Académique Documents
Professionnel Documents
Culture Documents
Substance abuse.
Health Promotions
Material adapted from Jane Ogden's excellent book, 'Health
Psychology', Open University Press, 1996, Chapter 5, in the hope
that you will buy it, either for yourself or as a class set.
Arm patch monitors alcohol tolerance
Patterns and predictions of smoking cessation among British Women (Graham and Der, 1999)
Guardian article on idea for persuading teenagers not to smoke
The American Lung Association programme, for example, has a programme involving a specific quit date, interruption
of conditioned responses supporting smoking, identification and preparation of plans for coping with temptations after cessation,
teaching relapse prevention skills, and follow-up contact and support. This programme, and its variants, has achieved long-term
abstinence rates of between 35 and 29 per cent (Lando et at. 1989; Rosenbaum and OShea 1992).
A study to examine the stages of change in predicting smoking cessation (DiClemente et al1991)
DiClemente and Prochaska (1982) developed their transtheoretical model of change to examine the stages of
change in addictive behaviours. This study examined the validity of the stages of change model and assessed
the relationship between stage of change and smoking cessation.
The stages of change model describes the following stages:
* Precontemplation: not seriously considering quitting in the next 6 months.
* Contemplation: considering quitting in the next 6 months.
* Action: making behavioural changes.
* Maintenance: maintaining these changes.
Individuals move backwards and forwards across the stages. In this study, the authors categorized those in
the contemplation stage as either contemplators (not considering quitting in the next 30 days) and those in the
preparation stage (planning to quit in the next 30 days).
Subjects 1466 subjects were recruited for a minimum intervention smoking cessation programme from
Texas and Rhode Island. The majority of the subjects were white, female, started smoking at about 16 and
smoked on average 29 cigarettes a day.
Design The subjects completed a set of measures at baseline and were followed up at 1 and 6 months.
Measures The subjects completed the following set of measures:
* Smoking abstinence self-efficacy (DiClemente et al. 1985), which measures a smoker's confidence that they
will not smoke in 20 challenging situations.
* Perceived stress scale (Cohen et al. 1985), which measures how much perceived stress an individual has
experienced in the past month.
* Fagerstrom Tolerance Questionnaire, which measures physical tolerance to nicotine.
* Smoking decisional balance scale (Velicer et al. 1985), which measures the perceived pros and cons of
smoking.
* Smoking processes of change scale (DiClemente and Prochaska 1985), which measures an individual's
stage of change. According to this scale, the subjects were defined as precontemplators (n = 166),
contemplators (n = 794) or as being in the preparation stage (n = 506).
* Demographic data, including age, gender, education and smoking history.
At baseline the results showed that those in the preparation stage smoked less, were less addicted, had higher
self-efficacy, rated the pros of smoking as less and the costs of smoking as more, and had attempted to quit
more often than the other two groups. At both 1 and 6 months, the subjects in the preparation stage had
attempted to quit more often and were more likely not to be smoking.
With regard to motivation intrinsic motivation was far better than extrinsic motivation in bringing about
positive changes in behaviour (DiClemente 1999). It is therefore important to change external reasons for
quitting into internal reasons.
day. These have been shown to be more effective than a placebo (Richmond et al. 1994), and may enhance
the impact of any behavioural intervention. Richmond et at. (1994), for example, compared the effectiveness
of a cognitive-behavioural intervention in combination with either active or placebo nicotine patches.
Participants using the active nicotine patch were most likely to be abstinent at the three (48 versus 21
percent) and six-month (33 versus 14 per cent) follow-up assessments. Six-month continuous abstinence
rates were also higher among the active nicotine group (25 per cent) than the control group (12 per cent).
Smokers are not a homogenous group. Some smokers may smoke predominantly out of habit; some due to an addiction to
nicotine (Fagerstrom 1982). Accordingly, the same therapeutic approach may not be optimal for both groups. Indeed, there is
evidence that cognitive-behavioural approaches may be best for those who smoke predominantly out of habit, while nicotine
replacements in combination with some form of psychological intervention may prove optimal for those with high levels of
nicotine dependency. Evidence in support of this hypothesis was provided by Hall et at. (1985), who assigned high and low
nicotine-dependent smokers to either an intensive behavioural intervention, nicotine gum, or a combination of both approaches. At
the one-year follow-up, 50 per cent of high nicotine-dependent smokers in the combined intervention were not smoking. This
compared with abstinence rates of 28 per cent among the equivalent group in the nicotine gum condition, and 11 per cent of those
who participated in behavioural intervention. In contrast, low dependent smokers gained most from the behavioural intervention.
Among this group, abstinence rates at one year were 47 per cent, in comparison to rates of 42 and 38 per cent in the nicotine gum
and combined interventions.
Even where individuals have failed to quit on one attempt, it may not be unreasonable to attempt further cessation fairly quickly
if the individual remains motivated to change. Gourlay et al. (1995), for example, randomly allocated 629 smokers who had
previously failed to quit smoking while using transdermal patches to either a placebo control condition or a further intervention
comprising transdermal nicotine patches, brief behavioural counselling (five to 10 minutes) and a booklet containing advice on
smoking cessation and instructions for the use of patches. While quit rates were, perhaps unsurprisingly, relatively low there was
still evidence of some benefit from the combined intervention, with six-month abstinence rates of 6.4 per cent of those receiving
the active intervention and 3.8 per cent in the placebo condition.
Cue exposure procedures focus on the environmental factors that have become associated with smoking and
drinking. For example, if an individual always smokes when they drink alcohol, alcohol will become a strong
external cue to smoke and vice versa. Cue exposure techniques gradually expose the individual to different
cues and encourage them to develop coping strategies to deal with them. This procedure aims to extinguish
the response to the cues over time and is opposite to cue avoidance procedures, which encourage individuals
not to go to the places where they may feel the urge to smoke.
Self-management procedures use a variety of behavioural techniques to promote smoking and drinking
cessation in individuals and may be carried out under professional guidance. Such procedures involve self
monitoring (keeping a record of own smoking/drinking behaviour), becoming aware of the causes of
smoking/drinking (What makes me smoke? Where do I smoke? Where do I drink?), and becoming aware of
the consequences of smoking /drinking (Does it make me feel better? What do I expect from
smoking/drinking?). However, used on their own self-management techniques do not appear to be any more
successful than other interventions (Hall et al. 1990).
Multi-perspective cessation clinics represent an integration of the above clinical approaches to smoking and
drinking cessation and use a combination of aversion therapies, contingency contracting, cue exposure and
self-management. Lando (1977) developed an integrated model of smoking cessation, which has served as a
model for subsequent clinics. His approach included the following procedures:
Lando's model has been evaluated and research suggests abstinence rates of 76 per cent at 6 months (Lando
1977) and 46 per cent at 12 months (Lando and McGovern 1982), the latter being higher than the control
group's abstinence rates. Killen et al. (1984) developed Lando's approach but used smoke holding rather than
rapid smoking, and introduced nicotine chewing gum into the programme. Their results showed similar high
abstinence rates to the study by Lando.
Self-help movements
Although clinical and public health interventions have proliferated over the last few decades, up to 90 per
cent of ex-smokers report having stopped without any formal help (Fiore et al. 1990). Lichtenstein and
Glasgow (1992) reviewed the literature on self-help quitting and reported that success rates tend to be about
10-20 per cent at 1-year follow-up and 3-5 per cent for continued cessation. The literature suggests that
lighter smokers are more likely to be successful at self quitting than heavy smokers and that minimal
interventions such as follow-up telephone calls can improve the rate of success. However, although many exsmokers report that 'I did it on my own', it is important not to discount their exposure to the multitude of
health education messages received via television, radio or leaflets.
1 Doctor's advice. In a classic study carried out in five general practices in London (Russell et al. 1979, see
Key Study 4 p43 in Harari and Legge, 2001), smokers visiting their GP over a 4-week period were allocated
to one of four groups:
Results at 12 months
Group % still abstinent
1
0.3
1.6
3.3
5.1
Research suggests that the effectiveness of doctor's advice may be increased if they receive training in
patient-centred counselling techniques (Wilson et al. 1988). See doctor - patient relationships.
Worksite interventions. Research into the effectiveness of no-smoking policies has produced conflicting
results, with some studies reporting an overall reduction in the number of cigarettes smoked for up to 12
months (e.g. Biener et al. 1989) and others suggesting that smoking outside work hours compensates for any
reduced smoking in the workplace (e.g. Gomel et al. 1993). In two Australian studies, public service workers
were surveyed about their attitudes to smoking bans in 44 government office buildings immediately after the
ban and 6 months later. The results suggested that although immediately after the ban many smokers felt
inconvenienced, these attitudes improved at 6 months with both smokers and non-smokers recognizing the
benefits of the ban. However, only 2 per cent stopped smoking during this period.
A pilot study to examine the effects of a workplace ban on smoking on craving, stress and
other behaviours (Gomel et al. 1993)
The ban was introduced on 1 August 1989 at the New South Wales Ambulance Service in Australia. This
study is interesting because it included physiological measures of smoking to identify any compensatory
smoking.
Subjects A screening question showed that 60 per cent (n = 47) of the employees were currently smoking.
Twenty-four subjects (15 males and 9 females) completed all measures. They had an average age of 34 years,
had smoked on average for 11 years and smoked on average 26 cigarettes a day.
Design The subjects completed a set of measures 1 week before the ban (time 1) and 1 (time 2) and 6 weeks
(time 3) after.
Measures At times 1, 2 and 3, the subjects were evaluated for cigarette and alcohol consumption,
demographic information (e.g. age), exhaled carbon monoxide and blood cotinine. The subjects also
completed daily record cards for 5 working days and 2 non-working days, including measures of smoking,
alcohol consumption, snack intake and ratings of subjective discomfort.
The results showed a reduction in self-reports of smoking in terms of number of cigarettes smoked during a
working day and the number smoked during working hours at both the 1-week and 6-week follow-ups
compared with baseline, indicating that the smokers were smoking less following the ban. However, although
there was an initial reduction in nicotinine at week 1, by 6 weeks blood nicotine levels were almost back to
baseline levels, suggesting that the smokers may have been compensating for the ban by smoking more
outside the workplace. The results also showed reductions in craving and stress following the ban; these
lower levels of stress were maintained, whereas craving gradually returned to baseline (supporting
compensatory smoking). The results showed no increases in snack intake or alcohol consumption.
The self-report data from this study suggest that worksite bans may be an effective form of public health
intervention for reducing smoking. However, the physiological data suggest that simply introducing a no
smoking policy may not be sufficient, as smokers may show compensatory smoking.
Community-based programmes. In the Stanford Five City Project, the experimental groups received intensive
face-to-face instruction on how to stop smoking and in addition were exposed to media information regarding
smoking cessation. The results showed a 13 per cent reduction in smoking rates compared with the control
group (Farquhar et al. 1990).
In the North Karelia Project, individuals in the target community received an intensive educational campaign
and were compared with the members of a neighbouring community who were not exposed to the campaign.
The results showed a 10 per cent reduction in smoking in men in North Karelia compared with men in the
control region. In addition, the results also showed a 24 per cent decline in cardiovascular deaths, a rate twice
that in the rest of the country (Puska et al. 1985). Other community-based programmes include the Australia
North Coast Study, which resulted in a 15 per cent reduction in smoking over 3 years (Egger et al. 1983), and
the Swiss National Research Programme, which resulted in a 8 per cent reduction over 3 years
(Autorengruppe Nationales Forschungsprogramm 1984).
Government interventions.
Restrictinglbanning advertising.
Increasing the cost. Research indicates a relationship between the cost of cigarettes and alcohol and
their consumption.
Banning smoking in public places. Smoking is already restricted to specific places in many countries
(e.g. in the UK most public transport is no smoking). A wider ban on smoking may promote smokingcessation. According to social learning theory, this would result in the cues to smoking (e.g.
restaurants, bars) becoming eventually disassociated from smoking. However, it is possible that this
would simply result in compensatory smoking in other places.
Banning cigarette smoking and alcohol drinking. But the government loses tax and consumption is
driven underground, just as drug-taking is. Also consider the unsuccessful prohibition era in the USA.
Baseline state
Pre-lapse state
High-risk situation. External (pub) or internal (upset) cue to start smoking
Coping behaviour. e.g. eating instead
Positive outcome expectancies. According to previous experience, the individual will either have positive
outcome expectancies if they carry out the behaviour (e.g. smoking will make me feel less anxious) or
negative outcome expectancies (e.g. getting drunk will make me feel sick).
No lapse or lapse?
high risk situation, a good coping mechanisms and negative outcome expectancies (smoking will make me
ill), the chances of a lapse will be reduced and the individual's self-efficacy will be increased. However, if
poor coping strategies and has positive outcome expectancies (I will be less anxious if I smoke), the chances
of a lapse will be high and the individual's self-efficacy will be reduced.
This lapse will either remain an isolated event and the individual will return to abstinence, or will become a
full-blown relapse. Marlatt and Gordon describe this transition as the abstinence violation effect (AVE).
The abstinence violation effect
The transition from initial lapse to full-blown relapse is determined by dissonance conflict and selfattribution. Dissonance is created by a conflict between a self-image as someone who no longer
smokes/drinks and the current behaviour (e.g. smoking/drinking). This conflict is exacerbated by a disease
model of addictions which emphasizes 'all or nothing', and minimized by a social learning model which
acknowledges the likelihood of lapses.
Self-
Family Therapy
Stanton and Shadish (1997), in a meta-analysis of family therapy, reported on its superiority over other
modalities of treatment such as individual counselling or therapy, peer group therapy, and family
psychoeducation. There was inconclusive evidence to demonstrate any particular school'' of family
therapy over another, partly because of a dearth of research and much commonality between them.
These positive conclusions held for both the adult and the adolescent studies reviewed. With the dearth
of research evidence in adolescent treatment outcome, these results are welcomed. The authors also
reported the evidence on the cost-effectiveness of family therapy. There was some evidence on the
effectiveness of family therapy approaches, both with fewer sessions required than with individual
therapy, but also with savings in social costs. Cost-effectiveness of these treatment approaches merits
significantly more attention.
More emphasis needs to be given to gender differences and outcome research, particularly given the
increased recognition of drug and alcohol use in females.
Treatment concepts tend to emphasise the importance of comprehensiveness, to include the treatment
of drug and alcohol-related behaviour as well as other comorbid and correlated behaviours (Kazdin,
1987). These areas might include educational difficulties and scholastic achievement, family conflict,
parental substance use, and involvement of other systems such as juvenile justice.
Although a high initial abstinence rate was reported (52 per cent), this had fallen to 25 per cent by the one-year follow-up a
relatively good outcome, but not comparable with the original success of the intervention. These facts support the Health Belief
Models assertion that perceived susceptibility is an influential factor in deciding upon health behaviour.
A further factor which may powerfully influence the outcome of any intervention is the emotional state of participants. Zelman
et al. (1992), for example, reported that 12 months following a smoking cessation course, 26 per cent of those who evidenced some
degree of depression at the time of the course were abstinent. This contrasted with 62 per cent of those who were not depressed.
They suggested that negative affect may have disrupted either the initial acquisition of coping skills during treatment or the generalization of those skills beyond. These findings may generalize to other populations and approaches. In a study of a communitywide stop smoking contest, Glasgow et al. (1985) also found perceived stress to be a major determinant of outcome, with those
highest on measures of stress experiencing the least success in quitting.
QUIT: http://www.quit.org.uk/
Acknowledgement
Paul Bennett and Simon Murphy (1997), Psychology and Health Promotion, Open University Press, 0335-19766-3.