Smoking Patterns and Dependence: Contrasting Chippers and Heavy Smokers.

Nicotine dependence is typically the driving motive behind tobacco use and cigarette smoking, and most current smokers are dependent. However, studies have documented that some people are able to engage in stable patterns of light smoking without progressing to dependence. Most people who smoke regularly progress to dependence; intermittent smoking is generally an unstable pattern leading either to progression to regular smoking or to desistence. However, we have demonstrated that some intermittent smokers can demonstrate substantial resistance to dependence, sustaining a regular pattern of light smoking for years without developing dependence. These smokers—dubbed “chippers” (CHs)—absorb nicotine from cigarettes in normal amounts and metabolize nicotine normally but, despite having smoked tens of thousands of cigarettes, show few signs of nicotine dependence and no sign of withdrawal even after several days of abstinence.

CHs do not seem to smoke to avoid nicotine depletion or to stave off withdrawal. These findings suggest that repeated exposure to smoking may not in itself inevitably lead to nicotine dependence. Low-rate smoking and less-than-daily smoking are common among teen smokers early in their smoking careers, but this pattern is typically subsequently displaced by daily and higher-rate smoking as smoking progresses. However, CHs seem to have failed to progress or “mature” into heavier and more consistent smoking; we have hypothesized that they may display patterns of smoking associated with earlier stages of the smoking career.

Smoking patterns can provide some clues to smoking motives. For example, if smokers smoke when stressed, this would bolster the notion that they are smoking to mitigate negative affect. In recent analyses of heavy smokers' (HSs') smoking patterns, we found that their ad lib smoking was not substantially associated with affective state. This lack of association between smoking and situational stimuli was explained in terms of HSs' addictive drive to smoke regularly to maintain blood nicotine levels and avoid lapsing into nicotine withdrawal, thus overriding any association between smoking and other stimuli. Contrasting HSs' smoking patterns with those of CHs may help test this hypothesis. If this explanation of HSs' smoking is valid, then we would expect CHs' smoking to demonstrate much stronger association with situational stimuli (which we refer to as “stimulus control”).

Several studies have used global retrospective self-report questionnaires (“smoking typology scales”) to ask CHs about their smoking patterns and motives. Compared with HSs, CHs tend to emphasize social motives, those related to the sensory pleasure of smoking and those associated with pleasant relaxation or smoking after meals (as opposed to motives associated with craving, relief of negative affect, stimulation, and habitual or automatic smoking). Thus, CHs may be what M. A. H. Russell, Peto, and Patel (1974) called “indulgent” smokers. However, questionnaires assessing smoking patterns are fraught with psychometric problems and do not accurately reflect smoking patterns. CHs may also fit the pattern described by Moran, Wechsler, and Rigotti, (2004) as “social smoking,” defined as smoking primarily with others and primarily as a social activity, implying smoking driven by external social motives rather than by internal or pharmacological motives.

In this study, we used data on smoking and nonsmoking situations collected in real time in real-world settings with ecological momentary assessment (EMA) to analyze CHs' smoking patterns. In an extreme-groups design, we contrasted CHs' patterns with those of closely matched HSs. We examined the hypothesis that CHs would be particularly likely to smoke when with others and when drinking alcohol , a pattern resembling the behavior of smokers early in their smoking careers.

We also assessed CHs' urges to smoke, both when smoking and when not smoking. Whereas some studies have suggested that CHs experience little craving, others have suggested that CHs do experience craving, especially when exposed to smoking cues, suggesting that CHs' craving might vary considerably according to the circumstances. We expected that CHs might experience craving in the occasional situation when they smoke but not when not smoking, whereas HSs may report craving even when not smoking (indicating their dependence).

We focused on stimulus control of smoking as a key differentiator of chipping versus heavy smoking. As dependence develops, smoking is expected to become increasingly driven by the ebb and flow of blood nicotine levels. In particular, because nicotine is cleared quickly from the body and thus has to be “topped off” frequently, for dependent smokers, the need to regularly replenish nicotine would tend to override and erode the stimulus control that might otherwise be exercised by situational stimuli. Whereas even dependent smokers are expected to have some discretion in when they smoke, the diminution of stimulus control and the development of stereotypy may be a hallmark of dependence, as use of the drug shifts from being a purely discretionary pleasure that accompanies certain activities, but which the smoker can take or leave, to a compulsive pattern of regular and stereotypic self-administration. Thus, we hypothesized that HSs' smoking would demonstrate less stimulus control than would CHs' smoking.

Whereas an analysis of particular antecedents can examine the association of smoking with particular situational variables, an analysis of overall stimulus control must look past associations with particular variables and the direction of those associations. For example, some CHs may tend to smoke when working and stressed, whereas others smoke when eating and relaxed. Both patterns demonstrate stimulus control over smoking, but a groupwise nomothetic analysis might show no effect. To assess the degree of stimulus control, we performed idiographic analyses, in which we modeled stimulus associations separately for each smoker and statistically estimated the overall magnitude of the associations across a range of situational stimuli. We then entered these estimates into a second-level analysis, which contrasted the average levels of stimulus control among CHs and HSs.

In our assessment, we avoided relying on global assessments or recall of smoking patterns; instead, we used EMA methods to collect real-time data about smoking and nonsmoking episodes in subjects' natural environments. Subjects noted when they were smoking and completed a situational and affective assessment. As a control or contrast for smoking occasions, the computer beeped subjects for a similar assessment at randomly selected nonsmoking times.

Discussion

This is the first study to contrast the smoking patterns of dependent and nondependent smokers. Although we have previously documented HSs' smoking patterns in two studies, this is the first study to examine smoking patterns in nondependent smokers. Smoking patterns of CHs selected to demonstrate resistance to nicotine dependence suggested that they were indulgent smokers who smoked in relaxing, undemanding situations, and when eating and drinking, but not when working. However, contrary to expectations, they were neither positive affect smokers (affect was not associated with smoking) nor social smokers (they smoked alone often—as often as did the HSs). CHs' smoking patterns distinguished them from HSs, but the nomothetic group differences understated the differences in stimulus control over smoking. When we considered idiographic measures of stimulus control, CHs' smoking proved to be under considerable stimulus control, particularly in association with concurrent activities. In every situational dimension we examined, CHs' smoking was under greater stimulus control than was that of HSs.

One issue in contrasting CHs' and HSs' smoking patterns is that CHs tend to concentrate their smoking later in the day. However, controlling for this by analyzing evening smoking made relatively little difference in the comparisons. This suggests that time of day, per se, does not matter as much in CHs' smoking as do the situations associated with relaxation, eating, drinking, and leisure time, which happen to concentrate in the evening hours. Controlling for time of day did, however, eliminate the initial finding that CHs (more than HSs) tended to smoke when experiencing low arousal; this was apparently due to CHs' tendency to smoke in the evening.

Our data show that CHs are not social smokers. If anything, CHs tended to smoke more when alone than with others. CHs smoked almost half their cigarettes when alone—the same as did the HSs. Moreover, even when others were present while CHs were smoking, more often than not, they were not smoking. Less than a quarter of all CHs' cigarettes were smoked in the presence of others who were smoking, and CHs' and HSs' smoking were equally likely to smoke when others were smoking (with no difference in the influence of others' smoking, after time of day was accounted for). Clearly, then, even though CHs sometimes smoked with others, their smoking is not just maintained by a desire to fit in or join other smokers, which suggests it is intrinsically motivated.

The picture of the typical chipper is what M. A. H. Russell et al. (1974) labeled an indulgent smoker—one who smokes when relaxed or socializing, and over meals, coffee, and drinks, but not when working. In fact, three quarters of CHs' cigarettes were smoked under such circumstances. CHs differed from HSs in this respect, though the difference was more quantitative than qualitative: HSs showed similar associations, but they were much weaker and often nonsignificant. It is striking that CHs' pattern of smoking appears to resemble patterns associated with early in smokers' careers, before they have progressed to regular daily smoking and to dependence. This is consistent with our hypothesis that CHs represent smokers who simply have not progressed developmentally into adult forms of dependent smoking.

Despite their pattern of indulgent smoking, CHs' smoking was not associated with positive affect; in general, CHs' affective state did not seem to matter, paralleling our findings for HSs. However, when CHs were smoking outside of indulgent situations, smoking was associated with negative affect. This could represent an attempt by CHs to cope with distress in these settings. Whether smoking in fact has any impact on affect cannot be discerned from these data, because we looked at the antecedents of smoking and not the consequences. In contrast to CHs, HSs were not more likely to smoke under negative affect in nonindulgent settings; their smoking was actually slightly more likely to occur under positive affect. It is not clear how to explain these differences.

In any case, our analysis suggests and illustrates an analytic strategy of going beyond analysis of overall relationships to partition situations into different categories that may display different smoking dynamics, looking for complex interactions among settings, activities, and affect. This approach has some parallels in studies of relapse episodes, where some episodes are associated with negative affect and others are associated with positive affect, smoking cues, and drinking, and certain associations with prior negative affect are seen only for a subset of relapse episodes.

Our largely negative findings on ad lib smoking and affect contrast strikingly with findings on cues that promote smoking under conditions of abstinence, that is, in relapse episodes. In that setting, negative affect appears to play a very powerful role in triggering temptation to smoke and actual smoking. During ad lib smoking, smokers may smoke on a regular schedule unconsciously designed to avoid withdrawal, thus blunting the association of smoking and negative affect. Moreover, proprioceptive cues associated with low nicotine levels or subtle increases in negative affect might by quite subtle and operate below the level of consciousness, making them unavailable to self-report. During ad lib smoking, these subtle cues may quickly trigger smoking without rising to consciousness. In abstinence, however, smokers are motivated to hold off smoking, and negative affect and craving can build to levels that are not only conscious but also intense. In addition, in abstinence, withdrawal-related negative affect, or withdrawal-related sensitization to negative affect from other sources, may also intensify affect and make it more important and more prominent as a driver of smoking. Finally, negative affect may also become particularly important in relapse because it disrupts smokers' attempts to cope with craving; this dynamic would not influence ad lib smoking.

We also note that the assessment and analysis of affect is controversial, with some theories viewing negative and positive affect as opposite poles of a single dimension as our assessment implies, and others viewing positive and negative affect as independent dimensions. The difference between the two positions turns on a difference in factor rotation, with a positive affect factor defined by a contrast of positive affect and high arousal versus negative affect and low arousal. Accordingly, the fact that we failed to find affect by arousal interactions suggests that the findings are not an artifact of the scoring affect according to the circumplex model. It is also notable that we have repeatedly found no relationship between smoking and affect, even when examining individual affect items, suggesting that the finding is not an artifact of how the items are aggregated into factors.

Whereas some laboratory studies have examined how affect may influence how intensely people smoke after they have lit up, our study examines only the variables associated with initially lighting up the cigarette. It has been pointed out that the stimuli associated with lighting up itself, and with the effects of the initial nicotine intake from the first puffs (called “intraadministration cues"), might come to acquire potent value as conditioned stimuli and may promote continued smoking after smoking has been initiated. Because our method focuses on stimuli that precede, and perhaps trigger, the act of smoking in the first place, these influences (which, in any case, cannot explain why an act of smoking is initiated) were not within the scope of our methods. Likewise, because our focus was on the most immediate antecedents or triggers of smoking, less acute phenomena (e.g., if having a bad day increases smoking over the whole day, even when feeling better) would not be seen in these analyses because the negative affect would pervade both smoking and nonsmoking occasions. Thus, our findings address the stimuli that cue smoking but not other kinds of stimulus influences.

What do these data tell us about CHs' motivation for smoking? We can rule out a number of motives for CHs' smoking. Because CHs do not experience withdrawal and do not maintain steady-state nicotine levels, withdrawal relief cannot be an important motive. The fact that CHs smoke when alone, and are no more likely than HSs to smoke when others are smoking, rules out purely social motives. That CHs do not seek out smoking when working, but instead avoid it, suggests that they are not motivated by performance enhancement. The fact that CHs are most likely to smoke in indulgent situations that are already positively reinforcing suggests that smoking might enhance the reinforcing value of already-reinforcing stimuli. This is consistent with the recent suggestions by Donny et al. (2003), who, in an experiment with rodents taught to self-administer nicotine, found that getting nicotine appeared to make accompanying stimuli reinforcing. In their work, stimuli previously paired with nicotine facilitated self-administration and were sufficient to maintain lever pressing on their own. In other words, nicotine, in addition to being reinforcing in itself, might lend reinforcement value to other stimuli. This suggests that CHs might smoke in circumstances that are already reinforcing to enhance the reinforcement value of those “natural” rewards. This hypothesis should be tested more systematically, both in CHs and in HSs.

This reinforcement-enhancement hypothesis might also explain the very striking relationship between smoking and drinking among CHs. Alcohol consumption was the single best predictor of smoking among CHs. Nevertheless, alcohol can explain only a small fraction of CHs' smoking; only one out of six cigarettes was smoked within 5 min of drinking. Just as CHs are not social smokers, they also are not just drinking smokers.

Our analysis of urges to smoke shows that CHs do express strong desire to smoke at the times they elect to smoke. Indeed, their urge levels at those times are essentially identical to those of HSs. This quantification could be misleading if CHs and HSs were using different scales to assess their craving relative to their range of craving experience. Having never experienced the intense craving that characterizes addictive smokers, CHs might rate cravings as intense that HSs consider to be mild. Alternatively, CHs may infer craving from the fact that they are smoking (“I am about to smoke, so I must be having an urge”). Taking the craving ratings at face value, the data suggest that CHs and HSs differ dramatically in the frequency and pervasiveness of craving. Whereas the urge intensity associated with smoking occasions was similar for CHs and HSs, HSs experienced this heightened craving state every 30 min (crudely, 32 occasions in 16 waking hours), whereas CHs were in this state only about once every 240 min (crudely, 4 occasions in 16 waking hours). Thus, CHs spend much less time in a craving state. Now consider the remaining part of the day, when subjects were not smoking. Whereas HSs were in craving states 53% of the remaining time, CHs were in craving states only 15% of the remaining time. In other words, HSs' craving is pervasive despite a high volume of smoking; CHs' craving is tightly confined despite smoking only rarely.

Whereas craving has typically been linked to dependence, the mere presence of an urge need not implicate dependence processes any more than a social drinker's desire (urge) to have a glass of wine with dinner. Urges become pathological when they become pervasive and become detached from stimulus control. Thus, the difference we see between CHs and HSs is in the frequency and intensity of their urges when they are not smoking.

One might say that CHs' cravings demonstrate situational specificity, appearing only in limited situations. The situational specificity of CHs' smoking was similarly demonstrated by our analysis of smoking in each group. The analysis demonstrated that CHs' smoking was under considerable stimulus control, much more so than HSs' smoking. Concurrent activities exercised the greatest influence over CHs' smoking, so much so that knowing what activity a chipper was engaged in would allow one to correctly predict smoking 85% of the time (vs. 67% for HSs). In every stimulus domain—affect, location, activity, eating and drinking, and social setting—CHs' smoking showed significantly more linkage to situational stimuli; it was under greater stimulus control. The fading of stimulus control may well be a hallmark of the development of dependence. A key transition in tobacco use (and other drug use) may occur when users transition from using drugs for particular recreational, or even medicinal, effects in particular contexts to needing and using the drug all the time, regardless of context. Consistent, regular, and stereotyped patterns of use are hallmarks of dependence. Thus, the loosening of stimulus control over smoking may be an important process in the development of dependence. We hypothesize that this loosening occurs over time as smokers proceed on a developmental trajectory toward dependence.

This discussion implicitly contrasts two patterns of smoking: one in which smoking is stimulus bound and largely concentrated in indulgent situations and one that is pervasive and relatively free of external stimulus control. We speculate that the situationally limited, indulgent pattern characterizes an early stage in the development of smoking. Smoking is initially triggered by social inducements and, for a time, is socially motivated and tied to social situations. As young smokers (like the rodents in Donny's studies) learn that nicotine can enhance the value of other reinforcers, smoking concentrates in indulgent situations where the smoker has access to other reinforcement. CHs, having failed to progress beyond this stage, represent the “fossilized” form of this pattern. Most smokers, however, progress to more frequent and less stimulus-bound smoking, as dependence begins to emerge and smoking comes to be dominated by the motives of craving and withdrawal relief (or avoidance).6 Research is needed on smoking patterns that emerge as young smokers traverse developmental trajectories of smoking toward dependence.

Our interpretation rests on the observation that CHs' smoking showed consistently stronger associations with a variety of situational variables. One might argue that HSs' heavier smoking makes it inherently more difficult to demonstrate associations with situational stimuli; if one is to smoke 30 times a day, one has little discretion about where or when to smoke. However, it is notable that HSs actually showed situational associations as strong as or stronger than did CHs for some variables, such as being in a vehicle or waiting. This demonstrates that even heavy HSs still have “room” to allocate their smoking differentially across contexts, as suggested by the boundary model of nicotine regulation. Conceptually, the fact that heavy, continuous smoking tends to obliterate stimulus associations is in fact consistent with the key point: As a smoker is driven to smoke frequently, stimulus control over the behavior is lost. Conversely, stimulus control must be relaxed to allow smoking to reach the high levels seen in dependent smokers.

Our findings on stimulus control may have implications for prevention and treatment. Our observations on CHs' smoking suggest that stimulus control may be able to act as a strong brake on smoking. Interventions that promote stimulus control of smoking (e.g., restrictions on where one can smoke) could conceivably impede progression toward heavy and dependent smoking. Indeed, it is striking that occasional smoking is more common in states that have strong smoking regulations. Stimulus control interventions might also help promote successful cessation. Cinciripini has demonstrated that imposing artificial stimulus control on smoking (during a structured reduction phase) can promote cessation, and the data on the stimulus specificity of relapse episodes suggest that exercising stimulus control by avoiding certain situational stimuli could prove effective in preventing relapse. More research is needed on stimulus control of smoking.

Our statistical approach to assessing stimulus control of smoking seemed to provide useful insight into smoking patterns. The analysis of group differences in associations with particular stimuli requires that many of the group members share the same pattern of associations, thus shifting the group means. However, this does not allow for idiographic differences in smoking patterns, which would be expected to affect stimulus control. In our ROC analysis, rather than assuming that smokers in each group would share particular stimulus associations (e.g., that all CHs would smoke more at home), we allowed for idiographic stimulus associations with smoking, such that some individuals might smoke more at home, others when at others' homes, and others at work. The difference in approaches was illustrated by our analysis of affect. When assessed nomothetically, by traditional analysis that required that subjects share similar associations between smoking and particular affects, there were no systematic associations between smoking and affect in either group and no differences between groups. However, the idiographic approach, which allowed associations to vary by individuals, indicated that smoking was under partial control of affective stimuli.

The finding that affect exercises some control over HSs' smoking, when assessed idiographically, may help explain why HSs report that their smoking is prompted by mood changes, even though nomothetic analyses have repeatedly shown no differences in mood between smoking and nonsmoking occasions; smokers' self-reports may pick up on the idiographic associations between smoking and mood. However, the magnitude of the associations between mood and smoking seen even in idiographic analyses does not approach that which smokers report on global questionnaires, suggesting that there is still a discrepancy between global retrospective reports and the detailed self-monitoring in this study. The fact that subjectively experienced affect plays such a prominent role in relapse may leave smokers with a broad impression that their smoking is linked to negative affect.

In any case, the study suggests that it is important to allow for idiographic associations in analyzing smoking patterns, particularly because stimulus associations with smoking might develop through accidental conditioning to certain stimuli and thus should be expected to vary across individuals, perhaps even randomly.

Although we have made considerable progress in understanding dependent smoking, relatively little attention has been paid to understanding nondependent or situation-bound smoking. Although heavy and dependent smoking is still the predominant smoking pattern in the United States and Western Europe, it may be important, for several reasons, to understand the patterns, motives, and reinforcers that drive and maintain low-level smoking. First, although heavier smoking leads to increased health risks (U.S. Department of Health and Human Services, 1998), even low-level smoking has adverse health consequences; Luoto reported that even nondaily smoking increases the risk of heart disease by 50%. Second, contrasting these patterns of smoking with more typical heavy or dependent smoking can help improve our understanding of how smoking develops and is maintained.

Finally, low-level and occasional smoking is becoming an increasingly common pattern, with 24% of U.S. smokers engaging in less-than-daily smoking, an increase of almost 50% between 1996 and 2001. Our sample of CHs was selected to represent an extreme of resistance to dependence (i.e., we recruited smokers who maintained low levels of smoking despite smoking on most days over many years) and thus was not representative of this growing group, many of whom smoke at lower levels and with less stability than seen in our CHs sample. Studies of smoking patterns among the full representative range of intermittent or nondependent smokers are needed.

Our study's conclusions are bounded by certain limitations. The study was done at a time when restrictions on smoking were relatively modest. The current climate of smoking regulations may have imposed some stimulus control on smokers while disrupting other associations. Our samples of CHs and HSs were small and arguably not representative. Very stringent criteria were applied for inclusion of CHs, and HSs were systematically selected to match the CHs sample. The validity of the results also depends on the validity of the EMA data on smoking situations. To the extent that these were biased by reactivity or by some kinds of systematic noncompliance (e.g., not recording cigarettes when very upset), the data could be misleading.

However, analyses suggested that compliance was very good and that the data were valid. The use of EMA methods, relying on real-time entry of real-world data regarding smoking situations, and the contrast to randomly sampled nonsmoking situations, was a significant strength of our methodology. The large number of observations per person may help compensate for the small sample of persons, and the observation of each person over 2 weeks of ad lib smoking helped ensure that each person's smoking patterns were adequately sampled. Finally, the use of a palmtop computer to collect the data helped ensure that data were recorded in a timely manner and enabled analysis of temporal patterns.

This study documents the smoking patterns of nondependent smokers and contrasts them to those of HSs. The study demonstrates that CHs are not social smokers but that their smoking is concentrated in situations associated with relaxation and consumption of food, coffee, and alcohol. An idiographic analysis demonstrated that CHs' smoking was under stronger stimulus control than was HSs' smoking, with specific patterns of stimulus associations being individual and idiosyncratic. Understanding how smoking is brought under stimulus control, and how it breaks out of such control as dependence develops, is an urgent agenda for the study of smoking and the development of nicotine dependence, with implications for prevention and cessation interventions.