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
consumptio
n 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 16—19-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.
Prochaska’s 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
smoker’s 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 smoker’s 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 followup 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 smoker’s 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
0.3
2
1.6
3
3.3
4
5.1
Russell et al’s study into the effect of doctor’s advice may not generalise to other places
as it was conducted in London. Doctor’s 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.
Gomel’s 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!