Review ArticleSmoking, traumatic event exposure, and post-traumatic stress: A critical review of the empirical literature☆
Section snippets
Smoking
Several developmental stages of smoking are implicitly embedded within the current review. Models of the progression of smoking behavior across the course of use suggest there are relatively distinct and generally well-specified stages, which include initiation, maintenance, and relapse (Flay, 1993). The initiation stage reflects smoking on the initial few “experimentation trials” and continued irregular use over time. The maintenance stage includes regular cigarette smoking ranging from weekly
Study selection criteria
We conducted a literature search with electronic search engines (i.e., PsycINFO and MEDLINE) to examine data bases using all combinations of the following key words: smoking or nicotine or cigarettes and trauma or post-traumatic stress disorder (or PTSD) or acute stress disorder (or ASD). We also collected all articles cited in these investigations that appeared potentially relevant to the review. Overall, these searches yielded 62 articles. Studies were then included only if they were focused
Evidence regarding the relations among smoking, traumatic event exposure, and PTSD
The natural starting point for an inspection of the nature of the smoking–traumatic event/PTSD relations is considering the extent to which these problems co-occur. We first review comparisons of smoking rates between persons with, versus without, PTSD and a study that estimated smoking rates among persons with PTSD without a comparison group. We then review studies investigating smoking rates among persons exposed to traumatic events, wherein persons were exposed to traumatic events without
Prevalence of smoking among persons exposed to traumatic events
Investigators also have explored the relation between exposure to traumatic events and smoking levels. In Hapke et al. (2005) study described above, significantly higher rates of ever-smoking, current smoking, ever being nicotine dependent, and current nicotine dependence were endorsed by traumatic event-exposed persons without PTSD (64%, 39%, 26%, and 14%, respectively) relative to persons without such exposure (58%, 36%, 19%, and 10%, respectively). When analyzed as a function of gender, the
Prevalence of traumatic event exposure and PTSD among smokers
Few studies have measured the prevalence of traumatic event exposure among smokers. Vest et al., 2002 investigated the relation between IPV and smoking among a random sample of 18,415 adult women. While the operational definition of smoker versus non-smoker was not specified, Vest et al. (2002) examined a portion of the Behavioral Risk Factor Surveillance System data, which Lemon et al. (2002; described above) also studied. In Lemon and associates' study, current smoking was defined as smoking
Covariation between severity of post-traumatic response and smoking behavior
Several tests have been conducted to examine the relation between levels of smoking behavior and the degree to which individuals respond symptomatically to traumatic event exposure. The vast majority of these studies compare smoking behavior between traumatic event-exposed individuals with, versus without, PTSD, which in this section, are critically analyzed first. We then review studies adopting other approaches to examining the covariation between smoking and indices of response to trauma
Other research related to the relation between smoking and PTSD
In addition to work on the co-occurrence of smoking, PTSD, and traumatic event exposure, several areas of work are beginning to address other factors implicated this relation. In this next section, we review evidence in these domains, organized according to amount of research conducted, beginning with the most well-researched.
Heritability
Shared genetic/familial factors were examined in Koenen et al. (2005) examination of the VET registry (described above). Specifically, a twin design was utilized to estimate the variance in nicotine dependence accounted for by shared familial vulnerability and non-shared environmental factors. The best-fitting model included significant genetic and individual-specific environmental factors. It was estimated that approximately 62% of the association between PTSD and nicotine dependence was
Depression
One study examined the role of histories of depression as a potential variable underlying the link between smoking and post-traumatic symptoms. Thorndike et al., 2006 examined the relations between nicotine dependence levels, PTSD symptoms, and gender among daily smokers. Participants were excluded on the basis of current depressive episodes and moderate levels of depressive symptoms (Beck Depression Inventory scores ≥ 16; Beck, Rush, Shaw, & Emery, 1979). The Structured Clinical Interview for
Cardiovascular functioning
The only other factor related to PTSD and smoking to receive empirical examination is cardiovascular functioning among groups characterized by one or both of these problems. This work aims to ultimately understand the health risks and poor outcomes in terms of morbidity and mortality observed among persons with PTSD (Friedman & Schnurr, 1995). Beckham et al. (2004) examined the relations between smoking status and cardiovascular functioning in terms of PTSD diagnostic status among
General conclusions and future directions
While we have provided brief summaries pertinent to individual areas of the smoking–PTSD/traumatic event exposure literature, we will now consider more general overarching conclusions and general directions for future research in this area.
Specificity of the smoking-traumatic event exposure/PTSD relations
While it appears clear that smoking commonly occurs with histories of traumatic event exposure and PTSD, there is little evidence speaking to the specificity of this association. Specifically, it is relatively unclear if it is factors specific to PTSD and/or smoking that result in high co-morbidity rates. For instance, reactions to the World Trade Center attacks included increases in not only smoking levels, but also other substances (e.g., marijuana use), and these effects were related to
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This paper was supported by an Arkansas Biosciences Institute grant awarded to Dr. Feldner and National Institute on Drug Abuse research grants (1 R01 DA018734-01A1, R03 DA16307-01, and 1 R21 DA016227-01) awarded to Dr. Zvolensky.