Abstract
Introduction:
Emerging literature implicates anhedonia—diminished capacity to experience pleasure—as a maintaining factor underlying cigarette smoking in adults. The role of anhedonia in adolescent smoking uptake has largely been uninvestigated, leaving unclear whether anhedonia is associated with smoking initiation and with psychosocial determinants of susceptibility to smoking initiation that could be targeted in prevention. This study examined the association of anhedonia with smoking initiation (ever smoke: yes/no) and factors indicative of susceptibility to smoking initiation among never-smokers (smoking outcome expectancies, curiosity about smoking, and willingness and future intention to initiate smoking).
Methods:
Ninth grade students enrolled in high schools in Los Angeles, CA (N = 3299; mean [SD] age = 14.1 [0.42] years) were administered in-classroom surveys of anhedonia, depression, smoking, and other characteristics.
Results:
For every 1 SD unit increase in anhedonia, there was (1) a 42% increase in odds of smoking initiation in the overall sample (odds ratio [95% CI] = 1.42 [1.30–1.56], p < .0001) and (2) higher scores on each marker of smoking initiation susceptibility in the subsample never-smokers (βs = .10–.19; ps ≤ .002). The associations remained after adjusting for demographics and major depression symptoms.
Conclusions:
By early adolescence: (1) anhedonia is associated with smoking initiation and (2) adolescents with higher (vs. lower) anhedonia who have never tried smoking may be more susceptible to smoking initiation perhaps due to stronger prosmoking intentions or willingness to smoke. Preventive interventions that target anhedonia and smoking-related intentions warrant consideration in interventions aimed at reducing risk of smoking initiation in affectively vulnerable youth.
Implications:
These data suggest that anhedonia may be useful to incorporate into theoretical models of the emotional determinants of smoking initiation risk and provide impetus for addressing anhedonia in smoking prevention efforts.
Introduction
Understanding the psychological correlates of smoking susceptibility and smoking initiation in adolescents is useful for identifying teens that may benefit most from smoking prevention efforts as well as highlight important variables to target in interventions to offset such risks. Anhedonia—diminished capacity to experience pleasure in response to rewarding activities—is a trait implicated in the etiology of smoking in adults1 that has received little attention in the adolescent smoking literature. While anhedonia is a key correlate and manifestation of depression,2 it is conceptually and empirically distinct from the overall level of depressive symptomatology3—a well-documented risk factor for adolescent smoking.4–7 Clarifying anhedonia’s role in adolescent smoking uptake over and above depression could shed light on a unique emotional pathway underlying smoking risk, which could open up new avenues for smoking prevention.
To the best of our knowledge, the work of Audrain-McGovern et al.8 is the only published study on anhedonia in adolescent smoking, which found that adolescents aged 16 years old with high (vs. low) anhedonia were more likely to have smoked at least one cigarette in the past 30 days. Over the subsequent 18-month follow-up period, anhedonia was associated with a steeper escalation in the number of cigarettes smoked in the past 30 days among smokers, but was not associated with change in smoking status from nonsmoker to smoker over the follow-up. It remains unclear whether anhedonia is associated with smoking initiation prior to age 16 and associated with psychosocial factors that contribute to susceptibility to smoking initiation in adolescents who have never smoked.
It is conceptually plausible that adolescents with higher (vs. lower) anhedonia are more susceptible to smoking initiation and more likely to initiate smoking early in adolescence. Anhedonic individuals are not entirely incapable of experiencing pleasure altogether. Rather, they require a higher threshold of reward stimulation to generate a hedonic response to reward. As such, they experience little pleasure from rewards that are routinely experienced (eg, food, social interaction), but can experience significant pleasure from novel, highly stimulating, and highly potent rewards, and therefore may be particularly motivated to seek out these rewards in order to enhance deficient positive emotions. Anhedonic teens may be more likely to develop cognitive expectations that cigarettes are particularly rewarding, even prior to directly experiencing smoking-induced pharmacological reward. Such cognitions could be developed through observation of pleasant responses to smoking from peers who smoke or extrapolation from direct experience of other high-potency reinforcers—anhedonia is associated with greater use of non-nicotine drugs of abuse,9 consumption of high-sugar foods,10 and engagement in extreme sports.11,12 Such expectations could cause anhedonic teens to be more inclined to overlook the aversive consequences of smoking and become more willing and susceptible to experiment with cigarettes.
This study of young adolescents examined cross-sectional relations of anhedonia with: (1) smoking initiation (ie, ever smoking) and (2) factors indicative of susceptibility to smoking initiation (eg, smoking outcome expectancies, smoking willingness/intention/curiosity) among never-smokers. We hypothesized that anhedonia would be associated with smoking initiation and that adolescent never-smokers with higher (vs. lower) anhedonia would endorse stronger expectancies for positive rewarding effects from smoking, lower expectancies of smoking-related negative consequences, and greater susceptibility to smoking. If these hypotheses are supported, the findings would have implications for offsetting the vulnerability that anhedonia may pose early in the smoking risk trajectory.
Methods
Participants and Procedures
Participants filled out surveys for the Happiness and Health study, a longitudinal survey of substance use and mental health among 10 public high schools in Los Angeles, CA. Details on school recruitment, student recruitment, and survey procedures have been published elsewhere.13 Study consent rate (82.3%) and survey completion rates among contenting students (99.6%) were comparable to or exceed smoking studies of public high school students in the region.14,15 Participants with data on smoking and anhedonia comprised the analytic sample for smoking initiation outcomes (N = 3299), and the subset of these who reported never having tried a cigarette comprised the available sample for analyses of smoking susceptibility (N = 2956).
Measures
Ever Smoking
Endorsement of either of the following two items based on the Youth Behavior Risk Surveillance Survey16—“Have you ever (smoked)…” “a few puffs of a cigarette” or “a whole cigarette”(yes/no)—were used to classify ever smoking.
Snaith–Hamilton Pleasure Scale—SHAPS
The SHAPS17 instructs respondents to rate self-statements regarding pleasure response to 14 common pleasant experiences spanning food, sensory, hobbies, and social events with broad relevance (eg, “I would enjoy seeing other people’s smiling faces” and “I would be able to enjoy a beautiful landscape or view”) on a four-point scale from definitely agree = 0 to definitely disagree =3. A sum across each item is calculated with higher total scores indicating higher anhedonia levels.18 In a prior teen sample, the SHAPS exhibited a unidimensional factor structure, adequate internal consistency, and strong convergent and discriminant validity.18 Internal consistency in this sample was adequate (α = .90).
Revised Children’s Anxiety and Depression Scale—RCADS
The 10-item Major Depressive Disorder (MDD) subscale of the RCADS19 was administered for which respondents report the frequency of DSM-based MDD symptoms on four-point scales. Responses are summed (α = .93; RCADS data available in 3136 students).
Susceptibility to Smoking Initiation
Based on prior work,20,21 susceptibility to smoking initiation was measured with three items, “Would you try cigarettes if one of your best friends offered it to you?” (Willingness), “Do you think you would use cigarettes in the next 6 months?” (Intention), and “Have you ever been curious about using cigarettes?” (Curiosity), each with a four-point scale from definitely not = 1 to definitely yes = 4. Because each item may reflect differing degrees of susceptibility,22 each item was analyzed separately along with a mean composite score (α = .81).
Expectancies
Adapted from prior work,23,24 participants rated how likely they would experience rewarding (“I think I might enjoy, experience pleasure, or feel good using cigarettes”) and aversive (“I think I might feel bad, sick, or embarrassed using cigarettes”) effects on a scale from definitely not = 1 to definitely yes = 3. The two items were analyzed both separately and as a composite mean indicative of prosmoking expectancies in which aversive effects were reversed scored (correlation between the two items: r = .41). Both items were positively correlated with smoking initiation in the overall sample (rs > .19, ps < .001), in support of their possible concurrent criterion validity.
Data Analysis
Analyses used generalized linear mixed models that accounted for clustering of data by school. Separate models were fit for each outcome, which included SHAPS as a regressor. Smoking initiation (ever smoking) was modeled with binary logistic regression, and the susceptibility and expectancy composites were modeled as continuous outcomes. For each item-level analysis, the outcome was the response to a single item with four possible response categories, responses with low frequencies were collapsed (see Table 1) and were modeled using ordinal or binary logistic generalized linear mixed models. Analyses were retested after controlling for demographic covariates (age, gender, ethnicity, and highest parental education) and then again after adding RCADS-MDD as an additional covariate. Results are reported as odds ratios (ORs) and linear regression weights (β) with 95% confidence intervals (CIs) for binary (initiation: yes vs. no) and continuous (susceptibility) outcomes, respectively. The scales of all continuous variables were standardized (mean = 0, SD = 1). Significance was set to .05 (two-tailed).
Table 1.
Descriptive Data on Sample Characteristics
| Entire sample (N = 3299) | Never-smokers (N = 2956) | Ever-smokers (N = 343) | |
|---|---|---|---|
| Sociodemographics | |||
| Male, % | 46.3% | 46.7% | 42.7% |
| Age, mean (SD) | 14.1 (0.42) | 14.07 (0.41) | 14.18 (0.45) |
| 13 years old or younger, % | 3.6% | 3.9% | 1.2% |
| 14 years old, % | 84.4% | 84.7% | 81.8% |
| 15 years old or older, % | 12.0% | 11.4% | 17.0% |
| Race, % | |||
| American Indian/Alaska Native | 1.0% | 1.0% | 1.5% |
| Asian | 16.8% | 17.9% | 7.1% |
| Black/African American | 5.0% | 5.0% | 4.5% |
| Hispanic/Latino | 48.1% | 46.8% | 59.3% |
| Native Hawaiian/Pacific Islander | 4.2% | 4.3% | 3.6% |
| White | 16.6% | 16.7% | 15.7% |
| Other | 1.5% | 1.5% | .9% |
| Multiethnic/multiracial | 6.8% | 6.8% | 7.4% |
| Highest parental education, % | – | – | – |
| Unknown | 12.9% | 12.8% | 14.0% |
| Eighth grade or less | 3.5% | 3.0% | 7.6% |
| Some high school | 7.9% | 7.4% | 12.8% |
| High school graduate | 14.7% | 14.1% | 19.2% |
| Some college | 16.9% | 16.9% | 16.6% |
| College graduate | 27.5% | 28.6% | 18.1% |
| Graduate degree | 16.6% | 17.2% | 11.7% |
| Anhedonia and depression | |||
| SHAPS, mean (SD) | 27.74 (6.95) | 23.39 (6.66) | 26.76 (8.50) |
| RCADS-MDD, mean (SD) | 7.80 (7.03) | 7.43 (6.78) | 11.15 (8.27) |
| Outcomes | |||
| Susceptibility composite, mean (SD) | 1.21 (.48) | 1.13 (.32) | 1.90 (.86) |
| Willingness to smoke, % | |||
| Definitely not | 84.5% | 89.8% | 38.8% |
| Probably not | 10.9% | 9.0% | 27.8% |
| Probably or definitely yes | 4.6% | 1.3% | 33.4% |
| Intention to smoke, % | |||
| Definitely not | 88.6% | 93.2% | 48.7% |
| Probably not, probably or definitely yes | 11.4% | 6.8% | 51.3% |
| Smoking curiosity, % | |||
| Definitely not | 82.9% | 86.6% | 51.0% |
| Probably not | 10.0% | 8.4% | 23.6% |
| Probably or definitely yes | 7.1% | 5.0% | 25.4% |
| Expectancy composite, mean (SD) | 1.49 (.65) | 1.42 (.59) | 2.07 (.80) |
| Expectation of reward, % | |||
| Definitely not | 80.2% | 84.3% | 44.4% |
| Probably not | 15.5% | 13.6% | 32.2% |
| Probably or definitely yes | 4.3% | 2.1% | 23.4% |
| Expectation of negative consequences, % | |||
| Definitely not | 10.9% | 10.4% | 15.9% |
| Probably not | 8.3% | 6.2% | 26.3% |
| Probably yes | 23.6% | 23.0% | 28.1% |
| Definitely yes | 57.2% | 60.4% | 29.6% |
3299 ninth grade students enrolled across 10 public high schools in the Los Angeles, CA, US Metropolitan area, who took part in the Happiness and Health study during fall 2013. RCADS-MDD = Revised Children’s Anxiety and Depression Scale—Major Depressive Disorder subscale; SHAPS = Snaith–Hamilton Pleasure Scale—measure of anhedonia.
Results
Preliminary Analyses
As shown in Table 1, the mean score on the RCADS-MDD in the overall sample was 7.8 (SD = 7.0; range 0–30), suggesting a mild level of major depression symptoms on average with ample interindividual variability; 14.9% surpassed the cutoff for clinically-significant MDD symptoms. The SHAPS average score in the overall sample was 23.7 (SD = 6.9; range 14–56), indicating a low to moderate level of anhedonia in the sample with notable degree of variation; 26.2% exceeded the cutoff for clinically-significant anhedonia. RCADS-MDD and SHAPS scores were intercorrelated (r = .22, p < .001). RCADS-MDD scores were higher in females than males (p < .001, d = .45), while SHAPS scores were slightly higher in males (p < .001, d = −.17); neither were not associated with other sociodemographic factors.
Primary Analysis
As shown in Table 2, generalized linear mixed models illustrated that, depending on the level of covariate adjustment, each increase in 1 SD unit in SHAPS scores was associated with a 27%–43% increase in odds of smoking initiation in the overall sample. In the subsample of never-smokers, anhedonia was associated with greater susceptibility and prosmoking expectancies for each outcome. Depending on the level of covariate adjustment, each increase in 1 SD unit in SHAPS scores was associated with anywhere from a: (1) 9%–19% increase in SD units on susceptibility and prosmoking expectancy composites and (2) 11%–40% increase in odds of reporting a higher response category on individual susceptibility and expectancy items.
Table 2.
Associations of Anhedonia to Smoking Initiation and Susceptibility
| Association of SHAPS (anhedonia) score with respective outcome | |||
|---|---|---|---|
| Outcome | Unadjusted | Adjusted for demographicsc | Adjusted for demographicsc and RCADS-MDD |
| Smoking initiation, OR (95% CI)a | 1.43 (1.30, 1.56) | 1.40 (1.28, 1.54) | 1.27 (1.15, 1.41) |
| Expectancy composite, β (95% CI)b | 0.19 (0.15, 0.22) | 0.18 (0.15, 0.22) | 0.16 (0.12, 0.19) |
| Rewarding effects, OR (95% CI)b | 1.31 (1.20, 1.43) | 1.31 (1.20, 1.43) | 1.19 (1.08, 1.31) |
| Aversive effects, OR (95% CI)b | 1.40 (1.30, 1.50) | 1.38 (1.28, 1.48) | 1.34 (1.24., 1.44) |
| Susceptibility composite, β (95% CI)b | 0.13 (0.10, 0.17) | 0.13 (0.09, 0.17) | 0.09 (0.05, 0.13) |
| Willingness, OR (95% CI)b | 1.37 (1.24, 1.51) | 1.38 (1.25, 1.53) | 1.29 (1.16, 1.44) |
| Intention, OR (95% CI)b | 1.39 (1.24, 1.56) | 1.38 (1.23, 1.56) | 1.28 (1.13, 1.45) |
| Curiosity, OR (95% CI)b | 1.25 (1.14, 1.37) | 1.24 (1.13, 1.37) | 1.11 (1.01, 1.23) |
Results from generalized linear mixed logistic regression model predicting odds of smoking initiation accounting for clustering by school. RCADS-MDD = Revised Children’s Anxiety and Depression Scale—Major Depressive Disorder subscale; SHAPS = Snaith–Hamilton Pleasure Scale—measure of anhedonia. OR = odds ratios indicating changes in odds of smoking initiation or the odds of endorsing a higher response option on the individual susceptibility and expectancy items for each increase in one SD unit in SHAPS. Response options for individual items can be found in Table 1. β = standardized regression parameter indicating predicted increase in SD units in the respective outcome variable associated with an increase in one SD unit of the SHAPS. CI = confidence interval.
aAnalyses use available data in the overall sample, Ns range from 3166 to 3299 across analyses due to different patterns of missing data across variables.
bAnalyses use available data in the sample of never-smokers, Ns range from 2895 to 2932 across analyses due to different patterns of missing data across variables.
cDemographic covariates are age, gender, ethnicity, and highest parental education.
All p-values of SHAPS parameter estimates are p < .0001 except the two adjusted curiosity models (p < .05).
Supplemental Analysis
Because a portion of the sample (N = 917; 28%) reported use of other tobacco products that might alter susceptibility to initial experimentation with cigarettes by providing direct experience with other tobacco, we reran all analyses after excluding these adolescents. These results were identical to the analyses in the larger sample that included these adolescents (p values were equal or lower to corresponding analysis p value in overall sample), suggesting that use of other tobacco products did not modify the results. We also tested whether the associations of anhedonia and smoking initiation and susceptibility indices differed between boys and girls by testing the interaction between SHAPS and gender. Results showed no evidence of differences in associations by gender for any outcomes (interaction p values ≥ .36).
Discussion
This study found that by ninth grade, adolescents with higher anhedonia were more likely to have initiated smoking, extending past data documenting this link in older samples.8 Since an earlier age of smoking onset is associated with greater likelihood of escalation to heavier and chronic smoking through later adolescence and adulthood,25 the long-term smoking trajectories associated with adolescent anhedonia warrant future investigation.
This study also provides new data that, among never-smokers, anhedonia is associated with various markers of susceptibility to smoking onset. Anhedonia was related to increased curiosity about smoking (a low threshold marker of susceptibility in which smoking initiation likelihood may be increased at some point in the future), willingness to smoke if offered by peers (a moderate threshold susceptibility marker), and intention to smoke in the next 6 months (a high threshold marker in which smoking initiation may be of relatively high likelihood in the near future).20,21 Consequently, anhedonia may be a risk factor for smoking initiation across a reasonably wide span of the susceptibility continuum. Smoking expectancy data indicated that adolescents with higher anhedonia may undervalue negative consequences associated with smoking and overvalue the rewarding, pleasurable effects of smoking relative to their peers with lower anhedonia.
This study has several strengths including a large, diverse sample, statistical control for cofactors as well as depression to show specificity of the findings to anhedonia, and the inclusion of multiple theoretically- and clinically-relevant outcome measures implicated in smoking initiation risk. Study limitations include a cross-sectional design, which precludes temporal or causal inferences, lack of data on smoking uptake beyond initiation, the use of singe-item measures of uncertain validity to assess certain outcomes, and failure to collect data on susceptibility markers for non-cigarette tobacco products and negative reinforcement smoking expectancies that could play a role in the relations studied herein. Pending replication in longitudinal research, targeting anhedonia very early the smoking uptake continuum may be valuable in smoking prevention. Specifically, anhedonia targeted interventions26 such as behavioral activation interventions27 that promote the engagement in meaningful and rewarding healthy alternative behaviors, positive psychotherapy28 that teaches how to savor pleasurable experiences through mindfulness and other exercises could be useful for affectively vulnerable teens. In addition, these results suggest that the application of empirically-based prevention strategies that challenge prosmoking expectancies and diffuse willingness to smoke when offered by peers (eg, changing expectancies through corrective feedback29 and decision-making skills training30) may potentially offset anhedonia-related smoking initiation risk.
Funding
This work was supported by the National Institute of Health (R01-DA033296). The funding agency had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Declaration of Interests
The authors report no potential conflicts of interests.
Contributor Information
Matthew D. Stone, Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA;.
Janet Audrain-McGovern, Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA;.
Adam M. Leventhal, Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA;; Department of Psychology, University of Southern California, Los Angeles, CA
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