is associated with hyperarousal symptoms.Extrapolating from this literature, one possible link between PTSD and smoking is that individuals with PTSD may smoke toregulate the experience of PTSD symptoms (Beckham et al., 1997; Thorndike, Wernicke, Pearlman, & Haaga, 2006). Indeed, from amotivational standpoint, smokers who report greater levels of PTSD symptomatology report smoking to reduce negative affect andto increase stimulation (Feldner et al., 2007) which may reflect an attempt to avoid aversive emotions elicited by re-experiencingsymptoms and to counteract numbing symptoms. From a psychopharmacological standpoint (see Rasmusson, Picciotto, &Krishnan-Sarin 2006 for an extensive review), nicotine has been linked to increases in various neuromodulators (e.g., neuropeptideY, allopregnanolone, DHEA) that are found to be at low baseline levels or have a muted release in individuals with PTSD. Increasesin these neuromodulators have been linked to reward-related responses in the nucleus accumbens as well as with decreased re-experiencing, avoidance, and hyperarousal PTSD symptoms. Therefore, smokers with PTSD may, in part, smoke to increaseparticular neuromodulators associated with decreased symptoms of PTSD.

Two studies have specifically assessed the relationship between PTSD symptomatology and smoking. Beckham et al. (1997)compared smoking status [heavy ≥25 cigarettes per day (cpd) vs. none or light-moderate b25 cpd] and PTSD symptomatologyamong 445 Vietnam combat veterans. They found that heavy smoking was significantly associated with avoidance andhyperarousal symptoms of PTSD as well as overall PTSD symptomatology. Heavy smoking also was marginally associated with re-experiencing symptoms in this sample. These results suggest that higher rates of smoking may be associated with PTSDsymptomatology overall as opposed to specific symptom clusters, but the marginal finding for re-experiencing makes a conclusiveinterpretation difficult.

In a sample of 157 smokers (24% with a lifetime diagnosis of PTSD), Thorndike et al. (2006) assessed the correlations betweennicotine dependence severity and PTSD symptoms. Results indicated that after controlling for depression proneness, total PTSDsymptoms as well as the three symptom clusters of PTSD all correlated positively with nicotine dependence among men but notwomen. Sex differences between the correlations were significant for total PTSD symptoms, and the hyperarousal and avoidancesymptom clusters, with a marginal difference between men and women on the re-experiencing cluster. These results suggest thatthere may be a sex difference in the association between nicotine dependence and PTSD symptomatology.

The current paper attempts to partially replicate and to expand upon the previous work (i.e., Beckham et al., 1997; Thorndikeet al., 2006) by: 1) using a sample in which approximately one-half satisfied criteria for current PTSD and all participantsexperienced a crime-related traumatic event, which satisfied Criterion A for PTSD, rather than combat-related trauma; this isimportant as smoking behavior may vary depending on presence of PTSD diagnosis vs. trauma exposure only and on trauma typeor severity (Feldner et al., 2007); and 2) including substance use disorder (SUD) diagnosis as an additional control variable.Substance use disorder was included in the current study because PTSD is associated with high rates of substance use (McFall et al.,1992) and smoking prevalence is high among substance users (Stark & Campbell, 1993).

In line with prior work, we predicted that greater PTSD symptomatology, both overall and for avoidance and hyperarousalsymptom clusters, would predict greater nicotine dependence severity, but only for men. Given the mixed findings for re-experiencing the association of smoking with PTSD re-experiencing is more exploratory. Also consistent with prior work, weexpected positive substance use disorder diagnosis to be associated with positive smoking status, and we expected SUD status topredict greater nicotine dependence severity scores among smokers.

2. Method

2.1. Participants

Participants were drawn from a larger study examining PTSD-SUD comorbidity in a sample of men and women recruited fromsubstance use treatment programs and newspaper advertisements (e.g., Coffey et al., 2002). To be eligible for the study, aparticipant had to have experienced a crime-related trauma (e.g., physical or sexual assault either as a child or as an adult)satisfying Diagnostic and Statistical Manual—IV (DSM-IV; APA, 1994) Criterion A for PTSD. Participants included a total of 117smokers and 96 non-smokers. Sample characteristics partitioned by PTSD group are presented in Table 1. Overall, 55% of the fullsamplemet diagnostic criteria for a SUD, with either cocaine or alcohol being themain substance of choice. Fifty-two percent of thefull sample met diagnostic criteria for PTSD. Participants were excluded from the study if they met diagnostic criteria for apsychotic disorder, were experiencing a current manic episode, or were currently experiencing severe depression (i.e., markedpsychomotor slowing). Participants were also excluded from the study if they were currently receiving exposure-based treatmentfor PTSD.

2.2. Measures

2.2.1. Structured diagnostic interview measuresPsychiatric status, including SUD,was assessed via the Structured Clinical Interview forDSM-IV (SCID-IV; First, Spitzer, Gibbon, &

Williams, 1996). The substance use section in earlier versions of the SCID (SCID-III-R; Spitzer & Williams, 1986) has demonstratedgood psychometric properties (e.g., Kranzler, Kadden, Babor, Tennen, & Rounsaville, 1996).

Table 1Mean (S.D.) sample characteristics by PTSD diagnosis

PTSD positive PTSD negative

Male (n=32) Female (n=77) Total (n=109) Male (n=53) Female (n=51) Total (n=104)

Age 34.5 (9.2) 34.5 (9.8) 34.5 (9.6) 38.5 (9.2) 36.2 (10.0) 37.4 (9.6)Race (%)Caucasian 78 70 73 55 73 64African-American 16 25 22 45 28 37Hispanic 3 4 4 0 0 0American Indian or Alaskan Native 0 1 1 0 0 0Other 3 0 1 0 0 0

Positive smoking status (%) 66 48 53 72 41 57No. of cigarettes/day (smokers only) 22.3 (13.4) 11.6 (8.8) 15.5 (11.8) 21.6 (10.8) 13.4 (6.6) 18.7 (10.3)Positive SUD diagnosis (%) 78 49 58 74 24 49CAPSTotal 67.2 (23.6) 58.1 (22.1) 60.2 (20.9) 32.1 (24.5) 11.3 (8.5) 21.6 (20.7)Avoidance 28.5 (11.7) 25.2 (11.0) 26.1 (10.3) 14.8 (13.1) 4.2 (3.6) 8.9 (10.6)Re-experiencing 17.2 (10.2) 14.0 (8.1) 14.7 (8.5) 3.6 (5.9) .9 (1.6) 2.9 (5.3)Hyperarousal 21.7 (8.4) 19.0 (8.6) 19.5 (7.7) 13.8 (10.3) 6.2 (5.8) 9.8 (8.9)

RTQ total score (smokers only) 35.0 (7.7) 28.1 (7.7) 30.6 (8.3) 33.7 (6.5) 27.5 (6.0) 31.5 (7.0)

Note: SUD=Substance Use Disorder; PTSD=Posttraumatic Stress Disorder; CAPS=Clinician Administered PTSD Scale (scores reflect mean of intensity andfrequency scores for each factor; RTQ=Revised Tolerance Questionnaire.

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DSM-IV PTSD Criterion A and trauma history were assessed with the National Women's Study (NWS) PTSD Module (Kilpatrick,Resnick, Saunders, & Best,1989; Resnick,1996). The NWS PTSDModule demonstrates good concurrent validity with the SCID-PTSDmodule and acceptable reliability (Resnick, 1996) and has been used in studies investigating trauma in both men and women (e.g.,Coffey, Schumacher, Brady, & Dansky Cotton, 2007; Reviere, Battle, Farber, & Kaslow, 2003). Participants were required to report atleast one crime-related Criterion A event (direct physical or sexual assault during childhood or adulthood) for inclusion in thelarger study.

The Clinician Administered PTSD Scale (CAPS; Blake et al., 1995) is a psychometrically sound, structured clinical interview usedto assess DSM-IV PTSD symptomatology and was used with the NWS PTSDModule to make a PTSD diagnosis. Symptoms are ratedon frequency and severity on a scale from 0–4. Symptom subscale scores, based upon DSM-IV PTSD symptom clusters (i.e.,avoidance, re-experiencing, and hyperarousal), were created by totaling the frequency scores and severity scores for each symptomcluster and summing these scores together. The total severity score for the CAPS (CAPS Total) was computed by taking the sum offrequency and intensity ratings for all items. Due to the overlap in PTSD and substance abuse/withdrawal symptoms (e.g., sleepdisturbance, irritability), probes were added to determine whether each PTSD symptomwas better attributed to substance abuse/withdrawal rather than PTSD. Symptoms better attributed to substance abuse/withdrawal were not scored on the CAPS.

A positive diagnosis of PTSD was made if the participant endorsed a crime-related Criterion A event on the NWS PTSD moduleand endorsed one re-experiencing, three avoidance and two hyperarousal symptoms related to the event on the CAPS. For a CAPSsymptom to be counted toward diagnosis, the symptom item needed a score of at least 1 on frequency rating and 2 on severityrating (see Weathers, Ruscio, & Keane, 1999 for comparison of CAPS scoring methods).

2.2.2. Self-report measureNicotine dependence severity was assessed by the Revised Tolerance Questionnaire (RTQ; Tate & Schmitz, 1993). The RTQ is a

revision of the Fagerström Test of Nicotine Dependence (FTND; Heatherton, Kozlowski, Frecker, & Fagerström, 1991), whichconsists of ten items rated on a five-point Likert scale. The RTQ has demonstrated good internal consistency and comparablevalidity in relation to the FTND (Tate & Schmitz, 1993).

2.3. Procedure

Participants who responded to the advertisement or were recruited from local SUD treatment facilities were briefly screenedeither over the phone or in person for possible substance dependence and history of experiencing an event that satisfied PTSDCriterion A. Eligible participants were scheduled for an assessment session, during which informed consent was obtained.Structured diagnostic interviews were conducted by an experienced research assistant and participants completed various self-report measures including the RTQ. All procedures were approved by an Institutional Review Board and all participants werecompensated for their time.

2.4. Data analysis

Chi-square tests were conducted to assess the relationship between 1) PTSD diagnosis and smoking status and 2) SUD statuswith smoking status. Following a significant Chi-square test, standardized residuals were examined to identify which cells hadthe most impact on the outcome. Standardized residuals greater than +2 were considered major contributors to the significantChi-square (Pett,1997). A set of regression analyses (describedbelow)were then conducted to testmodels assessing the relationship

Table 2Model summaries for logistic regressions predicting smoking status from sex, SUD, and total PTSD symptom level (Model 1) and from sex, SUD, and PTSD symptomclusters (Model 2)

Model R2 χ2 (df, n) B Wald χ2 p Odds ratio

Model 1 .24 58.26 (3, 213) b .001

Sex .32 .86 .354 1.38SUD 2.26 38.09 b .001 9.59CAPS total score − .01 1.73 .188 .99

Model 2 .25 59.75 (5, 213) b .001Sex .27 .61 .437 1.31SUD 2.26 37.57 b .001 9.57CAPS: avoidance − .002 .01 .918 1.00CAPS: re-experiencing − .04 2.07 .150 .97CAPS: hyperarousal .01 .17 .682 1.01

Note: SUD=Substance Use Disorder; PTSD=Posttraumatic Stress Disorder; CAPS=Clinician Administered PTSD Scale.

Table 3Model summaries for regression models predicting nicotine dependence severity from sex, SUD, and total PTSD symptoms level (Model 1), and from sex, SUD, andPTSD symptom clusters (Model 2)

Model R R2 Adjusted R2 F df B β t sri2

Model 1 .46 .21 .19 9.99⁎⁎ (3, 113)Sex 5.58 .37 4.07⁎⁎ .34SUD 1.80 .10 1.07 .09CAPS total score .04 .15 1.71 .14

Model 2 .49 .24 .20 6.95⁎⁎Sex 5.21 .34 3.78⁎⁎ .31SUD 1.84 .10 1.10 .09CAPS: avoidance .14 .26 2.05⁎ .17CAPS: re-experiencing − .13 − .17 −1.47 − .12

CAPS: hyperarousal .05 .06 .54 .05

Note: ⁎ p≤ .05, ⁎⁎ pb .001; SUD=Substance Use Disorder; PTSD=Posttraumatic Stress Disorder; CAPS=Clinician Administered PTSD Scale.

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between smoking, nicotine dependence, and PTSD symptoms. RTQ total score was used as the nicotine dependence severityvariable. Scores on the continuous dependent and independent variables were mean-centered prior to analysis.

A logistic regression analysis was conducted predicting smoking status (negative coded 0, positive coded 1) from sex (femalescoded 0, males coded 1), SUD status (negative coded 0, positive coded 1), and total CAPS scores. A second logistic regression wasconducted predicting smoking status from sex, SUD status, and CAPS subscale scores.

Another set of analyses was conducted on data from a sub-sample of smoking participants (n=117). A multiple regressionanalysis was conducted predicting smoking dependence severity by overall PTSD symptomatology. In this model sex, SUD status,and total CAPS scores were entered as predictors. A second regression analysis was conducted predicting nicotine dependenceseverity by sex, SUD status, and CAPS subscale scores. Sex and SUD status were included in the analyses to control for their effectson smoking status and nicotine dependence, allowing the relationship between PTSD symptoms and smoking to be assessedtaking into account these two variables.

3. Results

Chi-square tests indicated that smoking status did not differ as a function of PTSD status,χ2 (1, n=213)=.266, ns, φ=− .35. Smokingstatus was associated with SUD status, χ2 (1, n=213)=53.1, pb .001, φ=.50, with a greater number of smokers in the SUD-positivegroup (SUD+group: smokers=101 [43.7%], non-smokers 25 [10.8%]; SUD-group: smokers=33 [14.3%], non-smokers=72 [31.2%]).

Results of the logistic regression analyses are presented in Table 2. The logistic regression model predicting smoking statusfrom sex, SUD status, and overall PTSD symptom level, was significant compared to an intercept only model. Consistent with theChi-square test, positive SUD status predicted positive smoking status. Sex and total PTSD symptoms scores did not significantlypredict smoking status in the overall sample. The second logistic regressionmodel, predicting smoking status from sex, SUD status,and PTSD symptom clusters was significant compared to a model testing the intercept only. The relationship between SUD statusand smoking status remained but sex and PTSD symptom cluster scores did not significantly predict smoking status. Given thatthe entire sample was trauma-exposed, it may be that smoking rate (Beckham et al., 1997) as opposed to smoking status isrelated to PTSD symptoms. Thus similar logistic regression models to those ran for smoking status were conducted predictinglight-moderate (b25 cigarettes per day [cpd]) vs. heavy (≥25 cpd) smoker status in smokers only. In both models, only sex (Bs=1.6,pb .001 for both models) significantly predicted smoking rate with males being 5 times more likely than women to be heavysmokers.

Table 4Correlations between nicotine dependence severity and PTSD symptoms clusters by sex

CAPS avoidance CAPS re-experiencing CAPS hyperarousal CAPS total score

Males (n=59)CAPS avoidance 1

CAPS re-experiencing .61⁎⁎ 1CAPS hyperarousal .64⁎⁎ .48⁎⁎ 1CAPS total score .91⁎⁎ .80⁎⁎ .82⁎⁎ 1RTQ .33⁎ .15 .32⁎ .33⁎Females (n=58)CAPS avoidance 1CAPS re-experiencing .70⁎⁎ 1CAPS hyperarousal .70⁎⁎ .69⁎⁎ 1CAPS total score .92⁎⁎ .87⁎⁎ .88⁎ 1

RTQ .14 − .03 .03 .07

Note: ⁎ p≤ .05, ⁎⁎ p≤ .001; SUD=Substance Use Disorder; PTSD=Posttraumatic Stress Disorder; CAPS=Clinician Administered PTSD Scale; RTQ=Revised ToleranceQuestionnaire.

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Two regression models were conducted assessing the relationship between nicotine dependence severity and sex, SUD statusand PTSD (see Table 3) in the sub-sample of smokers. The first regression model predicted nicotine dependence severity by sex,SUD status, and total PTSD symptom level. In this model, only sex was a significant predictor, with being male predicting greaterdependence severity. In the second regression model, sex, SUD status and the three PTSD symptom clusters were entered aspredictors of nicotine dependence severity. In this model, sex and PTSD avoidance symptoms significantly predicted dependenceseverity. Greater nicotine dependence was associated with being male and with increased avoidance symptom levels. In both ofthese models, SUD status was not a significant predictor of nicotine dependence severity.

As a post-hoc analysis, correlation analyses were conducted assessing the relationship between nicotine dependence severityand PTSD symptomatology by sex (see Table 4). Nicotine dependence severity was significantly positively correlated with PTSDavoidance and hyperarousal symptom clusters and total PTSD symptom level in males. In females, PTSD symptomatology was notsignificantly correlated with nicotine dependence severity.

4. Discussion

This study assessed the relationship between PTSD, SUD, and two indices of tobacco cigarette use (smoking status and nicotinedependence severity) in a sample of men and women with a history of clinically significant trauma. Higher rates of smoking aretypically foundwithin both traumatized and SUD samples (e.g., Hapke et al., 2005). This patternwas observedwithin this traumatizedsample with 28% of non-SUDS participants and 78% of SUD participants (albeit traumatized) identifying as smokers. In the currentsample, smoking status was not associated with PTSD diagnosis, but findings of Chi-square tests and the logistic regression analysesindicated that individualswith apositive SUDdiagnosisweremore likely to be smokers than thosewithout a SUDdiagnosis. The failuretofinda relationshipbetween PTSDdiagnosis and smoking status in the current studymaybeexplainedby the fact that all participantsin this studyhadexperienceda traumatic event that satisfiedCriterionA forDSM-IVdiagnosis of PTSD. Itmaybe that greater likelihoodof smoking is related to the experience of a serious trauma in general and is not specific to PTSD diagnosis. Previous research suggeststhat smoking rates are higher among trauma-exposed individuals compared to non-traumatized individuals, and that withintraumatized samples more serious traumas, such as those that would meet Criterion A, are associated with higher smoking rates(see Feldner, Babson,&Zvolensky, 2007 for a comprehensive review). Thus, in regards to smoking status, the current study is consistentwith prior research on smoking and SUD but not fully consistent with prior research on smoking rates and PTSD status.

Level of self-reported nicotine dependence is another aspect of smoking that has been related to PTSD (e.g., Beckham et al.,1997; Thorndike et al., 2006); with greater nicotine dependence associated with greater PTSD symptomatology. In this study, wefound that PTSD symptoms were partly related to nicotine dependence severity in our smokers. Overall PTSD symptom level wasnot predictive of nicotine dependence severity but the level of avoidance symptomatology was a significant positive predictor ofnicotine dependence.

In addition to PTSD avoidance symptoms, sex was a significant predictor of nicotine dependence severity, with being maleassociated with higher levels of nicotine dependence compared to females. This finding is consistent with studies that suggestfemale smokers may be less dependent on nicotine than male smokers (e.g., Breslau, Kilbey, & Andreski, 1991). Examination of thecorrelations between PTSD symptomatology and nicotine dependence severity for each sex revealed avoidance and hyperarousalsymptoms, as well as overall PTSD symptomatology were positively associated with dependence severity for men, but not forwomen. This is generally consistent with Thorndike et al. (2006) who found all symptom clusters and overall PTSDsymptomatology to be significantly associated with nicotine dependence in males only. These correlations are also consistentwith Beckham et al. (1997) who found avoidance and hyperarousal and overall PTSD symptoms to be significantly related to level ofsmoking in a sample of male combat veterans.

The non-significant findings for re-experiencing, hyperarousal, and overall PTSD symptoms as predictors of nicotinedependence severity in the regression analyses, which is inconsistent with the findings of Beckham et al. (1997) and Thorndikeet al. (2006), may be related to differences in the samples andmeasures utilized. Beckham et al. assessed smoking rates, rather than

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nicotine dependence severity, and only examined veterans with PTSD diagnosis when assessing the relationship between heavysmoking and PTSD symptomatology. Although increased smoking rate is associated with increased nicotine dependence(Heatherton et al., 1991), the two are not synonymous. Thorndike and colleagues used a measure of nicotine dependence similar tothe one used in this study, but assessed a sample of community smokers with a presumably heterogeneous set of traumaticexperiences and only 24%whowere diagnosedwith lifetime PTSD. In contrast, the current study used a sample of participants whoall had experienced a Criterion A event that was crime-related with half the sample meeting current diagnosis for PTSD. It may bethat specific types of trauma, particularly violence related trauma, may make certain symptom clusters more salient in therelationship between smoking and PTSD.

Although the correlation results suggest that PTSD symptomatology is associated with nicotine dependence for males only, it isimportant to note that in the regression analyses, avoidance symptomatology accounted for significant variance in nicotinedependence severity beyond that accounted for by sex. The dearth of studies looking at specific PTSD symptom clusters andsmoking/nicotine dependence does not allow firm conclusions about how the three DSM-IV PTSD symptom clusters arespecifically related to smoking. Nonetheless, the findings of this study and the two previous studies specifically examiningsymptom clusters suggest the avoidance cluster may be the most related to nicotine dependence/smoking.

One interpretation of this finding is that the act of smoking may serve as an avoidant behavior among smokers with PTSD,particularly for males, who are more sensitive to the pharmacologic effects of nicotine than females (Perkins, Donny, & Caggiula,1999). The use of nicotine via smoking may function as an avoidance behavior by serving as a cognitive or affective distracter,shifting attention away from distressing thoughts and affect and toward the reinforcing effects of nicotine as well as the behaviorsassociated with smoking (e.g. leaving a stressful situation to go smoke). This hypothesis is in linewith preliminary work suggestingthat negative affect and trauma related cues are associated with smoking behavior (Beckham et al., 2005) as well as datademonstrating increases in alcohol and cocaine craving due to negative affect elicited by trauma cues in individuals with co-occurring PTSD and a substance use disorder (Coffey et al., 2002). Thus, from a clinical perspective, avoidance symptomsmay be animportant target for smoking cessation efforts among individuals with PTSD, particularly for males.

Future research should aim to elucidate themechanisms bywhich smoking is linked to PTSD-related avoidance symptoms. Thisstudy, as well as the two prior studies (Beckham et al., 1997; Thorndike et al., 2006), has examined avoidance as a 1-factorconstruct, but some researchers (Asmundson, Stapleton, & Taylor, 2004; Stewart, Conrod, Pihl, & Dongier, 1999) have posited thatPTSD avoidance symptoms may reflect both avoidance and numbing constructs. Future research should test the relationshipbetween numbing and nicotine dependence. From a clinical standpoint, treatment for smoking cessation among patients withPTSD may need to emphasize healthier substitutes to smoking as a way to cope with the distress and negative affect associatedwith PTSD which may be exacerbated by nicotine withdrawal. More importantly, given the growing evidence of the relationshipbetween PTSD symptomatology and smoking and nicotine dependence, it may be that treatment for PTSD should berecommended to smokers with PTSD wishing to quit, as this may enhance smoking cessation outcomes in this population. This isan empirical question worthy of attention given the high incidence of smoking and low quit rates in this population of smokers.

Acknowledgments

This research was supported by the National Institute on Drug Abuse grants DA10595. We wish to thank Drs. Bonnie DanskyCotton, Kathleen T. Brady, and Dean G. Kilpatrick and research assistants Jennifer Wieselquist, Lorri Ellen Campbell, Kristen BycroftRobinson, Susan Quello, and Francis Beylotte III for their contributions to this research.

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