The Role of Parental Smoking on Children's Attentional Bias to and Evaluation of Smoking-Related Cues

The goal of the current study was to examine whether exposure to parental smoking affects implicit cognitive mechanisms that may contribute to smoking initiation in children. To achieve this aim, the current study used a dot probe task to measure attentional bias and the Affect Misattribution Procedure (AMP) to measure evaluation of smoking-related cues in 8-12 year-old children. In addition, a modified Smoking Consequences Questionnaire (SCQ) was used to assess smoking outcome expectancies to determine if outcome expectancies related to these implicit measures. Results revealed that children of smokers (n = 67) showed an attentional bias away from smoking-related cues, whereas children of non-smokers (n = 76) did not show an attentional bias. Although all children exhibited a negative implicit affective response to smoking-related cues, children of smokers rated marginally more smoking-stimuli as unpleasant than children of non-smokers. Outcome expectancies largely did not relate to attentional bias or implicit affective responses. These findings suggest that unlike adults with smoking parents, preadolescents who are children of smokers do not show attentional biases toward smokingrelated cues, nor do they demonstrate favorable affective responses towards smoking stimuli. Why preadolescent children direct less attention toward and have more negative responses to smoking cues and how these responses are changed or reversed during adolescence are important areas for future research. EFFECT OF PARENTAL SMOKING ON ATTENTION AND AFFECT 4 The Role of Parental Smoking on Children’s Attentional Bias to and Evaluation of Smoking Related Cues Despite its well-documented adverse effects, smoking continues to be one of the greatest public health concerns. In the United States, cigarette smoking is consistently listed as the number one preventable cause of death (U.S. Department of Health and Human Services, 2014). Nearly six million people die globally every year from smoking-related illnesses, and that number is expected to rise to eight million annually in the next fifteen years (World Health Organization, 2011). Over half of children worldwide live with at least one parent who smokes (European Environment and Health Information System, 2007), and about one in four children in the United States lives with a parent who smokes (Soliman, Pollack, & Warner, 2004). The prevalence of parents who smoke is concerning given that children of smokers are more likely to become smokers than those whose parents do not smoke (Hill, Hawkins, Catalano, Abbott, & Guo, 2005). While there are certain genetic factors that contribute to smoking, they do not account for all of the variation in smoking behavior, leaving a significant role for environmental factors (Audrain-McGovern, Lerman, Wileyto, Rodriguez, & Shields, 2004; Sullivan & Kendler, 1999). Understanding the environmental mechanisms that lead to smoking initiation and maintenance, particularly in high-risk groups such as children of smokers, is critical for developing effective, evidence-based prevention and intervention programs. A longitudinal study that followed 808 10-11 year-olds for 10 years showed that parental smoking behaviors predicted the child’s risk of daily smoking initiation above any other family-related factors measured, even if the parent expressed disapproval of teen tobacco use and did not involve the child in their smoking behaviors (Hill et al., 2005). Thus, it appears that children’s exposure to smoking in the home influences their propensity to smoke. In addition, the likelihood EFFECT OF PARENTAL SMOKING ON ATTENTION AND AFFECT 5 of smoking initiation increases with the number of smoking parents and duration of exposure (Gilman et al., 2009). Although much research has established the link between parental and children’s smoking, the mechanisms responsible for this link are not clear. Researchers investigating possible causes for the link between parent and child smoking behavior have identified early exposure, availability, parental monitoring, and parental imitation as major mediators. However, most of the findings across studies yield inconsistent results, suggesting that other factors may be involved (Avenevoli & Merikangas, 2003), which include a range of cognitive mechanisms. Previous research has demonstrated gradual developmental shifts in beliefs and attitudes about smoking, with older children holding relatively more positive beliefs about the benefits and less negative beliefs about the consequences of smoking than younger children (Chassin, Presson, Sherman, & McGrew, 1987; Gillmore et al., 2002; O’Connor, Fite, Nowlin, & Colder, 2007). Consistent with these findings, other studies that have examined other substances such as alcohol have supported pre-adolescence and early adolescence as a key period for increasing positive outcome expectancies and decreasing negative outcome expectancies (Copeland, Proctor, Terlecki, Kulesza, & Williamson, 2014). However, some of those beliefs may shift more than once during adolescence; while middle school students’ perceptions of the health risks and addictive properties of smoking appeared to decrease over time, high school students perceptions of health risks and beliefs in addictive properties of smoking increased (Chassin, Presson, Rose, & Sherman, 2001). In addition to age-related changes in smoking expectancies, exposure to smoking via parental and/or peer smoking may shape beliefs about smoking. In one study, 7-12 year-old children who had family members or peers who smoked perceived smoking to have more EFFECT OF PARENTAL SMOKING ON ATTENTION AND AFFECT 6 positive and fewer negative consequences than children with no smoking family members or peers (Copeland et al., 2007). This study suggested that perception of the positive reinforcement of smoking related to age, but unlike the studies discussed above, older children reported fewer positive and more negative consequences. When modifying the SCQ for 11-19 year-old adolescents, non-smokers endorsed fewer factors related to the negative affect reduction, boredom reduction, social facilitation, and positive taste/sensorimotor aspects of smoking than smokers (Lewis-Esquerre, Rodrigue, & Kahler, 2005). Teens who intended to smoke in the next five years scored higher on taste/sensorimotor aspects of smoking, belief that smoking provides positive social consequences, and belief that smoking can reduce negative affect. Furthermore, parental smoking lead to lower endorsement of the negative physical feelings associated with smoking and higher endorsement of smoking reducing negative affect. While explicit measures, such as those measured in the studies reported above, typically involve self-report in the form of questionnaires that can be subject to bias, implicit assessments reflect automatic and involuntary judgments, and reactions over which participants have little if any control. As a result, they are less likely to produce response biases due to evaluation apprehension and social desirability, which are particularly salient when measuring explicit responses about socially stigmatizing behaviors such as cigarette smoking (Stuber, Galea, & Link, 2008). Using methods that minimize response bias is essential if we are to understand the cognitive mechanisms that may play a role in smoking initiation. The value of investigating implicit mechanisms is further underscored by the predictive significance of implicit measures; Stacy (1997) showed that implicit measures predicted marijuana use, a socially stigmatized behavior, while explicit measures predicted alcohol use, a socially acceptable behavior. In a review of studies examining addictive behaviors, Tiffany (1990) suggested that addictive EFFECT OF PARENTAL SMOKING ON ATTENTION AND AFFECT 7 behaviors are largely a result of automatic processes. This model would support focusing on stimuli and the responses they unconsciously evoke that might contribute to the activation of action schemata that are difficult to disrupt and lead to smoking behaviors. Attentional bias, a widely used implicit measure, is thought to play a role in smoking initiation and maintenance (Field & Cox, 2008). Increased implicit attention to smoking-related cues that are ubiquitous in the environment is one mechanism that might activate these schemas proposed by Tiffany (1990) and lead to smoking behavior. Attention is a cognitive process that allows selective processing of environmental information, attenuating irrelevant information while enhancing responses to and perceptions of other sensations, cues, and information. This biased processing shapes one’s perception of the environment and may subsequently influence behavior. Implicit attentional bias has been studied in the context of addiction-related cues to examine the extent to which an individual unconsciously focuses preferentially on a specific type of stimulus over another stimulus. Attentional bias is assessed through a variety of tasks, including the dot probe task (MacLeod, Mathews & Tata, 1986), where two images briefly appear on a screen before disappearing, with a dot appearing where one of the pictures was previously located. Participants are asked to indicate where the dot appears, and by measuring reaction time via a button press, experimenters can predict where the participant was directing their relative implicit attention, with faster reaction times when the dot replaces the image on which the participant was focused. When compared to non-smokers, smokers show an attentional bias towards smokingrelated stimuli during the dot probe task when the images are displayed for 500ms, likely reflecting initial shifts in attention (Ehram et al., 2002). Smokers have also shown this attentional bias with a visual probe when the cue was displayed for 2000ms, likely reflecting maintained EFFECT OF PARENTAL SMOKING ON ATTENTION AND AFFECT 8 attention (Bradley, Field, Mogg, & D