Theories of Smoking Evaluation

Nicotine regulation model Smokers smoked more low nicotine cigarettes during a week when all they had was low nicotine cigarettes; compared to fewer high nicotine cigarettes in another week when only high nicotine cigarettes were available. Many people crave cigarettes long after the nicotine has gone. This could be owing to the direct reinforcing effects of nicotine. Those who smoke few cigarettes probably do so because of reinforcing effects.

Nicotine regulation model - Does not explain initiation. Needs a psychological explanation as well. Smokers smoke nicotine free cigarettes and go without on long plane journeys. Also does not explain light smokers. A study of over 300 monozygotic twins (identical) and just under 200 same-sex dizygotic twins (fraternal) estimated the contribution of genetic factors and environmental factors to substance use in adolescence. It concluded that the major influences on the decision to use substances were environmental rather than genetic (Han et al., 1999). Nature nurture twin studies genetic components more predictive than environmental. Genetics stronger for light smokers. According to evolutionary psychologists, the persistence .of behaviour patterns such as smoking must reflect some evolutionary value. With the decline in the overall prevalence of smoking there has emerged what Pomerlau (1979) has described as a group of 'refractory' smokers who are more likely to have a variety of other problematic patterns of behaviour and cognition such as depression, anxiety and bulimia/bingeing. In ancient times these patterns may have been biologically adaptive or neutral. However, in contemporary society, a more active fight or flight response is inappropriate. Smoking would be valuable to this population because it can produce small but reliable adjustments to levels of arousal.

Psychobiological approach response to flight or fight. Causality not established. Ignores psychological and social influences. In 1966 Tomkins proposed his affect management model of smoking which was subsequently revised and extended by Ikard et al. (1969) who conducted a survey of a national (US) probability sample.

In a factor analysis of the responses they identified six smoking motivation factors: reduction of negative affect, habit, addiction, pleasure, stimulation and sensorimotor manipulation. In their study of smoking among young adults, Murray et al. (1988) added two additional reasons: boredom and nothing to do. In a survey they asked young adults to indicate which of these factors were important reasons for smoking in different situations. In all situations relaxation and control of negative affect were considered the most important reasons. At home boredom was also considered important, perhaps reflecting these young people's frustration with family life. At work addiction was considered important, perhaps reflecting the extent to which it disrupted their work routine, while socially habit was rated important.

Ikard et al (1969) USA survey self report. Situational dependent - it depends whether the smoker is at work or at home. This affects reliability. Dated study smokers now know about the bad effects of smoking so might answer differently today. In a sample of Scottish adults, Whiteman (1997) found that smoking was associated with hostility. However, they accept that 'presence of an association does not help in determining if the relationship is causal'. Indeed, they hypothesize that deprivation of smoking which was required for the study may have increased hostility. Whiteman (1997) Hostility in a Scottish sample who were deprived of smoking! Could be an ethnocentric misinterpretation of Scottish behaviour! Causality not established. In a study of nurses' smoking practices, Murray et al. (1983) found that those who reported the most stress were more likely to smoke. This relationship remained after controlling for the effect of family and friends' smoking practices. Murray et al (1983) Stressed nurses. Well controlled for effect of family and friends smoking. Murray et a1. (1988) conducted detailed interviews with a sample of young adults from the Midlands. These suggested that smoking had different meanings in different settings. For

example, at work going for a cigarette provided an opportunity to escape from the everyday routine. As one young factory worker said: We would say we were going to the toilet and have a quick cigarette. As long as they [management] didn't catch you. If they caught you, well, you'd be in trouble, sort of thing. But it was alright. We used to go in about every hour, something like that. (Murray et al., p. 49) Qualitative study Midlands. (Murray et al 1988). Graham's (1976, 1987) series of qualitative studies has provided a detailed understanding of the meaning of smoking to working-class women. In one of her studies (Graham, 1987) she asked a group of low-income mothers to complete a 24-hour diary detailing their everyday activities. Like the young workers in the study by Murray et a1. (1988), smoking was used as a means of organizing these women's daily routine. For example, one woman said: I smoke when I'm sitting down, having a cup of coffee. It's part and parcel of resting. Definitely, because it doesn't bother me if I haven't got a cigarette when I'm working. If I'm busy, it doesn't bother me, but it's nice to sit down afterwards and have a cigarette. (Graham, 1987, p. 52) Further, for these women smoking was not just a means of resting after completing certain household tasks but also a means of coping when there was a sort of breakdown in normal household routines. This was especially apparent when the demands of child care became excessive. Graham describes smoking as 'not simply a way of structuring caring: it is also part of the way smokers re-impose structure when it breaks down' (p. 54). She gives the example of one woman who said: If it's nice, I send them [children] out or ask them to play in the bedroom but normally I will sit in the kitchen and have a cup of coffee and a cigarette. The cup of coffee calms me best, then a cigarette and then it's just being on my own for a few minutes to sort of count to ten and start again. (Graham, 1987, p. 54) Graham (1987) Diary - link to boredom. something unpleasant. Avoidance of

If we examine the pattern of cigarette consumption compared with the retail price of cigarettes in the UK we can observe a remarkable

relationship. Figure 1 shows how the curve for consumption is the mirror image of the curve for retail price (Townsend, 1993). Since 1970 any increase in price has brought about a decrease in smoking. At the time of the study there was a slight decrease in the price of cigarettes (figures adjusted to take account of inflation) and a corresponding rise in smoking. This rise in smoking was particularly noticeable in young people and, according to Townsend (1993), regular smoking by 15-year-old boys increased from 20 per cent to 25 per cent and by 1619-year-old girls from 28 per cent to 32 per cent. This connection between price and consumption suggests an obvious policy for governments who want to reduce smoking.

Price increase affects poor not the rich. But it is effective for helping to prevent children from smoking.

Preventing and Quitting Evaluation

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.

Prochaskas stages of change model is a positive model. It suggests that if a smoker relapses after attempting to give up they can go back to an earlier stage and be more successful in the future. The model also suggests that the intervention can be tailor-made depending upon what stage the smoker is at. 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. In the experiment the sample did not generalise to males or other cultures. Nicotine fading procedures encourage smokers gradually to switch to brands of low nicotine cigarettes and gradually to smoke fewer cigarettes. It is believed that when the

smoker is ready to quit completely, their addiction to nicotine will be small enough to minimize any withdrawal symptoms. Although there is no evidence to support the effectiveness of nicotine fading on its own, it has been shown to be useful alongside other methods such as relapse prevention (e.g. Brown et al. 1984). But other evidence shows that people compensate by smoking more low-nicotine cigarettes. Nicotine fading has the problem of compensatory smoking, which can be linked to the nicotine regulation model. Nicotine replacement - gum satisfies the oral component, but tastes awful. So why not stick with patches and chew ordinary gum? The nicotine from the gum is slow to act and would therefore not provide adequate reinforcement, leading to the gum being discontinued (Learning theory). Likewise the bad taste of the gum is like a punishment, which also leads to disuse. Nicotine replacement might appear to work owing to the placebo effect. Nicotine fading and replacement will only work for those physiologically addicted to nicotine. Nicotine patches are not useful for smokers with low nicotine dependence. It is important to test for the level of addiction. A combination of behavioural therapy and nicotine replacement is best for high-nicotine dependent smokers. Aversion therapies aim to punish smoking rather than reward it. Early methodologies used crude techniques such as electric shocks, whereby each time an individual puffed on a cigarette or drank some alcohol they received a mild electric shock. However, this approach was found to be ineffective for smoking and drinking (e.g. Wilson 1978), the main reason being that it is difficult to transfer behaviours, which have been learnt in the laboratory to the real world. Rapid smoking is a more successful form of aversion therapy (Danaher 1977) and aims to make the actual process of smoking unpleasant. Smokers are required to sit in a closed room and take a puff every 6 seconds until it becomes so unpleasant they can't smoke anymore. Although there is some evidence to support rapid smoking as a smoking cessation technique, it has obvious side-effects, including increased blood carbon monoxide levels and heart rates.

Aversion therapy does not generalise. Electric shocks given in a laboratory lacks ecological validity. Better to give a negative stimulus such as making the smoker sick whilst smoking; for example Rapid smoking. Rapid smoking is unethical as it can put the smokers health at risk. Dealing with symptoms not the underlying causes (Behaviourist rather than Cognitive). Contingency contracting. Schwartz (1987) analysed a series of contingency contracting studies for smoking cessation that took place between 1967 and 1985 and concluded that

this procedure seems to be successful in promoting initial cessation, but once the contract is finished, or the money returned, relapse is common Contingency contracting has limited success as smokers relapse once the contract has finished. 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 ex-smokers 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. Self-help has limited success. Minimum intervention helps such as a health worker checking up from time to time. Do not ignore the power of health messages in contributing to the smokers success. 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:

(1) follow-up only, (2) questionnaire about their smoking behaviour and follow-up, (3) doctor's advice to stop smoking, questionnaire about their smoking behaviour and follow-up, (4) doctor's advice to stop smoking, leaflet giving tips on how to stop and followup.

All subjects were followed up at 1 and 12 months. Results at 12 months Group % still abstinent 1 2 3 0.3 1.6 3.3

5.1

Russell et als study into the effect of doctors advice may not generalise to other places as it was conducted in London. Doctors giving advice is relatively cheap and convenient. The results of the study are not brilliant compared with self-help. The follow-up was too soon. 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 worksite ban produced an attitude change but only 2% gave up! 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 nonworking 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. Gomels ambulance workers were drawn from a workforce made up of mainly smokers, so there might have been a lot of social pressure for them to continue to smoke. Only 24 completed the tests and these were probably the most motivated to give up. This fact makes the results more convincing that despite a reasonable level of motivation many smokers were unsuccessful in quitting. The physiological measures were objective and the self-report measures were subjective. There was concurrent validity as both types of measures supported craving returning after 6 weeks. There was evidence of compensatory smoking. Banning smoking in public places also suffers from compensatory smoking, but at least attempts to remove the cues to smoking. An outright ban drives smoking underground and the government lose tax!