The findings of the present study indicate that several variables derived from Behavioral Economic Theory, such as substitute reinforcers to smoking, complementary reinforcers to smoking and delay discounting can differentiate among young adult smoking practices. Nontreatment seekers, treatment seeking smokers who did and treatment seeking smokers who did not subsequently participate in a formal smoking cessation program were characterized by a lower level of substitute reinforcers to smoking compared to ex-smokers. Greater complementary reinforcers and higher delay discounting rates differentiated nontreatment seeking smokers from ex-smokers and treatment seeking smokers who subsequently attended a smoking cessation program. Young adult smokers who increased their substitute reinforcers across treatment were almost two times more likely to be quit at treatment end. These variables may be important to consider in recruitment and treatment approaches for smoking cessation interventions for young adult smokers.
The observation that ex-smokers had greater substitute alternative reinforcers than the three current smoking groups suggests that substitute reinforcers to smoking may play a role in the ability to quit smoking and maintaining smoking abstinence. These cross-sectional findings are consistent with our smoking cessation findings in that increases in substitute reinforcers to smoking during treatment appeared to confer a two-fold advantage in smoking cessation among young adults, at least in the short-term. The frequency of substitute alternative reinforcers has been shown to predict post-treatment cocaine, alcohol, and heroin abstinence (Higgins, Heil, & Lussier, 2004
; Smith et al., 2001
; Van Etten et al., 1998
). The present study now provides preliminary evidence that substitute reinforcers may facilitate smoking abstinence. Thus, helping young adult smokers identify, access and engage in substitute reinforcers for smoking (not just substitute behaviors) prior to and after a quit attempt may promote long-term cessation by replacing smoking associated rewards with other rewarding behaviors making a nonsmoking lifestyle as rewarding or more rewarding than a lifestyle involving cigarette use.
Behavioral Economic Theory is based in part on the premise that access, availability and involvement in alternative substitute reinforcers are critical in the choice and ability to discontinue a rewarding, yet unhealthy behavior such as smoking. If reinforcers are limited, then an individual may be more likely to choose to smoke because it is an easily available method to increase overall reinforcement and a reinforcement deprived environment may increase the rewarding value of smoking (Perkins et al., 2000
). Physical activity may be an especially good substitute reinforcer since it shares several of the same functions as smoking (e.g., weight and mood management) and has been shown to decrease smoking abstinence associated withdrawal symptoms, craving and negative affect (Ussher, Taylor, & Faulkner, 2008
). About 60% of the smoking cessation program participants defined physical activity as a substitute reinforcer that they chose to engage in (among other reinforcers) over the four weeks after their target quit day. Although we cannot quantify the amount of physical activity engaged in, the choice of physical activity at least twice over the 30-days after the quit day was associated with a significant reduction in cigarettes smoked (p = .003), but not significantly related to abstinence at the end of treatment (p > .10). Future research may want to delineate whether some substitute reinforcers are more effective at promoting smoking cessation than others and for which smokers.
Greater complementary reinforcers differentiated nontreatment seeking smokers from ex-smokers and treatment seeking smokers who subsequently attended a formal smoking cessation program, but not those treatment seekers who did not participate in a smoking cessation program. Complementary reinforcers to smoking (e.g., coffee, alcohol, smoking peers) may make smoking cigarettes even more enjoyable, hindering interest in quitting. In addition, these reinforcers are common triggers to smoke and contribute to relapse. Consistent with this notion, household smoking doubled the odds of being a treatment seeking smoker who did not attend treatment than a treatment seeking smoker who did attend a smoking cessation treatment program. Thus, the level of complementary reinforcers for smoking among young adult smokers may be a marker for how entrenched smoking is in a young adult smoker’s environment and how this may translate to a lack of interest in quitting as well as a tentative commitment to quit smoking. The level of complementary reinforcers or the change from baseline did not appear to be as important to achieving cessation as the level of substitute reinforcers among young adults.
Higher delay discounting differentiated nontreatment seeking smokers from ex-smokers and treatment seeking smokers who participated in a formal quit smoking program, but not those treatment seekers who did not participate in the quit smoking program. Thus, delay discounting may be a pre-treatment variable that can identify young adult smokers at risk of not participating in a smoking cessation program after enrolling due to tentative interest in quitting. This suggests that recruitment strategies and program components will need to appeal to delay discounting characteristics in young adult smokers not interested in quitting and those ambivalent about quitting within a formal program. Given that the benefits of smoking cessation (delayed in time) will be heavily discounted, maybe incentive-based components (relatively more immediate) for program participation and/or smoking cessation would promote interest in participation, actual participation, and successful abstinence (Petry, 2000
). Although delay discounting did not predict abstinence in our small sample of treatment seekers, we observed a slight shift in delay discounting toward greater impulsive decision making (−4.70 at baseline and −4.33 at end of treatment). The small increase in delay discounting occurred in those young adults who were quit and those not quit at the end of treatment. Thus, it may reflect insignificant variation in delay discounting or possibly a marker for relapse or relapse vulnerability.
Depression symptoms played a smaller role in differentiating these smoking groups than anticipated and contrary to our hypothesis, nontreatment seekers were less likely to have higher depression symptoms than ex-smokers. This may suggest that young adult smokers not interested in quitting may derive mood management benefits from nicotine, which serves to maintain their smoking behavior. In order for disinterest in quitting to be transformed to interest and subsequent quitting, the role of smoking in mood modulation among subgroups of young adults will need to be further delineated to determine if intervention components need to replace smoking with skills/behaviors of similar mood management function.
With respect to the demographic variables, ex-smokers and treatment seeking smokers who participated in treatment have either attended college or were currently attending college compared to nontreatment seekers and treatment seeking smokers who did not subsequently participate in treatment. Recent research has shown that non-college educated young adults were less likely to have made a quit attempt than college educated young adults (Green et al., 2007
). Nonwhites were more likely to be among the treatment seeking smokers who did not subsequently participate in treatment than ex-smokers, treatment seeking smokers who participated in treatment, and nontreatment seekers. This speaks to the importance of identifying smoking cessation program features that will appeal within and/or across racial groups of young adult smokers to maintain interest in quitting with the assistance of a formal program.
The between-group, cross-sectional comparisons made in the present study do not allow us to make statements regarding the temporal precedence of these variables and smoking behavior, although the smoking cessation findings do suggest an important role for substitute reinforcers in short-term quitting success. Further investigation with larger samples of young adults may determine whether these variables play a role in long-term smoking cessation. In addition, the small sample of smoking cessation program attendees does not permit an in-depth analysis of whether one type of substitute reinforcer is more important to smoking cessation or if the overall level is key to promoting smoking cessation. Of note, only demographic variables discriminated between nontreatment seeking young adult smokers and treatment seeking smokers who did not participate in smoking cessation treatment. Future research with larger numbers of young adults will be needed to determine whether other psychosocial variables differentiate these groups or if the differences are simply demographic. This is important as some comparisons involved small cells sizes and the representativeness of the present sample of young adults is not clear.
In general, these comparisons highlight variables that might be important to address in the recruitment and smoking cessation treatment approaches focused on young adult smokers. Young adults are more likely than older adults to make a quit attempt, less likely to seek assistance in their smoking cessation attempt and more likely to fail (Curry et al., 2007
; Rigotti et al., 2000
; Solberg et al., 2007
). Smoking cessation among young adults is a cancer control and public health challenge that will need to be met to prevent another generation of smoking attributable morbidity and mortality.