Professional Documents
Culture Documents
Smoking is one of the most significant and also preventable causes of death which is a public
health problem across many countries. According to statistics from the World Health Orga-
nization, in 2015, 1.1 billion people smoked tobacco and more than seven million people die
from smoking each year (WHO, 2017). Given reports demonstrating that the prevalence of
smoking among Iranians varied from 12.3% to 38.5% in men, and from 0.6% to 9.8% in
women (Moosazadeh, Ziaaddini, Mirzazadeh, Ashrafi-Asgarabad, & Haghdoost, 2013),
smoking cigarettes is also a critical issue threatening public health in Iran.
Among young adults, university students are one of the most vulnerable young age
groups affected by smoking. Indeed, research evidence has shown that 32.1% of the college
students aged 19–28 in the United States smoke cigarettes (Schulenberg et al., 2016). Nichter
et al. (2006) have also revealed that university students are at a higher risk of smoking ciga-
rettes and of a transition from a recreational pattern to a regular pattern of smoking. Previ-
ous research in Iran has also indicated that the lifetime prevalence and current rate of
tobacco use among Iranian university students is as high as 31% (51% for males and 15% for
females) and 11% (21.5% for males and 2% for females), respectively (Shamsi Meymandi,
Nakhaee, Divsalar, & Heravi, 2010). Moreover, there is evidence that shows the average age
of smoking initiation among Iranian university students is 15.9 years (Nakhaee, Divsalar, &
Bahreinifar, 2011). Therefore, more attention needs to be paid to this issue at universities.
Subsequent studies have investigated the relationship between the tendency to smoke cig-
arettes and a wide diversity of factors, ranging from psychological factors such as personality
characteristics (e.g., Harakeh, Scholte, de Vries, & Engels, 2006) and psychological disorders
(e.g., Mykletun, Overland, Aaro, Liabo, & Stewart, 2008) to social factors such as low social
support and the influence of peers (e.g., Oksuz, Mutlu, & Malhan, 2007). In line with these
studies, conducted research in Iran has also suggested a range of factors, including personal
(e.g., personality traits and wrong beliefs about smoking), familial (e.g., parents’ positive atti-
tudes toward substance use and poor parental authority), and social factors (e.g., friends’
substance use and easy access to cigarettes), which contribute to substance use and in
particular, tobacco use among Iranian youths (Darharaj, Habibi, Kelly, Edalatmehr, &
Kazemitabar, 2017; Ebrahimi, Sahebihagh, Ghofranipour, & Tabrizi, 2014). Existing litera-
ture also shows a great influence of parents and siblings on the Iranian youths’ tobacco use,
which may be due to the collectivist values of Iranian families that emphasize close family
networks and strong emotional family ties which, in turn, facilitate youths’ modeling of their
parents’ and older siblings’ behavior (Baheiraei, Hamzehgardeshi, Mohammadi, Nedjat, &
Mohammadi, 2013).
Some other studies have also indicated that interpersonal factors including attachment
styles and loneliness as well as other factors such as psychological problems are also associ-
ated with the onset and maintenance of smoking (e.g., DeWall & Pond, 2011; Lawrence,
Mitrou, & Zubrick, 2009; Scragg, Reeder, Wong, Glover, & Nosa, 2008). Attachment plays
an essential role in forming personality and it deeply affects individuals’ psychological well-
being (Meredith, Ownsworth, & Strong, 2008). Research has shown that insecure attachment
is associated with mistrust and communicational problems (Miga, Hare, Allen, & Manning,
2010). Kassel, Wardle, and Roberts (2007) developed a model according to which adults’
insecure attachment style as a contributing factor affects smoking, drug abuse, and alcohol
consumption through building dysfunctional attitudes and decreasing self-esteem. Thorberg
and Lyvers (2006) also found that substance users experience more insecure attachment and
less intimacy in comparison with nonusers.
Another factor which can significantly affect smoking is loneliness. Existing literature has
revealed that there is a significant relationship between loneliness and psychological prob-
lems such as alcoholism, suicide, depression, anxiety, and substance abuse (e.g., Mushtaq,
Shoib, Shah, & Mushtaq, 2014). For instance, DeWall and Pond (2011) found that loneliness
can increase the probability of smoking cigarettes, especially when this behavior is socially
accepted. A systematic review also revealed that a higher level of loneliness is associated with
being a smoker (Dyal & Valente, 2015). However, some other studies have concluded that
loneliness cannot be considered as a risk factor for smoking cigarettes, and there is no differ-
ence between lonely and nonlonely individuals in tobacco consumption (e.g., Hawkley,
Burleson, Berntson, & Cacioppo, 2003). Therefore, in order to clarify the relationship
between smoking and perceived loneliness, more investigations need to be conducted.
Finally, a further factor which is significantly associated with smoking is psychological
well-being. There is evidence that shows more than 90% of people with psychological prob-
lems are nicotine dependent (Williams & Ziedonis, 2004). Moreover, smoking cigarettes
228 M. HABIBI ET AL.
alleviates psychiatric symptoms and this factor, in turn, increases the likelihood of nicotine
dependence (Ziedonis, Williams, & Smelson, 2003). There is also evidence that smoking is
associated with higher levels of anxiety, depression, and some other psychological disorders
(Cuijpers, Smit, Ten Have, & De Graaf, 2007). Similarly, Morrell and Cohen (2006) argued
that about 41% of smokers not only meet the diagnostic criteria for a psychiatric disorder
but they also experience low levels of psychological health.
In summary, since the treatment of smoking dependency is very difficult and compli-
cated, it needs a comprehensive approach in which a combination of pharmacotherapy and
psychotherapy is applied (Ingersoll & Cohen, 2005). Despite this, it is undeniable that the
probability of relapse still remains high even with the use of the most effective treatment
methods. Indeed, many risk factors such as easy access to cigarettes and peer pressure can
play a significant role in treatment failure (Maisto & Connors, 2006). Therefore, the preven-
tion of smoking cigarettes among young people is considerably easier than the treatment. In
order to develop a prevention model, it is necessary to determine the contributing factors
involved in the onset and maintenance of smoking cigarettes. Accordingly, this study aimed
to compare the attachment styles, perceived loneliness, and psychological well-being
between smoking and nonsmoking university students. Specific hypothesis based on the
above-mentioned research literature was that compared to nonsmoking university students,
smokers will experience a higher level of insecure attachment, perceived loneliness, and psy-
chological well-being problems.
Methods
Participants
A total of 200 university students were recruited through advertisements at Shahid Beheshti
University, Tehran, Iran, by using a convenience sampling method. In these advertisements,
undergraduate and postgraduate smoking and nonsmoking students were invited to partici-
pate in this study. Among these participants, the first group consisted of 100 current smokers
(including 67 males and 33 females) who were defined as those who had smoked in the past
4 weeks prior to the study and they had smoked at least 100 cigarettes during their lifetime.
The age range of the smokers who participated in this study was between 18 and 25 years
old (M D 23.91, SD D 4.31). The nonsmokers also included 100 students who had never
smoked in their life. This group consisted of 59 males and 41 females who had a similar age
range (M D 24.49, SD D 4.52) and educational status in terms of schooling years with the
smoking participants.
Measures
Adult Attachment Scale
The Adult Attachment Scale (AAS) developed by Collins and Read (1990) is a self-report
scale which consisted of 18 items and it measures participants’ abilities for establishing the
relationship and attachment to their close others. The items are scored on a five-point Likert
scale, ranging from 1 (not characteristic of me at all) to 6 (exactly characteristic of me). This
scale assesses participants’ attachment styles in three different domains, including close (i.e.,
the extent to which someone feels comfortable with intimate relationships; e.g., I do not
THE JOURNAL OF PSYCHOLOGY 229
worry about someone getting too close to me), dependent (i.e., the extent to which someone
feels that he /she can depend on others; e.g., I am comfortable depending on others), and anx-
ious attachment styles (i.e., the extent to which someone is concerned about being rejected
by others; e.g., In relationships, I often worry that my partner does not really love me). In their
study, Collins and Read (1990) showed that the AAS has an acceptable internal consistency
and therefore it is reliable (Cronbach’s Alpha coefficients ranged from .78 for dependency
subscale to .85 for anxiety subscale). Similarly, the Persian version of the AAS which was
used in the current study had also an appropriate internal consistency (a D .84).
Loneliness Scale
This is a 38-item scale designed by Dehshiri, Borjali, Sheykhi, and Habibi (2008) that meas-
ures perceived loneliness among Iranian university students. The items are rated on a five-
point Likert scale ranging from 1 (very much) to 5 (not at all). This measure consisted of
three different subscales, including loneliness due to the lack of relationships with the family
(16 items; e.g., I get along well with my family members), loneliness due to the lack of rela-
tionships with friends (12 items; e.g., I am an important member of a friendly group), and
affective symptoms of loneliness (10 items; e.g., I am very irritable). Investigation of the psy-
chometric properties of the scale has shown its satisfactory internal consistency (a D .91) as
well as its test-retest reliability (r D .84). Moreover, significant relationships between the
Loneliness Scale with Revised UCLA Loneliness Scale (r D .60) and Oxford Happiness
Inventory (r D –.68) confirms its convergent and divergent validity, respectively (Dehshiri
et al., 2008).
Procedure
In order to prepare the Persian translation of the measures used in this study, including AAS
and GHQ, these instruments were translated into Persian and then back-translated into
English according to the guidelines for the cross-cultural adaptation of instruments (Guille-
min, Bombardier, & Beaton, 1993). The translations were conducted by a research team that
included both linguistics and psychologists. The face validity of the measures was also
proven by three mental health professionals. The measures were administered in a pilot
study in order to assess the applicability and possible defects of the questions. Finally, after
230 M. HABIBI ET AL.
making some minor changes to the measures, the questions were administered to the sub-
jects of this study.
The data were collected after obtaining ethical approval from the ethics board of Shahid
Beheshti University. The study was advertised on the university campus and the students
who were reported as being current smokers, as well as nonsmokers, were invited to partici-
pate. Moreover, all participants were provided with written consent forms and they were
informed that their participation in the study was voluntary and anonymous and that they
had the right to withdraw from the study at any point. Data collection was conducted indi-
vidually over a period of 2 months.
Analysis Strategy
There was no missing data in the current study dataset. The assumption of normality was
checked and no skew was observed. The decision whether to remove or retain the outliers
was taken by comparing the original mean with the 5% of the trimmed mean (Tabachnick &
Fidell, 2013). Two sets of Multivariate Analysis of Variance (MANOVA) were conducted,
with current smoking status (smoker vs. nonsmoker) being considered as a categorical inde-
pendent variable and the attachment styles (i.e., close, dependent, and anxious attachment
styles), as well as perceived loneliness (i.e., loneliness due to the lack of relationships with
the family, loneliness due to the lack of relationships with friends, and affective symptoms of
loneliness), being considered as dependent variables. Moreover, an independent samples t-
test was used to test whether smokers and nonsmokers differed on psychological well-being
problems as measured by using the total score obtained from the GHQ. Statistical analyses
were performed using SPSS version 21.
Results
There were no significant differences between the groups in the age, t (198) D –.92, p D .36,
or educational status, t (198) D 1.17, p D .27. The results of MANOVA for comparing smok-
ing and nonsmoking students in attachment styles and perceived loneliness have been
shown in Table 1.
As shown, there was a significant difference between the groups in the attachment
styles measured by the AAS. Indeed, compared to smokers, nonsmokers had signifi-
cantly higher scores in “close” and “dependent” subscales of the AAS, while smokers
experienced higher levels of “anxious” attachment style than nonsmokers, F (1, 198) D
Table 1. Comparison of Smoking and Non-Smoking University Students in Attachment Styles and Per-
ceived Loneliness.
Smokers (n D 100) Nonsmokers (n D 100) MANOVA
Close attachment style 13.74 4.63 21.52 4.14 78.29 <.001 .44
Anxious attachment style 19.52 5.79 13.02 4.32 40.41 <.001 .29
Dependent attachment style 13.78 3.77 17.66 4.22 30.03 <.001 .23
Loneliness due to the lack of relationships with family 33.46 7.50 17.38 8.37 102.23 <.001 .51
Loneliness due to the lack of relationships with friends 26.72 6.88 17.24 7.64 42.43 <.001 .30
Affective symptoms of loneliness 23.96 4.44 13.74 5.72 99.35 <.001 .50
THE JOURNAL OF PSYCHOLOGY 231
Discussion
This study compared smoking and nonsmoking university students in attachment
styles, perceived loneliness, and psychological well-being. Results revealed that there is
a significant difference between attachment styles of smoking and nonsmoking students
in that current smokers experienced more insecure attachment than nonsmokers. This
finding is in line with previous research on substance users which has suggested that
they are significantly different from nonusers in terms of attachment styles (e.g.,
Thorberg & Lyvers, 2006). Kassel et al. (2007) argued that insecure attachment causes
developing dysfunctional attitudes and a low level of self-esteem which seems to
encourage the smoking behavior. Hussong and Chassin (1994) also concluded that inse-
cure attachment style as a predisposing factor increases psychological distress which, in
turn, leads to smoking and substance use.
However, some other studies have suggested that self-regulation moderates the relation-
ship between insecure attachment style and substance use disorders. In fact, the character-
istics of a secure attachment style not only boost the ability to regulate emotions but also
increase the moderating role which self-regulation plays in the relationship between a
secure attachment style and the severity of substance use (Besharat, Noorbakhsh, Rostami,
& Farahani, 2012). Furthermore, there is evidence that shows young adults with higher lev-
els of a tendency toward smoking and substance use do not have intimate relationships
with their parents and experience more family conflicts (Darharaj et al., 2017). Therefore,
they become dependent on external objects such as drugs and cigarettes in order to sup-
press their psychological needs and personal deficiencies. On the other hand, while most
people with a secure attachment style seek social support in the case of emotional distress,
people with an insecure attachment style tend to look for other destructive behaviors such
as smoking, substance use, and alcohol use in similar situations (Kassel et al., 2007).
Consistent with previous research (DeWall & Pond, 2011; Dyal & Valente, 2015), the
results of this study also indicated that there is a significant difference between two
groups in terms of perceived loneliness. Indeed, the smokers felt lonelier compared to
nonsmokers. According to DeWall and Pond (2011), there is a positive relationship
between loneliness and smoking cigarettes and this relationship is stronger when smok-
ing is considered as a socially acceptable behavior. Lauder, Mummery, Jones, and
Caperchione (2006) also suggested that lonely individuals are less likely to consider
walking as a means of weight loss but instead they tend to use maladaptive behaviors
including smoking cigarettes. Thus, it can be concluded that compared to those with
good social interactions, isolated and lonely people have a different lifestyle which leads
them toward a variety of destructive behaviors such as smoking.
232 M. HABIBI ET AL.
Although previous research has indicated that there are differences in terms of loneli-
ness between smokers and nonsmokers, some studies have suggested otherwise. For exam-
ple, Cacioppo et al. (2002) found that there was no significant difference between lonely
and nonlonely people in smoking cigarettes, alcohol use, and weekly exercise. Given this
contradiction, it seems that psychological perception of loneliness and not loneliness per se
is a risk factor for smoking cigarettes which leads lonely people to perceive their social
world to be more threatening and less reinforcing (Cacioppo et al., 2002). Furthermore,
there is evidence that suggests cultural differences may also affect the relationship between
loneliness and smoking cigarettes; for instance, Page et al. (2008) found that while there
was a positive relationship between smoking and loneliness among Southeast Asian girls,
the opposite was true among Central-Eastern European girls. In other words, contrary to
Central Eastern European girls, Southeast Asian female smokers scored higher on loneli-
ness than nonsmokers, although these results were not observed among boys. Moreover,
social pressure, having wider social interactions, especially with smokers, and also confor-
mity to friends’ social norms can also act as encouraging factors toward smoking among
the youths (Darharaj et al., 2017). Therefore, apart from loneliness, interacting with smok-
ers might be another element which is associated with smoking cigarettes. This is of double
importance for university students due to their continual proximity to peers during a
period of at least 4 years in university, especially university dormitories.
In line with previous studies (e.g., Cuijpers et al., 2007), our findings also revealed
that there is a difference between smokers and nonsmokers in terms of psychological
well-being problems. That is, those students who smoked cigarettes suffered from a
higher level of psychological problems compared to nonsmokers. In a similar vein,
Kord Tamini, Raghibi, and Bakhshani (2012) argued that, in comparison with non-
smokers, smokers experienced a higher level of anxiety and a lower level of quality of
life and psychological health. Taking these findings into account, it can be suggested
that there is a mutual relationship between smoking cigarettes and psychological prob-
lems; on the one hand, not only is smoking cigarettes associated with the prevalence of
psychological problems but also it can trigger some psychiatric disorders (Cuijpers
et al., 2007). On the other hand, smokers usually report that smoking alleviates their
psychological health problems, including depression, anxiety, and stress. This is consis-
tent with the self-medication model according to which individuals who suffer from
psychological disorders initiate and maintain smoking cigarettes to relieve their unde-
sirable symptoms. However, this is a short-term effect that disappears after a while and
then withdrawal symptoms emerge due to which the person smokes more to relieve
these unpleasant symptoms (DeHay, Morris, May, Devine, & Waxmonsky, 2012).
In summary, according to the results of the current study and as suggested by previ-
ous research, it can be concluded that a low level of psychological well-being is a con-
tributing factor which triggers the tendency toward tobacco use. Moreover, the
psychological problems may not only influence the tendency toward smoking cigarettes
but they might also be exacerbated by it. This causes the formation of a vicious cycle
in which psychological problems lead the person to smoke more and, in turn, smoking
more exacerbates psychological symptoms. Furthermore, a high level of psychological
problems, particularly psychological distress which is significantly associated with lone-
liness (Paul, Ayis, & Ebrahim, 2006), elicits an inflammatory process through releasing
neuropeptides, particularly substance P (SP) and corticosteroid releasing factor (CRF).
THE JOURNAL OF PSYCHOLOGY 233
Conclusion
In conclusion, these results showed that smokers and nonsmokers are significantly different
in terms of attachment styles and perceived loneliness, in that smoking students experi-
enced more insecure attachment and higher levels of loneliness than nonsmoking students.
Moreover, these findings indicated that smokers experienced a lower level of mental health
than nonsmokers. Therefore, providing smoking university students with multimodal pre-
vention programs targeting these factors is important to reduce the level of their smoking.
Moreover, referring the results of current research about loneliness, and given studies indi-
cating that loneliness is associated with substance use, including drug use, alcohol consump-
tion, and smoking cigarettes (e.g., Mannes et al., 2016; Stickley, Koyanagi, Koposov, Schwab-
Stone, & Ruchkin, 2014), assessing loneliness levels among university students first and then
utilizing programs designed to treat loneliness such as Loneliness Intervention using Story
Theory to Enhance Nursing-sensitive outcomes (LISTEN; Theeke & Mallow, 2015) and
addressing maladaptive social cognition (Masi, Chen, Hawkley, & Cacioppo, 2011) may help
reduce substance use, particularly smoking cigarettes, among university students.
Author Notes
Mojtaba Habibi is an assistant professor at the Iran University of Medical Sciences, Tehran, Iran. His
research focuses on risk and protective factors of high-risk behavior, including smoking cigarettes,
drug use and alcohol consumption among youths.
234 M. HABIBI ET AL.
Farhad Hosseini is a master graduate of family therapy from Shahid Beheshti University. His research
interests include drug use and consequent risk behavior among patients with substance use and devel-
oping family-based prevention programs for this group.
Mohammad Darharaj is a master graduate of clinical psychology from Kharazmi University. He has
an interest in psychopathology among substance abusers. In particular, he works on personal, social,
and familial factors and consequences of substance among adolescents and young adults.
Ali Moghadamzadeh is an assistant professor at University of Tehran, Iran. His research focuses on
substance use, treatment implementation, and relapse prevention.
Farhad Radfar is a master graduate of clinical psychology at Shahid Beheshti University. He now
studies psychopathology of children and adolescents with pervasive developmental disorders, with a
concentration on developing and implementing parenting programs.
Yasaman Ghaffari has obtained her master’s degree in general psychology from University of Essex.
She has supervised the group therapy sessions among drug addicts at NHS in London, UK. She is also
interested in examining factors which lead the youths toward substance use.
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