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modified by smoking. In a more naturalistic study, smokers were asked to attend a
stressful social situation and were instructed either to smoke or not to smoke. Those
who could not smoke reported the occasion as more socially stressful than those who
could smoke (Gilbert and Spielberger 1987). Similarly, Metcalfe et al. (2003) used the
Reeder Stress Inventory to relate stress to health behaviours and concluded that
higher levels of stress was associated with smoking more cigarettes. This association
was also found in one large scale study of over 6000 Scottish men and women which
showed that higher levels of perceived stress were linked to smoking more (Heslop et
al. 2001).
High alcohol intake has been linked to illnesses such as coronary heart disease, cancer
and liver disease (see Chapter 5). Research has also examined the relationship between
stress and alcohol consumption. Many authors have suggested that work stress in particular, may promote alcohol use (e.g. Herold and Conlon 1981; Gupta and Jenkins
1984). The tension reduction theory suggests that people drink alcohol for its tensionreducing properties (Cappell and Greeley 1987). Tension refers to states such as fear,
anxiety, depression and distress. Therefore according to this model, negative moods are
the internal stressors, or the consequence of an external stressor, which cause alcohol
consumption due to the expected outcome of the alcohol. For example, if an individual
feels tense or anxious (their internal state) as a result of an exam (the external stressor)
and believes that alcohol will reduce this tension (the expected outcome), they may drink
alcohol to improve their mood. This theory has been supported by some evidence of the
relationship between negative mood and drinking behaviour (Violanti et al. 1983)
suggesting that people are more likely to drink when they are feeling depressed or
anxious. Similarly, both Metcalfe et al. (2003) and Heslop et al. (2001) reported an
association between perceived stress and drinking more alcohol (if a drinker). Furthermore, it has been suggested that medical students’ lifestyle and the occurrence of
problem drinking may be related to the stress they experience (Wolf and Kissling 1984).
In one study, this theory was tested experimentally and the health-related behaviours of
medical students were evaluated both before and during a stressful examination period.
The results showed that the students reported a deterioration in mood in terms of anxiety and depression and changes in their behaviour in terms of decreases in exercise and
food intake (Ogden and Mtandabari 1997). However, alcohol consumption also went
down. The authors concluded that acute exposure to stress resulted in negative changes
in those behaviours that had only a minimal influence on the students’ ability to perform
satisfactorily. Obviously chronic stress may have more damaging effects on longer-term
changes in behaviour.
Diet can influence health either through changes in body weight or via the over or under
consumption of specific dietary components (see Chapter 6). Greeno and Wing (1994)
proposed two hypotheses concerning the link between stress and eating: (1) the general
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