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I I I I I I I I I I 1 I I I I lournal of Behavioral Medieine. Vol. 16, No. 4, 11'93 The Favorite Cigarette of the Day Murray Jarvik,l•4 Joel D. Killen,2 Ann Varady,3 and Stephen P. Fortmann3 Accepted for publication: August 14, 1992 The choice of a favorite cigarette smoked during a given day varies considerably. Preferences are related to nicotine dependence and the Itfestyles of smokem In a sample of 5124 smok.ers, the "after-dinner cigarette" was chosen as the cigarette which they would miss mosr, while the nea larggest proportion of smokers (33%) said that they would miss the `fust cigarette of the morning" most. The latter group scored highest on tests of nicotine dependence. In contrast, infirquent smokers ("chippers") chose the after-dinner cigarette. KEY WORDS: postprandial smoking; nicotine dependenry; morning cigarette. INTRODUCTION The frequency of cigarette smoking varies considerably during the day, generally reaching a peak in late afternoon or early evening (Hasenfratz et aL, 1991). However, little is known about how intensity or the need to smoke changes during the day. The item contributing most of the predictive variance to the widely used Fagerstrom Tolerance Questionnaire describes the need for an early-morning cigarette (Lichtenstein and Mermeistein, 1986). In a refinement of this scale, Heatherton et aL (1991) dropped less discriminating items. However, neither questionnaire gives subjects the op- portunity to specify the urge for cigarettes other than the morning cigarette. Supported in part by NHLBI Grant HL39770 and California Tobacco-Related Disease Program Grant IRT-87. 1Psychopharmacology Unit (691/B151D), West Los Angeles VA Medical Center, Los Angeles, California 90073. 2National Institute of Child Health and Human Devebpment, Rockville, Maryland. V 3Center for Research in Disease Prevention, Stanford University School of Medicine, Stanford University, 1000 Welch Road, Palo Alto, California 94304. ~ 4To whom correspondence should be addressed. 413 0164771 V9710B00-0113S07AOr0 0 1993 Pkaum luWsW4'Corpotanon I

I I I I I I 414 Jarvik. Killen, Varady, ane Fortmann The choice of a favorite cigarette of the day might be based on mo- tives for smoking suggested by previous questionnaire studies. Withdrawal relief has frequently been proposed as the dominant motive for smoking (Schacter, 1979; Russell, 1989). The cigarette giving the maximum degree of withdrawal relief should be the first one in the morning. This cigarette follows the longest period of daily withdrawal and is preceded by the least acute nicotine tolerance. However, withdrawal relief is not an incentive for those smoking fewer than five cigarettes per day, ("chippers") (Shiffman et aL, 1990), although such smokers are a distinct minority. Thus, this small group of light smokers should be less interested in the first cigarette of the morning. Anecdotal reports and some previous surveys have indicated that most smokers report a cigarette after a meal is particularly satisfying (McKennell and Thomas, 1967). These surveys did not compare the post- prandial cigarette with others, nor did they relate this judgment of satisfaction to degree of nicotine dependence. METHOD 11 I I I I I I I I In two moderate-sized cities in the San Francisco Bay Area, 25,645 households were randomly telephoned. Seven thousand one hundred thirty- two smokers between 18 and 65 years of age were identified and asked to complete a 20-min baseline telephone interview which included questions about smoking history, personal characteristics, and medical status and a modified version of the Fagerstrom Tolerance Questionnaire (FTQ) (Fagerstrom and Schneider, 1989; Killen et aL, 1990). Smokers were also asked, "If you were to quit smoking which cigarette would you miss the most? (a) first cigarette of the morning, (b) after-dinner cigarette, or (c) other." Those selecting "other" were asked to identify further the "other" cigarette. In this fashion 5124 smokers, representing about 72% of smokers identified, completed the interview. Demographics of this sample are pre- sented in Table I. Upon completion of the interview, smokers were then asked if they wished to participate in a minimal-contact smoking cessation trial. Those who did choose to participate were required to quit smoking for 24 hr, with biochemical confirmation with an expired air carbon monoxide less than 9 ppm. Successful quitters then completed a postquit assessment bat- tery which included questions about withdrawal symptoms and cravings experienced after 24 hr of abstinence (Killen et al., 1990).

w M M M w M " W .00 as an " ~ *W an M w aw "M; 2 e 0 ~ n Table 1. Characteristics of Baseline Sample° d (1) Ist cig. in AM (n = 1694) (2) After dinner (n = 2218) (3) Other (n = 1139) 1 vs. 2 1 vs. 3 2 vs. 3 Age 39.5 (11.3) 37.3 (11.6) 37.2 (11.5) p < .05 p < .05 ns Age began smoking 17.1 (3.8) 17.3 (4.0) 17.6 (47) ns p < .05 ns Cigarettes/day 21.7 (11.4) 19.0 (10.5) 17.8 (11.2) p < .05 p<.05 p < .05 Mod. FTQ 15.3 (3.6) 13.2 (3.7) 12.2 (3.8) p < .05 p < .05 p < .05 Years of education 12.9 (2.1) 13.1 (2.1) 13.3 (2.1) p < .05 p < .05 ns '° Bonferroni T test to control for type I experimentwise error rate. ~ i U

A I I I I I I 1 1 I I I I I 416 Jarvik. Killen, Varady, and Fortmann ~ Male ~ Female Fig. 1. Percentage of male and female smokers choosing "first cigarette of the morning," "after-dinner cigarette," or "other cigarette." RESULTS In the sample of 5124 smokers, 5051 (males, 2570; females, 2481) answered the question, "Which cigarette would you miss the most?" Of these, 44% (n = 2218) chose the after-dinner cigarette as the one that they would miss most, 33% (n = 1694) picked the first cigarette in the morning, and 23% (n = 1139) selected an "other" category (see Fig. 1 and Table II). Of those choosing "other," 80 (7%) chose situations with a prevalence of less than 1% (not indicated in the table) and 156 (13.7%) made no choice. There was no significant difference between men and women in this choice. Our primary hypothesis was that the more highly nicotine-dependent smokers would report that they would miss the first cigarette of the morn- ing the most. To test the hypothesis, a stepwise multiple logistic analysis was conducted with the following independent variables: modified FTQ, sex, age, years of education, number of cigarettes smoked per day, marital status, and employment status. The dependent variable was dichotomized, with choice of first cigarette designated as one category and choice of af- ter-dinner cigarette as the second category. The results of the logistic analysis are presented in Table III.

I I I I I I a I I I I I I I I I I I Favorite Cigarette of the Day Table II. Frequency of Reports of the Situation Most Likely to Elicit Smoking Activity Frequency Percentage Alcohol 126 11.1 Last cig. of day 130 11.4 All cigs. 87 7.6 Stress 58 5.1 Afternoon 81 7.1 Socializing 50 4.4 Driving 71 6.2 At work 79 6.9 None 39 3.4 After work 33 2.9 Coffee 44 3.9 Phone 28 2.5 After sex 19 1.7 Both 33 2.9 Midmorning 13 1.1 When nervous 12 1.1 Other (<1% each) 80 7.0 Missing 156 13.7 Total 1139 100.0 417 Tabk III. Results of Stepwise Logistic Regression Analysis Variable Parameter est. SE XZ p value MOD FTQ .16 .01 195.9 <.001 AGE .01 .003 12.2 <.001 MARITAL .20 .08 6.9 <.01 EDUCATION -.04 .02 5.4 <.05 CIG/DAY(LOG) -.16 .07 4.9 <.05

I I I I I I ~ I I I I I L I I I I I I 418 Jarvik. Killen, Varady, and Fortmann Nicotine dependence, as measured by the modified FTQ, did indeed appear to be the factor that differentiated the choice of cigarette which would be missed most. Those with higher dependence scores were more likely to select the first cigarette of the morning. The mean modified FTQ score was approximately 2 points lower for after-dinner smokers (15.3 vs. 13.2) than for morning smokers (see Table I). Other variables entering the logistic model after the modified FTQ were in this order: age, marital status, years of education, and number of cigarettes smoked per day (log value). Smokers who preferred the first cigarette of the morning were, on average, slightly older and had fewer years of education. Marital status was dichotomized as married or not married (divorced, single, widowed). Married persons appeared to select the first cigarette of the morning somewhat more than unmar- ried respondents. Since the FTQ depends heavily on attitudes toward the first cigarette in the morning, we examined several additional measures of nicotine de- pendence. Those who preferred the first cigarette of the morning reported higher levels of craving and withdrawal symptoms following the 24-hr ab- stinence period (see Table IV). We compared subjects who smoke 25 cigarettes or more per day (N = 1327)[/5051, or 26%] with those who smoke fewer than 5 cigarettes per day (n = 435)[/5051, or 9% of the sample], i.e., "chippers" (Fig. 2). Chippers absorb about the same amount of nicotine per cigarette but are not physiologically dependent and have no withdrawal symptoms. Only 18% of our chippers prefer the f rst cigarette of the morning, while 41% of the heavy smokers prefer the first cigarette of the morning. However, there is only a 4% difference between these two groups in their preference for the after-dinner cigarette (40% heavy and 44% chippers). Also, only 18% of the heavy smokers choose "other," whereas 38% of the chippers choose "other." The difference between the two groups with respect to preference is highly significant (p < .001). DISCUSSION We were surprised that the after-dinner cigarette was chosen by the majority of smokers as the one they would miss the most. This cigarette was regarded as more desirable by respondents who scored comparatively lower on the measure of nicotine dependence. A sizable proportion of smokers did select the first cigarette of the morning. The results indicate that this cigarette may be a better index of nicotine dependence. It appears that the more dependent and heavier smokers would be most

M M an go W an " ~ M 9M M " M 40 W ~ so im on Table N. Craving and Withdrawal Scores of Those Who Quit Successfully for 24 hr (1) First cig. of day (n = 336) (2) After dinner (n = 427) (3) Other (n = 216) 1> 2 1 > 3 2 > 3° Craving (range 1-6) 4.0 (1.4) 3.6 (1.4) 3.3 (1.6) <.05 <.05 <.05 Withdrawal symptoms (range 1-6) 1.8 (1.1) 1.6 (1.2) 1.5 (1.1) <.05 <.05 ns ' Bonferroni T test to control for type 1 experimentwise error rate. i ~966699109

I I I I I I I I I I I I I I I I I I 420 Jarvik. Killen. Varady, and Fortmann ~ >=25 cigs/day ® <=5 cigs/day Fig. 2. Percentage of heavy and light smokers chooisng "first cigarette of the morning," "after-dinner cigarette," or "other cigarette." affected by the loss of the first cigarette. This may be related to the fact that withdrawal symptoms are apt to be worst first thing in the morning upon awakening, when blood nicotine levels are lowest. The two ciga- rettes may well fulfill different functions. It may be that the morning cigarette primarily provides withdrawal relief by curtailing overnight dep- rivation from nicotine, while the postprandial cigarette may be positively reinforcing. In the subsample of smokers who managed to quit for 24 hours, those who selected the first cigarette of the morning reported more severe craving and withdrawal symptoms than those preferring other cigarettes. Though the use of the term "craving" has been criticized, when used as an operational verbal response representing a subjective perception, the term may have substantial validity. "Craving" for cigarettes has been cor- related with blood nicotine levels and expired carbon monoxide measures (West and Schneider, 1987). Killen et aL (1991) found that the modified FTQ was highly correlated with craving measures and with success at ab- stinence. In addition, relapse after quitting was significantly associated with a verbal report of strength of craving for a cigarette (Killen et aL, 1991). The urge to smoke a cigarette on arising in the morning appears to be a major characteristic of dependent smokers. Uchtenstein and Mermelstein G7 ~ W 07 CT~ I

I I I I I I I I I I I I I I I I I Favorite Cigarette of the Day 421 (1986) have demonstrated that one item describing the need for an early- morning cigarette contributes most of the predictive variance to the Fagerstrom Tolerance Questionnaire. In contrast, smoking survey question- naires have generally ignored the effect of eating on smoking. Jarvik et aL (1989) confirmed the popular belief that a satisfying meal increased the urge to smoke and enhanced the enjoyment of a cigarette. The postprandial cigarette usually is extremely pleasant and often irresistible (Hasenfratz et at, 1989). It is not clear just what a meal does to make smoking a ciga- rette so rewarding. Part of the explanation is the finding that a meal may increase the hepatic metabolism of nicotine (Lee et at, 1989) and another that smoking slows gastric emptying time (Gritz et al., 1988). The cigarette smokers find most difficult to relinquish should be elic- ited by the most salient triggering cue. For a majority of smokers in this large and representative sample, this cue seems to be a satisfying meal. For many others, it appears to be morning awakening. Less regular but often very potent provocative cues for smoking as measured by relapse trig- gers included stressful experiences, alcohol, intellectual concentration, parties, and sexual activity (Shiffman, 1991; Marlatt, 1990). However, the cigarettes with the strongest habitual associations are the postprandial and the morning cigarettes. It is important for prospective quitters to develop coping skills to eliminate smoking at these highly precarious times. REFERENCES Fkgerstrom, K. 0., and Schneider, N. G. (1988). Measuring nicotine dependence in tobacco smoking: A review of the Fagerstrom tolerance questionnaire. J. Behav. Mea: 12: 159-182. Gritz, E. R., Ippoliti, A., Jarvik, M. E., Rose, J. E., Shiffman, S., Harrison, A., and Van Vunakis. H. (1988). The effect of nicotine on the delay of gastric emptying. Alintent. PharmacoL Ther. 2: 173-178.1. Hasenfratz, H., Pfiffner, D.. Pellaud, K., and Battig, K. (1989). Postlunch smoking for pleasure seeking or arousal maintenance? PharntacoL Biochem. Behav. 34: 631-639. Hasenfratz, M., Thut, G., and Battig, K. (1991). Twenty-four-hour monitoring of heart rate, motor activity and smoking behavior including comparisons between smokers and nonsmokers. Psycitophannacology, 82 (in press). Heatherton, T. F., Kozlowski, L. T., Frecker, R. C., and Fagerstrom, K. O. (1991). The Fagerstrom test for nicotine dependence: A revision of the Fagerstrom tolerance questionnaire. Br. J. Addict. 86: 1119-1127. Jarvik, M. E., Saniga, S. S., Herskovic, J. E., Weiner, H., and Oisboid, D. (1989). Potentiation of cigarette craving and satisfaction by two types of ineals. Addict. BehaK 14: 35-41. Killen, J. D., Fortmann, S. P., Newman, B., and Varady, A. (1990). Evaluation of a treatment approach combining nicotine gum with self-guided behavioral treatments for smoking relapse prevention.l. Consult. Clia. PapchoL 58: 85-92. Kilkn. J. D, Fortmann, S. P., Newman, B., and Varady, A. (1991). Prospective study of factors influencing the development of craving associated with smoking cessation. Prychophamtacology 105: 191-196.

I I I I I I I I I I I I I 1 1 I I I 422 Jarvik. Killen, Varady, and Fortmann Lee, B. L.. Jacob, P., 3rd, Jarvik, M. E., and Benowitz, N. L. (1989). Food and nicotine metabolism. Pharmacol. Biochem. Behav. 33(3): 621-625. Lichtenstein, E., and Mermelstein, R. J. (1986). Some methodological cautions in the use of the tolerance questionnaire. Addict. Behav. 11: 439-442. Marlatt, G. A. (1990). Cue exposure and relapse prevention in the treatment of addictive behaviors. Addict. Behav. 15(4): 395-399. McKennell. A. C., and Thomas, R. K. (1967). Adults' and adolescents' smoking habits and attitudes. London Govt. Soc. Surv. SS 353B: 248-252. Russell, M. A. (1989). Subjective and behavioural effects of nicotine in humans: Some sources of individual variation. Prog. Brain Res. 79: 289-302. Schacter, S. (1979). Regulation, withdrawal, and nicotine addiction. In Krasnegor, N. A. (ed.), Cigarette smoking as a dependence process, National Institute of Drug Abuse, Rockville, MD. Shiffman, S. (1991). Refining models of dependence: Variations across persons and situations. Br. J. Addict. 86(5): 611-615. Shiffman, S., Fischer, L. B., Zettler-Segal, M., and Benowitz, N. L. (1990). Nicotine exposure among nondependent smokers. Arch. Gen. Psychiat. 47(4): 333-336. West, R., and Schneider, N. G. (1987). Craving for cigarettes. Br. J. Addict. 82: 407-415. I