Smoking and Nicotine Addiction among Young People in Cyprus. Maria Karekla, Ph.D 1., & Margarita Kapsou, M.A 2.

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1 Smoking and Nicotine Addiction among Young People in Cyprus Maria Karekla, Ph.D 1., & Margarita Kapsou, M.A 2. 1 University of Nicosia, Nicosia, Cyprus 2 University of Cyprus, Nicosia, Cyprus Abstract In Cyprus, prevalence of smoking appears high among both adults and youth. Favorable social conditions for smoking, such as high levels of social acceptance, lack of restrictions regarding smoking in public places and sales of tobacco, and relatively scarce awareness raising activities, may be factors that contribute to the onset and maintenance of smoking. However, little empirical evidence exists regarding the main reasons why individuals smoke, and the extent to which physical addiction and psychosocial factors contribute to the maintenance of smoking. Levels of nicotine addiction were investigated among the smokers identified in the context of a nationwide study of smoking among young people in Cyprus. The sample consisted of middle and high school students, soldiers, college students, and working youth, who responded to self-completion questionnaires. Measures included the Fagerstrom test for nicotine dependence, and questions about smoking related behavior, knowledge, attitudes, and intentions. Psychosocial reasons, particularly going out, and dealing with negative emotions, were the most frequently cited reasons for smoking by smokers of all ages. Physical addiction was found within the low or very low range for the majority of middle, high school, and college students. Higher levels of addiction were identified among working youth and soldiers, although the latter may be accounted by the effect of gender, since addiction was significantly higher among the males in the sample. Higher addiction levels correlated with lower levels of knowledge about the consequences of smoking, and with lower motivation to quit. The low levels of addiction noted among younger ages suggest the need for public policies and prevention efforts targeting psychosocial dimensions that account for the onset and maintenance of smoking. Further research, using prospective and experimental paradigms, is required to provide insight into the parameters that are implicated in the subsequent increase of nicotine addiction at later ages.

2 Smoking and Nicotine Addiction among Young People in Cyprus Maria Karekla, Ph.D 1., & Margarita Kapsou, M.A 2. 1 University of Nicosia, Nicosia, Cyprus 2 University of Cyprus, Nicosia, Cyprus In Cyprus, prevalence of smoking appears high among both adults and youth (Christophi et al., 2008; Hibell et al., 2003). Favorable social conditions for smoking, such as high levels of social acceptance, lack of restrictions regarding smoking in public places and sales of tobacco, and relatively scarce awareness raising activities, may be factors that contribute to the onset and maintenance of smoking. However, little empirical evidence exists regarding the main reasons why individuals smoke, and the extent to which physical addiction and psychosocial factors contribute to the maintenance of smoking. Nicotine dependence is manifested through behaviors such as searching for a cigarette as soon as a person wakes up, withdrawal symptoms when the person does not smoke, experiencing stress when not smoking, and need to smoke more cigarettes to achieve the same effect (Fagerstrom, 1978; American Psychiatric Association, 2000). Nicotine dependence is associated with years and heaviness of smoking, but also with individual differences such as experiences of negative emotions and anxiety sensitivity (Stevens et al., 2005; Forsyth, Parker, & Finlay, 2003; Stewart & Kushner, 2001), and has been found to be an important predictor of continued smoking and unsuccessful quit attempts (Colby et al., 2000). The present study investigates levels of nicotine dependence among various age groups of young people in Cyprus, and explores the relations between nicotine dependence, attitudes and knowledge toward smoking, and motivation for smoking cessation in these populations. Methods Participants Participants were young smokers drawn from a nationwide study of smoking among young people in Cyprus (Karekla & Symeou, 2008). The full sample consisted of 1085 middle school (67 smokers), 767 high school students (183 smokers), 100 soldiers (57 smokers), 516 college and university students (183 smokers), and 107 young people up to 25 years of age who are working in Cyprus (58 smokers). Participants from all groups (except working young adults) were selected through random stratified sampling procedures, to ensure that the sample is representative of young people in Cyprus. A snowball sampling procedure was used to recruit the sample of working youth. For the purposes of this study, participants who responded yes, regularly to the question Do you smoke? were classified as regular smokers (N = 548), and their data were further analyzed to investigate relations between nicotine addiction and other smoking-related parameters. Measures All participants completed self-report questionnaires that included questions about smoking related behavior, knowledge, attitudes, and intentions. The questionnaires were compiled by the researchers, and included some questions drawn from the Global Youth Tobacco Survey (GYTS, 2001), and the National Youth Tobacco Survey Questionnaire (NYTS, 2000). To assess reasons for smoking among youth, participants responded to a series of 19 statements referring to possible reasons for smoking, using a five point Likert-

3 type scale to indicate how often they smoked for the reason reported in each statement. The Fagerstrom Scale of Nicotine Dependence (Fagerstrom, 1978; Heatherton et al., 1991), which consists of a series of six questions, was used to assess nicotine dependence in this study. Scores could range from 0-11, with values >7 indicating high levels of addiction. Participants also responded to a list of 30 statements, rated on a five point Likert-type scale, assessing their beliefs and knowledge about smoking and its effects. Both positive and negative beliefs about smoking were included in this section. Exploratory factor analysis classified these statements into three reliable factors (Cronbach alphas >.60), namely positive attitudes toward smoking and its social benefits, which included statements such as young people who smoke have more friends, awareness of myths and social harm, which included statements such as smoking ruins someone s reputation, and knowledge about smoking and its effects on health, which included statements such as smoking makes teeth yellow. Motivation to quit smoking was assessed using six questions about their intentions, attempts, and efficacy regarding smoking cessation. A mean motivation index was then calculated (minimum= 0, maximum= 6), where higher scores indicates greater motivation to quit smoking. Results The most frequently reported reasons for smoking by smokers of all ages were psychosocial. For all subgroups, the five most common reasons for smoking were: going out, in combination with other substances (e.g. alcohol, coffee), feeling angry/upset, feeling sad, and because smoking is pleasant and helps relaxation. Smokers in middle school cited smoking is pleasant and helps relaxation as the most frequent reason, and in combination with other substances as the fifth most frequent reason. Controlling body weight was another reason frequently cited by both men and women. Nicotine dependence was found within the low or very low range for the majority of middle, high school, and college students. High levels of addiction were reported for 7% of smokers in middle school, 3% in high school, 7% in college students, 16% in soldiers, and 19% among working youth. In high school and college, women and men reported comparable levels of nicotine addiction. Significantly higher levels of addiction were reported by boys compared to girls in middle school (boys: M = 4.00, S.D. = 2.74; girls M = 2.00, S.D. = 1.12, p <.05), and by men compared to women in the sample of working youth (men: M = 5.76, S.D. = 2.67; women M = 3.79, S.D. = 2.73, p <.05). Level of physical addiction also appeared to increase with age for the whole sample (r =.11, p <.01). Motivation to quit was at moderate levels for most participants (M = 3.10, S.D. = 1.45), while no significant differences appeared between different age groups and between men and women. Higher addiction levels correlated with lower levels of knowledge about the consequences of smoking. Specifically, higher addiction correlated with higher agreement with positive statements toward smoking (r =.09, p <.05), lower awareness of myths and social harm (r = -.28, p <.001), and lower levels of knowledge about smoking and its effects on health (r = -.20, p <.001). Higher levels of addiction was also correlated with lower motivation to quit smoking (r = -.33, p <.001). Discussion Reasons for smoking cited by young people in Cyprus are mostly psychosocial, and are indicative of the widespread misinformation and lack of

4 knowledge about smoking and its effects, which are more pronounced at younger ages. Use of tobacco as a substance expected to help relaxation, and as a coping strategy in dealing with negative emotions, appears prevalent, and may be linked to the lack healthy or adaptive strategies for dealing with negative emotions. These misconceptions, along with popular perceptions of smoking as a mainstream behavior for young people, appear to contribute to the maintenance of high rates of smoking among youth. Furthermore, the frequent association of smoking with other substances or situations (going out to have fun, alcohol, coffee) is likely to contribute to the development of a profoundly learned behavior or habit, which would later be hard to break. On the other hand, levels of nicotine addiction in this population range from low to moderate levels. As expected, these addiction levels are found to be higher among older cohorts. If this finding indeed reflects a trend of increased addiction levels as individuals get older, we should expect that, if these young people continue smoking, addiction levels will be much higher as they get older. These findings suggest that, nicotine addiction among youth is of a psychosocial, rather than physical nature, and point to the need for public policies and prevention efforts to target psychosocial dimensions that account for the onset and maintenance of smoking. Higher levels of nicotine dependence were identified among working youth and soldiers, although the latter may be accounted by the effect of gender, since dependence was significantly higher among the males for some of the age groups in the sample. Higher addiction among male participants may be a result of heavier smoking among boys and men compared to their female counterparts, as the former tend to start smoking at somewhat younger ages, and smoke a greater number of cigarettes per day. The effect of patterns of smoking on addiction in this population, as well as the possible reasons leading to different patterns of smoking among men and women need to be further investigated. This study provides some evidence regarding nicotine dependence in young Cypriots up to 25 years of age. Further research, using prospective and experimental paradigms, is required to provide insight into the parameters that are implicated in the subsequent increase of nicotine addiction at later ages. References American Psychiatric Association, Diagnostic and statistical manual of mental disorders, DSM-IV. 4th edition, 4th text rev. Washington, DC: American Psychiatric Association. CDC - Center for Disease Control, United States National Youth Tobacco Survey (NYTS). Atlanta: GA. Department of Health and Human Services, Center for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health. Center for Disease Control: Global Youth Tobacco Survey (GYTS). English core questionnaire, Christophi, C.A., Kolokotroni, O., Alpert, H.R., Warren, C.W., Jones, N.R., Demokritou, P., & Conolly, G.N. (2008). Prevalence and social environment of cigarette smoking in Cyprus youth. BMC Public Health, 8, 190. Corrao, M. A., Guindon, G., Sharma, E.N., & Shokoohi, D. F., eds, Tobacco control country profiles. Atlanta : The American Cancer Society. Published for the 11th World Conference on Tobacco OR Health.

5 Fagerström, K.O., Measuring degree of physical dependency of tobacco smoking with reference to individualization of treatment. Addictive Behaviors, 3, pp Forsyth, J.P., Parker, J.D, & Finlay, C.G., Anxiety sensitivity, controllability, and experiential avoidance and their relation to drug of choice and addiction severity in a residential sample of substance-abusing veterans. Addictive Behaviors, 28, pp Heatherton, T.F., Kozlowski, L.T., Frecker, R.C., Fagerstrom, K.O., The Fagerstrom Test for Nicotine Dependence: a revision of the Fagerstrom Tolerance Questionnaire. British Jounral of Addiction, 86, pp Hibell B., Andersson B., Bjarnasson T., Ahlstrom S., Balakireva O., Kokkevi A., & Morgan M., ESPAD Report 2003: Alcohol and other drug use among students in 35 European countries. Council of Europe, Co-operation Group to Combat Drug Abuse and Illicit Trafficking in Drugs (Pompidou Group). Stevens, S.L., Colwell, B.C. Smith, D.W., Robinson, & J., McMillan, C., An exploration of self-reported negative affect as a reason for smoking: Implications for tobacco prevention and intervention programs. Preventive Medicine 41, pp Stewart, S.H., & Kushner, M.G., Introduction to the special issue on Anxiety Sensitivity and Addictive Behaviors. Addictive Behaviors, 26, pp Information about the authors Maria Karekla, Ph.D., is an Assistant Professor at Intercollege, Nicosia, Cyprus. She holds a BS degree in Psychology and a BFA in Art Education from Valdosta State University (US), an MS degree in Clinical Psychology from University at Albany, State University of New York, and a Ph.D. in Clinical Psychology from the same university. She completed her residency at the University of Mississippi Medical Center with a specialization in Anxiety Disorders and Behavioral Medicine. Dr. Karekla s primary research and clinical interests are in the assessment and treatment of anxiety disorders and in behavioral medicine with a focus on bolstering quality of life parameters. Her research work has been supported by various research grants and has been published in international peer-reviewed journals. Margarita Kapsou is currently a Ph.D Candidate in the Cognitive, Developmental, and Educational Psychology Program at the University of Cyprus. She works with research projects health issues such as smoking, eating habits, and anxiety disorders, and actively works toward promoting and advocating for Sexual and Reproductive Health and Rights on a national and European level.

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