Subjective social status is indirectly associated with short-term smoking cessation through nicotine withdrawal symptoms

Abstract

This study used data collected from a smoking cessation program (N = 146) to evaluate whether subjective social status was indirectly associated with smoking cessation through nicotine withdrawal symptoms. Findings indicated that subjective social status was indirectly associated with smoking cessation through withdrawal symptoms, specifically through anger and anxiety symptoms. People with lower subjective social status reported more withdrawal symptoms, particularly symptoms related to anger and anxiety, shortly after a quit attempt, and as such, were less likely to achieve smoking abstinence. Findings from this study provide insight into why socioeconomically disadvantaged adults are less likely to remain abstinent after a quit attempt.

Keywords

smoking tobacco socioeconomic status subjective social status withdrawal

Introduction

Socioeconomically disadvantaged adults have a lower likelihood of smoking cessation relative to their more advantaged counterparts (Babb et al., 2017; Hiscock et al., 2012). Subjective social status (SSS), which is the perception of an individual’s socioeconomic position relative to others in society (Adler et al., 2000), also predicts both readiness to quit smoking (Garey et al., 2015) and smoking cessation outcomes (Reitzel et al., 2010, 2011, 2014; Whembolua et al., 2012). Specifically, adults who perceive themselves as having lower education, income, and occupational prestige than others express less desire to quit smoking and have lower cessation rates than adults who see themselves as having higher education, income, and occupational prestige.

SSS may influence cessation outcomes because social comparisons at the individual (I vs. similar others) and group-level (e.g. Blacks vs. Whites) often lead to perceptions of unfair inequalities, and may reflect relative deprivation (Smith et al., 2012; Wilkinson, 1999). Relative deprivation predicts many adverse outcomes such as obesity, delinquency, and poor physical and mental health, as well as depression and negative affect (Smith et al., 2012). Depression and negative affect are widely known to impact cessation outcomes (Kassel et al., 2003; Stepankova et al., 2017), and are also symptoms of nicotine withdrawal (McLaughlin et al., 2015). Reitzel et al. (2010) previously demonstrated that withdrawal-related depression mediated the association between SSS and smoking cessation. SSS is also associated with many other nicotine withdrawal symptoms, including sleep disturbances, anger, and anxiety (Cohen et al., 2008; Greitemeyer and Sagioglou, 2016, 2019; Zvolensky et al., 2017, 2018b, 2018c). Therefore, it is plausible that SSS is indirectly associated with smoking cessation not only through specific withdrawal-related symptoms, such as depression, but also through a composite of withdrawal symptom severity. However, no studies have investigated the association of SSS with composite nicotine withdrawal. Focusing on composite nicotine withdrawal, in addition to specific withdrawal symptoms, would provide more information about whether SSS is associated with the overall severity of nicotine withdrawal during a quit attempt.

The purpose of this study is to evaluate whether nicotine withdrawal symptom severity mediates the association between SSS and smoking cessation. SSS may be associated with smoking cessation indirectly through its association with the severity of nicotine withdrawal; therefore, we hypothesize that lower SSS will be associated with greater nicotine withdrawal severity, and greater nicotine withdrawal symptom severity will be associated with an increase in the odds of smoking after a quit attempt. Secondarily, we will also determine whether SSS is indirectly associated with cessation through its association with specific dimensions of the withdrawal syndrome. In particular, we hypothesize that SSS will be indirectly associated with smoking cessation through withdrawal-related anxiety, anger, sadness, and sleep disturbance symptoms. Overall, findings from this study may provide insight into the difficulties that socioeconomically disadvantaged adults have with remaining abstinent after a quit attempt.

Methods

This study is a secondary data analysis of a smoking cessation intervention that evaluated the influence of offering financial incentives for biochemically verified smoking abstinence among socioeconomically disadvantaged adults. Refer to Kendzor et al. (2015) for a full description of recruitment procedures and a detailed description of the intervention. Briefly, adults were recruited from a tobacco cessation clinic at a safety-net hospital in Dallas, TX, USA, and were randomly assigned to receive either nicotine replacement therapy (nicotine patch and nicotine gum or lozenges) and counseling sessions (i.e. usual care) or usual care with small financial incentives for smoking abstinence (i.e. contingency management; Kendzor et al., 2015). The contingency management group earned a US$20 gift card for biochemically confirmed abstinence (via expired carbon monoxide [CO]) on their scheduled quit date (i.e. abstinent overnight). The gift card amount increased by US$5 each week for every successive biochemically confirmed abstinent visit (i.e. abstinent for the previous 7 days) up to the fourth week after their scheduled quit date (up to US$150 total). Participants who were smoking at any visit were eligible to earn incentives for abstinence at the next visit, although the amount was reset to US$20. Informed consent was obtained from all participants, and the Institutional Review Boards of the University of Texas Southwestern Medical Center and the University of Texas Health Science Center approved the study protocol.

One week before the scheduled quit date (e.g. baseline interview), participants provided their sociodemographic information and completed a measure of SSS. On the first day after their scheduled quit attempt (i.e. participants were instructed to quit by 10 p.m. the evening prior), participants completed a measure of nicotine withdrawal symptom severity. Smoking abstinence was also assessed on the day after the quit attempt was initiated, and weekly thereafter, through the fourth week after the quit date. Complete smoking status data (i.e. self-reported smoking or biochemically verified abstinence) were available for 98 percent of participants on the day after the quit date and 86 percent of participants at the Week 4 visit. Participants who did not attend the visit, self-reported abstinence but did not provide a corroborating CO breath sample, or did not provide a self-report or a breath sample, were considered smoking.

Measures

Independent variable

SSS was measured using the MacArthur Scale of Subjective Social Status, which assesses relative social standing in society (Adler et al., 2000). This scale was depicted by a ladder with 10-rungs, and participants were asked to identify which rung best represented their social position in society compared to others according to their income, education, and occupational prestige. The highest rung on the ladder represented those with the most money, education, and prestigious jobs, and the lowest rung reflected those with the least money, education, and prestigious jobs (Adler et al., 2000).

Dependent variable

Self-reported smoking status was verified via expired CO levels. CO levels ⩾8–10 parts per million (ppm) suggest recent cigarette smoking with a sensitivity and specificity of approximately 90 percent (Benowitz et al., 2002). Thus, point prevalence abstinence for the fourth week was defined as self-reporting complete smoking abstinence over the past 7 days with a corroborating expired CO level of <8 ppm. Individuals with missing smoking status data at 4 weeks post-quit were considered smoking (i.e. intent to treat). Participants were categorized dichotomously as either smoking (0) or abstinent (1).

Mediator variable

Nicotine withdrawal symptom severity was assessed using the Wisconsin Smoking Withdrawal Scale (WSWS; Welsch et al., 1999), which is a 28-item self-report questionnaire that measures seven dimensions of smoking withdrawal: anger, anxiety, concentration, craving, hunger, sadness, and sleep. These dimensions of the WSWS correspond to six of the eight nicotine withdrawal symptoms listed in the Diagnostic and Statistical Manual (fifth edition) for tobacco use disorder (American Psychiatric Association, 2013). Nicotine withdrawal symptom severity was assessed during the past 24 hours using items that were scaled from 0 (strongly disagree) to 4 (strongly agree). Each dimension of nicotine withdrawal was measured using a unique subset of items, and these items were summed to compute the subscale score. All subscale scores were summed to compute the total score for the WSWS scale; with higher scores indicating greater withdrawal severity.

Previous research has shown that the WSWS has seven factors (i.e. seven dimensions of smoking withdrawal), and all factors load on to a single higher order factor (i.e. nicotine withdrawal; Castro et al., 2011; Welsch et al., 1999). In our sample, the WSWS had a four-factor structure (i.e. negative affect (concentration, sadness, anxiety, and anger), sleep, hunger, and craving), which was also observed in previous research (Welsch et al., 1999). But we chose not to combine subscales for negative affect to keep findings comparable with other studies that have used the 7-factor for WSWS (e.g. Castro et al., 2011; Kendzor et al., 2018), and because each subscale has clinical significance (American Psychiatric Association, 2013), and represent distinct psychological constructs (Welsch et al., 1999).

Statistical analyses

Bivariate correlations were computed for the independent, mediator, and dependent variables. Univariate and multivariable linear and logistic regressions were conducted to explore the association between SSS and nicotine withdrawal symptoms, and SSS and smoking status 4 weeks after the scheduled quit attempt. Covariates included in the multivariable models were the following: treatment group assignment in the parent study (i.e. usual care vs. contingency management; Kendzor et al., 2015), sex, years of age, race/ethnicity (Whites vs. non-Whites), education (years), annual household income (⩽US$10,000 (ref) vs. >US$10,000 vs. refused to answer), employment status (not employed vs. part/full-time employed), smoking status on the quit day (concurrent with the withdrawal symptom assessment), and nicotine dependence, which was measured using a summary score from the revised Wisconsin Inventory of Smoking Dependence Motives (WISDM) scale (Piper et al., 2004; Smith et al., 2010). Analyses were completed in SAS 9.4. (SAS Institute, 2013).

Mediation analyses were conducted using the PROCESS macro (Model 4) in SAS 9.4. (SAS Institute, 2013) to examine whether SSS was indirectly associated with smoking status 4 weeks post-quit date through nicotine withdrawal symptoms. The PROCESS macro used a mixture of linear and logit models to estimate direct and indirect effects, and 10,000 bootstrap samples were used to generate bias-corrected bootstrap confidence intervals for each model. Covariates, which were mentioned previously, were included in the mediation model if they attenuated effect estimates for independent and mediator variables by 10 percent or more (i.e. change in estimate criterion (CE); Tong and Lu, 2001). CE was used in the mediation analyses to avoid unnecessary adjustment and obtain precise estimates of direct and indirect effects (Schisterman et al., 2009).

Results

Participants (N = 146) had a mean age of 51.7 years (SD = 7.1), were primarily non-White (71.9%), female (58.9%), and had an average of 12 years of education (SD = 2.0). Most participants were not employed (86%), and on average, participants placed themselves on the fourth rung on the 10-rung SSS ladder (M = 4.2, SD = 2.1). One week before the quit date, participants had an average nicotine dependence score of 19.6 (SD = 12.1), and on the scheduled quit date, participants reported an average nicotine withdrawal score of 12.6 (SD = 4.4). Four weeks after the quit date, 37.7 percent of participants were abstinent (see Table 1 for complete details).

Table 1.

Sample characteristics (N = 146).

	Mean (SD) or N (%)
Age (years)	51.7 (SD = 7.1)
Females	86 (58.9%)
Non-White^a	105 (71.9%)
Education (years)	12.0 (SD = 2.0)
Employment status
Not employed^b	125 (85.6%)
At least part-time employment^c	21 (14.4%)
Annual household income
⩽US$10,000	71 (48.6%)
>US$10,000	58 (39.7%)
Refused to answer	17 (11.6%)
Subjective social status^d	4.2 (SD = 2.1)
Nicotine dependence^e	19.6 (SD = 12.9)
Nicotine withdrawal^f	12.6 (SD = 4.4)
Treatment group
Usual care	71 (48.6%)
Contingency management	75 (51.4%)
Smoking abstinence (% abstinent)
Quit day	106 (72.6%)
Week 4	55 (37.7%)

SD: standard deviation.

Whites (n = 41), African Americans (n = 91), Hispanics (n = 8), American Indian/Alaska Natives (n = 1), and more than one race (n = 5).

Unemployed and currently looking for work (n = 15), unemployed and not currently looking for work (n = 11), homemaker (n = 4), University student d (n = 3), retired (n = 13), and disabled (n = 75).

Regular part-time work (less than 40 hours per week; n = 15) and regular full-time work (40 or more hours a week; n = 6).

Subjective social status was measured using the MacArthur Scale of Subjective Social Status, which assesses relative social standing in society (Adler et al., 2000).

Nicotine dependence was measured using the Wisconsin Inventory of Smoking Dependence Motives, which assesses the severity of tobacco dependence (Piper et al., 2004; Smith et al., 2010).

Nicotine withdrawal was measured using the Wisconsin Smoking Withdrawal Scale, which assesses the severity of nicotine withdrawal symptoms (Welsch et al., 1999).

Unadjusted (β = −0.67, SE = 0.17, p < .01) and adjusted (β = −0.53, SE = 0.19, p < .01) linear regressions demonstrated that SSS was negatively associated with nicotine withdrawal symptom severity. SSS was also associated with smoking abstinence 4 weeks after the scheduled quit attempt in the unadjusted logistic regression analysis (odds ratio (OR) = 1.27; [95% CI = 1.07, 1.51]), but after adjusting for the potential mediator (e.g. nicotine withdrawal symptoms) and covariates, SSS was no longer associated with smoking abstinence (OR = 1.13; [95% CI = 0.92, 1.40]).

Mediation analyses

Of the potential confounders evaluated for inclusion in the mediation models, including smoking status on the quit date and treatment condition, only baseline nicotine dependence met the CE threshold. Baseline nicotine dependence confounded the association between SSS and nicotine withdrawal symptoms by 16%. Mediation analyses (also see Supplemental material) demonstrated that higher SSS was indirectly associated with an increase in the odds of smoking abstinence through lower nicotine withdrawal symptom severity (B = 0.07; [95% CI = 0.01, 0.14]). Importantly, this indirect effect seemed to be significantly influenced by withdrawal-related anger and anxiety. As shown in Table 2, SSS was indirectly associated with an increase in the odds of smoking abstinence through lower levels of withdrawal-related anger (B = 0.07; [95% CI = 0.02, 0.15]) and anxiety (B = 0.05; [95% CI = 0.01, 0.12]). Notably, no other withdrawal symptom was associated with smoking abstinence or mediated the association between SSS and smoking abstinence, and SSS was directly associated with smoking status in all mediation models.

Table 2.

Mediation models linking subjective social status to smoking status (0 = smoking, 1 = abstinent, N = 139).

Mediator	X → M^a (a path)		M → Y (b path)		X → Y (c′ path/direct effect)		X → M → Y (ab path/indirect effect)
Mediator	B (SE)	p	B (SE)	p	B (SE)	p	B (SE)	95% CI^b
WSWS total	−0.56 (0.17)	<.01	−0.12 (0.05)	.01	0.18 (0.09)	.05	0.07 (0.03)	0.01, 0.14
Anger	−0.13 (0.04)	<.01	−0.54 (0.19)	.01	0.18 (0.09)	.05	0.07 (0.04)	0.02, 0.15
Anxiety	−0.11 (0.04)	<.01	−0.46 (0.22)	.03	0.20 (0.09)	.03	0.05 (0.03)	0.01, 0.12
Sleep	−0.08 (0.04)	.03	−0.40 (0.22)	.07	0.22 (0.09)	.02	0.03 (0.02)	−0.01, 0.09
Concentration	−0.07 (0.03)	.03	−0.47 (0.25)	.07	0.22 (0.09)	.02	0.03 (0.03)	−0.01, 0.10
Craving	−0.09 (0.04)	.01	−0.27 (0.20)	.18	0.22 (0.09)	.02	0.02 (0.02)	−0.02, 0.08
Hunger	0.02 (0.03)	.58	−0.31 (0.25)	.22	0.26 (0.09)	.01	−0.01 (0.02)	−0.04, 0.02
Sadness	−0.09 (0.03)	<.01	−0.47 (0.27)	.08	0.21 (0.09)	.02	0.04 (0.03)	−0.01, 0.11

Note: X: independent variable (subjective social status at 1 week pre-quit); M: mediator (Wisconsin Smoking Withdrawal Scale (WSWS) at quit day); Y: dependent variable (smoking status 4 weeks post-quit date).

Analyses included baseline nicotine dependence as a covariate.

Bias corrected bootstrapped confidence intervals (10,000 bootstrap samples).

In a sensitivity analysis, we replicated our mediation model using a measure of nicotine withdrawal completed 1-week after participants quit smoking. The results were very similar to the primary analysis, but the effect sizes for withdrawal-related anger and anxiety were smaller than the effects sizes observed when nicotine withdrawal was measured less than 24 hours after quitting, which is expected because the onset of symptoms begin 4–24 hours following cessation, peak after 3 days, and decline over the course of 3–4 weeks (McLaughlin et al., 2015). We also conducted a sensitivity analysis using moderated mediation analysis to determine whether treatment condition (usual care vs. contingency management) moderated the direct effect of SSS on smoking abstinence 4 weeks after the quit date and whether treatment condition moderated the indirect effect of SSS on smoking abstinence through nicotine withdrawal. The results showed that treatment condition (usual care vs. contingency management) did not moderate the direct effect of SSS on smoking abstinence 4 weeks after the quit date, nor was there any evidence that treatment condition moderated the indirect effect that SSS had on smoking abstinence through nicotine withdrawal. Similarly, there was no evidence that the treatment condition moderated the indirect effect that SSS had on smoking abstinence through withdrawal-related anger or anxiety.

Discussion

This study evaluated whether SSS was indirectly associated with smoking cessation through nicotine withdrawal symptoms. It was hypothesized that lower SSS would be associated with greater nicotine withdrawal symptom severity, which would subsequently be associated with reduced odds of achieving abstinence during a quit attempt. These hypotheses were primarily supported; lower SSS was associated with greater nicotine withdrawal symptom severity on all measured dimensions, except hunger, and high levels of withdrawal symptoms increased the odds of smoking 4 weeks after a quit attempt. Although SSS was associated with most withdrawal symptoms, anger and anxiety were the only withdrawal symptoms that predicted smoking abstinence 4 weeks after a quit attempt.

Findings suggest that people who report lower SSS experience higher levels of anger during nicotine withdrawal, and withdrawal-related anger may be a mechanism through which SSS reduces the odds of achieving abstinence. These findings align with recent experimental research, which showed that relative deprivation mediated the association between SSS and feelings of anger and hostility (Greitemeyer and Sagioglou, 2016, 2019). Unfortunately, inequalities that are deemed to be unfair may elicit strong and persistent feelings of resentment and anger in lower SSS adults because social interactions and the social environment are replete with cues that signal social position and status (Han et al., 2010; Kraus et al., 2017). Smoking may help some individuals to cope with feelings of anger and resentment, but these feelings quickly resurface and possibly increase shortly after smoking cessation, which may increase the difficulty of maintaining smoking abstinence (Al’Absi et al., 2007).

Similarly, smoking may also serve as a maladaptive coping strategy to regulate symptoms of anxiety. Smoking impairs the development of adaptive coping mechanisms and increases maladaptive coping and emotional dysregulation (McGee et al., 2013), which is the inability to manage and regulate behavioral responses to internal and external stimuli (Tull and Aldao, 2015). Relatedly, studies have shown that lower SSS is associated with emotional dysregulation (Kauffman et al., 2020; Zvolensky et al., 2017). Zvolensky et al. (2017) demonstrated that higher levels of anxiety symptoms among individuals of lower SSS could be partly explained by a greater difficulty in regulating emotions compared to those of higher SSS. A recent study demonstrated that adult cigarette smokers with higher levels of emotional dysregulation were more nicotine dependent and reported more barriers to smoking cessation (Rogers et al., 2018). Using cigarettes or other tobacco products to manage withdrawal-related symptoms such as anger and anxiety may occur because lower SSS inhibits the ability to adaptively regulate or cope with affective states during a quit attempt.

Findings from this study have implications for cessation treatment. First, lower SSS is associated with more severe withdrawal symptoms shortly after quitting, and this effect is independent of pre-quit nicotine dependence levels. Thus, it may be beneficial to provide a higher dose of nicotine patches and instruct lower SSS adults to use more nicotine gum or lozenges throughout the day. Second, clinicians could also supplement nicotine replacement therapy with interventions that target anger and anxiety. A recent randomized clinical trial found that providing adult cigarette smokers with nicotine replacement therapy and five sessions (90 minutes each) of cognitive-behavioral therapy oriented toward teaching anger and stress coping skills improved quit rates 6 months later compared to only receiving nicotine replacement therapy and behavioral counseling (44% vs. 27.4%; p < .001; Yalcin et al., 2014). Notably, smoking cessation interventions that include components to address anxiety are effective for adults with high anxiety sensitivity (Smits et al., 2016; Zvolensky et al., 2018a). Supplementing standard cessation treatment with anxiety and anger management treatments may be beneficial for lower SSS adults.

This study has limitations. First, we were not able to replicate the second-order factor structure of the WSWS that has been found in previous research (Welsch et al., 1999), perhaps because of the limited sample size (MacCallum et al., 1999; Mundfrom et al., 2005). Nonetheless, analyzing these sub-scales individually is still important because they are clinically significant, predict cessation outcomes (Castro et al., 2011; Welsch et al., 1999), and findings can be compared with other studies using the WSWS. Second, the sample was predominately Black, female, and socioeconomically disadvantaged. Thus, the findings may be less generalizable to Whites and individuals of other racial/ethnic backgrounds, males, and adults of higher socioeconomic status. Third, because most of the participants were not employed (86%) and nearly half reported an annual household income of less than US$10,000 (49%), the potential influences of occupation and income on subjective social status and smoking cessation could not be thoroughly explored. Nevertheless, many studies show that SSS is associated with health outcomes even after controlling for income, occupation, and education (Zell et al., 2018), and SSS is sometimes conceptualized as a mechanism linking objective socioeconomic status and health outcomes (Demakakos et al., 2008; Hoebel et al., 2017). Therefore, a future study that includes participants from across the continuum of socioeconomic status might test a sequential mediator model with objective socioeconomic status as the first step in the causal process. Last, most nicotine withdrawal symptoms did not mediate the association between SSS and smoking cessation, and anger and anxiety only partly mediated the association. Thus, other mechanisms, not under investigation, in this study may link SSS to smoking cessation.

In summary, lower SSS was indirectly associated with an increase in the risk of smoking relapse 4 weeks after a quit attempt through greater nicotine withdrawal severity, which was observed only hours after the initiation of a quit attempt. Closer inspection of withdrawal symptoms revealed that anger and anxiety might be key mechanisms linking SSS and smoking cessation. Researchers are encouraged to identify protective factors for addressing nicotine withdrawal symptoms and smoking cessation, such as using problem-focused coping strategies, having family and friends provide positive support, and providing more nicotine replacement therapy (Bandiera et al., 2016; Carver et al., 1989). These strategies may improve cessation outcomes among socioeconomically disadvantaged populations.

Supplemental Material

Revised--Supplementary_materials – Supplemental material for Subjective social status is indirectly associated with short-term smoking cessation through nicotine withdrawal symptoms

Supplemental material, Revised--Supplementary_materials for Subjective social status is indirectly associated with short-term smoking cessation through nicotine withdrawal symptoms by Adam C Alexander, Oluwakemi Olurotimi, Emily T Hébert, Chaelin Karen Ra, Michael S Businelle and Darla E Kendzor in Journal of Health Psychology

Footnotes

Author contributions

D.K. and M.B. designed the parent study. A.A. formulated the research questions and hypotheses and conducted the secondary data analyses for this study. A.A. also prepared the first draft of the manuscript. All authors revised the first draft and approved the final manuscript.

Declaration of conflicting interests

The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: All authors declare that they have no affiliations with or involvement in any organization or entity with any financial interest (such as honoraria, educational grants, participation in speakers’ bureaus, membership, employment, consultancies, stock ownership, or other equity interest, and expert testimony or patent-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, knowledge, or beliefs) in the subject matter or materials discussed in this manuscript.

Ethical approval

Informed consent was obtained from all individual participants included in the study. Procedures performed in this study involving human participants were following the ethical standards of the institutional and national research committee and with the 1964 Helsinki declaration and its later amendments (or comparable ethical standards). The study procedures were also approved by the Institutional Review Board of the Oklahoma University Health Sciences Center.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by institutional funding provided by the University Of Texas School Of Public Health (to D.E.K. and M.S.B.), and the American Cancer Society grants MRSG-10-104-01-CPHPS (to D.E.K.) and MRSG-12-114-01-CPPB (M.S.B.). This work was partially supported by the University of Oklahoma Health Sciences Center, Oklahoma Tobacco Settlement Endowment Trust (TSET) grant 092-016-0002. The funders had no role in study design, data collection, and analysis, decision to publish, or preparation of the manuscript.

ORCID iD

Adam C Alexander

Supplemental material

Supplemental material for this article is available online.

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