Effects of Nicotine and Stress on Tobacco Chippers
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Running head: EFFECTS OF NICOTINE AND STRESS ON TOBACCO CHIPPERS
The Effects of Nicotine and Acute Psychological Stress on Neuroendocrine Response and Cardiovascular
Reactivity in a Sample of Tobacco Chippers
Jenny Pietroski
Saint Michael’s College, Vermont
Effects of Nicotine and Stress on Tobacco Chippers
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Abstract
The fact that cigarette smoking is the number one modifiable risk factor for cardiovascular disease has
prompted researchers to further investigate the pathophysiological mechanisms by which nicotine leads to
mortality and morbidity. Because nicotine affects the body by way of the sympathetic nervous system
(SNS) much like psychological stress does, several researchers have investigated the effects of nicotine
and stress together. Approximately 5-10% of adult smokers are light or occasional smokers (CDC, 1989)
and they are becoming an important group to study. Previous research has demonstrated that chippers
show greater myocardial reactivity to psychological stress under the influence of nicotine (21 mg nicotine
patch) as compared to chippers in a nicotine abstinence period (VanderKaay & Patterson, 2007). While
this finding is important, it may not be ecologically valid as chippers rarely consume such a this amount
of nicotine. Therefore, the present pilot study assessed the effects of a low dose nicotine administration
(7mg patch) and sixteen hour nicotine abstinence placebo patch on stress-induced cardiovascular
reactivity among chippers. Sixteen healthy chippers (11 males, 5 females, M = 21.4 years of age, SD =
2.22 years of age), received either a 7mg nicotine patch (n = 9) or a placebo patch (n = 7) which they
wore during a 16-hour cigarette smoking abstinence period. Cardiovascular reactivity (HR, SV, CO, SBP,
DBP, TPR) was recorded during a 10-minute seated baseline period, a 5-minute Star Mirror Trace Task
(SMTT), and a second 10-minute recovery period. Significant Task main effects were demonstrated for
HR, SV, SBP, DBP, and TPR (all p’s <.01), such that HR, SBP, DBP, and TPR increased from baseline
to SMTT and SV decreased. However, no differences in baseline cardiovascular functioning, Condition
main effects, or Task x Condition interactions were demonstrated. Consequently, wearing a 7mg nicotine
patch did not alter cardiovascular reactivity to psychological stress in this sample of chippers. More
research is needed to further demonstrate the biological mechanisms by which cigarette smoking can lead
to disease.
Effects of Nicotine and Stress on Tobacco Chippers
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The Effects of Nicotine and Acute Psychological Stress on Neuroendocrine Response and
Cardiovascular Reactivity in a Sample of Tobacco Chippers
According to the Center for Disease Control (CDC) approximately 43.3 million (one in
five) American adults are habitual smokers (2008). Cigarette smoking and exposure to tobacco
smoke has resulted in at least 438,000 premature deaths and approximately $96.8 billion in
productivity loss each year in the United States (Adhikari, Kahende, Malarcher, Pechacek, &
Tong; CDC, 2004). Alarmingly more than 2,600 Americans die each day from the condition
(CDC, 2004).Smoking is also attributed as one major cause of coronary heat disease, the single
leading cause of death in the United States (roughly 1 death every 33 seconds; CDC, 2004).
Tobacco use along with alcohol use contributes to roughly five-hundred thousand deaths and is
the leading cause of excessive health care costs (Epstein, King, Sher & Young, 2006; as cited in
Hurt et al., 1996). Several forms of cardiovascular disease are also directly related to tobacco
exposure including coronary heat disease, stroke, high blood pressure, atherosclerosis (hardening
of the artery), congestive heart failure, and other conditions (CDC, 2004).
Cigarette smoking and the addiction to nicotine, the primary pharmacological agent
found in cigarettes, is one of the most dangerous addictions. Habitual smokers primarily smoke
to maintain a certain blood nicotine level and prevent nicotine withdrawal (Shiffman & Paty,
2006). Nicotine is also known to be a vasoconstrictive substance that increases sympathetic
nervous system activity (i.e. blood pressure, heart rate). Chronic stimulation from of the
sympathetic nervous system due to nicotine can over time lead to hypertension or cardiovascular
disease.
Effects of Nicotine and Stress on Tobacco Chippers
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Currently researchers are examining the concept of ‘stress’ and the roll it plays in various
pathophysiolgical disease processes (Esch, Stefano, Fricchione, & Benson, 2002). The term
‘stress’ summarizes the effects of both environmental and psychosocial effects on physical and
mental well-being—in particular the cardiovascular system, central nervous system, and
endocrine system (Esch et al., 2002). Smoking for example, has been known to disrupt the
body’s effort towards “homeostasis” or equilibrium by disrupting CVR and endocrine
functioning (Esch et al., 2002; VanderKaay, 2007). Two key players of our auto regulatory stress
response (i.e. the body’s way of keeping homeostasis) include the hypothalamic-pituitary-adrenal
or HPA axis and the sympathoadrenal medullary system (SAM; Esch et al., 2002). Changes in
salivary cortisol levels is one way scientists can indicate if an individual is experiencing either
psychological and/or physical stress.
Hans Seyle, a pioneer in the field of health psychology, first described the body’s
response to stress as a three step process or “general adaptation syndrome” (GAS; Biondi &
Picardi, 1999) . The three stages include: the alarm stage, resistance stage, and exhaustion stage.
During the alarm stage your body quickly prepares for a “flight or flight” type of behavior (i.e.
get out of the dangerous situation as quickly as possible). The HPA, nervous system (SNS), and
adrenal glands become active and secrete the main stress hormone cortisol (Seyle, 1942). The
influx of stress hormones, specifically cortisol, allows the body’s defense system to kick in and
provide enough energy to escape the situation. As a result, the body may enter into the resistance
stage where cortisol may be released chronically. If the body fails to adapt to the stress, the
individual may enter into the final stage or exhaustion stage where the body becomes ill or dies
(Seyle, 1942).
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Because of the intimate relationship between nicotine and the sympathetic nervous
system, smokers often experience significant increases in heart rate (HR) and blood pressure.
Researchers have also investigated the influence of nicotine use and the physiological and
psychological responses. Several studies examining smoking and stress-induced cardiovascular
reactivity (i.e. the change in cardiovascular functioning during exposure to acute or chronic
psychological stress) have demonstrated that the combination of nicotine and psychological
stress can increase cardiovascular reactivity additively in cigarette smokers (MacDougall,
Musante, Howard, Hanes, & Dembroski, 1986; Perkins, Epstein, Jennings, & Stiller, 1986;
Tsuda, Steptoe, West, Fieldman, & Kirschbaum, 1996). On the other hand researchers have also
found the effect of nicotine on stress-induced cardiovascular reactivity to be negligible (Girdler,
Jamner, Murray Soles, & Shapiro, 1997; VanderKaay & Patterson, 2006). There are several
possible explanations for the inconclusive findings in this area of research such as differing
modes of nicotine administration (i.e. cigarette smoking, transdermal patch, nasal spray) and
varying study groups and designs (i.e. smokers vs. nonsmokers, smoking abstinence vs.
smoking).
In addition, cardiovascular reactivity and cortisol levels in response to a cognitive stress
task significantly increase (Uchino, Cacioppo, Malarkey, & Glaser, 1995). This particular study
also noted cortisol levels as a strong correlate to the individual’s heart rate and blood pressure.
Additional research conducted by Hughes, Arana, Amori, Stewart and Workman (1988) also
discovered enhanced cortisol levels in a small sample of male smokers during a brief nicotine
abstinence period. Al’Absi, Amunrud, and Wittmers (2002) further indicated a higher cortisol
concentration in smokers than non-smokers after a period of psychological stress.
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Research has also shown that cigarette smokers report smoking during periods of
increased psychological stress (Perkins & Grobe, 1994), and often times the withdrawal from
nicotine can produce a physiological response similar to that produced by psychological stress
(Parrott, 1995). Al’Absi et al. (2002), also indicated that systolic blood pressure in responses to
a psychological stressor was greater during a smoking abstinence (nicotine withdrawal)
condition as compared to when participants were allowed to smoke cigarettes on their regular
schedule. Other research has also reported similar findings among habitual cigarette smokers and
withdrawal from cigarettes in that the habitual smokers experience an enhanced cardiovascular
reactivity when exposed to psychological stress as compared to the nicotine condition
(VanderKaay & Patterson, 2006; Tsuda et al., 1996; Kirschbaum, Strasbuger, & Langrär,
1993). These withdrawal symptoms may also become exaggerated during times of psychological
stress (Koval & Pederson, 1999). In one study, women who were “light smokers” (i.e. smoked
no more than 5 cigarettes a day) experienced higher levels of stress and negative affect than did
their male counter parts (also light smokers; Presson, Chassin, & Sherman; 2002). The study
suggested a difference in sex and the relationship of smoking in response to psychological stress.
However, the greatest single factor contributing to the inconsistency in the stress/smoking
cardiovascular reactivity literature is that the participants recruited for the studies have all been
moderate to heavy smokers and their cardiovascular reactivity assessment prior to nicotine
addiction cannot be determined.
Interestingly, approximately 5-10% of adult smokers are light or occasional smokers
(CDC, 1989) and these individuals do not become addicted to nicotine despite repetitive use,
making them an interesting group to study. This group of occasional smokers is known as
Effects of Nicotine and Stress on Tobacco Chippers
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“chippers”. Chippers are defined as individuals who smoke at least two days per week and no
more than five cigarettes during the days that they do smoke (Sayette, Martin, Wertz, Shiffman,
& Parrott, 2001). On average, chippers smoke 1-4 cigarettes on any given day and fail to show
signs of dependence (Sayette, Martin, Wertz, Perrott, & Peters, 1994; as cited in Shiffman et al.,
2005 ;). Also unlike habitual smokers, these individuals fail to show any signs of withdrawal
after extended periods of time without nicotine (Shiffman & Paty, 2006). Instead, chippers tend
to emphasize various social and psychological motives (i.e. sensory pleasure, smoking to relax
after a meal; Shiffman and Paty, 2006) for their reasons for smoking rather than physiological
dependence. Epstein, Sher, Young, and King (2007) discovered a correlation between increased
alcohol consumption and an increased cigarette craving among tobacco chippers. Shiffman et al.,
(2005) also suggests alcohol as the most common environmental cue for smoking among this
particular group. Also, research on chippers has established that both tobacco chippers and
regular tobacco smokers share a similar smoking topography and metabolize nicotine in similar
ways (as cited in Brauer, Hatsukami, Hanson, & Shiffman, 1996; Shiffman, 1989; Shiffman et al.,
1992; Shiffman, Paty, Gyns, Kassel, & Elash, 1994; Presson, Chassin, & Sherman, 2002).
Additionally, research has also shown that chippers tend to have greater post-cigarette
heart rate and blood pressure as compared to habitual smokers (Shiffman, Zettler-Segal, Kassel,
Paty, Benowitz, & O-Brien, 1992). Presently, a study by VanderKaay (2007) is the only known
study to investigate cardiovascular reactivity between habitual smokers and chippers. This study
found that during nicotine administration, habitual smokers responded to psychological stress
with increases in vasoconstriction while chippers responded to psychological stress with more
myocardial responses. To date, no studies have investigated cortisol responses to stress in these
two cigarette smoking groups. Recent epidemiological studies have also reported that smoking
Effects of Nicotine and Stress on Tobacco Chippers
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1-4 cigarettes per day is associated with an almost three-fold increased risk for ischemic heart
disease (Bjartveit & Tverdal, 2006) as compared to a group of participants who had never
smoked. This study also indicated that participants who smoked a pack of cigarettes per day had
a four-fold increased risk for ischemic heart disease as compared to a group of individuals who
had never smoked.
One study conducted by Presson, Chassin, and Sherman (2002) discovered several
psychosocial antecedents of tobacco chipping. Chippers tended to have a positive attitude and
lack of concern for the damaging health consequences of smoking cigarettes (Presson et al.,
2002). One study also suggested that the smoking environments of chippers tend to inhibit
cigarette smoking behavior in comparison to habitual smokers (i.e. both their peers and parents
do not provide a supportive environment for the behavior; Presson et al., 2002). Along with the
low levels of smoking in their social environment, chippers tend to have a lower genetic
vulnerability (i.e. their biological parents had a low level of lifetime smoking history; Presson et
al., 2002). Chippers also tend to have an internal locus of control as well as a high expectation
for academic success and independence (Jessor & Jessor, 1997; as cited in Presson et al., 2002).
Presson et al. (2002) suggest that since these adult chippers show a high level of academic
expectation, educational attainment, and full-time employment, they are less likely to be
deviance prone. Presson et al. (2002) suggest that a positive attitude and health belief about
smoking, some high risk personality characteristics, lowered levels of positive affect, lower life
satisfaction, and a lack of belief in the addictive properties of smoking (nicotine especially) serve
as high risk characteristics for this particular behavior. On the other hand, Presson et al. (2002)
have found other protective risk factors including: low rates of smoking among friends and
parents, lower genetic vulnerability, high expectations for academic success (higher levels of
Effects of Nicotine and Stress on Tobacco Chippers
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conscientiousness especially), high levels of education attainment, and an internal locus of
control.
In conclusion, what makes chippers immune to nicotine dependence (biological factors,
psychological factors, or both) is still largely unknown. The current study attempted to assess the
effects of nicotine on cardiovascular reactivity during psychological stress in chippers as well as
the effects of nicotine on neuroendocrine functioning. Francine, Jaquet, Shapiro, Sebastian, and
Uijtdehaage (1994) also discovered that both male and female smokers experience an increase in
blood pressure and heart rate after smoking. Therefore we hypothesized that chippers in the
nicotine condition will show greater cardiovascular reactivity than chippers in the nicotine
abstinence condition. However, currently there is a lack of research examining neuroendocrine
functioning in response to acute nicotine administration in non-habitual smokers. The current
study addressed this issue by taking salivary cortisol samples after an acute dosage of nicotine
(7mg dosage) or placebo 16 hours prior to salivary cortisol sampling. One study conducted by
Uchino, Cacioppo, Malarkey, and Glaser (1995) examined the relationship between
cardiovascular reactivity and blood cortisol in response to a stressful task. The results showed
that HR, SBP and DBP were positively correlated to changes in cortisol levels. The linkage
between CVR and cortisol levels may suggest a biological mechanism responsible for the
harmful effects of chronic stress on the cardiovascular system. The current study will examine
both CVR and salivary cortisol levels in response to a stressful task. Therefore, we hypothesized
that chippers in the nicotine condition will show a greater neuroendocrine response than chippers
in the nicotine abstinence condition after a stressful task (i.e. higher concentration of cortisol in
saliva after the stressful task).
Effects of Nicotine and Stress on Tobacco Chippers 10
Method
Participants
Sixteen healthy tobacco chippers between the ages of 18 and 30 years were recruited
through flyers (Appendix A), word-of-mouth, emails, and online surveys in the Burlington
Vermont area between June 1st and August 5th, 2009. After answering the health information
screening sheet (HISS), eligible individuals were again contacted by phone and scheduled to
participate. Eleven males and five females between the ages of 18 and 30 years were included in
the study. Five participants were not American citizens (n=1; Spain, n=1; Italy, n=1; Japan, n=1;
Vietnam, n=1; Saudi Arabia) and were involved in one of Saint Michael’s College English
Intensive Programs. In the study, chippers (non-nicotine dependent, occasional cigarette
smokers) were defined as those participants who report smoking no more than five cigarettes per
day at least 2 days per week (Sayette, Martin, Wertz, Shiffman, & Parrott, 2001). Participants
accepted into the study reported no chronic health problems (e.g. cardiovascular disease,
hypertension, cancer, diabetes) and no use of prescribed medications that may affect
physiological responses (e.g. diuretics, beta-blockers) or mood responses (e.g. anxiolytics, antidepressants; see Appendix B). Eligible participants had a body mass index (BMI) between 18
and 30 and had the option of receiving payment for their participation ($20.00 cash).
Pharmacological Agents
Nicotine patches. A 7 mg nicotine patch (equate®, Novartis Consumer Health, Inc.,
Parsippany, NJ) was used to deliver nicotine to the participants sixteen hours before the initial
testing session. The active ingredient included 7 mg of nicotine and the inactive ingredients
were acrylate adhesive, aluminized polyester, cellulose paper, and methacrylic acid copolymer.
Nicotine patches were applied to the participants on the upper lateral side of the deltoid muscle
Effects of Nicotine and Stress on Tobacco Chippers 11
of their non-dominant arm during the pre-testing session (16 hrs before the scheduled testing
laboratory session). Patches were applied 16 hrs before the scheduled testing laboratory session
because plasma nicotine concentrations peak 6 to 16 hours after transdermal application
(Physician’s Desk Reference, 1995).
Placebo patches. A first aid adhesive patch (Johnson & Johnson, Consumer Companies,
Inc., Skillman, NJ) served as the placebo patch for the study. The adhesive pad was labeled
identically to the equate® nicotine patches. The placebo patches were also applied to the upper
lateral side of the deltoid muscle of their non-dominant arm during the pre-testing session (16 hrs
before the scheduled laboratory testing session).
Physiological Measurements
Heart rate, blood pressure, and impedance cardiography. A maximum of sixteen heart
rate (HR) readings were obtained using an electrocardiogram (ECG). A Bio-Impedance
Technology, Inc. Impedance Cardiography model HIC-3004/T and a Tango Blood Pressure
Monitor was used to measure systolic blood pressure (SBP), diastolic blood pressure (DBP),
cardiac output (CO), stroke volume (SV), and total peripheral resistance (TPR).
Salivary cortisol. Two salivary cortisol measurements were obtained by asking the
participant to chew on a synthetic fiber for approximately two minutes. The first saliva sample
was collected immediately following a ten minute baseline period while the second saliva sample
was collected following a fifteen minute final rest period. The samples were immediately stored
in a test tube, frozen, and then sent to the Salimetrics laboratory for assay and analysis at the
conclusion of the study.
Blood pressure. Systolic blood pressure (SBP) and diastolic blood pressure (DBP) were
measured by placing an adult sized blood pressure cuff to participants’ non-dominant upper arm.
Effects of Nicotine and Stress on Tobacco Chippers 12
The equipment used to take the reading was the automated blood pressure monitor located in
another room.
Heart rate. An electrocardiogram (ECG) connected to 3 bipolar silver-silver electrodes
measured the participants heart rate (HR). The COP-WIN/HRV 6.10 software program
(Bioimpedance Technology, Inc, Chapel Hill, NC) was used to determine interbeat interval (IBI)
for the calculation of HR. The COP-WIN/HRV 6.10 software was also used to analyze
impedance cardiography data.
Cardiac output and stroke volume. Stroke volume (SV) and cardiac output (CO) were
measured by three bipolar silver-silver electrodes attached to the impedance cardiograph
(mentioned above). The established tetrapolar band-electrode system unobtrusively connects the
aortic flow to variations in thoracic resistance (Sherwood, Allen, Fahrenberg, Kelsey, Lovallo, &
van Doornen, 1990; Miller & Hovath, 1978). Impedance cardiography examinations were also
done using the commercially available impedance cardiograph program (COP-WIN/HRV 6.10)
that operates on a Gateway model E2300 computer and permits online analysis using ensemble
averaging over a user specified period of time (55 sec). Stroke volume (SV) was also computed
using the Kubicek formula (Kubicek, Karnegis, Patterson, Witsoe, & Mattson, 1966). The
product of mean SV (ml) and HR (bpm) during each minute of recording was used to calculate
the participants’ cardiovascular outputs (1/min) (Kubicek et al., 1966).
Total peripheral resistance. Total peripheral resistance (TPR) was obtained based on
mean arterial pressure and cardiovascular output data. The total peripheral resistance (TPR) was
then calculated by the COP-WIN/HRV 6.10 program as follows: TPR (dyne-seconds/cm-5) =
(Mean Arterial Pressure/Cardiovascular Output) X 80.
Effects of Nicotine and Stress on Tobacco Chippers 13
Height and weight. Body Mass Index (BMI) was measured using the Detecto medical
scale and computed using the standard BMI algorhythm in which: weight (kg)/ height (m)2 =
BMI(Model 3P7044; Webb City, MO). Participants with a BMI in the obese range (30 and above)
and underweight range (20 and below) were not eligible to participate in the experimentation.
Task Description
Star Mirror Trace Task (SMTT). The SMTT consists of an apparatus that contains a
wooden platform attached to both a metal plate and a vertically hinged mirror (Mirror Tracer
Model 58024, Lafayette Instruments Corporation, Lafayette, IN). A piece of paper containing
the outline of a six-pointed star-shaped figure was held using clear adhesive tape at each corner.
For the task, participants were asked to trace the star-shaped figure while viewing its reversed
image in the mirror using a pen held in their dominant hand. A metal plate, positioned
horizontally to the wooden platform, blocked the participants’ view of the star-shaped figure on
the paper. Participants were told to trace the star as quickly and as accurately as possible while
avoiding errors, remaining seated, quiet, and free from movement except for their arm with the
pen. An experimenter using a manual clicking counter device remained in the room with the
participants and documented each error. Errors were defined as any time that the participant
moved the pen outside of the 5 mm thick outline of the star-shaped figure, lifted the pen off of
the figure, or discontinued movement with the pen. A loud clicking metronome was also
presented by a CD on a Gateway speaker while the participants completed the task. The task
lasted five minutes in duration and participants were told that the average person is able to trace
the star-shaped figure at least five times in that amount of time without error. The SMTT has
been documented to elicit increases in blood pressure (Krantz, Manuck, & Wing, 1986), as well
as heart rate, cardiac output, stroke volume, and total peripheral resistance changes during
Effects of Nicotine and Stress on Tobacco Chippers 14
laboratory challenges (Allen, Stoney, Ownes, & Matthews, 1993). The task is also considered to
be both frustrating and challenging for participants and has become a standard for producing
psychological stress in participants during many cardiovascular reactivity studies (Feldman,
Cohen, Leopore, Matthews, Kamarck, & Marsland, 1999; Owens, Stoney, & Matthews, 1993).
More specifically, laboratory studies investigating differential cardiovascular responses to
laboratory challenges such as the Stroop-Color-Word Test, reaction time testing, and the SMTT
have reported that the SMTT produces significantly greater DBP and TPR responses than the
other aforementioned tasks within a sample of healthy college males (Waldstein, Bachen, &
Manuck, 1997).
Assessment Measures
Cigarette smoking characteristics questionnaire (CSCQ). Firstly the 5-item
questionnaire determined the age of the participants first cigarette or “puff” of a cigarette as well
as the age at which the individual first began smoking cigarettes on a regular basis (i.e. 2-5 times
a week). This questionnaire also measured the type of cigarettes the participant currently smoked
(i.e. Camel Lights, Marlboro) as well as determining if the individual uses other tobacco
products (i.e. snuff, dip, chew, cigars, and pipes). Finally the questionnaire asked whether or not
the individual had ever previously used a transdermal nicotine patch (Appendix B).
Health information screening sheet (HISS). The 9-item HISS (VanderKaay, 2009)
determined whether or not the potential participant was healthy enough to participate in the study
(i.e. they do not currently suffer from any chronic diseases, have a healthy BMI (18-30), and are
not currently taking any prescribed medications that may affect physiological responses (e.g.
diuretics, beta-blockers) or mood responses (e.g. anxiolytics, anti-depressants)). Participant
eligibility could be determined after completion of the questionnaire (Appendix C).
Effects of Nicotine and Stress on Tobacco Chippers 15
Perceived Stress Scale (PSS). The 10-item PSS (Cohen, Kamarck, & Mermelstein, 1983)
measured the degree to which situations in one’s life are appraised as stressful (Appendix D).
According to Golden-Kreutz, Thornton, Wells-Di Gregorio, Frierson, Jim, Carpenter, Shelby,
and Anderson (2005) the PSS is used as a standardized, self-report questionnaire used to
determine the extent to which the participant perceives his or her life to be uncontrollable,
overloading, and unpredictable. Participants rated how often they experienced a particular
feeling in the past year on a 5-poing Likert-type scale ranging from 0 (never) to 4 (very often).
Cumulative scores range from 0-40, with a higher score indicating a greater overall amount of
stress (Golden-Kreutz et al., 2005).
Coping Styles Questionnaire (CSQ). The 32-item CSQ (Holahan & Moos, 1987) measured
the way certain individuals cope with stressful situations (Appendix E). Coping strategies such
as Avoidance, Active Coping, and Active-Behavioral were examined. The CSQ was used to
evaluate the coping style of participants before undergoing the stress-inducing Star Trace Mirror
Task (SMTT). Participants were asked to rank 32 items on a 4-point Likert-type scale. Subscales
for the CSQ include active behavioral, active cognitive and avoidant coping. Avoidant coping is
defined by avoidance of the problem or non-confrontational strategies to diminish stress (i.e.
drinking, smoking, eating). Active-cognitive coping is characterized by directly addressing or
confronting the problem cognitively through managing stressor evaluation. Active-cognitive
strategies include looking at the situation from a different perspective, perceiving events as more
positive and trying to understand the problem mentally. Active-behavioral coping is recognized
by using direct problem solving behaviors such as finding out more information, asking friends,
family, or a professional for help (Holahan & Moos, 1987).
Visual Analog Scale (VAS). This 11-item questionnaire was previously used by
Effects of Nicotine and Stress on Tobacco Chippers 16
VanderKaay (2007; Appendix F) and consists of an approximate 10 centimeter line in which the
participant ranks their agreement of the nine adjectives of happiness, boredom, anxiousness,
satisfaction, depression, interest, anger, frustration, and irritation. On one polar end “not at all” is
placed above the line while the other polar end has “extremely” written above. Participants are
asked to draw a small perpendicular line where they feel most accurately describes their mood
during the previous task (i.e. baseline, Star Trace Mirror Task, and rest period). Finally two
questions at the end address the difficulty and challenge of the previous task (participants draw a
perpendicular line on another ten centimeter line).
Post-testing questionnaire (PTQ). A self-report questionnaire designed by the
experimenter was utilized to assess any side effects that the participant experienced while
wearing the nicotine or placebo patch (Appendix G). The questionnaire also asked if the
participant correctly indicated which patch (nicotine or placebo) they were wearing and required
a brief description explaining the believed patch type.
Classification of Smoking by Motives (CSM). The CSM is a 34-item questionnaire that
measured both pharmacological and non-pharmacological motives for smoking (Russell, Peto, &
Patel, 1974; Appendix H). The questionnaire also assessed seven motives for smoking including:
“automatic”, “sedative”, “addictive”, “stimulation”, “indulgent”, and “sensorimotor
manipulation.” Participants were asked to rate the 34-items using a Likert-type scale 0 (not at
all)- 3(very much so).
Procedure
Participants will take part in both a pre-testing and testing session. The description of
each session is described below:
Effects of Nicotine and Stress on Tobacco Chippers 17
Pre-testing session. During the pre-testing session, each participant was required to come
to the Psychophysiology and Virtual Reality Laboratory (St. Edmund’s Hall 219) for a 15-minute
pre-testing/patch distribution session. The session took place approximately sixteen hours before
the laboratory testing session (i.e. plus or minus an hour). Informed consent (see Appendix I)
was obtained and participants completed the CSCQ and CSM, in fixed order. Each participant
received both a written and verbal instruction on the nicotine patch (see Appendix J). The
transdermal patch was applied to the participants’ arm and both the experimenter and participant
remained blind to the patch condition until the end of the testing session the following morning.
An adhesive knee bandage was also applied over the nicotine and placebo patches to assist with
the patches remaining securely attached. Participants were also informed that they should not
smoke or use any other tobacco products while using the nicotine patch (placebo or active) and
that doing so may cause possible life threatening side effects, as well as a threat to the validity of
the experiment. Finally, the participant’s height and weight were obtained to verify participant
eligibility.
Testing session. Testing sessions occurred between 8 am and 12 pm approximately
sixteen hours after the pre-testing/patch distribution session. The actual testing laboratory
session lasted approximately seventy minutes in duration. Participants were asked to refrain
from eating, drinking, and exercising four hours prior to the testing session to avoid and possible
interactions with cardiovascular and neuroendocrine responses.
Upon arrival to the laboratory, informed consent was reviewed and participants. Height
and weight were again obtained and recorded on the physiological data sheet (Appendix K). A
twenty-four hour profile (i.e. the participants diet in the past twenty four hours, if the participant
refrained from drinking alcohol and caffeine, amount of time since last cigarette, amount of time
Effects of Nicotine and Stress on Tobacco Chippers 18
since the participant last exercised, and current craving for a cigarette; Appendix L) was also
distributed while the participant was being hooked up to the cardiac equipment. Several other
measurements were also obtained through the following written questionnaires (i.e. PSS, NDSS,
EEQ, and CSQ). Next, tetrapolar band electrodes and bipolar silver-silver chloride electrodes
were placed onto the participant for data recording. Participants were seated and an inflatable
cuff was applied to the non-dominant arm and connected to an automated blood pressure monitor.
Cardiovascular measurements were obtained during a 10-minute seated baseline period in
which participants were instructed to rest quietly while listening to relaxing music (Moby
Ambient, 1993). Blood pressure (SBP, DBP), and impedance cardiography measurements (HR,
SV, CO, TPR) were also obtained during each of the last three minutes of the baseline period.
Following the baseline period the Visual Analog Scale (VAS) was administered to the
participant and the participants were asked to complete the VAS based on their mood during the
preceding resting baseline period. Following the VAS, participants provided a salivary cortisol
sample by placing a small piece of cotton (salivette) under their tongue. Immediately following
the salivary cortisol sample, participants were instructed about the Star Mirror Trace Task
(SMTT). Instructions included what an error consisted of as well as how to comfortably
maneuver the metal so that the participant could no longer see their hand without the use of a
mirror. The 5-min SMTT was then administered and one experimenter remained in the room
recording errors with a clicking device. A loud metronome was also played while the participant
traced the star for five consecutive minutes. A second experimenter remained in the testing room
and recorded impedance cardiography measurements were continuously throughout stress tasks
as well as one blood pressure measurement every sixty seconds.
Effects of Nicotine and Stress on Tobacco Chippers 19
After the five minute stress task the participant was asked to remain seated for another
15-minute recover period in which participants sat quietly while listening to relaxing music. At
the beginning of the recovery period, the VAS was administered and participants reported their
mood and feelings during the preceding SMTT. Impedance cardiography measurements were
recorded continuously throughout the recovery period and blood pressure readings were also
obtained every other minute. At the conclusion of the recovery period, participants were asked to
provide a second salivary cortisol sample and to complete another VAS as well as the Post
Testing Questionnaire (PTQ). Spot and band electrodes, the nicotine patch, and the blood
pressure cuff were removed and participants were debriefed about the purpose of the study.
Participants were also informed as to which type of nicotine patch (active or placebo) they were
wearing and received their compensation (20 dollars cash). A debriefing form addressed a wide
rage of questions the participant may have—including the use of deception during the SMTT
task to elicit a stress response. Any further questions were answered and the experimenters
addressed all comments and concerns. Lastly, the experimenter stressed the importance of
cigarette smoking cessation, which included cessation strategies and relevant contact information
of qualified smoking cessation counselors provided upon request.
Results
Sample Characteristics
The following were general characteristics of the final sample (n = 16): Sex (11 males, 5
females), Patch distribution (9 nicotine, 7 placebo), Age (M = 21.44 years, SD = 2.22 years,
range 18-27 years), BMI (M = 23.63, SD = 3.65), number of smoking days per week (M = 2.75
days, SD = 1.18 days, range 2-5 days), number of cigarettes smoked on smoking days (M = 2.59,
SD = 1.46, range 1-8 cigarettes), length of time being a cigarette smoker (M = 2.91, SD= 2.28,
Effects of Nicotine and Stress on Tobacco Chippers 20
range 1-8 years), age at the first time a cigarette was tried (M = 15.88 years, SD = 2.06 years,
range 12-21 years of age), and age began smoking regularly (M = 19.33 years, SD = 1.91 years,
range 16-24 years).
Assessment Measures
Perceived Stress Scale (PSS). The PSS was administered to examine psychological stress
levels within the sample over the past month. Results indicated that the sample over-all was
moderately stressed (M = 14.06, SD = 5.71, range 5-27).
Coping Styles Questionnaire (CSQ). The CSQ was given to examine three characteristics
of coping styles. For this sample of chippers the most common method of coping is Active
Behavioral (M = 21.07, SD = 4.74), followed Active Coping (M = 18.4, SD 4.24), and finally
Avoidance (M = 6.44, SD = 4.37), indicating an overall positive coping strategies profile.
Classification of Smoking by Motives (CSM). The CSM was administered to examine the
reasons for smoking. The following reasons for smoking for the present sample in ranked order
were: Psychosocial, Sensorimotor, Stimulation, Indulgent, Sedative, Addictive, and finally
Automatic, see Table 1.
Table 1.
Classification of Smoking by Motives (CSM)
subscale scores
Chippers
Rank
Smoking
Motives
Stimulation
4.13 ± 2.47
3
Indulgent
3.88 ± 2.23
4
Psychosocial
6.25 ± 2.25
1
Sensorimotor
5.33 ± 2.69
2
Addictive
1.75 ± 1.39
6
Automatic
0.75 ± 0.89
7
Sedative
2.11± 1.96
5
Effects of Nicotine and Stress on Tobacco Chippers 21
Enriched Environment Questionnaire (EEQ). The EEQ was administered to examine the
degree of enrichment in the participants’ environment during their adolescence. Results indicated
that the sample demonstrated higher levels of enrichment (M = 52.00, SD = 10.88, range 23-63).
Salivary cortisol. Results from Salimetrics take 4-6 weeks to be analyzed and thus are
not presented in this paper.
Exploratory Assessment of Nicotine/Placebo Patch Awareness and Patch Side Effects
At the conclusion of the testing session, participants completed a Post-Testing in which
they were asked to indicate which patch (nicotine, placebo) they believed they were wearing and
to rate on a scale of 0-10 how strongly they had felt a list of side effects while wearing either
patch. To assess nicotine/placebo patch awareness, a chi-square analyses was conducted
between the type of patch given (nicotine versus placebo) and the accuracy of guessing which
patch was given (correct versus incorrect). Results revealed that overall 56.3 percent of the
sample guessed accurately however they were significantly more likely to guess the placebo
patch correctly as compared to the nicotine patch, χ2 (1, n = 16) = 4.39, p < .04, refer to Table 2.
Table 2.
Frequencies for patch guess accuracy and type
of patch worn by condition
Chippers
Nicotine
Placebo
6
Accurate Guess
3
1
Inaccurate Guess
6
To assess differences in patch side effects that were reported by each condition, a series
of independent samples t-tests were conducted for each side effect. Analysis indicated that there
Effects of Nicotine and Stress on Tobacco Chippers 22
were no differences in patch side effects between conditions (p > 0.05), see Table 3.
Table 3.
Patch side effects by condition (mean ± SD)
Placebo
Nicotine
Cigarette urge
0.78 ± 1.30
0.71 ± 1.50
Itching at patch site
2.44 ± 2.45
1.00 ± 1.52
Burning at patch site
1.11 ± 1.96
0.00 ± 0.00
Heart palpitations
0.56 ± 1.67
0.71 ± 1.89
Increased heart rate
0.89 ± 1.96
0.43 ± 1.13
Headache
1.44 ± 2.45
0.43 ± 0.79
Decreased concentration 0.44 ±1.33
0.29 ± 0.76
Dizziness
0.67 ± 1.41
0.71 ± 1.50
Increased irritability
0.67 ± 2.0
1.00 ± 1.53
Baseline Cardiovascular Measurements
Within-Group Differences: Baseline period differences for each cardiovascular variable
(HR, CO, SV, SBP, DBP, and TPR) were assessed to examine Condition effects (7mg nicotine
patch versus placebo patch condition) on baseline cardiovascular measurements. A series of
independent t-tests were conducted on the initial baseline period cardiovascular values and did
not yield any differences in cardiovascular measurements between conditions which was
unexpected (p > .05).
Cardiovascular Reactivity
Star Mirror Tracing Task (SMTT)
Between Condition Comparisons. To assess the effects of nicotine and placebo on
cardiovascular measurements during acute psychological stress (SMTT) within chippers, a series
of repeated measures ANOVA’s were performed. Separate analyses were conducted for each
cardiovascular variable (HR, SV, CO, SBP, DBP, & TPR) using Task (Baseline, SMTT) as the
Effects of Nicotine and Stress on Tobacco Chippers 23
within-subjects factor and Condition (nicotine versus placebo) as the between-subjects factor.
All results across conditions during baseline and SMTT are presented in Table 4.
Significant Task main effects were demonstrated for the following cardiovascular
variables: HR, F(1, 13) = 25.38), p < .001, SV, F(1, 13) = 18.36, p < .01, SBP, F(1, 13) = 43.50,
p < .001, DBP, F(1, 13) = 40.29 p < .001, TPR, F(1, 12 ) = 60.59 p < .001, such that HR, SBP,
DBP, and TPR increased from baseline to SMTT and SV decreased indicating the SMTT was a
significantly stressful challenge. However, no significant Condition main effects or Task x
Condition interactions were demonstrated indicating that wearing a 7mg nicotine patch did not
alter cardiovascular reactivity to psychological stress in this sample of chippers.
Table 4.
Cardiovascular measurements for each group during Baseline and
SMTT by condition (mean ± SD)
Baseline
SMTT
Nicotine
HR (bpm)
70.35 ± 12.99
80.03 ± 14.56
CO (l/min)
5.00 ± 0.95
4.96 ± 0.90
SV (ml/beat)
73.21 ± 19.41
63.55 ± 13.84
SBP (mmHg)
111.96 ± 6.41
124.95 ± 11.40
DBP (mmHg)
73.67 ± 10.68
86.00 ± 8.99
-5
TPR (dyne-seconds/cm ) 1442.31 ± 330.43
1693.87± 356.41
Placebo
HR (bpm)
63.76 ± 7.18
73.04 ± 7.64
CO (l/min)
4.90 ± 1.50
4.65 ± 0.91
SV (ml/beat)
77.77 ± 22.09
64.50 ± 14.60
SBP (mmHg)
114.12 ± 5.98
128.49 ± 7.35
DBP (mmHg)
76.97 ± 8.68
89.76 ± 10.25
-5
TPR (dyne-seconds/cm ) 1636.17 ± 177.09
1822.93 ± 294.95
Note. SMTT = Star Mirror Tracing Task, HR = heart rate, CO = cardiac
output, SV = stroke volume, SBP = systolic blood pressure, DBP =
diastolic blood pressure, and TPR = total peripheral resistance.
Effects of Nicotine and Stress on Tobacco Chippers 24
Discussion
The current study was one of the first to assess the effects of nicotine and nicotine
abstinence on stress-induced cardiovascular reactivity in chippers. It is important to examine
chippers because they are still a largely unexamined group of smokers who do not appear to
become dependent upon the nicotine even after repeated exposure. Examining the effects of
nicotine and nicotine abstinence on stress-induced cardiovascular reactivity and neuroendocrine
function within chippers will further assist researchers with understanding psychophysiological
mechanisms by which cigarette smoking may lead to morbidity and mortality. Therefore, the
specific aims of the present study were to assess the effects of nicotine and nicotine abstinence
on stress-induced cardiovascular reactivity and neuroendocrine responses within chippers during
a sixteen hour nicotine administration or abstinence paradigm. Furthermore, because chippers are
considered to be ‘light smokers’ a 7mg nicotine transdermal patch was used to administer
nicotine as opposed to previous studies that used a 21 mg nicotine transdermal patch.
Interestingly one of the principle findings of the current study was that chippers did not
show increased cardiovascular reactivity (CVR) while in the nicotine condition (7mg nicotine
patch) as opposed to the nicotine abstinence condition (placebo patch). Research conducted by
Shiffman (1989) indicated a greater rise in HR as compared to smokers; however, the author
attributed this pattern as a result of a lower initial HR. It is also hypothesized that chippers have
an increase sensitivity to nicotine receptors which may result in increases in sympathetic nervous
system activation after smoking (as cited in VanderKaay, 2007; Shiffman, 1989). Contrary to the
study’s initial hypothesis, 7mg of nicotine did not create a significant CVR between the baseline
period and stressful SMTT. It is possible that no interaction between the nicotine condition and
CVR was found due to a low level of nicotine condition. Support for this may be found during
Effects of Nicotine and Stress on Tobacco Chippers 25
baseline cardiovascular measurements where no condition differences were demonstrated.
Nicotine has been shown to increase HR and BP simply by exposure (Taylor, 1980).
Even though the hypothesis was not supported, this was the first study to asses the effects
of nicotine and psychological stress (i.e. salivary cortisol levels) in a sample of chippers.
Relatively little is known about these unique smokers who make up roughly 5-10% of the
smoking population (CDC, 1989). The conditions of the study were designed to mirror a similar
nicotine administration healthy chippers expose themselves to, on average, each day (no more
than five cigarettes a day). Secondly, the present study examined the motivational reasons for
smoking (i.e. psychosocial, sensorimotor, indulgent, stimulation, addictive, automatic, and
sedative). Finally the study also examined the level of environmental enrichment chippers
experienced during adolescence in conjunction with their reasons for smoking (i.e. social
motives). The findings of the current study can possibly further our understanding of the
pathophysiological mechanisms by which occasional smoking can lead to increased
cardiovascular morbidity and mortality.
The current study also assessed the various motivational characteristics for smoking in a
sample of chippers. Interestingly, according to the Classification of Smoking by Motives
questionnaire (CSM), participants indicated a strong psychosocial motive for smoking (M =6.25,
SD = 2.25). Past research conducted by Presson, Chassin, and Sherman (2002) discovered that
chippers attitudes towards smoking, closely resembled future or heavy smokers. They also
suggest that like future heavy smokers, chippers tended to have positive attitudes toward
smoking and did not view it as something that is harmful to their health. On the other hand, their
smoking environment was similar to non-smokers in that their peers and families discouraged the
behavior (Presson et al., 2002).
Effects of Nicotine and Stress on Tobacco Chippers 26
Another interesting finding in the present study indicated a moderately high level of
environmental enrichment during the participant’s adolescence (M = 52.00, SD = 10.88, range
23-63). The Enriched Environment Questionnaire (EEQ) examined the participant’s level of
involvement in sports, time spent with caregivers, amount of accessible toys, parental academic
support, access to healthy food, time spent outside, involvement in music or theatre, access to
educational television programs, involvement in summer camps, access to books, and
opportunities to participate in water activities. The results suggest that chippers had a moderately
enriched environment during adolescence. Further analysis of habitual smokers and non-smokers
must to be conducted to see if there is a significant difference in enrichment between the groups.
Finally the current study also examined the placebo effect in the 7mg nicotine group
versus placebo group. Interestingly participants in the nicotine group were more likely to guess
incorrectly than participants in the placebo patch group (M = 67% of participants in the 7mg
nicotine patch group guessed incorrectly). Since chippers do not experience nicotine withdrawal,
they may not know what withdrawal symptoms to look for and thus attribute a head ache as a
result from being over-tired instead of a side effect of the nicotine. Shapiro (1964) defined a
placebo as “any therapeutic procedure or a specific component of that procedure where there is
no specific evidence of a given activity for a condition that is being treated” (as cited in
VanderKaay 2007; Shapiro, 1964). However, individuals in the placebo group almost always
guessed correctly (M = 85% of participants in the placebo group guessed correctly). Perhaps they
were able to decipher the difference between a placebo patch and actual nicotine patch by way of
physical appearance (i.e. the placebo patches were similar yet not exactly the same as the actual
7mg nicotine patch).
Limitations to the Present Study
Effects of Nicotine and Stress on Tobacco Chippers 27
The first possible limitation to the present study includes a relatively small sample size
(n=16) and predominantly male population (males = 11) indicating a relatively low level of
external validity. It is important to note that with a small sample size finding significant
interactions is difficult. It is also possible that no interaction between the nicotine condition and
CVR was found because of the previously mentioned confounding variables. On the other hand,
literature has suggested that chippers do in fact experience a significantly greater post-cigarette
heart rate and blood pressure as compared to their habitual smoker counterparts (Shiffman,
Zettler-Segal, Kassel, Paty, Benowitz, & O-Brien, 1992). Consequently, the method of
administering the 7mg of nicotine as well as the small dosage may also account for a negligible
CVR change. It is warranted that future studies use a more potent nicotine patch (21 mg nicotine
patch) sixteen hours before the testing session.
Finally, it was also reported that participants did not adhere and comply with the study
protocol. Firstly, several participants showered in between the pre-testing and post-testing
session and the water may have interfered with the nicotine administration. Caffeine abstention
the morning of the study may also have confounded the CVR readings. Several participants
consumed more than one cup of coffee during the 16 hour abstinence period. Since caffeine is a
stimulant it can therefore affect cardiovascular responses (VanderKaay, 2007).
Future Research
According to the knowledge of the author, the current study was the first to assess the
effects of nicotine on cardiovascular reactivity and neuroendocrine functioning in a group of
chippers. However, more research is needed, specifically regarding the effects of a higher
nicotine dosage (14mg or 21 mg nicotine patch) in a sample of healthy chippers. It is advisable
that future research recruit a higher number of participants as well as an equal amount of males
Effects of Nicotine and Stress on Tobacco Chippers 28
and females. Since the participants were predominantly Caucasian, there needs to be a greater
emphasis on cultural diversity. Future research should also maintain a stronger protocol
enforcement regarding caffeine consumption and nicotine patch adherence. Future studies should
also assess and compare the effects of nicotine and nicotine abstinence on stress-induced CVR
and neuroendocrine functioning within both chippers and habitual smokers. Lastly, researchers
should also assess and compare levels of environmental enrichment during adolescents in
habitual smokers and chippers.
Conclusion
In conclusion, results from the current study indicate that a 7mg dose of nicotine in a
sample of tobacco chippers does not significantly change cardiovascular reactivity (CVR).
Additionally it will be interesting to find out the results from Salimetrics regarding the salivary
cortisol levels between the nicotine condition and nicotine abstinence condition. The
psychosocial antecedents of tobacco chipping are an important risk factor that also needs to be
further studied. It is advisable that future studies continue to study these unique individuals in an
attempt to examine why some individuals are more prone to drug addiction and cardiovascular
morbidity and mortality.
Effects of Nicotine and Stress on Tobacco Chippers 29
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802-654-2879
vtsmokers@yahoo.com
Cigarette Smokers Research Study
email:
802-654-2879
vtsmokers@yahoo.com
Cigarette Smokers Research Study
email:
802-654-2879
vtsmokers@yahoo.com
Cigarette Smokers Research Study
email:
802-654-2879
vtsmokers@yahoo.com
Cigarette Smokers Research Study
email:
802-654-2879
vtsmokers@yahoo.com
Cigarette Smokers Research Study
email:
802-654-2879
vtsmokers@yahoo.com
Cigarette Smokers Research Study
email:
802-654-2879
vtsmokers@yahoo.com
Cigarette Smokers Research Study
email:
802-654-2879
vtsmokers@yahoo.com
Cigarette Smokers Research Study
email:
802-654-2879
vtsmokers@yahoo.com
Cigarette Smokers Research Study
email:
802-654-2879
vtsmokers@yahoo.com
Cigarette Smokers Research Study
email:
Effects of Nicotine and Stress on Tobacco Chippers 34
Appendix A
SAINT MICHAEL’S COLLEGE
Do you need $20 and socially
smoke?
If so, and you are…
18-30 years of age
Not overweight
…then you may be able to participate
in a research study for the summer
of 2009 at Saint Michael’s College!
Participants will receive compensation
$$$ and results of blood pressure
measurements.
For more information, please contact Jenny at
802-654-2879 or by e-mail:
vtsmokers@yahoo.com
Effects of Nicotine and Stress on Tobacco Chippers 35
Effects of Nicotine and Stress on Tobacco Chippers 36
Appendix B
Cigarette Smoking Characteristics Questionnaire (CSCQ)
At what age did you smoke your first cigarette or try cigarette smoking? (Even if your first
cigarette was just a puff off of someone else’s, please indicate that age) __________
At what age did you begin smoking cigarettes regularly? __________
What brand of cigarettes do you typically smoke?
(e.g. Camel Ultra Lights Hard Pack) _______________________
Do you use other types of tobacco products such as snuff, dip, chew, cigars, pipes etc.?
YES
NO (please circle one)
Have you ever used a transdermal nicotine patch before?
YES
NO (please circle one)
Effects of Nicotine and Stress on Tobacco Chippers 37
Appendix C
Health Information Screening Sheet (HISS)
DATE:_________________
NAME:___________________________________________________________
PHONE: (Home)__________________
AGE:_______ Height:__________ Weight___________
DO YOU HAVE ANY PERMANENT OR CHRONIC HEALTH PROBLEMS OR ANY PHYSICAL
DISABILITIES THAT EFFECT GENERAL ACTIVITY LEVELS (e.g. High BP, Asthma, Allergies,
Heart Condition, Ulcer, Arthritis, Diabetes, Cancer...):
Y/N
IF YES, SPECIFY:_____________________________________________
DO YOU TAKE ANY PRESCRIPTION DRUGS (Including hormones, oral contraceptives, etc): Y / N
IF YES, WHICH:_______________________________________________
FOR WHAT HEALTH PROBLEMS:_______________________________
DO YOU TAKE ANY NON-PRESCRIPTION DRUGS (ASPIRIN, ADVIL) REGULARLY:
Y/N
IF YES, WHAT AND HOW OFTEN:________________________________
FOR WHAT HEALTH PROBLEM:__________________________________
DO YOU SMOKE CIGARETTES?
YES
NO (please circle one)
If yes, how long have you been a cigarette smoker? __________
How many cigarettes do you typically smoke per day? _______
How many days per week do you smoke? _______
Are you currently in the process of quitting? _________________
DO YOU HAVE ANY PHYSICAL DISABILITIES THAT EFFECT GENERAL ACTIVITY
LEVELS: Y/N
IF YES, SPECIFIY:
______________________________________________________________________________
HAS YOUR HEALTH CHANGED IN THE LAST 6 MONTHS: Y/N
IF YES, HOW: ___________________________________________________________
DO YOU DRINK COFFEE, TEA, OR CAFFEINATED SODA: Y/N
IF YES, HOW MUCH A DAY: _____________________________________________
DO YOU EXERCISE REGULARLY: Y/N
IF YES HOW MANY HOURS A WEEK: ____________________________________
Effects of Nicotine and Stress on Tobacco Chippers 38
Appendix D
Cohen’s Perceived Stress Scale (PSS) – 10 items
Instructions: The questions in this scale ask you about your feelings and thoughts RIGHT NOW. In each
case, please indicate with a check how often you felt or thought a certain way.
1. In the last month, how often have you been upset because of something that happened unexpectedly?
___0=never ___1=almost never ___2=sometimes ___3=fairly often ___4=very often
2. In the last month, how often have you felt that you were unable to control the important things in your
life?
___0=never ___1=almost never ___2=sometimes ___3=fairly often ___4=very often
3. In the last month, how often have you felt nervous and "stressed"?
___0=never ___1=almost never ___2=sometimes ___3=fairly often ___4=very often
4. In the last month, how often have you felt confident about your ability to handle your personal
problems?
___0=never ___1=almost never ___2=sometimes ___3=fairly often ___4=very often
5. In the last month, how often have you felt that things were going your way?
___0=never ___1=almost never ___2=sometimes ___3=fairly often ___4=very often
6. In the last month, how often have you found that you could not cope with all the things that you had to
do?
___0=never ___1=almost never ___2=sometimes ___3=fairly often ___4=very often
7. In the last month, how often have you been able to control irritations in your life?
___0=never ___1=almost never ___2=sometimes ___3=fairly often ___4=very often
8. In the last month, how often have you felt that you were on top of things?
___0=never ___1=almost never ___2=sometimes ___3=fairly often ___4=very often
9. In the last month, how often have you been angered because of things that were outside of your control?
___0=never ___1=almost never ___2=sometimes ___3=fairly often ___4=very often
10. In the last month, how often have you felt difficulties were piling up so high that you could not
overcome them?
___0=never ___1=almost never ___2=sometimes ___3=fairly often ___4=very often
Effects of Nicotine and Stress on Tobacco Chippers 39
Appendix E
Coping Styles Questionnaire
Directions: Take a few minutes to identify the most important problem you have faced during the last
year. Then, using the scale below, indicate how often you used each of the following strategies to deal
with it.
0 = not at all
1 = a little
2 = occasionally
3 = fairly often
___ 1. Took things a day at a time.
___ 2. Got away from things for a while.
___ 3. Tried to find out more about the situation.
___ 4. Tried to reduce tension by drinking more.
___ 5. Talked with a professional person (e.g. doctor, lawyer, clergy, psychologists)
___ 6. Made a promise to myself that things would be different next time.
___ 7. Prepared for the worst.
___ 8. Let my feelings out somehow.
___ 9. Took it out on other people when I felt angry or depressed.
___ 10. Prayed for guidance and/or strength.
___ 11. Accepted it; nothing could be done.
___ 12. Talked with spouse or another relative about the problem.
___ 13. Talked with a friend about the problem.
___ 14. Tried to reduce tension by taking more tranquilizing drugs.
___ 15. Told myself things that helped me feel better.
___ 16. Kept my feelings to myself.
___ 17. Bargained or compromised to get something positive from the situation.
___ 18. Tried to reduce tension by exercising more.
___ 19. Tried to reduce tension by smoking more.
Effects of Nicotine and Stress on Tobacco Chippers 40
___ 20. Tried to see the positive side of the situation.
___ 21. Considered several alternatives for handling the problem.
___ 22. Made a plan of actions and followed it.
___ 23. Went over the situation in my mind to try to understand it.
___ 24. Tried to reduce tension by eating more.
___ 25. Got busy with other things to keep my mind off the problem.
___ 26. Drew on my past experiences.
___ 27. Avoided being with people in general.
___ 28. I knew what had to be done and tried harder to make things work.
___ 29. Tried to step back from the situation and be more objective.
___ 30. Refused to believe that it happened.
___ 31. Sought help from persons or groups with similar experiences.
___ 32. Tried not to act too hastily or follow my first hunch.
Effects of Nicotine and Stress on Tobacco Chippers 41
Appendix F
Visual Analog Scale (Baseline, SMTT)
Instructions: Below are words, which describe the feelings people have. Please read each one carefully and
rate how much you have had that feeling during the task (BASELINE, SMTT) including now. You may
mark anywhere on each line with a perpendicular line. Be sure to mark each line only once.
Happy
Not at all
Extremely
________________________________________________
Bored
________________________________________________
Anxious
________________________________________________
Satisfied
________________________________________________
Depressed
________________________________________________
Interested
________________________________________________
Angry
________________________________________________
Frustrated
________________________________________________
Irritated
________________________________________________
How challenging did you find the task?
Not at all
Extremely
________________________________________________
How difficult did you find the task?
Not at all
Extremely
________________________________________________
Effects of Nicotine and Stress on Tobacco Chippers 42
Appendix G
Post-Testing Questionnaire (PTQ)
Below are some sensations that people may experience with the nicotine patch. Please read each item
carefully and circle the number that best describes the following sensations. Be sure to answer each item.
1.
Have the urge for a cigarette
0 1 2 3 4 5 6 7 8 9
Not at all
Extreme
2.
Itching at site of patch
0 1 2 3 4 5 6 7 8 9
Not at all
Extreme
3.
Burning sensation at site of patch
0 1 2 3 4 5 6 7 8 9
Not at all
Extreme
4.
Heart palpitations
0 1 2 3
Not at all
5.
An increased heart rate
0 1 2 3 4 5 6 7 8 9
Not at all
Extreme
6.
Experience a headache
0 1 2 3 4 5 6 7 8 9
Not at all
Extreme
7.
Decreased concentration
0 1 2 3 4 5 6 7 8 9
Not at all
Extreme
8.
Experience dizziness
0 1 2 3 4 5 6 7 8 9
Not at all
Extreme
9.
Increased irritability
0 1 2 3 4 5 6 7 8 9
Not at all
Extreme
10.
Other, please describe
_____________________________________________________________
_____________________________________________________________
4 5 6 7 8 9
Extreme
12. Which patch do you think you are currently wearing? (Circle only one choice)
A. Contains Nicotine
B. Does not contain Nicotine
13. Why do you think that the patch you have on does or does not contain nicotine?
______________________________________________________________
______________________________________________________________
14. Did the participant guess his patch correctly or incorrectly?_________________________
Effects of Nicotine and Stress on Tobacco Chippers 43
Appendix H
Classification of Smoking by Motives (CSM)
Please answer the following items by circling the answer that best corresponds to you. Be sure to answer
each question.
1. I smoke in order to keep myself from slowing down.
0
Not at all
1
A little
2
Quite a bit
3
Very much so
2. Handling a cigarette is part of the enjoyment of smoking it.
0
Not at all
1
A little
2
Quite a bit
3
Very much so
3. I smoke for the pleasure of having something to put in my mouth.
0
Not at all
1
A little
2
Quite a bit
3
Very much so
4. I want to smoke most when I am comfortable and relaxed.
0
Not at all
1
A little
2
Quite a bit
3
Very much so
5. Part of the enjoyment of smoking is watching the smoke as I blow it out.
0
Not at all
1
A little
2
Quite a bit
3
Very much so
6. I smoke more when I am worried about something.
0
Not at all
1
A little
2
Quite a bit
3
Very much so
7. I like smoking while I am busy and working hard.
0
Not at all
1
A little
2
Quite a bit
3
Very much so
8. I smoke for the pleasure of offering and accepting cigarettes from other people.
0
1
2
3
Effects of Nicotine and Stress on Tobacco Chippers 44
Not at all
A little
Quite a bit
Very much so
9. When I have run out of cigarettes I find it almost unbearable until I can get them.
0
Not at all
1
A little
2
Quite a bit
3
Very much so
10. I smoke automatically without even being aware of it.
0
Not at all
1
A little
2
Quite a bit
3
Very much so
11. I feel I look more mature and sophisticated when smoking
0
Not at all
1
A little
2
Quite a bit
3
Very much so
12. Smoking helps to keep me going when I’m tired.
0
Not at all
1
A little
2
Quite a bit
3
Very much so
13. Part of the enjoyment of smoking comes from the steps I take to light up.
0
Not at all
1
A little
2
Quite a bit
3
Very much so
14. One reason I smoke is because it tastes so good.
0
Not at all
1
A little
2
Quite a bit
3
Very much so
15. After meals is the time I most enjoy smoking.
0
Not at all
1
A little
2
Quite a bit
3
Very much so
16. Smoking helps me to think and concentrate.
0
Not at all
1
A little
2
Quite a bit
3
Very much so
17. I am very much aware of the fact when I am not smoking.
0
1
2
3
Effects of Nicotine and Stress on Tobacco Chippers 45
Not at all
A little
Quite a bit
Very much so
18. It is easier to talk and get on with other people when smoking.
0
Not at all
1
A little
2
Quite a bit
3
Very much so
19. I light up a cigarette without realizing I still have one burning in the ashtray.
0
Not at all
1
A little
2
Quite a bit
3
Very much so
2
Quite a bit
3
Very much so
20. Smoking cheers me up.
0
Not at all
1
A little
21. I like a cigarette best when I am having a quiet rest.
0
Not at all
1
A little
2
Quite a bit
3
Very much so
22. While smoking I feel more confident with other people.
0
Not at all
1
A little
2
Quite a bit
3
Very much so
23. I get a definite lift and feel more alert when smoking.
0
Not at all
1
A little
2
Quite a bit
3
Very much so
24. Without a cigarette I don’t know what to do with my hands.
0
Not at all
1
A little
2
Quite a bit
3
Very much so
25. I only really enjoy smoking with a drink.
0
Not at all
1
A little
2
Quite a bit
3
Very much so
26. I smoke much more when I am with other people.
Effects of Nicotine and Stress on Tobacco Chippers 46
0
1
2
Not at all
A little
Quite a bit
27. I smoke because I like the smell so much.
0
Not at all
1
A little
2
Quite a bit
3
Very much so
3
Very much so
28. I usually only smoke when I can really sit back and enjoy it.
0
Not at all
1
A little
2
Quite a bit
3
Very much so
29. I light up a cigarette when I feel angry about something.
0
Not at all
1
A little
2
Quite a bit
3
Very much so
30. I find it a pleasure drawing the smoke into my lungs.
0
Not at all
1
A little
2
Quite a bit
3
Very much so
31. I get a real gnawing hunger to smoke when I haven’t smoked for a while.
0
Not at all
1
A little
2
Quite a bit
3
Very much so
32. I find myself smoking without remembering lighting up.
0
Not at all
1
A little
2
Quite a bit
3
Very much so
33. I smoke more when I am rushed and have lots to do.
0
Not at all
1
A little
2
Quite a bit
3
Very much so
34. I feel more attractive to the opposite sex when smoking.
0
Not at all
1
A little
2
Quite a bit
3
Very much so
Effects of Nicotine and Stress on Tobacco Chippers 47
Appendix I
Human Subjects Consent Form
CONSENT TO ACT AS A SUBJECT IN A RESEARCH STUDY
TITLE: “The Effects of Nicotine and Acute Psychological Stress on Neuroendocrine Response and
Cardiovascular Reactivity in a Sample of Tobacco Chippers”
INVESTIGATOR:
Jenny M. Pietroski
Saint Michael’s College
Cell Phone: 207-890-6378
DESCRIPTION: The goal of this study is to examine the physiological changes that occur in male and
female occasional smokers during two different tasks. I have been asked to participate in this study because I
am between the ages of 18 and 30, and in good mental and physical health. I understand that I will
participate in one (1) pre-laboratory session lasting approximately thirty (30) minutes and one (1) laboratory
testing session lasting approximately 1 hour and ten minutes (70 minutes). I will be asked to wear a nicotine
transdermal patch for approximately seventeen (17) hours and understand that it may (active) or may not
contain nicotine (placebo). This patch will be applied to me by the experimenter sixteen (16) hours prior to
my testing session. I understand that I will be asked to come to the laboratory the afternoon before my testing
session in order to have my patch applied. I will be unaware of which patch I am wearing until the conclusion
of my laboratory testing session; however, I will treat the patch that I wear as though it is the active nicotine
patch and follow all directions given to me by the experimenter. These instructions include abstaining from
all tobacco products, including cigarette smoking while wearing the patch. Prior to the testing laboratory
session, I will also avoid areas with cigarette smoke while wearing the patch, abstain from eating any food
and drinking any beverages for 4 hours, and abstain from physical exercise the morning of my scheduled
testing session. The measurements taken during my laboratory sessions will be blood pressure, heart activity,
and salivary cortisol. During each of my laboratory sessions (pre-and testing) I will be asked to complete
questionnaires about my medical history, smoking characteristics and my mood state. Additionally, during
my laboratory testing session, I will be asked to perform a 5-minute cognitive task. Blood pressure and heart
activity measurements will be taken before, during, and after this task. Since I may be wearing an active
nicotine patch for my visit, there may be some side effects associated; however, I certify that I have been
thoroughly informed of these possible side effects and have been given instruction and phone number of
emergency personnel to contact in case of an emergency.
The actual chronological order of events for the study is as follows:
Pre-Laboratory Session
- Written consent obtained
- Distribution of questionnaires
- Blood pressure measurements
- Distribution of written instructions and the transdermal nicotine (active or placebo) patch
- Laboratory testing session reminder (date and time)
Effects of Nicotine and Stress on Tobacco Chippers 48
Laboratory Testing Session
- Written consent obtained, height, weight, and blood pressure taken, electrodes for heart rate
and heart function applied, and questionnaire distribution
- Saliva sample obtained
- 10-minute rest period
- 5-minute cognitive task
- 15-minute recovery period
- Questionnaire distribution
- Saliva sample obtained
- Electrodes & nicotine patch removal
- Debriefing and questions answered
I understand that at the completion of the study session I will have the opportunity to speak to an
investigator if I have any questions, comments, or concerns.
RISKS AND BENEFITS: There may be some slight side effects associated with wearing the transdermal
nicotine patch. These side effects may consist of redness on the skin where the patch is attached, heart
palpitations, increased heart rate, nervousness, and agitation. If these side effects become severe, I
understand that I must consult a physician immediately. I also understand that under NO circumstances will I
be able to smoke while wearing the nicotine patch because doing so can cause a nicotine overdose and can be
life threatening. In addition to the effects of nicotine, there may be some slight discomfort with the
removal of the electrodes and minimal redness may be visible for approximately one (1) hour.
One benefit of this study is that it will help researchers further investigate the way that nicotine affects the
body both physically and mentally. This study may further show the dangers that nicotine and acute
psychological stress impose on the cardiovascular system. Additionally, if I am among those participants
who will wear the nicotine patch (as opposed to the placebo patch), then I will have the experience of wearing
an active transdermal nicotine patch and such patches have been documented as an effective method for
smoking cessation.
In the case of an emergency when wearing the patch, a physician can call Jenny M. Pietroski (207) 8906378 or Dr. Melissa VanderKaay Tomasulo, Research Advisor (802) 654-2921 or (802) 735-5230 to
determine if you are wearing a patch with nicotine or a placebo patch.
COSTS AND PAYMENTS: I understand that there is no cost to me. I further understand that for my
participation I will receive ten dollars ($20.00) compensation or extra course credit. I also understand that I
will not be penalized in any way if I choose not to complete the laboratory sessions.
CONFIDENTIALITY: I understand that any information about me obtained from this research, including
answers to questionnaires, medical history, or laboratory data will be kept strictly confidential. Such
information that will carry personally identifiable material will be kept in locked files, and will be accessible
only to those persons directly involved in the study. Individual data will be stored in locked files for a period
of 5 years, after which time it will be destroyed. It has been explained to me that my identity will not be
revealed in any description or publication of this research. Further, I consent to the publication of this
research for scientific purposes.
RIGHT TO WITHDRAW: I understand that I am free to refuse to participate in this study or to end my
participation at any time, and that my decision will not adversely affect me or cause the loss of benefits to
which I might otherwise be entitled. Additionally, the researcher can end my participation if the researcher
feels it is necessary.
Effects of Nicotine and Stress on Tobacco Chippers 49
VOLUNTARY CONSENT: I certify that I have read the preceding or it has been read to me and that I
understand its contents. I agree that risks to me have been explained to my satisfaction and I understand that
no compensation is available from Saint Michael’s College and its employees for any injury resulting from
my participation in this project. I certify that I am at least 18 years of age. Any questions that I have
pertaining to the research have been or will be answered by Jenny Pietroski or her lab assistants. A copy of
this consent form will be given to me. My signature below means that I freely agreed to participate in this
experimental study.
SIGNATURE:___________________________ Date: ________________
DATE:___________________
INVESTIGATOR:________________________
Effects of Nicotine and Stress on Tobacco Chippers 50
Appendix J
Written Instructions for the Transdermal Nicotine patch
To the participant:
You are receiving a nicotine transdermal patch. The patch may (active) or may not (placebo) contain
nicotine.
Please carefully read the instructions below and ask the experimenter any questions that you may have.
When should I wear the patch?
One of the experimenter’s colleagues will attach the patch 16 hours before you are scheduled for your
testing session. I understand that I will be asked to come to the laboratory between the afternoon before my
testing session in order to have my patch applied.
Where do I wear the patch?
The patch should be worn on the upper lateral side of the non-dominant arm just over the deltoid muscle.
This means that the patch will be worn between the elbow and the shoulder, on the outer side of the arm
that you do not write with.
How long do I wear the patch?
You will wear the patch for approximately 18 hours.
experimenter will remove the patch from you.
When your testing session is finished, the
Are there any side effects with wearing the patch?
While there is minimal risk associated with wearing this patch, there may be some slight side effects
associated with it. These side effects may consist of redness on the skin where the patch is attached, heart
palpitations, increased heart rate, nervousness, and agitation. You may also feel a tingling, slight itching
sensation while wearing the patch; however, this feeling should subside within 2-3 hours. If these feelings do
not subside, contact the researcher immediately.
What should I do if I am feeling more than these side effects or if the side effects worsen or are
severe?
If these side effects become severe, you must first take off the patch and then consult a physician
immediately. The emergency phone numbers are listed below. Also, please contact the experimenter and
report your condition.
Effects of Nicotine and Stress on Tobacco Chippers 51
Am I permitted to smoke while I am wearing the patch?
Under NO circumstances will you be able to smoke (anything!) while wearing the nicotine patch, doing so
can cause a nicotine overdose and may be potentially life threatening. Do NOT take the patch off and then
smoke a cigarette and then reapply the patch. The patch is designed to slowly add nicotine to your body over
the course of the seven hours you will be wearing it. Just because you remove the patch does not mean that
you no longer have nicotine in your body. You must also avoid cigarette-smoking areas.
After the removal of the nicotine patch, you must wait 4 hours before having a cigarette.
If you have any questions, concerns, or comments, please contact the In case of an emergency, please call one
of the following telephone numbers:


Emergency: 911
Fanny Allen Medical Center (802) 847-1170, Colchester, Vermont
In the case of an emergency when wearing the patch, a physician can contact Jenny Pietroski at (207) 8906378 or Dr. Melissa VanderKaay Tomasulo (802-735-5230), who will be able to determine if you are
wearing a patch with nicotine or a placebo patch. Don’t forget to inform the physician that you are in a
research study and that you may be wearing an active or a placebo nicotine patch.
KEEP THESE INSTRUCTIONS WITH YOU AT ALL TIMES SO THAT THE PHONE
NUMBERS PROVIDED WILL BE AVAILABLE TO YOU IN CASE OF AN EMERGENCY.
I have read all of the above instructions on the nicotine patch. I have had all questions answered by a
staff member and understand that under no circumstances will I be permitted to smoke while wearing the
patch. I also understand that I must wait 4 hours before having my next cigarette.
DATE:______________________ SIGNATURE:___________________________
I certify that a staff member or I have explained to the above individual the nature and purpose, the potential
benefits, and the possible risks associated with participating in this research study, and that I have answered
any questions that have been raised, and have witnessed the above signature.
DATE:___________________ EXPERIMENTER:___________________________
Effects of Nicotine and Stress on Tobacco Chippers 52
Appendix K
Physiological Data Sheet
Height and Weight:
Height:_____inches (cm x 0.394)
Weight:______lbs. (kg x 2.2)
Height:_____cm (inches x 2.54)
Weight:______kg (lbs x 0.454)
BMI: ______ (kg/m2)
Impedance Measurements:
____cm distance between front electrode bands
____cm distance between back electrode bands
Effects of Nicotine and Stress on Tobacco Chippers 53
Appendix L
24-Hour Profile
1. What and when have you eaten in the last 24 hours?____________________________
________________________________________________________________________
________________________________________________________________________
2. Have you eaten within the last 4 hours? Yes___ No___
3. Did you drink any caffeinated beverages (i.e. coffee, tea and soda) or eaten anything containing
caffeine (i.e. chocolate) in the past 12 hours?
4. Have you consumed any alcohol in the past 12 hours? Yes____No___If yes, how much?_________
5. Have you taken any prescription or non-prescription drugs in the past 24 hours? Yes___ No___ If yes,
what?__________
6. When was the last time (date and time) that you exercised and for how long?
________________________________________________________________________
7. When is the last time that you used any form of tobacco products (i.e. cigarettes, snuff, dip, chew,
cigars, pipes, hookahs, etc.) and how much was used? ___________________
________________________________________________________________________
8. Have you avoided areas with cigarette smoke in the past 12 hours? Yes___ No___
9. Please rate your current craving for a cigarette:
0
Very Low
1
2
3
4
5
6
7
8
9
10
Very High